Chronic pain means persistent or prolonged pain, usually with no or insufficient physical evidence to explain the pain (Dilling & Freyberger, 2019), that has far-reaching consequences for individuals’ private and working lives (e.g., Sagula & Rice, 2004). Chronic pain is one of the most significant causes of suffering worldwide (Lohman et al., 2010). People with chronic pain disease often experience a lack of symptom control, increased risk of unemployment, severe social withdrawal and diagnostic obscurity; all of which can lead to hospitalization (Egloff et al., 2009). While the exact prevalence is unclear, a large proportion of the population suffers from chronic pain, with prevalence estimates varying between 10.1 and 55.2% (Ospina & Harstall, 2002). In the United States, estimates show that 20.4% of adults (i.e. 50.0 million) have chronic pain and 8.0% of adults (19.6 million) have high-impact chronic pain (i.e. interfering with work or life nearly every day; Dahlhamer et al., 2018). In Europe, chronic pain affects approximately 20% of the population (van Hecke et al., 2013).
Since chronic pain is such a prevalent cause of suffering, effective interventions that address its complexity are of great importance. Although pain is described as a biopsychosocial phenomenon, pain research often focuses on the biological aspects of pain, whereas additional efforts are needed to clarify the role of psychological and social factors to improve interventions (Truchon, 2001). Biological, psychological and social aspects not only influence the amount and severity of pain, but pain also produces biological, psychological, and social changes, such as changes in the nervous system pathways (biological), coping efforts and beliefs about pain (psychological), emotional distress of spouses (social) and others that can affect responses to pain (Keefe & France, 1999). One relevant factor for chronic pain patients is their handling of and mindset toward stress. Chronic pain patients subjectively experience stress more frequently compared to people without chronic pain and have an objectively higher stress level, i.e. higher cortisol levels (Van Uum et al., 2008). Strain due to stress, on the other hand, can influence the pain processing of the central nerve system (CNS), which makes a speedy reduction or elimination of the pain unrealistic (Egloff et al., 2009). Chronic pain thus seems to elevate stress levels, which in turn leads to the persistence or even increase of chronic pain. Thereby, research on the so-called stress mindset shows that an individual’s attitude towards stress is important in handling stress and experiencing well-being outcomes (Crum et al., 2013). A stress mindset refers to an individual’s belief about whether stress is perceived to benefit performance, productivity, health and growth (referred to as the stress-is-enhancing mindset) or whether it is more likely to negatively impact these variables (referred to as the stress-is-debilitating mindset; Crum et al., 2013). Initial research into children with chronic pain suggests that chronic pain patients more often have a stress-is-debilitating mindset (Heathcote et al., 2018), which, in turn, may negatively affect their coping behaviors, such as active coping and positive reframing, as previous stress mindset research suggests (Crum et al., 2013, 2017). Positive reframing means trying to look at a situation from a more positive perspective or finding something good in what happened to you, while active coping means focusing on trying and/or taking action to change something about the stressful situation you are in (Knoll et al., 2005). Such coping behavior has been shown to positively affect well-being, leading to, e.g., less substance use or self-harming behavior and more satisfaction with weight, vitality and sleep (Chua et al., 2015).
At the same time, chronic pain patients can cause their spouses, peers and others emotional distress (Keefe & France, 1999), which can result in unresolved social stress for the chronic pain patient. Unresolved social stress, in turn, can be a risk factor for the chronification of the pain (Zimmermann, 2004). Another cause of social stress may be a lack of social identification, which is defined as “the positive emotional valuation of the relationship between self and ingroup” (Postmes et al., 2013, p. 599), where “ingroup” means a social group to which a person belongs. Chronic pain patients frequently withdraw from their social environment (Beeckman et al., 2020; Egloff et al., 2009) and have lower levels of social functioning (Simons et al., 2010) and social competence (Varni et al., 2006), which could lead them to identify less with their social groups. The perceived difference between the impaired self and one’s healthy peers, might also contribute to a lower level of social identification in chronic pain patients. A high level of social identification, on the other hand, is proven to have a beneficial outcome on psychological and physical health (e.g., Postmes et al., 2019; Steffens et al., 2017). Hence, a chronic pain disorder appears to lead to a lower level of social identification, while a high level of social identification, in contrast, would be beneficial for the physical and mental well-being of chronic pain patients. Given that individuals with chronic pain are likely to identify less with their social groups, this might negatively affect their coping behaviors, specifically instrumental and emotional support coping, which, in turn, would negatively affect their well-being. Instrumental support coping concerns either trying to ask or actually asking others for help or advice, while emotional support coping includes receiving encouraging support or sympathy from others or being comforted by others (Knoll et al., 2005). If chronic pain patients do not socially identify with their peers, they are probably less likely to seek instrumental or emotional support from them. However, using instrumental or emotional support coping would benefit their well-being (e.g., Crabtree et al., 2010; Sani et al., 2012).
This study aims to advance the biopsychosocial model of chronic pain by examining chronic pain patients’ stress mindset and social identification as important mechanisms in explaining why those participants engage in less beneficial coping behavior, which, in turn, influences their well-being. In doing so, we develop a model in which participants’ stress mindsets and social identification as well as their coping behavior mediates the relationship between chronic pain and well-being. In this study, we focus on general well-being and depressive symptoms as indicators of health, because we want to examine one positive and one negative indicator for people’s well-being, which is defined as “optimal psychological functioning and experience” (Ryan & Deci, 2001, p. 142), while depression means that an individual suffers from a range of depressive symptoms, e.g., depressed mood, loss of interest and enjoyment, reduced energy and diminished activity (Dilling & Freyberger, 2019). By examining and highlighting the pivotal role of chronic pain patients’ stress mindset and social identification, this study has important practical implications: To interrupt the upholding mechanism of chronic pain and to improve the well-being of chronic pain patients. Therapeutic interventions comprising stress education and how to foster social identification may be effective.
Theory and Hypothesis Development
Chronic Pain and Well-Being
Chronic pain often leads to insomnia, substance abuse, trust issues and problems in interactions with family and/or friends, as well as to losses in relationships, at work or in other areas of life (Sagula & Rice, 2004). It can also impede mobility and lead to a loss of physical strength, an impaired immune system, bad appetite, poor diet, dependence on medicine and/or caretakers/family, excessive use of the healthcare system, poor job performance or inability to work, isolation from society or family, anxiety, acrimony, frustration, depression or even to suicide (Niv & Devor, 2001). Altogether, chronic pain can create a negative downward spiral (Sagula & Rice, 2004) that not only affects physiological, but also psychological and social aspects (e.g., Lohman et al., 2010). Hence, it is not surprising that Gureje et al. (1998) find that chronic pain is associated with psychological illnesses, such as depression or anxiety disorders.
Chronic pain should therefore also affect a person's overall well-being, i.e., their “optimal psychological functioning and experience” (Ryan & Deci, 2001, p. 142). This definition is in line with that of the World Health Organization (WHO; Huber et al., 2011), which emphasizes that all three aspects of well-being—physical, psychological and social—are relevant. Indeed, Björnsdóttir et al. (2014) show that chronic pain patients report worse quality of life and less well-being compared to people without chronic pain. In summary, the literature implies that chronic pain patients have lower general well-being and poorer mental health than people without chronic pain. As depression is one of the most frequent mental illnesses (Lehtinen & Joukamaa, 1994) and therefore a common cause of bad mental health, we used depression as a negative indicator for well-being. Therefore, we predict:
Chronic pain patients report lower general well-being and more depression than people without chronic pain.
Stress Mindset and Chronic Pain
Chronic pain patients subjectively experience more stress than people without chronic pain, and hair sample analyses reveal that they have higher cortisol levels (Van Uum et al., 2008). Flor et al. (1985) show that patients with chronic back pain have higher muscular reactivity in their backs and return to the reactivity baseline slower when they discuss personally stressful situations. This was not the case for patients with chronic pain in other body parts. Those findings imply that chronic pain patients’ stress-related responses might play an important role for handling their chronic pain and that those patients show significant differences concerning stress compared to people without chronic pain. Stress is defined as the “relationship between the person and the environment that is appraised by the person as taxing or exceeding his or her resources and endangering his or her well-being” (Lazarus & Folkman, 1984, p. 21). Therefore, stress is “the experience of encountering or anticipating adversity in one’s goal-oriented efforts” (Carver & Connor-Smith, 2010, p. 684).
Despite the adaptive nature of the human body’s physiological response to stress (Sapolsky, 1996), the media and popular literature largely portray stress as something negative (Crum et al., 2013). However, individuals’ attitudes towards stress, i.e., their stress mindset, significantly influence their stress response. According to Crum et al. (2013), individuals differ whether they have a stress-is-enhancing mindset (SIE) or a stress-is-debilitating mindset (SID). An SIE mindset describes the perception that stress leads to better performance, productivity, health, well-being, learning and growth. An SID mindset, on the other hand, comprises the perception that stress negatively influences those variables (Crum et al., 2013). Individual’s mindsets affect their evaluation (e.g., Taylor & Gollwitzer, 1995), their behavior (e.g., Liberman et al., 2004) and their health (e.g., Crum & Langer, 2007). An SIE mindset influences evaluation, as it leads to a higher attention bias for positive stimuli and a higher level of cognitive flexibility (Crum et al., 2017), which might influence coping behaviors like positive reframing that could result in a better health.
Even though previous research shows that people with and without chronic pain differ in the stress they experience, it is unclear if there are also differences in their stress mindsets. Ben-Avi et al. (2018) assume that it is harder for a person to develop an SIE mindset if they are exposed to chronic stressors. As chronic pain patients are exposed to chronic stressors from their chronic pain and because they have heightened stress levels compared to those without chronic pain (Van Uum et al., 2008), the elevated strain due to their heightened stress likely leads to a negative view of stress, i.e. an SID mindset. Indeed, initial evidence supports this proposition: Heathcote et al. (2018) show that children with chronic pain are more likely to have an SID mindset than an SIE mindset compared to children without chronic pain. Within those children with chronic pain, those who had an SID mindset showed significantly more pain-related distress, such as fear of pain and pain catastrophizing and more functional constraints, such as activity limitations. Building upon this previous research, we predict:
Chronic pain patients report a lower SIE mindset compared to people without chronic pain.
Relationship Between Stress Mindset, Coping and Well-Being
Crum et al. (2013) show that the stress mindset is a significant predictor for health and life satisfaction. They argue that individuals with an SIE mindset report better health than those with an SID mindset. This could be especially relevant for chronic pain patients. It has been shown that having an SIE mindset leads to more positive affect (Crum et al., 2017). Positive affect on the other hand, was identified as a predictor for a lower pain level in chronic pain patients, while negative affect leads to a higher pain level (Zautra et al., 2005). Therefore, an SIE mindset may positively impact the pain level and well-being of chronic pain patients.
The question is which mechanism beyond affect is relevant for the influence of the stress mindset on health. Crum et al. (2013) suggest different associations of the stress mindset with motivational and physiological processes as a theoretical basis of this effect. They propose that an individual’s stress mindset influences how that person views stress psychologically as well as how they react to stress behaviorally. How a person responds to stress is described as coping, which is defined as “constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person” (Lazarus & Folkman, 1984, p. 141). Thus, coping is necessary for handling stressful situations (Folkman et al., 1986; Knoll et al., 2005) and it can improve well-being (e.g., Chua et al., 2015). Coping behaviors can be maladaptive (e.g., denial or avoidance) or adaptive (e.g., active coping or positive reframing) (Folkman & Lazarus, 1985). Crum et al. (2013) argue that a person with an SIE mindset would have the primary motivation to accept stress and utilize its positive consequences. Thus, this person would rather use a behavior that satisfies the requirements, the value or the goal, which underlie the stressful situation. Handling of stress in this way can best be classified as active coping, which means focusing on trying and/or taking action to change something about the stressful situation you are in (Knoll et al., 2005).
The literature implies that the stress mindset may also affect the coping behavior positive reframing, as the stress mindset influences cognition and affect. An SIE mindset leads to more positive affect, more attention to positive stimuli and higher level of cognitive flexibility (Crum et al., 2017). This could lead to people with SIE mindsets being more likely to positively reframe, as this coping behavior is based on such described cognitive processes. Specifically, positive reframing comprises looking at a situation from a more positive perspective or finding something good in what happened to you (Knoll et al., 2005). An SID mindset, however, may worsen those cognitive and affective outcomes (Crum et al., 2017). Hence, we predict:
An SIE mindset is associated with a more frequent use of positive reframing and active coping.
The beneficial impact of coping behaviors on well-being is well documented (e.g., Chua et al., 2015). Positive reframing is also a key psychotherapeutic technique in treating several mental illnesses, especially depression (e.g., Conoley & Garber, 1985). Therefore, we predict:
A more frequent use of positive reframing and active coping is related to a higher general well-being and less depression.
Combining these two hypotheses, we expect that chronic pain patients—compared to people without pain—report a lower SIE mindset, leading to less use of positive reframing and active coping, which, in turn, relates to their well-being. Thus, we predict:
The relationship of chronic pain with general well-being and depression is mediated by (1) an individual’s stress mindset and (2) their use of positive reframing and active coping.
Chronic pain is not only influenced by biological and psychological factors, but also by social factors (Ehde et al., 2014; Turk & Okifuji, 2002). One crucial social driver for one’s well-being is social identification (e.g., Steffens et al., 2017), which refers to a person’s relationship to a social group and the positive emotional evaluation of this relationship with a person or a group (Postmes et al., 2013). Meta-analyses find that greater levels of social identification are associated with less depression (Postmes et al., 2019) as well as with better psychological and physical health (Steffens et al., 2017). Social identification could also be an important factor for chronic pain patients. The same area of the brain that is responsible for the degree of pain a person feels—the cingulate gyrus (ACC)—is also responsible for the feeling of loneliness (Spitzer & Bonenberger, 2012). This means that when a person feels pain, the same brain area is activated as when they feel lonely or socially isolated. Researchers also assume that chronic pain can lead to loneliness, which can ultimately lead to depression (Spitzer & Bonenberger, 2012). Indeed, research shows that chronic pain patients have lower levels of social functioning (Simons et al., 2010), fewer social skills (Varni et al., 2006), and that they withdraw frequently from social interactions (Beeckman et al., 2020; Egloff et al., 2009). Haslam et al. (2016b) argue that difficult life transitions, like being diagnosed with a disease, can cause the loss of social relationships, which appears to apply for chronic pain patients. If chronic pain patients, on the one hand, withdraw from their social relationships and belong to fewer groups, they can also identify with fewer such groups, which will result in them having a lower level of social identification compared to people without chronic pain. On the other hand, chronic pain patients might view their belonging to social groups as less favorable, due to their chronic pain, which may also decrease their social identification. Klapow et al. (1995) show that chronic pain patients are less satisfied with the social support they receive from their environment compared to pain patients with a lower pain level. Such dissatisfaction may lower their social identification, because it might lead to a more negative emotional evaluation of the relationship. Furthermore, the negative aspects of a social relationship cloud the positive qualities in difficult times (Davis et al., 2004). It may be possible, that the greater strain experienced by chronic pain patients (e.g., Lohman et al., 2010) causes negative aspects of social relationships to be more ostensible in their perception. This would in turn also lead to a more negative emotional evaluation of those social relationships and thus to a lower level of social identification. Thus, we predict:
Chronic pain patients report a lower level of social identification compared to people without chronic pain.
Relations Between Social Identification, Coping and Well-Being
Social identification is an important basis for social support, which buffers stress (Haslam et al., 2005), protects mental health (Sani et al., 2012), and increases well-being (Crabtree et al., 2010). This could be especially relevant for chronic pain patients, who—as Hypothesis 1 argues—appear to already have an impaired well-being (e.g., Björnsdóttir et al., 2014) and have a lower level of social identification—as the previous section argues.
Following arguments of Haslam et al. (2016c), if individuals identify with their social groups, they are likely to receive more social support from them (Haslam et al., 2005). Seeking social support can be a coping behavior (Knoll et al., 2005). Social support can be divided into instrumental and emotional support—the former concerns either trying to ask or actually asking others for help or advice, while the latter comprises receiving encouraging support or sympathy from others or to be comforted by others (Knoll et al., 2005). If people identify less with social groups, they will likely seek and receive less instrumental and emotional support (Haslam et al., 2005), and use these coping behaviors less often. For example, if a person with chronic pain does not identify with another person or a group, they are probably less likely to ask to be taken to the doctor (instrumental support) or to ask them to come over to talk on days when the pain is especially strong (emotional support). Thus, they would be less likely to receive support. Therefore, we predict:
A higher level of social identification is associated with a more frequent use of instrumental and emotional support coping.
Social support positively influences mental health (Sani et al., 2012) and well-being (Crabtree et al., 2010). Research shows that social support is greatly relevant for well-being, especially in chronic pain patients. For example, active or passive support of another person can reduce pain (Brown et al., 2003). Likewise, Master et al. (2009) provide an overview of studies, which document the pain-attenuating effect of social relationships and show that even the mental representation of a loved, supporting person (e.g., looking at a picture of this person) can reduce pain. The importance of social identification and social support for pain reduction has also been shown experimentally. Platow et al. (2007) show that people who experience experimental pain in a laboratory setting (immersing a hand into a bath of ice water) report less pain when they receive support from a group member with whom they identify, than when they receive support from a group with which they do not identify. Hence, we predict:
A more frequent use of instrumental and emotional support coping is related to a higher general well-being and less depression.
In summary, we propose that chronic pain patients (compared to people without pain) report a lower level of social identification, which influences the amount of instrumental and emotional support that they seek and receive, and, ultimately relates to their well-being. Hence, we predict:
The relationship of chronic pain with general well-being and depression is mediated by (1) an individual’s social identification and (2) their use of instrumental and emotional support coping.
As the hypotheses contain a comparison between chronic pain patients and people without chronic pain, a quasi-experimental study design was implemented. Figure 1 shows an overview of the hypotheses.