- Natisha Nabbijohn and C. Meghan McMurtry
Chronic pain can impact and be impacted by numerous biological, psychological, and social factors (Bevers et al., 2016; Gatchel et al., 2007). Coping is the use of intentional and effortful thoughts or behaviors to manage internal and external demands of stressful situations or experiences (Compas et al., 2014). Improved health outcomes are associated with many ways of coping (herein referred to as “coping responses”; e.g., problem-solving, distraction) in youth with chronic pain, including decreased pain and increased quality of life (e.g., Compas et al., 2006; Eccleston et al., 2014). However, the field lacks clarity around what we are (or should be) measuring when assessing and determining coping effectiveness in the context of the pain experience. Theoretical models like the biopsychosocial model of chronic pain (Gatchel et al., 2007), as well as the transactional (Lazarus & Folkman, 1987) and motivational models (Skinner, 1994) of coping, offer valuable insights into understanding coping; however, they are underutilized and, when employed in isolation, are insufficient. Here, we summarize conceptual challenges within coping research and propose a model for understanding coping within individualized contexts related to pediatric chronic pain.
Conceptual Challenges
This section describes three challenges in coping theory: (1) countless coping responses; (2) oversimplified models; and (3) inconsistent coping response-outcome relationships.
Consistent with critiques of the broader coping literature (Skinner et al., 2003; Stanisławski, 2019), our review of 125 studies on coping in pediatric chronic pain demonstrated myriad conceptualizations and measures (Nabbijohn et al., 2021). For example, 21 questionnaires with varying conceptualizations of coping were identified, leading to 168 potentially unique coping responses. This extensive list of coping responses is partly a by-product of the various ways coping can be implemented (e.g., distraction can range from reading a book, to watching movies, to engaging in social activities, depending on the individual’s preferences and resource access). Since a single questionnaire cannot capture all coping responses, we question how useful these tools are in research and clinical contexts.
Most questionnaires utilize a nomothetic approach to categorize coping responses as a function of their intended purpose, and these higher-order categories are often used to understand coping (Nabbijohn et al., 2021). An example is Lazarus and Folkman’s problem- vs. emotion-focused coping; although influential, this conceptualization oversimplifies the coping process since responses do not usually fit solely within one category (e.g., planning guides problem-solving and calms emotions; Skinner et al., 2003). Alternative frameworks attempt to use additional dimensions and levels to capture more coping responses (e.g., control-based model), but these models are still not sufficiently exhaustive (Nabbijohn et al., 2021). Instead, these efforts lead to numerous taxonomies, which makes it challenging to compare, consolidate, apply, and build upon research.
Another issue is the assumption that coping responses are exclusively “adaptive” or “maladaptive”. For example, “active” coping responses (i.e., working directly to control pain), such as problem-solving, are seen as adaptive, whereas “passive” coping responses (i.e., avoiding or denying the pain), such as self-isolation or wishful thinking, are seen as maladaptive. This simplistic conceptual approach treats coping as though it operates independently in managing people’s pain experience, neglecting the reality that the etiology and treatment of chronic pain are intricately linked with biopsychosocial factors (Gatchel et al., 2007). Indeed, the effectiveness of coping responses can vary by biological (e.g., birth-assigned sex, age; Lynch et al., 2007), psychological (e.g., readiness to change, depression; Jensen et al., 2004), and social factors (e.g., ethnicity, culture; Hastie et al., 2004) as well as the assessed outcomes (e.g., quality of life, pain). For example, studies report a greater use of coping responses among females compared to males, as well as differences in the use of specific coping responses, such as females using more social support and males using more distraction (e.g., Bung et al., 2017; Casey et al., 2000; Keogh & Eccleston, 2006; Lynch et al., 2007). Systemic issues are also at play. Hood et al. (2023) called attention to the interrelationship between racism-based traumatic stress and chronic pain and noted that pain dismissal and obstacles in treatment faced by racialized individuals may promote the use of stoicism (i.e., enduring pain without displaying feelings or complaint) as a coping response (Hood et al., 2023). They also argue that the active/adaptive vs. passive/maladaptive coping dichotomy oversimplifies and overlooks culturally-specific coping, potentially perpetuating harmful inequities by dismissing responses like prayer as passive/maladaptive through a White, Eurocentric lens (Hood et al., 2023). Inadequate representation of diverse groups in research limits understanding of how coping responses and outcomes may differ in relation to sociocultural factors (Nabbijohn et al., 2021).
To address these conceptual challenges, the field would benefit from applying models that conceptualize coping across people, time, and situations. There are two current frameworks used to understand coping from an individualized lens. The transactional model was the earliest developed theory suggesting person-environment interactions play a powerful role by mediating cognitive appraisals of threat, selection of coping responses, and outcomes (Lazarus & Folkman, 1987). This model highlights how the situational context plays a crucial role in coping, as individuals may cope differently depending on who is present (e.g., peers vs. parents), the task demands, and the physical or social opportunities available to them. Integrating information from a biopsychosocial lens, such as acknowledging sociocultural factors at play (e.g., sex/gender, culture, resource accessibility), may lead to more realistic ways of assessing coping and tailoring recommendations to meet individual needs within specific situations. The second framework is the motivational model which highlights youth’s goals for coping in relation to psychological needs (i.e., relatedness, autonomy, competence; Skinner et al., 1994). An additional need related to chronic pain is pain management. Understanding the intentionality behind coping distinguishes it from similar constructs (e.g., adaption, stress responses; Audulv et al., 2016). Although these models exist, they are seldom referenced in the pediatric chronic pain coping literature (Nabbijohn et al., 2021). Also, using these models independently only captures parts of the coping process (i.e., motivational = coping goals; transactional = person-environment interactions and coping outcomes). An integrated way of conceptualizing coping is needed.
Proposing an Integrative Model of the Coping Process
We propose an integrative, process-oriented coping model combining motivational and transactional theories of coping with the biopsychological model of chronic pain (Figure 1, parts A-C). Applying the biopsychosocial model specifically to coping may broaden our understanding of factors impacting coping beyond the situational context. First, it is important to break down coping into three clear and operational parts: coping goals, coping responses, and coping outcomes (Rudolph et al., 1995; see Figure 1A). Drawing from the motivational model, the intention and effort involved in coping can be understood through an individual’s coping goals, which are reasons for using a particular coping response (e.g., to reduce one’s physical discomfort). Coping responses are the specific thoughts or behaviors initiated to accomplish a coping goal, such as using positive self-statements or seeking social support (commonly referred to as “coping strategies”). Lastly, coping outcomes are changes in internal and external demands of the pain experience because of a coping response. Each time a person engages in this process, it is referred to as a coping attempt.
Reflecting elements of the transactional model, coping goals are expected to influence an individual’s selection of responses and appraisals of outcomes; responses and outcomes influence each other as well as future coping goals (Figure 1B). This process may occur through cognitive reappraisal, where outcomes indicating improved well-being (e.g., reduced pain/emotional distress) or deemed congruent with one’s objectives may be regarded as effective attempts, reinforcing future utilization.
Figure 1. An integrative model of the coping process. (A) An attempt is made up of goals, responses, and outcomes impacted by numerous factors. (B) Appraisals of outcomes decrease or promote future goals and responses. (C) Examples of coping attempts using this model. For future attempts, “-” denotes a potential decrease and “+” denotes a potential increase.
Conversely, outcomes indicating worsened well-being (e.g., increased pain/emotional distress) or not aligning with a person’s coping goal may be appraised as an ineffective attempt, diminishing future use. Furthermore, biopsychosocial factors and other transactional factors related to the situation may act on all parts of the coping process, including coping goals (Ghio et al., 2021).
An example of using deep breathing in a coping attempt is used to illustrate this dynamic process (see Figure 1C). If a person opts for deep breathing with a goal of reducing their pain, and pain persists, they may evaluate this coping attempt as ineffective, and this appraisal may decrease future application. In contrast, if their goal was to function despite pain, and found themselves feeling calmer and more focused on task demands, they may appraise this as an effective coping attempt and use this strategy in the future. However, factors such as their readiness to self-manage pain experience or self-efficacy may influence their willingness to engage with deep breathing (i.e., acting on their coping response selection); an anxious predisposition or being in a public and/or a highly stimulating environment may limit changes in calmness (i.e., acting on their coping outcome). Focusing on coping effectiveness within a specific person/context decreases emphasis on labeling responses as uniformly (mal)adaptive and encourages consideration of factors that may have impacted effectiveness. Ideally, thinking about coping this way may help to assess coping as a dynamic construct and better understand the influence of individual, cultural, and situational factors. In turn, this approach may help clinicians to tailor coping interventions to the needs of youth with chronic pain.
Future Directions
The next step is to engage in theory testing and building, including examining the clinical utility of the proposed model. Evidence in support of this model may indicate that alternative methods of assessment are needed. For example, daily diaries and interviews capture information about person-specific and contextual factors. We recognize, however, that these approaches are not always feasible; questionnaires afford efficiency and consistency. When using questionnaires, researchers and clinicians may consider gathering supplemental information, using think-aloud methods, and/or performing levels of analysis (i.e., items, subscales). Lastly, we need to be less conclusive about relationships we observe between coping responses and outcomes, and more curious about the factors that may have contributed to the observed relationships.
A. Natisha Nabbijohn, MA
Graduate Student, Department of Psychology, University of Guelph
Guelph, Ontario, Canada
C. Meghan McMurtry, Ph.D., C.Psych
Associate Professor, Department of Psychology, University of Guelph and
Pediatric Chronic Pain Program, McMaster Children’s Hospital
Guelph, Ontario, Canada
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