____________________________________________________________ The Intersection of Pain and Culture
the pain by using wishful thinking, venting, or catastrophic thought patterns [76]. Some studies have found that active coping methods and positive reappraisals assist in improving well-being among individuals experiencing pain; those who use passive coping strategies such as wishful thinking and blaming oneself have poorer levels of well-being [77]. Catastrophizing is a coping method whereby one focuses on the pain stimulus, overstates the threat of the pain, and ultimately holds the belief that one cannot handle the pain [78]. Not surprisingly, this coping strategy is related to experiencing higher levels of pain, increased use of medication, and increased use of healthcare services across different age groups and different types of pain [78; 79]. Certain cultures/ethnicities display a greater tendency for catastrophizing, which may be at least partially explained by a culture categorization of collectivistic or individualistic. Indi- vidualistic cultures place an emphasis on individuality and an internal locus of control, with challenges often attributed to modifiable environmental factors [80]. In general, White European and American cultures tend to be individualistic. Those from individualistic cultures are believed to be more likely to use active coping strategies in order to “manipulate” their environment to deal with pain and more likely to with- draw into themselves [52]. Collectivistic cultures emphasize the collective unit, interpersonal relationships, and the support system, and those from collectivistic cultures often display an external locus of control [81]. Many racial/minority groups are categorized as collectivistic cultures. In general, individuals from collectivistic cultures tend to rely more on passive coping strategies in order to reduce internal feelings of helplessness and stress [80]. A systematic review of Hispanic Americans found that this group tended to employ catastrophizing more than their non-Hispanic White counterparts [142]. African Americans also exhibit higher levels of catastrophizing and related increased pain sensitivity [82; 145]. Practitioners should be careful not to automatically label patients who catastrophize as “faking it” [201]. Nor should it be viewed as maladaptive behavior requiring intervention. Instead, for some patients, catastrophizing may be a coping strategy to ensure they receive medical or psychological assistance [201]. African Americans have also historically relied on religion and spirituality to cope with racism and discrimination, and this appears to also extend to other challenges, including pain [145]. In a study of 939 veterans with chronic arthritis pain, African Americans were more likely to view a prayer as a helpful method and to use prayer and hope to cope with pain compared with their White counterparts [74]. In a systematic review, African Americans employed coping strategies that included prayer, catastrophizing, hoping, distraction, and problem solving more frequently to deal with pain compared with White patients. White patients attempted to ignore the pain more often than African Americans [171]. Hispanic Americans also depend on religion for pain-coping. Among this population, talking to a priest or a pastor is viewed as part of pain management, and asking God to help allevi-
ate pain is a coping mechanism for many Hispanics [142]. It is important to support patients’ spiritual coping while also providing education on other pain management options (e.g., medication) [16]. The theme of self-control (a passive coping method) is also prevalent among many racial and ethnic minority groups. In a small study with 35 African American patients recruited from oncology clinics, participants stated that continually talking about pain would amplify it and make them feel even more helpless and out of control. Family and the community were identified as important, but constantly talking about pain with family members was believed to push them away [83]. The question of whether religious coping (e.g., praying, seeking comfort in faith) is an example of active or passive coping has been raised. A study of 200 Latino patients with arthritis pain found that there was a positive relationship between active coping and religious coping [76]. For these patients, use of religious coping was also associated with greater psychologic well-being and adjustment [76]. However, some argue that prayer, hope, and meditation are examples of passive coping and lead to poor adjustment to pain [146]. In a study of Native Americans’ cancer pain experience, par- ticipants navigated a fine line between privacy and reliance on communal support [58]. By using traditional native cer- emonies, rituals, and prayers, they bring together their tribal relations for healing, coping, and support. Yet participants expressed concern about safeguarding their privacy, as tribal communities are often closed systems. Use of pain coping strategies is not static [157]. For immi- grants, strategies can alter over time as they become familiar with cultural norms of the host country, Western biomedical interventions, and different self-management strategies. The key is for practitioners to avoid stereotyping and pathologizing patients’ belief systems. HELP SEEKING Help seeking consists of the ways (formal and informal) in which individuals request assistance due to distress [84]. Understanding individuals’ patterns of help seeking allows for a greater appreciation of their attitudes toward pain and pain management. Asking for either formal or informal assistance implies different meanings in different cultures. Saint Arnault proposed the Cultural Determinants of Help Seeking Model, which posits that there are three major dimen- sions that influence how assistance is sought: perceptions and labeling, interpretations of meaning, and social context dynamics [85]. Perceptions and Labeling The sensations experienced by an individual are first perceived and labeled as a “symptom” or a form of atypical or abnormal state, which is perceived as distressing. This is then sifted through a specific cultural lens. As discussed, members of various cultural groups will have different levels of pain sen-
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