Belief in living a meaningful life and adjustment to chronic pain

Abstract

Objective

Chronic pain is a global health concern and often interferes with multiple aspects of individuals’ lives (eg, physical activities), diminishing a person’s ability to engage in activities that promote meaning in life. However, it is not well understood how believing that one can live a meaningful life despite pain could contribute to improved function among individuals with chronic pain. The aim of the present study was to better understand the role that belief in living a meaningful life despite pain might have on adjustment to chronic pain.

Methods

Participants (n = 164) were individuals with chronic pain who completed baseline data from 2 closely related randomized clinical trials. Hierarchical regression analyses were used to examine the hypotheses that one’s belief in living a meaningful life despite pain will be associated with function (pain interference and symptoms of posttraumatic stress disorder, depression, and anxiety) and that the belief in living a meaningful life despite pain would moderate the associations between pain intensity and function.

Results

Belief in living a meaningful life despite pain was significantly associated with less pain interference and less severe symptoms of posttraumatic stress disorder, anxiety, and depression, supporting the potential role of this variable in adaptive adjustment to chronic pain. However, one’s belief in living a meaningful life despite pain did not moderate the associations between pain intensity and function.

Conclusions

Results provide important theoretical and clinical information about how believing that one can live a meaningful life despite pain might serve as an important process for adjustment to chronic pain.

Chronic pain, usually defined as pain lasting at least 3 months,¹ is a global public health concern,² affecting 28% of individuals worldwide.³ Chronic pain often interferes with multiple aspects of individuals’ lives (eg, physical activity, mood, and social support^4–7), severely diminishing a person’s ability to engage in activities that promote meaning in life. However, it is not well understood how believing that one can live a meaningful life despite pain might contribute to improved function among individuals who have chronic pain.

The connections among pain beliefs, how individuals cope with their pain, and physical and mental health function have been a top priority for clinicians and researchers,^8–12 resulting in the widespread adoption of the biopsychosocial perspective of chronic pain.^10,11,13 Pain beliefs and how individuals cope with their pain include how individuals make meaning from their pain.⁹ The importance of these beliefs is recognized in many cognitive–behavioral therapy protocols, which often target pain-related beliefs and coping styles (eg, pain catastrophizing) while simultaneously increasing activities that are pleasurable or maintain a sense of meaning.^14,15

Managing stressful experiences, such as chronic pain, is an iterative process involving appraisals of the event interacting with pre-existing beliefs, values, and sense of meaning in life.¹⁶ To better understand the interrelationships among these factors, Ferreira-Valente and colleagues⁹ conducted interviews with 18 individuals with chronic pain and applied Park’s meaning-making model to the interview content. Results showed that although some pain appraisals characterized pain as a loss and a threat, pain can also coincide with changes in how people find purpose in the world. After interviewing 70 individuals with chronic pain, most of whom had either moderate or severe depression symptoms, Costanza and colleagues (2021) noted that the experience of pain could negate the benefits of engaging meaningfully with life.¹⁷ Indeed, meaning in life and physical health are significantly associated with each other,¹⁸ and purpose in life, a component of meaning in life,¹⁹ is associated with lower physical quality of life.²⁰ Furthermore, in a set of 3 studies, Boring and colleagues²¹ highlighted how specific aspects of meaning in life might play a differential role in the experience of chronic pain. The authors found that believing that one’s life and the world made sense (ie, comprehension) was consistently associated with less pain frequency and severity, whereas believing that one’s life was significant (ie, existential mattering) and having a sense of purpose in life were not (indeed, existential mattering was associated with more pain severity in one study).

Although the studies cited are valuable contributions to the literature, most do not directly measure beliefs about how individuals might maintain a sense of meaning in life despite having pain. To the best of our knowledge, no published studies have examined the relationship between belief in one’s ability to live a meaningful life despite pain and physical and mental health function in a sample of individuals with chronic pain. Moreover, if individuals believe that they can live a meaningful life despite pain, they might be more likely to manage their experience of pain more effectively, attenuating the associations among pain intensity, pain interference, and other important pain-relevant constructs.

Given these considerations, the aim of the present study was to better understand the role that belief in living a meaningful life despite pain might have in adjustment to chronic pain. Specifically, we sought to test the hypotheses that belief in living a meaningful life despite pain is significantly associated with better function (ie, less pain interference and posttraumatic stress disorder [PTSD], anxiety, and depressive symptoms; Hypothesis 1) and that belief in living a meaningful life despite pain moderates the associations between pain intensity and function, such that higher levels of belief will be associated with reduced strength of any association(s) between pain intensity and function (Hypothesis 2).

Methods

Participants and procedure

Participants were individuals with chronic pain who completed baseline data from 2 closely related randomized clinical trials, the Back on Track trial (BOT; NCT03687762) and Living in Full Even with Pain Study (LIFE; NCT03916276). Both trials included 3 active conditions (cognitive therapy, mindfulness meditation, and behavioral activation) and had as their primary aim the identification of shared and unique treatment mediators. Both trials included adult (≥18 years of age) participants with an average chronic pain intensity and pain interference (pain intensity only for the LIFE trial) of at least 3 on a 0–10 numeric rating scale for more than half of the days during the prior 3 months. Both trials excluded participants whose primary condition was headache, who had acute pain from a recent surgery or injury, or who endorsed symptoms that could have prevented full participation in the trial (eg, suicidal intent). The primary differences between the 2 trials were (1) the primary outcome and (2) inclusion criteria. The primary outcome in the BOT trial was pain interference, and the primary outcome in the LIFE trial was opioid medication use. Also, whereas the BOT trial included only individuals with a primary pain condition of chronic low back pain, the LIFE trial included anyone with chronic pain other than headache and also included only individuals who had a daily average opioid morphine milligram equivalent ≥20 over the prior week.

All participants provided informed consent, and procedures were approved by the Institutional Review Board at the University of Washington. All data for the present study were collected before participants began one of the 3 previously described treatments. Data were collected via a telephone interview with research staff, with data entered into REDCap.^22,23 Belief in living a meaningful life despite pain was one of several measures that were described to participants in both studies as optional to complete. The data for the analyses presented here came from those participants in the BOT or LIFE trial who elected to complete the item assessing belief in living a meaningful life despite pain (n = 164 out of a total of n = 443; see “Measures” section).

Measures

Demographic characteristics

Participants provided information on age, sex assigned at birth, gender identity, self-identified ethnicity, self-identified race, educational level, and marital status.

Belief in living a meaningful life despite pain

The item “I think that I can live a meaningful life, even with pain” from the Positive and Negative Response to Pain Scale²⁴ was used to assess belief in one’s ability to live a meaningful life despite pain. Participants responded to the item on a scale ranging from 0 (“I never feel this when I feel pain”) to 4 (“I feel this all the time when I feel pain”). Higher scores indicate greater belief in one’s ability to live a meaningful life despite pain.

Pain interference

Five psychometrically validated items from the Patient-Reported Outcomes Measurement Information System—Pain Interference (PROMIS-PI⁷) item bank were selected by study investigators to assess pain interference for the BOT and LIFE studies (“How much did pain interfere with your … enjoyment of life / ability to participate in leisure activities / day-to-day activities / ability to participate in social activities / household chores?”). The items were selected with the goal of developing a scale that was as brief as possible (ie, minimizing assessment burden) and that was reliable (ie, that achieved an alpha >0.80 in a pain sample [n = 849]), while ensuring that the key domains of pain interference were covered, including the degree to which pain interferes with an individual’s physical function, mental/emotional function, and social activities.⁷ Participants responded to the items on a scale ranging from 1 (“not at all”) to 5 (“very much”). Responses were converted to T-scores, where, in the normative sample, 50 represents the mean with a 10-point standard deviation. Higher scores indicate more pain interference (Cronbach’s α in the present sample = 0.86).

PTSD symptom severity

The PTSD Checklist—Civilian version (PCL-C²⁵) was used to assess PTSD symptom severity. The PCL-C contains 17 items that correspond to each symptom of PTSD listed in the Diagnostic and Statistical Manual, 4^th Edition.²⁶ With the PCL-C, respondents rate the severity of each symptom on a scale of 1 (“not at all”) to 5 (“extremely”). Total scores are calculated, with higher scores indicating more PTSD symptom severity. The internal consistency (Cronbach’s α) in the present sample was 0.90, indicating excellent reliability.

Anxiety and depression symptom severity

To assess anxiety and depression symptom severity, we used the 4-item PROMIS-Anxiety and PROMIS-Depression scales.²⁷ For both scales, participants rated the frequency with which they experienced each symptom in the prior 7 days on a scale of 1 (“never”) to 5 (“always”). Responses were then converted to T-scores, with higher scores representing more severe symptoms of depression and anxiety. The internal consistency (Cronbach’s α) for these 2 measures in the present sample was 0.90 for the PROMIS-Anxiety scale and 0.89 for the PROMIS-Depression scale, indicating good and excellent reliability, respectively.

Average pain intensity

A numeric rating scale ranging from 0 (“no pain”) to 10 (“pain as bad as you can imagine”) was used to assess 7-day recalled average pain intensity. Higher scores represent higher levels of pain intensity. A great deal of evidence supports the reliability and validity of the 0–10 numeric rating scale for assessing pain intensity,^28–30 and consensus groups recommend its use in pain research.^28,31

Data analysis

We first computed descriptive statistics (means and standard deviations for continuous variables and frequency and percentages for categorical variables) for the demographic and study variables to describe the sample. We also computed Pearson correlation coefficients between the study variables for descriptive purposes. We then conducted assumption tests to ensure that the variables met criteria for the planned regression analyses. Specifically, we computed the skewness and kurtosis of the study measures to ensure that they were adequately normal. We used absolute values of skewness and kurtosis, ≤3 and 10, respectively, to indicate an absence of marked deviation from a normal distribution.³² Next, residuals’ homoscedasticity and normality of residual distribution were assessed graphically, through the visual inspection of the normal probability plot of the residuals.³³ We also completed Durbin–Watson statistic tests to evaluate errors’ independence. The absence of multicollinearity was evaluated by computing analysis of the variance inflation factors for the predictor variables. Variance inflation factors lower than 5 were deemed to indicate an absence of problematic multicollinearity.³⁴

After this, we conducted 4 linear hierarchical regression analyses, one for each criterion variable (pain interference and PTSD, anxiety, and depressive symptom severity) to test the study hypotheses. Step 1 included demographic control variables (ie, age and sex at birth). Average pain intensity was entered in Step 2. The measure of one’s belief in one’s ability to live a meaningful life despite pain was entered in Step 3, and a term representing the interaction of pain intensity × ability to live a meaningful life despite pain was entered in Step 4. Pain intensity and ability to live a meaningful life despite pain were centered before being entered into the models to make coefficients of any significant effects easier to interpret. A significant (P < .05) main effect of the ability to live a meaningful life despite pain predicting one or more criterion variables would support the first study hypothesis. A significant interaction would indicate that the ability to live a meaningful life despite pain moderated the association between pain intensity and the criterion variable. If an interaction was found to be statistically significant (P < .05), we planned to use Johnson–Neyman plots³⁵ to explore the values at which meaningful life despite pain moderated the relationship between PTSD symptoms and each criterion variable (ie, regions of significance). All data analyses were completed in R.³⁶

Results

Sample and clinical characteristics

See Table 1 for the sample’s characteristics. The average age of participants was 51.5 years (SD = 14), with 131 (80%) of the participants being assigned the sex of female at birth. Comparatively, 127 participants (77%) identified as women; 32 participants (20%) identified as men; 1 participant (1%) self-identified as nonbinary; and 1 participant (1%) self-identified as transgender. Most participants (n = 136; 83%) self-identified as White, whereas 10 participants (6%) self-identified as Black. Most participants had a bachelor’s degree (n = 44; 27%), some college or no degree (n = 41; 25%), an associate’s degree or similar (n = 24; 15%), or a master’s degree (n = 23; 14%). About half of the participants were married (n = 84; 51%).

Table 1.

Sample characteristics.

Characteristic	Value
Age, mean (SD)	51.5 (14)
Sex assigned at birth (female), n (%)	131 (80)
Self-identified gender identity, n (%)
Woman	127 (77)
Man	32 (20)
Nonbinary	1 (1)
Transgender	1 (1)
Declined to answer	2 (1)
Unsure	1 (1)
Self-identified ethnicity (Hispanic or Latino/a), n (%)	8 (5)
Self-identified race, n (%)
American Indian or Alaska Native	1 (1)
Asian	4 (2)
Black	10 (6)
Multiracial	8 (5)
Native Hawaiian or Pacific Islander	1 (1)
White	136 (83)
Other	2 (1)
Not reported	2 (1)
Highest education level achieved, n (%)
High school graduate or GED	13 (8)
Some college, no degree	41 (25)
Associate’s degree / academic program	24 (15)
Bachelor’s degree	44 (27)
Master’s degree	23 (14)
Doctoral degree	6 (4)
Occupational/technical/vocational program	8 (5)
Professional school degree	5 (3)
Marital status, n (%)
Married	84 (51)
Divorced	29 (18)
Never married	27 (17)
Living with significant other	11 (7)
Widowed	9 (6)
Separated	4 (2)
Primary type of pain
Neuropathic pain	30 (21)
Arthritis	28 (20)
Pain from injury	22 (15)
Fibromyalgia	20 (14)
Soft tissue or muscle pain	20 (14)
Spinal cord injury–related pain	15 (11)
Cancer pain	2 (1)
Menstrual pain	2 (1)
RSD/CRPS	2 (1)
Chronic fatigue	1 (1)
Temporomandibular pain	1 (1)

Abbreviations: RSD = reflex sympathetic dystrophy; CRPS = chronic regional pain syndrome.

Table 2 provides descriptive information for study variables. Average pain intensity (mean = 6.53; SD = 1.50) approached what could be considered severe pain.^37,38 Pain interference (mean = 66.36; SD = 5.47) was high, more than 1.5 standard deviations above the normative average. PTSD symptom severity (mean = 40.02; SD = 13.18) was above the suggested 30–35 cutoff score to indicate potential PTSD diagnosis in civilians in nonspecialty clinics.³⁹ Anxiety (mean = 56.39; SD = 10.30) symptom severity and depression (mean = 56.15; SD = 9.18) symptom severity were both greater than 0.5 standard deviation, but less than 1 standard deviation, of the normative average.

Table 2.

Means, standard deviations, and correlations among study variables.

Variable	Mean	SD	1	2	3	4	5	6	7
1. Meaningful life	3.13	0.96
2. Pain interference (PROMIS-PI)	66.36	5.47	−0.18b
3. PTSD symptom severity (PCL-IV)	40.02	13.18	−0.38c	0.34c
4. Anxiety symptom severity (PROMIS-Anxiety)	56.39	10.30	−0.23c	0.29c	0.75c
5. Depression symptom severity (PROMIS-Depression)	56.15	9.18	−0.42c	0.43c	0.71c	0.71c
6. Pain intensity (NRS)	6.53	1.50	−0.02	0.45c	0.16b	0.11	0.11
7. Age	51.48	13.61	0.05	0.03	−0.22c	−0.22c	−0.10	0.02
8. Sex at birtha	0.80	0.40	−0.07	0.18b	0.18b	0.14	0.22c	0.13	−0.14

Abbreviations: NRS = 0–10 numerical rating scale; PCL-IV = Posttraumatic Checklist for DSM-IV; PROMIS-Anxiety = Patient Reported Outcome Measurement Information System Anxiety Short Form v1.0, 4a; PROMIS-Depression = Patient Reported Outcome Measurement Information System Anxiety Short Form v1.0, 4a; PROMIS-PI = Patient Reported Outcome Measurement Information System Pain Interference short form made from 4 items selected by study investigators.

^a1 = female, and 0 = male.

^b P ≤ .05.

^c P ≤ .01.

Correlations between study variables

Table 2 also presents the correlation coefficients between study variables. As can be seen, belief in living a meaningful life despite pain was significantly associated with less pain interference (r[162] = −0.18, P = .021), in addition to less PTSD (r[162] = −0.38, P < .001), anxiety, (r[162] = −0.23, P = .003), and depression (r[162] = −0.42, P < .001) symptom severity. All other associations were weak and nonsignificant. Higher levels of pain intensity were significantly correlated with higher pain interference levels (r[162] = 0.45, P < .001) and PTSD symptom severity (r[162] = 0.16, P = .047). Pain interference, PTSD symptom severity, anxiety symptom severity, and depression symptom severity were all significantly related with each other, with the absolute values of correlation coefficients ranging from r[162] = 0.29 (P < .001) between pain interference and anxiety symptom severity to r[162] = 0.75 (P < .001) between PTSD and anxiety symptom severity.

Tests of Hypothesis 1: direct effects of belief in a meaningful life despite pain on adjustment to chronic pain

Table 3 presents results of the 4 regression analyses conducted to test Hypotheses 1 and 2. As can be seen, the extent that one believes one is living a meaningful life despite pain was significantly associated with less pain interference (b = −1.02, 95% CI: −1.78 to −0.26, P = .010) and less severe PTSD symptoms (b = −3.99, 95% CI: −6.06 to −1.92, P < .001), anxiety symptoms (b = −2.24, 95% CI: −3.81 to −0.67, P = .006), and depression symptoms (b = −3.83, 95% CI: −5.14 to −2.51, P < .001), after adjustment for pain intensity, age, and sex assigned at birth. The effect sizes of these associations ranged from small (−0.18 for pain interference) to medium (−0.40 for depression symptom severity).

Table 3.

Results of the regression analysis.

	Pain interferencea			PTSD symptomsb			Anxiety symptoms			Depressive symptoms
Step and variable(s)	b (Std.)	95% CI	P	b (Std.)	95% CI	P	b (Std.)	95% CI	P	b (Std.)	95% CI	P
Step 1 (control variables)
Age	0.02 (0.05)	−0.04 to 0.08	.501	−0.18 (−0.19)	−0.33 to −0.04	.014	−0.15 (−0.20)	−0.27 to −0.04	.009	−0.05 (−0.07)	−0.15 to 0.06	.379
Sex assigned (female)	2.59 (0.19)	0.49 to 4.68	.017	5.17 (0.16)	0.22 to 10.12	.042	2.91 (0.11)	−0.97 to 6.78	.143	4.84 (0.21)	1.37 to 8.30	.007
Step 2
Pain intensity	1.83 (0.41)	1.28 to 2.38	<.001	1.27 (0.14)	−0.05 to 2.58	.061	0.72 (0.10)	−0.32 to 1.76	.176	0.50 (0.08)	−0.43 to 1.43	.291
Step 3
Meaningful life	−1.02 (−0.18)	−1.78 to −0.26	.010	−3.99 (−0.38)	−6.06 to −1.92	<.001	−2.24 (−0.21)	−3.81 to −0.67	.006	−3.83 (−0.40)	−5.14 to −2.51	<.001
Step 4
Pain intensity × meaningful life	0.08 (0.02)	−0.43 to 0.58	.768	0.42 (0.05)	−0.81 to 1.65	.503	0.64 (0.09)	−0.39 to 1.66	.227	0.01 (0.00)	−0.85 to 0.88	.973

Bolded estimates are significant at P < .05. Std. = Standardized.

^aBecause there was a significant interaction between pain intensity and study, we began to include a study variable as a control variable in Step 1 (b = −0.05 [standardized = −0.00], 95% CI: −2.03 to 1.92, P = .959) and a pain intensity × study interaction in Step 2 (b = −1.50 [standardized = −0.17], 95% CI: −2.83 to −0.17, P = .028).

^bBecause there was a significant interaction between meaningful life and study, we began to include a study variable as a control variable in Step 1 (b = −2.14 [standardized = −0.07], 95% CI: −6.80 to 2.52, P = .370) and a meaningful life × study interaction in Step 3 (b = −5.08 [standardized = −0.16], 95% CI: −9.88 to −0.28, P = .040).

Tests of Hypothesis 2: moderating effects of belief in a meaningful life despite pain on the associations between pain intensity and adjustment to chronic pain

As can be seen in Table 3, the extent that one believes that one is living a meaningful life despite pain did not significantly moderate the association between pain intensity and any of the criterion variables (all P values >.05) after adjustment for pain intensity, age, and sex assigned at birth. The effect sizes of these associations ranged from negligible (<0.01 for depressive symptom severity) to small (0.09 for anxiety symptom severity).

Discussion

The study findings indicate that the belief that one is living a meaningful life despite pain is significantly associated with less pain interference and less severe symptoms of PTSD, anxiety, and depression. However, greater endorsement of the belief that one is living a meaningful life despite pain does not appear to moderate the association between pain intensity and various measures of function. These findings have important theoretical and clinical implications with respect to meaning-making in the context of chronic pain.

Theoretical implications

Previous literature has suggested that maintaining a sense of meaning and purpose may be associated with adaptive meanings made and greater physical and mental health functioning.^{9,12,16,18,40–42} Part of maintaining a sense of meaning and purpose could be the belief that one can live a meaningful life despite pain. An important question with regard to the mechanisms of these effects is whether belief in living a meaningful life despite pain has beneficial effects via (1) increasing overall resilience (ie, directly increasing one’s ability to manage pain and pain-related stress), (2) buffering the negative impact of pain (ie, moderating effect), or (3) a combination of direct and buffering effects.

Although the present study does not allow for conclusions about the causal associations between the variables studied, the findings suggest that one’s belief in living a meaningful life despite pain has a direct association with function, indicating that an individual’s ability to find meaning in life despite pain is associated with more positive outcomes across all levels of pain intensity. On the other hand, because a significant association is a necessary but not sufficient condition for causal associations, the lack of significant association between living a meaningful life despite pain and pain intensity suggests that these variables do not directly influence each other. To the extent that causal associations are supported in future experimental research, this indicates that individuals will be similarly likely to benefit from meaning-making treatments focused on living a meaningful life despite pain, across all levels of pain intensity.

Although the present study did not evaluate the mechanisms underlying the significant associations between function and the belief in living a meaningful life despite pain, there are a number of possibilities. For example, it is possible that the beneficial effects of a belief that one can live a meaningful life despite pain could facilitate enhanced positive affect, pain acceptance (ie, it might be easier to accept pain if one is living a meaningful life despite pain), and pain self-efficacy beliefs (ie, meaning-making’s impact on positive mood could facilitate overall flexibility and ability to problem-solve). Higher levels of these positive factors could potentially help to offset the negative impact of chronic pain on function, especially psychological function.^8,43 Preliminary evidence for this possibility comes from the findings showing that stronger associations exist between belief in living a meaningful life despite pain and PTSD and depression symptoms, compared with the associations between belief in living a meaningful life despite pain and pain interference and anxiety symptoms. Similarly, 2 recent meta-analyses concluded that meaning in life and perceived purpose in life (a component of meaning in life⁴⁴) are more strongly related to depression than to anxiety.^41,45 Loss of meaning and purpose might be particularly problematic for individuals with chronic pain because chronic pain and depressive symptoms often co-occur.⁵ Indeed, loss of meaning might partially explain why depression is so prevalent among individuals with chronic pain. It could also be that decreased engagement in meaningful activities leads to depression, because such activities might be particularly rewarding. The loss of that reinforcement could then contribute to the perceived loss of meaning and purpose. More research is needed to test these ideas.

The strong association found between belief in living a meaningful life despite pain and PTSD symptom severity is also consistent with the findings from other research focused on meaning in life, chronic pain, and PTSD. The association between PTSD symptoms and meaning in life has been estimated to be a small to medium effect size,⁴⁶ and meaning in life could be a transdiagnostic factor that contributes to the maintenance of co-occurring chronic pain and PTSD.¹² Overall, the present findings add to the growing body of literature indicating that existential factors play an important role in individuals with chronic pain and in particular for those with co-occurring psychological distress (eg,^9,47), which was the case for the participants in this sample. It is also possible, though, that for those people coping well with pain (ie, who do not have elevated symptom severity profiles), a mechanism underpinning that adaptive response might be that they have maintained a sense of meaning in life despite the presence of chronic pain.

It is important to note that the concept of believing that one can live a meaningful life despite pain differs from pain management self-efficacy and pain acceptance in important ways. Pain management self-efficacy and pain acceptance are both mechanisms by which people cope with and manage pain. Pain management self-efficacy refers to an individual’s perspective on how well they can manage their pain and related emotions and help-seeking behaviors.⁴⁸ In contrast, pain acceptance refers to how much an individual is inclined to participate in life despite pain without attempting to control or avoid pain.⁴⁹ The belief in living a meaningful life despite pain is distinct from both of these constructs in that its focus is on maintaining a sense of meaning and purpose in life more broadly, within the context of experiencing pain; it does not represent mechanisms by which pain is managed per se. The present results and these important distinctions suggest that focusing specifically on increasing one’s strength of belief in living a meaningful life despite pain as a component of clinical treatment could serve as a unique contributing factor in improved function.

Clinical implications

Evidenced-based interventions for chronic pain (eg, cognitive–behavioral therapy for pain or hypnosis-based cognitive therapy) often focus on modifying unhelpful beliefs about pain. Part of this process is identifying and then changing an individual’s maladaptive “core beliefs” about pain—that is, entrenched beliefs about pain in relation to the perceived sense of self.¹⁴ Exploring how individuals develop and maintain a sense of meaning in life despite pain could help guide clinical decision-making and goal-setting. Moreover, the findings from the present study open the possibility that perceptions about living a meaningful life despite pain might be an intermediate belief affecting not only function but also core beliefs. Within therapeutic settings, an individual with chronic pain might ask, “What does my inability to lead a meaningful life despite pain say about me as a person?” This could lead to new avenues of insight and behavior change. In this regard, existential approaches to pain management should be considered as one potentially effective approach,^50,51 specifically targeting issues of meaning in life and sense of purpose.

The study findings also suggest the possibility (but do not prove it, given the cross-sectional nature of the data) that focusing on living a meaningful life despite pain in therapeutic contexts could help to reduce symptoms of PTSD and depression, as evidenced by the significant associations observed. Indeed, a recent pilot study of a meaning-based intervention showed that it had promise for reducing pain intensity among individuals with cancer pain.⁵² Logotherapy,⁵³ an intervention that focuses on meaning in life,⁵⁴ could also be adapted to result in greater clinical benefits for pain and pain-related outcomes.

The study findings are also in line with recent research supporting the potential clinical benefits of adopting a “whole-person” approach to health care.^55–57 Part of such an approach is a focus on meaning and purpose in life, which consistently predicts mental health, physical health, and all-cause mortality.^18,58,59 By orienting treatment around how individuals maintain meaning and purpose, providers can effectively adopt a whole-person approach to care that is inherently patient-centered.

Limitations and future directions

Limitations of the present work include the use of self-report scales to assess PTSD, anxiety, and depression symptoms, instead of conducting clinical interviews, to identify symptom levels and those who meet criteria for the conditions associated with these symptoms. Future research could examine how results change when individuals are diagnosed with these conditions through clinical interviews and how the belief in living a meaningful life despite pain might help reduce the risk of developing these conditions. Furthermore, we did not collect data on the types of stressful experiences participants were referencing when answering items on the PCL-C (eg, war trauma); therefore, we are not able to determine whether the experience would qualify as a Criterion A traumatic experience as defined by the American Psychiatric Association’s Diagnostic and Statistical Manual.⁶⁰ In addition, as noted previously, given the cross-sectional nature of the data, it is not possible to draw conclusions about the possible causal associations among the study variables. It is important that future research examine the causality of these (and similar) relationships to help inform appropriate treatment targets and test potential explanations of the present study’s cross-sectional results. We used a single-item rating scale to assess the construct of belief in living a meaningful life despite pain. As a result, we were unable to evaluate the reliability of this measure. That said, prior literature has established that the use of a single item to assess meaning and purpose is a valid approach to measurement.^18,58 Moreover, the associations of this single item with measures of function were as predicted, which suggests a degree of convergent validity. Current theory recognizes that meaning in life is comprised of 3 factors: purpose, comprehension, and mattering.⁴⁴ Similar to patterns that emerged in research by Boring and colleagues,²¹ it could be that results would have differed if these specific components of meaning in life had been assessed as the moderator. It could be, for instance, that individuals who have made sense of their pain and accommodated their experience of pain into pre-existing schemas might also evidence greater function. Future research could explore this and similar questions, providing clinicians and researchers with a better understanding of which meaning-related components might be most likely to improve outcomes. In addition, given that a relatively small subset (37%) of participants in the clinical trials that were the source of data for the present analyses provided the responses to the question about living a meaningful life despite pain, the sample of the present study could be different in some unknown way from the full sample of the clinical trials, or even from the entire population of individuals with chronic pain. Similar analyses would therefore need to be conducted in additional samples of individuals with chronic pain to determine the reliability and generalizability of the findings reported here. Finally, one of the clinical trials (LIFE) used in the present study recruited individuals on the basis of their opioid use, and there might be unmeasured confounds of opioid use contributing to the results. For instance, it could be that opioid use reduces one’s ability to engage in meaning-making activities, thus decreasing one’s beliefs that one can live a meaningful life despite pain. Future studies should consider and assess how opioid use (and other medications, such as medicinal cannabis) might affect individuals’ ability to engage in meaning-making activities and live a meaningful life despite pain.

Conclusions

These findings provide important new information about the associations between belief in one’s ability to live a meaningful life despite pain and measures of pain and key pain-related function domains. We found that one’s belief in living a meaningful life despite pain was significantly associated with decreased pain interference and less severe symptoms of PTSD, anxiety, and depression, supporting the potential protective role of this variable in adaptive adjustment to chronic pain. Future research is needed to evaluate the causal role of this construct in impacting pain and function over time, as well as to determine the extent to which targeting this domain in treatment might contribute to positive outcomes both in the short and long terms.

Funding

Funding was provided by the National Center for Complementary and Integrative Health (NCT03687762 and NCT03916276).

Conflicts of Interest: The authors have no conflicts of interest to report.