Pain 105 (2003) 197–204 www.elsevier.com/locate/pain

Coping or acceptance: what to do about chronic pain?

Lance M. McCracken*, Chris Eccleston

Pain Management Unit, Royal National Hospital for Rheumatic Diseases and University of Bath, Bath BA1 1RL, UK

Received 9 January 2003; received in revised form 5 March 2003; accepted 5 May 2003

Abstract Research and treatment of chronic pain over the past 20 or more years have tended to focus on patient coping as the primary behavioral contribution to adjustment. The purpose of the present study was to compare a coping approach to chronic pain with a different behavioral approach referred to as acceptance of chronic pain. These approaches were compared in terms of their ability to predict distress and disability in a sample of patients seeking treatment for chronic pain. Subjects were 230 adults assessed at a university pain management center. All patients completed the coping strategies questionnaire and the chronic pain acceptance questionnaire among other standard measures. Results showed that coping variables were relatively weakly related to acceptance of pain and relatively unreliably related to pain adjustment variables. On the other hand, acceptance of chronic pain was associated with less pain, disability, depression and pain-related anxiety, higher daily uptime, and better work status. Regression analyses examined the independent contributions of coping and acceptance to key adjustment indicators in relation to chronic pain. Results from these analyses demonstrated that acceptance of pain repeatedly accounted for more variance than coping variables. q 2003 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

Keywords: Chronic pain; coping; acceptance

1. Introduction two forms. One definition of coping includes behavior exhibited in response to pain regardless of the result and Patient behavior is now accepted to be important in the the second includes only behavior that successfully reduces development and maintenance of chronic pain and pain the impact of pain. Often both versions of the concept can associated disability. Early interpretations of this notion operate unchallenged within the same discussion, leading to focused largely on overt ‘pain behavior’ and its environ- potential confusion. A related problem regards the role of mental contingencies (Fordyce, 1976). During the early intention. Following Lazarus and Folkman (1984), coping is 1980s coping with pain came to be the focus of much of the commonly defined as the effortful (i.e. non-automatic) study undertaken by pain researchers interested in patient attempt to adapt to pain, or manage one’s own negative behavior. The idea of coping has immediate appeal and response to pain (Tunks and Bellissimo, 1988; Jensen et al., enjoys widespread acceptance by clinicians and clinical 1991a; Keefe et al., 1992). This definition may direct researchers. It has ostensibly contributed to treatments that attention toward behavior the pain sufferer or clinician produce clear benefits (Morley et al., 1999; Eccleston et al., judges to be purposeful and goal-directed, leaving vast 2002). It is also a term that is readily adopted by patients. amounts of patient behavior out of view. However, the common use of the idea of coping in chronic A second area of concern for coping is empirical. To date pain research has promulgated a number of conceptual and studies of coping with chronic pain have yet to clarify which empirical difficulties. In this paper we argue that the types of coping responses among the list of many are generally helpful (Jensen et al., 1991a). Although the explanatory power of coping may be bolstered by a broader success of any particular coping strategy is dependent upon behavioral framework. its behavioral context we are not able to look back across One significant problem with coping is conceptual. There approximately 20 years of published studies and conclude is some indiscriminant use of the term coping taking at least with any certainty which coping strategies are likely to * Corresponding author. Tel.: þ44-1225-473403; fax: þ44-1225- promote health and functioning. 473461. Studies of coping with pain have tended to contradict E-mail address: [email protected] (L.M. McCracken). their implied promise. Most results tend to focus on

0304-3959/03/$20.00 q 2003 International Association for the Study of Pain. Published by Elsevier B.V. All rights reserved. doi:10.1016/S0304-3959(03)00202-1 198 L.M. McCracken, C. Eccleston / Pain 105 (2003) 197–204 behaviors, the chronic or persistent use of which, patients disability and further health injurious behavior may do well to avoid. Typically they include rest, excessive (McCracken, 1998; McCracken et al., 1999). passivity (Brown and Nicassio, 1987; Jensen et al., 1991b) Not yet fully explored in the clinical literature is the and catastrophizing about pain (Main and Waddell, 1991; potential role of an acceptance of chronic pain Jensen et al., 1992; Turner et al., 2000; Tan et al., 2001). In (McCracken, 1998; Risdon et al., 2003). Psychological fact, Geisser et al. (1999) have recently argued that the acceptance in general has been defined as a willingness to reduction of unhelpful coping strategies should be the main remain in contact with thoughts and feelings without focus of treatment, rather than the increase of potentially having to follow them or change them (Hayes et al., helpful coping strategies. 1994). Acceptance of chronic pain has been defined as A final limitation with the coping approach is its heavy living with pain without reaction, disapproval, or attempts reliance on cognitive responses. Most studies of coping to reduce or avoid it (McCracken, 1998, 1999). Accep- with pain use the coping strategies questionnaire (CSQ, tance of chronic pain is, of course, more than a mental Rosenstiel and Keefe, 1983; Lester et al., 1996), or exercise and not simply a decision or a belief. Importantly, inventories like it. Measures of coping often rely on the acceptance involves a disengagement from struggling with observation and report of thoughts or attempts to change pain, a realistic approach to pain and pain-related thoughts rather than overt behaviors (for exceptions see circumstances, and an engagement in positive everyday the works by Jensen et al., 1995; Tan et al., 2001). In activities. There are a number of studies showing that most coping inventories, there is then, an emphasis on responses entailing acceptance can be directly enhanced in responses that are only directly observable by the treatment to produce relief from behavioral problems and individual pain sufferer. This emphasis produces problems unnecessary suffering in a range of conditions (Bach and for both research and clinical activity. It distances the Hayes, 2002; Jacobson et al., 2000; Kabat-Zinn et al., respondent further than is perhaps necessary from the 1985; Linehan, 1993). context of overt behavior, where most significant daily life There are a small number of empirical studies that demonstrate a positive association between acceptance and activity is occurring and significantly limits assessment successful adaptation to chronic pain. Jacob et al. (1993) methods. reported that people who accommodate to pain, defined as A research focus on ‘coping’ with chronic pain is not, in the ability to live a satisfying life despite chronic pain, isolation, a problem. Rather, our concern is that the demonstrated less depression and less overt pain behavior. narrowing of focus onto this one particular class of Schmitz et al. (1996) have shown that pain patients who behavior may have inadvertently led us away from other modify unachievable goals or substitute more achievable conceptualizations of how patients adapt to chronic pain. ones (accommodation) report less pain-related suffering. The dominance of the concept of coping leads us perhaps, McCracken (1998) found that patients with more accepting often unwittingly, to equate the successful adaptation of responses to chronic pain showed better adjustment as chronic pain with the reduction of some strategies and the measured by the self-report of depression, anxiety, and adoption of other strategies. Particularly occluded from disability. In a similar and more recent study McCracken view by the dominance of coping are those classes of et al. (1999) found that accepting pain was the most behavior that are automatic and those that are not aimed at powerful predictor of whether patients are classified as the direct control of the experience of sensations and dysfunctional or adaptive copers, independent of pain emotions. intensity or depression. The experience of chronic pain is often narrated as a The purpose of this study was to compare acceptance struggle to master, conquer, or in other ways succeed over of chronic pain and coping with chronic pain in adversity (Jackson, 2000). It may be notable in this predicting adjustment to chronic pain as measured by context that the Greek root of the word ‘cope’ is to strike anxiety, depression, and pain associated disability. We a blow (Merriam-Webster Dictionary, 2002). This spirit of argued above that the coping literature has not shown a struggling to alter an aversive event or one’s reaction to reliable picture of what the chronic pain sufferer is to do an aversive event is a dominant theme in the literature to function well in the context of chronic pain. The regarding coping with pain. Indeed, Aldrich et al. (2000) literature regarding acceptance of chronic pain on the have argued that some chronic pain patients can be other hand has a short but reliable record demonstrating characterized by the extent to which they persevere with its potential for guiding useful behavior change efforts. often unsuccessful attempts at controlling a fundamentally The acceptance approach has the added advantage of uncontrollable experience where control means analgesia. beingunalignedwithanagendatochangepatient McCracken (1998) suggested that such attempts to control experiences that are notoriously difficult to change. pain, in some cases, might be considered within a Based on these considerations we predicted that, in behavioral frame as forms of avoidance. Repeated comparison to coping, acceptance would demonstrate frustrating and damaging attempts to control private larger and more reliable relationships with indices of aversive events, like pain, can lead to exacerbated adjustment to chronic pain. L.M. McCracken, C. Eccleston / Pain 105 (2003) 197–204 199

2. Method internal consistency and concurrent validity (Rosenstiel and Keefe, 1983). 2.1. Participants 2.2.3. Depression Participants were 230 consecutive patients with chronic The Beck depression inventory (BDI; Beck et al., 1961) pain seeking treatment from a university pain management is a 21-item self-report measure assessing cognitive, center. The mean age of the sample was 46.4 ðsd ¼ 14:0Þ. behavioral, and physical symptoms of depression. Research Most were women (66.5%), married (56.1%; 20.4% single, evaluating the psychometric properties of the BDI has 15.7% divorced, 7.8% widowed), and Caucasian (80.4%; indicated that scores from this inventory are reliable and 17.0% Black, 1.7% Hispanic, 0.9% Asian). Average valid indices of depression (Beck et al., 1988). education was 14.0 years (sd ¼ 2:5; 90.9% $12 years). Most patients reported back pain (57.6%; 14.0% lower 2.2.4. Disability limbs, 7.0% cervical, 6.6% upper limbs, 5.7% thoracic, The sickness impact profile (SIP; Bergner et al., 1981)is 4.8% head or face, 4.3% other). The median duration of pain a 136-item measure of disability. The items assess the effect was 32.5 months (range 3–372). All patients completed a of illness on 12 categories of daily activity. Subjects endorse demographic questionnaire, a 100 mm visual analogue pain statements that describe current problems with functioning measure, reported on average daily uptime and work status, related to their health. The SIP provides an overall score as and completed the measures described below during their well as separate scores for physical, psychosocial, and other initial evaluation. dimensions. Research has shown that the SIP has satisfac- tory internal consistency, temporal stability, and validity 2.2. Measures (Bergner et al., 1981).

2.2.1. Acceptance of chronic pain 2.2.5. Pain-related anxiety The chronic pain acceptance questionnaire (CPAQ; The pain anxiety symptoms scale (PASS; McCracken Geiser, 1992) is a 34-item inventory designed to measure et al., 1992) assesses anxiety and fear responses associated acceptance of pain. All items of the CPAQ are rated on a 0 with chronic pain. It consists of four 10-item subscales (never true) to 6 (always true) scale. The original items were measuring: (a) cognitive anxiety responses, (b) escape and rationally derived to assess responses that entail acceptance avoidance, (c) fearful thinking, and (d) physiological of pain. Sample items include “3. It’s OK to experience anxiety responses. All items are rated on a frequency pain” and “6. It’s not necessary for me to control my pain in scale from 0 (never) to 5 (always). The PASS subscales have order to handle my life well”. Twenty-four of the 34 items demonstrated satisfactory internal consistency, temporal are summed to calculate the total score. The CPAQ items stability, and validity (McCracken and Gross, 1995). achieved a reliability coefficient of a ¼ 0:85 (Geiser, 1992). Data from several studies show that the total score from the CPAQ is correlated with standardized measures of 3. Results emotional distress and daily function supporting its validity as a measure of acceptance (Geiser, 1992; McCracken, Results from correlation analyses of acceptance, coping 1998; McCracken et al., 1999). scores, and measures of pain and functioning are shown in Table 1. Acceptance was not highly associated with the 2.2.2. Coping coping scores. There were small positive correlations The CSQ (Rosenstiel and Keefe, 1983) is a 42-item between acceptance and coping self-statements and ignor- measure of six strategies for coping with pain. The strategies ing and a small negative correlation with praying and include diverting attention, reinterpreting pain sensations, hoping. coping self-statements, ignoring pain sensations, praying, The results in Table 1 show that acceptance was and hoping, and increasing behavioral activity. Patients rate significantly correlated with each of the seven measures of each item by indicating how often they use that strategy to pain and daily functioning. The average magnitude of the cope with pain. The CSQ also assesses catastrophizing. We correlations was r ¼ 0:47. Greater acceptance of chronic have shown elsewhere that catastrophizing is distinct from pain was associated with less pain, disability, depression measures of coping, showing instead much stronger and pain-related anxiety, higher daily uptime, and better correlations with pain-related anxiety (McCracken and work status. Twenty-one of 42 of the correlations between Gross, 1993). For purposes of this study we examined the the coping scores and the pain and functioning variables six coping strategies from the CSQ excluding the catastro- reached standard significance levels ðp , 0:05Þ.The phizing scale. Others have adopted the strategy of examin- average magnitude of the significant correlations was ing catastrophizing separately from coping measures r ¼ 0:25. Diverting attention and praying and hoping were (Haythornthwaite et al., 1998; Turner et al., 2000; Jensen consistently associated with greater pain, disability, et al., 2001). The CSQ has demonstrated satisfactory depression, and pain-related anxiety, less uptime, and 200 L.M. McCracken, C. Eccleston / Pain 105 (2003) 197–204

Table 1 Correlations of acceptance, catastrophizing, and coping scales with pain, disability, work status, depression, and pain-related anxiety ðN ¼ 230Þ

Acceptance Pain Physical disability Psychosocial disability Uptime Work status Depression Pain-related anxiety

Acceptance 20.26*** 20.44*** 20.52*** 0.38*** 0.37*** 20.61*** 20.70*** Coping sales Diverting attention 20.13 0.34*** 0.29*** 0.20** 20.14* 20.20** 0.20** 0.29*** Reinterpreting pain 0.05 0.19** 0.21** 0.20** 0.00 20.08 0.12 0.09 Coping self-statements 0.30*** 0.09 20.02 20.09 0.13 0.07 20.14* 20.10 Ignoring pain 0.31*** 20.03 0.05 20.04 0.14 0.08 20.12 20.15* Praying and hoping 20.32*** 0.43*** 0.40*** 0.21** 20.21** 20.22** 0.23*** 0.42*** Increasing activity 0.03 0.16* 0.19** 0.04 20.02 20.11 0.06 0.11

*p , 0:05, **p , 0:01, ***p , 0:001. Note: Pain was assessed with a 100 mm visual analog scale, disability with the SIP, work status is coded 0 ¼ not working due to pain, 1 ¼ working or other, depression was assessed with the BDI, and pain-related anxiety was assessed with the PASS. worse work status. There were just two correlations showing Table 3 shows the results of the regression analyses when a possible positive influence of coping on patient function- the order of entry is reversed. Once again acceptance ing, a negative correlation between coping self-statements significantly contributed to each of the seven equations. In and depression and a negative correlation between ignoring pain and pain-related anxiety. Table 2 We next conducted two sets of regression analyses. In Hierarchical regression analyses examining prediction of pain, disability, functioning, and distress with acceptance of pain after controlling for these analyses we examined the relative contributions of coping variables. acceptance and coping to the prediction of pain, physical, and psychosocial disability, uptime, work status, depres- Step Predictor b (At entry) DR 2 p , R 2 sion, and pain-related anxiety. In the first set of analyses the coping variables were tested for entry and retention Pain : : 1 Praying and hoping 0.33 0.18 0.000 0.18 based on statistical criteria (p , 0 05 to enter, p . 0 10 to 2 Acceptance 20.13 0.016 0.05 0.20 remove). After the coping variables were selected the Physical disability acceptance score was entered in the final step. This allowed 1 Praying and hoping 0.37 0.13 0.000 for testing of the contribution of acceptance to the criterion 2 Coping self-statements 20.20 0.033 0.01 variables after all significant coping variables were taken 3 Reinterpreting pain 0.16 0.021 0.05 0.19 4 Acceptance 20.35 0.084 0.000 0.27 into account. In the second set of regression analyses the Psychosocial disability order of entry of variables was reversed, first acceptance 1 Praying and hoping 0.23 0.054 0.001 was entered and then the contribution of the coping 2 Coping self-statements 20.23 0.045 0.001 variables was tested after that. 3 Reinterpreting pain 0.21 0.035 0.01 0.13 Table 2 shows the results of the first set of regression 4 Acceptance 20.51 0.18 0.001 0.31 Uptime analyses. Praying and hoping showed significant contri- 1 Praying and hoping 20.21 0.044 0.01 butions to each of the seven regression equations. Coping 2 Coping self-statement 0.25 0.052 0.001 0.096 self-statements made significant contributions to six of the 3 Acceptance 0.31 0.064 0.001 0.16 seven, reinterpreting pain contributed to three, and Work status diverting attention to one. In general, praying and hoping 1 Praying and hoping 20.22 0.049 0.01 2 Coping self-statements 0.19 0.030 0.05 0.079 and reinterpreting pain predicted greater pain, disability, 3 Acceptance 0.32 0.069 0.001 0.015 and distress. Coping self-statements predicted less dis- Depression ability and distress. Diverting attention predicted greater 1 Praying and hoping 0.23 0.054 0.001 pain-related anxiety. Acceptance significantly contributed 2 Coping self-statements 20.27 0.060 0.001 to each of the seven equations, predicting less pain, 3 Reinterpreting pain 0.17 0.024 0.05 0.13 4 Acceptance 20.61 0.25 0.001 0.38 disability, and distress. The sums of variance increments Pain-related anxiety attributed to all selected coping variables ranged from 9.6 1 Praying and hoping 0.42 0.17 0.001 to 26%. The variance increments for acceptance ranged 2 Coping self-statements 20.31 0.081 0.001 from 1.6 to 26%. In two instances, in the prediction of 3 Diverting attention 0.17 0.017 0.05 0.26 depression and psychosocial disability, the variance 4 Acceptance 20.62 0.26 0.001 0.53 accounted for by acceptance was larger than the increment Note: Pain was assessed with a 100 mm visual analog scale, disability contributed by the selected set of coping variables. In the with the SIP, work status is coded 0 ¼ not working due to pain, case of pain-related anxiety coping and acceptance 1 ¼ working or other, depression was assessed with the BDI, and pain- related anxiety was assessed with the PASS. In these analyses the six accounted for equal increments. Across the seven equations coping scale scores were tested for entry ðp , 0:05Þ and removal ðp . the average variance contributed by coping and acceptance 0:10Þ on initial steps based on statistical criteria. After coping scores were 15 and 13%, respectively. meeting criteria were selected, the acceptance score was entered. L.M. McCracken, C. Eccleston / Pain 105 (2003) 197–204 201

Table 3 the variance explained, independently of coping, on all of Hierarchical regression analyses examining prediction of pain, disability, the outcomes, with variance increments averaging 13% functioning, and distress with coping variables after controlling for (compared to 15% for coping). When the model was acceptance of pain. reversed many of the coping effects fell away and accept- Step Predictor b (At entry) DR 2 p , R 2 ance continued to independently predict outcome on all adjustment measures with variance increments averaging Pain 24% (compared to 4.6% for coping). The regression results 1 Acceptance 20.26 0.066 0.001 are persuasive because acceptance was modeled as a single 2 Praying and hoping 0.39 0.13 0.001 0.20 Physical disability variable and coping was tested as a group of six variables, 1 Acceptance 20.44 0.20 0.001 any combination of which could have been selected as the 2 Praying and hoping 0.25 0.056 0.001 best predictor of the criterion variable. These results suggest 3 Reinterpreting pain 0.14 0.017 0.05 0.27 that acceptance may have more utility than coping for Psychosocial disability understanding adjustment to chronic pain. 1 Acceptance 20.52 0.27 0.001 2 Reinterpreting pain 0.19 0.036 0.001 0.30 Coping and acceptance were not highly associated with Uptime one another; only modest associations between acceptance 1 Acceptance 0.38 0.15 0.001 0.15 and a subset of coping strategies were found. It is interesting Work status that acceptance of pain is not related to diverting attention or 1 Acceptance 0.37 0.14 0.001 reinterpreting pain, is only minimally related to ignoring 2 Diverting attention 20.15 0.022 0.05 0.16 Depression pain, and is negatively related to praying and hoping. 1 Acceptance 20.61 0.37 0.001 Acceptance then is not a simple function of distraction, 2 Reinterpreting pain 0.15 0.022 0.01 0.39 thinking of the pain in other terms, or passively hoping for it Pain-related anxiety to be better. It is also not the same as ignoring or positive 1 Acceptance 20.70 0.49 0.001 thinking. Acceptance is not captured by current concep- 2 Praying and hoping 0.22 0.041 0.001 0.53 tualizations of coping with pain; its addition to our theories Note: Pain was assessed with a 100 mm visual analog scale, disability and models of how patients adapt to chronic pain may with the SIP, work status is coded 0 ¼ not working due to pain, improve our understanding of this process. 1 ¼ working or other, depression was assessed with the BDI, and pain- Coping, we have argued, is often (though not always) related anxiety was assessed with the PASS. In these analyses the acceptance of pain score was entered in the first step. The six coping scale operationalized as a set of strategies to control an aversive scores were tested for entry ðp , 0:05Þ and removal ðp . 0:10Þ on experience or one’s reaction to an aversive experience. We subsequent steps based on statistical criteria. would contend that when attempts at control over pain are successful they may give the pain sufferer beneficial results each case acceptance predicted less pain, disability, or at minimal cost, including emotional and opportunity costs. distress. Praying and hoping significantly contributed to Conversely, when attempts at controlling pain fail, and fail three equations; reinterpreting pain contributed significantly repeatedly, they may bring discouragement, frustration, to three and diverting attention to one. In each case the risks of exacerbating the problem, and missed opportunity coping variables predicted greater pain, disability, or for better results. distress. The variance contributed by acceptance ranged Attempts at control in uncontrollable situations can have from 6.6 to 49%. The variance contributed by the coping a significantly negative impact on adjustment to chronic variables ranged from 0 to 13%. In the equation for pain health problems (Christensen et al., 1995; Eitel et al., 1995). praying and hoping accounted for more variance then In terms of pain it has been demonstrated that when healthy acceptance. In all other equations the contribution of subjects try not to experience experimentally induced pain, acceptance was larger than the contribution of the selected they have delayed recovery after pain exposure (Cioffi and coping variables. Across the seven equations the average Holloway, 1993). No experimental study has yet been variance contributed by acceptance was 24% while the performed on the effect that failure to control pain has on average variance contributed by coping was 4.6%. suffering. However, failure more generally has been shown to adversely affect pain report and pain tolerance in healthy volunteers (Levine et al., 1993; Van den Hout et al., 2000). 4. Discussion The relationship between acceptance and control of chronic pain may be complex. The target for control This study showed that greater acceptance of chronic attempts may be crucial. Tan et al. (2002) showed that pain was associated with less pain, disability, depression, perceived control over effects of pain or life in general are and pain-related anxiety, higher daily uptime, and better more important correlates of functioning than perceptions of work status. Diverting attention and praying and hoping control over pain itself. Adopting a more accepting stance were consistently associated with greater pain and less concerning pain may lead chronic pain sufferers to a higher healthy functioning. Regression analyses revealed that in sense of general self-control (Jacob et al., 1993). In addition, the first and more conservative model acceptance added to chronic pain sufferers report increased acceptance of pain 202 L.M. McCracken, C. Eccleston / Pain 105 (2003) 197–204 following a treatment designed to enhance control over pain and Gifford, 1997; McCracken, in press). Second, further (Geiser, 1992). A patient’s wider context of experience may evidence is needed concerning the types of experimental influence the issue of pain control. Patients with chronic and clinical interventions that produce acceptance of pain who are told that they have failed a test of empathy are chronic pain. Third, it will be important to clarify notions more confronting of a pain inducing stimulus (Van den Hout of acceptance of chronic pain in relation to results from the et al., 2001), contrary to the expectation that an induced increasing number of studies on fear and avoidance of pain experience of failure would carry over to greater avoidance (see the study by Vlaeyen and Linton, 2000 for a review). of pain-related activity. Recent studies show that reduction of fear and avoidance In need of further discussion is our decision to may be the critical treatment process in explaining the deliberately exclude catastrophizing as a variable from our success of combined physical and behavioral rehabilitation analysis, even though it was available from one of the programs for chronic pain (McCracken and Gross, 1998; subscales of the CSQ. We adopted the view that cata- McCracken et al., 2002). It is obvious that fear, avoidance, strophizing is not best conceptualized as a coping strategy. and acceptance are highly interrelated. Studies demonstrate Catastrophizing is, of course, highly correlated with various that exposure-based treatment methods for pain-related fear measures of patient functioning and treatment outcome (see and avoidance can indeed lead to improvements in func- the work of Sullivan et al., 2001 for a review). However, its tional outcomes (Vlaeyen et al., 2001). This same type of remarkable predictive power is insufficient evidence for its exposure would be expected to enhance acceptance of pain. role as a coping strategy. In previous research we found a These results have some limitations that should be con- high correlation between catastrophizing and fear of pain sidered. First, our methods are correlational and cannot be (McCracken and Gross, 1993) and have suggested that used to unambiguously infer causal relationships. Addi- catastrophic thinking about pain is better considered as a tional research should compare acceptance and coping class of emotional distress responses rather than as a coping methods in experimental pain situations (Hayes et al., 1999) strategy. Indeed we have argued that it is best conceptual- or with alternative treatment designs (Geiser, 1992). ized as an extreme instantiation of worry about pain Second, we sampled the domain of coping with the contents (Eccleston et al., 2001). Others have similarly argued that of just one inventory, the CSQ. Other inventories exist catastrophizing is different from coping, sharing more that conceptualize pain coping strategies in different ways. content overlap with constructs related to depression Third, the patients who participated in this study were and anxiety, and suggested examining it separately seeking treatment in a specialty pain management facility (Haythornthwaite and Heinberg, 1999; Thorn et al., 1999; and had not yet received behavioral interventions. Results Turner et al., 2000; Turner and Aaron, 2001). Admittedly from these patients may not generalize to non-treatment- there is an ongoing debate about the status of catastrophiz- seekers, or patients at post-treatment. ing as a coping response (see the work of Sullivan et al., As with any psychological framework applied to pain, 2001 for a review of this issue). results such as these have the potential to mislead. We do It may be interesting to speculate about a relationship not intend to imply that there exists a single type of behavior between acceptance and catastrophizing. Catastrophizing is problem responsible for all maladjustment to chronic pain. normally defined as an automatic, unpleasant, magnifica- We do not intend acceptance to be the new model for all tory, and unrealistic interpretation of feared future events. In adjustment to chronic pain, although a broader view of comparison, acceptance is normally defined as a deliberate, patient behavior that includes acceptance will have advan- realistic, openness to immediate experience. Both accept- tages. It may be very important for some patients, minimally ance and catastrophizing include an acknowledgement that important for others, and of no importance to the remainder; pain will continue; however, in catastrophic thinking this that will depend on their unique history and circumstances, is characterized with a sense of helplessness, whereas in and remains to be seen. acceptance this acknowledgement is neutrally framed as a There is significant potential in the development of willingness to live with pain. This speculation deserves acceptance-based interventions for living with chronic pain. empirical attention. It may be that acceptance of chronic The clinical reality of chronic pain is that quickly after a pain and catastrophic thinking about chronic pain are intri- diagnosis of chronic pain the patient will be introduced to cately linked. An untested hypothesis is that enhanced the idea that he or she must ‘learn to live with pain’, or acceptance of pain may be the means to reduce the fre- ‘learn to manage pain’. Patients may ignore this advice and quency, unpleasantness, or impact of catastrophic thoughts carry on seeking a cure. They may interpret this to mean about pain. We plan further study focused on catastrophiz- engagement in a battle or struggle for control with an ing in the future. aversive, disabling aggressor. Treatment methods to disen- A clinically useful model of acceptance of chronic pain gage or distance them from that struggle may be effective will need empirical evidence for some of its basic tenets. and are a promising area for development. Acceptance- First, studies of the relationship between avoidance, langu- based interventions, or procedures based on similar age, and acceptance need to be extended into the field of principles, have shown significant promise for treatment chronic pain (Dougher, 1998; Hayes et al., 1999; Hayes of anxiety (McMain et al., 2001), depression (Dougher, L.M. McCracken, C. Eccleston / Pain 105 (2003) 197–204 203

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