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“LEARY 3 1293 10696 9508
Michigan State
University

 

 

This is to certify that the
dissertation entitled
EFFECTS OF A PSYCHOEDUCA TIONAL INTERVENTION ON PAIN

PERCEPTIONS, HEALTH BEHAVIOR, AND PSYCHOLOGICAL
DISTURBANCE IN CHRONIC PAIN PATIENTS

presented by

Joseph Al ex Jeney

has been accepted towards fulfillment
of the requirements for

 

 

 

Ph.D. degree in Counseling Psychology
4/5. 4 M};
Major professor
William E. Hinds
May 3, 1985 .
Date
MSU--n—“_T .~ .. r m

., r, ‘,' ' ‘ 0-12771

 

 

MSU

LIBRARIES
”-

 

 

RETURNING MATERIALS:
Place in book drop to
remove this checkout from
your record. .FINES will
be charged if book is
returned after the date
stamped below.

 

 

 

      
  

EFFECTS OF A PSYCHOEDUCATIONAL INTERVENTION ON PAIN
, PERCEPTIONS. HEALTH BEHAVIOR: AND PSYCHOLOGICAL
DISTURBANCE IN CHRONIC PAIN PATIENTS

By

Joseph Alex Jeney

'4.n:“

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

and Special Education

‘—

‘ 1985

 

 

ABSTRACT

EFFECTS OF A PSYOHOEOUOATIONAL INTERVENTION ON PAIN
PERCEPTIONS. HEALTH BEHAVIOR. AND PSYCHOLOGICAL
DISTURBANCE IN CHRONIC PAIN PATIENTS
By

Joseph Alex Jeney

This study investigated the impact of a psychoeducational inter-
vention for health care decision making and personal problem solving.
the Personal Paradigm Shift (Hinds. 1983). on pain perceptions. health
care behaviors. and psychological disturbance in chronic pain patients.
The research is based in the educational model of service delivery and
the concept of psychoeducation (Larson. 1984). The Personal Paradigm
Shift was used to determine its effectiveness in (a) reducing chronic
pain perceptions. (b) promoting a higher incidence of health care
behavior. (c) modifying certain types of psychological disturbance
toward "normality." and (d) encouraging the maintenance of treatment
gains.

Twelve groups of patients (total N = 51) in a multidisciplinary
pain clinic were randomly assigned to one of two treatments: training
in the structured Personal Paradigm Shift intervention. or group
discussion about stress and pain management. Treatment was adminis-

tered during the 1-week clinic stay. All groups received the customary

A

 

Joseph Alex Jeney

treatments for chronic pain. The design of the study was a pretest-
posttest control group design with follow-up measures.

Subjects completed the McGill Pain Questionnaire. a measure of
pain perception. at pretest. posttest. and 3-month follow-up. Subjects
also completed the Minnesota Multiphasic Personality Inventory (MMPI)
and Lifestyle Coping Inventory (Hinds. 1983). a measure of health
behavior performance. at pretest and 3-month follow-up. Follow-up
measures were collected by mail. and an 80% (n = 41) return rate was
obtained. with equivalent mortality in each of the treatment groups.

The group. not the individual. was the unit of analysis. and
analyses were performed on gain scores obtained from pretest-posttest
and pretest-follow-up comparisons. A multivariate analysis of variance
was performed on the pain data and found to be nonsignificant for both
the pretest-posttest comparison in > .05) and the pretest-follow-up
comparison (2 > .05). A multivariate analysis of variance was used on
four scales of the MMPI (Hypochondriasis. Depression. Hysteria. and
Psychasthenia) and was found to be nonsignificant (p > .05). A one-way
analysis of variance was performed on the health behavior data and was
found to be nonsignificant (p > .05). Chi-square tests on each of six
behavioral outcome measures collected at follow-up were also each found
to be nonsignificant (p > .05).

A discussion of reasons for lack of support of the hypotheses and

directions for further research were offered.

A

To my loving wife. Marilyn.

 

 

ACKNOWLEDGMENTS

To Bill Hinds. who shared his understanding of behavior change dynamics
with me and who helped me to carve out a niche for myself. I am

very grateful.

6'

Rochelle Habeck. Dozier Thornton. and Richard Houang. who helped me
to critically view my work from perspectives that had not occurred
to me.

To John Jerome. for his generosity with his time and energy. and

teaching me his vast knowledge of the chronic pain experience.

To Andy Porter and Steve Roudenbusch. for helping me realize that there

are several ways to view an analysis problem.

To Randy Fotiu. who performed an expert Job of the computer analysis of

of the data in this study.

To Margaret Parsons. "my editor" (I always wanted to say that). who

taught me the value of plain English.

To Sue Cooley. for a fast. professional typing Job amidst an onslaught

of dissertation mania.

To Kiersten. Ryan. and Marisa. for understanding my physical and

psychological absence during this task; I intend to make it

up to you.

 

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L' ‘ McQuellon. Dave Minden. Romy Valdez. Chip West. and Jackie
.. Nilliams. for your lasting friendship.

fig: ‘T’Tb the BJuesmobile and its regular passengers. this one's for you!
To Marilyn. for tolerating the variety of neurotic behavior I displayed.
-I‘ You were a stable presence for me to lean on. You shared with me

your sense of optimism. and you believed in me.

 

 

 

 

(4“!

 

 

LIST OF
LIST OF
LIST OF

Chapter
1.

2.

TABLE

TmLES O l O I C C O I I
FIGURES ..... . . .

APPENDICES . . . . . . .

INTRODUCTION . . . . . .

Introduction . . . . .

Need 0 o e o o O o o I a

Purpose . . . .
Research Hypotheses .
Theory . . . . . . . .
Overview . . . . . . .

REVIEW OF LITERATURE . . .

Conceptual Features of
ventions . . . . . .

Role of Psychologist-as-Educator . . . .

OF CONTENTS

Psychoeducational Inter-

General Behavior Change Manuals .
Personal Problem-Solving Programs

Cognitive Processes in Problem Solving
Coping Skills Training . . . . . . . .
Self-Control . . . . . .
Psychology of Chronic Pain . . . . .
Psychological Interventions for Chronic Pain

Operant Treatment of Chronic Pain

Cognitive-Behavioral Interventions for Chro

PaTneaa

a o o o O O O O o o o

i

o O I e o o o o o a u 0

Physiological Interventions for Chronic Pain .
Follow-Up Studies of Multicomponent Pain Clinics
suma ry O O O I I O O I I I O O O O I I I O I O

Page

viii

xi

 

Page
i 3 I METHODOLmY O O O O O I O O O I O O I 0 I O O O O I O 53

Description of Personal Paradigm Shift . . . . . . . 53

Stage 1: Awareness . . . . . . . . . . . . . . . . 56

i Stage 2: Decision Making . . . . . . . . . . . . . 58

| Stage 3: Oppositional Alternatives . . . . . . . . 59

Stage 4: Treatment Planning and Action . . . . . . 61

Summary of the Personal Paradigm Shift . . . . . . 64

Sample . . . . . . . . . . . . . . . . . . . . . . . 65

I Instrumentation . . . . . . . . . . . . . . . . . . 70

1 Description of McGill Pain Questionnaire . . . . . 70

; Minnesota Multiphasic Personality Inventory . . . 74
1 Description of the Shipley Institute of Living

Scale . . . . . . . . . . . . . . . . . . . . . 80

I Lifestyle Coping Inventory . . . . . . . . . . . . 81

Behavioral Outcome Measures . . . . . . . . . . . . 83

1 Procedures . . . . . . . . . . . . . . . . . . . . . 83

PPS Group . . . . . . . . . . . . . . . . . . 85

Discussion Group . . . . . . . . . . . . . . . . . 87

Design . . . . . . . . . . . . . . . . . . . . . . . 88

Hypotheses . . . . . . . . . . . . . . . . . . . . . 89

Analysis of Data . . . . . . . . . . . . . . . . . . 91

Group as Unit of Analysis . . . . . . . . . . . . 91

Use of Raw Gain Scores . . . . . . . . . . . . . . 92

Statistical Procedures . . . . . . . . . . . . . . 93

' Summary . . . . . . . . . . . . . . . . . . . . . . 94

4. ANALYSIS OF RESULTS . . . . . . . . . . . . . . . . . 97

Follow-Up Return Rate . . . . . . . . . . . . . . 97

Results . . . . . . . . . . . . . . . . . . . . . . 99

Hypothesis 1 . . . . . . . . . . . . . . . . . . 99

Hypothesis 2 . . . . . . . . . . . . . . . . . . . 105

Hypothesis 3 . . . . . . . . . . . . . . . . . . . 107

Hypothesis 4 . . . . . . . . . . . . . . . . . . . 110

Hypothesis 5 . . . . . . . . . . . . . . . . . . . 115

; Summary . . . . . . . . . . . . . . . . . . . . . . 118

5. SUMMARY AND CONCLUSIONS . . . . . . . . . . . . . . . 120

 

Summary . . . . . . . . . . . . . . . . . . . . . . 120
Discussion . . . . . . . . . . . . . . . . . . . . . 125
Pain Perceptions . . . . . . . . . . . . . . . . 126
Health Care Behavior . . . . . . . . . . . . . . . 127

vi

 

Page

Characteristic Psychological Disturbance . . . . . 128

The Process of the Personal Paradigm Shift . . . . 131

L1m1tat1ons Of the Study 0 O O O C O O O O I I O O I 134
Implications for Further Research . . . . . . . . . 138

APPENDI CES D O O O O O I C O I O O O O O O O O O O I l I O O O 142

REFERENCES 0 o o o a a o o o o I o o o o o I O I o a o I o o o 166

 

LE

LIST OF TABLES

Table Page

3.1 Age of Subjects . . . . . . . . . . . . . . . . . . . . 67

3.2 Race of Subjects . . . . . . . . . . . . . . . . . . . 67

3.3 Sex of Subjects . . . . . . . . . . . . . . . . . . . . 68

3.4 Marital Status of Subjects . . . . . . . . . . . . . . 68

3.5 Years of Education of Subjects . . . . . . . . . . . . 68

. 3.6 Work Composition of Subjects . . . . . . . . . . . . . 69

' 3.7 Estimated WAIS 10's of Subjects . . . . . . . . . . . . 69
3.8 Test-Retest Reliability Coefficients Reported for

the MMPI . . . . . . . . . . . . . . . . . . . . . . 75

4.1 Size of Groups at Each Measurement Point . . . . . . . 98

4.2 Mean McGill Pain Ratings at Pre-. Post-. and Three-
Month Follow-Up for Experimental and Control Groups . 101

4.3 Mean Gain Scores (Pretreatment-Posttreatment) on
McGill Pain Ratings for Experimental and Control

Groups . . . . . . . . . . . . . . . . . . . . . . . 103
4.4 Results of ANOVA on Pro-Post Sensory Pain Measure . . . 104
4.5 Results of ANOVA on Pre—Post Affective/Evaluative

Pain Measure . . . . . . . . . . . . . . . . . . . . 104
4.6 Results of ANOVA on Pro-Post NWC Pain Measure . . . . . 104

 

4.7 Mean Gain Scores (Pretreatment-Follow-Up) of McGill
Pain Ratings for Experimental and Control Groups . . 105

4.8 Results of ANOVA on Pre-Follow-Up Sensory Pain
masure I I I I I I I I I I I I I I I I I I I I I I I 106

 

 

4.9

4.11

4.1

H

4.1

Page
4.9 Results of ANOVA on Pre-Follow-Up Affective/
Evaluative Pain Measure . . . . . . . . . . . . . . . 107
4.10 Results of ANOVA on Pre-Follow—Up NWC Pain Measure . . 107
4.11 Mean Total Lifestyle Coping Inventory Scores at
Pretreatment and Follow-Up for Experimental and
Control Groups . . . . . . . . . . . . . . . . . . . 109
. 4.12 Gain Score Data on Lifestyle Coping Inventory for
i Pretreatment-Follow-Up Comparison for Experimental
I and Control Groups . . . . . . . . . . . . . . . . . 110
4.13 Mean MMPI T-Scores at Pretreatment and Three-Month
Follow-Up for Experimental and Control Groups . . . . 111
i 4.14 Mean MMPI Profiles at Pretreatment and Three-Month
Follow-Up for Experimental and Control Groups . . . . 112
4.15 Mean Gain Scores (Pretreatment-Follow-Up) on MMPI
Scales for Experimental and Control Groups . . . . . 113
4.16 Results of ANOVA on Pre-Follow-Up Hypochondriasis
sca16 I I I I I I I I I I I I I I I I I l I I I I I I 114
4.17 Results of ANOVA on Pre—Follow-Up Depression Scale . . 114
4.18 Results of ANOVA on Pre-Follow-Up Hysteria Scale . . . 115
4.19 Results of ANOVA on Pre-Follow-Up Psychasthenia Scale . 115

 

   

 

 

LIST OF FIGURES

Figure Page
3.1 overa11 DOSTgn I I I I I I I I I I I I I I I I I I I 90

4.1 Mean Sensory Pain Score of PPS and Discussion
Groups at Three Measurement Points . . . . . . . . 102

4.2 Mean Affective/Evaluative Pain Score of PPS and
Discussion Groups at Three Measurement Points . . 102

4.3 Mean Number of Words Chosen Pain Score of PPS and
Discussion Groups at Three Measurement Points . . 102

 

LIST OF APPENDICES

Appendix Page
A. ESTIMATED WAIS IQ VALUES USING SHIPLEY INSTITUTE
OF LIVING SCORES FOR EXPERIMENTAL AND CONTROL

GRWPS c a o o o e o o o o a o o o o a a o o a e o o o Ih3

Bo FOLLOW-UP QUESTIONNAIRE o o a e a o I c o o o o e u o o 11’s

C. MCGILL PAIN QUESTIONNAIRE o o o I c a c o o o a o o o c ‘1'8

D. SHIPLEY INSTITUTE OF LIVING SCALE . . . . . . . . . . . I5I

 

 

‘ E. LIFESWLE mPING INVENTORY I I O I I I I I O I I I I O I ‘51.
* F. INFORMED CONSENT FORM . . . . . . . . . . . . . . . . . 16h

 

   

 

CHAPTER 1

INTRODUCTION

Ihe_E£them

Thirty years ago. Sanford (l955) first called for a shift from a
"healing" orientation to a "teaching" orientation in the delivery of
psychological services. stating that "it is a practical necessity for
psychology to take definite steps to insure that technical knowledge
about human beings is made widely available to human beings" (p. 833%
Nine years later. Hobbs (1964) hailed "mental health's third revolu-
tion." pointing to an emerging change from a clinical to an educational
model. Later. Miller (1969). in his presidential address to the Ameri-
can Psychological Association. affirmed strongly the need for "giving
psychology away" to the public. Psychologists have continued to recog-
nize the need for a fundamental shift to a skills-training paradigm in
the delivery of human services (Larson. 198hL

During the past 15 years a number of practitioners have given
additional impetus to the psychologist—as-educator model (Authier.
Gustafson. Guerney. & Kasdorf. 1975; Guerney. Guerney. & Stollak.
1971/72; Guerney. Stollak. & Guerney. 1970. 1971; Larson. 198h; Mosher
& Sprinthall. 1971). In contrast to the traditional medical or illness
model. this new model provides for an educational orientation in the

delivery of human services. Psychoeducation involves the teaching of

personal and interpersonal attitudes and skills which the person can
apply to so1ve present and future psychological problems and enhance
his/her own and others' satisfaction with life (Guerney et al.. 1970L
The educational model calls for psychologists to teach personal and
interpersonal skills and competencies to people previously lacking in
these skills. The psychologist assumes the role of educator. teacher.
or consultant. and the person being served is considered a pupil rather
than a patient.

Although the movement to teach personal and interpersonal skills
has gained momentum in the educational system (Brown. 1971; Colley.
1975; Ivey & Alschuler. 1973; Mosher. 1977). it has been relatively
neg1ected in the health care system. Although many stress management
and self-help manuals provide coping information to health care
recipient groups. these programs are useful only when coping failure
is due to simple lack of knowledge (Lazarus & Folkman. 1984). The
educational model. in addition to providing information about the
consequences of stress. includes teaching life skills and encouraging
competency in personal prob1em solving and health care decision making.

During the last decade. the treatment of chronic pain has become a
major area in health care (Melzack. 1973; Melzack & Wall. 1982;
Sternbach. 1974; Turner & Chapman. 1982a. 1982b). Pain is undoubtedly
the most significant and perhaps the most common problem with which the
patient confronts the physician. Various medical and psychological
interventions have been employed with differing degrees of success in

the treatment of chronic pain patients. Health care professionals

 

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clearly recognize that pain is a complex phenomenon with physical.
behavioral. and psychological components. Patients who cannot be
safely treated with medical or surgical interventions need to develop
personal skills and competencies in order to live with their pain
(Sternbach. 1974).

Recent advances in the medical and psychological treatment of
chronic pain have been beneficial to those who live with pain (Melzack
& Wall. 1982; Sternbach. 1974; Roy & Tunks. 1982). However. these
treatments have not provided patients with a model for learning how to
observe. experience. and determine their own behavioral choice process
that influences personal health care. An intervention that teaches the
chronic pain patient skills for health care decision making and
personal behavior change can be a useful adjunct to the treatment
regimen. With the educational intervention model presented in this
research. chronic pain patients can learn a process for making sound
decisions about their health care and for instituting positive behavior
changes. This process will complement the goals of a pain management
program. extend the benefits of the program to the natural environment.

and increase the patient's satisfaction with life.

N399
The need for a psychoeducational intervention for chronic pain
patients can be demonstrated from four observations. First. there is
an ever-growing number of pain patients whose health care is extremely
costly and who are resistant to the traditional medical. physical. and

psychophysiological treatments for relief of pain (Steger & Fordyce.

1972).
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1972). Only 8 years ago. it was estimated that the annual health care
cost of chronic pain in the United States was $13 billion. excluding
the additional costs of compensation and lost wages (Aronoff. Evans. &
Enders. 1983). The National Institute of Health (NIH) has estimated
that as many as 15 million adults suffer from low back pain with a
minimum of 93 million work days lost every year (Aronoff et al.. 1983L
Sternbach. Wolf. Murphy. and Akeson (1973) observed that back-related
disabilities are responsible for nearly 20% of all compensation
payments made in a given year and are the single most costly health
problem in industry today.

A second factor suggesting the need for this study is the poor
maintenance of improvement rates following treatment of the chronic
pain patient (Painter. Seres. a Newman. 1980). Although change
immediately following treatment may be quite good. long-term success
rates are much worse. frequently below 30% (Loeser. 1974). It is clear
that these patients require additional intervention in order to retain
the benefits from the pain clinic in the natural environment.

Noncompliance with treatment regimens. long a nagging problem for
health care professionals. is the third factor indicating a need for
this study. Approximately 85% of chronic health problems. including
chronic pain. are partially the result of noncompliance with therapeu-
tic and preventive treatments (Sackett & Haynes. 1976). Between 15%
and 93% of patients fail to comply with medical regimens of all types.
and at least one—third of all patients fail to comply with even short-

term regimens (Becker & Maiman. 1975). An educational intervention can

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provide the patient with the skills necessary to involve the patient in
self-care and personal behavior change. This intervention would not
emphasize compliance. but internalization. defined as a behavior change
that results from the realization that a change to a new pattern will
be beneficial and worthy of acceptance (Suedfeld. 1982L

A fourth observation that marks the need for this study is that
clinical groups are typically poor problem solvers “fiZurilla &
Goldfried. 1971). McGuire and Sifneos (1970) called for teaching
problem-solving skills to psychotherapy patients. stating that the
deficit in learning with regard to solving internal conflicts blocks
efforts to initiate personal change. Similarly. Spivack. Flatt. and
Shure (1976) stated that many psychiatric groups display developmental
deficits in means-end thinking. a skill necessary to solve personal and
interpersonal problems. They suggested a direct educational approach
to strengthen these cognitive processes. Chronic pain patients. a
group which often exhibits a variety of psychological disturbances
(Sternbach. 1974). can benefit from a problem-solving perspective.
Thus. their pain symptoms constitute problems to be solved. and they
can then learn the psychological skills necessary to manage these

problems.

Bananas
The purpose of the research reported in the present study was to
determine the impact of a specific psychoeducational intervention. the

Personal Paradigm Shift (Hinds. 1983). on the health of chronic pain

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patients. In this study health is defined as a state of equilibrium.
including physical and psychological well-being. that people maintain or
want to restore when it is disrupted (Herzlich. 1973). Specifically.
this research explored the effectiveness of the Personal Paradigm Shift
in decreasing pain perceptions. encouraging health care behavior. and
modifying characteristic psychological disturbance in patients with

chronic pain.

B§§£i£§h_flxnflihfises

A number of research questions were formulated. It was hypothe-
sized that:

1. A psychoeducational intervention designed to teach chronic
pain patients concepts of personal problem solving and health care
decision making will decrease perceptions of chronic pain.

2. A psychoeducational intervention designed to teach chronic
pain patients concepts of personal problem solving and health care
decision making will promote the performance of health care behaviors.

3. A psychoeducational intervention designed to teach chronic
pain patients concepts of personal problem solving and health care
decision making will modify characteristic psychological disturbance in
the direction of normality.

4. Chronic pain patients who are taught personal problem solving
and health care management concepts will maintain positive behavior
gains after leaving the pain clinic and returning to their natural

environment.

 

 

 

Inset!

Psychoeducation and skills training are outgrowths of the
educational model in psychology. a model that emerged as an interface
of the fields of psychology and education. The principles of the
educational model are contrary to the fundamental tenets of the illness
or medical model. historically the dominant model in psychology.
According to the educational model. the client seeks services from a
psychological practitioner because of some perceived "dissatisfaction"
or "ambition" (Authier et al.. 1975). The practitioner assists the
client in a goal-setting process and teaches the client a specific set
of skills. ideally resulting in client satisfaction and goal achieve-
ment. The illness model presupposes that the patient arrives for
treatment with some "abnormality" or "illness" and the practitioner
engages in the process of diagnosis. prescription. and therapy. If the
therapy is successful. the patient is cured.

The role of the treatment participant in treatment is defined
differently in each model. In the educational framework. the partici-
pant is a pupil. or trainee. and the practitioner is an instructor or
teacher (Authier et al.. 1975; Guerney et al.. 1970. 1971. 1971/72;
Larson. 1984). The domain of the psychological educator is the affec-
tive. behavioral. and interpersonal. In the illness model. the rela-
tionship is between a therapist and a patient.

A definitive statement outlining the theoretical underpinnings of
psychoeducation has not yet been developed because a shift from the

psychologist as therapist to the psychologist as teacher has not

 

occurred (Authier et al.. 1975). Thus it is difficult to trace with
certainty the historical patterns which would have brought this shift
about. There are. however. several theoretical assumptions that serve
as the foundation for psychoeducation and skills training.

The first factor. the foundation for viewing the psychological
practitioner as teacher. is that the most important aspects of human
behavior result from experience and not from the unfolding of genetic
predisposition or instinct (Authier et al.. 1975). This principle is
such a pervasive part of psychology that to pinpoint exact points of
origin is not possible. Freud's insistence on the importance of life
experiences in shaping behavior was crucial throughout his theory of
human development. The emergence of a learning theory approach was
highlighted by Watson's (1916) belief that human attitudes. values. and
behaviors are extremely malleable. given proper environmental manipula-
tions. Forty years later. Wolpe (1958) proposed that learning was what
receiving psychological help was all about. This view of therapy as a
process of learning paved the way for the idea that teaching plays a
major role in providing psychological help. Several major historical
figures have viewed the psychologist as a teacher (Dollard & Miller.
1950; Mowrer. 1950; Rotter. 1954»

A second historical factor was instrumental in the development of
psychoeducation. This was the public's acceptance of its need for
psychological services. coupled with the profession's awareness that
this need would remain unmet if the model for delivery of these

services was not significantly altered. Rogers (1951) was among the

 

 

first to encourage psychologists to break way from the medical model.
Along with Skinner (1953). he introduced two cornerstone theoretical
concepts of psychoeducation. "proper interpersonal climate" and
"appropriate skill training."

The concept of proper interpersonal climate refers to the
practitionefls willingness to respect clients and encourage them to
choose their own goals. This includes. as well. a high degree of
respect for the client's own ability to reach these goals. given
appropriate environmental circumstances. Rogers believed that clients
themselves have the best aptitude for solving their own problems and
the right to do so. Larson (1984) has affirmed these ideas. stating
that a key assumption of psychoeducation is that clients are seen as
capable of directing their own learning rather than being passive
recipients of treatment.

Appropriate skill training means that psychologists must use their
expertise to design a program of personal or interpersonal content that
best fits the clientfis needs. Skinner (1953) advanced the attitude
that if things were not working out well for the client in treatment.
the helper must be the first to change strategies. not the client.
With the introduction of Skinnerian behavior modification. the skills
training movement was strengthened by making it desirable to target
special behavioral objectives and to develop effective teaching
strategies for accomplishing these objectives.

Intentionality. also called responsiveness. is another central

concept in understanding the theoretical basis of psychoeducation.

Ivey an

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9951' re:

 

 

10

Ivey and Alschuler (1973) defined intentionality as the capacity to
anticipate alternative experiences. choose among them. and attain
desired goals. People who behave intentionally are seldom faced with
only one solution to a problem. Likewise. Drum and Knott (1977)
observed that there is a benefit from learning "responsiveness" to life
situations as opposed to merely learning a discrete response to a
specific situation. These practitioners suggested that the goal of
psychoeducation is to teach people personal and interpersonal skills
that generalize to a wide range of future situations. The goal is to
build competence through skills acquisition.

Although numerous psychoeducational interventions are reported in
the literature. none has provided health care recipients with a syste-
matic model for personal behavior change and health care decision
making. Furthermore. no research has explored the potential of an
adjunctive psychoeducational intervention to a traditional medical
treatment regimen in extending the benefits accrued through participa-
tion in a multicomponent chronic pain program. In this research. the
Personal Paradigm Shift (Hinds. 1983) is employed with chronic pain
patients to determine its effect on pain perceptions and health care

behavior.

mm
In Chapter Two. the relevant literature is reviewed in the
following areas: existing behavior change and problem-solving
interventions. the concept of self-control and its outgrowth. coping

skills training. the concept and the psychology of chronic pain. and

 

 

 

11

the efficacy of psychological treatments for chronic pain with an
emphasis on follow-up studies of multicomponent chronic pain programs.
A description of the Personal Paradigm Shift (PPS). the research
design. instrumentation. and procedures are presented in Chapter Three.
In Chapter Four. the analyses of the results are presented. Conclu-
sions and implications for further research are presented in Chapter

Five.

 

 

 

CHAPTER 2

REVIEW OF LITERATURE

In the following review. four areas of research are examined.
First. a review of psychoeducational interventions is presented with a
particular focus on general life skills. behavior change training
manuals. and problem-solving training. Second. there is a brief
summary of the related concepts of self-control and self-management.
along with a discussion of their conceptual outgrowth. coping skills
training. A section on the psychology of chronic pain is then
presented. In the final portion of the review. there is consideration
of psychological interventions used in the treatment of chronic pain
and a focus on follow—up studies of multicomponent chronic pain

programs.

WWW
During the past few years educators have developed renewed
interest in a philosophy of education that emphasizes the facilitation
of the personal development of the individual. This area of study.
variously referred to as personal education. affective education.
humanistic education. psychological education. self-management. or
psychoeducation. is defined as the teaching of personal and

interpersonal skills to people previously lacking in such skills.

 

 

13

Practicing psychologists have been called on to include psychoeducation
among their areas of concentration in order to better serve the psycho-
logical needs of the community. A movement has taken form to abandon
the medical model of service delivery and replace it with a model that
gives people personal and interpersonal psychological skills.
Interventions that emerge from the psychoeducational model rest on
three basic assumptions (Larson. 1984). The first assumption is that
the practitioner becomes a teacher to the patient or client. Although
many thinkers have identified psychotherapy as a learning process. they
have failed to acknowledge the corollary that the therapist is a
teacher (Guerney et al.. 1970. 1971). Under the second assumption of
the psychoeducational model. clients' problems are viewed as skill or
competency deficits rather than as abnormalities or illnesses. Skills
training therapists argue that clients are actually lacking something
that must be "added to" the client through training. The third
assumption of the psychoeducational model is that by labeling problems
as competency deficits rather than as illnesses. the active participa-
tion of clients in solving their own problems is enlisted. A client
who is taught problem-solving skills is in a better position to solve

many different problems in diverse situations.

WW
Perhaps the most lucid statement regarding the role of the
psychologist who follows an educational model was offered by Guerney
and his colleagues (1970. 1971/72). describing the psychologist as one

whose work:

 

 

14

would derive directly or indirectly not with curing neurosis. not

with eliminating symptoms. and not with intellectual growth per

se. but with teaching personal and interpersonal attitudes.
concepts and skills which the student (client) can apply.
presently and in the future. to enhance his/her and others'

satisfaction with life. (p. 239)

These authors emphasized that adopting an educational orientation to
psychological practice does not mean intellectualization of practice.
but rather that full consideration of dynamic factors in understanding
behavior is also necessary.

The role of the psychologist as a skills trainer was further
clarified by Ivey and Alschuler (1973). who defined three statements of
"intent" that characterized this new role. First. they stated that a
goal of psychological education is to increase the individual's
intentionality. the capacity to anticipate alternative experiences.
choose among them. and attain desired goals. Second. intentionality
should be taught in the most inclusive and effective ways possible. a
focus on the strategies of the psychoeducational specialist. The final
statement of intent of the psychologist-as-educator is to "demystify"
the helping process by teaching skills to the widest audience possible.

A number of writers have contrasted the role of the psychologist
following an educational model with the role of the psychologist
following a traditional illness or medical model (Authier et al.. 1975;
Goldstein. 1981; Guerney et al.. 1970. 1971/72; Larson. 1984). Viewing

the client in educational terms assumes that the individual is defi-

ciemt in skills necessary for effective and satisfying daily living.

 

 

15

This is a different assumption than that of the psychodynamic/
psychoanalytic. humanistic. or behavior modification approaches. which
all assume that the patients have within themselves effective or
healthy behaviors which can be uncovered through therapy. According to
all three approaches. these latent behaviors can be realized by the
patient if the therapist is sufficiently skilled in removing the
obstacles to sUch realization. In contrast. the task of the skills
trainer is the active and deliberate teaching of desirable behaviors.
rather than the removal of obstacles to already existing behaviors.

Drawing this same contrast between the psychologist functioning
under the illness model and one functioning within the framework of the
educational model. Guerney and his colleagues (1970. 1971/72) observed
that there is a shift from passively undoing the negative in the
illness model to actively developing the positive in the educational
model. Furthermore. from the educational view. the psychologist has a
didactic emphasis. introduces more structure to the procedures. and has
much less flexibility than in traditional therapy procedures. Personal
and interpersonal skills require instruction. self-disciplined prac-
tice. and feedback in order to develop. The psychologist-as-educator
takes on the responsibility only for teaching the skills which he/she
believes will allow clients to solve their own problems

Certain conceptual shifts occur as the psychologist moves from a
medical model to an educational model (Guerney et aL. 1971). First.
there is a shift from covert to overt value judgments. Following an

educational model. the psychologist may clearly advocate certain values

 

 

16

over others. on the basis that the person is being taken from a "sick"
to a "well" behavior. A second conceptual shift is that there is a
movement from a case orientation to programmatic planning. The
psychological educator stakes out an area of knowledge or skill and
designs a course. a program for teaching. to reach the widest possible
group to be served. The final major conceptual shift is a shift in the
place of personality assessment. from a position of primary importance
in the helping process to one of secondary importance; and from general
to specific objectives in assessment. The educator takes skills defi-
cits for granted when implementing the program rather than spending
time determining what is wrong with the client (Guerney et al.. 1971L
Now that the major assumptions and characteristic features of
psychoeducation and skills training have been outlined. a discussion of
several specific psychoeducation programs will be presented. This
review is a representative rather than an exhaustive summary of general

behavior change programs.

Wan]:

A number of manuals exist that instruct trainees in the general
principles and strategies of behavior change. These manuals have been
variously termed general instructional manuals (Glasgow & Rosen. 1978.
1979). life skills manuals (Egan. 1975). and psychosocial coping skills
manuals (Larson. 1984). These general behavior change manuals are to
be distinguished from the proliferation of self-help manuals that teach
people to solve specific behavioral problems. such as sexual dysfunc-

tions. assertiveness problems. and weight problems.

A

 

 

17

General behavior change programs are categorized into four levels
of therapist involvement: self-administered by the trainee. minimal
contact with trainee. therapist administered. and therapist directed.
These manuals have generally not been validated in any systematic
manner. and no studies employing placebo and treatment controls have
been reported (Glasgow a Rosen. 1978L This review addresses common
features of these general instructional materials.

Most general behavior change manuals are written from a behavioral
point of view. These manuals usually instruct the reader or trainee
through a four—stage behavior change process: (a) specify a behavior
requiring change. (b) set goals and develop a self-change contract.

(c) self-monitor the target behaviofls frequency of occurrence. and

(d) rearrange relevant antecedents and consequences within an operant
learning framework (Glasgow & Rosen. 1978. 1979L These materials have
much potential in terms of cost effectiveness because clients learn a
set of principles that can be applied to a variety of problems rather
than learning a new set of procedures for each behavior change desired.

Perhaps the best known and most frequently used manual of general
behavior change principles is the program designed by Watson and Tharp
(1977). a guidebook for self-change that relies heavily on operant
methods and vicarious learning principles. Their manual is the only
one found that has been validated with systematic research (Barrera &
Glasgow. 1976). Exercises for developing skills in self-analysis and
information about how to achieve personal goals are provided. The

authors described the following steps in self-direction: (a) selecting

 

 

18

a goal; (b) specifying the behaviors needed to change in order to reach
the goal (target behaviorsh (c) making observations about those target
behaviors (self-knowledgeh (d) working out a plan for change which
applies basic psychological knowledge. either gradually replacing an
unwanted action with a desired one or arranging to be rewarded for
certain behaviors; and (e) readjusting plans based on increased self-
knowledge. Each of these steps is now considered in more detail.
Individuals begin the first step in the behavior change process.
selecting a goal. by thinking of a way they would like to either begin
behaving or stop behaving. Therefore. selection of a goal involves the
identification of either a behavior deficit or a behavior excess.
Step 2. identifying target behaviors. involves specifying a set of
behaviors that impede progress toward the goal one wishes to achieve.
In Step 3. the individual is asked to keep a diary of the antecedents
and consequences of the target behaviors. Step 4. the basic techniques
for achieving self-direction and working out a plan for change.
involves rearranging consequences through procedures of reinforcement.
extinction. and punishment. Undesirable behaviors are eliminated by
finding some incompatible. desired behavior that can be increased by
positive reinforcement. Sometimes self-direction involves identifying.
rearranging. and controlling the antecedents of behavior. In summary.
personal change is a process that occurs once an individual understands
how to manipulate the sequence of antecedents-behavior—consequences for

a personal problem.

 

19

Another general behavior change program based on principles of
behavior modification was developed by Williams and Long (1979L In
many ways their model for behavior change is similar to the model
proposed by Watson and Tharp (1977L Williams and Long emphasized a
basic principle of psychoeducation--that adequate information about the
process of behavior change can provide the motivation that people need
in order to change. Their model consists of five steps. In Step 1.
selecting a goal. the authors argue that the importance of the goal.
the measurability of the goal. and the level of the goal are each
factors that require consideration. The first factor. importance of
the goal. suggests that selecting a goal that requires the elimination
of long-standing behaviors may result in failure of the program and
make it difficult to remain motivated. The second factor. measurabil-
ity. means that it is imperative that nonbehavioral goals. 6.9.. "I
want to feel better about myself." be translated into measurable terms.
The final factor in selecting a goal. a person's awareness of the level
of a goal. refers to the rule that a stated goal should be only
slightly higher than the person's present level of functioning. The
next three steps of the program. monitoring target behaviors. changing
setting events. and establishing effective consequences. are all based
on operant principles and involve manipulation of the antecedents-
behavior-consequences paradigm. The final step of the program. con-
solidating gains. encourages the person to make the transition from
artificial support to natural support gradually. maintaining reinforce-

ment contingencies as a natural part of daily routine. Interestingly.

 

20

the authors noted that in many cases merely selecting a goal or the
combination of selecting a goal and monitoring target behavior is all
that is necessary to modify a behavior.

In summary. behavior change programs that follow an operant
learning orientation are based on the premise that there are orderly
relationships between a person's behavior and the external environment.
Behavior change occurs by altering the environment in two ways: first.
by altering the events that precede particular "target" behaviors. and
second. by altering events that follow "target" behaviors. These
programs follow the antecedents-behavior—consequences paradigm and
instruct the person in ways to manipulate the separate components of
the paradigm.

Drawing extensively on Bandura's (1969) social learning theory.
Goldstein (1981) developed an approach to psychological skill training
called the "Structured Learning Technique." a program tailored to fit
the needs and lifestyles of lower-class individuals. Therefore. the
program is brief. concrete. behavioral. and authoritatively adminis-
tered. Goldstein defined psychological skills training as "the
planned. systematic teaching of the specific behaviors needed and
consciously desired by the individual in order to function in an effec-
tive and satisfying manner. over an extended period of time. in a broad
array of positive. negative. and neutral interpersonal contexts"

(p. 3). Both personal and interpersonal skills constitute the content
of psychological skills training programs. Primarily. the principles

of modeling. role playing. and performance feedback are drawn upon in

 

21

this approach. Patients are provided with specific. detailed. frequent.
and vivid displays of adaptive behavior or of specific skills in which
they are deficient (modeling); given considerable opportunity and
encouragement to behaviorally rehearse or practice such modeled behav-
ior (role playing); provided with positive feedback. approval. or
regard for successful enactments (performance feedback); and required
to engage in a number of behaviors that enhance the likelihood that
there will be generalization of behavior (transfer of trainingL

A behavior change manual that introduces several concepts not
found in the operant-based programs is Cudney's (1975. 1976) "elimina-
tion of self-defeating behaviors" model. The main contribution of this
program is the idea that fear provides the energy for maintaining self-
defeating behaviors. Five elements operate in combination to continue
a self-defeating behavior pattern: choice. fear. techniques. disown-
ing. and minimizing. A person is constantly making choices at each
stage of development. and these choices can maintain self-defeating
behaviors. Fear. the second element in this model. energizes self-
defeating behavior and is probably unconscious. A major step in over-
coming the self-defeating behavior cycle is to become conscious of
fear. Techniques refer to the actions taken. the methods employed. and
the more obvious behaviors used by a person to continue a self-
defeating behavior pattern. a pattern Cudney believed is generally easy
to identify. The fourth element. disowning. is the person's tendency
to blame or project responsibility for the consequences of the self-

defeating behavior onto something or someone else. thus relieving the

 

22

individual of control or responsibility. Methods of disowning can be
clarified by creating a "blame list" Minimizing. the final element of
the model. occurs when the person ignores or minimizes the severity of
the consequences of the self-defeating behavior. Cudney stated that
the person is unaware that the entire self-defeating behavior pattern

results in being paid off with the very consequences that are feared.

EeLsonal_Enablem259111ns_E£99£ams

Numerous illustrations of personal problem-solving programs are
found in the literature (Carkhuff. 1976; Dixon. Heppner. Petersen. &
Ronning. 1979;1NZurilla & Goldfried. 1971; Goldfried & Davison. 1976;
Goldfried 8 Goldfried. 1975; Heppner. 1978; Mahoney. 1974; McKay.
Davis. & Fanning. 1981; Redd & Sleaton. 1976; Rudestam. 1980; Schmidt.
1976; Spivack. Platt. & Shure. 1976). Although these programs consist
of elements that are comparable to the features of general behavior
change programs. they are labeled specifically as "prob1em-solving"
methodologies in the literature and therefore are presented separately
here.

Problem solving was defined by Goldfried and Goldfried (1975) as
a behavioral process. whether overt or cognitive in nature. which
(a) makes available a variety of potentially effective response
alternatives for dealing with the problem situation and (b) increases
the probability of selecting the most effective response from among
these various alternatives. In problem-solving training. the goal is
not to provide specific solutions to specific problem situations but to

provide a general coping strategy for future situations.

Prc

SL‘C

the

60‘;

PVC

for

be‘:

Dr:

in:

no.

act

to

 

23

The link between the individual's ability to employ a problem-
solving process and psychological health has been addressed (Jahoda.
1958). The sequential ability to admit to a problem. consider it. make
a decision. and take action is viewed as a feature of positive mental
health. Jahoda added that an important affective element in this
process is the ability to tolerate the strain involved and to feel
dissatisfied until some resolution emerges. It is the process of
problem solving itself that is important. rather than simply finding a
successful resolution. that is the indicator of positive adjustment.

While there is no single agreed-upon model of problem solving.
there are several common stages or behaviors postulated in most models.
An excellent example of the prob1em-solving models was presented by
Goldfried and Goldfried (1975). Five sequential stages comprise their
program: (a) general orientation. (b) prob1em definition and
formulation. (c) generation of alternatives. (d) decision making. and
(e) verification and evaluation. Each stage is considered in detail
below.

General orientation. the initial step in the problem-solving
process. is the attitude with which one approaches the problem-solving
situation. Four aspects of orientation were highlighted by Goldfried
and Goldfried. First is a recognition that problem situations are a
normal aspect of living. The second aspect is the belief that one can
actively cope with such problem situations. Third. one must be ready
to recognize problem situations as they occur. Finally. one begins to

inhibit the temptation to act in an impulsive way to solve the problem.

 

24

Once a person has acquired a useful attitudinal set toward
problems. the second step of problem solving can begin. In this step.
problem definition and formulation. various aspects of the problem are
defined in concrete. operational terms. Rudestam (1980) suggested that
the person should determine whether the problem is primarily affective.
cognitive. behavioral. or a combination of all three. He also
recommended that the person assess whether the problem is one of
behavioral excess or deficit. As in the general behavior change
programs. the situational context of the problem is explored fully. and
antecedents and consequences of the problem are identified. In short.
the step of problem definition and formulation involves collecting
reliable information about the problem itself. Kanfer and Saslow
(1969) outlined several guidelines useful in this behavioral diagnosis
of a problem. These include identifying the people who object to and
support the problem. understanding what ramifications the problem has
for the person and those close to the person. and identifying the
satisfactions the person will continue to have if the problem remains
In addition. Kanfer and Saslow (1969) suggested that individuals
examine the consequences that removal of the problem would have for
them or for significant others.

Generation of alternatives. the third step in the prob1em-solving
process. primarily involves the technique of brainstorming (Dixon et
al.. 1979; Goldfried & Goldfried. 1975; Heppner. 1978). In brainstorm-
ing. the person attempts to generate as many alternatives as possible

to resolve the problem situation. while deferring judgment about the

25

quality of each alternative. The guiding axioms in brainstorming are
that quantity breeds quality and that judgment must be suspended about
the feasibility of any alternative. In a description of his personal
prob1em-solving model. Carkhuff (1973) argued that a much-needed addi-
tion to the step of generating alternatives is the construction of a
values hierarchy that will eventually assist in the selection of the
appropriate alternative. A values hierarchy is a ranked listing of the
things in life that the person values which are touched by or involved
in the problem. Thus the values hierarchy is the element that high-
lights the uniqueness of each person's prob1em-solving program.

The fourth step in solving personal problems is decision making.
the process of selecting one action from a number of alternative
courses of action (Goldfried a Goldfried. 1975). The person evaluates
the "goodness" of any particular action from the list of alternatives
by determining the likelihood that the action will resolve the issues
delineated in the problem-definition and formulation phase. Carkhuff
(1973) observed that the person. in choosing any course of action. must
determine whether such action helps or hinders a particular personal
value identified in the values hierarchy. Courses of action that are
congruent with an individual's value system are viewed as optimal.

Verification and evaluation is the final step in the personal
problem-solving process (Goldfried & Goldfried. 1975; Heppner. 1978L
This step involves testing out the plan of action and checking the
outcome of the response against some standard. If the actions are

congruent with the given standard. the individual is finished with the

ab

50

C0!

A_ -P

26

problem-solving process. However. if the actions are incongruent with
the standard. the person continues to perform the appropriate problem-
solving behaviors until a congruent action is selected. Two skills are
involved in this stage: identifying the consequences of actions and

comparing these consequences to a standard.

We

Specific cognitive problem-solving processes that mediate social
adjustment have been the focus of research by Spivak. Platt. and Shure
(1975). Thee authors argued that an understanding of cognitive pro-
cesses is crucial to devising educational tools for developing healthy
psychological adjustment. They proposed a group of cognitive skills
that are necessary for social adjustment. while emphasizing that social
adjustment is not a single ability.

Five problem-solving skills were highlighted by Spivak et a1.
(1975). The first skill is an awareness of the variety of possible
problems that beset human interactions and a sensitivity to the
existence of an interpersonal problem or at least to the potential of
problems when two people get together. A second skill is the capacity
to generate alternative solutions to problems. The third skill is the
ability to articulate the step-by-step means necessary to carry out the
solution. This skill is the recognition that obstacles must be over-
come and that the reactions of others must be taken into account. The
fourth skill involves consideration of the consequences of oneus

actions in terms of their impact on others and on oneself. The

 

27

understanding that how one feels and acts may be influenced by how
others feel and act is the fifth skill necessary for healthy social
adjustment. These skills are not personality traits but are behaviors
learned through experience with parents and may emerge at different

ages.

mm

The psychotherapeutic approach most closely identified with the
explicit teaching of coping skills is that of cognitive behavior
therapy (Beck. 1976; EflZurilla & Goldfried. 1971; Goldfried. 1980;
Goldfried & Goldfried. 1975; Mahoney. 1974; Meichenbaum. 1977; Roskies
& Lazarus. 1980). The cognitive behavior therapists have been instru-
mental in viewing the intervention process as training the client in
the use of more general coping skills instead of resolution of specific
problems. As with psychoeducational interventions. this orientation
carries with it the clear implication that the therapist is a teacher.
supervisor. and consultant who works with clients in a collaborative
effort to teach them how to function effectively.

A coping skill (Goldfried. 1980) may be defined as any class of
cognitive or overt behavior patterns that deal effectively with problem
situations. The aim of coping skills training is to teach new skills
that will broaden the response repertoire of the client and to increase
the person's competence in mastering stress and tolerating distress.
Therefore. generalization and maintenance of change are primary to

coping skills training.

28

Coping skills training can be conceptualized along a continuum
from teaching a single skill to teaching a comprehensive set of skills.
Coyne and Holroyd (1982) believed that a coping skills package is
preferable to treatments that teach a single coping skill for two
reasons. First. because the complex demands of everyday life often
require flexible coping skills. many stressful transactions cannot be
managed by simple procedures. Second. since stress responses are caused
by the person's transactions with the environment. people will continue
to think and behave in ways that generate the very arousal they are
trying to manage. Most comprehensive coping skills packages (Beck.
1976; Goldfried. 1980; Meichenbaum. 1977). in addition to providing
graduated practice in the use of both cognitive and behavioral coping
skills. teach clients to develop cognitive strategies or plans to
facilitate the adaptation to the potentially threatening event.

Within a coping skills framework. the view of training clients as
"personal scientists" who are skillful in the functional analysis and
systematic improvement of their own behavior has been promoted by
Mahoney (1974). Essentially. Mahoney argued that clients need to be
taught broadly based survival skills through multicomponent treatment
packages. He developed a paradigm which is similar to the components
that comprise problem-solving models. This paradigm includes
(a) orientation. (b) problem definition. (c) problem analysis.

(d) solution generation. (9) personal experimentation. (f) evaluation.
an:: (9) graduation. According to the model. therapy is an apprentice-

Sh'tp in problem solving.

 

 

29

Several treatment components are common to most coping skills
programs (Roskies & Lazarus. 1980). A first and fundamental element is
teaching the client the role of cognitions in producing the problem.
Training in the self-monitoring of maladaptive self-statements and
behaviors is the second feature of most coping skills programs. Third.
as mentioned above. clients are trained in the fundamentals of problem
solving. A fourth component from social learning theory is the
modeling and rehearsal of effective self-statements and positive self-
evaluation. Training in specific coping skills. such as relaxation and
assertiveness. is often provided. The final component of coping skills
programs is the in yiyg behavioral assignments that become increasingly
demanding over time.

The bridge that links coping theory with the clinical application
of coping skills was delineated by Roskies and Lazarus (1980). Both
areas share a common concern with process or dynamics as opposed to
structure or traits and an emphasis on the intra-individual as opposed to
the inter-individual. The authors additionally pointed out that both
areas emphasize coping management rather than placing emphasis on
features of the stressful situation itself.

Several clinical issues emerging from coping skills training were
highlighted by Goldfried (1980). Client expectations of the program
must be confronted immediately by emphasizing that the person is
learning a skill and personal change will therefore be gradual. Thus.
reducing anxiety during the early stages of skill training is viewed as

secondary. In addition. the client needs to monitor his/her own

30

success at coping with various situations following skills training and
then compare that to previous attempts at coping in order to evaluate
the personal effectiveness of the skills training. Finally. Goldfried
warned that having a coping skill in oneuirepertoire does not insure
that the skill will be used. The client must be trained to use affec-
tive cues to trigger the use of the skill.

According to the coping skills model. individuals are not only
capable of dealing effectively with problem situations but are also
aware of their abilities to do so. This concept has been referred to
as perceived control (Brehm. 1966). People tend to resist the influ-
ence of others if they believe that such influence undermines their
perceived freedom of choice. When people expect that they can success-
fully cope with a given event. the event will no longer be perceived as
stressful.

Perhaps the best-known application of coping skills training to
the management of stress is stress inoculation training (Meichenbaum.
1977). Stress inoculation training involves three phases: an educa-
tional phase. a rehearsal phase. and an application phase. The educa-
tional phase is designed to provide clients with a conceptual framework
for understanding the nature of their response to stressful events.
The most important aspect of this phase is that the conceptual frame-
work should lead naturally to the practice of specific cognitive and
behavioral methods. Within the conceptual framework. the client
rehearses coping skills involving both direct action and cognitive

teK:hniques. Once the client becomes proficient in using these skills.

 

the the
under a

trainin

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31

the therapist suggests that he/she test out and practice coping skills
under actual stress conditions. Application of the stress inoculation

training paradigm to pain management has been reported by Turk (1977L

fielizflnnirol

Self-control approaches (Kanfer. 1975. 1977; Mahoney a Thoresen.
197; Rimm & Masters. 1979) aim at providing clients with active coping
strategies for dealing with problem situations. Self-control is
defined as "a process through which an individual becomes the principal
agent in guiding. directing. and regulating those features of his own
behavior that might eventually lead to desired positive consequences"
(Goldfried & Merbaum. 1973. p. 11). A self-control program is approp-
riate when a person is behaving in a self-defeating manner and there
are no immediate and potent reinforcers of alternative behaviors in the
environment.

Kanfer (1977) outlined the requirements of a self-control
procedure. First. the behavior in question is one that has relatively
equal positive and aversive consequences. posing a conflict for the
person. Second. before the occurrence of the behavior. a controlling
response is introduced that reduces the probability of the occurrence;
Third. the controlling response is initiated by self-generated cues and
is not under direct control of the physical environment. Therefore.
persons generate new behavioral sequences for themselves. emphasizing
an internal locus of control.

The mechanisms of self-control can be explained within a cognitive

Inediational model (Kanfer. 1977). According to this model. self-control

32

involves behavioral shifts in which external influences. termed alpha
variables. are supplemented by self-generated cues and reinforcers.
called beta variables. Two outcomes are possible: (a) the probability
of a response with initial high likelihood of occurrence is decreased.
or (b) the probability of a response with initial low likelihood is
increased through the use of self-generated behaviors. The common
element in all selfecontrol situations is a change in what was ini-
tially a very stable or a very gratifying. but nevertheless self-
defeating. state of affairs.

Kanfer (1977) developed a three-stage model for self-control.
This model involves self-monitoring. self-evaluation. and self-
reinforcement. Sel f-monitoring involves careful observation and
recording of the target behavior. the stimulus environment in which the
behavior is carried out. and the antecedents and consequences of the
behavior. Self-monitoring therefore involves stimulus control. During
the stage of self-evaluation. clients compare their response with some
subjective standard derived from previous direct or vicarious experi-
ence. After the individuals evaluate their response according to the
standard. the stage of self-reinforcement is initiated. In the case of
a behavioral deficit. instances of the target behavior are rewarded.
In the case of a behavioral excess. responses that effectively compete
With behavioral excess are rewarded.

Following this brief review of the related areas of coping skills

training and sel f-control. a discussion of the psychology of pain.

33

psychological interventions for pain management. and selected research

of follow-up studies of pain interventions is presented.

W

Chronic pain is clearly a multifaceted phenomenon. Those who
suffer with chronic pain can provide eloquent testimony that it is far
more than simply a sensation. but is a highly personal experience for
which words alone are frequently awkward and inadequate symbols. With-
out successful management. chronic pain invades every waking and sleep-
ing moment and influences every activity. Unique among sensations.
pain is a commanding and demanding perception that dictates quality of
life and lifestyle choices.

Several writers have observed that the experience of pain is a
function of many different factors (Melzack. 1973; Melzack a Wall.
1982; Steger a Fordyce. 1982; Sternbach. 1974). Pain may be a function
of anxiety or fear level. past conditioning experiences. cognitive
expectations. pain history. perceived consequences of pain. various
personality and psychological factors. and tissue damage. Pain has not
only sensory qualities but also has emotional and motivational quali-
ties which may be subject to modification. There is widespread agree-
ment with Melzack and Wall's (1982) observation that "a knowledge of
pain perception goes beyond the problem of injury and the sensory
signals of pain" (p. 27).

The nature and range of the sensations covered by the word "pain"
elude precise definition (Melzack. 1973; Melzack 8. Wall. 1982;
Sternbach. 1974). An often-cited definition is that pain is an

34

"abstraction" used to refer to a great variety of different feelings
which have little in common except for the quality of physical hurt
(Sternbach. 1974). These unpleasant sensations vary greatly in
quality. intensity. location. and time course. Therefore. pain is
ultimately defined by the experiencer. based on a variety of specific
stimuli. experiences. and responses.

Chronic pain is considered to be pain that persists constantly or
intermittently for several months or more. long after it can serve a
useful function (Melzack a Wall. 1982; Sternbach. 1974). The pain
becomes intractable and the patient is unable to give meaning to it.
It therefore makes no sense as a warning signal since it cannot be
avoided or treated. The person is unable to take appropriate pain-
relieving action as in the case of acute pain. In many cases. unable
to find a purpose for the pain. chronic pain patients wonder how they
can deserve the pain and end up feeling punished by it. LeShan (1964)
wrote that the world of the chronic pain patient is a "nightmare" that
fosters feelings of meaninglessness. helplessness. and hopelessness.
The pain patient's perception of the world. relationship to others.
preoccupations. and activities all seem to alter rather markedly during
the experience of chronic pain.

Perhaps Melzack (1973. 1982) has done more than any other
researcher to delineate the various qualities of the chronic pain
experience and to highlight the psychological components of pain.
Arguing that current definitions of pain that rely solely on tissue

damage or sensory qualities are inadequate. Melzack stated that the

35

word "pain" represents a category of experiences signifying a multitude
of different unique experiences having different causes and character-
ized by different qualities varying along a number of sensory and
affective dimensions.

For many years the specificity theory of pain played a prominent
role in shaping thought regarding the experience of chronic pain. a
theory that described pain as a simple sensation serviced by a direct
transmission line to a pain center. As a more complete understanding
of pain emerged. Melzack and Wall (1965) formulated the "Gate Control
Theory" of pain. This theory proposes that a neural mechanism in the
dorsal horns of the spinal cord acts like a gate which can increase or
decrease the flow of nerve impulses from peripheral fibers to the
central nervous system. Somatic input is therefore subjected to the
modulating influence of the gate before it evokes pain perception and

response. The degree to which the gate increases or decreases sensory
transmission is determined by the relative activity in large-diameter
(A-beta) and small-diameter (A-delta and C) fibers. When the amount of
information that passes through the gate exceeds a critical level. it
aetivates the neural areas responsible for pain experience and
response.

The Gate Control Theory suggests that past experience. attention.
and emotion may all influence pain perception and response by acting on
the spinal gate mechanism. Some of these psychological mechanisms may
Open the gate while others may close it. Therefore. personal psycho-

IOQical needs and coping styles are important in determining the

36

person's response to the presence of pain. Coping styles. sense of
selfecontrol. and problem-solving skills all have considerable rele-
vance for patients in chronic pain. Patients who are taught a process
of personal health care decision making via a psychoeducational model

can be expected to demonstrate altered responses to their chronic pain.

Wu

Traditional medical interventions have been largely ineffective in
relieving the chronic pain sufferer (Loeser. 1974; Steger & Fordyce.
1972; Sternbach et al.. 1973). In fact. Loeser (1974) observed that
success rates for certain chronic pain problems. such as low back pain.
rarely exceed 60%. and long-term success rates are below 30%. Given
these disappointing results. Sternbach and his colleagues (1973) coined
the expression "low back loser" to describe patients who complain of
pain for 6 months or longer. have an inability to work and are sup-
ported by social security or disability. and are in continual search
for medical and surgical relief despite previous surgery. The recogni-
tion of psychological factors in chronic pain has prompted researchers
to study the effectiveness of psychological interventions in the man-
agement of chronic pain. This section is divided into two parts: a
brief review of the general effectiveness of the various psychological
interventions and a summary of follow-up studies of multicomponent
DPograms for chronic pain patients.

Due to the complexity of a pain problem for any given individual.

Psychological treatment strategies are combined into a comprehensive

37

multicomponent approach. The treatmemt modalities used in pain clinics
generally fall into three types: operant conditioning techniques.
cognitive behavioral techniques. and psychophysiological techniques. A
brief description of each of these methods along with related outcome

research is now presented.

W

A great deal of the published work in the area of pain management
has been reported by Fordyce and his associates (Fordyce. 1976; Fordyce
et al.. 1973) using an operant conditioning model. The goal of the
operant approach is to decrease operant. or learned. pain behaviors
and to replace them with behaviors inconsistent with the sick role.
1.9.. "well behaviors." This goal is accomplished by making changes in
the environmental contingencies. the rewards and punishments following
specific behaviors. so that desired behaviors are rewarded and pain
behaviors are not. Therefore. direct modification of pain is not a
goal of the operant approach.

There are four basic premises to the operant approach to pain
management (Fordyce. 1976). First. pain behavior. these behaviors
indicative of pain and suffering. may becomezchronic for reasons other
than the original cause. Pain behavior may have little or no link to
Physical "hurt? arising from the site of the damage which initiated the
Rain problem. Second. it is unnecessary to use intrapsychic variables

SUch as "personality" or "motivation" to conceptualize the pain prob-
lenm From the operant viewpoint. pain behavior can be understood

entirely in learning theory terms. A third premise is that treatment

38

strategies can be based on counterconditioning principles. Finally.
multiple behavioral methods exist for teaching patients to alter their
pain behavior.

The prototypical operant program was reported by Fordyce and his
associates (1973). In their program. the staff of an inpatient clinic
ignored patients' pain behaviors and praised actions inconsistent with
the sick role. Results showed that patients had significant increases
in physical therapy activities and decreases in medication intake from
admission to discharge. However. patients reported considerable pain
on questionnaires completed an average of 22 months after termination
of outpatient treatment. Patients retrospectively rated themselves as
having had significant decreases in pain and increases in activity
levels between admission and discharge. but no change following dis-
charge.

A review article of inpatient operant treatment studies by Turner
and Chapman (1982b) yielded several conclusions regarding the effec-
tiveness of operant interventions. Lengthy inpatient operant programs
appeared to increase physical activity levels and decrease medication
use while the patient was in the controlled hospital environment.
There is evidence from a few studies that these improvements were
maintained by most patients at follow-ups of from 1 to 8 years. How-
ewer. patients were carefully selected for participation in operant
Programs. and only a small percentage of the chronic pain population
was ever admitted to an inpatient operant program. There is very

little information concerning whether operant programs reduce

39

subjectively experienced pain since this is usually not a primary goal.
Finally. operant programs often consist of a plethora of independent
variables potentially affecting outcome. and because these are uncon-
trolled studies. it is difficult to assess the unique contributions of

contingency management techniques to reducing chronic pain behaviors.

WW
mam

A recent development in the field of pain management has been the
application of cognitive-behavioral theory and techniques to the
prevention and alleviation of pain (Goldfried. 1977; Meichenbaum &
Turk. 1976; Tan. 1982). An assumption of this approach is that the
beliefs. expectations. and attitudes people maintain in particular
situations can determine their emotional and behavioral reactions to
those situations. Since cognitive variables. such as distraction and
the meaning of the pain for the individual. and emotional variables.
such as anxiety. influence the experience of pain. it is logical that
the modification of cognitions could be used to alter the pain
experience. Unlike the operant approach. the cognitive-behavioral
model does not ignore the subjective experience of pain. Rather. it
views suffering as one of several aspects of a complex pain prob1em.

Cognitive-behavioral therapy aims to correct faulty cognitions
underlying emotional and behavioral disturbance. When applied to pain
problems. these interventions consist of such pain-control strategies
as relabeling sensations. relaxation. and imagery. These interventions

attempt to increase the patient's awareness of events that exacerbate

40

and actions that reduce pain. so that the patient may more effectively
avoid or cope adaptively with pain-increasing events and use pain-
relieving actions. The argument is that this awareness and knowledge
can give the chronic pain patient a sense of control over pain that
replaces feelings of anxiety and helplessness.

Cognitive-behavioral interventions have demonstrated potential to
alleviate reported pain in a variety of pain syndromes (Turner &
Chapman. 1982b). In the only direct comparison study of cognitive-
behavioral therapy with another psychological intervention. this
treatment was found to be more effective than electromyographic (EMG)
biofeedback (Holroyd. Andrasik. a Westbrook. 1977). but a combination
of cognitive-behavioral therapy and EMG biofeedback has not been found
in other studies to be more effective than cognitive-behavioral therapy
alone (Reeves. 1976). Most studies have not included objective behav-
ioral measures (such as observer ratings of pain behaviors. records of
medication use. health care utilization. employment. and activity
level) or adequate follow-up. In addition. outcome measures in these
studies have usually been too narrowly focused (Turner a Chapman.
1982b). Tan (1982) suggested that while cognitive-behavioral methods
for pain attenuation appear promising. the scientific evidence from
controlled studies for their efficacy with clinical pain is still

somewhat.meager.

41
.Ehxsiologlsal_Inte£xentions
19£_Qh£9n1§_E§1n

Two types of psychological interventions that emphasize the
control of physiological factors in the development of pain are muscle-
relaxation training and biofeedback. The purpose of relaxation
training is to relax tense muscles believed to cause musculoskeletal
pain and other related disorders. such as tension headaches. Although
many variations of muscle-relaxation training are currently practiced.
most involve progressively tensing and then relaxing major muscle
groups throughout the body. Most research using relaxation training
has been studies of tension of migraine-headache sufferers. and few
investigators have evaluated relaxation training with other chronic
pain syndromes (Turner. & Chapman. 1982a). Of the ten studies reviewed
by Turner and Chapman. eight showed decreases in the frequency. inten-
sity. and duration of self-reported headaches.

Biofeedback procedures have been used in chronic pain clinics in
conjunction with other treatment modalities. but application of bio-
feedback procedures alone to relieve chronic pain is a very limited
area of research. In biofeedback training. patients become aware of
particular involuntary processes through feedback of electronically
monitored physiological events and learn to bring these under control.
Four types of feedback are used with chronic pain syndromes: electro-
encephalographic (EEG) feedback. skin-temperature feedback. cephalic-
blood-volume feedback. and electromyographic feedback. Research has
dealt with the application of biofeedback to headaches. Turner and

Chapman (1982a) concluded that the various types of biofeedback.

42

usually with home relaxation practice. have been demonstrated to reduce
tension and migraine-headache activity. However. biofeedback appears
to be no more effective than muscle-relaxation training. a simpler and
far less costly alternative because it requires minimal equipment and
can betaught in groups. The success of biofeedback with other chronic

pain populations has not been convincingly demonstrated.

W5

Multicomponent pain clinics are emerging as the preferred mode of
treating the chronic pain patient. A variety of modalities are found
in these clinics. including physical therapy. relaxation training.
biofeedback. psychotherapy. educational classes. and family meetings.
Several shortcomings of studies of the effectiveness of multicomponent
pain clinics have been discussed (Aronoff. Evans. 8. Enders. 1983). The
first problem identified was the use of outcome measures with question-
able validity and reliability. The concept of "improvement in func-
tioning" requires an analysis of multiple factors and for many of these
factors. at present. few tests exist that have been standardized with
proven reliability. validity. and developed norms. Aronoff et al.
(1973) recommended the use of the McGill Pain Questionnaire (Melzack.
1975) since it fulfills these requirements. Comparisons between pre-
and post-treatment are difficult to make because of the failure of
researchers to use accepted standardized instruments and to use the
same instruments at each observation point. A second shortcoming of

follow-up studies is the problem of finding an appropriate comparison

43

group. Other criticisms include the variable lengths of time for
follow—ups. dependence on subjects' memory of events rather than actual
measurement at the time. and appropriately large sample sizes.

A study that sought to answer the question of why patients who do
well during a clinic program deteriorate shortly following discharge
and regress to pro-treatment levels within a few months was done by
Painter. Seres. and Newman (1980L The authors mailed 500 extensive
questionnaires to patients who completed a multicomponent pain program
and asked them to recall information that had been true for them
2 years previously. Of the 145 questionnaires returned. results showed
that 77% of the patients felt improved as a result of their pain center
experience. with an average pain reduction of 38%. Further improvement
following discharge was noted by 27% of the sample. with an average
additional reduction in pain of 21%. Deterioration was reported by 27%
of the sample. At the time of admission. 70% had been receiving com-
pensati on. whereas only 45% were receiving compensation on follow-up.
On admission. approximately 90% were unemployed. compared to 48% at
follow-up. A total of 61% of the patients reported that they had no
further medical care’for their pain after discharge. while 17% stated
that they were seeking other medical solutions. Additionally. 20%
reported having returned to the use of narcotic medications which had
been eliminated by the pain program. An interesting feature of this
study is the attempt to determine which factors were likely to influ-
ence long-term outcome. The authors found that the failure group

demonstrated fewer incentives for maintaining their gains. with most

44

continuing to receive financial compensation for their pain. Also. the
failure group was more likely to assume a passive. dependent stance.
with depression as a primary mode. Finally. these in the failure group
had done little to change their environment and continued to find
reinforcement for pain behavior.

In an attempt to avoid the problems inherent in self-report
questionnaires. Anderson. Cole. Gullickson. Hudgens. and Roberts (1977)
obtained their information in face-to-face interviews with 31 patients
who completed an outpatient pain program of a hospital. Follow-up time
varied from 6 months to 7 years. The authors reported that 25 patients
were leading "normal lives" and five patients were not. Although the
advantage of this study is that the evaluations were conducted face-to-
face. the methods by which it was determined that the patients were
leading a "normal life" were not made clear. Also. it was unclear
whether pro-treatment.measures were obtained and how these were com-
pared to post-treatment measures.

A multicomponent pain clinic study using group therapy. discus-
sion. behavioral methods. biofeedback. and relaxation was conducted
by Swanson and his associates (1976) using data from 200 patients.

At discharge. patients were rated by staff in three categories:

(a) modification of attitude. (b) reduction in medication. and

(c) improvement in physical functioning. Patients were subjectively
rated in each category as having made no progress. minimal progress.
moderate progress. or marked improvement. Pro-treatment measures were

pati ents' self-reports. while 3-month follow-up measures were mailed

45

questionnaires. Results indicated that 75% of the patients had
improved moderately or markedly at the 3-month follow-up. A shortcom-
ing of this study was the inconsistency in the measures used at differ-
ent times. thus making comparisons very difficult.

Employing a paradigm first devised by Fordyce and his associates
(1973). Roberts and Reinhardt (1980) evaluated outcomes of patients
treated in a "pure" behaviorally oriented program using two comparison
groups. A group of 26 treated patients was compared with 20 patients
rejected for treatment by the clinic and 12 patients who had refused
treatment. 'The follow-up in this case ranged from 1 to 8 years. In
general. a "successful" treatment outcome was a person who was employed
or normally active for at least 8 hours a day. receiving no compensa-
tion. no hospitalization since treatment. and no use of prescription
pain medication. Of the 26 treated participants. 77% met all these
criteria. Instrumentation employed was the Minnesota Multiphasic Per-
sonal ity Inventory (MMPI). the McGill Pain Questionnaire. and a daily
activity inventory. Treated subjects had significant decreases on the
Hypochondriasis (Hs) scale of the MMPI. in the number of hours in pain
per day. in the use of medications at follow-up. and were more often in
paid employment than subjects in the comparison groups. 'Treated sub-
jects also reported fewer pain-related hospitalizations than those in
the other groups and more often reported improved ability to engage in
sexual activity. In contrast to subjects in the comparison groups.
treated subjects had significantly lower scores on the Hypochondriasis

(Hs). Depression (0). and Hysteria (Hy) scales of the MMPI.

46

In another study using comparison groups. 100 patients who
completed a comprehensive outpatient pain rehabilitation program were
divided into three groups: (a) pending disability. (b) current
disability. and (c) no disability (Chapman. Brena. & Bradford. 1981).
Follow-up intervals ranged from 15 to 30 months. with a mean of 21
months. Forty-eight patients returned questionnaires. and an additional
40 patients were reached by phone and provided some information. ‘The
questionnaire included a daily activity sheet. a medication record. a
5-point visual analogue pain intensity rating. and two measures from
the McGill Pain Questionnaire. Results indicated that there were
significant overall decreases in reported pain intensity from pre- to
post-treatment and from pro-treatment to follow-up. The number of
reported daily activities increased significantly across groups from
pre-treatment to post-treatment and from pre-treatment to follow-up.
The results of the McGill Pain Questionnaire were not reported clearly.
so it is impossible to determine whether they were significant.
Patients reported decreases in the use of pain medications across all
groups. but again it is unclear whether the differences were statisti-
cally significant. Disability status was not significantly related to
any outcome.

Along with the multidisciplinary treatments received by patients
in a pain clinic program. the therapeutic regimen that patients are
expected to continue on their own following discharge is multifaceted
and requires basic behavioral and lifestyle changes. A study that

assessed long-term adherence to therapeutic regimens was conducted by

47

Lutz. Silbert. 8. Olshan (1983). Of 77 former patients from a multicom-
ponent clinic. 74% (n = 57) responded to mailed questionnaires. The
average length of follow-up time was 23 months. The questionnaire was
designed to assess treatment outcome along three dimensions: subjec-
tive pain. activity and lifestyle. and medication use. Compliance
rates were assessed for each of five separate home regimens. including
ambulation exercises. physical therapy and occupational therapy exer-
cises. home treatments. relaxation and self-hypnosis exercises. and use-
of proper body mechanics. Excluding the home treatments. compliance on
a daily basis with the therapy regimens varied from 32% to 52%. with an
average compliance rate of 42%. Overall compliance was extremely low.
with only 12% of respondents complying with the total combination of
prescribed regimens. 'The authors concluded that overall compliance is
not a useful measure because it does not explain long-term treatment
outcome as well as a separate assessment of individual regimens.

A novel. multielement approach with a strong educational component
was investigated by Goldsmith (1981L, The aim of this study was to
break the tension-anxiety-pain cycle by using various stress-reduction
and self-control strategies. Twenty chronic low back pain patients
were randomly assigned to one of two treatment groups. One group
received training in self-control techniques. assertiveness skills.
cognitive and behavioral depression management. and relaxation
techniques. while the second group received training in bodily
repositioning. Pro-treatment. post-treatment. and l-month follow-up

data were obtained on the McGill Pain Questionnaire and the Beck

48

Depression Inventory. Results indicated that in both groups there were
significant reductions on global pain ratings and in pain medication
use. Subjects reporting the most global self-monitored pain decrease
following educational treatments had the highest McGill affective pain
ratings. After treatment. affective pain ratings were lower and pain
intensity diminished. In contrast. those reporting the least global
pain reduction following the educational treatment had the highest
McGill evaluative pain scores. The conclusion was that the tension-
anxiety-pain hypothesis may be most valid with a subgroup of patients
who are depressed. with a large pain component which is affected by

emotional arousal.

Sumarx

Psychoeducation or psychological skills training has emerged as an
important area in the delivery of mental health services during the
past 15 years. The term "psychoeducation" refers to the teaching of
personal and interpersonal attitudes. skills. and concepts which the
person can apply both in the present and in the future to increase
their own and others' satisfaction with life. Two trends have encour-
aged the development of psychoeducation: the public's growing interest
in psychological knowledge and recognition by psychologists that psy-
chological knowledge can be shared.

Following the tenets of the educational model in psychology.
psychoeducation purports several assumptions: (a) the psychologist
assumes the role of teacher and the client the role of student.

(b) client problems are viewed as skill deficits rather than

49

"illnesses" or symptoms; and (c) clients are active rather than passive
participants in the learning process. Each of these assumptions is
essentially antithetical to those made in the medical model of service
delivery.

This review addressed the features of four related areas: general
instructional programs. problem-solving programs. coping skills train-
ing. and self-control. All of these areas share the aim of broadening
the person's repertoire of personal and interpersonal skills in order
to facilitate adaptation and performance in a variety of situations.

General behavior change programs tend to follow a similar format
of stages: (a) specify a behavior requiring change. (b) set goals and
develop a self-change contract. (c) self-monitor the target behaviors'
frequency of occurrence. and (d) rearrange antecedents and conse-
quences. These programs employ an operant approach to change.
instructing the person to manipulate the antecedents and consequences
of a target behavior. Emphasis is placed on the process of moving
through the stages. as opposed to generating one solution to a problem.
Other programs emphasize social-learning principles in behavior change.
including modeling. role playing. and performance feedback.

Closely related to general behavior change programs are the
probl em-sol ving programs. With some minor variations. these programs
typically instruct the person to engage in a process of (a) general
orientation. i.e.. problems are a part of life and are solvable;

(b) problem definition and formulation; (c) generation of alternatives.

(d) decision making. and (e) verification and evaluation. Programs

50

that depart from this format may highlight one variable thought to be
central to the process of solving problems. such as fear. Effective

problem solving has been found to be a feature of good psychological

adjustment.

Another area of literature that advances the concept of expanding
an individual's repertoire of personal and interpersonal skills is
coping skills training. The psychotherapeutic approach most closely
identified with the explicit teaching of coping skills is cognitive
behavior therapy. A coping skill is any type of cognitive or overt
behavior pattern that effectively deals with a problem situation.
Several components are common to coping skills treatments:

(a) highlighting the central role of cognitions in producing a problem.
(b) training in self-monitoring of self-statements. (c) training in the
fundamentals of problem solving. (d)lnodeling and rehearsal of effec-
tive self-statements. and (e) in yiyg behavioral assignments.

Individuals provided with coping skills training are encouraged to
view change as a slow. gradual process that initially has little
anxiety-reducing effects. In addition. acquisition of a skill is not
sufficient to insure that a person will use the skill. and an awareness
of affective cues that trigger the use of the skill is essential.

Self-control refers to the process through which a person becomes
the principal agent in guiding and directing those features of his/her
own behavior that may lead to desired positive consequences. 'The
domain of self-control covers self-directed behavior sequences in which

a person is exposed to a conflict and to a demand to take actions that

51

initially alter the likelihood of executing a previously probable
response. Individuals are instructed to regulate their own behavior
through a three-step process of self-monitoring. self-evaluation. and
self-reinforcement.

Chronic pain is a multifaceted phenomenon influenced by a constel—
lation of psychological and personality factors. The specificity
theory. viewing pain as strictly a physical sensation. has been
replaced by the Gate Control Theory. which regards pain as a complex
phenomenon with emotional and motivational components subject to modi-
fication. Most theorists regard pain as an "abstraction" used to refer
to a variety of feelings which have little in common except for the
quality of physical hurt. For the sufferer. chronic pain is intract-
able. having no meaning and serving no purpose.

In response to the growing acceptance of the Gate Control Theory
of Pain. a number of psychological interventions are currently used in
conjunction with more traditional medical intervention. These include
(a) physiological interventions: biofeedback and muscle-relaxation
training. (b) cognitive behavioral therapy. and (c) operant condition-
ing interventions. Each of these interventions addresses a different
aspect of the experience of the chronic pain patient.

The operant approach seeks to decrease learned pain behaviors and
to replace them with behaviors inconsistent with the sick role.
Operant interventions have been shown to increase physical activity

levels and decrease medication use during treatment. with some support

be

6C

ner
vii
Par
tiv
Pail
the:

"dtu

52

for maintenance of these gains. However. it has been difficult to
assess the unique contribution of contingency management techniques.

Cognitive-behavioral interventions attempt to alter faulty
cognitions underlying the pain experience. While these interventions
show much promise in alleviating reported pain. the scientific evidence
of their efficacy remains meager.

Research with muscle-relaxation training and biofeedback. which
focuses on the control of physiological factors in the development of
chronic pain. has been narrowly confined to one pain syndrome. headache
pain. Muscle relaxation appears effective in decreasing self-reported
headaches. although these studies have been hampered by poor controls.
Biofeedback. typically an adjunct to other treatments. has been found to
be no more effective than muscle-relaxation training in reducing head-
ache activity.

Follow-up studies investigating the effectiveness of multicompo-
nent pain clinics have several weaknesses: use of outcome measures
with questionable validity and reliability. use of inappropriate com-
parison groups. variable lengths of follow-up. dependence on retrospec-
tive measurements. and small sample sizes. In general. although 60% of
pain patients demonstrate significant gains during their treatment.
there is a notable regression in improvement once they return to their
natural environment and only 30% maintain their gains.

The methodology for the study is presented in Chapter Three.

CHAPTER 3

METHODOLOGY

In this chapter the methodology of the study is described.
Included in the chapter are a description of the Personal Paradigm
Shift.(PPS). the sample used. the instrumentation. the procedure. a
statement of research hypotheses. and an explanation of the statistical

procedures used for data analysis.

WWII

The PPS employs a psychoeducational approach to personal behavior
change and health care management. 'This program was developed by
Hinds (1983) over a period of several years of practicing psychotherapy
and teaching students in graduate-level courses. The instrument
evolved from his observations of the dynamics of how people learn the
process of personal change and make decisions about managing stress.
The reading level of the PPS was estimated to be at the sixth-grade
level using Fry's (1968) readability technique.

The procedure used in this program closely follows three assump-
tions associated with psychoeducational intervention models (Larson.

1984):

53

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54

l. The psychologist becomes a teacher to the client.

2. Health care behaviors are viewed as functional relationships
which can be unlearned or changed.

3. Clients are viewed as active participants in the treatment
process and are given responsibility for various choice points in the
treatment process.

The PPS provides an organized approach to self-care which can
assist patients in achieving their health care goals. Unlike many
health care interventions that ask for patient compliance. this program
attempts to achieve internalization as a means of altering behaviors
and maintaining change. Suedfeld (1982) described internalization as
the change in attitudes and associated behaviors that results from the
realization that a change to a new pattern will be beneficial.
rational. and worthy of acceptance. Internalization may involve a
shift in the value system to accommodate this new outlook. When inter-
nalization occurs in the context of health attitudes and behaviors. it
is called maintenance. In the PPS. treatment is seen as an educational
process that engages patients in helping themselves.

The PPS meets four of the six conditions that are thought to be
crucial to lifestyle intervention (Benfari. Eaken. & Stole. 1981):

l. The patient knows what change is desirable and why and
acquires the knowledge required for the change.

2. The patient has the skill or is learning the skill to
implement the knowledge for change.

3. The change is in the patient's self-interest.

Char

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mines

behav

”We.

55

4. The change is in the self-interest of related primary groups
(families. peers. etc.).

5. Both internal and external environmental systems require
change.

6. Internal and external change agents give their support to the
change and provide feedback through the process.

The fourth condition is not directly addressed in the PPS. and the
sixth condition is considered only in part because more emphasis is
placed on the recognition and development of personal control than on
environmental contingency controls. The PPS is organized to assist
the patient in identifying significant psychological. environmental.
and psychosocial lifestyle variables that affect health and pain. The
main feature of this program is that it involves the individual in
observing. experiencing. and determining his/her own behavioral-choice
process. ‘Treatment is an educational process that engages the person
in learning how to make personal change.

While many intervention programs in health care management
involve the patient as a passive change agent. the PPS involves the
person as an active agent in the change process. The PPS strives to
teach the patient about learning as it is related to personal behavior
change and choice. Patients can learn about the decisions they make in
managing their health which affect the quality of their lives.

Like other personal prob1em-solving programs. the PPS assumes that
behavior change proceeds through a sequence of stages. The change

process involves the experience of (a) personal health care awareness.

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56

(b) decision making. (c) oppositional alternatives. and (d) treatment
planning and action. Each stage comprises detailed steps designed to
educate individuals about the relationships between internal phenomena
(6%}! feelings. thoughts. physiological reactions) which maintain
personal problems and distress. ‘This detail within each stage of the
behavior change process is one factor that sets the PPS apart from

other prob1em-solving models.

Wes:

The stage of awareness comprises seven steps which guide the
person through a series of exercises designed to assess current health
care behaviors and to confront personal dynamics with the aim of creat-
ing self-understanding. Fttients are often unfamiliar with observing
such a process. and therefore this stage may be slow and difficult for
them. The key to this stage is that patients are confronted with
examining the critical relationships between internal and external
variables which maintain personal problems.

In Step 1 of the awareness stage. patients are asked to identify a
personal problem which they want to work on. The problem is described
with a label or ”theme." such as "workaholic." "sel f-sacrificer." or
”pain gets the best of meJ' Accurate identification of a workable
problem is essential to completion of the remainder of the program.

Once the patient has identified a theme. some initial goals are
set relating to that theme (Step 2). These goals are behavioral

objectives that assist the person in looking to the future with

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57

optimism. 'The person in pain may state an initial goal as "do more
things with my family."

Step 3 involves identifying antecedent events to a problem. a step
found in most behavior-change programs. A specific description of the
events. situations. or people that elicit problematic internal reac-
tions in the person is recorded. The person in chronic pain may list
the following: "getting into an argumentfl'"pushing myself too hardfl'
and "having others ask me how Inn doingJ'

Antecedent events affect internal reactions. i.e.. the beliefs
(thoughts). feelings. mental images. and physiological reactions that
occur within. These internal reactions are identified in Step 4. An
understanding of the relationship between these internal reactions is
the goal of this step.

Since any given behavior is an expression of the chain of
sequential steps which precede it. Step 5 is an examination of the
steps a person takes in the identified problem situation. Changing
these steps is seen as a necessary but not sufficient condition in
problem solving.

Step 6 addresses the consequences that follow a person's action(s)
in the problem situation. Consequences may be either internal or
external. A link is also established between self-evaluations and
consequences; i.e.. people make internal judgments about themselves
based on the consequences of their behavior. Finally. the person

acquires an awareness of the "needs" that are met by behaving in

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58

self-defeating ways. and emphasis is placed on identifying the level of
importance which these needs have for the person.

The final step of awareness is termed "taking a loss." Step 7. a
unique feature of the PPS not found in other behavior change manuals.
The task facing the person is to identify either the beliefs or the
level at which a need is maintained that must be "given up" before a
foundation can be made for behavior change. Personal change involves
not only gaining something but also giving up something. a feature not
usually understood by people. The second part of this step is the
acquisition of awareness of the assumptions the person makes about what
is needed in life in order to survive. assumptions the person accepts

as true and uses to guide behavior.

Stage_2:_0ecision_uak1n9

The stage of decision making requires patients to determine how
the critical information they have gained from the awareness stage
influences their decision making about personal change. This decision
making consists of three steps: constructing a balance sheet. making a
commitment to change. and confronting the fear barrier (Steps 8. 9. and
10). The process in this stage is not found in other behavior-change
manuals.

Step 8 requires that the patient construct a balance sheet. just
as an accountant would do. using thoughts and feelings as the critical
information. This step provides an opportunity to visualize. in a
concrete way. the specific conflicts that inhibit the ability to make

the identified change and the factors that motivate the desire for

char
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59

change. Until patients confront these factors. it is easy to avoid or
deny information that will provide the motivation to make a commitment
to a personal change. Using a balance sheet format. patients generate
the perceived punishments and rewards that they will accrue for chang-
ing or not changing.

The briefest step in the manual. Step 9. asks the person to
reflect on the data gathered from the previous step and make a
cognitive and emotional commitment to change. In a sense. the person
pledges to continue efforts toward personal change. .A person may not
elect to make a commitment to change and decide that the present state
of affairs is satisfactory.

The inhibiting influence of fear on behavior change is one of the
central concepts of the PPS and is addressed in Step 10. approaching
the fear barrier. In this step the person attempts to confront
resistance to change by identifying the fears associated with change.
Expectations about the experience of unpleasant emotions like shame or
pain are addressed. and additionally. the person identifies the usual

defenses used to avoid the experience of these emotions.

W

This stage is a creative process that assists in generating new
internal reactions. i.eu. beliefs. feelings. physiological reactions.
mental images. that are counter to the internal reactions identified in

the Awareness stage. The four steps (11 through 14) comprising this

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stage help patients to develop a new set of internal reactions which
will foster a sense of self-control.

The first building block in constructing a set of new internal
reactions to replace the old internal reactions is to once again record
the information from Step 3. stressful conditions of the problem. This
step is repeated as Step 11 to emphasize that a person really has very
little control over these factors. Hinds (1983) stated that a person
has control over the connection between variables (stress conditions -
internal reactions - behavior - consequences - self-evaluations). not
over the events. people. or places that trigger stress.

Step 12. developing new internal reactions (new feelings. new
beliefs. new images. new physiological reactions). is perhaps one of
the most critical and difficult steps in the PPS. The task is to begin
to think about new. healthy internal reactions that oppose the old.
unhealthy. yet familiar. internal reactions. This step encourages the
development of a "paradigm shifv'(Hinds. 1983). or a change in the way
persons view their experience. 'The chronic pain patient who is able to
develop new internal reactions to pain has a better foundation for new
satisfying behaviors. The second aspect of this step. the development
of new self-evaluations. follows naturally once new internal reactions
are in place.

Step 13. thinking about new actions. is a natural progression from
the previous step. In other behavior-change manuals. this step is
usually referred to as "developing alternatives." and the person is

directed to brainstorm as many alternative behaviors as possible while

61

reserving judgment as to the appropriateness of those behaviors. These
behaviors must be counter to the old behaviors. Although a person may
not fully believe that these new behaviors can be performed. the exer-
cise may be useful in itself.

Developing new consequences following from new actions is the goal
of Step 14. While new consequences may partly reflect projected or
expected losses. new gains will outweigh those losses. and keeping the
gains before oneself is the task in this step. New gains are fre-
quently felt as internal experiences. i.e.. more sel f-control. improved
sel f-esteem. greater sel f-confidence. However. they may also be
expressed in the external real m. i.e.. improved social life. more
contact with others. Identifying the needs now satisfied as a result
of these new consequences is the second part of this step.

W
amLAcflon

The final phase of the PPS consists of ten steps (15 through 24)
in which the patient begins to establish a firm foundation for personal
change. One of the reasons people do not maintain treatment goals is
that they leave out simple. yet crucial. supports for their new
actions. "Treatment Planning and Action" assists the person in
organizing those supports and using them effectively. These steps
together help to reduce fear and increase motivation for change while
preventing feelings of helplessness and hopelessness.

In Step 15. patients identify the initial goal they need to

achieve in order to stay motivated to change. This initial goal must

62

be realistic. specific. and countable. In this step. patients are
taught how to formulate initial change goals into behavioral terms and
are shown that goals which are within their resources will provide
motivation to continue the change process. The statement of goals in
specific. behavioral terms is a common feature of personal change
programs.

Creating support systems to prevent feelings of helplessness
during a personal change program is the objective of Step 16. The
rationale for developing support systems is that people need to
acknowledge their dependency on others in the course of living. and
drawing on the assets of others may provide a source of strength.

Step 17. seeking new information and finding a model. urges people
to identify others who have accomplished what they are attempting to do
and find information sources that may assist them in reaching change
goals. This step is based on concepts of observational learning and
modeling.

In Step 18. the task is to provide oneself with a small reward
immediately following the accomplishment of an initial change goal.
Positive reinforcement immediately following appropriate behavior is a
central principle of operant learning and encourages the development of
selfecontrol. The self-rewards must be personal andlneaningful so that
they continue to be a source of motivation.

A unique feature of the PPS is Step 19. developing an organized
"plan of attack" in working on a personal problem. Patients are

encouraged to determine the order of behaviors they will perform to

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63

achieve a satisfying solution to a problem. This sense of organization
becomes a predictable pathway for the patient to remain motivated to
work toward personal change and serves to demystify the process of
change.

People who are attempting behavior change often ignore feedback
from their efforts because it may show that they are making very little
progress toward their goal. and therefore they avoid discouragement and
possible failure. Feedback would then be regarded as an enemy rather
than an ally that may serve a selfecorrective function for the person.
In Step 20. the person is taught the meaning of feedback and shown how
to develop a feedback system. Feedback is most effectively used when
it is specific and accurate in providing a person with information
about progress toward a goal.

A further way to counteract failure to reach a change goal and
maintain motivation to change is to set a time frame for accomplishing
the goal. the task of Step 21. This encourages the person to adhere to
a schedule in working on a goal. There can be a sense of security in
the limits that are set for making a change. and these limits will help
a person avoid procrastination in working toward a goal.

Change is often a fearful experience because it requires that a
person let go of familiar and rewarding patterns of thinking. feeling.
and behaving and take a risk with a new mode of experiencing. The
phenomenon of fear of success is a last unconscious attempt by the

person to undermine personal change and once again begin the

64

self-defeating cycle. Step 23 helps the person think about ways to
counteract this fear of success.

The final step in "Treatment Planning and Action" is that the
person keep a daily or weekly diary recording gains made in achieving
behavior change. A written record of rewards may be motivating and

provide the final support system the person requires.

W

The PPS is a systematic and structured model for personal behavior
change and health care management that involves patients in observing.
experiencing. and determining their own behavioral choice process.
While seeking to educate patients in the process of making optimal
health care choices. it instructs them in the process of learning how
to learn about themselves. The PPS closely adheres to the assumptions
of psychoeducational approaches as described by Larson (1984). and it
meets most of the conditions thought to be important to lifestyle
intervention (Benfari et al.. 1981). The program assumes the patient
is an active agent in the change process as he/she progresses through
the four stages of health care awareness. decision making. generating
oppositional alternatives. and treatment planning and action. Unlike
other personal change programs found in the literature. the PPS is more
detailed (24 steps). accounts for a larger number of mediating variables
in personal change. and does not rely exclusively on the development of
operant relationships. The PPS is designed as an adjunct treatment for

patients who are involved in a regimen of medical treatment.

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Sample

The subjects for the study were recruited from patients admitted
by physicians to a chronic pain clinic in mid-Michigan. from April
through July 1984. ‘This clinic is a comprehensive. medically managed
rehabilitation program for both inpatients and outpatients. Typically.
the patient composition is about 70% outpatient and 30% inpatient. and
patients come from all geographic areas of Michigan.

Staff of the clinic include a physician. a fully licensed
psychologist. a licensed physical therapist. and an assistant physical
therapist. Duration of the program is 1 week; patients receive an
orientation to the clinic on Sunday evening. participate in treatments
throughout the week. and are generally discharged on Friday afternoon.
A few patients return the following week for particular treatments or
are referred out for ongoing psychological and/or medical services.

The treatment regimen consists of medical management. daily psychother-
apy. twice-daily physical therapy treatments. exercise. biofeedback and
muscle-relaxation training. vocational guidance. occupational therapy.
and educational classes in the psychophysiology of chronic pain. All
patients are referred to the clinic with the goal of obtaining signifi-
cant relief from chronic pain. The most frequent admitting diagnoses
are facet syndrome. degenerative disc disease. musculoskeletal syn-
drome. and back strain. The patients usually have been very active

using health care services for pain relief.

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A total of 51 patients volunteered to participate in the study.
Three patients initially accepted into the study were subsequently
excluded because they left the clinic before all treatments were
completed. There were three criteria for exclusion from participation
in the study: evidence of organic brain damage. schizophrenia. and
inability to read or write. The sample consisted of two groups:
patients assigned to the experimental condition receiving the PPS
intervention. and patients assigned to the control condition receiving
the Discussion group intervention. Methods for assignment to the two
groups are presented in detail in the Procedures section.

The demographic information for both the experimental group
subjects and the control group subjects are presented in Tables 3.1
through 3.7. The two groups were composed of a nearly equivalent
number of subjects: 26 in the PPS group and 25 in the Discussion
group. 'The mean age of the PPS group and the Discussion group was
42.77 and 44.48 years. respectively. The racial composition of the two
groups was quite similar. with Caucasians comprising over 80% of each
group and the remainder largely composed of Blacks. The PPS group was
evenly divided by sex. while the Discussion group had a higher percent-
age of females than males. Examination of the marital status of the
subjects revealed that most subjects in both groups were married. and
smaller percentages were single or divorced. Level of education was
roughly equivalent between groups. with 91% of the Discussion group and
100% of the PPS group having earned at least a tenth-grade education.

The employment status of the groups was roughly equivalent; more than

67

60% were either semi-skilled or unskilled. and about 11% of each group
were skilled laborers. Using total raw scores obtained from the
Shipley Institute of Living Scale (Shipley. 1940). estimated WAIS IQ
scores were calculated for all subjects (Paulson a Lin. 1970). Both
groups demonstrated mean estimated WAIS IQ's within the average range
of intellectual functioning (an IQ between 90 and 110). although the
mean estimated IQ for the PPS group was six points higher than that of
the Discussion group. Appendix A illustrates the estimated IQ scores

for all 12 weekly groups in the study.

Table 3.1: Age of Subjects

 

 

PPS Discussion
Mean 43.77 44.48
Median 40.00 46.00
Standard deviation 9.75 12.12

 

Table 3.2: Race of Subjects (in percent)

 

 

Race PPS Discussion
Asian 0 0
Black 12 13
Caucasian 88 83

Other 0 4

 

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68

Table 3.3: Sex of Subjects (in percent)

 

 

Sex PPS Discussion
Female 50 70
Male 50 30

 

Table 3.4: Marital Status of Subjects (in percent)

 

 

Category PPS Discussion
Single 11 15
Married 77 62
Widowed 0 4
Divorced 8 15
Separated 4 4

 

Table 3.5: Years of Education of Subjects (in percent)

 

Years PPS Discussion

 

Elementary (grades 1-6) 0 0
Junior high (grades 7-9) 0 0
Senior high (grades 10-12) 78.0
Some college 17 0
College graduate 4 0
Postgraduate 0 0

 

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Table 3.6: Work Composition of Subjects (in percent)

 

 

Category PPS Discussion
Unskilled 50.0 34.6
Semi-skilled 18.5 26.9
Skilled 11.5 11.5
Retired 3.8 3.8
Unemployed 0.0 11.5
Disability 14.0 3.8
No response 3.8 11.5

 

Table 3.7: Estimated WAIS IQ's of Subjects

 

PPS Discussion

 

Mean 104.58 98.42

 

Note: Shipley total raw scores were converted to estimated WAIS
IQ's (Paulson 5 Lin. 1970).

At pretreatment. a greater percentage of the PPS group (41%) was
employed or in a job-training program. compared to the Discussion group
(23%). Fifty-two percent of the PPS group was receiving workman's
compensation or some other income for pain (e.g.. insurance). compared
to 61% of the Discussion group. A greater percentage of the Discussion
group (76%) reported that their pain interfered with sexual inter-
course. compared to the PPS group (59%). Eighty-five percent of the PPS
group subjects had had at least one surgery for pain relief..as compared

to only 38% of the Discussion group subjects.

70

Using the present pain intensity (PPI) scale from the McGill Pain
Questionnaire (MPQ) (Melzack. 1975). a S-point scale of overall pain
intensity (0 = none. 1 = mild. 2 = discomforting. 3 = distressing. 4 =
horrible or excruciating). the PPS group had a mean rating of 3.02.
compared to the Discussion group with a mean rating of 2.78. at pre-
treatment. Patients were unable to reliably report the type and amount

of medication they were taking for pain relief.

Instnumentaflon

Several written instruments were selected as operational measures
of the primary hypothetical constructs in this study. They are the
McGill Pain Questionnaire (MPQ) (Melzack. 1975). the Minnesota
Multiphasic Personality Inventory (MMPI). and the Lifestyle Coping
Inventory (Hinds. 1983). The Shipley Institute of Living Scale
(Shipl ey. 1940) was used descriptively as an estimation of the current
intellectual functioning of the subjects. In addition. a brief follow-
up questionnaire regarding the health. pain. and employment status of
the subjects was constructed (Appendix 8).

MW
Questionnaine

The MPQ (Melzack. 1975) was selected as a verbal self-report
measure of the pain experience (Appendix C). Melzack believed that
many of the tools used to measure pain were limited because they
described pain as though it were a specific sensory quality that varied
only in intensity. The word "pain." according to Mel ack. refers to an

endless variety of qualities which are categorized under a single

71

linguistic label. not to a single sensation that varies only in inten-
sity.

Melzack and Torgerson (1971) began the specification of the
qualities of pain by asking groups of students. patients. and
physicians to classify 102 pain-related words into smaller groups.
Three main categories were obtained: (a) words that describe sensory
qualities of pain. in terms of temporal. spacial. thermal. or other
properties; (b) words that describe affective qualities. in terms of
tension. fear. and autonomic properties of pain; and (c) evaluative
words that describe the subjective overall intensity of the total pain
experience. 'These three main categories were classified into 16
subcategories consisting of groups of words that were considered
synonyms. Intensity values were assigned to each of the words. using
a scale from least (or mild) to worst (or excruciating) pain.

Using the research tool developed in the Melzack and Torgerson
(1971) study. several groups of patients with different illnesses were
asked to describe their present pain (Melzack. 1975). It was concluded
that four types of data could be obtained from the instrument: (a) a
pain rating index based on the pati ents' mean scale values of the words
in a given category. the FRI-(S); (b) a pain rating index based on the
rank values of the words in a given category. the PRI-(R); (c) the
number of words chosen across all categories; and (d) the present
pain intensity. or the number-word combination chosen as an indicator

of overall pain intensity at the time of administration. with l = mild.

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72

2 = discomforting. 3 = distressing. and 4 = horrible or excruciating.
In the present study. the types of measures used were b. c. and d.

W. All of the MP0 data
reported in this section are based on a series of studies reported in
Melzack (1975). For all word categories (sensory. affective. evalua-
tive). correlations of .90 or higher have been obtained between the
scale and rank methods for determining the pain rating index. The rank
value method of scoring the word descriptions of pain was used in the
present study since it is more easily computed than the scale value
method.

In Melzack's study.’ with a sample of 248 patients. the number of
words chosen correlated .89 with the rank value method of computing the
pain rating index. This high correlation is expected since the larger
the number of words chosen. the higher the pain rating index. The
patients' ratings of overall present pain intensity correlated
significantly (p, < .01) with the number of words chosen and the rank
value method of computing the pain rating index for each category of
pain descriptors. The correlation coefficients for the present pain
intensity and each of the other indices were: number of words chosen.
.32; pain rating index-rank method-sensory category. .29; pain rating
index-rank method-affective category. .42; pain rating index-rank
method-oval uative category. .49. The present pain intensity appears to
be a more labile indicator of pain than the other indices and more
susceptible to influence by variables other than the sensory dimensions

of pain. such as the individual's present mood state.

73

On the average. the sensory word descriptors were chosen more
frequently than the affective word descriptors (Melzack. 1975). Nearly
all patients chose a word in the evaluative category even though there
is no instruction that this represents a distinctive category. In
investigating whether patients tend to choose words from the same
subcategories on successive presentations of the questionnaire. an
analysis of ten patients responding to three administrations of the MPQ
at intervals ranging from 3 to 7 days revealed a mean consistency of
70.3%. with a range from 50% to 100% (Melzack. 1975).

Melzack (1975) reported mean values of each of the pain ratings
for a number of individual pain syndromes. With a sample of 14 back
pain patients (mean age of 48 years). a type of pain commonly found in
the sample of patients in the present study. the following means were
reported: mean present pain intensity. 2.6; mean number of words
chosen. 10.9; mean pain rating index-rank method-sensory category.
14.0; mean pain rating index-rank method-affective category. 3.5; mean
pain rating index-rank method-evaluative category. 3.3.

Wan. The MPQ has been found to meet commonly
accepted psychometric stands of validity (Reading. 1983). During the
past:8 years. the increase in the number of studies from a variety of
clinical settings that include the MPQ.as a dependent measure testifies
to its face validity. Distinctive sensory. sensory-affective. and
evaluative factors have emerged from an analysis of 102 back pain
patients (McCreary. Turner. a Dawson. 1982). supporting the construct
validity of the MP0. In regard to concurrent validity. MPQ scores have

74

been reported to be associated with analgesia requirements (Reading.
1983). Finally. the MPQ has been shown to be an efficient instrument
in distinguishing among patient groups with various pain syndromes
(Reading. 1983). Chronic pain involves more differentiation of the
sensory. affective. and evaluative components than does acute pain
(Reading. 1983). Chronic pain patients tend to use affective and

evaluative word descriptors more frequently than acute pain patients.

WW
MW).

The MMPI is designed to provide an objective assessment of the
major personality characteristics that influence personal and social
adjustment. Hathaway and McKinley (1967) have discussed in detail the
construction of the MMPI and the derivation of its scales.

Development of the MMPI scales proceeded by contrasting normal
groups with carefully studied clinical cases. More than 800 such
cases from the Neuropsychiatric Division of the University of Minnesota
Hospital were used as normative data. The primary criteria for
including an item on a particular scale was consistency of inclusion by
sample patients already diagnosed as having a specific mental syndrome
or condition.

W. Reliability of the Hypochondriasis (Hs).
Depression (0). Hysteria (Hy). and Psychasthenia (Pt) scales. the
scales of interest in the present study. has been reported to be quite
satisfactory. Hathaway and McKinley (1940. 1942) reported test-retest

coefficients on 10 samples of 40 normal patients. Cottle (1950)

75

reported l-week testrretest coefficients for 100 normal subjects.
Holzberg and Alessi (1949) reported test-retest coefficients for 30
psychiatric patients. The data from these studies are represented in
Table 3.8.

In the present study. Form R of the MMPI was used as a pretreat-
ment.measure since this instrument was routinely administered at admis-
sion to all patients who entered the pain clinic. Form R permits all
14 basic scales to be obtained from the first 399 items. The test was
administered according to standardized procedures described by Hathaway
and McKinley (1967. p. 9%. Thirteen overlay keys were used to hand
score the answer sheet of the Form R. Raw scores were converted to
appropriate I scores with a mean of 50 and a standard deviation of 10.
Four scales of the MMPI were used in this study: Hypochondriasis (Hs).

Depression (0). Hysteria (Hy). and Psychasthenia (PtL

Table 3.8: Test-Retest Reliability Coefficients Reported for the MMPI

 

 

Hathaway & Holzberg &
McKinley Cottle Alessi
Scale (1940.1942) (1950) (1949)

Normals Normals Psychiatric
Hypochondriasis (Hs) .80 .81 .67
Depression (0) .77 .66 .80
Hysteria (Hy) .57 .72 .87

Anxiety (Pt) .74 .90 .72

 

76

W. A convenient short-form administration
of the MMPI. the MMPI-168 (Overall 8. Gomez-Mont. 1974) was mailed to

subjects at the 3-month follow-up point. The MMPI-168 comprises the
first 168 items of Form R. and conventional scoring templates are used
to obtain raw scores on each of the scales. This short form was used
rather than Form R because it was felt that a shorter instrument would
increase the return rate.

W. High correlations have been reported
between the standard version of the MMPI and the abbreviated MMPI-168
for a sample of medical school patients and psychiatric patients with a
wide variety of diagnoses (Overall 8 Gomez—Mont. 1974). Correlations
ranged between .79 and .96 for all scales. with .96 for H5. .94 for D.
.92 for Hy. and .90 for Pt. the scales of interest in the present study.

Group and individual MMPI-168 data were analyzed in a study of
psychiatric inpatients comprising 70 white males and 70 white females
(Newmark. Newmark. 8. Cook. 1975). MMPI-168 items were taken from
standard form MMPI protocols and were scored and converted into stand-
ard scale K-corrected raw scores. Two doctoral-level clinical psychol-
ogists concurred on 90% of the protocols for a general diagnosis. In
most cases the standard deviation was smaller for the MMPI-168 than for
the comparable standard MMPI. Paired t—tests yielded significant (p, <
.001) mean differences between the two forms on only one scale. Social
Introversion (p < .001) for both male and female subjects. For males.
scale correlations ranged from .96 on Mania to .78 on Masculinity-

Femininity (mean = .88. median = .89). For females. scale correlations

77

ranged from .93 on Depression and Mania to .77 on Masculinity-
Femininity (mean = .88. median = .90). All correlations were statisti-
cally significant (p < .001).

MW. The utility of the MMPI-168 in decision-
making situations was assessed by determining the proportion of cases
in which it led to accurate decisions about the validity. high points.
and elevations of the corresponding standard MMPI profiles (Newmark et
al.. 1975). Criteria for valid profiles required that the three valid-
ity scales had I—scores g 70. Of the standard MMPI profiles that
were invalid. 88% of the male and 92% of the female subjects had
corresponding invalid MMPI-168 profiles. Of the valid profiles. sub-
jects' MMPI-168 scores permitted prediction of the one or two most
elevated scales on their standard MMPI profiles in approximately 72% of
the cases. with approximately the same prediction rate for both males
and females. Agreement for general diagnostic categories (psychotic.
neurotic. personality disorder) was 80% for males and 86% for females.
with a combined agreement rate of 83%.

Unlike studies that have examined agreements in code-type
classification of abbreviated and standard MMPI profiles. two studies
have shown that the MMPI-168 should be expected to yield equally valid
clinical decisions as the standard MMPI. Overall (1975) found that the
accuracy of identifying psychiatric patients in a combined group of
patients and normal college students was slightly superior when the
MMPI-168 form was used. as compared with the standard 400-item MMPI.

Also. the MMPI-168 was found to be slightly superior to the standard

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78

MMPI with respect to differential diagnosis among 10 major clinical
diagnostic groups.

Raw MMPI-168 scale scores were converted in the present study to
standard MMPI raw scores from a table provided by Overall. Higgins. and
DeSchweinitz (1976L. The conventional format for transforming raw
scores into scale scores was then followed.

W. The relationship between
psychological disturbance and the description of pain. as measured by
the MPQ. has been the subject of several studies (Bolyard. 1982;
Bradley. 1983; McCreary et a1" 1981; McCreary 8 Turner. 1977L
Patients with high scores on the H5. 0. and Hy scales of the MMPI
portray their pain as more intense than patients with high scores on
other MMPI scales (McCreary et al.. 1981). Patients with high He scale
scores portray their pain in terms of affective and evaluative descrip-
tors on the MPQ. whereas patients who have high scores on the D and Hy
scales portray their pain in terms of the affective descriptor dimen-
sion alone.

Research has shown that these three MMPI scales are more highly
related to the affective and evaluative dimensions than to the sensory
dimension of the pain experience (McCreary 8 Turner. 1977). The H5 and
Hy scales were found to correlate most highly with the affective and
evaluative dimensions. The D and Pt scales did not correlate signifi-
cantly with the affective dimensions and did not differentiate the

sensory from the affective or evaluative dimensions.

79

High scores on the MP0 have been found to be indicative of
psychological disturbance (Bolyard. 1982). Chronic pain patients
scoring high on both the sensory and affective dimensions of the MPQ
were more preoccupied with pain and perceived themselves as more
handicapped than patients scoring low on both dimensions. In addition.
the total MPQ.score was found to be a better discriminator of psycho-
logical disturbance than scores on the sensory or affective dimensions.

Both male and female chronic pain patients with MMPI profiles
characterized by elevations on scales H5. 0. and Hy. the neurotic
triad. showed greater pain-related disturbances in their daily
activities than did patients with relatively unelevated profiles or
those with profiles characterized by elevations on both the neurotic
triad scales and the Psychopathic Deviate and Schizophrenia scales
(Bradley. 1983). It was suggested that chronic pain patients who have
MMPI profiles with elevations on the neurotic triad scales suffer more
intense pain than do patients with other types of MMPI profiles. Sev- ’
eral investigators (Melzack 8 Wall. 1982; Sternbach. 1974; Watson.
1982; Woodforde 8 Mersky. 1972) have reported that chronic pain
patients. as a group. have elevated scores (I-scores of 70 or above.
i.e.. a I-score that is at least two standard deviations above normal)
on the Ms. D. and Hy scales. Sternbach and Ti mmermans (1975) concluded
that "neuroticism" in chronic pain patients is a result of the chronic
pain and may be reversible when the pain is reduced or abolished.

Also. Leavitt and Garron (1982) concluded that magnification of

mood-I
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1
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1940).

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80

mood-related attributes of pain may be associated with more openly

admitted psychological disturbance on the MMPI.

minimum
W

A brief estimate of the current intellectual functioning of the
sample was obtained with the Shipley Institute of Living Scale (Shipley.
1940). Although the Shipley was originally designed as a measure of
"intellectual impairment." research involving this scale has pointed to
its greater utility in clinical settings as a brief indicator of
current intellectual functioning (Bartz. 1968; Bartz 8 Loy. 1970;
Paulson 8 Lin. 1970; Prado 8 Taub. 1966). Two scales comprise the
Shipley: (a) a 40-word. multiple-choice vocabulary test and (b) a 20-
item abstraction test in which the subject is asked to grasp the
relationship involved in a progressive series of items and complete the
final missing number of the series (Appendix C). Both scales have a
lO-minute time limit. Raw scores from the two scales are summed into a
total raw score and then converted to estimated WAIS IQ values (Paul son
8 Lin. 1970).

Standardization of the Shipley occurred on 1.046 students from
fourth grade through college who had previously taken standardized
group intelligence tests. Correlations between total raw Shipley
scores and Full-Scale WAIS IQ's have been found to be high. ranging
from .73 to .90 in a number of studies under various clinical condi-
tions (Bartz. 1976; Stone 8 Ramer. 1965; Paulson 8 Lin. 1970; Wiens 8
Banaka. 1960). Reliability coefficients of .87. .89. and .92.

81

respectively. were reported for the vocabulary. abstraction. and total
raw scores (Shipley. 1940).

In a study investigating the relationship between the Shipley-
Hartford and the Wechsler Adult Intelligence Scale (WAIS) as a function
of age. 190 male and female psychiatric patients with varying diag-
noses. and from different socioeconomic levels. were selected from
three population samples (Paul son 8 Lin. 1970). It was found that the
WAIS Full-Scale IQ score correlated .74 with the Shipl ey vocabulary raw
score and .64 with the abstraction raw score. A correlation coeffi-
cient of .78 was reported between the total raw score (found by adding
the vocabulary raw score with the abstraction raw score) and the WAIS

Ful l-Scale IQ score.

MW
The Lifestyle Coping Inventory (Appendix E) is a l42-item sel f-

report inventory designed to assess an individual's present level of
health behavior (Hinds. 1983). 'i-lealth behavior." according to Stone
(1980). is broadly defined as all behaviors which have a significant
impact on health. The incl udes behaviors with either a positive or a
negative effect on health. The inventory was developed by gathering
items that had face validity as measures of health behavior and that
represented major categories of health behavior.

Seven major categories of health behavior are represented on the
Lifestyle Coping Inventory. They are: (a) nutritional actions (20
items). e.g.. "I eat two servings of vegetables daily"; (b) physical

care actions (18 items). 6.9.. "I walk when possible rather than ride

82

in an automobile"; (c) cognitive and emotional actions (37 items).
e.g.. "I share my feelings with others"; (d) low-risk actions (5
items). e.g.. "I drive the speed limit"; (e) environmental actions (9
items). e.g.. "I choose environments that are relaxing"; (f) social
support actions (14 items). e.g.. "I visit or talk to a good friend";
and (g) coping style actions (32 items). e.g.. "I make my own decisions
eyen though some people may not like them)‘ Individuals respond to
each declarative statement (e.g.. "I admit my mistakes to others") by
choosing one alternative among five possible choices: Choice A = Never
(0% of the time). Choice 8 = Rarely (0-25% of the time). Choice C =
Occasionally'(25-50% of the time). Choice 0 = Often (50-75% of the
time). and Choice E = Very Often (75-100% of the time). Point values
are assigned to each choice (Never = 0. Rarely = l. Occasionally = 2.
Often = 3. Very Often = 4). and point values are added for the total
score. Therefore. the higher the point total. the greater the number
of health behaviors. In the present study. the total point score
obtained by adding the seven behavioral categories is used.

The Lifestyle Coping Inventory was administered at pretreatment
and at the 3-month follow-up. This instrument was chosen to measure
changes in health behaviors as a result of the PPS treatment. Using
the total scores obtained from the pretreatment administration of the
Lifestyle Coping Inventory in the present study. the split-half

reliability coefficient was reported to be .74.

83

W

It is clear from previous research that chronic pain patients do
not maintain positive behavior gains over time following their dis-
charge from multicomponent pain treatment programs (Aronoff et a1"
1983). This study hypothesizes that subjects who are trained in the
behavior change model PPS and provided with a framework for making
personal behavior changes and decisions about their health care will
demonstrate maintenance of gains 3 months following pain clinic dis-
charge.

To evaluate whether participants maintained behavior gains made in
the treatment setting. a follow-up questionnaire was mailed to all
subjects 3 months following discharge from the pain clinic program.
Six:outcome measures were of particular interest in measuring main-
tenance of gains:

1. Employment status.

2. Status of receiving income because of pain in the form of
workman's compensation or some other payment.

3. Change in medically prescribed pain medication.

4. Pain interference with sexual intercourse.

S. Rehospitalization because of pain since discharge from the
pain clinic program.

6. Overall level of pain intensity.

Emcedunes
Subjects in the study were recruited following their admission to

the pain clinic. Each week. beginning on Sunday evening. a new group of

84

patients entered the clinic. Patients who presented with primary com-
plaints of chronic pain qualified for inclusion in the study. Exclusion
criteria were discussed previously.

As soon as it was deemed clinically appropriate by the pain clinic
staff. those patients who qualified for inclusion were informed by the
experimenter about the nature of the study and asked if they would be
willing to participate. Potential participants were told that the
purpose of the study was "to investigate two methods for managing stress
and pain. one that teaches personal problem solving and one that
involves group discussion." They were also told that their decision to
participate would not influence the treatments they would receive at the
pain clinic. All patients were told that they would receive the usual
and customary treatments from the staff. Once a patient agreed to
participate. a consent form was obtained (see Appendix F).

All patients. whether or not they agreed to participate in the
study. completed Form R of the MMPI and the MPQ as a customary admis-
sion assessment procedure. After each subject had signed a consent
form. the group of subjects was randomly assigned to either the experi-
mental condition (PPS) or the control condition (group discussion).

For a total of 12 weeks. each new weekly group of subjects was assigned
to either of the two conditions. resulting in six weekly groups of
experimental subjects and six weekly groups of control subjects. 'The
decision was made to randomly assign an entire weekly subject group to
a treatment condition rather than randomly assigning individual sub-

jects within each weekly subject group to a treatment for two reasons.

85

Typically. patients within each weekly group communicate frequently
with one another during treatments and progress through the stages of
group development often seen in therapy groups. Thus. possible con-
tamination factors might have been introduced if weekly groups were
split into experimental and control conditions. Clinic staff also felt
that problems would be created in the smooth flow of the program if

each weekly patient group was divided.

EESJimun

Six weekly patient groups were randomly assigned to the treatment
condition and were taught the psychoeducational program PPS (Hinds.
1983). In keeping with the tenets of the educational model. the
experimenter assumed the role of a "trainer." and the patients became
the "trainees." The goal of the trainer was to present the concepts of
behavior change of the PPS to the trainees in a meaningful way and
guide them through the individual steps of this four stage model.

The trainer began by providing an introduction to and a rationale
for the PPS. It was stated that the PPS is:

a manual that teaches people the psychological skills necessary to
understand their behavior and make changes in their behavior. PPS
is a way to learn how to solve personal problems. manage stress.
and make better decisions about how to improve emotional and physi-
cal health. The steps in the manual will help you to understand
the relationship between your feelings. thoughts. body reactions.
behaviors. and sel f-concept. In order to make the behavior changes
you want. you need to understand these relationships. Some reading
and writing will be a part of this program. but don't worry. there
are no right or wrong answers. You are only asked to write what
you think and feel at each of the 24 steps.

Group participants were instructed that their written responses to
each of the steps were confidential but that the trainer would look
them over if any participant so desired. Typically. group members
shared responses and reactions to each step with one another. and
active discussion began. Encouragement was given to ask questions and
to make comments whenever the need arose. All participants received
training in the PPS modules in a group. and no individual training was
provided.

PPS training was divided into four 1-1/2-hour sessions occurring
in the late morning from Tuesday through Friday of each week. Approxi-
mately one stage of the PPS model was taught each day. depending on the
speed of the grouplnembers in comprehending the concepts and the amount
of discussion generated. If a participant expressed confusion about
the meaning of a particular step. the trainer clarified the step and
gave examples. Participants who continued to express poor understand-
ing were encouraged to write down whatever came into their minds. no
matter how inaccurate it seemed. Group members were urged not to
evaluate and critique their thoughts and feelings but to write whatever
came into their awareness.

Certain steps in the PPS manual were particularly crucial and were
given special attention. Step 1. "Your Personal Problem." is one
example. The trainer emphasized that any problem could be selected to
work on. and illustrations of types of problems that people can have
(e.g. intrapersonal. interpersonal) were given. Participants did not

have to choose some feature of chronic pain as their problem. although

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87

many did. The trainer discouraged patients from selecting problems
"about other people." especially if the participant failed to own any
personal responsibility for the situation. At times this was quite a
difficult concept to explain. given the tendency of a number of
patients to project blame for their problems onto others.

The PPS manual was distributed one stage per day so that group
members were not overwhelmed with the material. The trainer suggested
that patients review steps they found difficult to understand in the

evening and return with questions the following session.

Qiscussionjmup.

Six weekly patient groups were randomly assigned to the control
group. which involved a discussion format. In these groups. the
experimenter assumed the role of a nondirective moderator of group
discussion. The goal of the moderator was to assist the group in
carrying on a discussion about general topics without adding new
material or psychological concepts to the discussion. The term
"moderator." as opposed to "trainer." best describes the experimenter's
role in the discussion groups.

Introduction to the group discussion was as follows:

We will be meeting here this week to talk with one another about

managing stress and coping with pain. Sometimes when people have

something in common with each other. like all of you do. it can be
helpful to share personal experiences.
At that point. the moderator presented a general question or topic to

discuss. such as. "How do all of you deal with the stress in your

life?" or "When was it that you first noticed your pain?" The

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88

moderator was careful not to introduce new material into the discus-
sion. especially concepts from the PPS model. The moderator was non-
directive and permitted the discussion to proceed in whatever direction
the group members wished. Although reflection was used as a communica-
tion tool. there was not an emphasis on uncovering feelings for each
member. Thus. the group was not defined as "psychotherapyJ'

As with PPS groups. Discussion groups met for four l-l/2-hour
sessions in the late morning from Tuesday through Friday of each week.
In addition to suggesting broad questions for discussion. the moderator
often began a session by briefly summarizing some of the main themes of
the previous day's discussion. In general. participants were free to

raise whatever issues concerned them.

129st
The design in the study is a pretest-posttest control group

design. with 3-month follow-up measures. a true experimental design

(Campbell 8 Stanley 1963). This design takes the following form:

where R refers to randomization of weekly subject groups to separate
treatments. X represents exposure of subjects to the PPS. and 0
represents measurement points of dependent variables.

The design is a hierarchical or nested design with the factor

"subjects" nested in the factor "weekly groups." and the factor "weekly

89

groups" nested in the factor "treatment condition." This design has
also been referred to as the split-plot design (Keppel. 1973; Kirk.
1968). Since there are equal 11's in each of the cells (six weekly
groups in each condition). the design is balanced. Figure 3.1 illus-

trates the overall design of the study.

Business:
The primary questions of interest in this study were:

1. Can a psychoeducational approach to personal problem solving
and health care decision making improve the general health of chronic
pain patients as measured by the quality of pain perceptions?

2. Can a psychoeducational approach to personal problem solving
and health care decision making improve the general health of chronic
pain patients as measured by performance of health care behaviors?

3. Can a psychoeducational approach to personal problem solving
and health care decision making affect characteristic psychological
disturbance in chronic pain patients?

4. Can a psychoeducational approach to personal problem solving
and health care decision making assist chronic pain patients in
maintaining behavior gains several months following termination of
clinic treatment?

The following hypotheses were tested to answer these primary

research questions.

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90

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91

1. Ho: The Personal Paradigm Shift groups will be no different
than Discussion groups in reducing perceptions of pain on
verbal pain report measures.

H : The Personal Paradigm Shift groups will show larger
reductions on verbal pain report measures than the
Discussion groups.

2. Ho: The Personal Paradigm Shift groups will be no different
than the Discussion groups in increasing health care
behavior performance as measured by a health behavior
inventory.

Ha: The Personal Paradigm Shift groups will show larger
increases in health care behavior performance on a health
behavior inventory than the Discussion groups.

3. H : The Personal Paradigm Shift groups will be no different
than the Discussion groups in reducing certain forms of psy-
chological disturbance as measured by changes in eleva-
tions of several scales of personality functioning.

H : The Personal Paradigm Shift groups will show larger
reductions in certain forms of psychological disturbance
as measured by several scales of personality functioning
than the Discussion groups.

4, Ho: Subjects assigned to the Personal Paradigm Shift
treatment will be no different than subjects assigned to
the Discussion treatment in maintaining health gains
3 months following pain clinic discharge as measured by
status on several behavior outcomes.

Ha: Subjects assigned to the Personal Paradigm Shift treatment
will maintain more health gains than subjects assigned to
the Discussion treatment 3 months following pain clinic

discharge as measured by status on several behavioral
outcomes.

AW
W

The procedure used in assigning subjects to treatments raises a
question as to the appropriate "unit of analysis" in the study (Cox.
1958; Glass 8 Stanley. 1970; Hopkins. 1982; Lumsdaine. 1953). The

92

unit of analysis is the smallest division of the collection of
experimental subjects who have been randomly assigned to the different
conditions in the experiment and who have responded independently of
each other for the duration of the experiment. Hopkins (1982) stated
that when the treatment is not administered individually to each sub-
ject. the statistical assumption of "independence of error" 0» 5) can
be violated if individual scores (rather than group means) are used as
the unit of analysis. Individual subjects did not respond to the treat-
ment independently of each other but were exposed to group factors that
may have affected their performance. Using the group as the unit of

analysis satisfied the assumption of independence of error components.

W

In this study. the primary interest was in measuring changes that
occurred as a result of the PPS. To this end. gain scores or
difference scores (Campbell 8 Stanley. 1963; Cox. 1958; Cronbach 8
Furby. 1970; Feldt. 1958; Keppel. 1973) were used to compare changes
between the two groups. rather than using the procedure of comparing
posttreatment (or follow-up) means. Gain scores are often used when
the concomitant observation is a pretreatment.score. as with parallel
forms of a test. The gain score method is a statistical procedure for
increasing precision. or reducing the standard error. by removing the
initial differences between subjects on the pretreatment observation.
It is a method that insures an unbiased estimate of treatment effects.

The raw gain score was computed by subtracting the pretreatment

mean from the posttreatment mean. or by subtracting the pretreatment

mean from the follow-up mean. The model for gain score analysis is
z = y - kx. where z is the difference score. y is the posttreatment
score. x is the pretreatment score. and k is the within-group regres-
sion coefficient.

Raw gain score analysis assumes (a) equality of population
variances and (b) a within-group regression coefficient of TIL There
is no cost of degrees of freedom when using raw gain scores. an important

consideration in this study because of the small sample size.

WW

Four statistical procedures were used in this study: (a) multi-
variate analysis of variance (MANOVA). (b) analysis of variance (ANOVA).
(c) student's j-test. and (d) chi-square. All of these procedures
except chi-square assume normally distributed error variance. homogene-
ity of error variance. and independence of error components.

A multivariate analysis of variance (MANOVA) was performed on the
mean gain scores of the three pain measures from the MPQ (sensory.
affective/evaluative» number of words chosen) obtained by subtracting
pretreatment group means from posttreatment group means. A second
MANOVA was conducted on the gain scores of the three pain measures
obtained by subtracting pretreatment from follow-up group means.

MANOVA was selected as the appropriate statistical procedure because it
controls for overall Type I error and it accounts for the correlations
between all three pain measures. The simultaneous response of the

experimental units contains more information about the total effect of

94

the treatment than does the series of responses considered singly.
Individual ANOVAs on each of the three pain measures were then examined
for descriptive and discussion purposes.

A MANOVA was performed on the four MMPI scales (H5. 0. Hy. Pt)
using gain scores obtained by subtracting the pretreatment means from
the follow-up means. Individual ANOVAs for each of the four MMPI
scales were then performed for explanatory purposes.

An ANOVA was performed on the total score of the coping inventory
by using gain scores obtained by subtracting the pretreatment group
means from the follow-up group means. ANOVA is robust with respect to
violations of the normality and homogeneity assumptions. and the inde-
pendence assumption was satisfied by using group as the unit of analy-
sis.

Chi-square tests of the difference between two independent propor-
tions were performed on all but one of the behavioral outcome measures
taken at the 3-month follow-up. In these analyses. individual subjects
are the unit of analysis. rather than groups. The use of this procedure
makes the assumption of independent samples. This assumption was satis-
fied because the groups were randomly assigned.

A t-test of the difference between two means was performed on the

remaining outcome measure. level of pain intensity.

Samar!

The purpose of this study was to determine the effectiveness of a
psychoeducational intervention for health care decision making and

personal problem solving. the PPS. on the health of chronic pain

tr

95

patients. For 12 consecutive weeks. each weekly group of patients
admitted to a multicomponent chronic pain clinic in mid-Michigan was
randomly assigned to one of two treatment conditions: the experimental
condition. receiving the PPS (Hinds. 1983). or the control condition.
participating in group discussion on managing stress and pain. Each
group met for a total of 6 hours during the week subjects were in the
clinic. All groups received the customary pain clinic treatments. The
total number of subjects was 51 (experimental = 26. control = 25).

Dependent measures were collected at three time periods:
pretreatment. posttreatment. and 3 months following termination of
treatment at the pain clinic. The MPQ.was administered at all three
points. while the MMPI and the Lifestyle Coping Inventory (Hinds. 1983)
were administered at pretreatment and 3-month follow-up. Six behav-
ioral outcome measures were also collected at pretreatment and at
follow-up.

The experimental unit of analysis was the group. since individual
subjects did not receive treatment independently of one another. To
increase precision and remove pretreatment differences. gain scores
were obtained by subtracting pretreatment from posttreatment group
means. and by subtracting pretreatment from follow-up group means.
MANONAs were performed on mean MPQ.gain scores obtained from pretreat-
ment to posttreatment and from pretreatment to follow-up. A MANOVA was
also performed using mean pretreatment-follow-up gain scores on the
four MMPI scales of interest. A one-way ANOVA was performed on the

total coping score from the Lifestyle Coping Inventory using

96

pretreatnent-follow-up comparison. Chi-square tests of the difference
between two independent proportions were conducted on five of these
behavioral outcome measures. and a.t-test was performed on the remaining
outcome measure. Level of significance was set at .05 for each statis-
tical procedure.

The results of the hypothesis tests and an interpretation of these

results are presented in Chapters Four and Five.

CHAPTER 4

ANALYSIS OF RESULTS

In this chapter the results of the data analyses are presented.
Each hypothesis is restated in testable form. and the results of the
analyses are given. followed by a statement as to whether the hypothe-
sis was accepted or rejected. The chapter is concluded with a summary

of the hypotheses tests.

.EQllQI:UR_Batu£n_Bate

The design for this study (see Figure 3.1. Chapter Three) was a
pretest-posttest control group design with follow-up. This design was
employed to compare the effects of a psychoeducational intervention for
health care decision making and a group discussion intervention on
chronic pain patients. Three types of dependent measures were used:
quality and quantity of pain perceptions. severity of psychological
disturbance. and reported frequency of health behaviors. Six
behavioral outcome measures were collected at 3-month follow-up to
measure maintenance of gains. Descriptions of each of the dependent
measures were provided in Chapter Three.

Twelve groups of subjects. randomly assigned to one of the two
conditions. each received treatment by the same trainer for a l-week

period during the pain clinic stay. Of the total sample of 51

97

98

subjects. 41 returned packets of follow-up dependent measures mailed
3 months following discharge from the pain clinic. for a return rate of
80%. Table 4.1 illustrates group size at pretreatment. posttreatment.

and 3-month follow-up.

Table 4.1: Size of Groups at Each Measurement Point

 

Measurement Point

 

 

Week Group
Pretest Posttest Follow-Up

11 .Q n
1 E 2 2 2
2 E 5 S 4
3 E 5 5 4
4 C 5 5 3
5 E 4 4 3
6 C 5 5 5
7 C 6 6 4
8 E 4 4 2
9 C 2 2 1
10 E 5 5 5
11 C 5 5 5
12 C 3 3 3
Total 51 51 41

Note: E = Experimental group-~Personal Paradigm Shift

C = Control group--Group Discussion

At least one subject in each of the 12 weekly groups returned the
mailed questionnaires. Five of the 12 groups retained all subjects at
follow-up. and four groups lost only one member. The sizes of the
experimental and control groups at pretest were n = 26 and n = 25.

respectively. The sizes of the experimental and control groups at

99

follow-up were n = 21 and n = 20. respectively. Therefore. the follow-

up response rate between the two groups was equivalent.

Results
In this section. each of the hypotheses of the study is evaluated

with the appropriate statistical analysis. A total of five statistical
hypotheses are presented. ‘Two hypotheses were constructed to test the
effects of the PPS on pain perceptions. a pretreatment-posttreatment
comparison and a pretreatment-follow-up comparison. One hypothesis

each was constructed to test the effects of the PPS on health care
behavior. certain forms of psychological disturbance. and maintenance of
health gains. The analyses of all hypotheses except the maintenance
hypothesis were performed on gain scores derived from either a
pretreatment-posttreatment comparison or a pretreatment-fol low-up

comparison.

1112911195154

The first hypothesis is concerned with changes in pain perceptions
from pretreatment to posttreatment.

Ho: There will be no difference between the mean gain scores of
the Personal Paradigm Shift group and the Discussion group on
the three pain ratings from the McGill Pain Questionnaire
(sensory. affective/evaluative. and number of words chosen)
derived from the pretreatment-posttreatment comparison.

H : The Personal Paradigm Shift group's mean gain scores will be
smaller than the Discussion group's mean gain scores on the
three pain ratings from the McGill Pain Questionnaire
(sensory. affective/evaluative. number of words chosen)
derived from the pretreatment-posttreatment comparison.

100

The group means for the three pain ratings from the MPQ (sensory.
affective/evaluative. number of words chosen) at all three measurement
points for all 12 weekly groups are presented in Table 4.2.

The two groups demonstrated comparable mean scores at pretreatment
on each of the three pain rating indices of the MP0. These scores are
similar to those reported for low back pain patients (Melzack. 1975).
At posttreatment. both groups exhibited decreases for each pain
measure. with the control group having slightly smaller scores than
the experimental group. At the 3-month follow-up point. both groups
exhibited increases in mean scores from the posttreatment levels. but
the control group regressed to a level that was higher than the
pretreatment.level on two of the pain ratings. sensory and affective!
evaluative. A graphic representation of the mean pain measures of the
groups at all three measurement points is presented in Figures 4.1
through 4.3.

Gain scores for the three pain ratings of the MP0 were obtained by
subtracting pretreatment scores from posttreatment scores. These data
are presented in Table 4.3. Positive numbers indicate an increase and
negative numbers indicate a decrease in perceived pain.

An examination of Table 4.3 reveals that both groups exhibited a
reduction in perceived pain for each of the pain measures from
pretreatment to posttreatment. Subjects in the control group showed
greater variability in scores. as indicated by the larger standard

deviations. particularly for the sensory pain rating.

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101

 

 

 

 

 

 

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103

Table 4.3: Mean Gain Scores (Pretreatment—Posttreatment) on McGill
Pain Ratings for Experimental and Control Groups

 

McGill Pain Ratings

 

Group 3_
Sensory Aff/Eval NWCa
X7 §Q_ 'X .§g 'X ‘§Q
Experimental 6 -2.99 3.58 -2.38 2.28 -2.43 1.99
Control 6 -2.73 7.57 -l.95 2.94 -3.75 4.58
Total 12 -2.86 5.65 -2.17 2.52 -3.09 3.44

 

.flote: Tabled entries are mean group gain scores obtained by subtracting
pretreatment means from posttreatment means.

aNumber of words chosen.

A multivariate analysis of variance (MANOVA) was performed on the
mean gain scores of the three pain ratings from the MPQ to determine
whether there was a significant change between groups from pretreatment
to posttreatment. The level of significance of the test was set at
.05. Results of the test showed no significant difference between the
groups. E (l. 10) = 2.87. p > .05. The null hypothesis was not
rejected.

Although the results of the MANOVA were not significant. the
results of each of the univariate ANOVAs of the pain measures are

.presented for illustration purposes in Tables 4.4 through 4.6.

104

Table 4.4: Results of ANOVA on Pre—Post Sensory Pain Measure

 

 

Source §§ _d_f _MS _E
Between 0.29 l 0.20 0.005 NS
Within 350.86 10 35.08

 

.Ngte: Tabled entries were computed using gain scores.

Table 4.5: Results of ANOVA on Pre-Post Affective/Evaluative Pain

 

 

Measure
Source _§§ _d_f MS f
Between 0.57 1 0.57 0.08 NS
Within 69.21 10 6.92

 

Note: Tabled entries were computed using gain scores.

Table 4.6: Results of ANOVA on Pre-Post NWCa Pain Measure

 

 

Source _S_§ g: MS f_
Between 5.27 l 5.27 0.42 NS
Within 124.99 10 12.49

 

.Ngte: Tabled entries were computed using gain scores.

aNumber of words chosen.

Months-11.5.2

105

The second hypothesis compared changes in pain perceptions from

pretreatment to 3-month follow-up.

Ho: There will be no difference between the mean gain scores of

the Personal Paradigm Shift group and the Discussion group on

the three pain ratings from the McGill Pain Questionnaire
(sensory. affective/evaluative. number of words chosen)
derived from the pretreatment-follow-up comparison.

H : The Personal Paradigm Shift group's mean gain scores will be

smaller than the Discussion group's mean gain scores on the
three pain ratings from the McGill Pain Questionnaire
(sensory. affective/evaluative. number of words chosen)
derived from the pretreatment-follow-up comparison.

The gain score data for the three pain ratings from the MPQ

obtained by subtracting pretreatment mean scores from 3-month follow-up

mean scores are presented in Table 4.7.

Positive numbers indicate an

increase and negative numbers indicate a decrease in perceived pain.

Table 4.7: Mean Gain Scores (Pretreatment-Follow-Up) of McGill Pain

Ratings for Experimental and Control Groups

 

McGill Pain Ratings

 

Group 3
Sensory -Aff/Eval __ NWC
'X §Q_ X §Q_ X ‘§Q_
Experimental 6 -l.65 4.44 -1.29 2.33 -2.10 3.14
Total 12 -1.09 4.78 -0.38 2.27 -l.32 1.32

 

.Ngte: Tabled entries are mean group gain scores obtained by subtracting
pretreatment means from follow-up means.

aNumber of words chosen.

106

The experimental group maintained decreases in perceived pain on
all three pain ratings. while the control group maintained decreases on
two pain ratings but increase on one measure. affective/evaluative
quality. The variability of the gain scores. indicated by the standard
deviations. was quite similar for both groups.

A MANOVA was performed on the mean gain scores of the three pain
ratings obtained by subtracting pretreatment mean scores from 3—month
follow-up mean scores. The level of significance was set at .05.
Results of the analysis were not significant. E (1.10) = .92. p > .05.
The null hypothesis was not rejected in favor of the alternate
hypothesis.

Although the results of this MANOVA were not significant. the
univariate ANOVAs for each of the three McGill pain measures on the
pretreatment-follow-up comparison are presented for illustration

purposes in Tables 4.8 through 4.10.

Table 4.8: Results of ANOVA on Pre-Follow-Up Sensory Pain Measure

 

 

Source 51 _d_i: _MS fi
Between 3.82 l 3.82 0.15 NS
Within 247.12 10 24.71

 

.Ngte: Tabled entries were computed using gain scores.

107

Table 4.9: Results of ANOVA on Pre-Follow-Up Affective/Evaluative
Pain Measure

 

 

Source _SS _d_f _M__S _E
Between 10.03 1 10.03 2.13 NS
Within 46.96 10 4.96

 

.flgte: Tabled entries were computed using gain scores.

Table 4.10: Results of ANOVA on Pre-Follow-Up NWCa Pain Measure

 

 

Source 5;; £1 MS 5
Between 7.39 l 7.39 0.98 NS
Within 75.70 10 7.57

 

.flgte: Tabled entries were computed using gain scores.

9Number of words chosen.

Hymns-115.3

The third hypothesis is concerned with change in performance of
health care behaviors.

Ho: There will be no difference between the mean gain scores of
the Personal Paradigm Shift group and the Discussion group
obtained from the Lifestyle Coping Inventory total scores at
pretreatment and 3-month follow-up.

Ha: The Personal Paradigm Shift group's mean gain score will be
greater than the Discussion group's mean gain score obtained
from the Lifestyle Coping Inventory total scores at pretreat-
ment and 3-month follow-up.

108

The Lifestyle Coping Inventory was administered only at pretreat-
ment and follow-up because it measures change in behaviors initiated by
patients after they left the pain clinic. The mean scores on the
Lifestyle Coping Inventory for the six experimental and six control
groups obtained at pretreatment and 3-m0nth follow-up points are pre-
sented in Table 4.11.

The range for the 12 weekly groups in the study was 78 points.
from a low score of 287.00 to a high score of 361.33. As seen in Table
4.11. both the experimental and the control groups demonstrated an
increase in grand mean coping scores from pretreatment to 3-month
follow-up.

The mean gain score data for the coping scores obtained by sub-
tracting pretreatment.mean scores from 3-month follow-up mean scores
are presented in Table 4.12. The experimental group demonstrated a
larger increase in coping scores than did the control group. In addi-
tion. the experimental group showed more variability in gain scores. as
indicated by the larger standard deviation.

To test the third hypothesis. a one-way analysis of variance
(ANOVA) was performed on the mean gain score data for the groups on the
Lifestyle Coping Inventory. Results of ANOVA were not significant.

E (1.10) = 0.72. p > .05. The null hypothesis was not rejected in

favor of the alternate hypothesis.

109

Table “.11: Mean Total Lifestyle Ceping Inventory Scores at
Pretreatment and Follow-Up for Experimental and
Control Groups

 

 

 

Group Pretreatment Follow-Up
X.... . x

Experimental
1 (EfZ) 296.00 344.50
2 (225) 320.80 298.50
3 (QfS) 317.20 323.00
1: (fie) 264 . 25 298 .67
5 (fie) 283.75 323.00
6 (3-5) 30h.ho ' 312.20

Grand mean 297.73 316.6h
Control
I (2‘5) 360.75 361 .33
2 (EfS) 293.80 287.00
3 (£f6) 305.80 342.50
1. (3-2) 355.00 31.6.00
5 (935) 316.00 339.60
6 (flf3) 293.33 294.67

Grand mean 320.78 328.52

 

Note: Total possible score is 568 points.

110

Table 4.12: Gain Score Data on Lifestyle Coping Inventory for
Pretreatment-Follow-Up Comparison for Experimental
and Control Groups

 

 

Group n X S0
Experimental 6 18.91 26.54
Control 6 7.74 18.30

Total 12 13.32 22.51

 

Note: Tabled entries are group mean gain scores.

Hypothesis.
The fourth hypotheSis is concerned with reductions in character-

istic forms of psychological disturbance in chronic pain patients.

Ho: There will be no difference between the mean gain scores of
the Personal Paradigm Shift group and the Discussion group
obtained from mean I-score elevations on the Hypochondriasis
(Hy). Depression (0). Hysteria (Hy). and Psychasthenia (Pt)
scales of the Minnesota Multiphasic Personality Inventory
(MMPI) at pretreatment and follow-up.

Ha: The Personal Paradigm Shift group's mean gain score will be
smaller than the Discussion group's mean gain score obtained
from mean I-score elevations on the Hypochondriasis (Hy).
Depression (0). Hysteria (Hy). and Psychasthenia (Pt) scales
of the Minnesota Multiphasic Personality Inventory (MMPI) at
pretreatment and follow-up.

The mean I-scores on the H5. 0. Hy. and Pt scales of the MMPI
profiles obtained at pretreatment:and 3-month follow-up are presented
in Table«4J3. At pretreatment the experimental group exhibited higher
elevations on each scale than did the control group. Table 4.h4
illustrates the mean elevations on the entire MMPI profile for the

experimental and control groups. Further pretreatment differences

111

observed between the experimental and control groups on several scales
(F. Pd. Pa. Sc. Ma) are difficult to account for since the groups were
randomly assigned to treatment conditions. These differences suggest

that the experimental group was more psychologically disturbed than the

control group.

Table 4.13: Mean MMPI I-Scores at Pretreatment and 3-Month Follow-Up
for Experimental and Control Groups

 

 

MMPI Scale
Group 11

_ Hs _ D _ Hy __ Pt

X _S_[)_ X SQ X _S_Q X S_D
Ere
Experimental 6 73.37 2.09 77 .76 3. 94 76.74 3.49 72.74 5.36
Control 6 72.13 7.77 64.23 6. 24 72.21 5.67 60.04 3.53
Mom-.02
Experimental 6 72.95 7.12 75.32 7.02 72.86 4.71 66.93 19.22
Control 6 71.05 8.50 65.85 5.07 69.98 4.80 56.20 5.89

 

The gain score data obtained by subtracting pretreatment group
mean I-scores from follow-up group mean I-scores for the four MMPI
scales of interest. H5. 0. Hy. and Pt. are presented in Table 4.15. A
"eQative number signifies a decrease in the elevation of a scale.

toward normality. and a positive number signifies an increase in

e18Vation. toward psychological disturbance.

112

Table 4.14

 

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113

Table 4.15: Mean Gain Scores (Pretreatment-Follow-Up) on MMPI Scales
for Experimental and Control Groups

 

 

HS 0 Hy Pt
Group n _ _ _ _
X §Q_ X §Q_ X §Q_ X §Q_
Experi-
mental 6 -5.42 8.64 ‘ -2.43 8.15 -3.87 5.67 -S.81 9.16
CORtPOl 6 -1008 2068 1063 6044 -2023 2047 -3 084 3052

Total 12 -3.25 6.51 -O.4O 7.32 -3.05 4.26 -4.82 6.69

 

Note: Mean group gain scores were obtained by subtracting pretreat-
ment means from follow-up means.

lkscores for the experimental group decreased on all four scales
of the MMPI from pretreatment to 3-month follow-up. The control group
showed decreases in.I-score elevations on all scales except the
0 scale. where a slight increase was shown. The experimental group
demonstrated larger decreases than the control group in mean I-score
elevations on all four scales. In addition. the experimental group
showed greater variability in gain scores than the control group. as
indicated by the standard deviations.

To test the fourth hypothesis. a MANOVA was performed on the mean
gain scores for the four MMPI scales and was found to be nonsignificant.
E (1.10) = 0.78. p > .05. The null hypothesis of no difference was not

rejected in favor of the alternate hypothesis.

1':

Ta

In

114

Although the MANOVA was not found to be significant. the results

of the univariate ANOVAs for each of the MMPI scales under considera-

tion are presented for illustration purposes in Tables 4.16 through

4.19.

Table 4.16: Results of ANOVA on Pre-Follow-Up

Hypochondriasis Scale

 

 

 

Source §_S_ _d_f & 5
Between 56.55 1 56.55 1.38 NS
Within 409.48 10 49.45
‘flgte: Tabled entries were computed using gain scores.

Table 4.17: Results of ANOVA on Pre—Follow-Up

Depression Scale

 

 

 

Source g d_f MS f_
Between 49.45 1 49.45 0.92 NS
Within 539.50 10 53.95
”mtg: Tabled entries were computed using gain scores.

115

Table 4.18: Results of ANOVA on Pre-Follow-Up Hysteria Scale

 

 

Source §§ g1 MS ‘5
Between 8.08 l 8.08 0.24 NS
Within 191.65 10 19.16

 

.flgte: Tabled entries were computed using gain scores.

Table 4.19: Results of ANOVA on Pre-Follow-Up Psychasthenia Scale

 

 

Source SS if MS 5
Between 11.66 1 11.66 0.24 NS
Within 481.71 10 48.17

 

‘flgte: Tabled entries were computed using gain scores.

W
The fifth hypothesis. a hypothesis about subjects' behavior.

concerns maintenance of health gains 3 months following pain clinic
treatment. In this case. individual subjects are the unit of analysis.
rather than subject group. Therefore. all subjects in the experimental
condition (PPS) are compared with all subjects in the control condition
(Discussion). Comparisons are performed only using follow-up data.
obtained for 21 subjects in the PPS group and 20 subjects in the

discussion group.

116

Ho: There will be no difference at follow-up between the
proportion of subjects who received the Personal Paradigm
Shift intervention and subjects who received the Discussion
intervention in their status on each of the six behavioral
outcome measures.

Ha: At follow-up. a greater proportion of subjects who received
the Personal Paradigm Shift intervention compared to subjects
who received the Discussion intervention will demonstrate
gains on each of six behavioral outcome measures.

Six behavioral outcomes were assessed at the 3-month follow-up

point:

1. Employment status

2. Receiving income for pain in the form of workman's compensa-

tion or some other reimbursement

3. Extent of medication use

4. Pain interference with sexual intercourse

5. Rehospitalization for pain

6. Level of overall pain intensity

We. The proportion of subjects in each treatment

condition who were gainfully employed. full or part time. or who were
involved in a job-training program. was assessed at the 3-month follow-
up point. It was found that 40% (n = 8) of the PPS subjects and 24% (n
= 5) of the Discussion group subjects were employed. A chi-square test
of the significance of the difference between independent proportions
was used to determine if this difference was significant. Results were
not significant. x2 (1. u = 41) = 1.24. p, > .05. The null hypothesis
was not rejected.

.Beceiying_1n;ome_ign_pa1n_status. The proportion of subjects in

each treatment condition who were receiving income for pain at the

117

follow-up point was assessed. It was found that 53% (n = 10) of the
PPS group and 57% (n = 12) of the Discussion group were receiving
workman's compensation or some other form of income for their pain.
Results of chi-square test were found to be not significant. x2 (1. N =
40) = .08. .p > .05. The null hypothesis was not rejected in favor of
the alternate hypothesis.

W50. Level of pain medication use was
evaluated by asking subjects to compare amount of pain medication they
were taking at 3-month follow-up with the amount at pretreatment. Four
choices were available: (a) taking no medication for pain. (b) taking
less medication for pain. (c) taking more medication for pain. and
(d) no change between now and then in medication for pain. Categories
of choices were collapsed so that the none/less choices constituted one
category and the same/more choices constituted the other category. A
chi-square test of the significance of the difference between independ-
ent proportions was performed. It was found that 65% (n = 13) and 55%
(n 8 ll) of the PPS and Discussion groups. respectively. were either
taking less medication at follow-up than at pretreatment or were taking
no medication. The test was not significant. X2 (1. 3 =40) = .08. .p >
.05. The null hypothesis was not rejected.

W253. The proportion of
subjects in each treatment condition who indicated that their pain
interfered with sexual intercourse was assessed. It was found that 58%
(n = 11) of the PPS subjects and 81% (n = 17) of the Discussion

subjects experienced pain interference with sexual intercourse. A

118

chi-square test of the difference between independent proportions was
performed and was not significant. x2 (1. fl =h0) = 2.53. n > .05. The
null hypothesis was not rejected.

.Bahasnitaljzatign_£gn_pa1n. It was hypothesized that the propor-
tion of subjects in the PPS group who were rehospitalized for treatment
of chronic pain would be significantly less than the proportion of
subjects in the Discussion group who were rehospitalized. On1y two
subjects in each of the treatment groups were rehospitalized. demon-
strating no significant difference between the groups. and eliminating
the need for a statistical analysis.

Lexe1_Q£_Qxenall_pa1n_1ntensity. The Present Pain Intensity
scale of the MPQ.was used to assess overall pain intensity at follow-
up. Subjects were asked the following: Which one word describes your
pain right now? Five choices with a point value assigned to each
choice were available: none (0). mild (l). discomforting (2).
distressing (3). horrible or excruciating (4). The mean Present Pain
Intensity scores for the PPS and Discussion groups were 2.35 and 2.80.
respectively. with the PPS subjects demonstrating a 1ower level of pain
intensity at follow-up. Results of a trtest were not significant (1 =
-1.47. _d_f = 38. p > .05). The null hypothesis was not rejected in

favor of the alternate hypothesis.

Sum

A series of hypotheses were tested to determine the effect of the

psychoeducational intervention PPS on pain perception. health care

119

behavior. and characteristic psychological disturbance of chronic pain
patients. Maintenance of health gains was also tested. The statisti-
cal procedures used to test the hypotheses were MANOVA. ANOVA. chi-
square. and jrtest.

Hypotheses l and 2 predicted differences between the PPS group and
the Discussion group on pain perceptions. one predicting differences at
posttreatmemt and the other predicting differences at follow-up. In
both cases. the null hypothesis was not rejected at the .05 alpha
level.

Hypothesis 3 predicted differences between the PPS group and the
Discussion group on performance of health care behaviors. The null
hypothesis of no differences was not rejected at the .05 alpha level.

Hypothesis 4 predicted differences between the PPS group and the
Discussion group on characteristic psychological disturbance found in
chronic pain patients. The null hypothesis of no differences was not
rejected at the .05 alpha level.

Hypothesis 5 predicted differences between the PPS group and the
Discussion group on several behavioral outcomes at follow-up: employ-
ment status. receiving income~for pain. extent of medication use. pain
interference with sexual intercourse. rehospitalization for pain. and
level of pain intensity. The null hypothesis was not rejected at the
.05 alpha level for any test of this hypothesis.

In Chapter Five. a summary of the study is presented. Results of
the study are discussed. along with limitations. Finally. implications

for future research are proposed.

CHAPTER 5

SUMMARY AND CONCLUSIONS

The major purpose of this study was to assess the effects of the
psychoeducational intervention Personal Paradigm Shift on perceptions
of pain. health care management.behavior. and certain forms of psycho-
logical disturbance in chronic pain patients. In this chapter. a
summary of the study is presented. followed by a discussion of the
results and limitations of the study. Finally. implications for future

research with psychoeducation and chronic pain patients are discussed.

Sum
The purpose of this study was to determine the impact of a

psychoeducational intervention for health care management and personal
problem solving. PPS. on pain perception. health care behavior. and
psychological disturbance in patients at a multicomponent pain clinic.
The need for this study emerged from several observations: climbing
health care costs. disappointing maintenance of gains in the treatment
of chronic pain patients. and poor prob1em-solving abilities in these
patients. In conjunction with a multicomponent. medically prescribed
pain treatment program. it was hypothesized that the PPS would assist
patients in identifying important psychological. environmental. and

psychosocial variables that influence chronic pain and health. Unlike

120

121

interventions that demand patient compliance. the PPS involves the
patient in an educational process of observing and determining the
choices made for personal health care. The PPS teaches the patient how
to make personal change.

The theoretical underpinnings of the PPS arise from the tradition
of the educational model of service delivery. A pervasive feature of
this model is that the most important aspects of human behavior result
from experience or learning. In contrast to the illness model. the
educational model assumes that the individual is lacking or deficient
in the personal and interpersonal skills for effective. satisfying
daily living. Clients are engaged in a process of goal setting and
are actively and deliberately taught skills for goal attainment and
satisfaction.

It was argued that the PPS involves the patient in observing.
experiencing. and determining his/her own choice process in personal
health care. As an adjunct to a traditional medical treatment regimen.
the PPS assists the patient in identifying the psychological and
psychosocial variables that influence chronic pain and general health
and provides a structure for making personal change.

The PPS closely follows several tenets associated with the use of
psychoeducational interventions: (a) the psychologist becomes a
teacher to the patienb.(b) patient problems are viewed as competency
deficits. and (c) patients actively participate in solving their own

problems.

122

Four areas of literature were reviewed: features of psychoeduca-
tional interventions with a focus on problem-solving programs; coping
skills training and self-control: psychology of chronic pain; and a
brief summary of existing psychological interventions for chronic pain.
with a review of follow-up pain studies.

A common feature of general behavior change manuals. probl em-
solving manuals. and coping skills training is the goal of teaching
patients a set of principles which have application to a variety of
personal problems. Personal problem-solving manuals typically
instruct the patient through a five-stage process of behavior change:
(a) general orientation. (b) problem definition and formulation.

(c) generation of alternatives. (d) decision making. and (e) verifica-
tion. These manuals are usually logical and teach operant principles
of behavior change.

Specific contributions to increasing a patient's response reper-
toire in coping with problems from the cognitive-behavioral arena are
coping skills training and self-control. Training in the fundamental
role of cognitions in personal problems. the process of self-
monitoring. and principles of problem solving mark coping skills pro-
grams. A closely related area. self-control. is concerned with the
individual becoming the principal agent in guiding. directing. and
controlling those features of behavior that lead to desired positive
consequences.

This study was carried out with a sample of chronic pain patients.

Chronic pain is a multifaceted phenomenon. ultimately defined by the

123

experiencer. with clear psychological and motivational components.
Psychological mechanisms. such as coping styles and other cognitive-
affective mechanisms. influence pain perception and response. Pain
treatment programs combine several psychological interventions into a
comprehensive approach. including operant conditioning. cognitive-
behavioral techniques. and muscle-relaxation methods. ‘These interven-
tions have demonstrated effectiveness in alleviating pain and assisting
the patient in coping with pain.

Follow-up studies of multicomponent pain programs often demon-
strate good results immediately following treatment but show regression
in patients months after discharge from treatment. Shortcomings of
these studies include use of questionable outcome measures. inapprop-
riate comparison groups. and small sample sizes.

For 12 consecutive weeks. each weekly group of patients admitted
to a multicomponent pain clinic of an urban hospital was randomly
assigned to one of two treatment groups. One group received the
psychoeducational intervention. PPS: the other participated in group
discussion about pain and stress. Thus. each treatment condition
comprised six groups of patients. iAll patients received the customary
pain clinic treatments. A total of 51 subjects participated in the
study.

Dependent measures were collected at three periods: pretreatment.
posttreatment. and 3-month follow-up. The instruments were the McGill
Pain Questionnaire. the Minnesota Multiphasic Personality Inventory.

and the Lifestyle Coping Inventory. a self-report measure of health

121-1

care behaviors spanning a variety of domains. Several behavioral
outcome measures indicative of maintenance of gains were also assessed
at follow-up.

Three pain rating indices from the MP0 were computed at all three
measurement points: a mean sensory score. mean affective/eval uative
score. and mean number of words chosen. Mean elevations on the H5. D.
Hy. and Pt scales of the MMPI were assessed at pretreatment and follow-
up. A total mean score from the Lifestyle Coping Inventory. represent-
ing number and frequency of performance of health behaviors. was
assessed at pretreatment and follow-up. Follow-up was completed by
mail. and an 80% return 'rate was noted. with an equivalent response
rate for each group.

A pretest-posttest control group design with follow-up measures
was used to test the hypotheses. The unit of analysis was designated
as the weekly group since individuals within groups were not independ-
ent of one another. Analyses were performed using mean gain scores
(post minus pre and follow-up minus pre) as the observations. Two
MANOVAs were performed on the mean gain scores of the three pain meas-
ures. one examining the pretest-posttest comparison. the other examin-
ing the pretest-follow-up comparison; no significant differences were
found between groups for either test at the .05 level of significance.

A MANOVA was performed on mean gain score observations obtained
from the pretest-follow-up comparison on the four MMPI scales. and no
significant difference was observed between the groups at the .05 level

of significance. A one-way ANOVA was computed using mean gain scores

125

obtained from the pretest-follow-up comparison on the total mean coping
scores on the Lifestyle Coping Inventory. and no significant differ-
ences between groups were found at the .05 level of significance.

Chi-square tests of the difference between two independent propor-
tions on each of five outcome measures (employment status. compensation
status. pain interference with sexual intercourse. rehospitalization for
pain. and extent of medication use) did not reveal any significant
differences between groups at the .05 level. A _t-test performed on the
sixth outcome»measure. level of pain intensity. also was nonsignificant
at the .05 level.

Close examination of the data revealed that. despite the absence
of statistically significant differences between groups. for 10 of the
11 total dependent measures. the mean gain scores for the PPS group
were greater in the hypothesized direction than the mean gain scores

for the Discussion group.

Discussion
The results of this treatment study did not demonstrate support

for the original hypotheses. It was found that groups of chronic pain
patients who received the psychological intervention PPS did not
significantly differ from patient groups who participated in group
discussion on stress and pain in reducing pain perceptions. increasing
performance of health care behaviors. or modifying the severity of
characteristic psychological disturbance often seen in chronic pain

patients. Also. the PPS groups were not significantly better than

discussion groups in maintaining gains 3 months following treatment. as

 

 

126

indicated by several behavioral indices. A discussion of these results
with implications for theory and limitations of the study is now

presented.

Wiens

Changes in perceptions of the pain experience as measured by the
type and number of word descriptors chosen on the MPO were not signifi-
cantly different between groups from pretreatment to posttreatment or
from pretreatment to follow-up. The relationship between the personal
skills acquired through the PPS and the perception of pain may be
understood in two ways.. In keeping with the principles of the gate-
control theory of pain (Melzack & Wall. 1965). learning skills for
managing the internal environment (affects. cognitions) through an
intervention like the PPS would seem to influence the experience and
therefore the report of pain. On the other hand. subjects in the study
were not required to choose ”managing chronic pain" as the personal
theme to be examined in the PPS. Many varieties of personal problems
were chosen. Perhaps it is unreasonable to assume that a verbal pain
report would be affected by an intervention that did not deal exclu-
sively with the pain experience. Furthermore. since the MP0 was the
only instrument that specifically addressed pain. and relief from pain
was the patients' primary goal. at 3-month follow-up patients may have
used the instrument as a cry for help or as a means of seeking atten-
tion of staff if they were experiencing psychological distress.
I‘lnally. a further factor contributing to nonsignificance was some

Patients' lack of attention to the instructions to circle words that

127

described "present" pain. There is no way to be certain that patients
were not also reporting verbal descriptions of past or familiar pain.

The groups reduced pain perceptions at approximately the same rate
from pretreatment to posttreatment. The PPS group retained this level
of gains at follow-up. while the control group regressed to pretreatment
levels. although this difference was not statistically significant.
Perhaps the PPS group required more time to integrate the behavior
change concepts. and therefore a difference between groups could have
been detected over a longer follow-up period. If a later measurement
demonstrated continued slight improvement for the PPS group and contin-
ued regression for the control group. it would suggest that the PPS

subjects had internalized the health care management process.

Won

The difference between the changes in the two groups from
pretreatment to follow-up in performance of health care behavior was
found not to be significant. However. the PPS group exhibited a larger
gain. increasing 18.91 points as compared to the control group's 7.73
points. It is difficult to assess the clinical meaningfulness of this
increase since that requires further validation studies.

The effect of the PPS on behavior is a hypothesis that deserves
further scrutiny. Intuitively speaking. instruction in an organized
Process of awareness of the psychological and psychosocial variables
that influence an individual's actions would seem to have a potential

effect on future actions. The PPS defines the relationship between

128

behavior and internal mediating variables (emotions. thoughts.
physiological reactions) and the relationship between behavior and
consequences. It delineates certain intrapsychic variables that affect
behavior. including the central role of fear and the notion of "taking
a loss" in changing behavior. Future research needs to explore the
relationship between the PPS and behavior change. Again. the short
treatment period coupled with the early follow-up may not have been
sufficient to demonstrate behavior changes that would eventually
appear.

WW1
Distunbanss

Certain types of psychological disturbance are frequently observed
in chronic pain patients. including hypochondriasis. hysterical pat-
terns. depression. and anxious ruminative tendencies (Sternbach. 1974).
Changes in these types of disturbances. as measured by four scales of
the MMPI. Hs. D. Hy. and Pt. were not found to be significantly differ-
ent between groups from pretreatment to follow-up. The Hs scale meas-
ures neurotic concern with bodily functions and tendency to sematicize
problems. High scores indicate pessimism and show low levels of
insight. Since the H5 scale reflects a stable character trait which is
not thought to be easily subject to change. the personal skills taught
in the PPS might not be expected to affect it. Nevertheless. the PPS
group exhibited a mean gain score decrease of -5.42 (from a I-score of

78.37 to 72.95). while the control group decreased only -l.08 (from a I-

129

score of 72.13 to 71.05). However. the small sample size weakened the
statistical test of any real difference that may have existed.

The D scale. a mood indicator. provides an index of current
satisfaction with life. High scorers are depressed. dysphoric. guilty.
and exhibit poor self-confidence. Changes between groups in scale
elevation from pretreatment to follow-up were not significantly differ-
ent. It is reasonable to hypothesize that patients may experience more
control over their internal environment. therefore alleviating depres-
sive feelings. through training in the PPS model. Assisting a chronic
pain patient in understanding the relationships between stressful
events. internal reactions. behavior. and consequences would seem
likely to benefit these patients. Once an awareness of these relation-
ships occurs. patients can learn to change and manipulate the relation-
ships between these phenomena and enjoy greater satisfaction with life
even though still experiencing chronic pain. Since depression for
these patients often is of a long-term nature. a habitual response to
the cycle of chronic pain. this type of depression is much more diffi-
cult to alleviate (Roy a Tunks. 1982).

The difference between the two groups on the mean gain scores on
the Hy scale was not found to be significant. The Hy scale measures
two features: denial of psychological problems and denial of social
anxiety. High scorers somaticize problems. are immature. and demand
much affection and attention. In a study of two groups of chronic pain
patients receiving psychological treatment. one group received surgery

for pain relief and another did not (Sternbach & Timmermans. 1975).

130

Results showed that the group which received surgery with resulting
pain reduction significantly decreased scores on Hy. while the other
group showed no change. The personality features indicated by an
elevated Hy scale may be subject to change only following significant
pain relief. despite any psychological treatment that is provided.

On the Pt scale. a measure of anxiety and an overall indicator of
psychological turmoil. the PPS group demonstrated a mean gain score
reduction of -S.82 points (from 72.74 to 66.93) and the Discussion
group a mean reduction of -3.84 (from 60.04 to 56.20). a nonsignificant
difference. The PPS reduction in this scale seems clinically
significant even though it is not statistically significant. Simply
participating in pain clinic treatments could have a reassuring effect
on patients. showing them that others share their predicament in coping
with pain. Further effects from training. notably an increased sense
of perceived control. could affect anxiety and internal turmoil. A
more intensive training period in the PPS might result in larger
reductions on the Pt scale. toward a more "normal" elevation.

Examination of the mean pretreatment MMPI profiles (Table 4.14)
reveals that the PPS group appeared to be more psychologically
disturbed than the Discussion group. ‘These pretreatment differences
are difficult to account for since groups were randomly assigned to
each condition. The PPS group showed more variation on almost all of
the dependent variables than did the Discussion group. This greater
variation increased the standard error and thus made statistical

significance more difficult to achieve. The use of gain scores

131

increased the precision of the experiment and controlled for these
pretreatment differences.

In general. "personal ity" changes as measured by the MMPI may be
difficult to achieve without accompanying reductions in chronic pain.
There is support for the idea that neuroticism is the result of chronic
pain and that neuroticism will be reduced when the pain is alleviated

(Sternbach. 1974; Sternbach & Timmermans. 1975).

W
W

Unlike other behavior change programs (Glasgow & Rosen. 1978.
1979; D'Zurilla a Goldfried. 1971). the PPS explores the intrapsychic
mediating variables influencing the behavioral choice process and is
directly applicable to health care management (Hinds. 1983). Patients
are taught why change is so difficult and how resistance must be over-
come before changes can be made. The emotion of fear plays a central
role in this resistance to change. Skills to assist the individual in
remaining motivated to make changes are developed. a feature often
overlooked in other behavior change programs. In this section. a dis-
cussion of patients' process reactions to the PPS is presented.

One difficulty encountered was maintaining the patient's concen-
tration on one "stress theme." or personal problem. throughout the PPS
process. The tendency of some patients to become tangential may. in
itself. be an indication of poor problem-solving skills. This may
reflect the concentration difficulties that result from having chronic

pain. A further explanation of the difficulty in remaining focused on

"1
pa

to

St

132

one problem may be that this behavior is a resistance to examining the
internal environment. which is perceived as threatening.

Successful completion of "Step 1: A Personal Theme" is crucial to
the patient's engagement in the PPS process. Some patients exhibited a
poor ability to formulate a problem in specific. behavioral terms.
Instead. they were excessively global and vague in their problem
definitions. Some projected responsibility onto other people in their
lives for "causing" their problem. making completion of the following
steps nearly impossible.

In the step that requires awareness of internal reactions. some
patients struggled with the task of identifying the "beliefs" that
influence behavior in a stressful situation. Perhaps this exercise
demands an extended process of introspection and a certain level of
cognition not typically characteristic of this group of patients.

More guidance in this important step may be necessary.

A clear understanding of the relationship between behavior and
consequences requires emphasis by the instructor. Patients seemed to
have more difficulty identifying those consequences that are internal
(feelings) rather than external.

Perhaps the most significant step in Stage 1 is identifying a
"loss" the patient must take in making a behavior change. Many
patients needed to give more thought to this step before they were able
to write their response because they were uncertain about the specific
loss involved in working on their problem. 'The task presented in this

step requires an awareness of intrapsychic processes that may not be at

133

a conscious level for many patients. thus requiring assistance from the
trainer.

Many comments were made about the value of constructing the
"balance sheet" in Stage 2. Decision Making. A visual confrontation of
the rewards and punishments for deciding to make or not to make a
change was helpful. An important connection for patients to make is
the link between making a commitment to change and confronting the fear
to change. Here again. fears are often not conscious to the individ-
ual. requiring assistance from the trainer.

Patients often expressed satisfaction with the completion of the
first two stages of the‘PPS. commenting that these stages were benefi-
cial in and of themselves. ‘This observation suggests that awareness of
the components of a problem alone may be sufficient for change or
resolution. a view previously made by Williams and Long (1975).

Stage 3. Charting Oppositional Alternatives. proved to be the most
difficult stage for patients to complete. It is possible that patients
who are bound by a ”pain" perspective of themselves and the world are
unable to generate alternative ways of thinking. feeling. and behaving
without considerable difficulty (Melzack & Wall. 1982; Sternbach.
1982L Although it was clear that some patients had trouble with this
stage. it appears that there is value in understanding the concept of
”oppositional alternatives" even if personal examples are not currently
available.

Stage 4. Charting Planning and Action. was experienced by patients

as the easiest to complete. The steps in this stage elicited

 

13h

considerable discussion. particularly the step of identifying external
support systems and reinforcement for self-change. Most patients
appeared to benefit from this exercise despite difficulties with pre-

vious steps.

W

A number of factors may account for the absence of statistically
significant findings. These include small sample size. inappropriate
dependent measures. the phenomenon of improvement in both groups. brief
treatment period. rejection of the rehabilitation model of treatment.
and pretreatment differences between groups. Each of these factors is
discussed here with implications for the use of psychoeducational
interventions with psychologically disturbed populations.

The small sample size was a clear methodological limitation.
Since the group was the unit of analysis because individual subjects
were not independent of one another. analyses were based on only 11
degrees of freedom. limiting the power of the statistical tests to
detect small gains. The treatment would have to exert a powerful
influence on patients to obtain significant results with this sample
size.

It is possible that the dependent measures employed in the study.
the MP0. the MMPI. and the Lifestyle Coping Inventory. were inapprop-
riate. and other measures more suitable to the effect of the PPS on
this sample might be selected. The nature of the effect of the PPS on
chronic pain patients is not yet well established. so constructs dif-

ferent from those investigated in this study need to be identified and

135

researched. The question is whether the PPS influences the affective.
cognitive. perceptual. or behavioral realm of functioning. One means
of exploring this question would be to examine the experience of pain
patients as they progress through the stages. listening to their reac-
tions to the concepts presented. 'Two constructs that may be influenced
by the PPS are sense of coherence (Antonovsky. 1980) and self-efficacy
(Bandura. 1977). Sense of coherence is defined as a global orientation
which expresses the extent to which one has a pervasive and enduring.
though dynamic. feeling of confidence that one's internal and external
environments are predictable. Bandura (1977) theorized that an impor-
tant process in behavior change is the degree to which persons acquire
the expectancy that they will be able to perform the new or goal
behaviors toward which the change procedures are oriented. Intui-
tively. it appears that the PPS would influence both of these concepts.
Both groups in the study demonstrated improvement on several of
the dependent measures. ‘This phenomenon made it difficult to obtain
statistical significance and conclude that one treatment results in
greater gains than the other. Although the experimenter assumed only
a role of discussion moderator. and the groups did not have a formal
agenda. some control groups developed a surprising degree of cohesive-
ness. Group members shared important thoughts and feelings. and some
Inembers seemed to experience the healing effects of being with others
who shared their problems. The intention of the discussion group
treatment was simply to control for the factor of group participation

in the study. Patients seemed to experience more benefit than

136

initially expected from the group process. which often consisted only
of sharing common symptoms because a more therapeutic exploration of
feelings was avoided by the trainer.

The time available to administer treatment in the clinic setting
was brief. a factor that may have contributed to the lack of measurable
effectiveness of the PPS condition. While most behavior change manuals
consist of four or five steps. the PPS comprises 24 steps. a complex
intervention demanding concentration. persistence. and motivation from
participants. Group members who experienced difficulty comprehending
the concepts early in the process may have remained confused throughout
because there was insufficient time for clarification and discussion.
The short duration of treatment might not have permitted internal iza-
tion of the behavior change model in the PPS.

A characteristic noted in certain subjects was the inability or
unwillingness to view themselves and their treatment from the perspec-
tive of the rehabilitation model. A number of patients held firmly to
the illness model in stating what they needed and wanted from clinic
staff and where responsibility in their own treatment lay. These
subjects expected that the medical system should "cure" them of pain.
viewing themsel ves as passive participants in treatment. Employing the
PPS intervention encouraged patients to discard the illness view and
assume a rehabilitation perspective of their reaction to their pain.
Active involvement in and benefit from the PPS are antithetical to

acceptance of the illness model.

137

Pretreatment differences between the PPS and Discussion groups on
the MMPI profiles affected nonsignificant outcomes. PPS groups showed
greater elevations than Discussion groups on several scales. indicating
that these groups were comprised of more psychologically disturbed
individuals. Therefore. there was considerable within-groups varia-
tion. making it difficult to detect small changes between the PPS and
Discussion groups. An examination of the E-values obtained from the
ANOVA values revealed few values greater than 1.0. indicating that
within-groups variation was nearly as large as between-groups varia-
tion. These large within-groups differences may be more effectively
controlled by performing an analysis using group size as a covariate in
future studies of this kind.

Results of this study have implications for the theory of psycho-
education (Larson. 1984) and. therefore. the optimal use of the PPS
with chronic pain patients. The question becomes: When is psychoedu-
cation appropriate.iand when do patients require something different.
such as psychotherapy? Lazarus and Folkman (1984) spoke of the "trivi-
alization of distress" among some practitioners. This phenomenon
occurs when the existential distress that some>patients experience is
ignored and the assumption is made that patients only require knowledge
to get better. Chronic pain patients are typically quite psychologi-
cally disturbed individuals. as noted by close examination of the MMPI
profiles in Appendix 1. Perhaps the very obstacle that has led to
their coping deficiency in the first place is the obstacle that will

obstruct the success of the psychoeducational intervention. Some

138

chronic pain patients who have internalized a rehabilitation perspec-
tive seem to require only more knowledge to fill the gaps and improve
coping ability. 0thers*whose coping failure is not due to an uncompli-
cated lack of knowledge may require intensive psychotherapeutic treat-

ment before using a psychoeducational model like the PPS.

W

The results of this study document the need for further explora-
tion of the psychoeducational intervention PPS as an adjunct procedure
in the treatment of the chronic pain patient. As an initial experimen-
tal investigation of the PPS. this research addressed the effectiveness
of educating chronic pain patients in managing the psychological and
psychosocial factors that affect pain and health. Several implications
of this research are now presented.

Refinements in the PPS manual for use with a chronic pain popula-
tion are encouraged. The goal of these alterations should be to sim-
plify the text and improve the level of comprehension. To this end.
the use of more diverse examples of "stress themes" or personal prob-
lems would be beneficial. The language of the program should be more
"pictorial." concrete. and free from jargon that might confuse. thus
better tailored to the level of psychological sophistication of the
patients. The longer. more difficult steps should be condensed. with-
out sacrificing the meaning of the concepts.

Perhaps introductory notes regarding the optimal duration of the
training period would assist trainers in preparing to teach the

progrann A more realistic time period to instruct pain patients is

 

139

2 weeks. meeting four or five times each for 2-hour sessions. The
added length could optimally be used to clarify concepts and provide
more individualized attention.

A final note concerning use of the PPS manual is to recommend that
the trainer choose a personal stress theme and complete the PPS before
instructing others. There is a value to be gained from personal
experience and familiarity with application of the concepts that may
not be acquired through an impersonal perusal of the program. The PPS
intervention becomes training not only for the patients but also for
the trainer.

The question as to the use of individuals or groups in the
research analysis merits further consideration. Since research with
PPS is in the initial stages. studies employing either unit of analysis
would serve different purposes. yet both could provide useful informa-
tion. Both studies using groups and studies using individual subjects
could help determine the most effective means for delivery of the
intervention.

Descriptive "case" studies detailing the experience of single pain
patients with the PPS would assist in identifying patterns in the way
patients struggle with personal change. Identification of points in
the program where pain patients may psychologically withdraw or resist
would be helpful to the trainer in anticipating problems of motivation
and fear of change. A more complete understanding of the effect that

chronic pain has on the psychological health and problem-solving

Th0

abilities of these patients would be a valuable contribution to
rehabilitation efforts.

Refinements in the PPS manual would enhance ease of administration
in group settings. Conducting treatment over a longer period and
increasing the number of groups would have increased the power of the
present study. Use of samersize groups would control for some of the
within-group differences that were evident in the present study. ‘The
use of the group setting is attractive for two reasons: first. cura-
tive factors present in any group seem to enhance attraction to the
task. and second. teaching the PPS in group settings is in keeping with
the mission of counseling psychology. to train large numbers of indi-
viduals in personal and interpersonal skills.

Further research might examine the effectiveness of training pain
patient groups in the PPS versus training in one of the other popular
behavior change programs. such as the program developed by Goldfried and
Goldfried (1975) or Watson and Tharp (1977). This type of study could
explore the added benefit of the lengthier PPS program and its inclu-
sion of several concepts not found in these other programs. Again. a
much larger sample size would be necessary in such a study to increase
power and the possibility of achieving statistical significance.

Exploration of more appropriate dependent measures to employ in
determining the effect of the PPS on chronic pain patients is indi-
cated. The guiding question is: Does the PPS influence the cognitive.
affective. or behavioral realm of experience. and how is this influence

most optimally measured? It would be worthwhilerto investigate effects

1h]

on an individual's cognitive framework or view of the world. Does the
PPS have an effect on locus of control. ego strength. self-efficacy. or
certain attitudinal variables? These are questions that were not
answered in the present research and require further study.

To more adequately address the maintenance hypothesis. a longer
follow-up time'would be needed. a study that may be beyond the realm of
the doctoral dissertation. The ability to determine a regression
effect for the control groups in this research would be improved if
dependent measures were gathered 9 to 12 months following termination
of treatment. Within this time frame. patients would have more fully
returned to their living environments. and internalization of PPS
concepts could be better determined.

Finally. efforts to continue to integrate the educational model
into the health care system and to encourage patients to assume greater
responsibility for their rehabilitation are encouraged. Psychoeduca-
tion would seem to have potential benefit in helping to decrease health
care costs. ‘This study was one attempt to explore the utility of

psychoeducation for a health care population.

 

 

APPENDICES

1112

APPENDIX A

ESTIMATED WAIS-1Q VALUES USING SHIPLEY INSTITUTE
OF LIVING SCORES FOR EXPERIMENTAL

AND CONTROL GROUPS

143

 

1AA

Estimated WAIS-IQ Values Using Shipley Institute of Living Scores for
Experimental and Control Groups

 

 

 

“6:32?” ‘33:???
Experimental
1 62.50 121.00
2 51.60 105.80
3 h6.60 102.80
A 39.75 96.75
5 35.00 89.50
6 60.00 111.h0
Grand mean 50.91 10h.5h
Control
I 33.60 92.00
2 A1.00 98.00
3 h1.50 97.17
4 49.00 103.50
S h6.20 102.60
6 h2.26 99.20
Grand mean h2.h7 98.h2

 

Note:

score and Abstraction subtest raw score.

Shipley total raw scores computed by adding Verbal subtest raw

Total scores were then con-
verted to estimated WAIS-105 using age-level tables in Paulson and
Lin (1970).

 

APPENDIX 8

FOLLDWéUP QUESTIONNAIRE

1115

8.

1&6

FOLLOW-UP QUESTIONNAIRE

When did your pain begin? Year: Month:

How many surgeries have you had for your pain? (check one)

None One Two Three or more

 

Which gng_word describes your pain right now? (circle the word)

None Mild Discomforting Distressing Horrible or Excruciating
Which one word described your pain when you first entered the
Pain Clinic? (circle the word)

None Mild Discomforting Distressing Horrible or Excruciating

Since you were a patient at the Pain Clinic, what treatments have
you tried to relieve your pain? (check the line or lines)

Postural exercises

___ None ____Brace or cast
_ Bed rest _ Injections
___ Physical therapy ___ Drugs

_ Traction _ Surgery

___ Chiropractor ____0ther

Ri ht now, as compared to before you entered the Pain Clinic, are
you: c eck only one below)

I"

Taking less medication for pain

Taking 22 medication for pain

Taking more medication for pain

No change between now and then in medication for pain

 

Since you were in the Pain Clinic three months ago, have you been
hOSpitalized for your pain? Yes No

 

Right now, are you receiving any income for your pain?

Yes No If yes, from whom? Workman's Compensation
Pension Insurance

Before you entered the Pain Clinic, were you receiving any income
for your pain? Yes No If yes, from whom?

Workman's Compensation Pension Insurance

10.

II.

12.

1&7

Does your pain currently interfere with sexual intercourse?

Yes No

 

Are you currently working at a job? Yes No

If yes, are you working full time? Part time?
Job training

Estimate the extent of your pain relief due to your Pain Clinic
stay:(check only one)

Complete pain relief Fairly good pain relief
Very good pain relief None or slight pain relief
Good pain relief

APPENDIX C

McGILL PAIN QUESTIONNAIRE

1118

 

1&9

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APPENDIX D

SHIPLEY INSTITUTE OF LIVING SCALE

151

 

NAME

152

In the‘test below, the first word in each line is printed in capital letters. Opposite it are four other words.

Draw a line under the one word which means the same thing, or most nearly the same thing, as the first word. A
samPle has been worked out for you. If you don't know. guess. Be sure to underline the one word in each line that
means the same thing as the first word.

(1)

(2)

(3)

(4)

(5)

(6)

(7)

(8)

(9)
(10)
(11)
(12)
(I3)
(14)
(15)
(16)
(17)
(18)
(19)
(2°)
(21)
(22)
(25)
(24)
(25)
(26)
(27)
(28)
(29)
(5°)
(31)
(32)
(33)
(34)
(35)
(36)
(37)
(38)
(39)
(4°)

LARGE

TALK
PERMIT
PARDON
coucn
REMEMBER
TUMBLE
morons
CORDIAL
EVIDENT
IMPOSTOR
MERIT
FASCINATE
lNDlCA‘l’E
IGNORANT
FORTIFY
RENOWN
NARRATE
MASSIVE
HILARITY
SMIRCHED
SQUANDER
CAPTION
FACILITATE
JOCOSE
APPRISE
RUE
DENIZEN
DIVEST
AMULET
lNEXORABLE
SERRATED
LISSOM
MOLLll-‘Y
PLAGlARlZE
ORlFlCE
QUERULOUS
PARIAH
ABET
TEMERITY
PRISTINF.

In 27!!

red

draw
allow
forgive
pin

swim
drink
silvery
swift
green
conductor
deserve
welcome
defy

red
submerge
length
yield
bright
laughter
stolen
tease
drum
help
humorous
reduce
eat
senator
dispossess
charm
untidy
dried
moldy
mitigate
appropriate
brush
maniacal
outcast
wahen
rashness
vain

SAMPLE
big
BEGIN HERE

eat

sew
pound
eraser
recall
dress
tilted
muddy
obvious
ofiicer
distrust
fix
excite
sharp
strengthen
head
buy
large
speed
pointed
belittle
ballast
turn
paltry
strew
lament
inhabitant
intrude
orphan
involatile
notched
loose
direct
intend
hole
curious
priest
ensue
timidity
sound

“WHIIIWdl-Jfil

silent

speak
cut

di\ ide
sofa
number
fall
young
leafy
sceptical
booIt
fight
stir
signify
uninformed
vent
fame
associate
speedy
grace
remade
cut
beading
strip
fervid
inform
dominate
fish

rally
dingo
rigid
armed
supple
pertain
revoke
building
devout
lentil
incite
desire
first

wet

sleep
drive
tell
glass
defy
think
dreadful
hearty
afraid
pretender
separate
enchant
bicker
precise
deaden
loyalty
tell

low
malice
soiled
VI“:
‘9‘
bewilder
plain
delight
one
atom
pledge
pond
sparse
blunt
convex
abuse
maintain
lute
complaining
locker
placate
kindness

level

153

NAME_._

 

Complete the following. Each dash (—) calls for either a number or a letter to be filled in. Every line is a
separate item. Take the items in order, but don’t spend too much time on any one.

START HERE
(1) I 2 3 4 s ._
(2) white black short long down _ __
(3) AB BC CD D—
(4) Z Y X W V U .—
(3) 1232123432 34343 436___
(6) NE/SW SE/NW E/W N/-..
(7) escape scape cape - ._ --
(8) oh ho rat tar mood -
(9) A 2 B Y C X D --
(10) tot tot bard drab 537 _ __ _-
(ll) mist is wasp as pint in tone _ _
(12) 57326 73265 32657 26573

c -- —- — — —

(13) knit in spud up both to stay . -

(14) Scotland landscape scapegoat . _ , . ,_ _ee

(13) surgeon 1234567 snore 17639 rogue _ _ _. -- _

(l6) tam tan rib rid rat raw hip _- _. - -

(17) tar pitch throw saloon bar rod fee tip end plank , meals

(18) 3124 82 73 134 46 13___
(19) lag leg pen pin big bog rob.

(20) two or four r one 0 three _

W lfl‘l'ha l-ta'ruaa d Urine
For. 2713

APPENDIX E

LIFESTYLE COPING INVENTORY

15h

 

155

LIE§§IXL§ QQELLIE MEEIQB!

b7

Willias C. Hinds
Professor, Counseling
Psychology Prograa

437 Erickson Hall
Michigan State University
c 1983

This docusant is not to be duplicated without the express authorization
of the author.

156

hark each state-ent as a weekly average if it applies to your actions.
' Alsost Always —

 

 

 

 

 

Often
Occasionally ——
'Rarel
Never
1. I keep sy living environaent quiet. A D C D E
2. I eat two servings of vegetables daily. A D C D E
3. I follow ey own values. rather than go out of sy way to sake
sure people like se. A 8 C D E
4. I let others sake choices rather than try and sanipulate thee
to seat ay needs. A D C D E
5. I let other people know when I's sick. i A I C D E
6. I avoid salting sy food at the table. A B c D E
7. I provide sysalf with ssall and constant self rewards to
keep se activated. ' A D C D E
8. I express sy feelings of anger. A D C D E
9. I avoid shoulds and should note in sy self-statesents. A D C D E
10. I engage in an active sport, e.g. racquetball, swissing,
touch football, tennis, etc. at least once a week. A D C D E
ii. I avoid eating seat and instead substitute fish and poultry. A D C D E
12. I let others win sosetises. rather than try to win in
seat situations. A D C D E
13. I balance work and play, rather than pay a high price
for success. A 8 C D E
14. I drive at the speed liait. A D C D E
15. I build in self-iaprovesent actions in sy lifestyle. A B C D E

16. I keep sy weight within ten pounds of what I consider
sy ideal weight. A 8 C D E

17. I have brown rice rather than white rice. A D C D E

 

 

157

Health Prosotion - Stress Reduction

Behavioral Coping Inventory by Uillias C. Hinds

This inventory is designed to help you understand your health prosotion -
stress reduction actions. The following pages cover various lifestyle.
nutritional. drug, exercise, environsental, probles solving and psychosocial
habits that affect your health and stress levels. Your answers can provide
you with valuable feedback when cospared with others who have taken this
instrusent. Please answer each ites honestly as possible. Your health
prosotion - stress reduction intervention strategies depend on self-
generated accurate feedback.

Directions:

1) Uith this inventory, you should have a special answer sheet on which to
sark your answers.

2) Please sake no sarks on this booklet: it will be used again by other
people.

3) Use any soft, black, lead pencil (such as a No. 2) to sake your sark on
the answer sheet.

1) Fill in your nase and other inforsetion on the answer sheet. Follow
carefully the instructions for filling in your nase.

5) hake a heavy, dark sark for each answer - ngg a cross or a check sark.

6) If you sake a sistaka or change your sind. erase carefully and
thoroughly.

7) Mark on your answer.sheet one of five possible choices.

Choice A I Never (03 of the Tise)

Choice 8 I Rarely (0-25x of the Tise)

Choice C I Occasionally (25x - 50x of the Tise)
Choice D I Often (50% - 753 of the Tise)
Choice E I Very Often (753 - 1008 of the Tise)

Exasple: Question One. I eat two servings of vegetables daily.

Answer: Choice 8 - 253 of the Tise.

A 8 C D E
Ouestion One X

Please turn the page and begin.

 

18.

I9.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

158

I sake sure to include fiber in sy diet.

I choose environsents which have an artistic or
esthetic value.

I relax and get interested, rather than get angry
with people who are slower than we.

I seek out others at work or in the neighborhood.

I avoid sugar and sweets (cookies, cakes, ice creas).
I practice sose fors of relaxation at least fifteen,
sinutes a day, e.g. progressive relaxation, yoga,
biofeedback. seditation, isagery exercises or deep
breathing exercises.

I avoid drinking or eating slot before going to bed.

I avoid asking generalizations about syself, e.g. I’s
dusb, ugly, a failure. etc.

I engage in activities that give as a sense
of cospetency, e.g. hobby, pasttise, evocation, etc.

I visit or talk to a good friend.
I keep sy living environsent clean.
I avoid the use of tobacco.

I sake sy own decisions, even though sose people sight
not like then.

I set sy own standards, rather than worry about other's
standards for as.

I take advice fros others.

I share sy experiences with other people.
I get out and talk with groups of people.
I engage in thoughts that relax sy body.
I wear seat belts when I drive.

I use thought stopping strategies to avosd obsessing
over events with no control.

I stick up for sy own rights.

I invite people over to sy place for drinks or a seal.

 

 

40.

41.

42.

- 43.

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

58.

59.

60.

61.

62.

159

when waiting in lines, I asuse syself, rather than get angry.

I avoid taking sore then two alcoholic drinks a day.

I seek feedback on sy actions.

I get sy teeth cleaned twice a year.

I eat whole bread instead of white bread.

I use pepper and herbs to season sy food instead of salt.
I walk when possible rather than ride in an sutosobile.

I let others express what they are feeling.

I drink only two cups or less of tea or coffee with
caffeine a day.

I let syself be dependent. rather then appear tough and
strong sost of the tise.

I accept that people are interested in what I say.
I seek out others. rather than feel neglected or rejected.

I accept sy worthiness as a person, and express it to
other people.

I go out of sy way to talk to strangers.
I do activities with a social group.

Hy living environsent is convenient, e.g. seals, laundry
services, telephone, etc.

I substitute low calorie drinks for high calorie drinks.

I engage in resistance exercise to tone and strengthen sy
suscles. For exesple: weights or isosetric exercise.

I express and share with others a wide range of

esotions, e.g. anger. distress, fear, shase.

I avoid perfectionistic self-standards.

I let syself cry.

I seek out experiences where I have to be alone.

I's outgoing in new situations.

63.

64.

65.

66.

67.

69.

70.

71.

72.

73.

74.
75.
76.
77.

78.

79.

80.

81.

82.

83.

84.

85.

I60

I trust others, rather than acting like the world is
full of hostile people. ‘

I use positive isegination to approach fearful events.

I avoid worrying about consequences which I can
not predict.

I avoid saving up (inhibiting) sy feelings, e.g. anger.
distress, etc.

I avoid personalizing things I can't control.

Uhan I get into a stressed state. I take a
break.

I sake sure I get an adequate asount of sleep.
I avoid high-sodius foods.

I eat two servings of fruit daily.

I clisb stairs rather than ride an elevator.

I avoid cosparing syself to other people. and instead
set salfcstandarda for isprovesents.

I use visualization to relax sy body.

I choose environsents free of air pollution.

I relax rather than try to lead in sost situations.
I share sy esotions with other people.

I sake desands on others, even though it say not
sake as popular with thee.

I do things Just for the enjoysent of doing thes, even
if I have to "waste“ sose tise.

I choose environsents that are relaxing.

I get together with sy co-workers.

I go to the park or visit a pleasant environsent.
I label what I’a feeling.

I set sodest action standards for syself so I can seat
sy goals.

I engage in active physical work, e.g. washing the car,
housework, chopping wood. at leastftwice a week.

 

 

86.

87.

88.

89.

91.

92.

93.

95.

96.

97.

98.

99.

100.

101.

102.

103.

104.

105.

106.

I6]

I get physical exass at least once a year, e.g. heart,
pap ssear, breast axes, prostate gland, etc.

I avoid processed foods, and instead eat fresh foods.

I eat foods that are steased, baked or boiled instead
of pan fried or french fried.

Uhen I's suffering fros an illness or injury, I take
ties to restore sy physical self.

I share sy feelings with others.
I spontaneously express sy feelings.

Once I have decided on an action, I do not spend tise
worrying about whether people are going to criticize se.

a year.

I relax during seals and don’t discuss business or
stressful subJacts.

I eat low fat snacks.

I choose environsents with little noise pollution.
I use polyunsaturated sargarine instead of butter.
I floss sy teeth once a day.

I let syself experience the distress of loss.

I avoid saking negative interpretations about events
in sy life.

I try to understand the beliefs that
sotivate as.

I listen to others, rather than arguing for sy point
of view sost of the ties.

I get involved in group activities.

I think about ay strengths and skills, rather than
worry about being weak and helpless.

I say twice as aany positive statesents to
syself as negative.

I avoid Justifying sy actions and sistakes to syself
and others.

A 8 C D E

A 8 C D E

 

 

107.

108.

109.

110.

111.

112.

113.

114.

115.

116.

117.

118.

119.

120.

121.

122.

123.

124.

125.

126.

127.

128.

129.

I

I

I62

walk a half an hour a day at one tise.

get together with a cossunity group.

By living environsent is organized.

I

read labels on foods and beverages so I know about

their nutritional contents.

I

-spend twenty sinutes three tiaes a week engaged in

aerobic exercise, e.g. Jogging, cycling, swissing,
rebounding, etc.

I

I

I

avoid dwelling on the past.
accept the fact that others will not like as.

confront people, rather than worrying about others

approving of as.

I

I

I

I

laugh and feel Joyful.

cognitively reward syself for accosplishing tasks.
avoid saking negative statesents about others.

engage in stretching or lisbering exercises once a day.
set low fat cheese instead of high fat cheese.

take ties to play.

drink beverages that contain little sugar.

think of the future with positive expectations.

avoid thinking in tarss of obsolutes, e.g. rights and

wrongs, good and bad.

I

I

as assertive in a wide variety of situations.

face conflicts head on, rather than avoid frictions

and difficulties.

I

1'

take a break, rather than try to hurry.

ll let things sit, rather than try to do sore than

three things at once.

I

I

adsit sy sistakas to others.

get together with a political action group.

 

130.

131.

132.

133.

134.

135.

136.

List

137.

138.

139.

List

140.

141.

142.

I63

I sake an effort to be around friends and associates.
I get involved in friendships with sany people.

I try and keep close relationships.

I avoid buying processed foods that are highly salted.

I accept sy lisitations and do not becose discouraged
when other people do things well.

I avoid eating sore than three eggs a week.

I get together with a religious group.

any other strategies you use to prosota your own health.

 

 

 

your top three strategies for the relief of stress.

 

 

 

I"

 

 

 

APPENDIX F

INFORMED CONSENT FORM

 

 

161+

165

INFORMED CONSENT FORM

I understand that the purpose of my participation in this study
is to investigate the effects of an educational treatment on the way
people view their pain and the kinds of decisions people make about
their health care. I understand that by participating in this study
I will be assigned to one of two groups: (l) a group that learns
personal problem solving or (2) a group that participates in discus-
sion about stress and pain.

I will be identified by code number only and not by name. I
understand that for all information recorded, my confidentiality
will be strictly maintained.

I understand that by my participation, I will be asked to
complete several paper-and-pencil inventories about my pain, my health
habits, and my personality. I understand that I will complete these
inventories at three different times: (i) at the beginning of the
week before my treatments, (2) at the end of the week after my treat-
ments, and (3) three months following my discharge from the pain
clinic. I understand that I will be mailed the inventories three
months after I am discharged and I am to complete these inventories
and mail them back to the investigator in the self-addressed envelope
provided. By my signature, I agree to complete these inventories to
the best of my ability.

The details of this study have been explained to me and my
questions answered to my satisfaction. I participate in this study
freely, trusting that new knowledge may be obtained which may be of
value to me and to others who have pain.

I understand that there is no guarantee that my participation
in this study will result in benefit to me. I understand that whether
or not I agree to participate in this study I will receive the usual
pain clinic treatments. I am free to discontinue my participation
totally. Finally, I understand that I may request a summary of the
results of this study, and those results will be mailed to me.

Signature of Participant
Date

 

 

Signature of Researcher
Date

I65

 

 

 

REFERENCES

I66

 

REFERENCES

Anderson. T. P.. Cole. T. M.. Gullickson. G.. Hudgens. A.. &
Roberts. A. H. (I977). Behavior modification of chronic pain:
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£95125. 122. 96-100.

Antonovsky. A. (I980)..flealth..stne§s..and.cgping. San Francisco:
Jossey-Bass.

 

Aronoff. G. M.. Evans. W. D.. a Enders. P. L. (1983). A review of I
follow-up studies of multidisciplinary pain units. Rain..1§.
1-11e

Authier. J.. Gustafson. K.. Guerney. B.. & Kasdorf. J. (1975). The
psychological practitioner as a teacher: A theoretical-historical

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Bandura. A. (I969). 312111213135 91 behavior Wu. New York:
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Bandura. A. (1977). Self-efficacy: Toward a unifying theory of behav-
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Barrera. M.. Jr.. & Glasgow. R. E. (I976). Design and evaluation of a
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Bartz. N. R. (1968). Relationship of the WAIS. BETA. and Shipley-
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Bartz. W. R.. & Loy. D. L. (1970). The Shipley-Hartford as a brief 10
screening device. .lgunnal.9I.Qlln1;al.E§¥Qthng¥. 26. 74-75.

Beck. A. (1976). Wmmmmm. New
York: Meridian.

Becker. M. H.. & Maiman. L. A. (I975). Sociobehavioral determinants of
compliance with health and medical care recommendations. .Menical

MD .13.! 10-24 a
Benfari. R.. Eaken. E.. & Stole. J. (1981). Behavioral intervention and

compliance to treatment regimes. Annual Review 91 Eubjug Health.
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Bolyard. R. L. (I982). The use of the sensory and affective pain
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8648.

Brehm. J. W. (I966)..A.Ih29£¥.Qi.n§¥§helegieel.Leaeianee. New York:
Academic.

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