Toward a science and practice of resilience in the face of pain

Authors: Liesbet Goubert & Hester Trompetter

AIM

This topical review asks how a resilience perspective might broaden our understanding of adaptation to persistent pain. The authors are particularly interested in why some people continue to function well and maintain meaningful lives despite experiencing substantial pain.

Their central proposal is that adaptation can be understood through two related processes: recovery, such as reducing disability or distress, and sustainability, meaning maintaining or rebuilding positive aspects of life in the presence of pain. They explore several psychological theories that might help explain this second process and identify potentially modifiable resilience mechanisms.

METHODS

This is a topical and conceptual review, rather than a systematic review designed to comprehensively identify or quantitatively synthesise all available evidence.

The authors searched Web of Science and PubMed for literature concerning risk and resilience in pain, then used this literature to develop their argument. They draw particularly on three theoretical traditions: the Psychological Flexibility Model, the Broaden-and-Build Theory of positive emotions, and Self-Determination Theory (SDT).

The paper therefore brings together theory and empirical findings from observational, experimental and intervention research. Its main contribution is conceptual: proposing a way of understanding resilience in pain and identifying mechanisms and outcomes that may deserve greater attention in research and clinical practice.

RESULTS / FINDINGS

The authors propose defining resilience in pain as the capacity to restore and sustain a fulfilling life in the presence of pain. An important part of their argument is the distinction between recovery and sustainability.

Recovery concerns returning towards previous functioning or reducing adverse consequences such as disability, depression and distress. Much existing pain research already addresses this dimension.

Sustainability concerns maintaining or developing positive functioning despite pain: engaging in meaningful activities, experiencing psychological and social well-being, pursuing personally valued goals and continuing to participate in life.

The distinction matters because reduced distress and positive well-being are related but not necessarily opposite ends of a single continuum. Someone may therefore experience ongoing pain or some disability while simultaneously having meaningful relationships, pursuing valued activities and experiencing positive aspects of life.

From this perspective, the authors propose complementing the study of risk mechanisms with the study of resilience mechanisms. Pain research has developed substantial knowledge around processes such as fear, catastrophising and avoidance. A resilience approach additionally asks what processes help people continue moving towards meaningful lives.

Three possibilities receive particular attention.

The first is psychological flexibility: the capacity to remain in contact with difficult experiences while adapting behaviour according to the situation and pursuing personally meaningful values and goals. This includes processes such as acceptance, mindfulness, values and committed action. The authors describe evidence associating greater psychological flexibility with better physical and psychological functioning and discuss Acceptance and Commitment Therapy (ACT) as an intervention designed to develop these processes. Intervention evidence available at the time suggested potentially useful effects, although studies frequently involved small samples and inactive comparison groups.

The second is positive affect. Drawing on Broaden-and-Build Theory, the authors propose that positive emotions may do more than indicate that somebody is doing well. Experiences such as enjoyment may broaden attention and behavioural possibilities and, over time, contribute to psychological and social resources. Studies discussed in the review link positive affect with pain sensitivity, recovery from pain and buffering of negative emotional states. However, direct research on positive psychology interventions specifically for people with chronic pain was still at an early stage.

The third is satisfaction of basic psychological needs, drawn from Self-Determination Theory. SDT proposes three fundamental needs: autonomy, experiencing choice and volition; competence, experiencing oneself as capable; and relatedness, feeling meaningfully connected with others.

Pain can interfere with each of these. Conversely, environments that support autonomy, competence and connection may help people maintain motivation and engagement in meaningful activities. The pain-specific evidence was relatively limited, but studies discussed by the authors suggest potentially relevant roles for autonomy-supportive communication from clinicians and support from partners.

Together, these ideas form the paper’s proposed dual-factor model. Adaptation to persistent pain involves both processes that reduce or buffer disability and distress and processes that support positive functioning. Psychological flexibility, positive emotions and psychological need satisfaction are proposed as potentially important mechanisms connecting these two dimensions.

LIMITATIONS & INTERPRETIVE CAUTIONS

The paper’s strength lies primarily in its conceptual integration. It connects several established psychological traditions with pain research and draws attention to an aspect of adaptation that can be overlooked when outcomes are defined mainly through pain, disability and psychological distress.

The empirical support is less developed than the conceptual framework. Evidence differs considerably across the proposed mechanisms. Psychological flexibility and ACT had received substantial pain-specific research attention, whereas the application of Self-Determination Theory and positive psychology interventions to persistent pain was comparatively early in development.

The underlying evidence also includes a mixture of cross-sectional associations, experimental studies, longitudinal research and intervention trials. These forms of evidence contribute differently to understanding whether a proposed factor predicts resilience, causes better outcomes, or can successfully be modified to improve people’s lives.

The authors themselves identify another important methodological issue: constructs such as psychological flexibility describe dynamic processes, yet much of the research had measured them using questionnaires at a single point in time. Diary studies, experimental approaches and longitudinal designs may better capture how resilience processes change within individuals and interact with pain over time.

Finally, this is a selective topical review rather than a systematic evidence synthesis. The three theories provide plausible and potentially useful perspectives on resilience, but their selection and integration represent the authors’ conceptual proposal rather than an exhaustive comparison of all possible models of adaptation to pain.

IN PRACTICE

For physiotherapy, perhaps the most useful contribution of this paper is the distinction between helping someone recover from a problem and helping them sustain a good life while dealing with it.

These goals can coexist. We might assess whether pain interference, disability or distress are improving while also asking whether someone is returning to activities they value, reconnecting socially, experiencing enjoyment, developing confidence and pursuing meaningful goals.

This becomes particularly relevant when pain persists. If success is defined entirely through pain reduction or removal of disability, important improvements in a person’s life may remain invisible. A resilience perspective creates space for another clinically meaningful trajectory: living increasingly well even while some symptoms remain.

The proposed mechanisms also offer useful questions rather than a rigid treatment recipe. Is rehabilitation helping this person make choices that feel genuinely their own? Are they developing competence and confidence? Are they reconnecting with meaningful people and activities? Can difficult sensations and emotions coexist with movement towards valued goals? Are there opportunities for enjoyment and positive experiences within rehabilitation rather than rehabilitation becoming entirely organised around correcting problems?

There is also an interesting implication for outcome measurement. Measuring pain intensity and disability captures only part of the model proposed in this paper. Outcomes such as values-based activity, vitality, well-being and meaningful participation may reveal changes that conventional symptom-focused measures overlook.

The evidence presented in this review supports different parts of these ideas to different degrees, so the framework is better understood as a promising direction for thinking, measurement and research than as evidence for one established resilience treatment.

More broadly, it raises a valuable clinical question: when we say that someone with persistent pain is “getting better”, what exactly do we mean? Recovery from pain-related difficulties is one possibility. Increasing capacity to build and sustain a meaningful life is another. This paper argues that pain rehabilitation may benefit from paying attention to both.

Reference

Goubert, L., & Trompetter, H. (2017). Toward a science and practice of resilience in the face of pain. European Journal of Pain, 21(8), 1301–1315. https://doi.org/10.1002/ejp.1062