Healthy and Maladaptive Dependency and Its Relationshipto Pain Management and Perceptions in Physical TherapyPatients

Steven K. Huprich • Patrick Hoban •

Ashley Boys • Alexandra Rosen

� Springer Science+Business Media New York 2013

Abstract This study examined the association among

healthy and maladaptive aspects of interpersonal depen-

dency and the management of pain in physical therapy

outpatients. Ninety-eight patients were administered the

Relationship Profile Test, West Haven-Yale Multidimen-

sional Pain Inventory, and Pain Catastrophizing Scale.

Results indicated that Destructive Overdependence was

positively associated with an increased number of office

visits, pain interference in one’s daily life, pain severity,

affective distress, and receiving positive partner responses.

Dysfunctional Detachment was associated with affective

distress, pain interference in one’s daily life, and rumina-

tion about pain. Healthy Dependency was only associated

with receiving distracting responses from others. Believing

that a spouse/partner is supportive and caring about one’s

pain partially mediated the relationship between overde-

pendency and pain interfering in one’s life. These results

support the clinical utility of assessing interpersonal

dependency for its relationship to managing one’s pain and

health care utilization.

Keywords Dependency � Detachment �Overdependency � Pain interference

Interpersonal Dependency and its Relationship

to Pain Management and Perception in Physical

Therapy Patients

Though there have been multiple theories about the per-

ception and management of pain, most modern studies take

a biopsychosocial approach (Asmundson & Wright, 2004;

Novy, Nelson, Francis, & Turk, 1995; Turk & Flor, 1999).

This framework considers the physical, psychological, and

social factors of pain, and how these factor interact and are

expressed behaviorally. Within the psychological factor,

there are several issues to be considered. For instance,

some communicate their pain in order to gain the attention

of another person or time off from unpleasant activities,

while others benefit from social reinforcement (Turk, 2001,

p. 1784). Specifically, pain behaviors, such as grimacing or

limping, are initially reinforced by others’ attention to the

behaviors. Individuals learn this pattern, and pain behav-

iors continue even without the reinforcements (Novy et al.,

1995).

Studies have found that individuals notably differ in

their experience and management of pain. Using the West

Haven-Yale Multidimensional Pain inventory (WHYMPI;

Kerns, Turk, & Rudy, 1985), Turk and Rudy (1988) found

that chronic pain patients can be divided into three distinct

clusters. The Dysfunctional Group (DYS) includes indi-

viduals who report higher levels of pain severity, pain

interfering with their lives, and lower levels of perceived

control and activity level. The Adaptive Copers Group

(AC) includes individuals who report lower levels of pain

severity, pain interfering in one’s life, affective distress,

and higher levels of activity and perceptions of control.

The Interpersonally Distressed Group (ID) includes all of

the aspects of the DYS group plus high levels of inter-

personal distress. Individuals in this group believe that their

S. K. Huprich (&) � A. Boys � A. Rosen

Department of Psychology, Eastern Michigan University, 361A

Mark Jefferson Science Complex, Ypsilanti, MI 48197, USA

e-mail: shuprich@emich.edu

P. Hoban

Probility Physical Therapy, Ann Arbor, MI, USA

123

J Clin Psychol Med Settings

DOI 10.1007/s10880-013-9372-1

significant others are not supportive and do not assist with

their pain management. Besides demonstrating there are

individual differences in pain perception and management,

this study also highlights how there are social and inter-

personal variables related to the perception and manage-

ment of pain (Alschuler, Hoodin, Susan, Murphy, &

Geisser, 2011; Turk & Rudy, 1988).

Considering this issue further, some studies have found

that in order to garner support, pain patients catastrophize1

their symptoms to others in order to obtain increased

attention, proximity seeking, and/or assistance (Boothby

,Thorn, Overduin, & Ward, 2004; Sullivan et al., 2001;

Sullivan, Tripp, Rodgers, & Stanish, 2000). For example,

in a sample of spinal injury patients, catastrophizing was

more common in those living with a significant other than

in those living alone or with someone else not considered

significant other. Research involving couples (in which one

partner experiences chronic pain) demonstrates that the

level of catastrophizing in one partner changes in propor-

tion to the level of catastrophizing in the other. Specifi-

cally, one partner will display very high levels of pain

behavior to overcompensate for a spouse who does not

respond with equal intensity, in order to garner more sup-

port from the spouse, as well as sources of outside help for

the both of them (Gauthier, Thibault, & Sullivan, 2011).

In addition to being a mechanism by which one

‘‘proves’’ his/her needs for help, catastrophzing occurs in

individuals who perceive their partner’s responses to be

more solicitous (Giardino et al., 2003). For instance, in a

sample of back pain patients, those classified as dysfunc-

tional in their ability to cope with pain had significantly

higher levels of catastrophizing than those classified as

adaptive or interpersonally distressed. However, interper-

sonally distressed patients expressed the most non-verbal

pain behaviors. There are at least three possibilities why

these individuals expresses their pain in this fashion. One is

that pain patients with more interpersonal distress are

afraid to ask for support. This behavior occurs because, in

the event that they do not receive it, they could experience

less assistance than what they presently have (Rusu &

Hasenbring, 2008). Another possibility is that interper-

sonally distressed catastrophizers have learned to demon-

strate their pain adequately through their body language,

thus not needing to express themselves verbally. For

instance, in a group of patients undergoing a cold pressor

test, Sullivan, Martel, Tripp, Savard, and Crombez (2006)

found a positive correlation between the Pain Catastro-

phizing Scale and inferences of high pain ratings given by

observers watching them. Finally, catastrophizing may be

associated with higher levels of pain intensity, which

has been demonstrated in those experiencing affective

(Giardino et al., 2003) and sensory pain (Sullivan & D’Eon,

1990). Thus, while catastrophizing can be adaptive in some

cases, it can also be maladaptive.

Interpersonal Dependency

Being powerless and ineffectual, and looking to others to

provide support and guidance, are core components of the

dependent personality (Bornstein, 1993). Indeed, there is

robust literature showing the relationship between inter-

personal dependency, help seeking behaviors, and physical

and psychological care. For instance, in classroom and

laboratory settings, dependent students ask for help and

support from professors significantly more often than their

non-dependent peers (Diener, 1967; Sroufe, Fox, & Pancake,

1983). High levels of dependency and help seeking

behavior are also associated with higher levels of both

physical and psychological disorders (Bornstein, 1998a,

1998b; Greenberg & Bornstein, 1988a, 1988b; Fisher &

Greenberg, 1977), negative perceptions of one’s physical

health and emotional well-being, (Huprich, Hsiao, Por-

cerelli, Bornstein, & Markova, 2010), and more physical

symptoms and health care utilization (Porcerelli, Bornstein,

Markova, & Huprich, 2009). When utilizing the health care

system, individuals with higher levels of dependency show

a shorter delay in seeking treatment and tend to stay in

treatment longer (Bornstein, Krukonis, Manning, Mastrsi-

mone, & Rossner, 1993; Greenberg & Bornstein, 1988a,

1988b), as well as requesting and receiving a greater

number of consultations and more medication than non-

dependent patients (O’Neill & Bornstein, 2001). Highly

dependent patients also have fewer missed treatment ses-

sions than their non-dependent counterparts (Poldrugo &

Forti, 1988).

These studies demonstrate that, contrary to what might

be expected, highly dependent individuals actively seek out

help or assistance. In fact, in a review of the empirical

literature on dependent persons’ interpersonal behavior,

Bornstein (1995a) identified three conditions under which

highly dependent people become most active with others:

(1) situations in which they must compete with others for

attention and caregiving; (2) situations in which they seek

to obtain the approval of a caretaker, and (3) situations in

which they seek guidance or support from a caregiver.

Across these studies, individuals with high levels of

dependency actively and assertively pursue care and help

in ways that are readily observable to others.

As noted above, high levels of help-seeking and catas-

trophizing have been reported in patients experiencing

acute and chronic pain(e.g., Sullivan et al., 2001). Given

1 Catastrophizing is the cognitive and affective intensification of the

pain experience, which includes rumination about the pain the sense

that one is helplessly subjected to its control on one’s psychological

experience.

J Clin Psychol Med Settings

123

these patterns of relationships, it is reasonable to consider

whether the chronic pain patient’s non-verbal attempts at

help-seeking are related to his/her level of interpersonal

dependency. In fact, the relationship of interpersonal

dependency and pain management has not been well

studied in the literature. Thus, it seemed timely to inves-

tigate the relationship of these two variables in order to

understand their relationship better. In the present study,

we were interested in considering this relationship in

physical therapy patients. These patients are ideal to study,

as they are composed of individuals with acute and chronic

problems and include people of all ages, thus yielding a

heterogeneous group upon which to broadly study the

dependency-pain relationship. Also, physical therapy,

unlike other medical treatments, requires patients’ active

participation and engagement, thereby making it an opti-

mal domain in which to study interpersonal dependency. In

the present study, measures of interpersonal dependency

(which included subscales assessing healthy dependency,

overdependency, and detachment), the impact of pain on

the patient’s life, the perception of partners’ responses to

patients’ pain, patients’ activity level given their pain, and

pain catastrophizing were administered. The total number

of treatment sessions was also recorded. As previous

studies have found a relationship between dependency, the

utilization of health care, and negative perceptions of

physical health, it was hypothesized that overdependency

would be positively correlated with the number of treat-

ment sessions, the impact of the individual’s pain on his/

her life, a reduction in activity level, and catastrophizing.

Because the research on detachment and pain management

is limited, no a priori hypotheses were offered.

Method

Procedures

The study was approved by the first author’s institutional

review board and by the CEO and owner of the treatment

facility (the second author). Participants were recruited

from a physical therapy treatment facility over the course

of 6 months. Research assistants went to the facility

between 6 and 12 h per week during this time period. They

approached patients after their initial appointment with a

physical therapist and were asked if they would like to be

included in the study. Patients who agreed completed a

series of questionnaires and were given a $10 dollar gift

card. All patients who agreed to participate completed the

questionnaires provided to them. The number of treatment

sessions attended was collected after patients were for-

mally discharged from the treatment facility.

Measures

Relationship Profile Test (RPT; Bornstein & Languirand,

2003). The RPT is a 30-item questionnaire that asks par-

ticipants to respond to a series of self-statements, each

rated on a 5 point Likert scale, ranging from 1 (not at all

true of me) to 5 (very true of me). The RPT yields three,

10-item subscale scores: Destructive Overdependence

(DO), Dysfunctional Detachment (DD), and Healthy

Dependency (HD). RPT statements are written to target the

four components of each personality style (i.e., cognitive,

emotional, motivational, behavioral) as well as other core

features of each dimension in question. Items were derived

from the theoretical and empirical literature on each of the

personality dimensions and are represented by the follow-

ing: ‘‘I am most comfortable when someone else takes

charge’’ and ‘‘Being responsible for things makes me

nervous’’ (DO); ‘‘I don’t like to reveal too much personal

information’’ and ‘‘I wish I had more time by myself’’

(DD); and ‘‘I see myself as a capable person who copes

well with disappointments and setbacks’’ and ‘‘I am com-

fortable asking for help’’ (HD). Studies on the RPT’s

construct validity confirm that DO, DD, and HD scores

show theoretically predicted relationships with measures of

attachment, relatedness, identity, and overall satisfaction

with life (Bornstein, Geiselman, Eisen, & Languirand,

2002; Bornstein & Huprich, 2006; Bornstein et al., 2003).

For instance, DO is positively correlated with nonasser-

tiveness in interpersonal relationships and being overly

accommodating, while DD is positively correlated with

being isolated from others and appearing cold or distant.

By contrast, HD is negatively correlated with eight

domains of interpersonal problems (Bornstein & Huprich,

2006). Bornstein and Huprich (2006) also found three year

test–retest reliability to be .57 for DO, .51 for DD, and .49

for HD. In the present study, the Cronbach’s alphas for DO,

DD, and HD were .86, .75, and .84, respectively.

West Haven-Yale Multidimensional Pain Inventory

(WHYMPI; Kerns et al., 1985). The WHYMPI is a 52 item

questionnaire that assesses three aspects of pain: impact of

pain on the patient’s life, the perception of partner

responses, and one’s activity level. For the current study,

questions pertaining to the first two scales: Part 1 (impact

of pain on people’s lives) and Part 2 (perception of part-

ner’s responses) were administered. The impact of pain

component consists of six subscales, each rated on a

7-point scale: Pain Severity (3 items, e.g., ‘‘level of pain at

present moment’’), Pain-Related Interference (9 items, e.g.,

‘‘affects ability to work’’), Support (3 items; e.g., ‘‘degree

of spouse attentiveness to pain problem’’), Self-Control (2

items; e.g., ‘‘amount of control over life in the past week’’),

and Negative Mood (3 items; e.g., ‘‘degree of irritability

J Clin Psychol Med Settings

123

during the past week’’). The perception of partner respon-

ses scale consists of three subscales, rated on a 6-point

scale ranging from ‘‘never’’ to ‘‘frequently’’: Punishing

Responses (4 items; e.g., ‘‘ignores me’’), Solicitous

Responses (5 items; e.g., ‘‘gets me something to eat’’), and

Distracting Responses (4 items, e.g., ‘‘involves me in

activities’’). In the present study, internal consistency

reliability (Cronbach’s alpha) for Part 1 was .85 and .68 for

Part 2.

Pain Catastrophizing Scale (PCS; Sullivan, Bishop, &

Pivik, 1995). The PCS is a 13-item self-report measure that

assesses the extent to which individuals catastrophize their

pain. The PCS has three dimensions (subscales) of catas-

trophizing: Rumination (4 items; e.g., ‘‘I keep thinking

about how badly I want the pain to stop’’), Magnification

(3 items; e.g., ‘‘I wonder whether something serious may

happen’’), and Helplessness (6 items; e.g., ‘‘I feel I can’t go

on’’). The PCS has been shown to have a high degree of

stability over a six-week period (r = .75) and a Cronbach’s

alpha of .87 (Sullivan et al., 1995). In the present study,

Cronbach’s alpha was .88 for the Rumination scale, .73 for

the Magnification scale, and .83 for the Helplessness scale.

Results

Though 103 participants agreed to participate, some were

eliminated in the analyses as they omitted at least one full

page of the questionnaire data. The final sample thus con-

sisted of 98 individuals—69 women (73 %), 25 men (27 %)

and 4 who did not report their sex. The mean age of par-

ticipants was 51.38 with a range of 15–84 (SD = 17.61).

They attended a mean of 16.88 (10.79) appointments, which

ranged between 5 and 73. They had a mean of 0.40 (0.92)

cancelled and 0.26 (0.75) missed appointments. Their

ICD-10 (World Health Organization, 1992) medical diag-

noses varied, although the most commonly occurring ones

were: Lumbago (27), Cervicalagia (16), Unspecified Joint

Pain (15), Pain in Thoracic Spine (6), Pain in Limb (3), and

Thoracic Outlet Syndrome (2). There were no significant

gender differences in age, RPT, PCS, and WHYMPI total

and scaled scores, nor in the number of appointments

attended, cancelled, or missed. Age was not significantly

correlated with any of the aforementioned variables.

Pearson correlations were calculated between the num-

ber of office visits, RPT, WHYMPI, and PCS scales (see

Table 1). DO was significantly correlated with number of

office visits (r = .28, p \ .05). On the WHYMPI, DO was

significantly correlated with Part 1 Subtotal (r = .94,

p \ .01—the impact of pain on a person’s life), and the,

Part 2 Subtotal (r = .34, p \ .01—the perception of part-

ner’s responses). Considering the subscale correlations

more specifically, DO was positively correlated with the

Interference (r = .90, p \ .01), Support (r = .44, p \ .05),

Pain Severity (r = .78, p \ .05), Affective Distress

(r = .25, p \ .05), and Solicitous Responses (from others)

(r = .24, p \ .05) subscales. There were no significant

correlations between DO and the PCS scales.

DD was significantly correlated with the WHYMPI Part

1 subtotal (r = .41, p \ .05). More specifically, DD was

correlated with the WHYMPI Interference (r = .30,

p \ .05) and Affective Distress (r = .38, p \ .01) sub-

scales. DD was significantly correlated with the PCS

Rumination subscale (r = .30, p \ .01) and Total Score

(r = .26, p \ .05 respectively).

HD was only correlated with receiving distracting

responses on the WHYMPI (r = .23, p \ .05).

In order to determine the unique effects of the WHYMPI

and PCS scales in predicting DO and DD, a series of

regression analyses were conducted. DO was predicted by

Interference, Support, Pain Severity, Affective Distress,

and Solicitous Responses WHYMPI scales. The Adjusted

R2 = .95, and every scale except Solicitous responses

uniquely predicted DO scores. (See Table 2). DD was

predicted by Interference, Affective Distress, and Rumi-

nation. The Adjusted R2 = .18, though none of these scales

significantly and uniquely predicted variance in DD.

Table 1 Correlations between the RPT and frequency of appoint-

ments, WHYMPI, and PCS subscales

DO DD HD

Total visits .28* .03 .01

WHYMPI

Interference .90** .30* .16

Support .44* .02 .05

Pain severity .78* .16 -.08

Self-control -.18 -.18 .13

Affective distress .25* .38** -.13

Solicitous responses .24* .02 .19

Punishing responses .20 .19 -.10

Distracting responses .20 -.13 .23*

Part 1 subtotal .94** .41* .08

Part 2 subtotal .34** .12 .17

PCS

Magnification -.16 .06 .03

Rumination .09 .30** .04

Helplessness .20 .16 .04

Total Score .19 .26* .04

DO destructive overdependence, DD dysfunctional detachment, HD

healthy dependency, WHYMPI west haven-yale multidimensional

pain inventory, PCS pain catastrophizing scale

* p \ .05, ** p \ .01

J Clin Psychol Med Settings

123

Given the high positive correlations between DO with

the Part 1 subtotal (impact of pain; r = .94), believing that

a partner/spouse is supportive and caring about one’s pain

(r = .44), and reporting that a spouse intentionally pro-

vides help (r = .24), we considered the possibility these

latter two experiences might mediate the relationship

between DO and Part 1 subtotal. We performed these

analyses using Preacher and Hayes (2008) bootstrapping

techniques and their SPSS� macro for mediation. We

found that having a spouse/partner who is supportive

mediated this relationship (Z = -3.24, p \ .01), but that

having a spouse do things to help out did not (Z = .42,

p = .67). In other words, believing that a spouse/partner is

supportive and caring about one’s pain slightly reduced the

relationship between overdependency and pain interfering

in one’s life; whereas, having a spouse/partner actually do

things to help out did not.

Discussion

This study provides evidence to suggest that, in a mixed

sample of physical therapy patients, there is a relationship

between adaptive and maladaptive dependency and the

experience and management of pain. Such results expand

our understanding of the health and personality interface.

The most notable findings were the very high, positive

correlations between the DO scale and the impact of pain on

a person’s life, specifically associated with interference in

daily activities and pain severity. Thus, having destructive

levels of overdependency is strongly associated with the

experience of pain and its impairment on individuals’ daily

lives. Within a biopsychosocial model of pain, it would

appear that destructive overdependency corresponds with

the intensity of one’s pain experience and its adverse effects

on one’s life. Though also positively correlated with DO,

obtaining solicitous responses, seeking out interpersonal

support from others, and affective distress was less associ-

ated with destructive aspects of dependency. Yet, it is

notable that, even with the advantage of assistance from

others, having higher levels of destructive overdependency

remains associated with emotional and physical distress.

Additionally, it may be that this lower level of association in

seeking responses from others may be due to a fear that by

expressing too much distress, the overly dependent person

might drive away the one who is helpful.

This said, the mediation analysis demonstrated that

having the perception of a significant other who cares does

more to reduce the relationship of overdependency with the

perception of pain interfering with one’s life. It also is

important to note that actual caregiving behaviors by a

spouse or significant other did not significantly reduce the

overdependency-pain interference perception. In other

words, it is not enough to have someone who does things to

help out—there must be someone who is perceived to be

understanding of one’s pain.

Furthermore, pain catastrophizing was not related to

destructive overdependency, which was originally

hypothesized. Why this did not occur is unclear, though it

might be that patients in physical therapy are receiving the

kinds of care and support they need from caregivers to

buffer their need or desire to catastrophize their pain. In

other words, it may be they perceive their caregivers as

understanding and accepting their experiences of pain, such

that they do not need to be overly expressive of it vis-a-vis

catastrophizing. Alternatively, and more parsimoniously, it

may be that catastrophizing one’s experiences of pain does

not have a relationship with overdependency. In this case,

the PCS assessed thoughts and feelings one has when s/he

is in pain. It might be that individuals can readily separate

their ideas when they are in pain from the experience of

care they receive from other. These ideas should be eval-

uated in larger and more medically diverse samples, par-

ticularly patients who are not yet in treatment, as it may be

that treatment provides the care and support they need such

that catastrophizing is unnecessary.

Also as expected, people who scored higher in overde-

pendency had more office visits. This is most likely related

to a dependent person’s need to seek out and pursue those

who provide help (Bornstein, 1995a). Such findings have

already been well-documented within the health care system

with psychiatric inpatients, outpatients, medical patients,

and primary care outpatients (e.g., Bornstein, 1995b; Bornstein

et al., 1993; O’Neill & Bornstein, 2001, 2006; Porcerelli et al.,

2009).

Contrary to what was predicted, DD was not signifi-

cantly correlated with the impact of pain on a person’s life,

nor any other interpersonal variables as assessed on the

WHYMPI. However, DD did significantly correlate with

Table 2 Regression analyses: predicting destructive overdependence

and dysfunctional detachment with WHYMPI and PCS scales

Criterion Predictors Std. Beta t p

Adjusted R2 = .95

DO Interference .70 14.25 \.001

Support .28 7.81 \.001

Pain severity .28 6.33 \.001

Affective distress .13 -3.911 \.001

Solicitous responses -.04 -0.99 .33

Adjusted R2 = .18

DD Rumination .15 1.13 .26

Affective distress .25 1.88 .07

Rumination .22 1.70 .10

DO destructive overdependence, DD dysfunctional detachment

J Clin Psychol Med Settings

123

the Pain Catastrophizing Scale, indicating a relationship

between detachment and catastrophizing, similar to results

found by Boothby et al. (2004). This stands in contrast to

our original hypothesis that only overdependency would be

correlated with catastrophizing. One reason for this may be

that catastrophizing sometimes pushes people away instead

of drawing in others. Alternatively, detached individuals

might catastrophize because others are not there to be of

help to them. Of course, catastrophizing and detachment

may reciprocally influence each other as well.

These findings have the potential to inform treatment. In

that vein, several issues should be considered. Maladaptive

levels of dependency—DO and DD as measured here—are

associated with more problematic ways in which pain

interferes with one’s life. For overly dependent persons,

these concerns will likely be expressed to health care

providers who, by necessity of their profession, will be

required to attend to such concerns. Care providers who

show an understanding and empathy for the pain experi-

ence are likely to be of some help to such patients. How-

ever, if caregivers are not mindful that the patient’s need to

remain dependent motivates his or her actions, caregivers’

empathy will be quickly consumed and sought out more

regularly. This means that it would likely increase the

number of visits the patient requests. Care providers who

both accept the patients’ experience of pain while also

encouraging their capacity to tolerate the pain (and

continuing their health maintenance and recovery efforts)

could lessen patients’ needs for a caring other and sub-

sequent demands for attention.

For overly detached persons, care providers should pay

particular attention to patients’ reports of pain and respond

to it. Knowing that detachment is associated with catastro-

phizing, caregivers who show their tolerance of the patient’s

subjective pain might facilitate the patient’s ability to tol-

erate his/her pain. Such acceptance models for the patient

that others can be a useful resource when it comes to man-

aging one’s pain. However, it is important to understand

why a patient is detached when considering how to manage

their care. For instance, being elderly and having few friends

might lead to catastrophizing in order to obtain the attention

of a caregiver. Such patients might benefit from additional

contact from the caregiver to assist in their recovery. By way

of contrast, the catastrophizing, detached patient also might

have driven others away, despite having a number of sup-

portive individuals to whom s/he may turn. In this case, the

care provider could provide support to the patient, but per-

haps discuss how social support can be most useful when the

patient’s expressions of pain are moderated in their

expression. We believe that these issues would generalize

across patient settings (e.g., orthopedic rehabilitation, post-

surgery, cancer, etc.), though such ideas would benefit from

empirical verification.

For those who possess healthy dependency, it should be

noted that pain can be managed in highly adaptive ways.

Having controlled for age and gender, this study demon-

strates that the mismanagement of pain is more associated

with individuals who need others too much or too little.

Indeed, pain severity and interference have extremely high

levels of association to overdependency. Though many

factors affect the pain-interpersonal relatedness interface,

these findings suggest that, in this modest-sized, physical

therapy sample, overdependency can be a destructive force

when it comes to patients’ ability to manage their pain.

These findings must be tempered, however, by the fact that

we did not have a good way to control for the severity of

the injury/disease process or its duration. However, most

patients had multiple physical problems for which they

were referred for treatment.

The current study had a few other important limitations.

First, as this was a preliminary investigation, we did not

make efforts to control for Type I error. Second, data was

collected from a single physical therapy site on a relatively

small sample. Thus, the generalizability of these results is

limited. Third, the data is based on self-reports. Gauging

personality on self-report data alone can be difficult because

answers could have been influenced by conscious or non-

conscious efforts to present oneself as more or less distressed

than what is actually experienced, or limited insight and

awareness into one’s dependency and perceptions of pain

(Ganellen, 2007). Furthermore, it has been well-documented

that self-reports and perceptions of others do not agree well

(Oltmanns & Turkheimer, 2006). Thus, it is unclear as to

whether solicitous or punishing responses by others were

actually provided. Nevertheless, our focus was more on

patients’ perceptions, so attempting to confirm the actual

behavior of partners was not as central to understanding this

study’s results. Finally, Part 2 of the WHYMPI suffered

from some limits to its internal consistency (alpha = .68). It

is not clear why this occurred; thus, the correlations with the

PCS, and RPT might have been diminished.

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