Disability & Rehabilitation, 2013; 35(14): 1182–1190
© 2013 Informa UK, Ltd.
ISSN 0963-8288 print/ISSN 1464-5165 online
DOI: 10.3109/09638288.2012.723791
RESEARCH PAPER
What does coping mean to the worker with pain-related disability?
A qualitative study
Linda J. Carroll1, J. Peter Rothe1 & Dejan Ozegovic2
1
Department of Public Health Sciences and Alberta Centre for Injury Control and Research, School of Public Health, University
of Alberta, Alberta, Canada and 2Alberta Centre for Injury Control and Research, School of Public Health, University of Alberta,
Alberta, Canada
Implications for Rehabilitation
Purpose: Pain coping is important in health outcomes. In the
current literature, pain coping usually means those goaldirected strategies to manage pain. The study goal was to
explore what personal meaning “coping” has for work-disabled
individuals in pain. Method: Qualitative, in depth interviews
with follow-up verification interviews were conducted with 13
volunteers who were off work and in rehabilitation for chronic
pain from a musculoskeletal injury. The two main questions
were: (1) How did participants understand the term “coping
with pain”; and (2) how did they come to this understanding of
coping. The theoretical approach was social phenomenology
and data were analyzed using thematic analysis. Results:
The dominant theme was that pain coping is an intrinsic and
life-defining attitude and belief. This understanding primarily
arose through early modeling by parents and significant others.
Secondary theme was that coping is practical strategies to
manage or eliminate pain. This arose through more current
interactions with health care providers and others in the
social network. Conclusions: Researchers’ and clinicians’ view
of coping may not always match the views held by individuals
with chronic pain. This might impact on the effectiveness
of interventions designed to modify coping behaviors, and
alternative ways of intervening may be needed.
t Coping has an important impact on health recovery
after musculoskeletal injuries but interventions to
modify pain coping strategies in those with chronic
pain have met with modest success.
t The dominant model for coping in the research literature defines coping as a behavioral and/or cognitive
response to a stressful situation.
t A qualitative study to examine what personal meaning
“coping” holds for work-disabled persons with chronic
pain suggests that coping is primarily conceptualized
as an intrinsic and life-defining attitude/belief learned
early in life.
t The above incongruence between the dominant
research model of coping and the views of workers
with chronic pain might impact on the effectiveness
of interventions designed to modify coping behaviors
for this population, and alternative ways of intervening may be needed.
illnesses and cancer [1–6]. Different stressful situations (for
example, relationship stresses versus losses versus health
threats) have been shown to engender different types of
coping strategies, although some types of coping, for example,
self blame and catastrophizing – which can be thought of as
ruminating, magnifying the event and feeling helplessness,
appear to be generally non-adaptive [7]. It has been suggested
that the type of coping which is the most adaptive depends on
the nature of the stressful situation. For example, a situational
stressor (such as a work deadline) might call for a different
type of coping than an interpersonal stressor [8]. Similarly,
it has been demonstrated that adaptive coping in a stressful
Keywords: Chronic pain, coping, qualitative
Introduction
Coping can be thought of as the efforts one makes to solve
personal and interpersonal problems and to manage stressful
situations, in order to minimize their effect on one’s wellbeing. Coping has been studied extensively in the context of
many stressful events, such as exposure to acts of terrorism,
natural disasters, loss due to suicide or divorce, mental
Correspondence: Linda J. Carroll, 4075 RTF, 8308 – 114 Street, Edmonton, AB, Canada T6G 2E1. Tel.: (780) 492–9767.
Fax: (780) 492–7154. E-mail: lcarroll@ualberta.ca
(Accepted August 2012)
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Meaning of coping
situation that is clearly within the individual’s control (for
example, preparing for an exam) differs from adaptive coping
in a situation that is not (or no longer) within that person’s
control (for example, awaiting a grade after an exam) [9].
de Ridder and Schreurs point to a number of conceptual
issues to be considered when applying the concept of coping
to health conditions in particular. These include the question
of whether coping should be considered a trait or a state. In
other words, is coping style a function of global and stable
individual characteristics, or is coping a dynamic, process oriented construct? These authors point out that coping researchers frequently focus their attention on behavioral, cognitive
or emotional coping strategies, neglecting other important
aspects of coping, such as how potentially stressful events are
judged and interpreted, or what personal and interpersonal
resources (supportive social network, self-esteem, others)
help in forming the foundation for effective coping [7,10].
Pain is one type of stressor, and is an especially common
one. The prevalence rate of chronic pain is similar across the
western world—20–30% of the adult population suffers from
chronic pain problems [11–13]. Chronic pain is an especially
important problem in the working population because it is
one of the most common causes of work disability in developed countries [14]. During any 2-year period, almost 10% of
workers develop chronic back pain [15]; workers with back
pain lose an average of 5.3 h of productive work each week
because of pain [16].
Over the past two decades, pain-related coping has become
a frequent topic of research investigation and theoretical discourse. For those with chronic pain problems, coping style has
been shown to be associated with concurrent and subsequent
pain severity, health status, outcomes (including return to
work), psychological status, response to treatment and maintenance of treatment gains [17–22]. In this literature, coping
has also been linked to a particular belief—expectations. It
has been shown that those who expect severe symptoms after
a musculoskeletal injury also use less adaptive coping strategies [23]. Given this finding, it may be that coping serves a key
role in mediating the observed association between expectations for recovery (and possibly other pain-related beliefs)
and actual recovery after a musculoskeletal injury [23–27].
Such findings have lead to an interest in developing interventions to modify coping, in an effort to improve outcomes
in those with chronic pain. Yet studies in this area suggest that
coping behavior is resistant to change, requiring intensive
interventions and, while such interventions have met with
some success [28,29], they appear to result in less improvement than might be hoped [30–32]. This suggests that coping
is resistant to change in some manner we do not yet understand, and there may be a partial answer in developing a better understanding of how individuals in pain understand the
construct of coping.
In the pain literature, the most commonly used conceptualization of coping has arisen from the transactional model of
stress [33]. This model defines coping as a process of purposeful efforts to manage stressors, which are those “external and/
or internal demands that are appraised as taxing or exceeding
the resources of the person” [34]. Thus, by this definition,
©  Informa UK, Ltd.
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pain coping is dynamic and process-oriented (as opposed to
a stable individual characteristic) and involves specific, intentional, goal-directed psychological and/or behavioral efforts
to minimize the physical, psychological or social harm of
pain. This model places an emphasis on the actual behavioral
and/or cognitive coping strategies used, along with the individual’s cognitive appraisal of the situation.
Most studies of chronic pain-related coping (including coping intervention studies) have adopted this model of coping,
and the majority of pain-coping studies have used a quantitative paradigm. This has generally included administration of
one of a variety of coping questionnaires, which ask individuals with chronic pain whether (and/or how often) they engage
in particular cognitive or behavioral activities (pain coping
strategies) to cope with their pain. (for examples of coping
questionnaires, see [35–39]) There have been far fewer studies using qualitative research paradigms to examine coping in
those with musculoskeletal pain, but these have also been useful in identifying types of coping strategies used by individuals with pain problems [26,40–43]. Examining the behavioral
and cognitive strategies used by people to cope with their pain
has a substantial impact on their health and other outcomes.
However, it is also important to step back and study how individuals with pain problems understand and conceptualize coping. Such an investigation may help clinicians and researchers
to develop more effective ways of intervening with those who
engage in ineffective ways of coping with pain. Gaining a better understanding of how individuals with pain understand
coping will help to both inform pain coping theory and aid
in developing ways of assisting those in pain to enhance the
effectiveness of their ways of coping. Thus, understanding the
lived experiences of those with pain problems is important in
both theory development and clinical management [44].
The current study was designed to address two questions
about pain coping that to date have not been fully explored:
(a) what does “coping” mean to the individual with chronic
pain (how do individuals with pain assign common sense
meaning to coping); and (b) how have individuals come to
develop that meaning of coping? To address these questions,
we used qualitative methods, since that methodology can
help define what relevance pain coping has to individuals and
how it relates to their expectations and self-identity, social
relationships and social contacts. Our population of interest
in this study was persons who were work-disabled because of
chronic (duration of 3 months or more) musculoskeletal pain.
Musculoskeletal injuries and conditions, such as neck, shoulder and low back pain, are the leading cause of workplace disability, and these conditions have been widely documented as
being responsible for a high level of personal, financial and
societal burden [45,46].
Methods
Study design
We used a qualitative study design, involving in depth individual interviews, with the overall goal of assessing how
injured individuals understand and perceive “coping”. Our
theoretical approach to this study was social phenomenology,
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which is grounded in the earlier theoretical work done by
social science philosophers Schutz, and Berger & Luckmann
[47,48]. This approach places emphasis on the intent or
motives underlying peoples’ actions (in this case, coping), and
the taken-for-granted common sense principles that people
use in coping. Phenomenology emphasizes the shared meaning of experiences through the principle of intersubjectivity.
Because the world is social and not private, the researcher and
those being researched share its meaning. There are common
ground and common assumptions in how people establish
that meaning and what meaning it establishes [49,50]. Thus,
our study objective was to engage in in-depth interviews so
that we could extract generalized observations from the convergence of injured workers’ shared relevancies, experiences,
attitudes and assumptions.
Table I. Characteristics of participants.
Participants and setting
The study took place in Edmonton, Alberta, Canada, one of
two major cities in a province which has universal health care
coverage. We recruited participants for this study from two
rehabilitation facilities. One was a large, province-wide, multidisciplinary rehabilitation facility operated by the Workers
Compensation Board in Alberta, Canada. It is the largest
provider of occupational rehabilitation and disability management services in the province. In addition, to allow for the
possibility that individuals being treated at that facility might
have different views than those being treated at a private
rehabilitation clinic, we also recruited patients from a private
rehabilitation clinic which also has a large occupational-injury
patient complement. The recruitment strategy was purposive
sampling, in order to reflect the typical characteristics of
those with a prolonged course of work-related disability. The
study sample consisted of 13 volunteers (10 males and three
females) with musculoskeletal pain, all of whom were being
treated for work-related musculoskeletal injuries, which had
occurred at least 3 months prior to the study. Approximately
half the participants lived locally and half were from outside
the city. Participants’ age group, sex, type of occupation at the
time of injury, part of body injured (location of chronic pain)
participants and time since injury are listed in Table I. At the
time of the interview, all were collecting workers’ compensation or disability benefits for chronic pain arising from these
injuries. Characteristics of the study sample were similar to
those of the larger population of WCB benefit recipients who
have prolonged pain problems from musculoskeletal injuries,
that is, the majority were male, over the age of 40, with high
school or less education, and suffering from back or neck/
shoulder injuries [51].
Contact was made with participants through informational
posters which invited participation and provided general
information about the study. These were posted in a conspicuous spot in the two rehabilitation centres which comprised our
sampling frame. Interested individuals were asked to phone
the study coordinator, at which time they were screened for
inclusion criteria, provided with more information about
the study, and arrangements were made for a data collection
interview. Participants were provided with a small monetary
reimbursement for their time, effort and expenditures.
Code #
1
Age range
40’s
Gender
M
Type of job
when injured
Construction
2
50’s
M
Manual labour
3
40’s
M
Transport
4
50’s
M
Industry
5
50’s
M
Construction
6
40’s
M
Construction
7
60s
F
Service Sector
8
60s
M
Skilled labour
9
30’s
F
Service sector
10
40s
M
Heavy labour
11
50s
F
Service sector
12
40s
M
Construction
13
30s
M
Transport
Part of body
injured, time
since injury
Back, 4 years
ago
Back, 4 years
ago
Neck/
shoulder, 7
months ago
Neck/
shoulder 18
months ago
Neck/
shoulder, 2
years ago
Neck/
shoulder 1
year ago
Neck/
shoulder 14
months ago,
had surgery
Neck/shoulder 4 months
ago. Prior
injuries
Lower
extremity 7
months ago.
Prior back
injury
Back, lower
extremity, 2
years ago
Back, lower
extremity, 3
months ago
Back, lower
extremity; 2
years ago.
Back, neck 2
years ago
Data collection
Semi-structured interviews were conducted in a private
office within the rehabilitation clinics. The interview format
consisted of two interviewers in tandem with a respondent
in a closed room around a table. The interview design maintained conversational levels in which free flow of information
could be assured [52]. The principles of social phenomenology guided the interviews. An interview guide was developed
in advance, informed by the literature, informal discussions
with people in pain and health care professional and researchers’ experience with patients with chronic pain. However,
interviews were designed to be iterative so that additional
themes could be formulated within and between interviews,
as interviews progressed. This process is consistent with
social-phenomenology theory, that is, we seek to discover the
world as it is experienced by those involved in it, in order to
explore the nature of human experience and the meaning that
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Meaning of coping
people attach to their experiences [53]. An iterative approach
permitted us to deal with unanticipated issues, classifications,
illustrations and additional relevant information. It offered
respondents opportunities to articulate their feelings, experiences and perceptions as fully as possible. Questions were
conversational and, although pre-defined, they did not follow
a particular sequence. The emphasis was on the logic-in-use
or pattern of discourse, the way in which they reasoned their
responses, and made connections across phenomena. To help
arrive at embedded meanings, we sought maximal use of
probes and tags to gain the most descriptive account possible,
from the general to the specific, from the public to the private
and personal, and from the least defensive to the most [52].
The main topic areas addressed by the interview were as follows: (1) How do you understand the term “coping with pain”;
and (2) how did you come to know about this understanding
of coping? Interviews lasted between 1.5 and 2 h, and were
audio recorded and transcribed verbatim.
A three-step data verification process was used. The first
was the use of inter-respondent verification procedures during interviews whereby respondents were asked about critical
issues or anomalies that were raised by earlier participants.
The second was another on-site verification process, which
consisted of tagged responses and probes, whereby the interviewer introduced such phrases as, “Do you mean that . . . ,”
“Are you saying that . . .” and “Give me an example of . . .” to
attain a more embedded sense of meaning and to ensure clarification, illustration and expansion of ideas [49]. The third step
re-engaged participants after the first round of data analysis,
and involved a follow-up interview (also recorded and transcribed) in which participants were invited to comment on the
initial interpretations to ensure accuracy and relevance, and to
provide participants with the opportunity to clarify, correct,
add comments and further information.
Ethics approval for this study was granted by the University
of Alberta’s Health Research Ethics Board. Prior to the start of
the interview, all participants provided written informed consent to participate in the study and to permit audio recording
of the interviews. They were assured that participation would
have no bearing on their health care or on their benefits and
that information they provided would not be reported to their
insurer or their health care providers. Once the interview
process was completed, names and personally identifying
information were deleted and numerical codes were assigned
to ensure confidentiality.
Data analysis
Our goal for data analysis was to identify, through thematic
analysis, dominant patterns or themes embedded in the data
[54]. We used an induction strategy, which is a process of
elaboration in which descriptions are achieved through an
iterative approach from the analysis of one interviewee to
the next [55]. First, the verbatim transcriptions were read
several times as a group. The information was then classified
and coded into tentative emerging themes. This first round
of analysis became the foundation for engaging interviewees
with verification interviews, which also became part of the
data pool for analysis. The identification of emerging themes
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was followed by extraction of sub-themes and social contexts
within which the sub themes were embedded. In a recursive process, as interviews were coded and thematized, each
successive interview (including the verification interviews)
became a source for additional generalizations, and the originally coded interviews were reassessed for themes or codes
that arose from later reviews. Eventually a body of interrelated
generalizations was elaborated, through thematic indexing, to
elaborate how participants constructed their ways of coping
with pain [56]. Through a process of constant comparison
across all interviews and between interviews and analysis,
similarities and differences across interview material were
identified. The initial analysis was conducted by the second
author, and then reviewed by the first author. Any areas of
discrepancy between these two authors was discussed and
consensus reached. Finally, agreement on the final themes
was obtained from all authors.
Results
Saturation was reached with 13 participants. The findings
from the interviews support the idea that there are overarching meanings that typify how injured workers understand and
experience the concept of coping with pain. Quotations from
the interviews are followed by the number of the informant
in round brackets. These insider thoughts and experiences
provide rich perspectives on the meaning of coping, and the
context in which coping occurs.
Meaning of coping
There were two main conceptualizations of what “coping”
means: an intrinsic and life-defining (or sometimes lifechanging) attitude; and behavioral/cognitive strategies for
managing their pain. However coping was defined, however,
a common thread for the persons in this study was that living
with chronic pain means struggling to cope, and struggling
to understand what it means to cope. How these respondents
defined and understood coping served as the foundation for
how they cope.
Coping as an intrinsic and life-defining attitude
A typical view expressed was that the concept of coping did
not primarily mean a series of strategies used to manage pain;
rather coping had become an intrinsic part of their overall
world view, self-view and belief system. The meaning of coping transcended the day-to-day management of pain. Coping
was more than technique or strategy; it was a life-altering
experience; a definition or re-definition of life. For example,
an injured worker, whose injury had occurred 20 months
previously, told us that coping was intrinsic change in himself; the need to alter his perspectives, attitudes, life style and
his expectations. He described himself as being “forced” to
live with pain—something he had never before experienced.
Coping, to him, meant:
“[looking at] things in a different perspective. [Coping is a] rationalization in the brain [that] things will get better . . . I know I’m going to be
in pain and I know it’s going to be hurting but I know I’m slowly getting
better . . . I’m trying to make the best of everything I can.” (participant 4)
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For the above individual, coping was less about “managing” the pain, and more about understanding and coming to
terms with the realization that he would never be the same,
but that his condition was slowly getting better. He talked
about having to accept that his injury and pain had taken
away his freedom of movement. Similarly, another participant
equated coping with understanding and accepting the pain;
using the “power of the mind” to do so. He believed that pain
is a mental state, and that the mind is:
“. . . more powerful than any drug in the world. The mind. Understanding your pain and working through it.” Furthermore, he went
on to say “. . . a human should be able to survive anything. Basically.
Pain or mental anguish, or whatever, you should be able to work your
way through it. Knowledge and understanding will make you work
through it . . . You’ve got to be able to take pain. You’ve got to be able to
figure out a way to ‘yeah, okay, that pain is there.’ You’ve got to accept
it!” (participant 2)
For participant 6, coping reflects: “. . . mind over matter . . . I
think one of the keys [to coping] might be – so much of a person’s
personality plays a part”. Another emphasized the importance
of “perseverance” and belief in coping: “It’s faith . . . you know
what – it’s what you believe. What’s the belief? If you don’t believe
that your body is not going to heal, then it isn’t” (Participant 7).
Another spoke about having to have the right attitude: “it’s all
about the right attitude. If you’re grumpy and angry and bitchy,
it’s ain’t going to help. Nothing’s going to help. Not even the right
physio people, nothing”. He went on to reflect his belief that “attitude” is the essential component in coping with all life’s problems,
and that: “If you’ve got a bad attitude no, you can’t [cope], it’s an
impossibility” (Participant 8).
Participant 11 was more specific in her assertion that the
essence of coping is having a positive attitude, and seeing the
positive in every situation, no matter how difficult:
“. . . you still have to bring that around – to come out with a positive.
I’m a very positive person. Sometimes it just takes me a little while to
get back to, ‘well, OK there was a good part to this and I have to find
it’. As hard as it’s going to be, you need to find it [the positive]. You
have to come up with at least a thread of positive in this ordeal. And
come around. And, you can do it. So you get up, up and you can carry
on. You can do it. So stop crying, and get up, and go out there, and do
what you have to do.”
Likewise, participant 10 said about coping: “a lot of it has
to do with the fact that it’s your personal makeup, the type of
person you are. Right? . . . But you know, I come from pretty
sturdy stock”.
Coping as cognitive or behavioral strategy
As a secondary theme, coping was conceptualized as strategy-oriented; a practical action to manage or (less often) to
eliminate the pain. This included such things as using ice or
heat, medications, engaging in activities (as distraction) or,
alternatively avoiding activities (because they make the pain
worse), doing their physiotherapy exercises or (alternatively)
avoiding doing their physiotherapy exercises, among other
strategies. To illustrate, one participant with shoulder pain
defined personal coping as: “. . . dealing with it [pain]. Dealing
with it within your abilities and limitations” (Participant 3).
He further described coping as practical actions, such as
“exercising – just loosening it up” to manage the pain, and
went on to say:
“I’d like to be 100% again. I would like that. I’m thinking [I will get to]
90, 95% . . . It won’t be the [range of] motion, it would be more the
strength I think . . . that’s for my job—what I need is my strength. The
[range of] motion you can get around, but the strength is the thing
you really need.” (participant 3)
For this individual, successful management of pain was
idealized as the way to attain the future goal of gaining his
strength back, and “coping” meant an active process of
improving shoulder strength through exercise. For participant 4, coping was described as involving an intrinsic change
in himself; however, he also went on to describe some of the
coping strategies he had learned: “. . . ice certainly makes a
difference and then in the mornings it is somewhat stiff and
then I find a hot shower and . . . a little stretching helps it out”.
He also talked about effective coping as involving “. . .reading your body and just knowing what you are, or what your
limitations are, but at the same time . . . also pushing those
boundaries” (participant 4).
In contrast, another participant with shoulder pain also saw
coping as a way of managing the pain, but rather than using
exercise to improve strength and movement, his way of coping
focused on using his other arm more and avoiding those activities that made his pain worse. He said that to him, coping means:
“trying to live with it in a way, [that] to me is coping . . . trying to find a
way to deal with it. I used to take a lot of pain killers . . . and I decided
to stop because I didn’t want to get used to it, get a pill to control my
pain so I kind of wanted to myself control the pain in a way. Trying
like say to live with it and trying to avoid those things that will alleviate pain. Go easy on the exercise . . . I go easy, I use ice at home . . . just
to alleviate some of the pain.” (participant 5)
Similarly, another interviewee described his meaning of
coping as strategy oriented: “. . . trying to find strategies and
ways to deal with pain and managing it one way or another”
(participant 13). Although some participants conceptualized
coping as a way of managing the pain, for others, coping meant
pain cessation—one copes in order to put an end to the experience of pain (typically through use of medication). For example, participant 13 went on to say: “[Coping] means a lot to
me, actually. When you’re in pain constantly every day—you’ll
pretty much to do anything not to be”. He talked about relying
on medication to cope with his back injury because “nothing
else seems to take the pain away”.
Coping with pain is related to other life aspects
A complementary theme emerging from the data is that pain
coping is complex—pain coping cannot occur in isolation
of coping with other aspects of life. For example, one young
injured worker emphasized the importance of “stress” when
talking about the personal meaning that coping has for him.
He described this as a key factor in his life.
“. . . being able to deal with stress . . . Yeah, coping with life—yeah
—coping with pain . . . If you’re stressed out, you feel that stress everywhere—you’re in pain . . . stress . . . it doesn’t help. [Stress] makes the
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Meaning of coping
pain go from a 10 up to a 70 [on a 100 point scale of pain intensity]. I
think that one of the things that makes it hurt the most is stress. Coping with stress with pain . . . If somebody’s acting or doing something
to make me feel stressed, I just leave. That’s all there is to it. I give them
the ‘toodles’” (participant 13).
Another participant (1) also highlighted the negative
impact stress has on his ability to cope:
“Stress is a hard one. It takes a lot of physical and mental out of me . . .
you’re stressed your body’s not working right . . . nothing is going good.
Stress is not a good, a good feeling to have. It’s something everybody
goes through, obviously, you know, from time to time. But to have it
as top dog, always weighing on you. It’s difficult for you to cope . . . it’s
harder to cope when you’re stressed, isn’t it? . . . The more stress I’m in,
the more pain I have.”
In summary, the meaning of coping appeared to be understood by study participants in two ways, although these
themes sometimes overlapped. The dominant theme was to
see coping as an intrinsic and life-defining attitude and belief
system; and, related to this, to see coping with pain as a complex phenomenon that encompasses coping with other areas
of one’s life. In this way, “coping” was an expression of “the
way I am”. The secondary conceptualization of coping was as a
way of managing or eliminating pain through practical strategies. In that respect, coping was conceptualized as “what I do”.
Where did they learn this meaning of coping?
Personal meanings of coping are not haphazard views about
life. They represent a fundamental reference point for a
person’s beliefs, attitudes and behaviors. The interview data
showed three prominent ways of having come to a personal
meaning of coping. These were: (1) through family role
models, including modeling by parents and significant others during their childhood and early adulthood (by far, the
predominant theme); (2) through their health care providers;
and (c) through recent and current interactions with others
who also have pain problems (e.g. in treatment programs and
support groups).
The most prominent theme to emerge was that the understanding of what coping means came early in life. This was
especially true for those individuals who saw coping as an
intrinsic part of their world and self view. These early lessons
on the meaning of coping were learned primarily from parents
but also through other early experiences. Sometimes “coping”
was understood through the lifestyle experienced as a child.
For example, living on the farm denoted toughness—no whining, and getting the job done, regardless of health. An injured
worker said:
“I did grow up on a farm . . . You just keep on going. That’s what we
were told. Sure we had a little bit of sympathy . . . We could whine for
a few days, but then it was get up and go. Get back at your chores and
keep going.” (participant 7)
Sometimes, learning about what it means to cope meant
living in a family situation where a parent (often a father) was
a role model for “toughing it out”. For example, one injured
worker said: “My Dad . . . handles pain, like, he’s got a really
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high pain threshold. He just deals with pain like I’ve never
seen anybody else” (participant 3). Another participant also
learned about coping from his father: “. . . my father . . . He was
a tough man . . . I learned [coping] from that” (participant 8).
For many other participants, learning what it means to cope
with pain also came from early life experiences in how pain
was managed in the family. The message here was that a child
may be injured, but should not be “coddled” by parents—that
child must learn to go on with life. For example:
“I also think that it [my understanding of coping] goes back to, you
know, when you’re a kid and hurt yourself you cry. Well, you know,
some parents will coddle and that might be important at an age, but
sooner or later that has to stop. A skinned knee is a skinned knee. ‘Wake
up kid . . . put a bandaid on it and stop crying.’ So as you get older, you
have choices to make whether you are going to continue a sport or go to
work the next day under some pain, right.” (participant 6)
Early models for coping were not necessarily limited to
coping with illness or injury, but were more general in nature:
coping with life’s hardships of many kinds. One participant
learned what it means to cope by understanding how his
father coped with his wife’s death.
“When my Mom died, he [my father] lost ‘till death do them part.’ He
went out and he drank for a week. He didn’t want to stop drinking he
says, and then he just woke up on Monday and went to work. And ever
since that I think that if he’s strong enough to deal with losing his love, I
should be able to deal with life right. I just get up and go.” (participant 13)
Sometimes the role model for toughness was another family member. One participant told us about learning about
coping from his brother, a millwright by trade who became
debilitated because of knee problems, and had to walk with a
leg brace and cane. According to the interviewee:
“He [my brother] brought himself around. He went back to work . . . well,
hell, if he can do it, why can’t I? He is older than me. And now I’ve come to
the realization, well he’s been a physical labourer all his life too; he’s never
had an office job, an easy job. So why am I such a wimp?” (participant 2)
This interviewee came to believe that he should cope with adversity
like his brother did:
“Understand it. Get over it. Life goes on . . . And I’ll tell you, nine
people out of ten don’t really give a shit if you got pain. You can tell
them all you want . . . Don’t cry to yourself and to people around you.
Because it gets the point that they don’t give you a rat’s tooth about it.”
He has analyzed his brother’s experiences and has come to
the conclusion that the final responsibility for coping lies with
the person in pain. Coping means toughing it out, as exemplified by his brother’s actions.
For others, early models of coping involved learning to be
positive in the face of adversity, rather than being “tough”. For
example, one woman talked about the importance of positive thinking and positive attitude, and she attributed having
developed this attitude to her mother’s influence, saying:
“. . . I’ve just always just been a really positive person . . . I don’t know,
maybe it came from [how I was] raised. My mom’s a psych nurse so
she has always been a great support.” (participant 11)
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L. J. Carroll et al.
Although not the dominant theme, the influence of health
care professionals and/or the respondent’s current social
network (including fellow rehabilitation patients) was also
apparent. This arose when participants were discussing coping as strategy oriented, rather than as intrinsic attitudes and
beliefs.
For example,
“[The therapist] has taught me mental imagery . . . My pain was probably a nine when we started . . . to about a two when we finished . . .”
(participant 2)
This respondent talked about having been taught imagery
techniques by his physical therapist, which helped, not only
with decreasing the pain through use of narcotics, but also
with smoking cessation. He described the imaging techniques
that he has been taught as “retraining the brain”.
Yet another respondent had learned about pain coping
strategies from a psychologist he was seeing, and in pain
management classes offered as part of his rehabilitation
program:
“. . . I find that . . . having Dr. (psychologist) to talk to and then just
those classes I had while I was at the (name of treatment facility) certainly has helped in the coping and just putting things into perspective.”
(participant 4)
Yet for others, the perspective of coping advocated by their
health care providers received mixed reviews; for example:
“Stretching. They tried to tell me stretching helps. They’re full of it.
Stretching does not help. Not me anyways. It makes me want to cry and
it makes me feel like my back is going to jump out and run away . . .”
(participant 13)
For others who saw pain coping as strategy oriented, learning
about coping came by word of mouth, talking about ideas with
co-workers, gym mates or other people in pain. As one participant said: “I like to hear about how they are dealing with their
pain because I know how I’m dealing with mine . . .” (participant
7). Another told us: “. . . . that’s how you learn, is from the other
workers” (participant 8). One worker went a step further, starting her own coping group, telling us: “. . .we just went and had
to learn how to cope with no money and our problems . . . So
we started our own coping group” (participant 7). However, not
everyone found sharing ideas on coping useful. Respondents 12
and 13 were both adamant that “it doesn’t help talking about it”.
In summary, the personal meaning of coping backstops
the approach taken to coping. The main way of understanding
what coping means was through early role modeling by parents
and significant others. This was especially true when defining
coping as an intrinsic part of their overall world view, self view
and belief system—an aspect of “who I am”. When coping was
conceptualized as an intrinsic characteristic—toughness or
positivity—involving resilience, it was generally learned at an
early age. Understanding the concept of coping through interactions with health care providers and others with pain problems was a secondary theme which emerged, and was related
to the idea of coping being a strategy, or “what I do”.
Discussion
We conducted a qualitative study of how individuals with
chronic pain conceptualize “coping”. Those interviewed had
pain problems of a severity to have lead to work disability, and all were in rehabilitation treatment. The dominant
theme emerging from the interviews was that pain coping is
an intrinsic and life-defining attitude and belief; an idea that
arose primarily through early modeling by parents and significant others. The secondary conceptualization of coping was
that of practical strategies to manage or eliminate pain; this
generally arose through more current interactions with health
care providers and others in the current social network.
These ideas of coping can be compared and contrasted
with how coping is commonly presented in much of the current pain coping literature. That is, in the published literature,
coping (in general) is most commonly understood to mean
deliberate, goal-directed strategies to manage an unpleasant
situation or stressor. Pain is one such stressor. In the pain coping literature, “coping” with pain generally refers to the various
cognitive and/or behavioral efforts used by persons in pain to
manage that pain. In other words, coping is something people
do (i.e. a behavior and/or cognitive act). Questionnaires
designed to assess coping typically ask respondents what
they do (and how often) in response to pain. Interventions
addressing coping are typically educational and cognitivebehavioral in orientation, aimed at changing what people in
pain do (cognitively or behavioraly) in response to pain.
However, in our study, the idea that coping means engaging in strategies or activities to manage or eliminate pain was
clearly a secondary theme, despite that idea’s prominence in
the pain coping literature. Interestingly, to many in our sample
of workers with long standing and disabling pain problems,
the concept of “coping” with pain had a much more profound
and personal meaning. The dominant and most salient theme
elicited from interviews with these individuals was that pain
coping is complex and represents a fundamental and intrinsic
stance in attitudes and beliefs. Pain coping was described as a
complex process that could not be isolated from other aspects
of life.
Consistent with the idea that coping is a construct of deep
personal meaning, involving intrinsic and core beliefs and
attitudes, participants in this study who held this view primarily attributed their understanding of how to cope (i.e. how
they learned what it is “to cope”) as stemming primarily from
the early influences of parents and significant others, who
passed along their values. These values include, for example,
the importance of being physically and mentally “tough” or of
having a positive attitude. These lessons in coping transcended
the type of adversity—coping with pain was to be approached
in the same way as coping with other life events. This view
conceptualized coping primarily as an intrinsic resilience,
learned at an early age. The message from these participants
was that coping had to do with “who I am”. In contrast, when
coping was seen as something one does to manage or eliminate
the pain (i.e. the view that “coping” is equated with engaging
in “coping strategies”), the role of health care providers, colleagues, friends and fellow pain sufferers in helping (or not
Disability & Rehabilitation
Meaning of coping
helping) became important in understanding how to cope
with pain. This conceptualization of “coping” corresponds
much more closely with the conceptualization of coping more
commonly seen in the literature.
One interesting conjecture that arises from these data
is that the fundamental view that coping arises from early
lessons in how to face adversity and reflects “the way I am”
may be incompatible with an intervention philosophy that
coping is a set of behaviors. This may be part of the explanation of why even the most intensive interventions to address
coping have only modest success. That is, for at least some
individuals with pain, the paradigm behind educational and
cognitive-behavioral coping interventions does not match
their personal paradigm of what coping means. It may be that
for these individuals, a more effective intervention approach
might begin by explicitly recognizing and attending to their
personal meanings of coping and the fundamental life stances
that comprise coping—that is, the coping intervention paradigm may need to match the patient’s coping paradigm. On
the other hand, for those whose own coping paradigm is
primarily strategy-oriented, the more usual educational and
cognitive-behavioral approach may be a closer treatment
match, and thus (potentially) more effective. This possibility
could be tested through randomized controlled trials.
However, before engaging in intervention studies, it is
important to better understand the linkages among world/life
views and attitudes learned in early life; beliefs and attitudes
specific to pain; pain coping definitions, beliefs and activities;
and pain outcomes. We have evidence that certain beliefs
about pain (e.g. pessimism about recovery, the belief that work
will make the pain problem worse) are associated with poorer
recovery outcomes [57–59]. However, our understanding of
these linkages is limited and questions remain. For example, if
an individual grows up with models of needing to be “tough”
(or alternatively “positive”) when facing adversity such as
pain problems, what implications does that have for his or her
attitudes toward pain, how he or she copes, and openness to
modifying maladaptive beliefs, attitudes and ways of dealing
with pain?
Our study has strengths and weaknesses. The social phenomenological approach used to explore the personal meanings of coping is well-suited to this research aim, and those
participating in this study were representative of the target
population, which was individuals with pain problems of a
severity as to lead to work disability. This is a socially and
clinically relevant group, given both the personal and societal
costs of work disability. However, these findings arise from
a relatively small sample, and may not reflect the experience
and ideas of persons with less severe or more acute pain problems, or those who have not sought rehabilitation. It may also
be that volunteers to this type of study relate different experiences and conceptualizations than non-participants would
have, and that the phenomenon of coping might be viewed
very differently by these groups. However, the ways of coping
mentioned by participants (e.g., exercise, medications, talking with others, mental imagery, avoidance of those activities
that hurt) are typical of those strategies endorsed in larger,
quantitative studies.
©  Informa UK, Ltd.
1189
Quantitative studies conducted to date have lead to significant advances in our understanding of coping and pain
outcomes. However, the findings in this study suggest that
the use of strategy-oriented coping questionnaires when
conducting research on coping and its role in pain disability and recovery may not capture all the relevant information. The addition of qualitative methods to explore pain
patients’ personal meanings of coping and the associated
fundamental life stances that comprise coping can help us
to better understand and contextualize the existing findings
from quantitative studies and develop new ways of addressing the issues. Quantitative and qualitative studies arise from
different research paradigms, and produce different levels of
meaning [60]. Integrating these complementary approaches
by respecting what knowledge each brings can aid in formulating a more complete, embodied picture of coping with
chronic pain.
Declaration of Interest: This study was made possible by a
grant from WCB-Alberta Research Program.
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