Disbelief
While such disbelief may be due to a number of reasons, stigma is chief among them. In our healthcare system, stigma makes us emphasize the limits of an individual patient’s abilities to cope. In so doing, we tend to imply that, in general, coping well with pain really isn’t possible. Let’s explain.
No one wants to be judged as not coping well and so often patients with chronic pain tend to deny that they are coping poorly. Instead, 
they assert, for instance, that they cope exceptionally well under the circumstances, even when by most measures they may not be. By doing so, they emphasize the limits of coping: they assert having a high pain tolerance even though, say, they remain on daily use of opioids and are disabled from pain; so, they imply that there really is no point in discussing coping any further. The implication is that learning to cope better is not such a powerful intervention since they remain in rough shape despite coping exceptionally well. Notice what happens here. The individual’s experience of coping gets generalized to coping in general – to what’s possible with coping.
This way of perceiving oneself really comes out of stigma and the understandable response to it of not wanting to be judged for coping poorly. But is this understandable response to stigma really true of coping in general – that coping only gets you so far when it comes to managing pain?
Healthcare providers too tend to emphasize an individual’s limits to coping and generalize it to what’s possible with coping. When patients aren’t doing well and so present for care, healthcare providers of course don’t want to make them feel worse, but better. So, providers tend to avoid recommendations to learn how to cope better, because such recommendations are hard to hear for many patients. In other words, recommendations to learn to cope better imply a judgment that patients aren’t coping very well at the present time. Patients can feel stigmatized in response to such recommendations to learn to cope better. So, healthcare providers tend to instead respond with reassuring statements, such as ‘You’ve suffered long enough, let’s try this procedure…’ or ‘You should’ve come in sooner.’ These kinds of reassurance, while resolving the problem of stigma, emphasize individuals’ limits of their coping in language that implies coping only gets you so far. It’s as if to say, ‘Don’t try to continue doing this on your own… You’re at a point at which you now really have to rely on medical care.’
In these circumstances, healthcare providers aren’t being disingenuous. It’s safe to assume that for the most part they really believe that typical cases of chronic pain are impossible to cope with successfully and so patients must instead rely on interventional and surgical procedures or certain medications, such as opioids.
So, when chronic pain rehabilitation providers come along and make a statement about the power of coping, that it’s apt to be the most powerful intervention that we have, it’s not commonly believed, at least, until we review the following explanations.
Reminders of what we already know
Wittgenstein,1 arguably the most influential philosopher of the twentieth century, liked to point out our tendency for getting caught up in a line of reasoning that subsequently leads to denying something we actually know is true. Philosophy, it turns out, is full of such lines of thought (e.g., the so-called problem of ‘other minds’). In such situations, he’d admonish us to remind ourselves of what we really already know.2
Now, philosophy is not the only area in life in which we can get caught up in a line of reasoning that actually leads to a confusion. An example in healthcare might be the afore-mentioned conclusion that the levels of coping, which patients exhibit, are the actual limit of what’s possible for coping with pain – that we can’t get much beyond a certain level of coping because chronic pain is simply intolerable.
Let’s step back a bit, then, and remind ourselves of what we already know. We know that chronic pain is common. Epidemiological studies put the prevalence of chronic pain between 20-30% of the general population. But, then again, we don’t need studies to tell us. Almost everyone either has chronic pain themselves or knows someone who does. We might also notice that only some of these people are taking opioids for their pain or are disabled. Still others self-manage their pain without opioids and remain at work. In other words, they cope well.
Now, the differences don’t lie in the severity of the injury associated with the pain or even in the severity of pain itself. The majority of people with pain who rate their pain as moderate to severe do not manage their pain with opioids.3, 4, 5 The same is true for those who remain at work.6, 7, 8, 9 So, even people with moderate to severe chronic pain can cope well with it.
Now notice that we run right into the problem of stigma when we talk like this. By noticing these differences, are we saying that one group of people are better than the other group? By simply observing a difference between people, it seems as if we are critically judging one group against the other, or stigmatizing one group but not the other.
The point, here, though, is not to judge, but just show what’s possible.
Let’s remind ourselves of a few more things that we already know. To be sure, sometimes some people do make note of these differences and do it in a way that is highly judgmental or stigmatizing. But, the acknowledgment of these differences doesn’t have to be done in a judgmental way.
There are times and places in which everyone of us can acknowledge the fact that some people cope better than others in all facets of life and we never mean it in a judgmental or critical way.
Suppose there are two different people who each have a flat tire on a stretch of interstate highway in which there’s hardly any room on the shoulder and there are a lot of semi-trucks driving by at 75 miles per hour. This kind of experience isn’t pleasant for anyone, including the two people in our example. Now, suppose one of these individuals is a relatively new driver who has never had a flat tire and who has never changed a tire before. When the tire blew, it gave him quite a start. His heart started pounding, his hands got clammy, and he didn’t quite know what to do after pulling over. We might imagine him fumbling around for the spare and the tools, but lacking self-confidence to proceed, he starts to try to change the tire, but then stops, only to start again, becoming doubtful of his abilities and then stopping again. Meanwhile, the semi-trucks keep racing by and the whole experience leaves him rattled. He decides to simply call for a tow truck. The other person, who is also a new driver, grew up with a parent who tinkered with cars and so she was taught from a fairly young age how to make simple repairs herself. In this process, she was shown how to change a tire and had actually rotated the tires of her parent’s car a number of times. When the tire blew, she was a little surprised, but not startled. She pulled over and, rather than having a fear-based reaction of becoming rattled, she had the response of it being an inconvenience for her. She got out and, while the semi-trucks raced by her, she proceeded to change the tire. Once done, she kept on driving.
Notice the differences in how each coped with the same adversity. Now notice that we don’t typically judge one person as better than the other in such situations. Of course, the first person didn’t cope as well, but we don’t think of him as a worse person. In fact, we might even have empathy for him, as every one of us has had some experience in which we met our match and didn’t cope very well.
Notice too that the differences in coping between each respective person lie in what one has learned or not. That is to say, coping is the product of a learning process. The first individual in our example had never learned to change a tire and had never had the opportunity to practice it. As such, he didn’t know what to do, was frightened and overwhelmed, and needed to rely on others. In other words, he found the problem of having a flat tire intolerable. The other individual had been taught what to do and had had the opportunity to practice it many times before. She found the experience tolerable and was able to move on from it all by herself.
The lesson here is that, if we taught the first person in this example how to change a tire and provided him with opportunities to practice with a little coaching along the way, he too would find that such experiences are tolerable and would be able to manage it by himself and subsequently move on from it.
That is to say, the same problem would go from intolerable to tolerable. The problem would remain the same. The only difference that accounts for the problem becoming tolerable and manageable independently is that one learns how to cope with it.
Herein lies the power of coping. It’s what makes the intolerable into something that is tolerable. It’s what makes the unmanageable into the manageable. It’s what allows people to go from being stuck in life to being able to move on with the rest of their life.
Now, we don’t have to make up fictional examples to demonstrate how a process of learning can lead to making problems in life go from intolerable to tolerable. Think of the training that soldiers go through when they first join the armed services. It’s often called ‘boot camp’. Its rigorous and demanding, but it’s essentially a course in which people learn how to tolerate the adversities of war and learn that they can do it. In other words, they learn how to cope with problems that they once would have found intolerable and gain the confidence that they really can do it.
What if there was a boot camp for chronic pain? Well, there is.
Chronic pain rehabilitation programs
Every day people around the world go through a process of learning how to tolerate adversities that they had previously found intolerable. The process of learning involves multiple experts from different disciplines teaching them and providing them with opportunities to practice, giving them supportive coaching along the way. In the process, they get so good at dealing with these adversities that they become able to manage them so well that they can move on with the rest of their life.
The people are patients in chronic pain rehabilitation programs and their adversities are moderate to severe chronic pain along with the numerous common problems associated with such pain – reliance on opioids, disability, insomnia, depression, anxiety, strained relationships, loneliness, lack of meaningful activities for their daily lives, and so on.
With a willingness to learn, an openness to feedback, motivation and perseverance, they proceed through the program and they learn how to cope with pain so well that their once intolerable pain becomes now tolerable and manageable. As a result, they can begin to move on with the rest of their life and subsequently they no longer have the associated problems that had once come along with their pain.
They no longer have to rely on opioid pain medications. They go back to work. They are no longer depressed or anxious because of pain. They go to family functions and they fulfill their family obligations. Their relationships are no longer strained. In other words, they are engaged in life.
They still have pain, though. To be sure, it is typically less.10, 11 However, it’s not the reduction in pain levels that accounts for the differences described above. It’s the changes in their levels of coping that accounts for the difference. They have learned to cope with pain well -- really well.
They’ve gone through a course of learning that makes what was once intolerable pain become tolerable. Chronic pain rehabilitation programs are a bridge that leads back into life.
It’s in this way that learning to cope with pain and getting really good at it is one of the most powerful interventions that we have for the management of chronic pain.
References
1. Wittgenstein, L. (1953). Philosophical Investigations. New York: MacMillan.
2. Despite the apparent logic of the argument, how can we conclude, for example, in the problem of ‘other minds’, that we cannot know another’s subjective experience or ‘mind’, when we get up in the morning with our spouse and have breakfast together everyday, talking about our respective plans for the day?
3. Breivek, H., Collett, B., Ventafridda, V., Cohen R., & Gallacher, D. (2006). Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. European Journal of Pain, 10, 287-333.
4. Fredheim, A. M., Mahic, M., Skurtveit, S., Dale, O., Romundstadt, P., & Borchgrevink, P. C. (2014). Chronic pain and use of opioids: A population-based pharmacoepidemiological study from the Norwegian Prescription Database and the Nord-Trondelag Health Study. Pain, 155, 1213-1221.
5. Toblin, R. L., Mack, K. A., Perveen, G., & Paulozzi, L. J. (2011). A population-based survey of chronic pain and its treatment with prescription drugs. Pain, 152, 1249-1255.
6. Cassidy, J. D., Carroll, L., & Cote, P. (1998). The Saskatchewan health and back pain survey: The prevalence of low back pain and related disability in Saskatchewan adults. Spine, 23, 1860-1866.
7. Cote, P., Cassidy, J. D., & Carroll, L. (1998). The Saskatchewan health and back pain survey: The prevalence of neck pain and related disability in Saskatchewan adults. Spine, 23, 1689-1698.
8. Linton, S. J., & Buer, N. (1995). Working despite pain: Factors associated with work attendance versus dysfunction. International Journal of Behavior Medicine, 2, 252-262.
9. Von Korff, M., Dworkin, S. F., & La Resche, L. (1990). Graded chronic pain status: An epidemiologic evaluation. Pain, 40, 279-291.
10. Gatchel, R. J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic non-malignant pain. Journal of Pain, 7, 779-793.
11. Turk, D. C. (2002). Clinical effectiveness and cost-effectiveness of treatments for patients with chronic pain. The Clinical Journal of Pain, 18, 355-365.
Date of publication: October 23, 2015
Date of last modification: March 25, 2021
