Enmeshment and chronic pain
Chronic pain is by its nature prolonged and aversive, generally causing considerable disruption to the sufferer’s life. Pain can present overwhelming obstacles to normal activities: work, leisure, and relationships with family and friends. The subjectivity of the experience can impose real isolation, and the personal meaning of pain and its impacts may threaten the individual’s sense of who he or she is (Clyde and Williams 2002; Morley and Eccleston 2004). Researchers and clinicians have only recently begun to study the impact of pain on future possible health and self-identity. Reviews consistently show that depression in pain is significantly higher than in the general population, and often higher than in other medically ill populations (Banks and Kerns 1996; Fishbain et al. 1997; Sullivan et al. 1992), which leads to the important issue of what it is about chronic pain that causes such distress.
Pain and the self
Persistent pain can generate interruptions to attention, memory processes and current thinking, interference with a range of everyday activities, and can pose a threat to identity. Morley and Eccleston (2004) have therefore proposed the framework of the three levels of interruption, interference, and identity. They referred to the tremendous value of pain as a threat and the capacity to threaten a person at different levels and argue that problem-solving similarly needs to occur at each level. It has been argued that chronic pain establishes itself in the context of an ongoing and unfolding personal dynamic related to the current stage of a life cycle. Pain will impact on ongoing developmental tasks and particular goals determined by motivational states and earlier experiences (Morley and Eccleston 2004). While a wealth of experimental studies have shown that the extent of the interruption is a function of stimulus characteristics and individual differences in threat perception (Eccleston and Crombez 1999), the effect of interference with activities of daily life can be seen in the frequent reports of frustration made by chronic pain patients (Harris et al. 2003; Morley et al. 2005; Price 1999; Wade et al. 1990). More specifically, Morley and Eccleston (2004) suggest the interference with mundane ‘low-level’ everyday tasks is psychologically significant because they put a burden on others and exert pressure on the sufferer to redefine the self. In addition, there is evidence linking self-reported depression in chronic pain to interference with social roles (Harris et al. 2003; Morley and Eccleston 2004). A key issue in any threat to identity is whether repeated interference with major goals will impact on the self-schemas and therefore on the person’s identity (Leventhal et al. 1999). In pain, it has been suggested that current pain interferes with an individual’s current tasks, plans, and goals and causes a ‘biographical disruption’ (Bury 1988) that changes the person’s perspective of himself or herself with regard to the past and future (Hellstrom et al. 2000, 2001). Biographical disruptions appear to enhance emotional distress, and might lead to anxious and depressed mood, which in turn might inhibit active problem-solving (Morley and Eccleston 2004; Morley et al. 2005).
How pain might impact on identity can be further understood by the psychology of motivation and goal-related behaviour, as encompassed in self-regulation and self-discrepancy theories. However it would be beyond the scope of the present chapter to review the various conceptualizations in contemporary psychology (Carver and Scheier 1999; Carver et al. 1999; Karoly 1999; Oatley 1992; Higgins 1997). Goals are often classified into ‘approach’ goals, a tendency to reduce the discrepancy between the current position and the goal, and ‘avoidance’ goals, which require the person to increase the discrepancy between the current state and the goal (Carver and Scheier 1998, 1999). A crucial implication that follows from the frameworks of both Higgins’ and Carver and Scheier is that individuals who are dominated by avoidance goals are more likely to experience anxiety and fear when these goals are threatened. In contrast, individuals whose primary goal state is approach-oriented will experience a sense of loss and sadness when these goals are threatened. Self-discrepancy theory (Higgins 1987, 1997) proposes that the self is represented in three domains, actual, ideal, and ought self. The common method used in self-discrepancy research asks participants to generate a list of descriptors that characterize the various aspects of the self. Studies have confirmed the relationship between self-discrepancies and experienced affect (Higgins 1987, 1997; Higgins and Tykocinski 1992; Higgins et al. 1994). However, selfdiscrepancy methodology has been criticized on grounds that it does not directly assess particular explicit goals, and attributes represent rather meta-cognition and the representation of a person’s motivation and goals (Morley and Eccleston 2004). It has been argued that self-regulation and self-discrepancy theory might provide a useful framework for understanding the variety of emotional experience in chronic pain patients by providing a starting point for more compelling systematic research in this area (Morley and Eccleston 2004). In a first attempt, Morley et al. (2005) developed a new method of assessing future possible selves (Ross and Buehler 2004) and self-pain enmeshment (Pincus and Morley 2001), which was based on self-discrepancy theory (Higgins 1987, 1997) and the concept of possible selves, which was introduced by Markus and Nurius (1986). Chronic pain patients generated characteristics describing their current actual self, hoped- for self, and feared-for self, and made judgements about the degree to which their future possible selves (hoped-for and feared-for) were dependent on the absence or presence of pain, as an indicator for pain enmeshment. Analyses showed that the degree of role interference attributable to pain, and the proportion of hoped-for self characteristics that could be achieved even in the presence of pain predicted the magnitude of depression and acceptance scores. Finally, it should be noted that self-regulation and self-discrepancy theories, which have not been developed in the context of chronic pain, do not appear to make predictions concerning the enmeshment of pain and self as encapsulated in the Schema Enmeshment Model of Pain (SEMP; Pincus and Morley 2001), which is described below, and future research will have to examine its appropriateness for the field of chronic pain.