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Coping with pain: conceptual concerns and future directions
Pain, Sl(1992) 131-134 0 1992 Elsevier Science
131 Publishers
B.V. All rights reserved
0304-3959/92/$05.00
PAIN 02117
Guest Editorial Coping with pain: conceptual concerns and future directions Francis J. Keefe a*h,Alfred N. Salley, Jr. a and John C. Lefebvre ’ Duke University Medico1 Center and h Duke lJnic,ersiry. Durhum. NC (USA) (Received
and accepted
Introduction
In a recent issue of Pain, Jensen et al. (1991) a review of the literature on coping with chronic pain. Their review was important in several respects. First, it provided a timely and comprehensive overview that not only addressed pain coping research but also considered research on other cognitive variables (e.g., locus of control, self-efficacy, attributional styles, expectancies) that are essential to an understanding of coping processes. Second, Jensen et al. highlighted strengths and weaknesses of pain coping strategy measures that need to be considered in interpreting findings from past research. Finally, their review identified a number of gaps in research that need to be addressed by future investigators. Although Jensen et al.‘s review makes a strong contribution to the pain literature, several fundamental concerns need to be addressed. These can be divided into three basic groups: conceptual concerns, specific concerns regarding literature on the Coping Strategies Questionnaire (Rosenstiel and Keefe 1983) and future research directions. presented
Conceptual
concerns
Jensen et al. define coping as “purposeful effort to manage or vitiate the negative impact of stress”. In talking about coping in chronic pain patients, however, one needs to answer a question posed by Wilbert Fordyce in reaction to a workshop featuring pain coping measures: “Coping with what?” (Fordyce 1991).
Correspondence 10: F.J. Keefc, gram. Box 3159. Duke University 27710. USA.
Ph.D., Pain Management Medical Center, Durham,
ProNC
h
24 April 1992)
One might expect that the pain experience is the primary stressor with which chronic pain patients must cope. In most patients, however, multiple stressors (e.g., loss of income, confinement, marital discord) arc present and different sources of stress interact. It is often difficult, if not impossible, to determine whether pain or lifestyle changes are the most salient source of stress. Questionnaires currently used to study coping in chronic pain patients have taken two approaches to the problem of defining the source of stress. First, some questionnaires such as the Coping Strategies Questionnaire (CSQ) and Vanderbilt Pain Management Inventory (Brown and Nicassio 1987) are specifically designed to assess coping strategies used to manage pain. Second, other questionnaires such as the Ways of Coping Checklist (Folkman and Lazarus 1980) assess coping strategies used to cope with a self-defined stressor. One problem with the second type of questionnaire is that the self-defined stressor may differ considerably across patients. Pooling data for different stressors into the same analysis can be quite problematic since coping strategies used to manage one stressor (e.g.. pain) may be quite different from those used to manage other sources of stress. Given these problems. we believe the best research strategy is to specify for the patient the stressor of interest and then ask patients how they cope with this stressor. Using this strategy one can empirically investigate whether the coping strategies of chronic pain patients differ greatly or are quite similar across a number of salient stressors. Another important conceptual problem in the pain coping literature is the labelling of strategies as passive. Some strategies that are typically labelled as passive (e.g., taking medication) require that the patient actively comply with a treatment regimen. In fact, a passive non-compliant approach may render any medication trial ineffective. It is hard to conceive of a truly passive coping strategy in that almost any purposeful strategy requires a decision and effort on the part of the patient.
Jensen et al. note that many coping instruments focus primarily on cognitive strategies. Cognitive strategies are an appealing target for assessment because they: (1) have been studied in experimental research, (2) can be altered through clinical interventions, and (3) appear to relate to measures of pain and adjustment. Jensen et al., however, argue that more attention be given to behavioral coping strategies, e.g., taking medications, resting in bed, etc. The assessment of behavioral coping strategies has certain problems. As one moves from cognitive to behavioral strategies the distinction between coping efforts and outcome becomes much more difficult. What one investigator views as a behavioral coping effort (e.g., resting in bed, taking medications), another investigator is likely to view as an outcome of coping. A focus on behavioral coping increases the likelihood of confounding coping and adjustment measures. One of the most interesting conceptual issues is the role of emotional distress in determining coping responses. Most coping studies have conceptualized emotional adjustment as an outcome rather than a determinant of coping. Given that most coping research has been correlational, studies have not yet fully addressed the temporal relationships between coping and emotional adjustment. Longitudinal studies using path analytic methods may enable investigators to better identify relationships between coping and emotional distress. Personality may play an important role in the choice of coping strategies. Patients whose personality makes them prone to depression may cope with pain differently than patients who do not have this personality disposition. Future research studies need to examine the relationship of personality to pain coping strategies. Future studies also need to determine the unique contributions that coping strategies and personality make to the understanding of pain and adjustment in chronic pain patients. Even if coping measures are found to relate to personality dispositions, assessments of coping may still prove useful. A focus on coping provides behavioral clinicians with immediate targets for assessment and intervention efforts. Chronic pain patients who are reluctant to complete personality questionnaires are often quite willing to complete coping inventories. Although these patients may not readily admit feeling depressed or anxious, they may be open to discussing how they cope with pain and willing to learn new ways of cognitively and behaviorally managing pain. Coping Strategies
Questionnaire
research
Jensen et al. highlight several weaknesses of research studies using the CSQ. Although their criticisms of a number of studies are appropriate, their critical
comments need to be balanced by pointing out some of the positive features of CSQ studies. One major strength of studies using the CSQ is that they have attempted to document and control for disease severity before analyzing the contribution of coping variables. For example, in our research on osteoarthritis, we have assessed disease severity using X-rays of knee joints and controlled for the effects of disease severity in predictive analyses (Keefe et al. 1987a, b). A concern for the effects of disease severity is often lacking in studies of psychological variables (e.g., stress, coping) carried out in medical patients. The fact that CSQ coping measures explain a significant proportion of variance in measures of adjustment after controlling for disease severity is noteworthy. Along the same lines, with very few exceptions (Keefe and Williams l990), studies using the CSQ have controlled for background variables that might explain adjustment. These background variables have not only included demographics (age, sex) but also variables that behavioral researchers consider quite important (e.g., disability compensation status, chronicity of pain). Some CSQ studies have even controlled for pain level in evaluating the effects of coping on adjustment (e.g., Keefe et al. 1987b). Researchers using the CSQ have entered demographic and behavioral variables into the regression model first. Thus, the effects of CSQ coping variables have been examined only after controlling for effects due to other significant background variables. This data analysis strategy is a conservative one that may actually underestimate the percentage of variance that can by explained by coping variables. It is quite likely that coping variables would explain a much larger proportion of variance in adjustment if they were allowed to compete directly with other variables for order of entry into a regression model. We are currently testing out this possibility in our own research lab. A final point that needs to be highlighted regards the purpose of the CSQ. The CSQ was originally designed to measure: (1) the frequency that patients use a variety of cognitive and behavioral coping skills and (2) the perceived effectiveness of these skills in controlling and decreasing pain. We agree with Jensen et al. that many researchers using the CSQ discuss their results simply in terms of the frequency of coping strategies and fail to distinguish between measures of coping frequency and ratings of perceived effectiveness. Frankly, we can take some of the blame for this tendency since we have often entered CSQ scales measuring coping frequency together with the effectiveness ratings into principal components analyses. As Jensen et al. and Zautra and Manne (in press) note, it makes more sense conceptually to separate the analysis of measures of coping frequency from the analysis of ratings of coping effectiveness.
133
Future directions
Jensen et al. conclude, on the basis of their review, that additional research on coping is warranted. Several of the future research directions they mention are the subject of current research efforts. For example, the need for true experimental tests of coping skills interventions has been addressed by recent studies that have directly attempted to alter coping or self-efficacy and compared this approach to plausible control interventions. We recently conducted a randomized, controlled study designed to determine whether a cognitive-behavioral intervention designed to improve pain coping skills could reduce pain, physical disability and psychological disability, and pain behavior in osteoarthritic knee pain patients (Keefe et al. 1990). This study found that patients receiving pain coping skills training had significantly lower levels of pain and psychological disability post-treatment than patients receiving arthritis education. Patients in the pain coping skills training group who reported increases in the perceived effectiveness of their coping strategies were much more likely to have lower levels of physical disability post-treatment. We are currently conducting a similar experimental test of a pain coping skills intervention in rheumatoid arthritis patients having persistent pain following knee replacement surgery. Jensen et al. also call for further research examining moderating factors that may be important in understanding coping. Previous studies have failed to identify many age-related differences in coping strategies (Rosenstiel and Keefe 1983; Keefe and Williams 1990). Although other potential moderating variables such as gender, pain duration, and disease severity have received considerable research attention, they typically explain a very modest or non-significant proportion of variance when compared to coping variables. Recent research suggests that pain severity may be an important moderating variable (Jensen and Karoly 19911, and future investigations need to consider thisvariable when testing the effects of coping on adjustment. Research also suggests that there are differences in the use of pain coping strategies across pain diagnostic groups (Keefe et al. 1991) and the influence of patient diagnosis on coping deserves further investigation. One of the most important future directions for pain coping research is examining the social context of coping. Zautra and Manne (in press) maintain that the behavior of significant others may determine the choice of coping strategies. Manne and Zautra (1989) found that patients whose spouses are critical may be more likely to employ maladaptive coping strategies such as wishful thinking, while those whose spouses are more supportive tend to employ more adaptive problemfocussed coping strategies. We are currently conducting a study designed to determine whether spouses of
arthritis patients can be taught to prompt and reinforce adaptive pain coping skills. As part of this study we are assessing spouses’ expectations about coping skills training and their beliefs about patients’ efficacy in managing pain. Future studies of coping need to consider the effects that spouses’ pain coping styles and beliefs may have on patients’ coping efforts. Most clinical studies of coping have focussed on questionnaire measures. New methodologies may provide a more definitive test of the importance of coping variables in chronic pain. Intensive daily diary methods similar to those used by Affleck et al. (1992) in studies of pain-mood relationships in rheumatoid arthritis could be extended to analyze the relation of coping to pain and adjustment in chronic pain patients. The diary methods used by Affleck et al. feature systematic training in diary recording, frequent checks on compliance with recording, and sophisticated methods to control for autocorrelation. Psychophysical methods for testing pain perception (Heft et al. 1980; Price et al. 1986) could be applied much more widely in the study of coping in patients having chronic pain. Thermal pain stimulation, for example, can provide a controlled nociceptive stimulus against which one can directly compare the effects of different coping skills interventions. Psychophysical laboratory methods could be applied with individual patients early in the course of chronic pain to identify the coping strategies that are most effective in controlling pain. Early recognition of effective pain coping strategies could be useful in planning treatment interventions for patients likely to have persistent pain. Jensen et al. recommend that researchers make greater use of longitudinal designs to study pain coping skills. Several longitudinal studies have begun to address this area. Gil et al. (1992) examined the degree to which pain coping strategies predicted sickle cell disease patients’ health care use and activity level of 9-month follow-up. Gil et al. found that a coping factor derived from CSQ responses obtained at initial baseline was associated with more frequent health care contacts and activity reduction in the subsequent 9 months. These investigators are currently collecting 18 months of follow-up data in order to determine whether the findings are replicable over this longer time period. Ideally, longitudinal analyses of coping would identify subjects before they have persistent pain, assess their coping strategies and then follow the subjects to determine who developed persistent pain. To date, no studies in the pain coping literature have used this study design. Dworkin et al. (1992), however, have carried out a prospective study demonstrating that psychological factors (state and trait anxiety, depression, life satisfaction, and disease conviction) assessed shortly after the onset of herpes zoster infection predicted the persistence of postherpetic neuralgia. These
134
results are promising and suggest that postherpetic neuralgia may provide a good model in which to examine the longitudinal effects of pain coping strategies.
Conclusion Although the pain coping literature does have some limitations, some promising findings have been obtained. Jensen et al. have done the field a great service by providing a comprehensive and critical review of the coping literature. We believe that the time has come for a second generation of studies on pain coping. The next generation of studies, informed by the successes and mistakes of earlier research, is likely to further advance our understanding of the complex process of coping with chronic pain.
References Affleck, G., Tennen, H., &rows, S. and Higgins, P., Neuroticism and the pain-mood relation in rheumatoid arthritis: insights from a prospective daily study, J. Consult. Clin. Psychol., 60 (1992) 119-126. Brown, G.K. and Nicassio, P.M., The development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients, Pain, 31 (1987) 53-65. Dworkin, R.H., Hartstein, G., Rosner, H.L., Walther, R.R., Sweeney, E.W. and Brand, L., A high-risk method for studying psychosocial antecedents of chronic pain: the prospective investigation of herpes zoster, J. Abnorm. Psychol., 101 (1992) 200-205. Folkman, S. and Lazarus, R.S., An analysis of coping in a middle-aged community sample, J. Hlth Sot. Behav., 21 (1980) 219-231. Fordyce, W., Personal communication, 1991. Gil, K.M., Abrams, M.R., Phillips, G. and Williams, D.A., Sickle cell disease pain-2: predicting health care use and activity level at
nine-month follow-up, J. Consult. Clin. Psychol., 60 (1992) 267273. Heft, M.W., Gracely, R.H., Dubner, R. and McGrath, P.A., A validation model for verbal descriptor scaling of human clinical pain, Pain, 9 (1980) 363-373. Jensen, M.P. and Karoly, P., Control beliefs, coping efforts, and adjustment to chronic pain, J. Consult. Clin. Psychol., 59 (1991) 431-438. Jensen, M.P., Turner, J.A., Romano, J.M. and Karoly, P., Coping with chronic pain: a critical review of the literature, Pain, 47 (1991) 249-283. Keefe, F.J. and Williams, D.A., A comparison of coping strategies in chronic pain patients in different age groups, J. Gerontol., 45 (1990) 161-165. Keefe, F.J., Caldwell, D.S., Queen, K.T., Gil, K.M., Martinez, S., Crisson, J.E., Ogden, W. and Nunley, J., Osteoarthritic knee pain: a behavioral analysis, Pain, 28 (1987a) 309-321. Keefe, F.J., Caldwell, D.S., Queen, K.T., Gil, K.M., Martinez, S., Crisson, J.E., Ogden, W. and Nunley, J., Pain coping strategies in osteoarthritis patients, J. Consult. Clin. Psychol., 55 (1987b) 208212. Keefe, F.J., Caldwell, D.S., Williams, D.A., Gil, K.M., Mitchell, D., Martinez, S., Nunley, J., Beckham, J.C., Crisson, J.E. and Helms, M., Pain coping skills training in the management of osteoarthritic knee pain: a comparative study, Behav. Ther., 21 (1990) 49-62. Keefe, F.J., Caldwell, D.S., Martinez, S., Nunley, J., Beckham, J. and Williams, D.A., Analyzing pain in rheumatoid arthritis patients: pain coping strategies in patients who have had knee replacement surgery, Pain, 49 (1991) 153-160. Manne, S.L. and Zautra, A.J., Couples coping with chronic illness: women with rheumatoid arthritis and their healthy husbands, J. Behav. Med., 13 (1990) 327-342. Price, D.D., Harkins, SW., Rafii, A. and Price, C., A simultaneous comparison of fentanyl’s analgesic effects on clinical and experimental pain, Pain, 24 (1984) 197-203. Rosenstiel, A.R. and Keefe, F.J., The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment, Pain, 17 (1983) 33-44. Zautra, A. and Manne, S., Coping with rheumatoid arthritis: a review of a decade of research, Ann. Behav. Med., in press.
131 Publishers
B.V. All rights reserved
0304-3959/92/$05.00
PAIN 02117
Guest Editorial Coping with pain: conceptual concerns and future directions Francis J. Keefe a*h,Alfred N. Salley, Jr. a and John C. Lefebvre ’ Duke University Medico1 Center and h Duke lJnic,ersiry. Durhum. NC (USA) (Received
and accepted
Introduction
In a recent issue of Pain, Jensen et al. (1991) a review of the literature on coping with chronic pain. Their review was important in several respects. First, it provided a timely and comprehensive overview that not only addressed pain coping research but also considered research on other cognitive variables (e.g., locus of control, self-efficacy, attributional styles, expectancies) that are essential to an understanding of coping processes. Second, Jensen et al. highlighted strengths and weaknesses of pain coping strategy measures that need to be considered in interpreting findings from past research. Finally, their review identified a number of gaps in research that need to be addressed by future investigators. Although Jensen et al.‘s review makes a strong contribution to the pain literature, several fundamental concerns need to be addressed. These can be divided into three basic groups: conceptual concerns, specific concerns regarding literature on the Coping Strategies Questionnaire (Rosenstiel and Keefe 1983) and future research directions. presented
Conceptual
concerns
Jensen et al. define coping as “purposeful effort to manage or vitiate the negative impact of stress”. In talking about coping in chronic pain patients, however, one needs to answer a question posed by Wilbert Fordyce in reaction to a workshop featuring pain coping measures: “Coping with what?” (Fordyce 1991).
Correspondence 10: F.J. Keefc, gram. Box 3159. Duke University 27710. USA.
Ph.D., Pain Management Medical Center, Durham,
ProNC
h
24 April 1992)
One might expect that the pain experience is the primary stressor with which chronic pain patients must cope. In most patients, however, multiple stressors (e.g., loss of income, confinement, marital discord) arc present and different sources of stress interact. It is often difficult, if not impossible, to determine whether pain or lifestyle changes are the most salient source of stress. Questionnaires currently used to study coping in chronic pain patients have taken two approaches to the problem of defining the source of stress. First, some questionnaires such as the Coping Strategies Questionnaire (CSQ) and Vanderbilt Pain Management Inventory (Brown and Nicassio 1987) are specifically designed to assess coping strategies used to manage pain. Second, other questionnaires such as the Ways of Coping Checklist (Folkman and Lazarus 1980) assess coping strategies used to cope with a self-defined stressor. One problem with the second type of questionnaire is that the self-defined stressor may differ considerably across patients. Pooling data for different stressors into the same analysis can be quite problematic since coping strategies used to manage one stressor (e.g.. pain) may be quite different from those used to manage other sources of stress. Given these problems. we believe the best research strategy is to specify for the patient the stressor of interest and then ask patients how they cope with this stressor. Using this strategy one can empirically investigate whether the coping strategies of chronic pain patients differ greatly or are quite similar across a number of salient stressors. Another important conceptual problem in the pain coping literature is the labelling of strategies as passive. Some strategies that are typically labelled as passive (e.g., taking medication) require that the patient actively comply with a treatment regimen. In fact, a passive non-compliant approach may render any medication trial ineffective. It is hard to conceive of a truly passive coping strategy in that almost any purposeful strategy requires a decision and effort on the part of the patient.
Jensen et al. note that many coping instruments focus primarily on cognitive strategies. Cognitive strategies are an appealing target for assessment because they: (1) have been studied in experimental research, (2) can be altered through clinical interventions, and (3) appear to relate to measures of pain and adjustment. Jensen et al., however, argue that more attention be given to behavioral coping strategies, e.g., taking medications, resting in bed, etc. The assessment of behavioral coping strategies has certain problems. As one moves from cognitive to behavioral strategies the distinction between coping efforts and outcome becomes much more difficult. What one investigator views as a behavioral coping effort (e.g., resting in bed, taking medications), another investigator is likely to view as an outcome of coping. A focus on behavioral coping increases the likelihood of confounding coping and adjustment measures. One of the most interesting conceptual issues is the role of emotional distress in determining coping responses. Most coping studies have conceptualized emotional adjustment as an outcome rather than a determinant of coping. Given that most coping research has been correlational, studies have not yet fully addressed the temporal relationships between coping and emotional adjustment. Longitudinal studies using path analytic methods may enable investigators to better identify relationships between coping and emotional distress. Personality may play an important role in the choice of coping strategies. Patients whose personality makes them prone to depression may cope with pain differently than patients who do not have this personality disposition. Future research studies need to examine the relationship of personality to pain coping strategies. Future studies also need to determine the unique contributions that coping strategies and personality make to the understanding of pain and adjustment in chronic pain patients. Even if coping measures are found to relate to personality dispositions, assessments of coping may still prove useful. A focus on coping provides behavioral clinicians with immediate targets for assessment and intervention efforts. Chronic pain patients who are reluctant to complete personality questionnaires are often quite willing to complete coping inventories. Although these patients may not readily admit feeling depressed or anxious, they may be open to discussing how they cope with pain and willing to learn new ways of cognitively and behaviorally managing pain. Coping Strategies
Questionnaire
research
Jensen et al. highlight several weaknesses of research studies using the CSQ. Although their criticisms of a number of studies are appropriate, their critical
comments need to be balanced by pointing out some of the positive features of CSQ studies. One major strength of studies using the CSQ is that they have attempted to document and control for disease severity before analyzing the contribution of coping variables. For example, in our research on osteoarthritis, we have assessed disease severity using X-rays of knee joints and controlled for the effects of disease severity in predictive analyses (Keefe et al. 1987a, b). A concern for the effects of disease severity is often lacking in studies of psychological variables (e.g., stress, coping) carried out in medical patients. The fact that CSQ coping measures explain a significant proportion of variance in measures of adjustment after controlling for disease severity is noteworthy. Along the same lines, with very few exceptions (Keefe and Williams l990), studies using the CSQ have controlled for background variables that might explain adjustment. These background variables have not only included demographics (age, sex) but also variables that behavioral researchers consider quite important (e.g., disability compensation status, chronicity of pain). Some CSQ studies have even controlled for pain level in evaluating the effects of coping on adjustment (e.g., Keefe et al. 1987b). Researchers using the CSQ have entered demographic and behavioral variables into the regression model first. Thus, the effects of CSQ coping variables have been examined only after controlling for effects due to other significant background variables. This data analysis strategy is a conservative one that may actually underestimate the percentage of variance that can by explained by coping variables. It is quite likely that coping variables would explain a much larger proportion of variance in adjustment if they were allowed to compete directly with other variables for order of entry into a regression model. We are currently testing out this possibility in our own research lab. A final point that needs to be highlighted regards the purpose of the CSQ. The CSQ was originally designed to measure: (1) the frequency that patients use a variety of cognitive and behavioral coping skills and (2) the perceived effectiveness of these skills in controlling and decreasing pain. We agree with Jensen et al. that many researchers using the CSQ discuss their results simply in terms of the frequency of coping strategies and fail to distinguish between measures of coping frequency and ratings of perceived effectiveness. Frankly, we can take some of the blame for this tendency since we have often entered CSQ scales measuring coping frequency together with the effectiveness ratings into principal components analyses. As Jensen et al. and Zautra and Manne (in press) note, it makes more sense conceptually to separate the analysis of measures of coping frequency from the analysis of ratings of coping effectiveness.
133
Future directions
Jensen et al. conclude, on the basis of their review, that additional research on coping is warranted. Several of the future research directions they mention are the subject of current research efforts. For example, the need for true experimental tests of coping skills interventions has been addressed by recent studies that have directly attempted to alter coping or self-efficacy and compared this approach to plausible control interventions. We recently conducted a randomized, controlled study designed to determine whether a cognitive-behavioral intervention designed to improve pain coping skills could reduce pain, physical disability and psychological disability, and pain behavior in osteoarthritic knee pain patients (Keefe et al. 1990). This study found that patients receiving pain coping skills training had significantly lower levels of pain and psychological disability post-treatment than patients receiving arthritis education. Patients in the pain coping skills training group who reported increases in the perceived effectiveness of their coping strategies were much more likely to have lower levels of physical disability post-treatment. We are currently conducting a similar experimental test of a pain coping skills intervention in rheumatoid arthritis patients having persistent pain following knee replacement surgery. Jensen et al. also call for further research examining moderating factors that may be important in understanding coping. Previous studies have failed to identify many age-related differences in coping strategies (Rosenstiel and Keefe 1983; Keefe and Williams 1990). Although other potential moderating variables such as gender, pain duration, and disease severity have received considerable research attention, they typically explain a very modest or non-significant proportion of variance when compared to coping variables. Recent research suggests that pain severity may be an important moderating variable (Jensen and Karoly 19911, and future investigations need to consider thisvariable when testing the effects of coping on adjustment. Research also suggests that there are differences in the use of pain coping strategies across pain diagnostic groups (Keefe et al. 1991) and the influence of patient diagnosis on coping deserves further investigation. One of the most important future directions for pain coping research is examining the social context of coping. Zautra and Manne (in press) maintain that the behavior of significant others may determine the choice of coping strategies. Manne and Zautra (1989) found that patients whose spouses are critical may be more likely to employ maladaptive coping strategies such as wishful thinking, while those whose spouses are more supportive tend to employ more adaptive problemfocussed coping strategies. We are currently conducting a study designed to determine whether spouses of
arthritis patients can be taught to prompt and reinforce adaptive pain coping skills. As part of this study we are assessing spouses’ expectations about coping skills training and their beliefs about patients’ efficacy in managing pain. Future studies of coping need to consider the effects that spouses’ pain coping styles and beliefs may have on patients’ coping efforts. Most clinical studies of coping have focussed on questionnaire measures. New methodologies may provide a more definitive test of the importance of coping variables in chronic pain. Intensive daily diary methods similar to those used by Affleck et al. (1992) in studies of pain-mood relationships in rheumatoid arthritis could be extended to analyze the relation of coping to pain and adjustment in chronic pain patients. The diary methods used by Affleck et al. feature systematic training in diary recording, frequent checks on compliance with recording, and sophisticated methods to control for autocorrelation. Psychophysical methods for testing pain perception (Heft et al. 1980; Price et al. 1986) could be applied much more widely in the study of coping in patients having chronic pain. Thermal pain stimulation, for example, can provide a controlled nociceptive stimulus against which one can directly compare the effects of different coping skills interventions. Psychophysical laboratory methods could be applied with individual patients early in the course of chronic pain to identify the coping strategies that are most effective in controlling pain. Early recognition of effective pain coping strategies could be useful in planning treatment interventions for patients likely to have persistent pain. Jensen et al. recommend that researchers make greater use of longitudinal designs to study pain coping skills. Several longitudinal studies have begun to address this area. Gil et al. (1992) examined the degree to which pain coping strategies predicted sickle cell disease patients’ health care use and activity level of 9-month follow-up. Gil et al. found that a coping factor derived from CSQ responses obtained at initial baseline was associated with more frequent health care contacts and activity reduction in the subsequent 9 months. These investigators are currently collecting 18 months of follow-up data in order to determine whether the findings are replicable over this longer time period. Ideally, longitudinal analyses of coping would identify subjects before they have persistent pain, assess their coping strategies and then follow the subjects to determine who developed persistent pain. To date, no studies in the pain coping literature have used this study design. Dworkin et al. (1992), however, have carried out a prospective study demonstrating that psychological factors (state and trait anxiety, depression, life satisfaction, and disease conviction) assessed shortly after the onset of herpes zoster infection predicted the persistence of postherpetic neuralgia. These
134
results are promising and suggest that postherpetic neuralgia may provide a good model in which to examine the longitudinal effects of pain coping strategies.
Conclusion Although the pain coping literature does have some limitations, some promising findings have been obtained. Jensen et al. have done the field a great service by providing a comprehensive and critical review of the coping literature. We believe that the time has come for a second generation of studies on pain coping. The next generation of studies, informed by the successes and mistakes of earlier research, is likely to further advance our understanding of the complex process of coping with chronic pain.
References Affleck, G., Tennen, H., &rows, S. and Higgins, P., Neuroticism and the pain-mood relation in rheumatoid arthritis: insights from a prospective daily study, J. Consult. Clin. Psychol., 60 (1992) 119-126. Brown, G.K. and Nicassio, P.M., The development of a questionnaire for the assessment of active and passive coping strategies in chronic pain patients, Pain, 31 (1987) 53-65. Dworkin, R.H., Hartstein, G., Rosner, H.L., Walther, R.R., Sweeney, E.W. and Brand, L., A high-risk method for studying psychosocial antecedents of chronic pain: the prospective investigation of herpes zoster, J. Abnorm. Psychol., 101 (1992) 200-205. Folkman, S. and Lazarus, R.S., An analysis of coping in a middle-aged community sample, J. Hlth Sot. Behav., 21 (1980) 219-231. Fordyce, W., Personal communication, 1991. Gil, K.M., Abrams, M.R., Phillips, G. and Williams, D.A., Sickle cell disease pain-2: predicting health care use and activity level at
nine-month follow-up, J. Consult. Clin. Psychol., 60 (1992) 267273. Heft, M.W., Gracely, R.H., Dubner, R. and McGrath, P.A., A validation model for verbal descriptor scaling of human clinical pain, Pain, 9 (1980) 363-373. Jensen, M.P. and Karoly, P., Control beliefs, coping efforts, and adjustment to chronic pain, J. Consult. Clin. Psychol., 59 (1991) 431-438. Jensen, M.P., Turner, J.A., Romano, J.M. and Karoly, P., Coping with chronic pain: a critical review of the literature, Pain, 47 (1991) 249-283. Keefe, F.J. and Williams, D.A., A comparison of coping strategies in chronic pain patients in different age groups, J. Gerontol., 45 (1990) 161-165. Keefe, F.J., Caldwell, D.S., Queen, K.T., Gil, K.M., Martinez, S., Crisson, J.E., Ogden, W. and Nunley, J., Osteoarthritic knee pain: a behavioral analysis, Pain, 28 (1987a) 309-321. Keefe, F.J., Caldwell, D.S., Queen, K.T., Gil, K.M., Martinez, S., Crisson, J.E., Ogden, W. and Nunley, J., Pain coping strategies in osteoarthritis patients, J. Consult. Clin. Psychol., 55 (1987b) 208212. Keefe, F.J., Caldwell, D.S., Williams, D.A., Gil, K.M., Mitchell, D., Martinez, S., Nunley, J., Beckham, J.C., Crisson, J.E. and Helms, M., Pain coping skills training in the management of osteoarthritic knee pain: a comparative study, Behav. Ther., 21 (1990) 49-62. Keefe, F.J., Caldwell, D.S., Martinez, S., Nunley, J., Beckham, J. and Williams, D.A., Analyzing pain in rheumatoid arthritis patients: pain coping strategies in patients who have had knee replacement surgery, Pain, 49 (1991) 153-160. Manne, S.L. and Zautra, A.J., Couples coping with chronic illness: women with rheumatoid arthritis and their healthy husbands, J. Behav. Med., 13 (1990) 327-342. Price, D.D., Harkins, SW., Rafii, A. and Price, C., A simultaneous comparison of fentanyl’s analgesic effects on clinical and experimental pain, Pain, 24 (1984) 197-203. Rosenstiel, A.R. and Keefe, F.J., The use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment, Pain, 17 (1983) 33-44. Zautra, A. and Manne, S., Coping with rheumatoid arthritis: a review of a decade of research, Ann. Behav. Med., in press.