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.