Coping: neither good, nor bad, but "it depends"

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Coping is a concept we often use in chronic pain management.
Our aim as clinicians is to help people with chronic pain cope with their pain so they can do more of what is important to them.

Most of us know that coping mediates between the individual and whatever challenge he or she is facing. Coping reduces the impact of the challenge. Most of us also know that there are a range of coping strategies that people can use - and most of us have learned that coping strategies can be "adaptive" or "maladaptive", "active" or "passive", "approach" or "avoidant". Unfortunately, much of the time this dichotomous taxonomy turns into a "do this" and "don't do that" list of good or bad strategies.

What this means is that strategies such as resting and delegating are both considered "passive", therefore "avoidant" and consequently are "maladaptive" - and as clinicians we tell people "don't do that" because they feature on our list of bad strategies.

I thought this too until I started researching the ways that people who cope well with pain deal with pain in their lives.
I thought, when I began my study, that I would find a neat list of strategies that people used, and that these would fall into the "adaptive", "active" and "approach" categories of coping.

They don't. Nope, people who live well with their chronic pain just do not do what I expected.

People who cope well use "anything and everything", or as my participants put it "anything that works".
Back to the drawing board you'd think! But I spent a long time listening to the ways people solve the problem of how to get on with life despite chronic pain, and something struck me: when a person talked about using a coping strategy, any coping strategy, it wasn't all about the pain. In fact, pain rarely got a mention. What did get discussed was how, by using "anything that works", people got to do what they valued in their lives. In other words, they judged whether a strategy worked by how well it helped them do what they prioritised.

 

In technical terms this is called functional contextualism - evaluating an action in the context in which it is used. Coping strategies cannot, within this framework, be evaluated in isolation from the where and why of its use.

Let me give you a brief example: Resting is usually thought of as an unhelpful way to manage chronic pain. It's thought to lead to deconditioning, avoidance and fear of pain, and loss of good things in life. Yet, what if, by resting in the afternoon, a person is able to go out to celebrate her 21st birthday? In the context of a person having a 21st birthday party, resting in the afternoon enables her to do something she values.

If resting is the only coping strategy this person has, or if resting is the primary way this person copes with painful flare-ups, and if resting also interferes with this person's overall ability to live independently, then perhaps resting is not useful for her all the time. On the other hand, if she has many different ways to deal with her pain, and she also uses planning and medication and exercise, and if she's able to live independently and do the things she wants to be able to do, resting has usefulness.

That's functional contextualism, and that's how people who cope well with pain use their coping strategies.

What does this mean for us as clinicians?

It means we need to take time to understand why, when, where and how the people we work with do the things that are important to them. If they don't know how to do what's important, if they only have a few coping strategies to choose from, and if they're distressed because their one strategy gets in the way of things they value, then and only then are their coping strategies unhelpful. It also means that using a coping strategies inventory might not be a good way to decide if a person needs help developing coping strategies. We might instead choose to use something like the Chronic Pain Coping Inventory as a way to identify the range of strategies an individual knows about, rather than whether the things they use are "passive" or "active". To measure whether their strategies are working for them - well my guess would be to use something like the Canadian Occupational Performance Measure, or a disability outcome measure.

Biglan, Anthony, & Hayes, Steven C (1996). Should the behavioral sciences become more pragmatic? The case for functional contextualism in research on human behavior Applied & Preventive Psychology, 5 (1), 47-57 DOI: 10.1016/S0962-1849(96)80026-6

Hayes, Steven C., Levin, Michael E., Plumb-Vilardaga, Jennifer, Villatte, Jennifer L., & Pistorello, Jacqueline. (2013). Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior Therapy, 44(2), 180-198.