On the problem of coping


Coping. Lots of meanings, lots of negative connotations, used widely by health professionals, rejected by others (why would you need coping skills if you can get rid of your pain?).

I’ll bet one of the problems with coping is that we don’t really know what we’re defining. Is coping the result of dealing with something? Or is it the process of dealing with something? Or is it the range of strategies used when dealing with something? What if, after having dealt with the ‘something’ that shook our world, the world doesn’t go back to the way it was? What if ‘coping’ becomes a way of living?

The reason this topic came up for me is having just written a review for Paincloud on activity patterns (Cane, Nielson & Mazmanian, 2018), I got to thinking about the way we conceptualise ‘problems’ in life.  It’s like we imagine that life is going along its merry way, then all of a sudden and out of the blue – WHAM! An event happens to stop us in our tracks and we have to deal with it.

But let’s step back for a minute: how many of us have a well-ordered, bimbling existence where life is going along without any hiccoughs?!

Back to coping. The concept of coping is defined by Lazarus and Folkman (1980) as “the cognitive and behavioral efforts made to master, tolerate, or reduce external and internal demands and conflicts among them.” It’s identified as a transactional process and one that occurs within a context where the person has both resources and constraints, and a direction in which he or she wants to go.

By contrast, if we look at the research into coping in people with persistent pain, most of the attention is on the “what the person does” and the resources he or she has (see for example Rosenstiel & Keefe, 1983; Jensen, Turner, Romano & Karoly, 1991; Snow-Turkey, Norris & Tan, 1996; and much more recently, measures of coping by Sleijswer-Koehorst, Bijker, Cuijpers, Scholten-Peeters & Coppieters, in press). There are some studies exploring the goals set by the person (Schmitz, Saile & Nilges, 1996), but few studies examine the context in which the person is coping – nor what happens once the coping efforts are successful.

Measuring coping falls into three main buckets: the repertoire (how many strategies do you have?); the variation (which ones do you use and do they match the demands?); and the fitness approach (the choice of strategy depends on the way a person appraises the situation) (Kato, 2012). Out of these three, Kato chose to develop a measure of coping flexibility. Coping flexibility refers to “the ability to discontinue an ineffective coping strategy, and produce and implement an alternative coping strategy”. The Coping Flexibility Scale aims to measure this ability, based on the idea that by appraising the situation, implementing a strategy, then appraising the effectiveness of that strategy and applying a new one, the person is more effective at dealing with the challenge.

One of the most popular measures of coping for pain is the 14-item Coping Strategies Questionnaire (Riddle & Jensen, 2013). It suggests different ways of coping, some of which are seen as helpful, while others are not. Oddly enough, and why I started writing this blog, it doesn’t include the way we go about daily activities – activity patterns. In the study by Cane, Nielson & Maxmanian (2018), two main forms of activity pattern were found: avoidant-pacing, and  overdoing (as measured by the Patterns of Activity Measure – Pain). The avoidant-pacing group used pacing for daily activity management, but did so with the intention of avoiding flare-ups. The overdoing group just did a lot of activity. After treatment, some people moved group – from the two original groups, two more emerged: avoidant-pacing, pacing, mixed and overdoing. The pacing group basically did what everyone says is a great way to manage pain: picking out the right level of activity and sticking with it, using a quote-based approach. The definition used in this study was “… preplanned strategy that involved breaking activities into smaller parts, alternating periods of activity and rest (or an alternate activity), and using predetermined time intervals (or quotas) to establish when to stop an activity. The description of activity pacing provided to patients identified the goal or function of activity pacing as facilitating the completion of activities and ultimately increasing overall activity and functioning.”

As usual there are vulnerabilities in the way this study was conducted, and the main one for me is the follow-up period is non-existent. The reason I worry about this is that in my daily life, as I’m sure happens in many of yours, my pattern of activity varies wildly from week to week. Some weeks, like the weeks just before I headed to Sunderland for Paincloud, and the weeks just after I got back, were incredibly busy. I pushed myself to get things done because there were a heap of deadlines! This week I plan to have some down-time – this afternoon, in fact, because I want to play with some silversmithing.

And it occurred to me that we expect such a lot from the people we work with who live with pain. We ask all sorts of intrusive questions about daily life and we expect people to be able to recall what they did, why they did it, and to make changes and be consistent about these until we’re satisfied they’re “coping”.

But what if coping is actually the way we live our lives? What if coping involves all the myriad self-evaluative activities we all do – like, how hungry, tired, irritable, frustrated, rushed, achey, restless, enthusiastic, apologetic we feel – and endlessly and constantly adjusting the actions and behaviours we do so we can do what, for a moment or two, we think is The Most Important thing for now.

Life is a constant flowing forward. It’s a stream, an avalanche, a train going one way only. We can’t stop the world to get off. And once we’ve “coped” with something, life doesn’t return to “normal” because we’re different. Maybe our priorities change, or our circumstances have, or we have a new insight into what we want, or we work out the goal we had is more important than we thought. What if we are expecting the people who live with pain to do something we’re not even capable of?

I suppose part of my musing is related to mindfulness. Mindfulness involves continually returning to what I want to pay attention to, and doing so without judgement, and also observing without judgement. But it always involves coming back to what I intend to attend to. On and on and on. And the lovely thing about it is that it’s endlessly gentle and forgiving. Let go of the things I forgot to do, or the rushing towards what needs doing. I wonder what would happen if we encouraged people to be mindful for brief moments throughout the day all day long. Would that encourage coping flexibility? Would it encourage using a broader repertoire of ways of dealing with things? Would it help people to be more aware of everyday choosing and prioritising and managing actions to meet what’s valued in life?

To summarise: currently coping is measured using a “catalogue” of actions, often out of the context of daily decision-making and activity management. Activity management can vary from day to day, hour to hour, month to month. Being flexible with how we go about life seems, at least to me, to depend on my being aware of what’s important to me, what my energy is like, and the context in which I life. How well do we measure these constructs in pain management?

Cane, D., Nielson, W. R., & Mazmanian, D. (2018). Patterns of pain-related activity: replicability, treatment-related changes, and relationship to functioning. Pain, 159(12), 2522-2529.

Folkman, S., & Lazarus, R. S. (1980). An Analysis of Coping in a Middle-Aged Community Sample. Journal of Health and Social Behavior, 21(3), 219-239. doi:10.2307/2136617

Jensen, M. P., Turner, J. A., Romano, J. M., & Karoly, P. (1991). Coping with chronic pain: A critical review of the literature. Pain, 47(3), 249-283. doi:http://dx.doi.org/10.1016/0304-3959%2891%2990216-K

Kato, T. (2012). Development of the Coping Flexibility Scale: Evidence for the coping flexibility hypothesis. Journal of counseling psychology, 59(2), 262-273.

Riddle, D.L &  Jensen, M.P. (2013). Construct and criterion-based validity of brief pain coping scales in persons with chronic knee osteoarthritis pain. Pain Medicine 14(2):265-275. doi:10.1111/pmc.12007

Rosenstiel, A. K., & Keefe, F. J. (1983). The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. Pain, 17(1), 33-44.

Schmitz, U., Saile, H., & Nilges, P. (1996). Coping with chronic pain: flexible goal adjustment as an interactive buffer against pain-related distress. Pain, 67(1), 41-51.

Sleijser-Koehorst, M. L. S., Bijker, L., Cuijpers, p., Scholten-Peeters, G. G. M., & Coppieters, M. Preferred self-administered questionnaires to assess fear of movement, coping, self-efficacy and catastrophizing in patients with musculoskeletal pain – A modified Delphi study. Pain. in press

Snow-Turek, A. L., Norris, M. P., & Tan, G. (1996). Active and passive coping strategies in chronic pain patients. Pain, 64(3), 455-462. doi:10.1016/0304-3959(95)00190-5

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7 comments

  1. Bronnie, as you well know, I am not a great fan of the so-called biopsychosocial model of pain. At best it is an approach or guide for the clinician who engages with people experiencing pain. At worst it defaults to biomedical reductionism.

    In my opinion, when one looks at the attempts by psychiatrists and psychologists to categorise various coping styles, the model has fallen down badly. Through their promotion of negative connotations they have succeeded in alienating innumerable individuals experiencing pain and have provided clinicians with a stigmatising terminology, which includes: pain-prone; somatising, catastrophising, malingering, and activity intolerant.

    But from your review of the relevant literature is there any discussion of the different philosophical approaches that are being employed to help those in pain endure their pain and suffering?

    After all, as Hardy et al. (1952) point out: “ … the culture in which a man finds himself becomes the conditioning influence in the formation of the individual reaction patterns to pain . . . A knowledge of group attitudes toward pain is extremely important to an understanding of the individua1 reaction” (p. 23).

    Reference

    Hardy JD, Wolff HG, Goodell H. Pain Sensations and Reactions. Baltimore:
    Williams and Wilkins Company, 1952.

    1. John I suspect your view of psychological approaches to pain is incomplete – and perhaps viewed through rather blurry lenses. How some people use psychological terms does not mean the terms themselves are useless.

      What practical suggestions would you make to a person who is struggling to manage daily life? Would you simply listen, acknowledge and agree that it’s tough – and leave them there? To me this looks like two people in a third space simply digging a deeper and deeper hole. Being empathic is not enough in some cases – and there’s research suggesting that expanding the repertoire of ways of coping DOES provide a way forwards for people, while applying these ways in a flexible manner helps.

      Yes, our society does look down on people who don’t fit within the typical recovery narrative. Medical management has undoubtedly had a hand in shaping the expectation that people “should” never need to have pain, never encounter disability, and return to “normal”.

      You may be interested in a paper in press: Kugelmann, R., Watson, K., & Frisby, G. Social representations of chronic pain in newspapers, online media, and film. Pain. In press.

      I’d be interested in your thoughts on how we could change the social representation of pain in our communities.

      1. Bronnie, but you have not answered my question: “But from your review of the relevant literature is there any discussion of the different philosophical approaches that are being employed to help those in pain endure their pain and suffering?” I agree with you that empathy is not helpful in this respect.

        As for the use of the terms I mentioned, I agree with Wittgenstein when he wrote: “The meaning of a word is its use in the language (PI § 43). Moreover, I did not say that these terms were useless. Stigmatising was the word I used.

      2. Stigma arises from social construction of the meaning of words and “us” vs “them” – but not the words themselves. Describing a behaviour as, for example, catastrophising, is not itself stigmatising, this only arises when the term is used to separate and stereotype the person.
        Regarding a philosophy I would think relational frame theory with functional contextualism as the philosophical stance might be the one that is most useful. It’s the approach I consider – ie that actions don’t stand outside of the function and context in which they occur. For more information you may wish to read this: Biglan, A., & Hayes, S. C. (1996). Should the behavioral sciences become more pragmatic? The case for functional contextualism in research on human behavior. Applied and Preventive Psychology, 5(1), 47-57. It’s available here: https://contextualscience.org/files/BiglanHayes,+1996.pdf

  2. Bonnie, a good start to changing the social representation of pain in our communities would be to update the current definition of pain as promulgated by the International Association for the Study of Pain (IASP). As it stands, those people experiencing pain in whom there is no evidence of discernible tissue damage are virtually excluded (but they can get in should they be reporting pain for psychological reasons). As you know, some of us have offered a reconsidered definition. that is much more inclusive.

    1. I believe the new definition removes the phrase in the notes where pain with no discernible tissue damage is equated with psychological problems. The existing definition dates back to 1986 (and the orientation of the authors who wrote it) so it’s unsurprising this phrase was included. The definition itself (without the note) remains useful and descriptive.

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