LOCUS OF CONTROL

AND

PSYCHOSOCIAL ADJUSTMENT TO CHRONIC PAIN

by

BRENDA LEE SAWYER HOOGE

B.A., U n i v e r s i t y of Saskatchewan, 1968 M . S c , Simmons C o l l e g e , 1974

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF

THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF ARTS

i n

THE FACULTY OF GRADUATE STUDIES

(Department of C o u n s e l l i n g P s y c h o l o g y )

We a c c e p t t h i s t h e s i s as c o n f o r m i n g

to the r e q u i r e d s t a n d a r d

THE UNIVERSITY OF BRITISH COLUMBIA

Oct o b e r 1983

© Brenda Lee Sawyer Hooge, 1983

I n p r e s e n t i n g t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the r e q u i r e m e n t s f o r

an advanced degree a t the U n i v e r s i t y of B r i t i s h C o l u m b i a , I agree t h a t

the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r r e f e r e n c e and s t u d y . I

f u r t h e r agree t h a t p e r m i s s i o n f o r e x t e n s i v e c o p y i n g of t h i s t h e s i s f o r

s c h o l a r l y purposes may be g r a n t e d by the Head of my Department or by h i s

or her r e p r e s e n t a t i v e s . I t i s u n d e r s t o o d t h a t c o p y i n g or p u b l i c a t i o n of

t h i s t h e s i s f o r f i n a n c i a l g a i n s h a l l not be a l l o w e d w i t h o u t my w r i t t e n

p e r m i s s i o n .

Department of C o u n s e l l i n g P s y c h o l o g y

The U n i v e r s i t y of B r i t i s h C o l umbia V a n c o u v e r , Canada V6T 1Y3

Date

ABSTRACT

T h i s s t u d y sought t o examine the r e l a t i o n s h i p s between l o c u s of

c o n t r o l , p s y c h o s o c i a l a d j u s t m e n t to c h r o n i c p a i n , and r e p o r t e d l e v e l s o f

p a i n f o r c h r o n i c p a i n p a t i e n t s who had completed an i n - p a t i e n t ,

m u l t i d i s c i p l i n a r y p a i n t r e a t m e n t program. The sample c o n s i s t e d o f f o r t y

one i n d i v i d u a l s drawn from B r i t i s h C o l u m b i a , A l b e r t a , and Saskatchewan

a l l of whom had completed a p a i n t r e a t m e n t program i n V a n c o u v e r , B r i t i s h

C o l u m b i a d u r i n g the y e a r s 1979-1982. A l l i n d i v i d u a l s c ompleted the

f o l l o w i n g q u e s t i o n n a i r e s : a B i o g r a p h i c a l ^ I n f o r m a t i o n Q u e s t i o n n a i r e ,

R o t t e r ' s Locus o f C o n t r o l S c a l e , the Adjus t m e n t t o C h r o n i c P a i n S c a l e

(ACPS), and the M c G i l l P a i n Q u e s t i o n n a i r e .

F i v e h y p o t h e s e s were t e s t e d . H y p o t h e s e s One, Two, and Three were

t e s t e d u s i n g P e a r s o n Product-Moment c o r r e l a t i o n c o e f f i c i e n t s t o

e s t a b l i s h the r e l a t i o n s h i p s between v a r i a b l e s . Hypotheses Four and F i v e

were t e s t e d u s i n g i n d e p e n d e n t groups t - t e s t s f o r the d i f f e r e n c e between

means t o d e t e r m i n e i f t h e r e was a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e

between the means of the two groups on d i f f e r e n t v a r i a b l e s o f

p s y c h o s o c i a l a d j u s t m e n t to c h r o n i c p a i n .

S i g n i f i c a n t n e g a t i v e c o r r e l a t i o n s were found f o r fe m a l e s between

t h e Locus of C o n t r o l s c o r e s and the ACPS s c o r e s s u g g e s t i n g a

r e l a t i o n s h i p between an i n t e r n a l l o c u s of c o n t r o l and poor p s y c h o s o c i a l

a d j u s t m e n t . S i m i l a r l y , a s i g n i f i c a n t i n t e r a c t i o n was found between

- i i i -

i n t e r n a l i t y and h i g h l e v e l s o f r e p o r t e d p a i n f o r f e m a l e s . F o r males, a

s i g n i f i c a n t c o r r e l a t i o n was found between e x t e r n a l l o c u s of c o n t r o l and

h i g h l e v e l s of r e p o r t e d p a i n . A s e c o n d a r y a n a l y s i s found a s i g n i f i c a n t

c u r v i l i n e a r r e l a t i o n s h i p between the extremes of l o c u s of c o n t r o l ( i . e .

h i g h i n t e r n a l s and h i g h e x t e r n a l s ) and poor p s y c h o s o c i a l a d j u s t m e n t t o

c h r o n i c p a i n .

I m p l i c a t i o n s f o r the c o n s t r u c t i v e use of the l o c u s o f c o n t r o l

measure as a t h e r a p e u t i c i n t e r v e n t i o n s t r a t e g y i n c o u n s e l l i n g c h r o n i c

p a i n p a t i e n t s are d i s c u s s e d .

- i v -

TABLE OF CONTENTS

PAGE

A b s t r a c t i i

T a b l e o f C o n t e n t s i v

L i s t o f T a b l e s v i i

L i s t of F i g u r e s v i i i

Acknowledgements i x

D e d i c a t i o n x

CHAPTER I

INTRODUCTION

Statement o f the P r o b l e m 1

O b j e c t i v e s of the Study 6

S i g n i f i c a n c e of the Study 7

L i m i t a t i o n s 8

Overview of the Study 8

CHAPTER I I

REVIEW OF THE LITERATURE

I n t r o d u c t i o n 10

C h r o n i c P a i n - A S o c i e t a l P e r s p e c t i v e 10

P a i n P e r c e p t i o n and Measurement 13

Treatment S t r a t e g i e s 15

E v a l u a t i o n of A d j u s t m e n t 19

Gender D i f f e r e n c e s i n C h r o n i c P a i n 20

- v -

TABLE OF CONTENTS c o n t i n u e d

PAGE

Lo c u s of C o n t r o l - T h e o r e t i c a l C o n t e x t 23

Loc u s of C o n t r o l - C o n c e p t u a l Assumptions 28

L o c u s o f C o n t r o l - Gender D i f f e r e n c e s 30

Summary 31

CHAPTER I I I

METHODOLOGY

Sample C h a r a c t e r i s t i c s 33

I n s t r u m e n t a t i o n 34

Data C o l l e c t i o n 43

R e s e a r c h Hypotheses and Method of T e s t i n g 44

Summary 46

CHAPTER IV

RESULTS

H y p o t h e s e s , Method o f T e s t i n g and R e s u l t s 47

Secondary A n a l y s i s 58

Summary of R e s u l t s 59

CHAPTER V

SUMMARY, CONCLUSIONS AND DISCUSSION

Summary 61

C o n c l u s i o n s and D i s c u s s i o n 63

L i m i t a t i o n s of the Study 73

- v i -

TABLE OF CONTENTS c o n t i n u e d

PAGE

I m p l i c a t i o n s of the Study 75

S u g g e s t i o n s f o r F u t u r e R e s e a r c h 79

C o n c l u s i o n 81

R e f e r e n c e s

A p p e n d i c e s

83

90

- v i i -

LIST OF TABLES

TABLE PAGE

I n t e r n a l c o n s i s t e n c y s c o r e s f o r the A d j u s t m e n t 38 to C h r o n i c P a i n S c a l e (ACPS).

Item a n a l y s i s r e s u l t s f o r the A d j u s t m e n t t o C h r o n i c 39 P a i n S c a l e (ACPS).

P e a r s o n Product-Moment C o r r e l a t i o n C o e f f i c i e n t s f o r 54 males and f e m a l e s u s i n g t o t a l s c o r e s f o r each sex on Locus of C o n t r o l and MPQ.

T - t e s t u s i n g A d j u s t m e n t to C h r o n i c P a i n S c a l e s c o r e s 55 to compare males and f e m a l e s .

Means and S t a n d a r d D e v i a t i o n s of ACPS s c o r e s f o r 56 two a d j u s t e r groups of males and f e m a l e s .

T - t e s t u s i n g Locus of C o n t r o l s c o r e s t o compare good 57 and poor a d j u s t e r s .

- v i i i -

LIST OF FIGURES

FIGURE PAGE

Locus of C o n t r o l s c o r e s and ACPS s c o r e s f o r a l l 49 s u b j e c t s .

L o c us of C o n t r o l s c o r e s and ACPS s c o r e s f o r 51 male s u b j e c t s .

3 Locus of C o n t r o l s c o r e s and ACPS s c o r e s f o r female s u b j e c t s .

53

- i x -

Acknowledgements

I would l i k e t o e x p r e s s my a p p r e c i a t i o n t o my c h a i r p e r s o n , •

Dr. Marv Westwood, and to my committee member, Dr. Sharon Kahn, f o r

t h e i r s u p e r v i s i o n , p a t i e n c e , s u p p o r t , f e e d b a c k and humour. B o t h have

i n f l u e n c e d my p r o f e s s i o n a l development as a c o u n s e l l o r and r e s e a r c h e r

and I am g r a t e f u l f o r t h e i r e x p e r t i s e . A l t h o u g h Dr. J i m Vargo was

u n a v a i l a b l e d u r i n g the l a t t e r s t a g e s of my t h e s i s , I a p p r e c i a t e h i s

a s s i s t a n c e d u r i n g the p r e l i m i n a r y s t a g e s of my r e s e a r c h .

To my husband, Jo h n , and t o our c h i l d r e n , Andrea and Samuel,

I am e s p e c i a l l y t h a n k f u l f o r t h e i r o n g o i n g s u p p o r t , l o v e , and

encouragement t h r o u g h the many y e a r s i t took me to complete t h i s

d e g r e e . To my p a r e n t s , M i l d r e d and John Sawyer, I am g r a t e f u l f o r

t e a c h i n g me p e r s e v e r a n c e and f o r v a l u i n g my s p i r i t . My s i s t e r , S i d ,

s u s t a i n s me w i t h u n f a i l i n g good a d v i c e , g e n e r o s i t y , and c a r i n g .

I want t o thank my many f r i e n d s a t Synergy who h e l p me dance

w i t h o u t bumping on the w a l l s .

F i n a l l y , I would l i k e t o thank my dear f r i e n d s C a r e n , M u f f ,

and Sharon f o r t h e i r l o v e and u n d e r s t a n d i n g . W i t h o u t t h e i r i n s p i r a t i o n

I would not have had the m o t i v a t i o n to complete t h i s t h e s i s .

- x -

DEDICATION

T h i s t h e s i s i s d e d i c a t e d t o the memory of

S h a r i Podersky-Cannon,

a f r i e n d who h e l p e d me t o l i v e , and t o know how and why.

CHAPTER ONE

I n t r o d u c t i o n

C h r o n i c p a i n i s one of the most p r e v a l e n t and d i f f i c u l t

p roblems p h y s i c i a n s t r e a t . C h r o n i c p a i n r a n k s among the l e a d i n g m e d i c a l

problems i n terms of p h y s i c i a n v i s i t s , h o s p i t a l i z a t i o n , c o s t s , and

d i s a b i l i t y payments ( N a g i , R i l e y , & Newby, 1973). P a i n , b o t h a c u t e and

c h r o n i c , a f f l i c t s about o n e - t h i r d of the p o p u l a t i o n of the U n i t e d S t a t e s

each y e a r . I t r a n k s as perhaps the most f r e q u e n t cause o f d i s a b i l i t y

and s u f f e r i n g , y e t i t i s o n l y now coming t o be r e c o g n i z e d as a d i s e a s e

e n t i t y w i t h s e r i o u s i n d i v i d u a l and s o c i e t a l impact ( L o r e n z , 1 9 8 1 ) .

C h r o n i c p a i n b e h a v i o r s appear t o s h a r e c e r t a i n i m p o r t a n t c o m m o n a l i t i e s

w i t h a d d i c t i v e s t a t e s , i n c l u d i n g s e l f - d e s t r u c t i v e f e a t u r e s ,

i n t r a c t a b i l i t y t o t r e a t m e n t , f r e q u e n c y of r e c u r r e n c e , and h i g h i n c i d e n c e

o f i a t r o g e n e s i s . S e r e s , P a i n t e r , and Newman (1981) made the p o i n t t h a t

p s y c h o l o g i c a l , s o c i a l , and e n v i r o n m e n t a l f a c t o r s appear t o be more

c l o s e l y r e l a t e d t o p a i n and t o p a i n r e l i e f t h a n a r e such f a c t o r s as

s e v e r i t y of i n j u r y , number of s u r g e r i e s , or r a d i o g r a p h i c f i n d i n g s .

Statement o f t h e P r o b l e m

The c o g n i t i v e , o v e r t b e h a v i o r a l , and p h y s i o l o g i c a l r e s p o n s e s

seen i n c h r o n i c p a i n p a t i e n t s a r e the e n d p r o d u c t s of an extended

l e a r n i n g h i s t o r y ( K e e f e , 1 9 8 2 ) . A t the " a c u t e s t a g e " o f c o p i n g w i t h

- 2 -

p a i n , p a t i e n t s d i s p l a y p a i n b e h a v i o r p a t t e r n s t h a t a r e a d a p t i v e . A t

t h i s s t a g e , d e c r e a s e s i n a c t i v i t y and i n c r e a s e s i n m e d i c a t i o n i n t a k e may

promote h e a l i n g o f t i s s u e damage. M u s c l e spasm may i m m o b i l i z e j o i n t s

and a t l e a s t i n i t i a l l y p r o t e c t the i n d i v i d u a l from r e i n j u r y . As h e a l i n g

b e g i n s to t a k e p l a c e (2-6 months p o s t - i n j u r y ) p a i n p e r s i s t s f o r some

p a t i e n t s . These p a t i e n t s may e n t e r a " p r e - c h r o n i c " s t a g e i n w h i c h

p a i n - b e h a v i o r p a t t e r n s may become more f i r m l y e n t r e n c h e d . P a t i e n t s a t

t h i s s t a g e t y p i c a l l y a t t e m p t t o r e t u r n t o a more a c t i v e l i f e s t y l e . The

manner i n w h i c h t h e p a t i e n t approaches t h i s t a s k may be c r i t i c a l .

P a t i e n t s who g r a d u a l l y resume a c t i v i t y w i t h o u t e x a c e r b a t i n g p a i n a r e

more l i k e l y t o become p a i n f r e e . P a t i e n t s who a r e u n a b l e because of

f i n a n c i a l c o n s i d e r a t i o n s or u n w i l l i n g to g r a d u a l l y resume a c t i v i t y a r e

l i k e l y t o be a t h i g h r i s k f o r d e v e l o p i n g c h r o n i c p a i n .

P a t i e n t s who a b r u p t l y resume a c t i v i t y o f t e n e x p e r i e n c e a

f l a l r - u p i n p a i n and r e v e r t t o p a i n b e h a v i o r s such as r e l i a n c e on

b e d r e s t and p a i n m e d i c a t i o n . Each attempt to resume a c t i v i t y t h a t f a i l s

l e a d s once a g a i n t o t h e s e p a i n b e h a v i o r s , and as time c o n t i n u e s and i f

t h i s p a t t e r n i s r e p e a t e d , the p a i n b e h a v i o r s become s t r o n g e r and

m a l a d a p t i v e . P a t i e n t s may become c a u t i o u s and guarded i n t h e i r

movements - p a t t e r n s t h a t l e a d t o a s h o r t e n i n g of m u s c l e s , i n c r e a s e d

m uscle spasm, and f a t i g u e . P a t i e n t s may a l s o become c o n v i n c e d t h a t

t h e r e i s l i t t l e t h a t they can do to c o n t r o l p a i n and may become prone t o

c o g n i t i v e d i s t o r t i o n s s e r v i n g t o i n c r e a s e d e p r e s s i o n and dru g

dependency.

As t h e s e p a i n b e h a v i o r p a t t e r n s r e c u r , the l i k e l i h o o d t h a t

t h e y w i l l l e a d to p o s i t i v e s o c i a l consequences i s a l s o i n c r e a s e d . T hat

- 3 -

i s , spouse and f a m i l y members may become q u i t e c o n c e r n e d and t a k e over

many of the p a t i e n t ' s r e s p o n s i b i l i t i e s and a c t u a l l y e n f o r c e i n a c t i v i t y

and p a i n m e d i c a t i o n i n t a k e . A t the " c h r o n i c p a i n s t a g e " (6 months p l u s

p o s t - i n j u r y ) e v i d e n c e f o r u n d e r l y i n g t i s s u e damage r e s p o n s i b l e f o r p a i n

i s o f t e n a b s e n t or m i n i m a l . P o w e r f u l p o s i t i v e consequences such as

s o l i c i t o u s a t t e n t i o n from f a m i l y or spouse, a v o i d a n c e o f unwanted work

or home r e s p o n s i b i l i t i e s , and f i n a n c i a l c o m p e n s a t i o n , however, may s e r v e

to r e i n f o r c e and m a i n t a i n p a i n b e h a v i o r p a t t e r n s .

Many o b s e r v e r s have d e s c r i b e d the s t r e s s f u l n a t u r e o f the

c h r o n i c p a i n syndrome. To be s u c c e s s f u l i n terms of p a i n management

c o n s i d e r a b l e s e l f - d i s c i p l i n e on t h e p a r t o f t h e p a t i e n t and adherence t o

m o d a l i t i e s l e a r n e d i n the t r e a t m e n t p r o c e s s a r e r e q u i r e d . F a i l u r e t o

i n c o r p o r a t e t h e s e b e h a v i o r s o f t e n has as the consequence t h e

p e r p e t u a t i o n of c h r o n i c p a i n . T h i s f a i l u r e or l a c k o f a d j u s t m e n t t o

p a i n management c o u l d r e s u l t from an i n a b i l i t y t o r e c o g n i z e the

consequences of one's b e h a v i o r on t h e outcome o f t r e a t m e n t .

S p e c i f i c a l l y , t he c o n c e p t o f l o c u s of c o n t r o l ( R o t t e r , 1966)

can be a p p l i e d to an a n a l y s i s of c h r o n i c p a i n p a t i e n t s ' p s y c h o s o c i a l

a d j u s t m e n t t o or management of p a i n a f t e r an i n - p a t i e n t p a i n t r e a t m e n t

program. The l o c u s o f c o n t r o l c o n s t r u c t r e f e r s to the degree t o w h i c h

i n d i v i d u a l s p e r c e i v e t h e e v e n t s i n t h e i r l i v e s as b e i n g a consequence o f

t h e i r own a c t i o n s , and t h e r e b y c o n t r o l l a b l e ( i n t e r n a l c o n t r o l ) , or as

b e i n g u n r e l a t e d t o t h e i r own b e h a v i o r s and, t h e r e f o r e , beyond p e r s o n a l

c o n t r o l ( e x t e r n a l c o n t r o l ) . I n d i v i d u a l s w i t h an i n t e r n a l l o c u s of

c o n t r o l t e n d t o b e l i e v e t h a t e v e n t s and rewards a r e c o n t i n g e n t upon

- 4 -

t h e i r own b e h a v i o r , w h i l e i n d i v i d u a l s w i t h an e x t e r n a l l o c u s o f c o n t r o l

b e l i e v e t h a t e v e n t s and rewards a r e l a r g e l y the r e s u l t of l u c k , chance,

o r f a t e .

A c c o r d i n g t o Phares (1976) I-E s c o r e s ( r e f l e c t i n g t h e

s u b j e c t ' s l o c u s of c o n t r o l ) can be a l t e r e d by a range of c o n d i t i o n s .

These c o n d i t i o n s i n c l u d e b o t h v e r y s p e c i f i c i n f l u e n c e s whose e f f e c t s may

be t r a n s i t o r y and narrow, and a l s o changes t h a t have more p e r v a s i v e ,

permanent e f f e c t s on b e h a v i o r . Locus of c o n t r o l can be a l t e r e d by a

v a r i e t y of e n v i r o n m e n t a l f o r c e s . Some of t h e s e f o r c e s i n c l u d e f a c t o r s

t h a t accompany age changes, c o n d i t i o n s t h a t a f f e c t a s u b j e c t ' s c e r t a i n t y

t h a t c o n t r o l can be e x e r t e d , w o r l d or n a t i o n a l e v e n t s , s p e c i a l t r a i n i n g

programs, and a v a r i e t y of t h e r a p e u t i c t e c h n i q u e s .

I n t e r n a l c o n t r o l can be c o n s t r u e d as a v e r y s p e c i f i c

e x p e c t a n c y or a v e r y g e n e r a l one, but i n e i t h e r c a s e i t i s i m p o r t a n t t o

u n d e r s t a n d the c o n d i t i o n s t h a t w i l l a f f e c t i t s s t r e n g t h . As Phares

s t a t e d i n o r d e r to enhance i n d i v i d u a l s ' c a p a c i t y t o cope w i t h the w o r l d

s u c c e s s f u l l y , one must i n f l u e n c e t h e i r g e n e r a l i z e d e x p e c t a n c y f o r

i n t e r n a l c o n t r o l . P h a r e s s u g g e s t e d f u r t h e r t h a t p e r c e i v e d c o n t r o l may

be viewed as a somewhat narrow e x p e c t a n c y a r i s i n g out of a s p e c i f i c

s i t u a t i o n , or i t may be viewed as a r e l a t i v e l y s t a b l e c h a r a c t e r i s t i c

t h a t p e r s o n s c a r r y w i t h them from s i t u a t i o n t o s i t u a t i o n .

I f c h r o n i c p a i n p a t i e n t s a r e viewed from an e x t e r n a l l o c u s o f

c o n t r o l framework as some a u t h o r s have s u g g e s t e d ( A b r a m o w i t z , 1969;

Harrow & F e r r a n t e , 1969; S k e v i n g t o n , 1979), t h e n f a i l u r e t o manage one's

p a i n w e l l a f t e r t r e a t m e n t p r o b a b l y r e s u l t s from a v i e w p o i n t of the

- 5 -

p a t i e n t s t h a t t h e i r a c t i o n s do not a f f e c t t h e i r m e d i c a l c o n d i t i o n . T h i s

p o i n t o f v i e w s u g g e s t s t h a t the h i g h l y s t r e s s f u l n a t u r e of the c h r o n i c

p a i n p r o c e s s i t s e l f t ends t o make i n d i v i d u a l s more e x t e r n a l i n t h e i r

l o c u s o f c o n t r o l . T h e r e f o r e , i t c o u l d be i m p o r t a n t t o know

p r e - t r e a t m e n t whether an i n d i v i d u a l has an i n t e r n a l o r e x t e r n a l l o c u s o f

c o n t r o l . I f the f e e l i n g of c o n t r o l were absent ( h i g h E s c o r e ) t h e n t h e

e f f e c t i v e n e s s o f many b e h a v i o r a l i n t e r v e n t i o n s t r a t e g i e s on the

m o t i v a t i o n a l components o f p a i n c o u l d be e x p e c t e d t o be s u b s t a n t i a l l y

r e d u c e d .

Changes i n l o c u s o f c o n t r o l o c c u r as a r e s u l t o f n a t u r a l

e v e n t s o r a d e l i b e r a t e e f f o r t on the p a r t o f the i n d i v i d u a l s c o n c e r n e d .

Examples of t h i s a r e found i n s t u d i e s of s u c c e s s f u l p s y c h o t h e r a p y , where

r e c o v e r y i s accompanied by an i n c r e a s e i n i n t e r n a l i t y so t h a t p a t i e n t s

t a k e g r e a t e r p e r s o n a l c o n t r o l o f t h e i r w o r l d . H e r e , an i n c r e a s e i n

i n t e r n a l i t y i s a s i g n o f r e c o v e r y .

P a t i e n t s ' b e l i e f s about t h e i r c h r o n i c p a i n , and t h e i r c o p i n g

w i t h p a i n , may be d e t e r m i n e d by a c o g n i t i v e s t y l e such as l o c u s o f

c o n t r o l r a t h e r t h a n by the a c t u a l s e v e r i t y of t h e i r d i s a b i l i t y . C o p i n g

s t r a t e g i e s a r e d e t e r m i n e d by an i n d i v i d u a l ' s b a s i c p e r s o n a l i t y s t y l e .

L ocus of c o n t r o l i s a p e r s o n a l i t y v a r i a b l e t h a t e l u c i d a t e s how an

i n d i v i d u a l behaves w i t h i n a s o c i a l system ( L e f c o u r t , 1976). The

e x t e r n a l l y o r i e n t e d i n d i v i d u a l may have t r o u b l e c o m p l y i n g w i t h

t r e a t m e n t s t h a t r e q u i r e autonomous b e h a v i o r . I n d i v i d u a l s who have

sought s o c i a l r e i n f o r c e m e n t from e x t e r n a l f a c t o r s may f i n d

- 6 -

r e h a b i l i t a t i o n d i f f i c u l t . The i n t e r n a l l y l o c a t e d i n d i v i d u a l may have

d i f f i c u l t y c o p i n g w i t h the dependent n a t u r e of c e r t a i n t r e a t m e n t s .

Hence, t h e r o l e o f a p e r s o n a l i t y v a r i a b l e l i k e l o c u s o f c o n t r o l i n

i n t e r a c t i n g w i t h c h r o n i c p a i n management seems t o w a r r a n t f u r t h e r

i n v e s t i g a t i o n .

O b j e c t i v e s o f t h e Study

I t i s c l e a r from the l i t e r a t u r e t h a t t h e r e i s w i d e - s p r e a d

i n t e r e s t i n f a c t o r s w h i c h i n f l u e n c e c h r o n i c p a i n t r e a t m e n t and

management. T h i s s t u d y i s d e s i g n e d t o e x p l o r e the i n t e r n a l - e x t e r n a l

l o c u s o f c o n t r o l d i m e n s i o n and i t s ' r e l a t i o n s h i p t o the p s y c h o s o c i a l

a d j u s t m e n t o f c h r o n i c p a i n p a t i e n t s who have completed an i n - p a t i e n t ,

m u l t i d i s c i p l i n a r y p a i n t r e a t m e n t program. The s t u d y w i l l a t t e m p t t o

answer the f o l l o w i n g q u e s t i o n s :

1. I s t h e r e a r e l a t i o n s h i p between l o c u s o f c o n t r o l ( R o t t e r ' s i n t e r n a l - e x t e r n a l ) and p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n f o r c h r o n i c p a i n p a t i e n t s who have completed an i n - p a t i e n t p a i n t r e a t m e n t program?

2. I s t h e r e a r e l a t i o n s h i p between l o c u s o f c o n t r o l and ad j u s t m e n t t o c h r o n i c p a i n f o r males and f o r f e m a l e s who have completed an i n - p a t i e n t p a i n t r e a t m e n t program?

3. I s l o c u s of c o n t r o l o r i e n t a t i o n r e l a t e d t o r e p o r t e d p a i n f o r p a t i e n t s f o l l o w i n g an i n - p a t i e n t p a i n t r e a t m e n t program?

4. Are t h e r e gender d i f f e r e n c e s i n the p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n ?

5. Do the good a d j u s t e r s d i f f e r from the poor a d j u s t e r s i n terms of l o c u s of c o n t r o l ?

- 7 -

S i g n i f i c a n c e o f t h e Study

I n o r d e r t o b e t t e r u n d e r s t a n d the q u e s t i o n o f w h i c h

i n t e r v e n t i o n works b e s t f o r whom, i n f o r m a t i o n r e g a r d i n g the l o c u s o f

c o n t r o l o r i e n t a t i o n o f i n d i v i d u a l c h r o n i c p a i n p a t i e n t s may be

i m p o r t a n t . I n t e r v e n t i o n s may be more e f f e c t i v e i f t h e y a r e t a i l o r e d t o

d i f f e r e n t i n d i v i d u a l s . F o r i n s t a n c e , e x t e r n a l l y o r i e n t e d i n d i v i d u a l s do

not see t h e m s e l v e s as h a v i n g c o n t r o l o ver t h e i r f a t e , and t h e r e f o r e may

not comply w i t h t r e a t m e n t s t h a t r e q u i r e more autonomous b e h a v i o r .

The f i n d i n g s w i l l be viewed as s u p p o r t i n g the need f o r t h e

a p p l i c a t i o n o f d i f f e r e n t i a l t r e a t m e n t s t r a t e g i e s f o r p a t i e n t s .

S t r i c k l a n d (1978) c o n c l u d e d a f t e r a r e v i e w o f the l i t e r a t u r e t h a t

e x t e r n a l s tend t o respond more f a v o r a b l y t o i n t e r v e n t i o n s w i t h imposed

s t r u c t u r e , whereas i n t e r n a l s p r e f e r t h o s e i n w h i c h t h e y can e x e r c i s e

t h e i r own r e s p o n s i b i l i t y o r s e l f - c o n t r o l . Hence, i n t e r v e n t i o n s may be

d i f f e r e n t i a l l y e f f e c t i v e f o r p a t i e n t s d e p e n d i n g on t h e i r c o p i n g s t y l e s

or p e r s o n a l i t y p r e d i s p o s i t i o n s .

I t i s p o s t u l a t e d t h a t p r o v i d e r s o f p a i n t r e a t m e n t would do

w e l l t o d e t e r m i n e the p o s t u r e of the p a t i e n t s on the l o c u s o f c o n t r o l

d i m e n s i o n , i n o r d e r t o make a v a i l a b l e a more n o n d i r e c t i v e , p a t i e n t

p a r t i c i p a t i n g program t o i n t e r n a l l y o r i e n t e d i n d i v i d u a l s , and a more

s t a f f c o n t r o l l e d and s t r u c t u r e d program f o r e x t e r n a l l y o r i e n t e d

i n d i v i d u a l s . P h a r e s (1976) made the p o i n t t h a t perhaps i n t e r n a l s can be

e n r o l l e d i n more i n d e p e n d e n t , s e l f - r e g u l a t e d programs w h i l e e x t e r n a l s

would p r o f i t most from programs t h a t r e l y on p r e s t i g e , s u g g e s t i o n , o r

s u p p o r t from o t h e r s .

- 8 -

E x i s t i n g d a t a p r o v i d e a v e r y s t r o n g b a s i s f o r the s y s t e m a t i c

i n c o r p o r a t i o n of v a r i o u s means of e v a l u a t i n g l o c u s of c o n t r o l b e l i e f s

i n t o d i a g n o s t i c and t h e r a p e u t i c e f f o r t s . C a r e f u l e v a l u a t i o n o f

p a t i e n t s ' l o c u s o f c o n t r o l b e l i e f s can be a r e a l h e l p t o u n d e r s t a n d i n g

t h o s e p e r s o n s and t o p l a n n i n g a s e n s i b l e , e f f i c i e n t program t o b r i n g

about d e s i r e d changes i n b e h a v i o r . A l t e r n a t e l y , p a i n t r e a t m e n t programs

c o u l d a p p l y t e c h n i q u e s t h a t would enhance an i n t e r n a l l o c u s of c o n t r o l

( i f the i n d i v i d u a l l a c k s s u f f i c i e n t s e l f - c o n f i d e n c e t o m e d i a t e c e r t a i n

d e s i r e d b e h a v i o r s ) or t h a t would reduce an i n t e r n a l l o c u s o f c o n t r o l ( i f

the i n d i v i d u a l e x p e r i e n c e s overwhelming g u i l t ) .

L i m i t a t i o n s

The r e s e a r c h sample used i n t h i s s t u d y was r e s t r i c t e d t o

s u b j e c t s who agreed t o p a r t i c i p a t e on a v o l u n t e e r b a s i s , t h e r e f o r e t h e

r e s u l t s may be c o n s i d e r e d r e l e v a n t o n l y t o the i n d i v i d u a l s s t u d i e d and

may not be g e n e r a l i z e d t o o t h e r c h r o n i c p a i n p a t i e n t s . A l l s u b j e c t s

were r e s i d e n t s o f a Western C a n a d i a n p r o v i n c e and had c o m p l e t e d an

i n - p a t i e n t p a i n t r e a t m e n t program w i t h i n the p a s t t h r e e y e a r s . Such a

sample may respond d i f f e r e n t l y from an i n v o l u n t a r y c h r o n i c p a i n

p o p u l a t i o n .

O v e r v i e w o f t h e S t u d y

T h i s t h e s i s was o r g a n i z e d i n t o f i v e c h a p t e r s p l u s r e f e r e n c e s

and a p p e n d i c e s . The f i r s t c h a p t e r p r o v i d e d an i n t r o d u c t i o n t o t h e

s t u d y . C h a p t e r two p r o v i d e s t h e c o n c e p t u a l f o u n d a t i o n f o r t h i s r e s e a r c h

and c o n t a i n s a r e v i e w of the r e l e v a n t l i t e r a t u r e . C h a p t e r Three

- 9 -

d e s c r i b e s the methodology of the s t u d y . Hypotheses t o be t e s t e d and

method of t e s t i n g i n t h i s s t u d y a r e s t a t e d a t the c o n c l u s i o n of t h i s

c h a p t e r . C h a p t e r Four p r e s e n t s the r e s u l t s of the d a t a a n a l y s e s and

t e s t s of h y p o t h e s e s . C h a p t e r F i v e p r o v i d e s the c o n c l u s i o n s , d i s c u s s i o n

and summary of the r e s u l t s , as w e l l as i m p l i c a t i o n s a r i s i n g out of t h e s e

f i n d i n g s and s u g g e s t i o n s f o r f u r t h e r r e s e a r c h .

- 10 -

CHAPTER TWO

Review o f t h e L i t e r a t u r e

I n t r o d u c t i o n

The r e v i e w o f the l i t e r a t u r e r e l e v a n t t o t h i s s t u d y i s

o r g a n i z e d i n t o two main a r e a s of i n t e r e s t . The f i r s t s e c t i o n c o n c e r n s

i s s u e s i n v o l v i n g the concept o f c h r o n i c p a i n . I n c l u d e d here i s an

o v e r a l l s o c i e t a l p e r s p e c t i v e , p a i n p e r c e p t i o n and measurement, t r e a t m e n t

s t r a t e g i e s , e v a l u a t i o n o f a d j u s t m e n t , and gender d i f f e r e n c e s . The

second s e c t i o n p r e s e n t s the r e s e a r c h r e l a t e d t o l o c u s o f c o n t r o l .

I n c l u d e d here i s the t h e o r e t i c a l c o n t e x t o f the c o n s t r u c t , c o n c e p t u a l

a s s u m p t i o n s , and a d i s c u s s i o n o f gender d i f f e r e n c e s .

C h r o n i c P a i n - A S o c i e t a l P e r s p e c t i v e

P a i n i s a u n i v e r s a l human e x p e r i e n c e t h a t i s u s u a l l y t h o u g h t

t o be a d i r e c t consequence o f b o d i l y damage o r p h y s i o l o g i c a l

d y s f u n c t i o n . As M e l z a c k (1973) s t a t e d , however, t h e r e i s over-whelming

e v i d e n c e t h a t the r e p o r t of p a i n does not have a s i m p l e one-to-one

r e l a t i o n s h i p w i t h e i t h e r b o d i l y damage o r p h y s i o l o g i c a l d y s f u n c t i o n .

Extreme i l l u s t r a t i o n s o f t h i s a r e the p e r s o n who shows no e v i d e n c e o f

p a i n i n s p i t e of i n j u r y and the p e r s o n who r e p o r t s p a i n i n t h e absence

o f i n j u r i o u s s t i m u l i .

The c u r r e n t abundance of l i t e r a t u r e on c h r o n i c p a i n i s one

i n d i c a t i o n t h a t i t i s a common c l i n i c a l p roblem w h i c h remains p o o r l y

- 11 -

u n d e r s t o o d . C h r o n i c p a i n has become r e c o g n i z e d as a c o n d i t i o n d i s t i n c t

from a c u t e p a i n . Among the n e u r o s u r g e o n s , a n e s t h e s i o l o g i s t s ,

p h y s i o l o g i s t s , p s y c h o l o g i s t s , p s y c h i a t r i s t s , and o t h e r h e a l t h

p r o f e s s i o n a l s who have d e a l t w i t h c h r o n i c p a i n , t h e r e i s l i m i t e d

agreement as t o the n a t u r e and t r e a t m e n t o f t h i s c o n d i t i o n . C h r o n i c

p a i n r e m a i n s , as d e s c r i b e d by M e l z a c k , a p u z z l e . M e l z a c k n o t e d t h a t t h e

c l a s s i c a l s p e c i f i c i t y and p a t t e r n t h e o r i e s o f p a i n l a c k u n i t y , f a i l t o

i n t e g r a t e d i v e r s e t h e o r e t i c a l mechanisms, and have not r e c e i v e d

s u b s t a n t i a l e m p i r i c a l v e r i f i c a t i o n .

To a v o i d c o n f u s i o n between p a i n thought of as a metaphor f o r

a l l t y p e s of a n g u i s h and p a i n w h i c h i s f e l t a t a l o c a t i o n i n t h e body,

the I n t e r n a t i o n a l A s s o c i a t i o n f o r the Study of P a i n (1979) d e f i n e d p a i n

as "an u n p l e a s a n t s e n s o r y and e m o t i o n a l e x p e r i e n c e a s s o c i a t e d w i t h

a c t u a l o r p o t e n t i a l t i s s u e damage, or d e s c r i b e d i n terms of such damage"

( p . 2 5 0 ) . Few would d i s a g r e e w i t h B l a c k ' s (1975) c h a r a c t e r i z a t i o n o f

the c h r o n i c p a i n p a t i e n t as h a v i n g i n t r a c t a b l e , o f t e n m u l t i p l e , p a i n

c o m p l a i n t s f o r a t l e a s t s i x months w h i c h a r e u s u a l l y i n c o n g r u e n t w i t h

e x i s t i n g somatogenic p r o b l e m s . B l a c k f u r t h e r n o t e d t h a t p a t i e n t s w i t h

t h i s c h r o n i c p a i n syndrome o f t e n r e v e a l :

a h i s t o r y o f m u l t i p l e p h y s i c i a n c o n t a c t s and many

n o n p r o d u c t i v e d i a g n o s t i c p r o c e d u r e s ; e x c e s s i v e

p r e o c c u p a t i o n w i t h the p a i n problem; an a l t e r e d

b e h a v i o r p a t t e r n w i t h some of the f e a t u r e s o f

d e p r e s s i o n , a n x i e t y , and n e u r o t i c i s m ; and, i n

p a r t i c u l a r , no r e a l i s t i c p l a n s f o r t h e d i s t a n t f u t u r e ,

( p . 1000)

- 12 -

F o r d y c e ( 1 9 7 6 ) , S t e r n b a c h (1968) and o t h e r s have s u g g e s t e d a

v a r i e t y o f p s y c h o s o c i a l f a c t o r s t h a t can e x a g g e r a t e or p r o l o n g b o t h t h e

e x p r e s s i o n and e x p e r i e n c e o f c h r o n i c p a i n . These f a c t o r s i n c l u d e :

a) s y s t e m a t i c s o c i a l r e i n f o r c e m e n t o f d i s a b i l i t y and

e x p r e s s i o n s o f s u f f e r i n g ( p a i n b e h a v i o r ) ;

b) monetary compensation f o r p a i n t h r o u g h p e r s o n a l i n j u r y

l i t i g a t i o n and d i s a b i l i t y c l a i m s ;

c ) e n v i r o n m e n t a l s t r e s s e s l e a d i n g t o a f f e c t i v e d i s t r e s s

( a n x i e t y , d e p r e s s i o n ) ;

d) s y s t e m a t i c a s s o c i a t i o n between p a i n b e h a v i o r and t i m e o u t

f r o m s t r e s s o r from u n p l e a s a n t v o c a t i o n a l o r f a m i l y

r e s p o n s i b i l i t i e s ;

e) c h r o n i c p a i n as j u s t i f i c a t i o n o f f a i l u r e s t o l i v e up t o

s e l f - e x p e c t a t i o n s or the e x p e c t a t i o n s o f o t h e r s ;

f ) p a i n p r o v i d i n g j u s t i f i c a t i o n o f dependence on a n a l g e s i c s

and/or a l c o h o l ;

g) p a s t and p r e s e n t i a t r o g e n i c e x p e r i e n c e s w i t h the h e a l t h

c a r e system;

h) l a c k o f p r o s p e c t s f o r s a t i s f y i n g one's needs o u t s i d e o f

the p a i n p a t i e n t r o l e .

T y p i c a l l y , t h e c h r o n i c p a i n p a t i e n t i s f i r m l y c o n v i n c e d t h a t he o r she

has a s t r i c t l y p h y s i c a l problem and hence seeks out the surgeon and

o t h e r s o m a t i c s p e c i a l i s t s but shuns the p s y c h i a t r i s t o r p s y c h o l o g i s t . A

combined c o n s i d e r a t i o n o f b o t h the p h y s i c a l and p s y c h o l o g i c a l f a c t o r s ,

however, a l l o w s a v i e w of c h r o n i c p a i n as a s p e c i f i c p s y c h o b i o l o g i c a l

d i s o r d e r .

- 13 -

A r o n o f f and Evans (1982) see c h r o n i c p a i n as a complex

p s y c h o s o m a t i c p r o c e s s i n w h i c h s u f f e r i n g i s a l e a r n e d and g o a l d i r e c t e d

b e h a v i o r . They r e g a r d s u f f e r i n g as t h e e m o t i o n a l r e a c t i o n t o p a i n

s e n s a t i o n and, as s u c h , i t i s t hought to be amenable to change even when

t h e s e n s o r y q u a l i t y o f the p a i n remains unchanged. Comprehensive,

m u l t i d i s c i p l i n a r y p a i n t r e a t m e n t programs a l l f o c u s on t e a c h i n g c h r o n i c

p a i n s u f f e r e r s ways t o manage p a i n w h i l e m a i n t a i n i n g s e l f - r e l i a n c e ,

s e l f - c o n t r o l and t h e h i g h e s t p o s s i b l e p h y s i c a l and e m o t i o n a l f u n c t i o n .

A c e n t r a l g o a l i n most m u l t i d i s c i p l i n a r y t r e a t m e n t approaches i s an

improved q u a l i t y of l i f e i n s p i t e of any r e s i d u a l p a i n and s u f f e r i n g .

P a i n P e r c e p t i o n and Measurement

One o f t h e most d i f f i c u l t t a s k s f a c i n g b o t h r e s e a r c h

i n v e s t i g a t o r s and h e a l t h p r o f e s s i o n a l s i s the measurement o f c l i n i c a l

p a i n . As noted e a r l i e r , p a i n i s a s u b j e c t i v e , u n p l e a s a n t e x p e r i e n c e

t h a t may be a s s o c i a t e d w i t h a c t u a l or p o t e n t i a l t i s s u e damage, and w h i c h

i s d e t e r m i n e d by s e n s o r y i n f o r m a t i o n , a f f e c t i v e r e a c t i o n s , and

c o g n i t i o n s ( I n t e r n a t i o n a l A s s o c i a t i o n f o r the Study o f P a i n , 1 9 7 9 ) .

Assessment of the p a t i e n t ' s r e p o r t o f p a i n e x p e r i e n c e s i s

i m p o r t a n t f o r s e v e r a l r e a s o n s . F i r s t , p a t i e n t s who show improvements i n

b e h a v i o r but who c o n t i n u e t o c o m p l a i n of p a i n may e l i c i t r e s p o n s e s f r o m

spouse o r f a m i l y members t h a t may r e v e r s e t h e r a p e u t i c b e n e f i t s . Second,

t h e p e r s i s t e n t r e p o r t o f p a i n a l s o i n c r e a s e s t h e l i k e l i h o o d t h a t c h r o n i c

p a i n p a t i e n t s may undergo m u l t i p l e d i a g n o s t i c and s u r g i c a l t r e a t m e n t ,

f a c t o r s o f t e n a s s o c i a t e d w i t h poor outcome. T h i r d , and perhaps most

- 14 -

i m p o r t a n t , the p e r c e p t i o n o f p a i n i s o f t e n the p a t i e n t ' s p r i m a r y

c o n c e r n .

The meaning of c o n t r o l i n p a i n p e r c e p t i o n i s not e n t i r e l y

c l e a r . A v e r i l l (1973) i n an a n a l y s i s o f c o n t r o l as a v a r i a b l e , showed

t h a t i t has been used t o r e f e r t o b e h a v i o r a l c o n t r o l , c o g n i t i v e c o n t r o l ,

or d e c i s i o n a l c o n t r o l . Not a l l i n d i v i d u a l s f e e l e q u a l l y c a p a b l e o f

h a n d l i n g the r e s p o n s i b i l i t y t h a t c o n t r o l i m p l i e s . C l i n i c a l l y , some

p a t i e n t s may be b e t t e r o f f y i e l d i n g c o n t r o l t o the h e a l t h - c a r e

p r o v i d e r . F o r i n s t a n c e , w i t h p l a c e b o m e d i c a t i o n a n x i e t y r e d u c t i o n

o c c u r s by the d e m o n s t r a t i o n t h a t something i s b e i n g done t o c o n t r o l p a i n

even i f i t i s not the p a t i e n t who i s e x e r t i n g c o n t r o l .

Weisenberg (1980) s t a t e d t h a t a n x i e t y r e d u c t i o n i s i m p o r t a n t

i n p a i n p e r c e p t i o n m a i n l y when i t i s combined w i t h a p e r s o n ' s f e e l i n g o f

c o n t r o l . H i s a n a l y s i s i m p l i e s t h a t a n x i e t y r e d u c t i o n s t r a t e g i e s such as

d e s e n s i t i z a t i o n , m o d e l i n g , and r e l a x a t i o n i n c r e a s e t o l e r a n c e t o p a i n by

g i v i n g t he p e r s o n a f e e l i n g t h a t the p a i n w i l l and can be c o n t r o l l e d by

someone, whether the p a t i e n t h i m s e l f o r a t r u s t e d o t h e r p e r s o n t o whom

he has y i e l d e d h i s own power of c o n t r o l . He proposed t h a t when t h e

f e e l i n g o f c o n t r o l i s a b s e n t , t h e e f f e c t i v e n e s s o f many b e h a v i o r a l

i n t e r v e n t i o n s on the m o t i v a t i o n a l component of p a i n would be

s u b s t a n t i a l l y r e d u c e d . T h i s b e h a v i o r r e g u l a t i o n o f p a i n i s an e s s e n t i a l

p a r t o f t h e c o n t r o l o f p a i n .

T r a d i t i o n a l l y , p a i n r e p o r t has been a s s e s s e d u s i n g n u m e r i c a l ,

v e r b a l , o r v i s u a l r a t i n g s c a l e s . P a t i e n t s a r e asked t o s e l e c t a number

o r a word t o d e s c r i b e the i n t e n s i t y o f t h e i r p a i n . A v a r i a t i o n o f t h i s

- 15 -

a p p r o a c h , t h e v i s u a l a n a l o g u e s c a l e ( H u s k i s s o n , 1 9 7 4 ) , has been w i d e l y

used t o a s s e s s p a i n i n t e n s i t y i n c h r o n i c p a i n t r e a t m e n t programs.

R a t i n g s c a l e s have two major problems (Lodge and T u r s k y , 1 9 8 1 ) . F i r s t ,

t h e s e s c a l e s measure o n l y one d i m e n s i o n , i n t e n s i t y , o f a p e r c e p t u a l

phenomenon t h a t i s m u l t i d i m e n s i o n a l . Second, t h e d i s t a n c e s between

r e s p o n s e s on t h e s e s c a l e s a r e unknown but a r e u s u a l l y t r e a t e d

s t a t i s t i c a l l y as though t h e y were e q u a l ( T u r s k y , Jamner, and F r i e d m a n ,

1982). P a i n r e s e a r c h e r s have r e c e n t l y d e v o t e d major e f f o r t s t o

d e v e l o p i n g p a i n p e r c e p t i o n measures t h a t a s s e s s the m u l t i d i m e n s i o n a l

a s p e c t s o f p a i n r e p o r t i n a v a l i d and q u a n t i f i a b l e manner. The M c G i l l

P a i n Q u e s t i o n n a i r e ( M e l z a c k , 1975) i s one r e s u l t o f t h i s r e s e a r c h and i s

p r o b a b l y t h e most commonly used measure o f p a i n r e p o r t s i n c e i t i s f r e e

f r o m many of t h e d i f f i c u l t i e s a s s o c i a t e d w i t h n u m e r i c a l , v e r b a l and

v i s u a l a n a l o g u e s c a l e s .

T reatment S t r a t e g i e s

R e c o g n i t i o n t h a t c h r o n i c p a i n i s a complex n e u r o p h y s i o l o g i c a l ,

b e h a v i o r a l , and p s y c h o l o g i c a l phenomenon has l e d t o the development o f

i n n o v a t i v e t r e a t m e n t programs. These programs s h a r e one common

a s s u m p t i o n . S p e c i f i c a l l y , i f c h r o n i c p a i n i s complex, t h e n a

c o m b i n a t i o n o f t r e a t m e n t t e c h n i q u e s i s needed t o s u c c e s s f u l l y t r e a t

p a t i e n t s . There has been a r a p i d growth i n the number of p a i n c l i n i c s

a round t h e w o r l d s i n c e t h e c o n c e p t o f a m u l t i d i s c i p l i n a r y a p p r o a c h t o

p a i n problems was f i r s t i n t r o d u c e d ( B o n i c a & B l a c k , 1 9 7 4 ) . However,

t h e r e have been c o m p a r a t i v e l y few r e p o r t e d s t u d i e s o f the e f f e c t i v e n e s s

- 16 -

o f such c l i n i c s . H a l l e t t and P i l o w s k y (1982) r e v i e w e d t h o s e r e s u l t s

w h i c h have been p u b l i s h e d and c o n c l u d e d t h a t the e v i d e n c e thus f a r

a v a i l a b l e s u g g e s t s t h a t m u l t i d i s c i p l i n a r y p a i n c l i n i c s make a u s e f u l and

i m p o r t a n t c o n t r i b u t i o n t o the management of p a i n syndromes.

P a i n c l i n i c s v a r y i n t h e i r emphases and a p p r o a c h e s . However,

the i m p o r t a n c e of p s y c h o l o g i c a l and p e r s o n a l i t y f a c t o r s i n c h r o n i c p a i n

has become i n c r e a s i n g l y r e c o g n i z e d ( F o r d y c e , 1976; S t e r n b a c h , 1968), and

w i t h t h i s has e v o l v e d t h e e s t a b l i s h m e n t of i n - p a t i e n t u n i t s . S t e r n b a c h

(1974) has argued t h a t o n l y i n - p a t i e n t programs a r e adequate f o r t h e

r e h a b i l i t a t i o n of t h e c h r o n i c p a i n p a t i e n t because they p r o v i d e c l o s e

d a i l y m o n i t o r i n g and s u p e r v i s i o n of the p a t i e n t ' s b e h a v i o r .

P s y c h o l o g i c a l approaches f o r p a i n c o n t r o l , p a r t i c u l a r l y

b e h a v i o r a l and c o g n i t i v e i n t e r v e n t i o n s , have r e c e n t l y i n c r e a s e d

c o n s i d e r a b l y . Three r e l a t e d f a c t o r s seem to be m a i n l y r e s p o n s i b l e f o r

t h i s . F i r s t , the i n f l u e n c e of contemporary c o n c e p t s of p a i n , most

n o t a b l y the g a t e c o n t r o l t h e o r y ( M e l z a c k & W a l l , 1975), w h i c h views p a i n

as a complex phenomenon r e s u l t i n g from the i n t e r a c t i o n o f c o g n i t i v e ,

m o t i v a t i o n a l and s e n s o r y components. Such c o n c e p t s emphasize t h a t p a i n

i s p o t e n t i a l l y m o d i f i a b l e by p s y c h o l o g i c a l methods. Second, t h e f a i l u r e

o f p u r e l y s o m a t i c ( m e d i c a l and s u r g i c a l ) t h e r a p i e s i n a d e q u a t e l y

a l l e v i a t i n g p a i n f o r many c h r o n i c p a i n p a t i e n t s , as w e l l as the

o c c u r r e n c e of d e b i l i t a t i n g s i d e - e f f e c t s due t o such t r e a t m e n t s ( M e l z a c k ,

1 9 7 3 ) . T h i r d , t h e s u b s t a n t i a l e v i d e n c e o f p s y c h o l o g i c a l i l l n e s s i n

c h r o n i c p a i n p a t i e n t s , many of whom do not respond w e l l t o t r a d i t i o n a l

p s y c h i a t r i c t e c h n i q u e s (Merskey, 1980).

- 17 -

T r a d i t i o n a l management of c h r o n i c p a i n has g e n e r a l l y

encompassed such o p t i o n s as bed r e s t , p h y s i c a l t h e r a p y , p o t e n t

m e d i c a t i o n s , n e r v e b l o c k s , s u r g e r y , and, a t t i m e s , o p e r a t i v e l e s i o n s t o

the c e n t r a l nervous system. A l t h o u g h t h e s e t e c h n i q u e s may be u s e f u l i n

a m e l i o r a t i n g u n c o m p l i c a t e d c h r o n i c p a i n , a c u t e p a i n , and t e r m i n a l

c a n c e r p a i n , t h e i r e f f e c t i v e n e s s i s m a r g i n a l i n d e a l i n g w i t h the c h r o n i c

p a i n syndromes most o f t e n e n c o u n t e r e d i n p a i n c e n t e r s . E x p e r i e n c e has

dem o n s t r a t e d the i m p o r t a n c e of the m u l t i d i s c i p l i n a r y team approach t o

c h r o n i c p a i n , p a r t i c u l a r l y when t h e p a i n p r o b l e m has e l u d e d d i a g n o s i s

and/or adequate management v i a c o n v e n t i o n a l methods ( L o r e n z , 1981).

P a i n c e n t e r s u s u a l l y combine t r a d i t i o n a l p h y s i c a l and m e d i c a l

t r e a t m e n t s i n t o a model t h a t d e a l s w i t h t h e p a t i e n t as a t o t a l b e i n g .

There a r e f e a t u r e s w h i c h a r e common t o most c h r o n i c p a i n c l i n i c s w i t h

d i f f e r i n g emphases on c e r t a i n a s p e c t s . P a t i e n t s a r e i n v o l v e d i n an

a c t i v e program s t r e s s i n g e x e r c i s e and a p p l i c a t i o n o f p r o p e r e x e r c i s e

p r i n c i p l e s t o p o s t u r e mechanics and t o d a i l y a c t i v i t i e s . I n c l u d e d i n

t h i s i s p h y s i c a l t h e r a p y , r e c r e a t i o n a l and p o o l e x e r c i s e s , and movement

t h e r a p y . P s y c h o t h e r a p y i n g r o u p s , i n d i v i d u a l l y , and w i t h the spouse

and/or f a m i l y i s an i m p o r t a n t p a r t o f most programs and might i n c l u d e

o p e r a n t c o n d i t i o n i n g t e c h n i q u e s , h y p n o s i s , m o d e l i n g , and c o g n i t i v e

c o p i n g s k i l l s o r s t r a t e g i e s . D a i l y l e c t u r e s and d i s c u s s i o n groups

p r o v i d e p a t i e n t s w i t h i n f o r m a t i o n r e g a r d i n g the s o u r c e o f the p a i n and

t h e r e a s o n a b l e t h e r a p i e s a v a i l a b l e . B i o f e e d b a c k and r e l a x a t i o n t r a i n i n g

a re used as a p p r o p r i a t e t o the p a t i e n t ' s needs. P a t i e n t s a r e a s s i s t e d

i n drug w i t h d r a w a l and d a i l y m o n i t o r i n g o f m e d i c a l p r o b l e m s . V o c a t i o n a l

- 18 -

r e h a b i l i t a t i o n c o u n s e l l i n g i s p a r t o f any comprehensive program. The

r o l e of the p a i n c e n t e r as a t u r n i n g p o i n t i n the p a t i e n t ' s l i f e i s

s t r e s s e d .

The emphasis i n t h e s e c e n t e r s i s on r e t u r n t o e m o t i o n a l h e a l t h

and f u n c t i o n i n g i n s p i t e o f p h y s i c a l symptoms. T o t a l r e l i e f of p a i n i s

o f t e n an u n r e a l i s t i c g o a l as e v i d e n c e d by the p a t i e n t s ' e x t e n s i v e

h i s t o r i e s of p r i o r t r e a t m e n t f a i l u r e . Most p a i n c l i n i c s , t h e r e f o r e ,

a p p r oach p a i n w i t h t h e concept of c o n t r o l and management, and t h e r e a r e

c e r t a i n b a s i c and c h a r a c t e r i s t i c g o a l s w h i c h t h e y have i n common. These

i n c l u d e :

a) e l i m i n a t i n g the s o u r c e of p a i n when f e a s i b l e ;

b) t e a c h i n g the p a t i e n t t o f u n c t i o n w i t h i n p a i n l i m i t a t i o n s ;

c ) i m p r o v i n g p a i n c o n t r o l t h r o u g h p h y s i c a l t h e r a p y and

p s y c h o l o g i c a l methods;

d) r e l i e v i n g d r u g dependence;

e) t r e a t i n g u n d e r l y i n g d e p r e s s i o n and i n s o m n i a ;

f ) a d d r e s s i n g s e c o n d a r y g a i n i s s u e s ;

g) i m p r o v i n g f a m i l y and community s u p p o r t systems;

h) p r o v i d i n g a c c e s s t o v o c a t i o n a l and o c c u p a t i o n a l

r e h a b i l i t a t i o n ;

i ) r e t u r n i n g the p a t i e n t t o a f u n c t i o n a l and p r o d u c t i v e

l i f e s t y l e ;

j ) s t o p p i n g p a t i e n t s ' ' d o c t o r s h o p p i n g ' i n s e a r c h o f

symptomatic r e l i e f .

- 19 -

E v a l u a t i o n o f Adju s t m e n t

Long term f o l l o w - u p s t u d i e s o f the p h y s i c a l and p s y c h o s o c i a l

a d j u s t m e n t of the c h r o n i c p a i n p a t i e n t f o l l o w i n g t r e a t m e n t a r e r a r e l y

r e p o r t e d i n the l i t e r a t u r e . A few s t u d i e s have r e p o r t e d improvement i n

p s y c h o l o g i c a l ( S t e r n b a c h , 1974) as w e l l as p h y s i c a l f u n c t i o n ( C a i r n s ,

Thomas, Mooney, & Pace, 1976; I g n e l z i , S t e r n b a c h , & Timmermans, 1977;

Newman, S e r e s , Yospe, & G a r l i n g t o n , 1978) i n p a t i e n t s f o l l o w i n g p a i n

c l i n i c t r e a t m e n t programs.

V e r y few s t u d i e s have employed s t a t i s t i c a l t e c h n i q u e s t o

examine the s e p a r a t e c o n t r i b u t i o n s o f m u l t i p l e v a r i a b l e s t o p a t i e n t s '

s e l f - p e r c e p t i o n s of improvement i n t h e i r p a i n c o n d i t i o n . Toomey,

T a y l o r , S k e l t o n , and C a r r o n (1982) i n t h e i r s t u d y of the s t a b i l i t y o f

s e l f - r e p o r t measures of improvement i n c h r o n i c p a i n p a t i e n t s , n o t e d the

need f o r u s i n g m u l t i p l e , f u n c t i o n a l c r i t e r i a i n a s s e s s i n g r e s p o n s e t o

t r e a t m e n t , i n c l u d i n g b o t h g l o b a l p a i n r a t i n g s and f u n c t i o n a l - b e h a v i o r

measures of improvement. I n c l u d e d i n the l a t t e r would be changes i n

p h y s i c a l a b i l i t i e s ( e . g . a b i l i t y t o w a l k and bend, amount of time spent

l y i n g down due t o p a i n ) , changes i n v o c a t i o n a l r e h a b i l i t a t i o n s t a t u s ,

changes i n r e c r e a t i o n and s o c i a l a c t i v i t i e s , and changes i n

h e a l t h - s e e k i n g b e h a v i o r s ( e . g . absence of drug m i s u s e , no a d d i t i o n a l

s u r g e r i e s f o r p a i n r e f l i e f ) . S e l f - r a t i n g s o f p a i n f r e q u e n c y and

i n t e n s i t y would be used s i n c e r e s u l t s s u ggest t h a t p a t i e n t s a r e i n c l i n e d

t o judge improvement i n terms o f reduced e x p o s u r e t o p a i n as w e l l as

enhanced p h y s i c a l f u n c t i o n i n g . T h i s l e n d s s u p p o r t t o b e h a v i o r a l l y based

t r e a t m e n t programs w h i c h emphasize i n c r e a s e d l e v e l s o f f u n c t i o n i n g and

i n a t t e n t i o n t o p a i n - r e l a t e d b e h a v i o r s ( F o r d y c e , 1976). Other f a c t o r s

- 20 -

w h i c h c o n t r i b u t e t o s u c c e s s f u l o r u n s u c c e s s f u l a d j u s t m e n t t o c h r o n i c

p a i n i n c l u d e changes i n p s y c h o l o g i c a l measures ( e . g . of d e p r e s s i o n ,

a n x i e t y , s e l f - e s t e e m ) and g e n e r a l l i f e o u t l o o k and a t t i t u d e . A l l o f t h e

above c r i t e r i a a r e the ones w h i c h p a t i e n t s u s u a l l y a s s o c i a t e w i t h

improvement o r nonimprovement o f t h e i r c h r o n i c p a i n o v e r an extended

p e r i o d o f t i m e .

Gender D i f f e r e n c e s i n C h r o n i c P a i n

I t i s i n t e r e s t i n g t o note t h a t most of the l i t e r a t u r e on

c h r o n i c p a i n seems t o f o c u s on men. T h i s may be a p p r o p r i a t e s i n c e

r e p r e s e n t a t i o n i n Worker's Compensation programs and r e h a b i l i t a t i o n

s e r v i c e s f o r c h r o n i c p a i n p a t i e n t s i n v o l v e s h i g h e r p r o p o r t i o n s o f

ma l e s . However, women do use th e s e programs and s e r v i c e s ,

n o t w i t h s t a n d i n g t he d e a r t h o f l i t e r a t u r e w h i c h d e a l s w i t h women and

c h r o n i c p a i n . L i k e l y i t would be c o r r e c t t o say t h a t women s u f f e r i n g

from c h r o n i c p a i n f a c e d i f f e r e n t p e r s o n a l , s o c i a l , and c u l t u r a l

a d j u s t m e n t s t h a n do men w i t h c h r o n i c p a i n .

Crook (1982) d i s c u s s e d t he h i s t o r i c a l , s o c i a l r o l e , and

s o c i o e c o n o m i c p e r s p e c t i v e s o f women w i t h c h r o n i c p a i n and c o n c l u d e d t h a t

women do have d i f f e r e n t needs t h a n men t h a t , i n g e n e r a l , a r e n o t b e i n g

r e c o g n i z e d by h e a l t h p r o f e s s i o n a l s l a r g e l y because o f unexamined

a s s u m p t i o n s r e g a r d i n g what t h e s e needs a r e . H i s t o r i c a l l y , t o women

c o m p l a i n i n g o f p a i n o f t e n t he f i r s t e x p l a n a t i o n s g i v e n a r e based on the

a s s u m p t i o n of the f r a i l i t y of the female body and the h e a l t h problems

t h r o u g h o u t the female l i f e c y c l e . These e x p l a n a t i o n s and the

p r e s c r i p t i o n s f o r symptom management ( e . g . bed r e s t , c u r t a i l i n g o r

- 21 -

d i s c o n t i n u i n g p h y s i c a l a c t i v i t i e s and work, and l i m i t i n g any a c t i v i t i e s

w h i c h cause d i s c o m f o r t ) do n o t h i n g t o a l l a y f e a r s but r a t h e r r e i n f o r c e

h e l p l e s s n e s s .

Women and men are o f t e n o f f e r e d p s y c h o l o g i c a l e x p l a n a t i o n s o f

t h e i r c h r o n i c p a i n , but women s u f f e r a d o u b l e l i a b i l i t y i n t h i s r e g a r d .

That i s , women are more l i k e l y t o i n t e r p r e t t h e i r p a i n symptoms

p s y c h o l o g i c a l l y and t o p r e s e n t them i n t h i s way, and a r e most l i k e l y t o

a c c e p t p s y c h o l o g i c a l i n t e r p r e t a t i o n s and t r e a t m e n t ( C h e s l e r , 1972).

S p l i t t i n g i n t e r p r e t a t i o n s o f p a i n i n t o e x c l u s i v e b i o l o g i c a l and

p s y c h o l o g i c a l c a t e g o r i e s tends t o be a p o w e r f u l means of p l a c i n g t h e

blame on t h e p a t i e n t .

A n o t h e r way of e x a m i n i n g the e x p e r i e n c e o f women w i t h c h r o n i c

p a i n i s t o u n d e r s t a n d the d i f f e r e n c e between male and female s o c i a l

r o l e s . U n d e n i a b l y , f a m i l y and c a r e t a k i n g r o l e s a r e much more

s p e c i f i c a l l y bound t o the female t h a n t h e y a r e t o the male, and women

o f t e n t h i n k t h a t one of t h e i r p r i m a r y f u n c t i o n s i s t o m a i n t a i n t he

e m o t i o n a l c l i m a t e o f the f a m i l y . An i m p o r t a n t d e t e r m i n a n t o f how women

p e r c e i v e t he w o r l d i s the s o c i a l i z a t i o n o f women t o s e r v e o t h e r s w i t h i n

t h e i r n u r t u r a n t r o l e . The c a r i n g and d o i n g f o r o t h e r s becomes a p a r t o f

the e x p e c t a t i o n s of o t h e r s r e s u l t i n g i n f e e l i n g s of l o s s , a n x i e t y and

g u i l t f o r the women w i t h c h r o n i c p a i n i f she i s no l o n g e r a b l e t o f u l f i l

t h i s r o l e f u n c t i o n . As B r i s c o e (1978) s t a t e d males and females do

d i f f e r i n t h e i r i l l n e s s b e l i e f s r e g a r d i n g b e h a v i o r and e x p e c t a t i o n s .

B r i s c o e t e s t e d t he h y p o t h e s i s t h a t women e x p r e s s g r e a t e r

d i s s a t i s f a c t i o n w i t h t h e i r h e a l t h t h a n men and found no d i f f e r e n c e i n

- 22 -

e x p r e s s e d s a t i s f a c t i o n , o r i n number or s e v e r i t y o f symptoms r e p o r t e d .

However, the r e s u l t s of t h a t r e s e a r c h appear t o i n d i c a t e t h a t i l l n e s s i s

more s o c i a l l y a c c e p t a b l e i n women t h a n i n men, a v i e w s u p p o r t e d by o t h e r

r e s e a r c h ( V e r b r u g g e , 1976). C o n t r a r y t o B r i s c o e ' s v i e w , V e r brugge

s t a t e d f u r t h e r t h a t a p a r t from the i n c r e a s e d u t i l i z a t i o n o f h e a l t h

s e r v i c e s around r e p r o d u c t i o n and a n a t o m i c a l d i f f e r e n c e s , h e a l t h and

m o r b i d i t y s t a t i s t i c s i n d i c a t e t h a t w h i l e t he female l i f e e x p e c t a t i o n

exceeds t h a t o f males a t e v e r y age, women e x h i b i t h i g h e r i l l n e s s r a t e s

f o r b o t h a c u t e and c h r o n i c d i s e a s e . An adequate i n t e r p r e t a t i o n o f t h e s e

d a t a must, however, t a k e a c c o u n t o f the f a c t t h a t i l l n e s s may be

r e g a r d e d i n s o c i a l as w e l l as i n c l i n i c a l t e r m s , and t h a t one s h o u l d

d i s t i n g u i s h between e x p e r i e n c e d i l l n e s s and d i a g n o s e d i l l n e s s . Thus,

V e r b r u g g e has s u g g e s t e d t h a t males a r e , i n f a c t , t he p h y s i c a l l y s i c k e r

sex (due t o bo t h i n h e r i t e d and a c q u i r e d h e a l t h r i s k s ) but t h a t s o c i a l

and p s y c h o l o g i c a l f a c t o r s enhance female r e p o r t s t o such an e x t e n t t h a t

a female e x c e s s appears o v e r a l l . The r e a s o n s f o r the g r e a t e r m o r b i d i t y

w i t h l e s s e r m o r t a l i t y f o r women a r e not r e a d i l y a p p a r e n t , a r e s u b j e c t t o

much s p e c u l a t i o n , and a r e i m p o r t a n t t o c o n s i d e r i n view of how the

c h a n g i n g r o l e s o f women may i n f l u e n c e t h e s e i l l n e s s s t a t i s t i c s .

Some o f the u s u a l e x p l a n a t i o n s put f o r t h t o e x p l a i n t h e h i g h e r

m o r b i d i t y r a t e o f i l l n e s s f o r women a r e female dependency, p a s s i v i t y ,

and a c u l t u r a l l y a c c e p t e d s i c k r o l e . One must a l s o c o n s i d e r t h r e e o t h e r

p o s s i b l e e x p l a n a t i o n s . The f i r s t i s t h e gender p r e f e r e n c e i n

d i s t r i b u t i o n of some d i s e a s e s . The second i s an i a t r o g e n i c component o f

p h y s i c i a n judgement o f t h e i l l n e s s t h a t d e t e r m i n e s how women as p a t i e n t s

- 23 -

a r e viewed and t r e a t e d . The t h i r d i s the d i f f e r e n t p e r c e p t i o n o f

i l l n e s s r o l e s o f women as compared w i t h men. As Crook (1982) n o t e d i t

i s more commonly e n c o u n t e r e d and more s o c i a l l y a c c e p t e d f o r a man t o

abandon h i s f a m i l y r e s p o n s i b i l i t i e s on ac c o u n t of s i c k n e s s and c h r o n i c

p a i n t h a n f o r a woman t o do t h e same t h i n g . Women, i n g e n e r a l , do not

r e l i n q u i s h t h e i r c a r e t a k i n g r e s p o n s i b i l i t i e s and t h i s r e s u l t s i n a

c o n f l i c t between t h e i r i l l n e s s r o l e s and t h e i r o t h e r r o l e s .

I f a woman a l s o has an o c c u p a t i o n a l r o l e t he s i t u a t i o n i s

c o m p l i c a t e d f u r t h e r . F o r women who drop out of the work f o r c e due t o

c h r o n i c p a i n t h e r e a r e u s u a l l y two a l t e r n a t i v e s b o t h of w h i c h r e n d e r

women p o w e r l e s s . I f she i s m a r r i e d she r e t u r n s t o the home, s u p p o r t e d

by someone e l s e . I f she i s s i n g l e , widowed or d i v o r c e d she i s o f t e n

r e l e g a t e d t o p o v e r t y u n s u p p o r t e d by adequate r e h a b i l i t a t i o n o r

compe n s a t i o n s e r v i c e s .

An i n v e s t i g a t i o n i n t o t he p s y c h o s o c i a l a d j u s t m e n t o f c h r o n i c

p a i n p a t i e n t s needs t o a d d r e s s a l l o f th e s e f a c t o r s d i s c u s s e d above.

These a r e some of the v a r i a b l e s w h i c h i n f l u e n c e t h e female e x p e r i e n c e o f

c h r o n i c p a i n and d i f f e r e n t i a t e i t from the male e x p e r i e n c e .

L o c u s o f C o n t r o l - T h e o r e t i c a l C o n t e x t

The p h rase " l o c u s of c o n t r o l " r e f e r s t o the p e r c e i v e d s o u r c e

of c o n t r o l over one's b e h a v i o r . A c c o r d i n g t o the concept of l o c u s o f

c o n t r o l ( R o t t e r , 1966), when i n d i v i d u a l s c h a r a c t e r i s t i c a l l y p e r c e i v e

r e i n f o r c e r s as n o n c o n t i n g e n t l y r e l a t e d t o t h e i r b e h a v i o r the o c c u r r e n c e

- 24 -

o f r e i n f o r c e m e n t i s a t t r i b u t e d t o l u c k , chance, f a t e o r t o p o w e r f u l

o t h e r s and such i n d i v i d u a l s a r e s a i d t o be e x t e r n a l l y o r i e n t e d .

C o n v e r s e l y , when i n d i v i d u a l s c h a r a c t e r i s t i c a l l y p e r c e i v e r e i n f o r c e r s as

dependent e n t i r e l y upon t h e i r own e f f o r t s , such i n d i v i d u a l s a r e s a i d t o

be i n t e r n a l l y o r i e n t e d . I n d i v i d u a l d i f f e r e n c e s e x i s t w i t h r e s p e c t t o

magnitude of i n t e r n a l v e r s u s e x t e r n a l o r i e n t a t i o n s .

S i n c e the i n t r o d u c t i o n o f the l o c u s o f c o n t r o l c o n cept and the

development of a s c a l e t o measure i n t e r n a l - e x t e r n a l o r i e n t a t i o n

( R o t t e r ' s Locus o f C o n t r o l S c a l e , 1966), c o n s i d e r a b l e r e s e a r c h has

d e m o n s t r a t e d t h a t d i f f e r e n c e s i n o r i e n t a t i o n d e t e r m i n e not o n l y how an

i n d i v i d u a l p e r c e i v e s , but a l s o r e a c t s t o s i t u a t i o n s and e v e n t s ( J o e ,

1971; L e f c o u r t , 1966, 1976; P r o c u i k & L u s s i e r , 1975; R o t t e r , 1966,

1 975). I n t e r n a l l y o r i e n t e d i n d i v i d u a l s o f t e n have been d e s c r i b e d as

more a c t i v e , a l e r t and d i r e c t i n a t t e m p t i n g to c o n t r o l and m a n i p u l a t e

t h e i r e n v i r o n m e n t s t h a n e x t e r n a l l y o r i e n t e d p e r s o n s ( L e f c o u r t , 1976;

P h a r e s , 1976). Because l o c u s of c o n t r o l r e f e r s to e x p e c t a n c i e s as t o

t h e amount o f c o n t r o l one has o v e r i m p o r t a n t l i f e e v e n t s , a h i g h e r

f r e q u e n c y and l e v e l of c o p i n g e f f o r t s and o v e r a l l g e n e r a l a c t i v i t y m i g ht

be a n t i c i p a t e d from i n t e r n a l s . I n c o n t r a s t , e x t e r n a l s o f t e n have been

d e s c r i b e d as more p a s s i v e , a p a t h e t i c , a n x i o u s , l e s s s e l f - c o n f i d e n t , and

l e s s c o n f i d e n t o f t h e i r a b i l i t y t o c o n t r o l e v e n t s h a p p e n i n g t o them o r

around them.

A n o t h e r a p p r o a c h t o l o c u s of c o n t r o l (LOC) was t a k e n by

L e venson ( 1 9 7 3 ) . She r e a s o n e d t h a t e x t e r n a l l y o r i e n t e d i n d i v i d u a l s

m i g ht r e s p o n d d i f f e r e n t l y a c c o r d i n g t o whether they saw p o w e r f u l o t h e r s

o r chance as r e s p o n s i b l e f o r t h e i r b e h a v i o r . She expanded R o t t e r ' s

- 25 -

c o n c e p t to produce a t h r e e - d i m e n s i o n a l i n s t r u m e n t and d e m o n s t r a t e d t h a t ,

i n a d d i t i o n t o i n t e r n a l c o n t r o l ( L O C - I ) , t h e d i m e n s i o n s of c o n t r o l by

p o w e r f u l o t h e r s (LOC-PO) and by chance (LOC-C) were c o n s i s t e n t f a c t o r s .

L e venson's d i s t i n c t i o n may be i m p o r t a n t t o the u n d e r s t a n d i n g o f t h e

n a t u r e of e x t e r n a l i t y .

L o c us o f c o n t r o l seems e s p e c i a l l y r e l e v a n t t o a d i s c u s s i o n o f

t r e a t m e n t of c h r o n i c p a i n p a t i e n t s . A c c o r d i n g t o Bowers (1968) p e o p l e

who b e l i e v e t hemselves u n a b l e t o r e l i e v e o r a v o i d p a i n o r s t r e s s s u f f e r

more t h a n th o s e who p e r c e i v e t h e m s e l v e s to have c o n t r o l a v a i l a b l e .

A t t r i b u t i o n t h e o r y s t a t e s t h a t p e o p l e seek causes or e x p l a n t i o n s f o r t h e

o b s e r v e d e v e n t s t h a t t a k e p l a c e around them. U s i n g an a t t r i b u t i o n

t h e o r y d e r i v a t i o n , D a v i s o n and V a l i n s (1969) showed how t o l e r a n c e t o

p a i n i n c r e a s e d when s u b j e c t s were t a u g h t t o a t t r i b u t e changes i n p a i n

t o l e r a n c e t o t h e i r own e f f o r t s as opposed to the e f f e c t s of a p i l l .

A t t r i b u t i o n o f c o n t r o l as due t o i n t e r n a l r a t h e r t h a n e x t e r n a l

f a c t o r s has been used by G o t t l i e b (1977) as a key f a c t o r i n the

t r e a t m e n t of p a t i e n t s w i t h c h r o n i c low back p a i n . He found t h a t s u c h

p a t i e n t s e x h i b i t a l e a r n e d h e l p l e s s n e s s as a r e s u l t of t h e i r d i s a b i l i t y

and t h a t h e l p l e s s n e s s tends t o become r e i n f o r c e d by m a s s i v e m e d i c a t i o n

and dependency on o t h e r s . They f e e l u n a b l e to e x e r t c o n t r o l o v e r t h e i r

p a i n and t h e i r l i v i n g s i t u a t i o n . As p a r t of a comprehensive t r e a t m e n t

program, t h e s e p a t i e n t s a r e t a u g h t s e l f - r e g u l a t i o n r a t h e r t h a n d r u g

r e g u l a t i o n f o r d e a l i n g w i t h t h e i r p a i n .

The u n p r e d i c t a b i l i t y of c h r o n i c p a i n might l e a d one t o suppose

a s i g n i f i c a n t r e l a t i o n s h i p between l e a r n e d h e l p l e s s n e s s and l o c u s o f

- 26 -

c o n t r o l . A s t u d y by M i l l e r and S e l i g m a n (1973) f a i l e d t o d e m o n s t r a t e a

c o n v i n c i n g l i n k between l e a r n e d h e l p l e s s n e s s and l o c u s of c o n t r o l and

s t u d i e s s t i l l need to be done w i t h p a i n p a t i e n t s i n t h i s a r e a . However,

d e p r e s s i o n i s common i n c h r o n i c p a i n p a t i e n t s ( S t e r n b a c h , 1978) and

s e v e r a l s t u d i e s have examined the a s s o c i a t i o n between p e r c e i v e d l o c u s o f

c o n t r o l of r e i n f o r c e m e n t c o n t i n g e n c i e s and the symptoms o f d e p r e s s i o n

( A b r a m o w i t z , 1969; A r c h e r , 1980; Becker & L e s i a k , 1977; C a l h o u n , Cheney,

& Dawes, 1974; D i s t e f a n o , P r y e r , & S m i t h , 1971; Emmelkamp &

C o h e n - K e t t e n i s , 1975; Fogg, Kohaut, & G a y t o n , 1977; Harrow & F e r r a n t e ,

1969; Lamont, 1972). These s t u d i e s r e p o r t a c o n s i s t e n t a s s o c i a t i o n

between d e p r e s s i v e symptoms and b e l i e f t h a t outcomes a r e e x t e r n a l l y

c o n t r o l l e d ( h i g h E s c o r e s ) . I t i s t h e r e f o r e c o n c e i v a b l e t h a t c h r o n i c

p a i n p a t i e n t s e x h i b i t an e x t e r n a l l o c u s o f c o n t r o l .

The r e s e a r c h e v i d e n c e l i n k i n g l o c u s of c o n t r o l and d e p r e s s i o n

i s f a r from c l e a r f o r s e v e r a l r e a s o n s . F i r s t , most s t u d i e s used c o l l e g e

s t u d e n t s and p r o v i d e no e v i d e n c e t h a t d e p r e s s i o n i n o t h e r w i s e n o r m a l l y

f u n c t i o n i n g c o l l e g e - a g e p e o p l e i s on a c o ntinuum w i t h the d e p r e s s i o n

found i n a p s y c h i a t r i c p o p u l a t i o n . Second, tho s e s t u d i e s t h a t used

p a t i e n t s have used h o s p i t a l i z e d p a t i e n t s and as Harrow and F e r r a n t e

(1969) p o i n t o u t , m e n t a l h o s p i t a l i z a t i o n i s o f t e n a t l e a s t p a r t l y

c o e r c i v e and may w e l l produce a sense o f u n c o n t r o l l a b i l i t y i r r e s p e c t i v e

of the p a t i e n t ' s d i s o r d e r . T h i r d , the e f f e c t of age on l o c u s of c o n t r o l

seldom i s c o n s i d e r e d . Because R o t t e r (1966) d e f i n e d l o c u s o f c o n t r o l i n

s o c i a l l e a r n i n g terms as a r e s u l t of s u b j e c t i v e p r o b a b i l i t y e s t i m a t e s o f

o u c o m e c o n t i n g e n c i e s based on e x p e r i e n c e , i t i s a t l e a s t p o s s i b l e t h a t

l o c u s of c o n t r o l s c o r e s w i l l change i n the c o u r s e of one's l i f e .

- 27 -

C o s t e l l o (1982) found a h i g h c o r r e l a t i o n between d e p r e s s i o n

and e x t e r n a l i t y , c o n t r o l l i n g f o r age and u s i n g b o t h s t u d e n t s and

p s y c h i a t r i c o u t p a t i e n t s . T h i s i s of some s i g n i f i c a n c e f o r c a u s a l models

of d e p r e s s i o n , such as the r e v i s e d l e a r n e d h e l p l e s s n e s s model (Abramson,

S e l i g m a n , & T e a s d a l e , 1 978), w h i c h makes e x t e n s i v e use o f d a t a from

s t u d e n t s t o argue t h a t c l i n i c a l d e p r e s s i o n i s a r e s u l t o f a t t r i b u t i n g

r e s p o n s i b i l i t y f o r outcome c o n t i n g e n c i e s t o e x t e r n a l f a c t o r s . C o s t e l l o

s t a t e d , however, t h a t u n t i l l o n g i t u d i n a l d a t a a r e c o l l e c t e d i t i s

u n c e r t a i n whether e x t e r n a l i t y has a t r u l y c a u s a l r e l a t i o n s h i p t o

d e p r e s s i o n .

I n v i e w o f the dependence of c h r o n i c p a i n p a t i e n t s on f a m i l y

and p r o f e s s i o n a l s , and S t e r n b a c h ' s (1978) d e s c r i p t i o n of the c h r o n i c

p a i n p a t i e n t as a " p e t i t i o n e r f o r a i d " , e x t e r n a l i t y f o r t h i s p o p u l a t i o n

might t a k e the form o f a b e l i e f i n " p o w e r f u l o t h e r s " . A l t e r n a t i v e l y ,

p a t i e n t s who f e e l h e l p l e s s and have l o s t f a i t h i n the m e d i c a l community

may be more i n c l i n e d t o b e l i e v e i n chance h a p p e n i n g s .

S k e v i n g t o n (1979) s t u d i e d l o c u s o f c o n t r o l w i t h r e s p e c t t o

t h r e e c a t e g o r i e s o f p a i n p a t i e n t s - low back p a i n , p s y c h o s o m a t i c p a i n ,

and r h e u m a t o i d a r t h r i t i s p a i n - and found t h a t b e l i e f s about t h e

c o n t r o l l a b l i t y o f e v e n t s i n f l u e n c e the r e p o r t i n g o f p a i n w i t h b o t h t h e

low back p a i n and r h e u m a t o i d a r t h r i t i s p a t i e n t s . On the chance

d i m e n s i o n of l o c u s of c o n t r o l , S k e v i n g t o n ' s h y p o t h e s i s t h a t p a i n

p a t i e n t s would have h i g h e r e x t e r n a l i t y was c o n f i r m e d . T h i s s t u d y

i n d i c a t e d a s u b s t a n t i v e b e l i e f i n an e x t e r n a l l o c u s o f c o n t r o l among

c h r o n i c p a i n p a t i e n t s .

- 28 -

B e l i e f s t h a t the w o r l d i s governed by chance may i n c r e a s e t h e

l i k e l i h o o d o f h e l p l e s s n e s s more th a n a b e l i e f i n a w o r l d c o n t r o l l e d by

" p o w e r f u l o t h e r s " s i n c e chance happenings a r e c o m p l e t e l y

u n c o n t r o l l a b l e . T h i s may shed some l i g h t on the l a c k of r e l a t i o n s h i p

between l o c u s o f c o n t r o l and l e a r n e d h e l p l e s s n e s s . Where t h e r e a r e

i d e n t i f i a b l e " p o w e r f u l o t h e r s " c o n t r o l l i n g the w o r l d , c h a n g i n g t h e

s i t u a t i o n may appear more h o p e f u l t h a n i n s i t u a t i o n s where chance t a k e s

o v e r , as " o t h e r s " may be p r e v e n t e d from e x e r c i s i n g c o n t r o l .

L o c u s o f c o n t r o l - C o n c e p t u a l A s s u m p t i o n s

A pr o b l e m i n c o n c e p t u a l i z a t i o n i s the i n t r u s i o n o f a good/bad

d i c h o t o m y . Throughout much of the l o c u s o f c o n t r o l r e s e a r c h t h e r e seems

t o be a t a c i t a s s u m p t i o n t h a t i n t e r n a l l o c u s o f c o n t r o l i s d e s i r a b l e

w h i l e an e x t e r n a l one i s n o t . R o t t e r (1975) d i s c u s s e s how i n s p i t e o f

f e a r s and even w a r n i n g s t o t h e c o n t r a r y , some p s y c h o l o g i s t s q u i c k l y

assume t h a t i t i s good t o be i n t e r n a l and bad t o be e x t e r n a l . Of

c o u r s e , i n some s e n s e s , t h i s may be t r u e , but the problem t h e n l i e s i n

assuming t h a t a l l good t h i n g s a r e c h a r a c t e r i s t i c o f i n t e r n a l s and a l l

bad t h i n g s a r e c h a r a c t e r i s t i c o f e x t e r n a l s . I n t e r n a l s s h o u l d be more

l i b e r a l , more s o c i a l l y s k i l l e d , b e t t e r a d j u s t e d , more e f f i c i e n t , e t c .

A s i d e from the p e c u l i a r i t i e s o f one t e s t o r a n o t h e r t h e r e i s no l o g i c a l

b a s i s t o assume any r e l a t i o n s h i p .

R o t t e r (1975) a l s o n o t e d t h a t the p r o b l e m o f t h e r e l a t i o n s h i p

between such a g e n e r a l i z e d e x p e c t a n c y as l o c u s o f c o n t r o l and a d j u s t m e n t

i s c o m p l i c a t e d . A d j u s t m e n t i s o n l y a v a l u e c o n c e p t , and any

- 29 -

r e l a t i o n s h i p must depend upon t h e d e f i n i t i o n o f a d j u s t m e n t . I t seems

c l e a r t h a t s e l f - r e p o r t l o c u s of c o n t r o l s c a l e s c o r r e l a t e w i t h

s e l f - r e p o r t s c a l e s of a n x i e t y , a d j u s t m e n t , or s c a l e s i n v o l v i n g

s e l f - d e s c r i p t i o n s o f symptoms. However, t h e r e a r e s t u d i e s ( L i p p ,

K o l s t o e , James & R a n d a l l , 1968; P h a r e s , 1968) t h a t s u ggest t h a t i t i s

t y p i c a l o f i n t e r n a l s t o r e p r e s s ( o r f o r g e t ) f a i l u r e s and u n p l e a s a n t

e x p e r i e n c e s . C o n s e q u e n t l y t h e y may r e p o r t ( o r a d m i t ) l e s s a n x i e t y ,

fewer symptoms, e t c . , and t h e r e b y c r e a t e a p o s i t i v e r e l a t i o n s h i p between

i n t e r n a l i t y and a d j u s t m e n t .

I t may be b e t t e r f o r p e o p l e who a r e i n o b v i o u s d i f f i c u l t i e s ,

who a r e t r y i n g t o cope w i t h f a i l i n g a b i l i t i e s , s u c h as c h r o n i c p a i n

p a t i e n t s , t o have a g r e a t e r f e e l i n g t h a t t h e y c a n , i n f a c t , c o n t r o l what

happens t o them ( i . e . be more i n t e r n a l ) . Many p e o p l e , however, may

a l r e a d y f e e l t h a t they have more c o n t r o l t h a n i s w a r r a n t e d by r e a l i t y

( i . e . extreme i n t e r n a l s ) , and t h e y may e x p e r i e n c e ( o r have e x p e r i e n c e d )

s t r o n g trauma when th e y d i s c o v e r t h a t they cannot c o n t r o l some t h i n g s

s u c h as a c c i d e n t s o r d i s e a s e . The e a r l y h y p o t h e s i s ( R o t t e r , 1966) t h a t

l o c u s of c o n t r o l would have a c u r v i l i n e a r r e l a t i o n s h i p w i t h b o t h

extremes of t h e I-E d i m e n s i o n r e f l e c t i n g m a l a d j u s t m e n t has not been

borne o u t , but the f a u l t may be i n the methods of measurement of t h e

a d j u s t m e n t v a r i a b l e . I n t h i s v i e w , i t i s p e o p l e n e a r e r the m i d d l e who

respond i n a more r e a l i s t i c f a s h i o n . That i s , some s i t u a t i o n s , on a

r e a l i s t i c b a s i s , w i l l seem l a r g e l y w i t h i n t h e i n d i v i d u a l s ' c o n t r o l ,

w h i l e o t h e r s w i l l n o t . To be a b l e t o d i s t i n g u i s h between t h e s e two

c l a s s e s o f s i t u a t i o n s might be the most e f f e c t i v e mode. As Phares

(1976) p o i n t e d out perhaps more r e s e a r c h s h o u l d be devoted t o the means

- 30 -

o f t e a c h i n g i n d i v i d u a l s when one o r the o t h e r l o c u s o f c o n t r o l b e l i e f i s

the more u s e f u l . P r o b a b l y p e o p l e would b e n e f i t from l e a r n i n g how t o

d i s c r i m i n a t e among s i t u a t i o n s as r e g a r d s an a p p r o p r i a t e l o c u s of c o n t r o l

b e l i e f .

L o c us o f C o n t r o l - Gender D i f f e r e n c e s

I t a ppears from a r e v i e w of the l i t e r a t u r e t h a t u n t i l r e c e n t l y

t h e r e were few r e p o r t e d gender d i f f e r e n c e s on the Locus of C o n t r o l

S c a l e . Many s t u d i e s do not r e p o r t s e p a r a t e means f o r males and f e m a l e s

and a l a r g e m a j o r i t y of s t u d i e s d i d not f i n d s i g n i f i c a n t d i f f e r e n c e s i n

t h e I-E s c o r e s between men and women. A l t h o u g h R o t t e r (1966) s t a t e d

t h a t sex d i f f e r e n c e s on the I-E s c a l e among c o l l e g e s t u d e n t s appeared t o

be m i n i m a l , s t u d i e s by F e a t h e r (1968) and Marks (1972) showed t h a t

f e m a l e s earned s i g n i f i c a n t l y h i g h e r e x t e r n a l s c o r e s t h a n m a l e s .

R o t t e r has s u g g e s t e d t h a t sex d i f f e r e n c e s may be r e l a t e d t o

g e o g r a p h i c a l d i f f e r e n c e s as w e l l as s e x - r o l e i d e n t i f i c a t i o n . I t seems

t h a t f e m a l e s have a h i g h e r b e l i e f i n e x t e r n a l c o n t r o l of t h e i r l i v e s ,

a l t h o u g h a s t u d y of c o l l e g e s t u d e n t s i n f i v e c o u n t r i e s i n d i c a t e d t h a t

b e l i e f i n e x t e r n a l i t y v a r i e d w i t h the c u l t u r e ( M c G i n n i e s , Nordholm,

Ward, & Bhanthumnavin, 1974). T a i t , DeGood, and C a r r o n (1982) s t u d i e d

c h r o n i c low-back p a t i e n t s i n t h e U.S. and New Z e a l a n d and found t h a t i n

b o t h c o u n t r i e s women r a t e d t h e m s e l v e s as h a v i n g l e s s p e r s o n a l c o n t r o l

o v e r h e a l t h t h e n men, a f i n d i n g t h a t t h e y suggest i n d i c a t e s t h a t men

f e e l l e s s h e l p l e s s i n d e a l i n g w i t h t h e i r p a i n .

Gruen, K o r t e , and Baum (1974) found t h a t i n the b l a c k

p o p u l a t i o n sex d i f f e r e n c e s were r e v e r s e d , w i t h g i r l s s i g n i f i c a n t l y more

- 31 -

i n t e r n a l t h a n boys. I t may be t h a t i n d i v i d u a l d i f f e r e n c e s i n l o c u s o f

c o n t r o l r e f l e c t r e a l d i f f e r e n c e s i n o p p o r t u n i t i e s t o c o n t r o l the r e s u l t s

o f one's b e h a v i o r and, i n g e n e r a l , f e m a l e s a r e s o c i a l i z e d t o make l e s s

c o n n e c t i o n between t h e i r b e h a v i o r and i t s ' c o n s e q u e n c e s . A

p o w e r - h e l p l e s s n e s s f a c t o r may have some v a l i d i t y i n a d i s c u s s i o n o f

female e x t e r n a l i t y and perhaps e x t e r n a l i t y f o r a l l c h r o n i c p a i n

p a t i e n t s .

F u r t h e r r e s e a r c h i s needed t o u n d e r s t a n d b e t t e r t h e

r e l a t i o n s h i p s between gender, p e r c e p t i o n s o f c o n t r o l , and r e s p o n s e t o

t r e a t m e n t . However, i t i s l i k e l y t h a t gender d i f f e r e n c e s i n l o c u s o f

c o n t r o l b e l i e f s i f and when th e y o c c u r , a r e a c c o u n t e d f o r l e s s by

b i o l o g i c a l v a r i a b l e s than by s o c i a l i z a t i o n p a t t e r n s , d i f f e r e n t s e x - r o l e

d e f i n i t i o n s , and/or d i f f e r e n t p e r c e p t i o n s o f c o n t r o l .

Summary

I n t h i s c h a p t e r the l i t e r a t u r e r e l e v a n t t o l o c u s o f c o n t r o l

and p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n was r e v i e w e d . T h i s

l i t e r a t u r e r e v i e w u n d e r l i e s the i n t e r e s t i n and i m p o r t a n c e o f the l o c u s

o f c o n t r o l c o n s t r u c t and i t s ' a p p l i c a t i o n t o the p s y c h o s o c i a l

a d j u s t m e n t of c h r o n i c p a i n p a t i e n t s , but d e m o n s t r a t e s t h a t the

i n v e s t i g a t i o n i s j u s t b e g i n n i n g .

I t was n o t e d t h a t t h e p r o b l e m o f c h r o n i c p a i n f o r i n d i v i d u a l s

i s v e r y complex. I t may be t h a t the s t a b i l i t y o f l o c u s o f c o n t r o l as a

p e r s o n a l i t y t r a i t as i m p l i e d i n e a r l i e r r e s e a r c h must be l o o k e d a t

d i f f e r e n t l y . P e r h a p s , f o r c h r o n i c p a i n p a t i e n t s one needs t o be aware

- 32 -

o f a more t r a n s i e n t a t t r i b u t i o n about c o n t r o l , governed by s o c i a l ,

e n v i r o n m e n t a l and i n d i v i d u a l f a c t o r s .

T h i s p r e s e n t s t u d y i s concerned w i t h e x p l o r i n g the

r e l a t i o n s h i p s between l o c u s of c o n t r o l , p s y c h o s o c i a l a d j u s t m e n t t o

c h r o n i c p a i n , and p r e s e n t p a i n r a t i n g s .

- 33 -

CHAPTER THREE

Meth o d o l o g y

T h i s c h a p t e r p r e s e n t s t h e sample, d e s c r i p t i o n o f the

i n s t r u m e n t s , d a t a c o l l e c t i o n p r o c e d u r e s , and the h y p o t h e s e s w i t h t h e

a n a l y s e s used t o t e s t t h e h y p o t h e s e s .

Sample C h a r a c t e r i s t i c s

F o r t y one s u b j e c t s p a r t i c i p a t e d i n t h i s s t u d y . The s u b j e c t s

were twenty e i g h t males and t h i r t e e n f e m a l e s r e s i d i n g i n B r i t i s h

C o l u m b i a , A l b e r t a o r Saskatchewan. A l l had completed an i n - p a t i e n t ,

m u l t i d i s c i p l i n a r y p a i n t r e a t m e n t program i n Va n c o u v e r , B r i t i s h C o l umbia

w i t h i n the p a s t 3-1/2 y e a r s .

F o r a l l s u b j e c t s , 19.5% were i n the age range 20-40 y e a r s and

80.5% were i n the age range 41-61+ y e a r s . A l l p a r t i c i p a n t s r e p o r t e d

s t i l l e x p e r i e n c i n g some p a i n . F o r the f e m a l e s , 53.8% had e x p e r i e n c e d

c h r o n i c p a i n f i v e y e a r s o r l o n g e r , w h i l e f o r the males 78.6% had

e x p e r i e n c e d c h r o n i c p a i n f o r t h a t p e r i o d o f t i m e . None of t h e

p a r t i c i p a n t s had e x p e r i e n c e d c h r o n i c p a i n f o r l e s s t h a n two y e a r s .

R e p o r t i n g on p a i n - r e l a t e d s u r g e r y p r i o r t o the r e s i d e n t i a l t r e a t m e n t

program, the f i g u r e s were 78.6% f o r the males and 64.3% f o r the

f e m a l e s . Two males r e p o r t e d a d d i t i o n a l p a i n - r e l a t e d s u r g e r y s i n c e

c o m p l e t i o n o f the t r e a t m e n t program and 16.7% of the sample r e p o r t e d

r e c e n t h o s p i t a l a d m i s s i o n s f o r p a i n - r e l a t e d p r o b l e m s . R e p o r t i n g on

- 34 -

m e d i c a t i o n use f o r p a i n , 53.6% i n d i c a t e d the same as b e f o r e o r l e s s now,

43.9% i n d i c a t e d no usage now, and 2.4% i n d i c a t e d more usage now.

R e p o r t i n g on time spent i n bed o r l y i n g down due t o p a i n , 46.3% r e p o r t e d

e i t h e r the same as b e f o r e or more time than b e f o r e . R e p o r t i n g on

a b i l i t y t o bend o r w a l k , 34.1% r e p o r t e d e i t h e r t h e same as b e f o r e

t r e a t m e n t o r worse s i n c e t r e a t m e n t .

I n s t r u m e n t a t i o n

THE LOCUS OF CONTROL SCALE

R o t t e r ' s I n t e r n a l - E x t e r n a l ( I - E ) S c a l e ( R o t t e r , 1966) c o n s i s t s

o f a 2 9 - i t e m f o r c e d c h o i c e t e s t . S i x o f the i t e m s a r e " f i l l e r s "

i n t e n d e d t o d i s g u i s e the n a t u r e and purpose of the s c a l e . S c o r i n g

c o r r e s p o n d s t o 1 p o i n t f o r each endorsement of an e x t e r n a l c o n t r o l

i t e m . S c o r e s may range from 0 (an i n d i v i d u a l w i t h b e l i e f i n c o m p l e t e l y

i n t e r n a l c o n t r o l ) t o 23 (an i n d i v i d u a l w i t h b e l i e f i n c o m p l e t e l y

e x t e r n a l c o n t r o l ) . The P e r s o n a l L ocus o f C o n t r o l s u b s c a l e ( i t e m s

2,6,11,15,16,23,25), a measure of p e r s o n a l c o n t r o l , and the

S o c i o - p o l i t i c a l Locus of C o n t r o l s u b s c a l e ( i t e m s 3,12,17,20,22,29), a

measure of c o n t r o l over s o c i o - p o l i t i c a l f o r c e s , a r e s c o r e d i n the same

manner as the f u l l s c a l e I-E ( M i r e l s , 1970). A copy of the Locus of

C o n t r o l S c a l e i s found i n Ap p e n d i x D.

R e l i a b i l i t y :

I n t e r n a l c o n s i s t e n c y a n a l y s i s ( K u d e r - R i c h a r d s o n ) y i e l d e d a _r

o f .70. T e s t - r e t e s t r e l i a b i l i t y c o e f f i c i e n t s o f the s c a l e range .60 t o

- 35 -

.83 a f t e r one month, and f r o m .49 t o .61 a f t e r two months. R o t t e r

s p e c u l a t e s t h a t the low r e l i a b i l i t y f o r the l a t t e r p e r i o d may be due t o

d i f f e r e n c e s i n t e s t a d m i n i s t r a t i o n . The f i r s t r e t e s t was a d m i n i s t e r e d

i n a group s i t u a t i o n , the second i n d i v i d u a l l y . However, no s p e c i f i c

method of a d m i n s t r a t i o n i s s u g g e s t e d ( R o t t e r , 1966).

V a l i d i t y :

C o n t e n t V a l i d i t y . R e s e a r c h has i n d i c a t e d t h a t the R o t t e r

Locus of C o n t r o l S c a l e c o n s i s t s of a number of s u b f a c t o r s and i s

m u l t i d i m e n s i o n a l (Abrahamson, Schluderman, & Schlederman, 1973; K l e i b e r ,

Vedman, & Menaker, 1973; M i r e l s , 1970; R e i d & Ware, 1973).

C o n s t r u c t V a l i d i t y . Numerous s t u d i e s have e s t a b l i s h e d t h e

c o n s t r u c t v a l i d i t y of t h e s c a l e s u p p o r t i n g p r e d i c t e d d i f f e r e n c e s i n

b e h a v i o r and p e r s o n a l i t y d i m e n s i o n s on the b a s i s of l o c u s of c o n t r o l

( J o e , 1971; L e f c o u r t , 1966; P h a r e s , 1976; R o t t e r , 1966).

ADJUSTMENT TO CHRONIC PAIN SCALE (ACPS)

P s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n was measured by t h e

A d j u s t m e n t t o C h r o n i c P a i n S c a l e (ACPS). T h i s i n s t r u m e n t was m o d e l l e d

on the P s y c h o s o c i a l A d j u s t m e n t t o I l l n e s s S c a l e ( D e r o g a t i s , 1975). The

ACPS i s a s e l f - r e p o r t q u e s t i o n n a i r e w h i c h can be used t o g a t h e r

i n f o r m a t i o n about p a t i e n t s ' o p i n i o n s on t h e i r own a d j u s t m e n t . The ACPS

q u e s t i o n n a i r e c o n s i s t s of 27 i t e m s , each composed of f o u r s t a t e m e n t s

used as a 4 - p o i n t s c a l e where the s u b j e c t ' s r e s p o n s e may range from 0

'no d i s t u r b a n c e ' t o 3 'marked d i s t u r b a n c e ' . Thus, t h e l o w e r s c o r e s

- 36 -

i n d i c a t e b e t t e r a d justment and h i g h e r s c o r e s i n d i c a t e p o o r e r

a d j u s t m e n t . A copy of the ACPS i s found i n Ap p e n d i x E.

Each of the 27 i t e m s c o n t a i n e d i n t h i s i n s t r u m e n t p e r t a i n t o

an a s p e c t of ad j u s t m e n t and can be grouped a c c o r d i n g t o seven s u b t e s t s

as f o l l o w s :

( 1 ) H e a l t h c a r e : Item numbers 1,2, and 3. The i t e m s a re con c e r n e d w i t h

t h e c u r r e n t h e a l t h c a r e p o s t u r e and whether i t i s c o n d u c i v e t o

p o s i t i v e a d justment to c h r o n i c p a i n a f t e r t r e a t e m e n t .

(2) V o c a t i o n a l e n v i r o n m e n t : Item numbers 4, 5, 6, and 7. The i t e m s i n

t h i s s u b t e s t a s s e s s d i s r u p t i o n i n j o b p e r f o r m a n c e , j o b

s a t i s f a c t i o n , and a d j u s t m e n t w h i c h i s a t t r i b u t a b l e t o c h r o n i c p a i n

or d i s a b i l i t y .

( 3 ) Domestic E n v i r o n m e n t : Items numbers 8, 9, 10, and 11. The i t e m s i n

t h i s s u b t e s t a s s e s s c h r o n i c p a i n i n d u c e d d i f f i c u l t i e s w h i c h a r i s e

p r i m a r i l y i n the home or u s u a l f a m i l y e n v i r o n m e n t . I t i s d e s i g n e d

t o a s s e s s problems i n a d a p t a t i o n e x p e r i e n c e d by t h e p a t i e n t and t h e

f a m i l y u n i t i n r e s p o n s e t o t h e s u b j e c t ' s c h r o n i c p a i n .

( 4 ) S e x u a l R e l a t i o n s h i p s : Items numbers 12, 13, 14, and 15. The i t e m s

i n t h i s s u b t e s t a s s e s s any s h i f t s i n q u a l i t y o f s e x u a l b e h a v i o r or

r e l a t i o n s h i p a t t r i b u t a b l e t o c h r o n i c p a i n .

(5) Extended F a m i l y R e l a t i o n s h i p s : Items numbers 16, 17, and 18. The

item s i n t h i s s u b t e s t r e f l e c t any d i f f i c u l t i e s i n r e l a t i o n s h i p s

w i t h i n t h e extended f a m i l y c o n s t e l l a t i o n t h a t a r i s e as d i r e c t o r

i n d i r e c t e f f e c t s of t h e c h r o n i c p a i n .

- 37 -

(6) S o c i a l E n v i r o n m e n t : Items numbers 19, 20, 21, and 22. The i t e m s of

t h i s s u b t e s t a s s e s s the degree t o w h i c h c h r o n i c p a i n has i m p a i r e d

t h e s u b j e c t s ' s o c i a l and l e i s u r e a c t i v i t i e s .

( 7 ) P s y c h o l o g i c a l D i s t r e s s : Items numbers 23, 24, 25, 26 and 27. The

i t e m s i n t h i s s u b t e s t c o v e r the degree t o w h i c h p e r t i n e n t

p s y c h o l o g i c a l d i f f i c u l t i e s have r i s e n a s s o c i a t e d w i t h t h e

o c c u r r e n c e of c h r o n i c p a i n .

I n s t r u m e n t A n a l y s i s

R e l i a b i l i t y :

R e l i a b i l i t y o f the ACPS was a s s e s s e d u s i n g the L a b o r a t o r y o f

E d u c a t i o n a l R e s e a r c h T e s t A n a l y s i s Package (LERTAP). T h i s program uses

an i n t e r n a l c o n s i s t e n c y method based on Hoyt's (1941) p r o c e d u r e and i s

t h e most a p p r o p r i a t e a n a l y t i c t e c h n i q u e f o r L i k e r t - t y p e s c a l e s .

I n t e r n a l c o n s i s t e n c y i s an e s t i m a t e of the e x t e n t t o w h i c h each t e s t

i t e m t a p s whatever the t e s t i t e m i s m e a s u r i n g . I f one c o n s i d e r s each

t e s t i t e m as a sample t e s t from t h e t o t a l domain t h e n t h e i n t e r n a l

c o n s i s t e n c y i s r o u g h l y e q u i v a l e n t t o t h e average c o r r e l a t i o n between a l l

p a i r s of i t e m s . Hoyt's anova approach a l l o w s f o r the d i f f e r e n t i a l

w e i g h t i n g o f t e s t i t e m s and hence has some advantage o v e r o t h e r

a l g e b r a i c a l l y e q u i v a l e n t p r o c e d u r e s such as K u d e r - R i c h a r d s o n f o r m u l a s

and Cronbach's c o e f f i c i e n t a l p h a . The summary o f r e s u l t s i s p r e s e n t e d

i n T a b l e 1.

- 38 -

TABLE 1

I n t e r n a l C o n s i s t e n c y S c o r e s f o r the ACPS

S u b t e s t Hoyt E s t i m a t e of R e l i a b i l i t y

1 0.83

2 0.48

3 0.35

4 0.83

5 0.57

6 0.83

7 0.85

T o t a l T e s t 0.89

Item A n a l y s i s . I t em a n a l y s i s i s the s e l e c t i o n o f an i t e m f o r

i n c l u s i o n i n one's s c a l e based on t h e r e l i a b i l i t y and v a l i d i t y o f t h e

i t e m . A s t r a i g h t f o r w a r d i t e m a n a l y s i s p r o c e d u r e i s the i t e m - t o - t o t a l

c o r r e l a t i o n t e c h n i q u e . LERTAP c a l c u l a t e d i n d i v i d u a l i t e m c o r r e l a t i o n s

( P e a r s o n ' s ) w i t h the t o t a l t e s t s c o r e s . Item c o r r e l a t i o n s o f 0.30 t o

0.50 w i t h t o t a l t e s t s c o r e s a r e c o n s i d e r e d good, w h i l e c o e f f i c i e n t s

g r e a t e r t h a n 0.50 i n d i c a t e s u p e r i o r i t e m s . The summary of r e s u l t s i s

p r e s e n t e d i n T a b l e 2.

A n o t h e r p r o c e d u r e f o r i t e m a n a l y s i s can be t h e s i z e o f t h e

s t a n d a r d d e v i a t i o n c a l c u a t e d f o r each i t e m . F o r a 4 - p o i n t s c a l e ( s u c h

- 39 -

TABLE 2

Item A n a l y s i s R e s u l t s f o r t h e ACPS

ACPS Item S t a n d a r d D e i v a t i o n T o t a l T e s t C o r r e l a t i o n s

S u b t e s t 1 1 2 3

S u b t e s t 2 4 5 6 7

S u b t e s t 3 8 9 10 11

S u b t e s t 4 12 13 14 15

S u b t e s t 5 16 17 18

S u b t e s t 6 19 20 21 22

S u b t e s t 7 23 24 25 26 27

0.84 1.03 0.87

0.94 1.35 1.04 1.19

0.71 0.95 1.01 0.83

0.88 0.99 0.86 0.76

0.78 0.75 0.75

1.04 1.01 0.88 1.03

0.94 0.91 0.81 1.07 0.99

0.46 0.54 0.54

0.32 0.51 0.30 0.21

0.55 0.32 0.31 0.45

0.69 0.62 0.55 0.55

0.57 0.30 0.61

0.55 0.63 0.76 0.65

0.53 0.70 0.58 0.62 0.70

- 40 -

as the ACPS) a s t a n d a r d d e v i a t i o n of 0.80 t o 1.00 would be c o n s i d e r e d

good, w h i l e a s t a n d a r d d e v i a t i o n g r e a t e r t h a n 1.00 would i n d i c a t e

s u p e r i o r i t e m s . I n o t h e r words, the degree of r e s p o n s e t o t h e s e i t e m s

would be d i s p e r s e d by at l e a s t one s c a l e s t e p on a 4 - p o i n t s c a l e . The

summary of t h e s e r e s u l t s i s p r e s e n t e d i n T a b l e 2.

V a l i d i t y :

C o n t e n t v a l i d i t y i s o f t e n the main c o n c e r n i n a t t i t u d e

measurement, and r e f e r s t o the degree t h a t the s c o r e o r s c a l e used

r e p r e s e n t s the c o n c e p t s about w h i c h g e n e r a l i z a t i o n s a r e t o be made.

One's m e a s u r i n g i n s t r u m e n t shows c o n t e n t v a l i d i t y t o t h e degree t h a t

s a m p l i n g from the domain of c o n t e n t i s r e p r e s e n t a t i v e of a l l s t r a t a and

t o the degree t h a t i t e m s c o n s t r u c t e d t a p the s u b t l e t i e s of meaning

w i t h i n each of t h e s e a r e a s . There i s no s i n g l e s t a t i s t i c a l c r i t e r i o n

w h i c h can be used t o d e t e r m i n e whether o r not one has p r o p e r l y sampled

from the domain of c o n t e n t . However, the r e s e a r c h e r can t a k e s e v e r a l

p r e c a u t i o n s t o h e l p g u a r a n t e e the r e p r e s e n t a t i o n o f the v a r i o u s shades

o f meaning from w i t h i n the domain. The ACPS was c o n s t r u c t e d w i t h

c o n t e n t v a l i d i t y p r o c e d u r e i n mind as f o l l o w s :

a) The domain of c o n t e n t was i d e n t i f i e d ( i . e . p s y c h o s o c i a l

a d j u s t m e n t t o c h r o n i c p a i n ) and a r r a n g e d i n t o seven m a j o r

components;

b) S e v e r a l i t e m s were w r i t t e n and r e - w r i t t e n , o r adapted from

e x i s t i n g s c a l e s ;

c ) The ACPS was t h e n d e s i g n e d , c r i t i c a l l y a n a l y z e d , and

m o d i f i e d w i t h r e s p e c t t o f o r m a t , c o n t e n t , and v o c a b u l a r y .

- 41 -

V a l i d i t y o f the ACPS was f u r t h e r a s s e s s e d u s i n g an i n t e r n a l

c o n s i s t e n c y a p proach i n v o l v i n g i t e m a n a l y s i s as d i s c u s s e d p r e v i o u s l y .

H i g h i n t e r n a l c o n s i s t e n c y between i t e m s on t h e ACPS i l l u s t r a t e t h i s

a s p e c t o f v a l i d i t y .

Comment:

The i m p l i c a t i o n o f t h e s e f i n d i n g s i s t h a t the ACPS can be

a d m i n i s t e r e d w i t h an a c c e p t a b l e degree of r e l i a b i l i t y and w i t h an

i n i t i a l measure of c o n f i d e n c e i n i t s ' v a l i d i t y . C o n c l u s i v e demonstra­

t i o n t h a t an i n s t r u m e n t p o s s e s s e s v a l i d i t y i n c r e a s e s over t i m e as i t i s

used i n a number of s t u d i e s and i s shown t o behave i n a c o n s i s t e n t

manner.

W i t h minor e x p e c t a t i o n s , t h e s e p a r a t e s u b t e s t s a r e r e l a t i v e l y

i n d e p e n d e n t of each o t h e r and c o n t r i b u t e s i g n i f i c a n t l y t o the t o t a l

s c o r e . T h i s f i n d i n g s u p p o r t s t h e c o n t e n t i o n t h a t t h e i n s t r u m e n t appears

to have a s a t i s f a c t o r y s t r u c t u r e f o r a s s e s s i n g m u l t i p l e domains subsumed

w i t h i n p s y c h o s o c i a l a d j u s t m e n t . R e v i s i o n o f i t e m s i n the Domestic

Environment s u b s c a l e , as w e l l as tho s e i n the V o c a t i o n a l and E x t e n d e d

F a m i l y s u b s c a l e s , c o u l d f u r t h e r s t r e n g t h e n the p s y c h o m e t r i c p r o p e r t i e s

of t h i s i n s t r u m e n t .

MCGILL PAIN QUESTIONNAIRE (MPQ)

The M c G i l l P a i n Q u e s t i o n n a i r e ( M e l z a c k , 1975) i s a p a i n -

p e r c e p t i o n measure t h a t a s s e s s e s the m u l t i d i m e n s i o n a l a s p e c t s o f p a i n -

r e p o r t . As such i t i s f r e e from many of the d i f f i c u l t i e s a s s o c i a t e d

- 42 -

w i t h n u m e r i c a l , v e r b a l and v i s u a l a n a l o g u e s c a l e s . The MPQ c o n s i s t s of

20 c a t e g o r y s c a l e s of a d j e c t i v e p a i n d e s c r i p t o r s t h a t a r e c o n s i d e r e d t o

be r e p r e s e n t a t i v e of the s e n s o r y , a f f e c t i v e , and e v a l u a t i v e d i m e n s i o n s

of p a i n ( M e l z a c k , 1975). T h i s q u e s t i o n n n a i r e i s p r o b a b l y the most

common measure of p a i n r e p o r t c u r r e n t l y used i n c h r o n i c p a i n r e s e a r c h

s t u d i e s and i s d e s i g n e d t o e v a l u a t e b o t h the q u a l i t y and the i n t e n s i t y

o f p a i n . The MPQ has been shown t o d i s t i n g u i s h d i f f e r e n t p a i n

c o n d i t i o n s w i t h 77% e f f i c i e n c y ( D u b u i s s o n & M e l z a c k , 1976), a s s i s t i n

d e t e r m i n i n g the f u n c t i o n a l s t a t u s of p a i n ( L e a v i t t & G a r r o n , 1980), and

p e r f o r m as a dependent measure i n p a i n t r e a t m e n t e v a l u a t i o n s (Fox &

M e l z a c k , 1976). A copy of the MPQ i s found i n App e n d i x F.

R e l i a b i l i t y :

Three i n v e s t i g a t i o n s of the MPQ's r e l i a b i l i t y have been

p u b l i s h e d (Fox & M e l z a c k , 1976; M e l z a c k , 1975; M e l z a c k & P e r r y , 1975)

and a l l y i e l d e v i d e n c e s u g g e s t i n g t h a t i n d i v i d u a l s ' c h o i c e s of c a t e g o r y

s c a l e s appear t o be a d e q u a t e l y c o n s i s t e n t a c r o s s one week time p e r i o d s .

Graham, Bond, G e e k o v i c h and Cooke (1980) t e s t e d c a n c e r p a i n p a t i e n t s

w i t h t h e MPQ a t 4 s u c c e s s i v e w e e k l y i n t e r v a l s and found c o n s e c u t i v e

c o n s i s t e n c y r a t i n g s o f 75.0%, 66.0%, and 80.4%. Thus, the MPQ y i e l d s

h i g h l y comparable measures when a d m i n i s t e r e d more t h a n once.

V a l i d i t y :

C o n t e n t and C o n s t r u c t V a l i d i t y . S e v e r a l i n v e s t i g a t i o n s (Fox &

M e l z a c k , 1976; and M e l z a c k & P e r r y , 1975) have p r o v i d e d c o n s i s t e n t and

- 43 -

p o s i t i v e e v i d e n c e r e g a r d i n g t h e c o n t e n t and c o n s t r u c t v a l i d i t y o f t h e

MPQ. P r i e t o , Hopson, B r a d l e y , B y r n e , G e i s i n g e r , Midox and M a r c h i s e l l o

(1980) found t h a t low back p a i n p a t i e n t s ' r e s p o n s e s t o the MPQ produced

3 f a c t o r s t h a t were composed s o l e l y of s e n s o r y , a f f e c t i v e and e v a l u a t i v e

c a t e g o r y s c a l e s , r e s p e c t i v e l y . T h i s l a t t e r s t u d y as w e l l as R e a d i n g ' s

(1979) f a c t o r a n a l y s i s of p a t i e n t s ' r e s p o n s e s p r o v i d e f u r t h e r e v i d e n c e

c o n c e r n i n g the c o n s t r u c t v a l i d i t y of the MPQ.

D a t a C o l l e c t i o n

I n i t i a l c o n t a c t w i t h the s u b j e c t s was made by a l e t t e r

( A p p e n d i x A) s e n t t o one hundred i n d i v i d u a l s who had completed t h e p a i n

t r e a t m e n t program. They were a s i m p l e random sample s e l e c t e d by u s i n g a

t a b l e of random numbers. I n c l u d e d i n the m a i l i n g were the f o l l o w i n g :

a) I n s t r u c t i o n Sheet ( A p p e n d i x B ) ;

b) B i o g r a p h i c a l I n f o r m a t i o n Q u e s t i o n n a i r e ( A ppendix C ) ;

c) R o t t e r ' s Locus of C o n t r o l S c a l e ( A p p e n d i x D);

d) Adju s t m e n t t o C h r o n i c P a i n S c a l e ( A p p e n d i x E ) ;

e) M c G i l l P a i n Q u e s t i o n n a i r e ( A p p e n d i x F ) ;

f ) A stamped, s e l f a d d r e s s e d r e t u r n e n v e l o p e .

A l l s u b j e c t s were asked t o f i l l out the q u e s t i o n n a i r e s and

r e t u r n them by m a i l i n the e n v e l o p e p r o v i d e d . Two weeks a f t e r the

m a i l i n g a l l s u b j e c t s were c o n t a c t e d by t e l e p h o n e f o l l o w u p .

- 44 -

R e s e a r c h Hypotheses and Method o f T e s t i n g

H y p o t h e s i s 1.

There w i l l be a s t a t i s t i c a l l y s i g n i f i c a n t l i n e a r r e l a t i o n s h i p between

l o c u s o f c o n t r o l , as measured on R o t t e r ' s Locus of C o n t r o l S c a l e , and

p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n , as measured on the Adj u s t m e n t

t o C h r o n i c P a i n S c a l e (ACPS), f o r p a t i e n t s who have completed an

i n - p a t i e n t , m u l t i d i s c i p l i n a r y p a i n t r e a t m e n t program.

A P e a r s o n Product-moment c o r r e l a t i o n c o e f f i c i e n t was computed u s i n g

t o t a l s c o r e s f o r each s u b j e c t on l o c u s o f c o n t r o l and t o t a l s c o r e s f o r

each s u b j e c t on a d j u s t m e n t t o c h r o n i c p a i n .

H y p o t h e s i s 2.

There w i l l be a s t a t i s t i c a l l y s i g n i f i c a n t p o s i t i v e r e l a t i o n s h i p between

l o c u s o f c o n t r o l , as measured on R o t t e r ' s L ocus o f C o n t r o l S c a l e , and

a d j u s t m e n t to c h r o n i c p a i n , as measured on the Adj u s t m e n t t o C h r o n i c '

P a i n S c a l e (ACPS), f o r males who have completed an i n - p a t i e n t p a i n

t r e a t m e n t program and f o r f e m a l e s who have completed an i n - p a t i e n t p a i n

t r e a t m e n t program.

P e a r s o n Product-moment c o r r e l a t i o n c o e f f i c i e n t s were c a l c u l a t e d , one f o r

males and one f o r f e m a l e s , u s i n g t o t a l s c o r e s f o r each male and each

female on l o c u s of c o n t r o l and t o t a l ACPS s c o r e s f o r each male and each

f e m a l e .

- 45 -

H y p o t h e s i s 3.

There w i l l be a s t a t i s t i c a l l y s i g n i f i c a n t l i n e a r r e l a t i o n s h i p between

the t o t a l s c o r e s on R o t t e r ' s L o c u s o f C o n t r o l S c a l e and t o t a l s c o r e s on

t h e M c G i l l P a i n Q u e s t i o n n a i r e (MPQ) f o r p a t i e n t s f o l l o w i n g an

i n - p a t i e n t , m u l t i d i s c i p l i n a r y p a i n t r e a t m e n t program.

A P e a r s o n Product-moment c o r r e l a t i o n c o e f f i c i e n t was computed u s i n g

t o t a l s c o r e s f o r each s u b j e c t on l o c u s o f c o n t r o l and t o t a l MPQ s c o r e s

f o r each s u b j e c t .

H y p o t h e s i s 4.

Mean Adjustment t o C h r o n i c P a i n S c o r e s (ACPS) f o r males w i l l be

s i g n i f i c a n t l y d i f f e r e n t t h a n mean ACPS s c o r e s f o r f e m a l e s .

The i n d e p e n d e n t groups t - t e s t f o r t h e d i f f e r e n c e between means was used

to d e t e r m i n e i f t h e r e was a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e between

th e means o f t h e two groups a t t h e .05 l e v e l o f s i g n i f i c a n c e .

H y p o t h e s i s 5.

Those s u b j e c t s who r e p o r t good a d j u s t m e n t on t h e ACPS ( l o w e r s c o r e s )

w i l l s c o r e s i g n i f i c a n t l y d i f f e r e n t on the Locus of C o n t r o l S c a l e t h a n

t h o s e s u b j e c t s who r e p o r t poor a d j u s t m e n t on the ACPS. The i n d e p e n d e n t

groups t - t e s t f o r the d i f f e r e n c e between means was used t o d e t e r m i n e i f

t h e r e was a s t a t i s t i c a l l y s i g n i f i c a n t d i f f e r e n c e between t h e means of

the two groups a t the .05 l e v e l of s i g n i f i c a n c e .

- 46 -

Summary

I n t h i s c h a p t e r a d e s c r i p t i o n o f the sample was p r e s e n t e d ,

f o l l o w e d by a d e s c r i p t i o n o f t h e i n s t r u m e n t s , d a t a c o l l e c t i o n

p r o c e d u r e s , and the r e s e a r c h h y p o t h e s e s and the methods of t e s t i n g . The

f o l l o w i n g c h a p t e r p r e s e n t s the r e s u l t s o f the d a t a a n a l y s e s .

- 47 -

CHAPTER FOUR

R e s u l t s

I n t h e p r e c e d i n g c h a p t e r , the p r o c e d u r e f o r b o t h d a t a

c o l l e c t i o n and a n a l y s i s were p r e s e n t e d . T h i s c h a p t e r c o n s i s t s of a

r e s t a t e m e n t , f o r the c o n v e n i e n c e of the r e a d e r , of each r e s e a r c h

h y p o t h e s i s a l o n g w i t h the method o f t e s t i n g and a summary o f t h e r e s u l t s

o f t h e a n a l y s i s c a r r i e d out t o t e s t each h y p o t h e s i s .

H y p o t h e s e s , Method o f T e s t i n g and R e s u l t s

H y p o t h e s i s 1 s t a t e d t h a t t h e r e w i l l be a s t a t i s t i c a l l y s i g n i f i c a n t

l i n e a r r e l a t i o n s h i p between l o c u s o f c o n t r o l , as measured on R o t t e r ' s

L o cus o f C o n t r o l S c a l e , and p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n , as

measured on the Adjustment to C h r o n i c P a i n s c a l e (ACPS), f o r p a t i e n t s

who have c o m p l e t e d an i n - p a t i e n t , m u l t i d i s c i p l i n a r y p a i n t r e a t m e n t

program.

I n a n a l y z i n g the d a t a a P e a r s o n Product-moment c o r r e l a t i o n

c o e f f i c i e n t was c a l c u l a t e d u s i n g t o t a l s c o r e s f o r each s u b j e c t on l o c u s

o f c o n t r o l and t o t a l s c o r e s f o r each s u b j e c t on a d j u s t m e n t t o c h r o n i c

p a i n . The r e s u l t s of the s t a t i s t i c a l a n a l y s i s on 41 s u b j e c t s r e v e a l no

s t a t i s t i c a l l y s i g n i f i c a n t l i n e a r r e l a t i o n s h i p ( r = -0.05, _p = 0.39)

between how p e o p l e r a t e t h e m s e l v e s on the Locus of C o n t r o l S c a l e and

s e l f - r a t i n g s on the ACPS. That i s , p a r t i c i p a n t s who s c o r e h i g h on the

Locus of C o n t r o l S c a l e ( e x t e r n a l ) do not n e c e s s a r i l y s c o r e h i g h on the

- 48 -

ACPS (p o o r a d j u s t m e n t ) . The p r o b a b i l i t y of a Type I e r r o r i s q u i t e h i g h

(0.39) and t h e r e f o r e i t i s l i k e l y t h a t the n u l l h y p o t h e s i s i s t r u e .

L o cus of c o n t r o l s c o r e s and a d j u s t m e n t t o c h r o n i c p a i n s c o r e s f o r a l l

s u b j e c t s a r e p r e s e n t e d g r a p h i c a l l y i n F i g u r e 1.

W h i l e t h e c o r r e l a t i o n c o e f f i c i e n t i s low and appears

n o n s i g n i f i c a n t a c c o r d i n g t o the s t a t i s t i c a l t e s t , the g r a p h i c

r e p r e s e n t a t i o n of the d a t a i n d i c a t e s a t r e n d i n the d i r e c t i o n o f an

i n v e r s e r e l a t i o n s h i p between l o c u s of c o n t r o l s c o r e s and a d j u s t m e n t t o

c h r o n i c p a i n s c o r e s . More of the d a t a p o i n t s a r e i n Quadrants 1 and 3

(X of ACPS s c o r e s = 36.59; X of LOC s c o r e s = 7.44) i n d i c a t i n g perhaps

t h a t p a r t i c i p a n t s who s c o r e d low on the Locus of C o n t r o l S c a l e

( i n t e r n a l ) may s c o r e h i g h on t h e ACPS (p o o r a d j u s t m e n t ) .

The p r e s e n c e of two o u t l i e r s i n d i c a t e s t h a t the s t a t i s t i c a l

a n a l y s i s may have been a f f e c t e d by o u t l i e r c o n t a m i n a t i o n . The s c o r e s of

these two r e s e a r c h s u b j e c t s d i f f e r r e m a r k a b l y from the g e n e r a l p a t t e r n

e s t a b l i s h e d by o t h e r s u b j e c t s i n the sample. C l o s e r i n s p e c t i o n o f the

i n d i v i d u a l s c o r e s r e v e a l e d t h a t the two s u b j e c t s r e p r e s e n t the extremes

of the i n t e r n a l - e x t e r n a l s c a l e . T h e i r s c o r e s c o u l d be v i e w e d as

d e v i a n t s or o u t l i e r s i n the s t a t i s t i c a l a n a l y s i s . A r e c a l c u l a t i o n o f

t h e P e a r s o n Product-moment c o r r e l a t i o n c o e f f i c i e n t on t h e "trimmed" d a t a

may r e v e a l a d i f f e r e n t c o r r e l a t i o n c o e f f i c i e n t , s i n c e i t i s p o s s i b l e

t h a t t h e o u t l i e r s c o n t a m i n a t e d the d a t a r e s u l t i n g i n a h i g h l y s u s p e c t

c o r r e l a t i o n c o e f f i c i e n t .

A r e c a l c u l a t i o n of the P e a r s o n Product-moment c o r r e l a t i o n

c o e f f i c i e n t was done, o m i t t i n g the two s u b j e c t s d e f i n e d above as

o u t l i e r s , u s i n g t o t a l s c o r e s f o r each s u b j e c t on l o c u s of c o n t r o l and

- 49 -

<D u o o

o u +-> c o CJ

20

19

18

17

16

15

14

13

12

11

10

9

8

7

% 6| 10 O

o 5

4

3

2

1

0 l 10 20 30 40 50 60 70

Adjustment to Chronic Pain Scores

Figure 1. Locus of control scores and Adjustment to chronic pain scores for 41 subjects, r = -0.05.

- 50 -

t o t a l s c o r e s f o r each s u b j e c t on a d j u s t m e n t t o c h r o n i c p a i n . The

r e s u l t s of t h i s second s t a t i s t i c a l a n a l y s i s on 39 s u b j e c t s r e v e a l no

s t a t i s t i c a l l y s i g n i f i c a n t i n v e r s e r e l a t i o n s h i p (r_ = -0.07, jo = 0.33)

between how p e o p l e r a t e t h e m s e l v e s on the Locus of C o n t r o l S c a l e and

s e l f - r a t i n g s on t h e ACPS. However, the n e g a t i v e r v a l u e i n d i c a t e s

perhaps a t r e n d t h a t p a r t i c i p a n t s who s c o r e low on the Locus of C o n t r o l

S c a l e ( i n t e r n a l ) may s c o r e h i g h on t h e ACPS (p o o r a d j u s t m e n t ) .

H y p o t h e s i s 2 s t a t e d t h a t t h e r e w i l l be a s t a t i s t i c a l l y s i g n i f i c a n t

l i n e a r r e l a t i o n s h i p between l o c u s of c o n t r o l , as measured on R o t t e r ' s

L o c us of C o n t r o l S c a l e , and p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n , as

measured on the Adjustment t o C h r o n i c P a i n S c a l e (ACPS), f o r males and

f o r f e m a l e s s e p a r a t e l y who have completed an i n - p a t i e n t , m u l t i d i s c i p l i n ­

a r y p a i n t r e a t m e n t programs.

I n a n a l y z i n g the d a t a two P e a r s o n Product-moment c o r r e l a t i o n

c o e f f i c i e n t s were c a l c u l a t e d , one f o r males and one f o r f e m a l e s , u s i n g

t o t a l s c o r e s f o r each sex on l o c u s of c o n t r o l and t o t a l s c o r e s f o r each

sex on a d j u s t m e n t t o c h r o n i c p a i n . The r e s u l t s of t h e s t a t i s t i c a l

a n a l y s i s f o r 28 male s u b j e c t s r e v e a l no s t a t i s t i c a l l y s i g n i f i c a n t l i n e a r

r e l a t i o n s h i p (_r = 0.25, _p = 0.10) between how males r a t e t h e m s e l v e s on

the Locus of C o n t r o l S c a l e and how they r a t e t h e m s e l v e s on the

A d j u s t m e n t t o C h r o n i c P a i n S c a l e . That i s , males who s c o r e h i g h on the

l o c u s of c o n t r o l s c a l e ( e x t e r n a l ) do not n e c e s s a r i l y s c o r e h i g h on the

ACPS ( p o o r a d j u s t m e n t ) . L o cus of c o n t r o l s c o r e s and a d j u s t m e n t t o

c h r o n i c p a i n s c o r e s f o r male s u b j e c t s a r e p r e s e n t e d g r a p h i c a l l y i n

F i g u r e 2.

- 51 -

m U o o

o u +-> c o o

m O

o

20

19

18

17

16

15

14

13

12

11

10

9

8

7

6

5

4

3

2

1

01 10 20 30 40 50

Adjustment to Chronic Pain Scores

60 70

Figure 2. Locus of control scores and Adjustment to chronic pain scores for 28 male subjects, r = 0.25.

- 52 -

The r e s u l t s of the s t a t i s t i c a l analysis for 13 female subjects

reveal a s t a t i s t i c a l l y s i g n i f i c a n t inverse r e l a t i o n s h i p (r_ = -0.74, p_ =

0.002) between how females rate themselves on the Locus of Control Scale

and how they rate themselves on the ACPS. That i s , females who score

high on the Locus of Control Scale (external) also score low on the ACPS

(good adjustment). Locus of control scores and psychosocial adjustment

to chronic pain scores for female subjects are presented graphically i n

Figure 3.

Hypothesis 3 stated that there w i l l be a s t a t i s t i c a l l y s i g n i f i c a n t

l i n e a r r e l a t i o n s h i p between the t o t a l scores on Rotter's Locus of

Control Scale and the t o t a l scores on the M c G i l l Pain Questionnaire

(MPQ) for patients following an inpatient, m u l t i d i s c i p l i n a r y pain

treatment program.

In analyzing the data a Pearson Product-moment c o r r e l a t i o n

c o e f f i c i e n t was calculated using t o t a l scores for each subject for locus

of control and for MPQ. One subject was dropped from the analysis since

no MPQ score was a v a i l a b l e . The r e s u l t s of the s t a t i s t i c a l analysis on

40 subjects reveal no s t a t i s t i c a l l y s i g n i f i c a n t l i n e a r r e l a t i o n s h i p (r =

0.04, jo = 0.39) between i n d i v i d u a l s ' locus of control scores and t h e i r

present rating of pain scores. That i s , p a r t i c i p a n t s who score high on

the Locus of Control Scale (external) do not necessarily score high on

the MPQ.

It i s possible that a r e l a t i o n s h i p between the variables of

locus of control and reported pain may have been obscured by t r e a t i n g

the two genders as a homogenous group. Pearson Product-moment

c o r r e l a t i o n c o e f f i c i e n t s were calculated for males and females

- 53 -

10 20 30 40 50 60 70

Adjustment to Chronic Pain Scores

Figure 3. Locus of control scores and Adjustment to chronic pain scores for 13 female subjects, r = 0.74.

s e p a r a t e l y u s i n g t o t a l s c o r e s f o r each sex f o r l o c u s of c o n t r o l and

MPQ. The r e s u l t s of t h e s e s t a t i s t i c a l a n a l y s e s a r e p r e s e n t e d i n

T a b l e 3.

TABLE 3

P e a r s o n Product-Moment C o r r e l a t i o n C o e f f i c i e n t s F o r Males and F emales U s i n g T o t a l S c o r e s F o r Each Sex on Locus of C o n t r o l and MPQ

Male s Females n = 27 n = 13

r 0.33 -0.74

p_ 0.05 0.00

F o r males, t h e r e appears t o be a s t a t i s t i c a l l y s i g n i f i c a n t

l i n e a r r e l a t i o n s h i p (r_ = 0.33) between how they r a t e t h e m s e l v e s on l o c u s

of c o n t r o l and t h e i r p r e s e n t r a t i n g of p a i n . That i s , males who s c o r e

h i g h on l o c u s of c o n t r o l ( e x t e r n a l ) a l s o s c o r e h i g h on the MPQ ( h i g h

r a t i n g of p a i n ) . F o r f e m a l e s , t h e r e appears t o be a s t a t i s t i c a l l y

s i g n i f i c a n t i n v e r s e r e l a t i o n s h i p Or = -0.74) between how they r a t e

t h e m s e l v e s on l o c u s of c o n t r o l and t h e i r p r e s e n t r a t i n g of p a i n . That

i s , f e m a l e s who s c o r e low on l o c u s of c o n t r o l ( i n t e r n a l ) a l s o s c o r e h i g h

on the MPQ ( h i g h r a t i n g of p a i n ) .

H y p o t h e s i s 4 s t a t e d t h a t the mean ACPS ( a d j u s t m e n t t o c h r o n i c p a i n )

s c o r e s f o r male s u b j e c t s w i l l be d i f f e r e n t t h a n the mean ACPS s c o r e s f o r

fe m a l e s u b j e c t s .

- 55 -

I n a n a l y z i n g the d a t a , a t w o - t a i l e d t - t e s t f o r i n d e p e n d e n t

groups was done to d e t e r m i n e the s i g n i f i c a n c e of the d i f f e r e n c e between

t h e means on the male and the f e m a l e groups. The l e v e l of s i g n i f i c a n c e

was s e t a t .05. The means, s t a n d a r d d e v i a t i o n s and the r e s u l t s of t h e

t - t e s t u s i n g the ACPS t o compare the two groups a r e p r e s e n t e d i n

T a b l e 4.

TABLE 4

T - t e s t U s i n g A d j u s t m e n t t o C h r o n i c P a i n S c o r e s t o Compare Ma l e s and Females

S t a n d a r d V a r i a b l e Mean D e v i a t i o n t_ g_

M a l e s 38.11 13.03 n = 28

1.07 0.29

Females 33.31 14.03 n = 13

The h y p o t h e s i s t h a t t h e p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c

p a i n of males i s d i f f e r e n t t h a n the p s y c h o s o c i a l a d j u s t m e n t to c h r o n i c

p a i n of f e m a l e s i s not s u p p o r t e d by the r e s u l t s of the a n a l y s i s . That

i s , a f t e r an i n - p a t i e n t , m u l t i d i s c i p l i n a r y p a i n t r e a t m e n t program no

s i g n i f i c a n t d i f f e r e n c e s a r e f ound between the male and f e m a l e groups on

the mean s c o r e s of the ACPS.

- 56 -

H y p o t h e s i s 5 s t a t e d t h a t t h o s e s u b j e c t s who r e p o r t e d good p s y c h o s o c i a l

a d j u s t m e n t on the ACPS ( l o w e r s c o r e s ) w i l l have s i g n i f i c a n t l y d i f f e r e n t

s c o r e s on the Locus of C o n t r o l S c a l e t h a n t h o s e s u b j e c t s who r e p o r t poor

p s y c h o s o c i a l a d j u s t m e n t on the ACPS ( h i g h e r s c o r e s ) .

The s u b j e c t s were 24 males and f e m a l e s s e l e c t e d from the t o t a l

sample of 41 on the b a s i s of t h e i r s c o r e s on the ACPS. The good

a d j u s t e r s (n = 9) c o n s i s t e d of p a r t i c i p a n t s who s c o r e d f r o m 10-24 on t h e

ACPS and the poor a d j u s t e r s (n = 15) c o n s i s t e d of t h o s e who s c o r e d f r o m

44-63 on t h e ACPS. These groups r e p r e s e n t e d r o u g h l y the l o w e r and upper

t h i r d s of the ACPS s c o r e d i s t r i b u t i o n . The means and s t a n d a r d

d e v i a t i o n s f o r ACPS s c o r e s f o r the good and poor a d j u s t e r s w i t h a

breakdown by sex i s p r e s e n t e d i n T a b l e 5.

TABLE 5

Means and S t a n d a r d D e v i a t i o n s of ACPS S c o r e s f o r Two A d j u s t e r Groups of Males and Females

Good A d j u s t e r s P o o r A d j u s t e r s

V a r i a b l e M a l e s Females T o t a l M a l e s Females T o t a l

N 4 5 9 11 4 15

Mean 14.50 19.80 17.44 50.46 50.00 50.33

S t a n d a r d 5.45 3.70 5.08 4.00 8.68 5.26 D e v i a t i o n

- 57 -

I n a n a l y z i n g the d a t a a t w o - t a i l e d t - t e s t f o r i n d e p e n d e n t

groups was done t o d e t e r m i n e the s i g n i f i c a n c e of the d i f f e r e n c e between

t h e means of t h e 2 g r o u p s . The l e v e l o f s i g n i f i c a n c e was s e t a t .05-

The means, s t a n d a r d d e v i a t i o n s , and the r e s u l t s of the t - t e s t u s i n g

l o c u s of c o n t r o l s c o r e s t o compare the 2 groups a r e p r e s e n t e d i n T a b l e

6.

TABLE 6

T - t e s t U s i n g L o cus of C o n t r o l S c o r e s t o Compare Good and Poor A d j u s t e r s

V a r i a b l e Mean S t a n d a r d D e v i a t i o n

Good a d j u s t e r s 8.22 n = 9

2.73

0.27 0.79

Poor a d j u s t e r s 7.80 n = 15

4.21

The h y p o t h e s i s t h a t t h o s e s u b j e c t s who r e p o r t good

p s y c h o s o c i a l a d j u s t m e n t to c h r o n i c p a i n w i l l have d i f f e r e n t l o c u s o f

c o n t r o l s c o r e s t h a n t h o s e s u b j e c t s who r e p o r t poor p s y c h o s o c i a l

a d j u s t m e n t i s not s u p p o r t e d by the r e s u l t s of the a n a l y s i s . No

s i g n i f i c a n t d i f f e r e n c e s a r e found between t h o s e s u b j e c t s who r e p o r t good

p s y c h o s o c i a l a d j u s t m e n t and t h o s e s u b j e c t s who r e p o r t poor p s y c h o s o c i a l

a d j u s t m e n t on the mean s c o r e s of the Locus of C o n t r o l S c a l e .

- 58 -

Secondary A n a l y s i s

I n a d d i t i o n to the above f i v e a n a l y s e s , a s e c o n d a r y a n a l y s i s

was p e r f o r m e d t o e x p l o r e a n o t h e r p o s s i b l e r e l a t i o n s h i p .

H y p o t h e s i s 1 examined t h e c o r r e l a t i o n between l o c u s of c o n t r o l and

p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n . F u r t h e r e x a m i n a t i o n of t h e

s c a t t e r p l o t of the r e s e a r c h d a t a i n d i c a t e d t h a t t h e r e l a t i o n s h i p between

the v a r i a b l e s l o c u s of c o n t r o l and p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c

p a i n might be n o n l i n e a r . I n t h o s e i n s t a n c e s where t h e r e l a t i o n s h i p

between v a r i a b l e s i s m a r k e d l y n o n l i n e a r t h e P e a r s o n Product-moment

c o r r e l a t i o n c o e f f i c i e n t i s i n a p p r o p r i a t e , and would u n d e r e s t i m a t e the

s t r e n g t h of a s s o c i a t i o n . R o t t e r (1966) and P h a r e s (1976) i n d i c a t e d some

s u p p o r t f o r t h e e x i s t e n c e of a c u r v i l i n e a r r e l a t i o n s h i p between t h e

extremes of l o c u s of c o n t r o l s c o r e s and m a l a d j u s t m e n t .

To t e s t the c u r v i l i n e a r i t y of the d a t a a c o r r e l a t i o n r a t i o

( e t a ) was c a l c u l a t e d u s i n g t o t a l s c o r e s f o r each s u b j e c t on l o c u s of

c o n t r o l and ACPS. The r e s u l t s of t h e s t a t i s t i c a l a n a l y s i s on 41

s u b j e c t s r e v e a l a s t a t i s t i c a l d e p a r t u r e from l i n e a r i t y ( e t a = 0.62, e t a

s q u a r e d = 0.39) between how p e o p l e r a t e t h e m s e l v e s on t h e Locus of

C o n t r o l S c a l e and s e l f - r a t i n g s on the ACPS. That i s , p a r t i c i p a n t s who

s c o r e h i g h on the Locus of C o n t r o l S c a l e ( e x t e r n a l ) and p a r t i c i p a n t s who

s c o r e low on the Locus of C o n t r o l S c a l e ( i n t e r n a l ) t e n d t o s c o r e h i g h on

t h e ACPS (p o o r a d j u s t m e n t ) . About 39% of the t o t a l v a r i a n c e i s

a c c o u n t e d f o r by the i n d e p e n d e n t v a r i a b l e , p s y c h o s o c i a l a d j u s t m e n t t o

c h r o n i c p a i n .

- 59 -

Summary o f R e s u l t s

T h i s s t u d y was d e s i g n e d t o i n v e s t i g a t e f i v e h y p o t h e s i s each

c o n c e r n e d w i t h t h e v a r i a b l e of l o c u s of c o n t r o l and p s y c h o s o c i a l

a d j u s t m e n t t o c h r o n i c p a i n . The summary p r e s e n t s the r e s u l t s of the

t e s t i n g of each h y p o t h e s i s .

H y p o t h e s e s

1. There appears t o be no s t a t i s t i c a l l y s i g n i f i c a n t l i n e a r

r e l a t i o n s h i p between how p a r t i c i p a n t s r a t e t h e m s e l v e s on

l o c u s of c o n t r o l and s e l f - r a t i n g s on p s y c h o s o c i a l

a d j u s t m e n t t o c h r o n i c p a i n .

2. There appears t o be no s t a t i s t i c a l l y s i g n i f i c a n t l i n e a r

r e l a t i o n s h i p between how males r a t e t h e m s e l v e s on l o c u s of

c o n t r o l and s e l f - r a t i n g s on p s y c h o s o c i a l a d j u s t m e n t t o

c h r o n i c p a i n . There appears t o be a s t a t i s t i c a l l y

s i g n i f i c a n t i n v e r s e l i n e a r r e l a t i o n s h i p between how

f e m a l e s r a t e t h e m s e l v e s on l o c u s of c o n t r o l and

s e l f - r a t i n g s on p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n .

3. There appears t o be no s t a t i s t i c a l l y s i g n i f i c a n t l i n e a r

r e l a t i o n s h i p between p a r t i c i p a n t s ' l o c u s of c o n t r o l s c o r e s

and t h e i r p r e s e n t r a t i n g of p a i n . F o r males, t h e r e

appears t o be a s i g n i f i c a n t l i n e a r r e l a t i o n s h i p between

how they r a t e t h e m s e l v e s on l o c u s of c o n t r o l and t h e i r

p r e s e n t r a t i n g of p a i n . F o r f e m a l e s , t h e r e appears t o be

a s t a t i s t i c a l l y s i g n i f i c a n t i n v e r s e r e l a t i o n s h i p between

- 60 -

how they r a t e t h e m s e l v e s on l o c u s of c o n t r o l and t h e i r

p r e s e n t r a t i n g of p a i n .

4. There appears t o be no s i g n i f i c a n t d i f f e r e n c e i n the

p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n s c o r e s (ACPS) of

males and f e m a l e s .

5. There appears t o be no s i g n i f i c a n t d i f f e r e n c e i n the l o c u s

of c o n t r o l s c o r e s between t h o s e s u b j e c t s who r e p o r t good

p s y c h o s o c i a l a d j u s t m e n t and t h o s e s u b j e c t s who r e p o r t poor

p s y c h o s o c i a l a d j u s t m e n t .

Supplementary A n a l y s i s

1. There appears t o be a s t a t i s t i c a l l y s i g n i f i c a n t

c u r v i l i n e a r r e l a t i o n s h i p between t h e extremes of l o c u s of

c o n t r o l ( i n t e r n a l s and e x t e r n a l s ) and poor p s y c h o s o c i a l

a d j u s t m e n t t o c h r o n i c p a i n .

- 61 -

CHAPTER V

Summary, C o n c l u s i o n and D i s c u s s i o n

The p r e c e d i n g c h a p t e r p r e s e n t e d a r e s t a t e m e n t o f each

h y p o t h e s i s a l o n g w i t h the method of t e s t i n g and t h e r e s u l t s o f t h e

a n a l y s i s c a r r i e d o ut t o t e s t each h y p o t h e s i s . T h i s c h a p t e r p r e s e n t s a

summary, c o n c l u s i o n s and d i s c u s s i o n . I n a d d i t i o n , l i m i t a t i o n s o f the

i n v e s t i g a t i o n , i m p l i c a t i o n s and s u g g e s t i o n s f o r f u t u r e r e s e a r c h a r e

d i s c u s s e d .

Summary

C h r o n i c p a i n p a t i e n t s c o n s t i t u t e a p o p u l a t i o n where t h e i s s " e

o f c o n t r o l o v e r r e i n f o r c e m e n t i s l i k e l y t o be an i m p o r t a n t f a c t o r i n

t h e i r r e h a b i l i t a t i o n o r p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n .

R e g a r d l e s s o f how p h y s i c a l l y o r m e d i c a l l y a d v i s a b l e some a c t i v i t i e s may

be, i f t h e y a r e not p e r c e i v e d and i n t e r p r e t e d as b e n e f i c i a l o r w i t h i n

one's c o n t r o l t h e n t h e impact o f t r e a t m e n t may f a i l on p s y c h o l o g i c a l

g r o u n d s .

The v a r i a b l e s i n v o l v e d i n p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c

p a i n a r e numerous. I n an e f f o r t t o b e t t e r u n d e r s t a n d c e r t a i n f a c t o r s

w h i c h c o n t r i b u t e t o poor and good p s y c h o s o c i a l a d j u s t m e n t , t h i s s t u d y

sought t o examine the r e l a t i o n s h i p between i n t e r n a l - e x t e r n a l l o c u s o f

c o n t r o l and p s y c h o s o c i a l a d j u s t m e n t . The r e s e a r c h was i n t e n d e d t o see

whether t h e r e i s any v a l i d i t y i n a p p l y i n g the c o n s t r u c t o f l o c u s o f

c o n t r o l t o the c o n c e p t s of p s y c h o s o c i a l a d j u s t m e n t to c h r o n i c p a i n and

- 62 -

r e p o r t e d p a i n f o r s u b j e c t s who had c ompleted a m u l t i d i s c i p l i n a r y p a i n

t r e a t m e n t program. The r e s e a r c h q u e s t i o n s assumed t h a t a r e l a t i o n s h i p

e x i s t s between an i n d i v i d u a l ' s b e l i e f t h a t d e s i r e d outcomes a r e

c o n t i n g e n t upon h i s / h e r own b e h a v i o r and good p s y c h o s o c i a l a d j u s t m e n t as

r e l a t e d t o v a r i o u s a r e a s of one's l f e . F u r t h e r m o r e , i t was r e a s o n e d

t h a t l o c u s of c o n t r o l , as a p e r s o n a l i t y measure, would be r e f l e c t e d by

t h e degree of an i n d i v i d u a l ' s r e p o r t e d p a i n p o s t - t r e a t m e n t .

The o b j e c t i v e s of the s t u d y were to answer f i v e q u e s t i o n s .

F i r s t , i s t h e r e a r e l a t i o n s h i p between l o c u s of c o n t r o l and p s y c h o s o c i a l

a d j u s t m e n t t o c h r o n i c p a i n f o r c h r o n i c p a i n p a t i e n t s who have c o m p l e t e d

an i n - p a t i e n t , m u l t i d i s c i p l i n a r y p a i n t r e a t m e n t program? Second, i s

t h e r e a r e l a t i o n s h i p between l o c u s of c o n t r o l and a d j u s t m e n t t o c h r o n i c

p a i n f o r males and f o r f e m a l e s . T h i r d , i s l o c u s of c o n t r o l r e l a t e d t o

r e p o r t e d p a i n f o r c h r o n i c p a i n p a t i e n t s p o s t - t r e a t m e n t ? F o u r t h , are

t h e r e gender d i f f e r e n c e s i n t h e p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c

p a i n ? F i f t h , do the good a d j u s t e r s d i f f e r from the poor a d j u s t e r s i n

terms of l o c u s of c o n t r o l ? To answer the q u e s t i o n s d e v e l o p e d f o r the

s t u d y , a sample of f o r t y one s u b j e c t s was drawn from t h r o u g h o u t W e s t e r n

Canada. A l l f o r t y one s u b j e c t s had c ompleted a s i x - w e e k r e s i d e n t i a l ,

m u l t i d i s c i p l i n a r y p a i n t r e a t m e n t program i n V a n c o u v e r , B r i t i s h C o l u m b i a

w i t h i n t h e p a s t t h r e e y e a r s . Each s u b j e c t was m a i l e d q u e s t i o n n a i r e s .

I n terms of the o b j e c t i v e s of the s t u d y the r e s u l t s i n d i c a t e

t h a t t h e r e appears t o be a s t a t i s t i c a l l y s i g n i f i c a n t c u r v i l i n e a r

r e l a t i o n s h i p between the extreme s c o r e s of l o c u s of c o n t r o l ( i n t e r n a l s

and e x t e r n a l s ) and poor p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n . The

- 63 -

s t u d y f u r t h e r d e m o n s t r a t e s a s t r o n g c o r r e l a t i o n f o r f e m a l e s between

i n t e r n a l i t y and poor p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n . No

c o r r e l a t i o n was found between r e p o r t e d p a i n s c o r e s and l o c u s o f c o n t r o l

s c o r e s when the sexes were a n a l y z e d t o g e t h e r . However, t h e r e were

s i g n i f i c a n t c o r r e l a t i o n s f o r males between e x t e r n a l s c o r e s o f l o c u s o f

c o n t r o l and h i g h l e v e l s o f r e p o r t e d p a i n , and f o r fe m a l e s between

i n t e r n a l s c o r e s of l o c u s o f c o n t r o l and h i g h l e v e l s o f r e p o r t e d p a i n .

I t was no t e d t h a t no s i g n i f i c a n t d i f f e r e n c e s e x i s t e d between males and

fe m a l e s i n t h e i r r e p o r t e d p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n .

A d d i t i o n a l l y , t h e r e were no s i g n i f i c a n t d i f f e r e n c e s between t h e r e p o r t e d

good a d j u s t e r s and the r e p o r t e d poor a d j u s t e r s i n t h e i r l o c u s o f c o n t r o l

s c o r e s .

C o n c l u s i o n s and D i s c u s s i o n

L o c u s o f C o n t r o l and P s y c h o s o c i a l A d j u s t m e n t

T h e r e appears t o be no s i g n i f i c a n t l i n e a r r e l a t i o n s h i p between

how s u b j e c t s ' r a t e t h e m s e l v e s on the Locus o f C o n t r o l S c a l e and

s e l f - r a t i n g s on t h e ACPS. However, the r e s u l t s o f a s e c o n d a r y a n a l y s i s

a r e s u p p o r t i v e of a c u r v i l i n e a r r e l a t i o n s h i p between l o c u s o f c o n t r o l

and p s y c h o s o c i a l a d j u s t m e n t f o r a l l s u b j e c t s . There i s some e v i d e n c e t o

s u p p o r t the c o n t e n t i o n t h a t t h e r e might be a U-shaped r e l a t i o n s h i p w i t h

b o t h v e r y e x t e r n a l and v e r y i n t e r n a l s u b j e c t s i n d i c a t i n g poor

p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n .

A p o s s i b l e e x p l a n a t i o n m ight be t h a t e x t r e m e l y i n t e r n a l

i n d i v i d u a l s c o u l d be so overwhelmed w i t h a sense o f p e r s o n a l

- 64 -

r e s p o n s i b i l i t y o v e r each f a i l u r e o f t h e i r own r e g a r d i n g p a i n management

and hence f e e l v e r y h e l p l e s s . Due t o the v e r y f r u s t r a t i n g and

u n p r e d i c t a b l e n a t u r e o f c h r o n i c p a i n , t h e s e extreme i n t e r n a l s might

r e a c t w i t h u n c e r t a i n t y r e g a r d i n g t h e i r own i n s t r u m e n t a l i t y . The v e r y

a t t r i b u t e w h i c h i n o t h e r s i t u a t i o n s enhances i n d i v i d u a l s ' c a p a c i t y t o

cope s u c c e s s f u l l y w i t h the w o r l d ( i . e . an i n t e r n a l l o c u s of c o n t r o l ) i n

t h i s i n s t a n c e may make a d j u s t m e n t o r a d a p t a t i o n d i f f i c u l t .

A l t e r n a t e l y , i t i s p o s s i b l e t h a t s i n c e i n t e r n a l s a r e more

r e s i s t a n t t o i n f l u e n c e ( S t r i c k l a n d , 1978) t h e y m ight have responded t o

the t r e a t m e n t w i t h r e l u c t a n c e . There i s e v i d e n c e t o suggest t h a t

i n t e r n a l s have g r e a t e r s u c c e s s i n d e a l i n g w i t h t h e i r e n v i r o n m e n t s t h a n

t h o s e who s c o r e h i g h on e x t e r n a l i t y . I n t e r n a l s t e n d to use i n f o r m a t i o n

more p r o d u c t i v e l y , and a r e l e s s m a n i p u l a t e d o r c o e r c e d ( L e f c o u r t , 1966;

D o c t o r , 1971). S i n c e s u c c e s s i n a p a i n t r e a t m e n t program ( i . e . b e t t e r

p s y c h o s o c i a l a d j u s t m e n t i n t h i s s t u d y ) i s dependent, a t l e a s t i n p a r t ,

on c o m p l i a n c e to b e h a v i o r a l i n t e r v e n t i o n s i t i s p o s s i b l e t o s p e c u l a t e

t h a t the i n d i v i d u a l s who r e p o r t e d h i g h i n t e r n a l i t y were v e r y r e s i s t a n t

t o i n s t r u c t i o n . That i s , they may have had d i f f i c u l t y c o p i n g w i t h t h e

dependent n a t u r e o f c e r t a i n t r e a t m e n t s . There i s a l s o the p o s s i b i l i t y

t h a t i n t e r n a l s , f e e l i n g more i n c o n t r o l , may i n e f f e c t have l e s s o f a

need t o a c t i v e l y r espond t o t h e r a p e u t i c i n t e r v e n t i o n s .

I f c h r o n i c p a i n p a t i e n t s a r e viewed from an e x t e r n a l l o c u s o f

c o n t r o l framework as some r e s e a r c h s u g g e s t s ( A b r a m o w i t z , 1969; Harrow &

F e r r a n t e , 1969; S k e v i n g t o n , 1979) then f a i l u r e to a d j u s t w e l l on the

p s y c h o s o c i a l d i m e n s i o n s a f t e r a p a i n t r e a t m e n t program may r e s u l t from

- 65 -

a v i e w p o i n t o f the i n d i v i d u a l t h a t one's a c t i o n do not a f f e c t one's p a i n

c o n d i t i o n . The extreme e x t e r n a l s ' i n a b i l i t y to see how t h e i r b e h a v i o r

m i g h t i n f l u e n c e p a i n management, may r e s u l t i n p a s s i v i t y and l o s s o f

i n i t i a t i v e .

As d i s c u s s e d i n the r e v i e w o f the l i t e r a t u r e t h e r e i s some

s p e c u l a t i o n about b o t h extremes o f l o c u s of c o n t r o l and the r e l a t i o n s h i p

t o m a l a d j u s t m e n t ( P h a r e s , 1976; R o t t e r , 1975). P e r h a p s , poor a d j u s t m e n t

i s found i n b o t h p e o p l e who p o s s e s s a s t r o n g g e n e r a l i z e d e x p e c t a n c y t h a t

outcomes a r e t h e i r own r e s p o n s i b i l i t y and p e o p l e who do n o t e x p e c t t o

a t t a i n v a l u e d g o a l s or outcomes. Thus, a p o p u l a t i o n o f extreme

i n t e r n a l s and extreme e x t e r n a l s , h a v i n g b o t h v e r y h i g h and v e r y low

g e n e r a l i z e d e x p e c t a n c i e s f o r s u c c e s s i n a t t a i n i n g i m p o r t a n t g o a l s , may

show poor a d j u s t m e n t . The e x t e r n a l s t h i n k t h e y cannot do a n y t h i n g about

t h e i r c h r o n i c p a i n and are p o o r l y a d j u s t e d p s y c h o s o c i a l l y . The

i n t e r n a l s may be p o o r l y a d j u s t e d because of g u i l t and r e s p o n s i b i l i t y

t hey f e e l o v er i n a b i l i t y t o cope w e l l w i t h t h e i r c h r o n i c p a i n .

L o c u s o f C o n t r o l and P s y c h o s o c i a l A d j u s t m e n t f o r Ma l e s and Females

The r e s u l t s o f the s t a t i s t i c a l a n a l y s i s appear t o i n d i c a t e a

gender d i f f e r e n c e between the r e l a t i o n s h i p o f l o c u s o f c o n t r o l s c o r e s

and a d j u s t m e n t t o c h r o n i c p a i n s c o r e s . Females who i n d i c a t e d an

e x t e r n a l l o c u s o f c o n t r o l a l s o tended t o i n d i c a t e b e t t e r p s y c h o s o c i a l

a d j u s t m e n t t o c h r o n i c p a i n .

One p o s s i b l e e x p l a n a t i o n f o r the e x t e r n a l f e m a l e s i n d i c a t i n g

good a d j u s t m e n t i s t h a t they may have u n d e r p l a y e d t h e i r symptoms

- 66 -

r e s p o n d i n g on t h e ACPS i n the' d i r e c t i o n of l e s s d i s t r e s s . T h i s t h i n k i n g

i s s u p p o r t e d by P h a r e s (1976) who s t a t e d t h a t e x t e r n a l s may be b e t t e r

a b l e t o h a n d l e t h r e a t e n i n g m a t e r i a l because t h e i r e x t e r n a l i t y p r o v i d e s a

c o n v e n i e n t mode of a n x i e t y r e d u c t i o n , namely d e n i a l . I n t h i s case the

p o t e n t i a l l y t h r e a t e n i n g s t i m u l i would be f a i l u r e o r p e r s o n a l i n a d e q u a c y ,

and one would respond t o items on the q u e s t i o n n a i r e i n a s o c i a l l y

d e s i r a b l e way. Per h a p s t h e f e m a l e e x t e r n a l s had a g r e a t e r need t o be

seen i n a s o c i a l l y a c c e p t a b l e l i g h t and thus were l e s s w i l l i n g ( o r a b l e )

t h a n the f e m a l e i n t e r n a l s and the males t o acknowledge t h e e x t e n t of

t h e i r d i f f i c u l t i e s .

P e r haps an e x p l a n a t i o n f o r f i n d i n g f e m a l e e x t e r n a l s r e p o r t i n g

b e t t e r p s y c h o s o c i a l a d j u s t m e n t i s s t r i c t l y a m a t t e r of hgher l e v e l s o f

c o m p l i a n c e i n f e m a l e s . A r e c e n t s u r v e y of the l i t e r a t u r e on c o n f o r m i t y ,

p e r s u a d a b i l i t y and i n f l u e n c e a b i l i t y i n d i c a t e s t h a t women a r e not as

c o m p l i a n t i n group s i t u a t i o n s as they a r e u s u a l l y p o r t r a y e d as b e i n g

( E a g l y , 1978). They a r e , however, more l i k e l y t o conform than men when

the s i t u a t i o n i n v o l v e s male e x p e r t i s e or when t h e i r b e h a v i o r i s b e i n g

e v a l u a t e d i n the p r e s e n c e of a male e x p e r t as was the case f o r t h e p a i n

c e n t e r p o p u l t i o n f r o m w h i c h the sample was drawn.

I n v i e w of the b e t t e r a d j u s t m e n t w h i c h appears t o be r e p o r t e d

by t he e x t e r n a l l y o r i e n t e d f e m a l e s , i t appears t h a t e x t e r n a l s a r e

r e s p o n s i v e t o the more p r e s t i g i o u s s o u r c e s of t h e r a p e u t i c i n f l u e n c e

w i t h i n a s t r u c t u r e d s i t u a t i o n . That i s , they a r e r e c e p t i v e t o

s u g g e s t i o n s and d i r e c t i o n s g i v e n by p r o f e s s i o n a l s , a view s u p p o r t e d by

Abramowitz, Abramowitz, Roback, and J a c k s o n ( 1 9 7 4 ) , B a l c h and Ross

- 67 -

( 1 9 7 5 ) , and K i l m a n n , A l b e r t , and S o t i l e ( 1 9 7 5 ) . T h i s v i e w s u g g e s t s t h a t

i f t he t r e a t m e n t s t r a t e g i e s a r e c l o s e l y c o n t r o l l e d , e x t e r n a l s s h o u l d

demonstrae more t h e r a p e u t i c r e s p o n s i v e n e s s t h a n i n t e r n a l s . T h i s

appeared t o be so f o r the fe m a l e s i n the p r e s e n t s t u d y .

F o r t h e female i n t e r n a l s r e p o r t i n g poor p s y c h o s o c i a l

a d j u s t m e n t i t appears t h a t f e e l i n g one c o n t r o l s one's r e i n f o r c e m e n t i s

not s u f f i c i e n t . F o r women c o p i n g w i t h c h r o n i c p a i n i t does not seem t o

h e l p t o have a b e l i e f system i n w h i c h they p e r c e i v e the e v e n t s i n t h e i r

l i v e s as b e i n g a consequence of t h e i r own a c t i o n s , and t h e r e b y

c o n t r o l l a b l e . P e r h a p s , t h e s e f e m a l e s may e x p e r i e n c e tremendous

d i f f i c u l t y w i t h t h e i r s ense of i n s t r u m e n t a l i t y r e g a r d i n g management of

p a i n . The v e r y n a t u r e of c h r o n i c p a i n makes ad j u s t m e n t h a r d . D e s p i t e

t h e i r p e r c e p t i o n t h a t outcome i s c o n t i n g e n t upon t h e i r own c o n t r o l ,

t o t a l r e l i e f from c h r o n i c p a i n i s e l u s i v e . F r u s t r a t i o n i s e x p e r i e n c e d ,

and a h e i g h t e n e d sense of h e l p l e s s n e s s and h o p e l e s s n e s s . These

i n d i v i d u a l s may f e e l t h a t they have more c o n t r o l than i s w a r r a n t e d by

r e a l i t y , and e x p e r i e n c e g r e a t d i f f i c u l t y when th e y d i s c o v e r t h a t t h e y

cannot c o n t r o l some t h i n g s such as c h r o n i c p a i n . I n f a c t , t h e f e m a l e

i n t e r n a l s who tended t o r e p o r t poor p s y c h o s o c i a l a d j u s t m e n t may be more

r e p r e s e n t a t i v e of c h r o n i c p a i n p a t i e n t s i n g e n e r a l . T h i s n o t i o n i s

g i v e n some s u p p o r t by the e v i d e n c e p r e v i o u s l y d i s c u s s e d s u p p o r t i n g a

U-shaped r e l a t i o n s h i p w i t h both v e r y e x t e r n a l and v e r y i n t e r n a l

i n d i v i d u a l s i n d i c a t i n g poor p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n .

I n a l a r g e number of s t u d i e s L e f c o u r t (1976) f o u n d t h a t

p e r s o n s h o l d i n g an i n t e r n a l l o c u s of c o n t r o l can w i t h s t a n d p r e s s u r e s

- 68 -

d i r e c t i n g them t o behave i n c e r t a i n c i r c u m s c r i b e d manners. T h i s i s not

t r u e i n a l l i n s t a n c e s , as i n t e r n a l s do y i e l d t o p r e s s u r e s but not t o the

same p r e s s u r e s as e x t e r n a l s . S t a t e m e n t s p r e s e n t e d by a u t h o r i t i e s do not

seem t o i m p r e s s i n t e r n a l s , but i n t e r n a l s do respond t o r e a s o n e d

arguments r e g a r d l e s s of the s t a t u s of the s o u r c e . I n t e r n a l s a l s o s h i f t

t h e i r own a t t i t u d e s and b e h a v i o r s when a l l o w e d more a c t i v e

p a r t i c i p a t i o n . E x t e r n a l s appear t o be more r e s p o n s i v e t o more

p r e s t i g i o u s s o u r c e s of i n f l u e n c e , and the d e s i r e f o r a f f i l i a t i o n and

dependence may be more i m p o r t a n t t o e x t e r n a l s ( J o h n s o n , Ackerman, F r a n k ,

& F i o n d a , 1968). F o r c h r o n i c p a i n p a t i e n t s , p a r t i c u l a r l y f o r f e m a l e s ,

an i n t e r n a l l o c u s of c o n t r o l seems t o be a s s o c i a t e d w i t h a tendency t o

be c i r c u m s p e c t i n the f a c e of p r e s s u r e to y i e l d t o i n f l u e n c e .

F o r m a l es, t h e r e appears t o be no s i g n i f i c a n t l i n e a r

r e l a t i o n s h i p between l o c u s of c o n t r o l s c o r e s and p s y c h o s o c i a l

a d j u s t m e n t t o c h r o n i c p a i n . The absence of any s i g n i f i c a n t r e l a t i o n s h i p

i s p u z z l i n g g i v e n the v e r y s t r o n g c o r r e l a t i o n f o r f e m a l e s between t h e s e

v a r i a b l e s . P e r h a p s , the g e n e r a l l y d i f f e r e n t p a t t e r n s of male and femal e

s o c i a l i z a t i o n r e q u i r e d i f f e r e n t a d j u s t m e n t c r i t e r i a f o r males and

f e m a l e s . That i s , s i n c e t r a d i t i o n a l l y d e f i n e d f e m a l e r o l e s may i m p l y

g r e a t e r c o n c e r n w i t h emotions and f e e l i n g s , w h i l e male r o l e s

t r a d i t i o n a l l y have been a s s o c i a t e d w i t h g r e a t e r o v e r t a c t i v i t y and

i n s t r u m e n t a l a c t s , the n o t i o n s of p s y c h o s o c i a l a d j u s t m e n t as p r e s e n t e d

h e r e might make more sense as c r i t e r i a f o r ad j u s t m e n t f o r f e m a l e s t h a n

f o r m a l e s .

A l t e r n a t e l y , r e s e a r c h has shown t h a t p e o p l e i n many m i n o r i t y

- 69 -

and d i s a d v a n t a g e d groups t e n d t o s c o r e i n t h e e x t e r n a l d i r e c t i o n ,

p e r c e i v i n g t h e i r l i f e s i t u a t i o n s r e a l i s t i c a l l y ( Gruen, K o r t e , Baum, &

1974). I n g e n e r a l b l a c k s , women, and l o w e r s o c i o e c o n o m i c c l a s s

i n d i v i d u a l s have more r e s t r i c t i o n s on t h e i r own s u c c e s s e s r e g a r d l e s s o f

what they do o r do not do. Perhaps t h o s e f e m a l e s who r e p o r t e d good

p s y c h o s o c i a l a d j u s t m e n t and s c o r e d I n the d i r e c t i o n of e x t e r n a l i t y have

a r e a l i s t i c p e r c e p t i o n of t h e i r i n s t r u m e n t a l i t y i n t h i s s i t u a t i o n .

M a l e s , on the o t h e r hand are not a f f e c t e d i n t h e same way by s o c i a l l y

d e t e r m i n e d r e s t r a i n t s . The r e l a t i o n s h i p between p e r c e i v e d l o c u s of

c o n t r o l and s i t u a t i o n a l p o w e r l e s s n e s s ( i . e . a s i t u a t i o n of an i n d i v i d u a l

c o p i n g w i t h c h r o n i c p a i n ) may be m e d i a t e d i n p a r t a t l e a s t by the

v a r i a b l e of gender.

Locus of C o n t r o l and P r e s e n t P a i n R a t i n g s

There appears t o be no s i g n i f i c a n t s t a t i s t i c a l s u p p o r t f o r a

l i n e a r r e l a t i o n s h i p between l o c u s of c o n t r o l s c o r e s and MPQ s c o r e s f o r

a l l s u b j e c t s . However, when t h e two sexes a r e t r e a t e d s e p a r a t e l y

s t a t i s t i c a l l y s i g n i f i c a n t r e s u l t s a r e o b t a i n e d . M a l e s who s c o r e d h i g h

on l o c u s of c o n t r o l ( e x t e r n a l ) a l s o s c o r e d h i g h on the MPQ ( h i g h r a t i n g

of p a i n ) . Females who s c o r e d low on l o c u s of c o n t r o l ( i n t e r n a l ) s c o r e d

h i g h on the MPQ ( h i g h r a t i n g of p a i n ) .

The f i n d i n g s f o r the f e m a l e s i s c o n s i s t e n t w i t h the r e s u l t s o f

h y p o t h e s i s two s i n c e t h e female i n t e r n a l s r e p o r t i n g h i g h l e v e l s of p a i n

a l s o r e p o r t e d p o o r e r p s y c h o s o c i a l a d j u s t m e n t t o t h e i r p a i n . As n o t e d

e a r l i e r , i t i s p o s s i b l e t h a t t h e s e f e m a l e s may e x p e r i e n c e f r u s t r a t i o n i n

- 70 -

d e a l i n g w i t h the v a r i a b l e n a t u r e o f c h r o n i c p a i n and hence e x p e r i e n c e

d i f f i c u l t y w i t h t h e i r sense of i n s t r u m e n t a l i t y . These f e e l i n g s of

h e l p l e s s n e s s do n o t p r e c l u d e good r e s p o n s e t o t r e a t m e n t and p a i n

management. L o g i c a l l y , i f i n d i v i d u a l s r e p o r t poor p s y c h o s o c i a l

a d j u s t m e n t t o c h r o n i c p a i n t h o s e same i n d i v i d u a l s would be e x p e c t e d t o

e x p e r i e n c e h i g h l e v e l s of p a i n .

The r e s u l t s f o r the males seem t o s u g g e s t t h a t males w i t h h i g h

r e p o r t e d p a i n tend t o see t h e m s e l v e s as h a v i n g l e s s p e r s o n a l c o n t r o l

o v e r t h e i r p a i n ( e x t e r n a l ) . F o r t h e s e i n d i v i d u a l s who e x p e r i e n c e an

absence of c o n t r o l , t h e e f f e c t i v e n e s s of many b e h a v i o r a l i n t e r v e n t i o n s

on t h e m o t i v a t i o n a l component of p a i n i s l i k e l y s u b s t a n t i a l l y r e d u c e d .

Weisenberg (1980) s u p p o r t s t h i s n o t i o n by f u r t h e r s t a t i n g t h a t a n x i e t y

r e d u c t i o n i s i m p o r t a n t i n p a i n p e r c e p t i o n m a i n l y when i t i s combined

w i t h an i n d i v i d u a l ' s f e e l i n g of c o n t r o l . Males w i t h an e x t e r n a l l o c u s

of c o n t r o l may see th e m s e l v e s as h a v i n g l e s s p e r s o n a l c o n t r o l over t h e i r

p a i n . F o r these males the e x p e r i e n c e of c h r o n i c p a i n may o c c a s i o n more

of an a t t i t u d e of h e l p l e s s n e s s , p r e c l u d i n g , as w i t h the f e m a l e s , good

r e s p o n s e t o p a i n management.

P s y c h o s o c i a l A d j u s t m e n t f o r Ma l e s and Females

There was no s i g n i f i c a n t s t a t i s t i c a l s u p p o r t f o r gender

d i f f e r e n c e s i n p s y c h o s o c i a l a d j u s t m e n t to c h r o n i c p a i n c o n t r a r y t o the

f i n d i n g s of Toomey, T a y l o r , S h e l t o n , and C a r r o n (1982) who f o u n d t h a t

males a r e d e c i d e d l y more c o n s e r v a t i v e t h a n females i n r e p o r t i n g

improvement i n a wide sp e c t r u m of a r e a s . P o s s i b l y the f i n d i n g s of the

- 71 -

p r e s e n t r e s e a r c h were a f f e c t e d by the v a l i d i t y of the ACPS as a

m e a s u r i n g i n s t r u m e n t . W h i l e any e x p l a n a t i o n of t h e s e r e s u l t s i s

s p e c u l a t i v e , i t may be t h a t the seven s u b t e s t s of t h e ACPS do not have

the same meaning f o r males and f e m a l e s . A n o t h e r p o s s i b l e e x p l a n a t i o n

f o r t he l a c k of gender d i f f e r e n c e s i s t h a t the ACPS f a i l s t o measure a l l

of the complex and m u l t i p l e f a c t o r s i n p s y c h o s o c i a l a d j u s t m e n t t o

c h r o n i c p a i n w h i c h would have d i f f e r e n t i m p o r t a n c e f o r each s ex.

A l t h o u g h t h e r e was no s i g n i f i c a n t d i f f e r e n c e i n the

p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n o f males and f e m a l e s u s i n g t o t a l

ACPS s c o r e s , subsequent t - t e s t s on the seven s u b t e s t s and on the twenty

s e v e n i t e m s r e v e a l e d some s i g n f i c a n t d i f f e r e n c e s . S u b t e s t 2, V o c a t i o n a l

E n v i r o n m e n t , r e v e a l e d s i g n i f i c a n t d i f f e r e n c e s between the males and

f e m a l e s w i t h the f e m a l e s r e p o r t i n g b e t t e r a d j u s t m e n t t h a n the males.

However, t h e Hoyt e s t i m a t e of r e l i a b i l i t y f o r t h i s s u b t e s t was low

and i t i s l i k e l y t h a t i f the r e l i a b i l i t y of the s u b t e s t were improved

th e mean d i f f e r e n c e would d e c r e a s e .

Two i t e m s i n S u b t e s t 7, P s y c h o l o g i c a l D i s t r e s s , ( w i t h a h i g h

e s t i m a t e of r e l i a b i l i t y ) , r e v e a l e d s i g n i f i c a n t d i f f e r e n c e s between males

and f e m a l e s . M a l e s i n d i c a t e d more d i s t r e s s t h a n f e m a l e s i n t h e amount

of w o r r y i n g they do s i n c e the development of t h e i r c h r o n i c p a i n , and

males a l s o e x p e r i e n c e more d e p r e s s i o n t h a n f e m a l e s r e l a t e d t o t h e

e x p e r i e n c e of c h r o n i c p a i n . L i t i g a t i o n , c o m p e n s a t i o n , and t r a d i t i o n a l

male and femal e r o l e s may e x p l a i n t h e s e r e s u l t s . The c u l t u r a l

s t e r e o t y p e r e q u i r i n g males t o be more p h y s i c a l l y s t r o n g and v o c a t i o n a l l y

p r o d u c t i v e t h a n f e m a l e s may cause males t o w o r r y more and be more

- 72 -

d e p r e s s e d t h a n f e m a l e s when f a c e d w i t h c h r o n i c p a i n , d i s a b i l i t y , and

v o c a t i o n a l d i s r u p t i o n . The r e s u l t s of t h e s e a n a l y s e s a r e p r e s e n t e d i n

A p p e n d i x G.

L o cus of C o n t r o l and Good and Poor P s y c h o s o c i a l A d j u s t m e n t

There appears to be no s i g n i f i c a n t d i f f e r e n c e i n the l o c u s o f

c o n t r o l s c o r e s f o r r e p o r t e d good a d j u s t e r s and r e p o r t e d poor a d j u s t e r s .

The r e s u l t s c a l l i n t o q u e s t i o n the t h e o r e t i c a l r a t i o n a l e f o r t h i s

h y p o t h e s i s , namely, t h a t i n d i v i d u a l s who r e p o r t good p s y c h o s o c i a l

a d j u s t m e n t t o c h r o n i c p a i n a r e more l i k e l y t o have d i f f e r e n t l e v e l s of

e x p e c t a n c y as t o t h e amount of c o n t r o l t h e y have o v e r t h e i r l i f e e v e n t s

t h a n t h o s e i n d i v i d u a l s who r e p o r t p o o r e r p s y c h o s o c i a l a d j u s t m e n t t o

c h r o n i c p a i n . The l a c k of s u b s t a n t i a t i o n f o r the h y p o t h e s i s may

p o s s i b l y have r e s u l t e d f r o m m e t h o d o l o g i c a l c o n s i d e r a t i o n s . The s u b j e c t

p o o l was s m a l l ( n i n e good a d j u s t e r s and f i f t e e n poor a d j u s t e r s ) .

M o r e o v er, the s u b j e c t s p a r t i c i p a t i n g were v o l u n t e e r s . B o t h of t h e s e

f a c t o r s make the g e n e r a l i z a b i l i t y of the r e s u l t s d u b i o u s .

P i v o t a l t o t h i s h y p o t h e s i s was the concept t h a t t h e r e would be

a d i f f e r e n c e i n l o c u s of c o n t r o l o r i e n t a t i o n between t h o s e s u b j e c t s who

r e p o r t poor p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n and t h o s e s u b j e c t s

who r e p o r t good p s y c h o s o c i a l a d j u s t m e n t . I f however, the r e s u l t s of the

s u p p l e m e n t a r y a n a l y s i s t o h y p o t h e s i s one a r e s u p p o r t e d ( t h a t t h e r e might

be a c u r v i l i n e a r r e l a t i o n s h i p w i t h b o t h v e r y e x t e r n a l and v e r y i n t e r n a l

s u b j e c t s i n d i c a t i n g poor p s y c h o s o c i a l a d j u s t m e n t ) then the q u e s t i o n

a d d r e s s e d i n t h i s h y p o t h e s i s i s moot.

- 73 -

I n f a c t , t h e r e was a marked d i f f e r e n c e i n the v a r i a b i l i t y of

the two groups as p r e s e n t e d i n T a b l e 6. The r e p o r t e d poor a d j u s t e r s

extreme s c o r e s may r e f l e c t t h e i r tendency t o be e i t h e r i n t e r n a l or

e x t e r n a l . The r e p o r t e d good a d j u s t e r s , i n c o n t r a s t , were more

homogeneous i n t h e i r r e s p o n s e s r e f l e c t i n g a commonality i n t h e i r

r e p o r t e d l o c u s of c o n t r o l s c o r e s .

L i m i t a t i o n s of t h e I n v e s t i g a t i o n

The c u r r e n t r e s e a r c h sample was r e s t r i c t e d t o s u b j e c t s who

a g reed to p a r t i c i p a t e on a v o l u n t e e r b a s i s . T h i s may have b i a s e d the

sample towards i n c l u d i n g c h r o n i c p a i n p a t i e n t s whose e x p e r i e n c e s w i t h

the c h r o n i c p a i n t r e a t m e n t c e n t r e were g e n e r a l l y p o s i t i v e . The

i n d i v i d u a l s who c o n s e n t e d t o p a r t i c i p a t e i n t h i s r e s e a r c h p r o j e c t

g e n e r a l l y may have e x p e r i e n c e d b e t t e r p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c

p a i n t h a n t h o s e who d i d not p a r t i c i p a t e . T h i s a f f e c t s the

g e n e r a l i z a b i l i t y of the f i n d i n g s t o the g e n e r a l p o p u l a t i o n s i n c e t h e r e

i s no way of knowing whether s u b j e c t s who r e s p o n d t o f o l l o w u p assessment

d i f f e r i n some s y s t e m a t i c way from th o s e who do n o t .

T h i s s t u d y i s based e x c l u s i v e l y on s e l f - r e p o r t t e c h n i q u e s

w h i c h a r e s u b j e c t t o d i s t o r t i o n by the i n d i v i d u a l ( K e e f e , 1982).

Sanders (1980) f o u n d t h a t c h r o n i c low-back p a i n p a t i e n t s c o n s i s t e n t l y

d i s t o r t e d t h e i r r e p o r t s of a c t i v i t y i n a n e g a t i v e d i r e c t i o n . The d e s i g n

might have been s t r e n g t h e n e d had f a c e t o f a c e i n t e r v i e w s w i t h the

s u b j e c t s been a t t e m p t e d and o b s e r v a t i o n a l d a t a c o l l e c t e d .

- 74 -

T h i s was a s t u d y t o o b s e r v e the r e l a t i o n s h i p s between l o c u s of

c o n t r o l , p s y c h o s o c i a l a d j u s t m e n t to c h r o n i c p a i n , and r e p o r t e d p a i n .

These r e l a t i o n s h i p s s u r f a c e d w i t h the i n s t r u m e n t s a p p l i e d and t h e

v a l i d i t y and r e l i a b i l i t y of the i n s t r u m e n t s i s , t h e r e f o r e , c r u c i a l t o

t h e s t u d y . A l t h o u g h the r e s e a r c h e r has c o n f i d e n c e i n R o t t e r ' s Locus of

C o n t r o l S c a l e and the M c G i l l P a i n Q u e s t i o n n a i r e , the r e l i a b i l i t y and

v a l i d i t y of the A djustment to C h r o n i c P a i n S c a l e have not y e t been w e l l

e s t a b l i s h e d .

R e l a t i o n s h i p s between v a r i a b l e s perhaps were o b s c u r e d by

t r e a t i n g the two sexes as a homogenous group. Once the sexes were

d i v i d e d the s m a l l sample of f e m a l e s made i t d i f f i c u l t t o g e n e r a l i z e from

the r e s u l t s . A much l a r g e r sample would have been n e c e s s a r y i n o r d e r t o

a t t a i n a more adequate number of f e m a l e s from w h i c h t o g e n e r a l i z e . The

r e s u l t s i n d i c a t e t h a t the l o c u s of c o n t r o l c o n cept might have a

d i f f e r e n t l e v e l of c o m p l e x i t y f o r each sex. Hence, i t would be

a d v i s a b l e t o t a k e sex s p e c i f i c i t y i n t o a c c o u n t .

T h i s s t u d y i s c o r r e l a t i o n a l i n n a t u r e and i t i s i m p o s s i b l e t o

s e p a r a t e cause from e f f e c t i n any d e f i n i t i v e way. Does poor

p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n l e a d t o h i g h l y e x t e r n a l and

h i g h l y i n t e r n a l b e l i e f systems or do the extremes of l o c u s of c o n t r o l

o r i e n t a t i o n l e a d t o poor p s y c h o s o c i a l a d j u s t m e n t ? Or do t h e same

c o n d i t i o n s ( s o c i a l , f a m i l i a l , and p e r s o n a l c o r r e l a t e s ) t h a t l e a d t o

extreme e x t e r n a l and extreme i n t e r n a l b e l i e f s a l s o l e a d t o poor

p s y c h o s o c i a l a d j u s t m e n t ? These a r e i m p o r t a n t q u e s t i o n s , but t h e

r e s e a r c h c i t e d does n o t , by i t s n a t u r e , a l l o w us t o i n v e s t i g a t e the

cause and e f f e c t q u e s t i o n .

- 75 -

No e f f o r t was made by t h e r e s e a r c h e r t o d i f f e r e n t i a t e between

t h o s e s u b j e c t s i n v o l v e d i n l i t i g a t i o n or c o m p e n s a t i o n cases and t h o s e

n o t . I t i s p o s s i b l e t h a t l i t i g a t i o n and c o m p e n s a t i o n have i m p l i c a t i o n s

r e g a r d i n g gender d i f f e r e n c e s i n a d j u s t m e n t t o c h r o n i c p a i n , l o c u s of

c o n t r o l , and r e s p o n s e s t o p a i n . The c o m p e n s a t i o n and l e g a l systems

appear t o reward i l l n e s s b e h a v i o r s and dependency and t o p u n i s h

i n d i v i d u a l s ' e f f o r t s t o e x e r t c o n t r o l over t h e i r p a i n c o n d i t i o n s .

T h i s s t u d y may not have a d e q u a t e l y i n v e s t i g a t e d the c o ncept of

r e i n f o r c e m e n t v a l u e . I t was assumed t h a t i n d i v i d u a l s e x p e r i e n c i n g

c h r o n i c p a i n p l a c e a h i g h v a l u e on b e i n g w e l l a d j u s t e d on a v a r i e t y o f

p s y c h o s o c i a l d i m e n s i o n s , t h e r e i n f o r c e m e n t i n t h i s i n v e s t i g a t i o n .

However, the v a l u e of t h i s r e i n f o r c e m e n t was perhaps not the same f o r

a l l p a r t i c i p a n t s . I t might be d i f f e r e n t f o r males and f o r f e m a l e s , and

a l s o f o r t h o s e i n d i v i d u a l i n v o l v e d i n l i t i g a t i o n or c o m p e n s a t i o n

d i s p u t e s and f o r t h o s e not so i n v o l v e d .

I m p l i c a t i o n s of t h e Study

The i m p l i c a t i o n s of t h i s s t u d y w o u l d appear t o be i n t e r e s t i n g

i n terms of d i f f e r e n t i a l t r e a t m e n t s t r a t e g i e s f o r c h r o n i c p a i n p a t i e n t s

and of t r e a t m e n t s t r a t e g i e s d e s i g n e d t o change l o c u s of c o n t r o l

b e l i e f s . T h i s s t u d y seems t o i n d i c a t e b o t h a c u r v i l i n e a r r e l a t i o n s h i p

between the extremes of l o c u s of c o n t r o l and poor p s y c h o s o c i a l

a d j u s t m e n t t o c h r o n i c p a i n , and, f o r f e m a l e s , a r e l a t i o n s h i p between

i n t e r n a l i t y and poor p s y c h o s o c i a l a d j u s t m e n t .

I n g e n e r a l p a s t s t u d i e s r e p o r t t h a t i n d i v i d u a l s w i t h an

- 76 -

i n t e r n a l l o c u s of c o n t r o l p e r f o r m b e t t e r and f u n c t i o n more s u c c e s s f u l l y

i n numerous p e r s o n a l and s o c i a l a r e a s than do i n d i v i d u a l s w i t h an

e x t e r n a l l o c u s of c o n t r o l . A c o m p a r i s o n of t h e r e s u l t s of t h i s s t u d y

w i t h the l i t e r a t u r e cannot be r e a d i l y done s i n c e few r e p o r t s examine t h e

r e l a t i o n s h i p between l o c u s of c o n t r o l and p s y c h o s o c i a l a d j u s t m e n t f o r

c h r o n i c p a i n p a t i e n t s . However, the f i n d i n g s i n t h i s s t u d y appear t o

c o n t r a d i c t t h e p r e v i o u s l y c i t e d l i t e r a t u r e and r a i s e i n t e r e s t i n g

q u e s t i o n s r e g a r d i n g the concept of l o c u s of c o n t r o l f o r c h r o n i c p a i n

p a t i e n t s and f o r male and female c h r o n i c p a i n p a t i e n t s s e p a r a t e l y .

The f i n d i n g s i n t h i s r e s e a r c h have i m p l i c a t i o n s f o r

c o u n s e l l o r s , t h e r a p i s t s , and h e a l t h p r o f e s s i o n a l s who a r e t r e a t i n g

c h r o n i c p a i n p a t i e n t s . I t may be b e n e f i c i a l t o measure t h e l o c u s o f

c o n t r o l o r i e n t a t i o n of i n d i v i d u a l s upon i n i t i a l assessment p r i o r t o

t r e a t m e n t s i n c e the r e s u l t s of t h i s s t u d y appear to s u ggest p o o r e r

p s y c h o s o c i a l a d j u s t m e n t f o r b o t h extreme e x t e r n a l s and extreme

i n t e r n a l s . The r e s u l t s of t h i s measure c o u l d t h e n h e l p the t h e r a p i s t

e s t a b l i s h t r e a t m e n t s t r a t e g i e s t a i l o r e d t o i n d i v i d u a l s ' g e n e r a l i z e d

e x p e c t a n c i e s r e g a r d i n g l o c u s of c o n t r o l . S i m i l a r l y , t h e s e measures

c o u l d h e l p t h e t h e r a p i s t e s t a b l i s h g o a l s f o r change w i t h t h e i r c l i e n t s

t o i n c r e a s e the i n d i v i d u a l s sense of i n s t r u m e n t a l i t y l e a d i n g t o b e t t e r

p s y c h o s o c i a l a d j u s t m e n t t o p a i n .

F o r t h o s e i n d i v i d u a l s r e p o r t i n g h i g h e x t e r n a l l o c u s of c o n t r o l

s c o r e s e n c o u r a g i n g an i n t e r n a l l o c u s of c o n t r o l would be one of the

t r e a t m e n t g o a l s . Not a g r e a t d e a l of s y s t e m a t i c r e s e a r c h has been

c a r r i e d out i n t h i s a r e a and t h e f i n d i n g s a r e s t i l l s k e t c h y . However,

- 77 -

P h a r e s (1976) n o t e d t h a t what r e s e a r c h has been a c c o m p l i s h e d and

r e p o r t e d seems c o n s i s t e n t w i t h the v i e w t h a t an i n t e r n a l l o c u s of

c o n t r o l may be one p r e r e q u i s i t e of competent b e h a v i o r and enhanced

c o p i n g e f f o r t s .

I n t e r n a l i t y t r a i n i n g f o r the extreme e x t e r n a l s c o u l d t a k e many

fo r m s , but one s h o u l d keep i n mind t h a t changes i n b e l i e f s o r

e x p e c t a n c i e s a r e o n l y r e l e v a n t i f accompanied by d e s i r e d b e h a v i o r

change. However, o b t a i n i n g b e h a v i o r change d a t a i s not always p o s s i b l e

and e x p e c t a n c y d a t a w i l l add t o u n d e r s t a n d i n g of the change o r l a c k of

change i n b e h a v i o r s . Thus, use of a l o c u s of c o n t r o l measure i s

recommended i n c o n j u n c t i o n w i t h b e h a v i o r a l measures t o e v a l u a t e

t r e a t m e n t programs f o r c h r o n i c p a i n p a t i e n t s .

The g o a l of i n t e r n a l i t y t r a i n i n g s h o u l d be t o t r a i n

r e s p o n s i b l e i n t e r n a l s who w i l l r e c o g n i z e the need t o use h e a l t h

p r o f e s s i o n a l s as an a p p r o p r i a t e r e s o u r c e , but who w i l l a l s o see t h a t

a c t i o n s of t h e i r own (based on sound a d v i c e ) w i l l be n e c e s s a r y t o o b t a i n

and m a i n t a i n p a i n management. DeCharms (1968) emphasized f o u r major

c o n c e p t s : ( 1 ) s e l f - c o n c e p t , (2) achievement m o t i v a t i o n , (3) r e a l i s t i c

g o a l - s e t t i n g , and (4) p e r s o n a l c a u s a t i o n t r a i n i n g . O t h e r r e s e a r c h e r s

s u g g e s t t h a t the e x p e r i e n c e of problem c o n f r o n t a t i o n l e a d s t o a

h e i g h t e n e d f e e l i n g of i n t e r n a l c o n t r o l ( G o t t e s f e l d & D o z i e r , 1966), and

t h e r e i s a s h i t i n i n t e r n a l i t y f o r s e l f - d e t e r m i n a t i o n groups ( T o b i a s &

MacDonald, 1977). Support f o r the n o t i o n t h a t e f f e c t i v e l y c o p i n g w i t h

one's problems can r a i s e i n t e r n a l b e l i e f s was r e v e a l e d i n the work of

Dua ( 1 9 7 0 ) . He i n d i c a t e d t h a t b o t h a c t i o n - o r i e n t e d and r e e d u c a t i v e

t h e r a p y l e d t o i n c r e a s e d i n t e r n a l s c o r e s .

- 78 -

I t i s c l e a r t h a t b e l i e f i n an i n t e r n a l l o c u s of c o n t r o l can

p r o v i d e i n d i v i d u a l s w i t h a g r e a t e r sense of c o n t r o l and thus a g r e a t e r

p o t e n t i a l f o r power and e f f i c a c y . R e d u c t i o n of the e x t e r n a l s ' sense of

p o w e r l e s s n e s s , h o p e l e s s n e s s and h e l p l e s s n e s s i s the aim on i n t e r n a l i t y

t r a i n i n g . D i s c u s s i o n s and b e h a v i o r a s s i g n m e n t s d e s i g n e d t o i n c r e a s e the

e x t e n t t o w h i c h the i n d i v i d u a l s f e e l i n c o n t r o l of t h e i r e nvironment

ought t o be u s e f u l t h e r a p e u t i c p r o c e d u r e s .

F o r t h o s e i n d i v i d u a l s who r e p o r t e d extreme i n t e r n a l l o c u s o f

c o n t r o l s c o r e s , and a l s o f o r t h o s e f e m a l e s r e p o r t i n g i n t e r n a l i t y , t h e

i m p l i c a t i o n s f o r c o u n s e l l o r s and t h e r a p i s t s a r e of a d i f f e r e n t n a t u r e .

The t h e r a p e u t i c g o a l s f o r t h e s e i n d i v i d u a l s i s t o change one's

e x p e c t a t i o n s r e g a r d i n g p e r s o n a l r e s p o n s i b i l i t y . S i n c e the i s s u e h e r e i s

an overwhelming sense of power or c o n t r o l over one's e n v i r o n m e n t ,

t e c h n i q u e s c o u l d be used t o reduce the i n t e r n a l l o c u s of c o n t r o l w h i c h

i s c a u s i n g g u i l t , h e l p l e s s n e s s , f r u s t r a t i o n and f e e l i n g s of d e f e a t i n

p a i n management. These c l i e n t s need t o l e a r n t h a t some of the c o n t r o l

w h i c h they e x p e r i e n c e i s u n r e a l i s t i c i n d e a l i n g w i t h c h r o n i c p a i n , and

t h a t i t i s a p p r o p r i a t e i n c e r t a i n s i t u a t i o n s t o d i s c r i m i n a t e and g i v e up

some c o n t r o l . I n t h i s way t h e i r e x p e c t a n c y f o r s u c c e s s would be

enhanced. As MacDonald (1971) n o t e d m o t i v a t i o n c o u p l e d w i t h p o s i t i v e

e x p e c t a n c y e q u a l s o p t i m i s m ; m o t i v a t i o n c o u p l e d w i t h n e g a t i v e e x p e c t a n c y

e q u a l s d e s p a i r .

C o u n s e l l o r s and t h e r a p i s t s need a l s o t o be aware t h a t gender

d i f f e r e n c e s may e x i s t r e g a r d i n g c h r o n i c p a t i e n t s ' e x p e r i e n c e s of p a i n ,

meanings of p a i n , p s y c h o s o c i a l a d j u s t m e n t t o p a i n , and l o c u s of c o n t r o l

- 79 -

b e l i e f s . F u r t h e r r e s e a r c h needs t o be done i n t h e s e a r e a s , but

p r e l i m i n a r y r e s u l t s appear to i n d i c a t e t h a t perhaps d i f f e r e n t i a l

t r e a t m e n t s t r a t e g i e s may be a p p r o p r i a t e f o r t h e two s e x e s as w e l l as

t r a i n i n g t o a l t e r l o c u s of c o n t r o l b e l i e f s .

I t i s i m p o r t a n t t o r e a l i z e t h a t the s o l u t i o n i s not t o f i n d

the r i g h t t h e r a p e u t i c t e c h n i q u e to enhance a p p r o p r i a t e i n t e r n a l c o n t r o l

b e l i e f s . Many such t e c h n i q u e s w i l l have a p p r o p r i a t e e f f e c t s . R a t h e r ,

the g o a l s h o u l d be the s y s t e m a t i c i n v e s t i g a t i o n of the e f f e c t of

d i f f e r e n t t e c h n i q u e s w i t h v a r i o u s k i n d s of p a t i e n t s and t h e i r subsequent

p s y c h o s o c i a l a d j u s t m e n t to c h r o n i c p a i n . Then one might be i n a

p o s i t i o n t o s t a t e t h a t f o r one i n d i v i d u a l one c o u l d a t t e m p t t o i n c r e a s e

h i s or h e r i n t e r n a l i t y by means of a R o g e r i a n approach encompassing

warmth, a c c e p t a n c e and l i s t e n i n g , w h i l e f o r a n o t h e r p a t i e n t one s h o u l d

u t i l i z e a c t i v e , m a n i p u l a t o r y t e c h n q i u e s .

S i m i l a r l y , i n t e r n a l s c o u l d be encouraged t o p a r t i c i p a t e i n t h e

management of t h e i r t r e a t m e n t s u b j e c t i n g them to fewer e n v i r o n m e n t a l

c o n s t r a i n t s , w h i l e e x t e r n a l s might p r o f i t most f r o m t r e a t m e n t s r e l y i n g

on p r e s t i g e s u g g e s t i o n or s u p p o r t from o t h e r s . I n t h e s e ways, the

c o n s t r u c t of i n t e r n a l and e x t e r n a l l o c u s of c o n t r o l as an e x p e c t a n c y f o r

s u c c e s s c o u l d be o p e r a t i o n a l i z e d as measures f o r i n - p a t i e n t and

o u t - p a t i e n t t r e a t m e n t outcome r e s e a r c h .

S u g g e s t i o n s f o r F u t u r e R e s e a r c h

R e s e a r c h d e a l i n g w i t h the r e l a t i o n s h i p between the l o c u s o f

c o n t r o l c o n s t r u c t and p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n appears t o

- 80 -

be a new a r e a of i n v e s t i g a t i o n . Based on t h e r e s u l t s of t h i s s t u d y ,

f u t u r e r e s e a r c h might f i r s t c o n s i d e r r e p l i c a t i o n of the s t u d y w i t h a

l a r g e r sample.

The c u r r e n t i n v e s t i g a t i o n was f u r t h e r l i m i t e d i n t h a t o n l y

p s y c h o s o c i a l v a r i a b l e s were used t o p r e d i c t a d j u s t m e n t . S i n c e the

p s y c h o s o c i a l v a r i a b l e s a r e o n l y one s e t of f a c t o r s i n f l u e n c i n g

a d j u s t m e n t t o c h r o n i c p a i n , t h e p r e d i c t i v e power of the s t u d y would have

been i n c r e a s e d had v a r i a b l e s been i n c l u d e d such as e v a l u a t i o n s of

f u n c t i o n a l s t a t u s , e v a l u a t i o n s o f m e d i c a t i o n o r a l c o h o l usage, and

e v a l u a t i o n s of s u r g e r i e s and t r e a t m e n t s i n c e d i s c h a r g e .

R e f i n e m e n t of the ACPS as a m e a s u r i n g i n s t r u m e n t would a l s o

i n c l u d e t a k i n g the p o s s i b i l i t y of gender d i f f e r e n c e s i n t o a c c o u n t s i n c e

t h e ACPS does not appear t o a p p l y t o b o t h s e x e s i n t h e same way. The

g e n e r a l l y d i f f e r e n t p a t t e r n s of m a s c u l i n e and f e m i n i n e e x p e r i e n c e may

r e q u i r e d i f f e r e n t a d j u s t m e n t c r i t e r i a f o r males and f e m a l e s , s i n c e the

ACPS does not appear t o p r e d i c t p s y c h o s o c i a l a d j u s t m e n t f o r mal e s . I t

may n o t be enough t o say t h a t t h e more i n t e r n a l f e m a l e s e x p e r i e n c e d

p o o r e r p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n w i t h o u t u n d e r s t a n d i n g

w h i c h f e m a l e s and what k i n d s of a d j u s t m e n t . S p e c i f i c a l l y , t he v a r i a b l e s

must be weighed more c o m p l e t e l y and the gender d i f f e r e n c e s l o o k e d a t

more c r i t i c a l l y t o i l l u m i n a t e p a t t e r n s and t h e i r i n t e r p l a y w i t h

p e r s o n a l i t y .

S i m i l a r l y , a f a c t o r a n a l y s i s of the l o c u s of c o n t r o l s c a l e

might i n d i c a t e t h a t w h i l e s i m i l a r f o r the sexes the l o c u s of c o n t r o l

c o n c e p t might have a d i f f e r e n t l e v e l of c o m p l e x i t y f o r each sex. Hence,

- 81 -

s e x s p e c i f i c i t y s h o u l d be c o n s i d e r e d i n f u t u r e s t u d i e s u s i n g t h e l o c u s

of c o n t r o l c o n s t r u c t .

The h y p o t h e s i s t h a t a c u r v i l i n a r r e l a t i o n s h i p e x i s t s between

p s y c h o s o c i a l a d j u s t m e n t to c h r o n i c p a i n and l o c u s of c o n t r o l s h o u l d be

i n v e s t i g a t e d f u r t h e r . A c c e p t i n g t h e n o t i o n of a U-shaped r e l a t i o n s h i p

i t appears t h a t both the extreme e x t e r n a l s and extreme i n t e r n a l s a r e

more p o o r l y a d j u s t e d p s y c h o s o c i a l l y . S i n c e each i s r e l a t i v e l y removed

from the m i d d l e of the d i s t r i b u t i o n , each seems l i k e l y t o respond i n an

i n f l e x i b l e way a f t e r c a t e g o r i z i n g s i t u a t i o n s . The p e o p l e n e a r e r the

m i d d l e s h o u l d respond t o s i t u a t i o n s i n a more r e a l i s t i c f a s h i o n . F u t u r e

r e s e a r c h might a l s o i n v e s t i g a t e t h e r e l a t i o n s h i p of o t h e r v a r i a b l e s such

as age, s e x , c h r o n i c i t y , e t c . t o good and poor p s y c h o s o c i a l a d j u s t m e n t

t o c h r o n i c p a i n and t o l o c u s of c o n t r o l o r i e n t a t i o n .

C o n c l u s i o n

Based on the measures used i n t h i s s t u d y and the s t a t i s t i c a l

a n a l y s e s a p p l i e d , the r e l a t i o n s h i p s between l o c u s of c o n t r o l ,

p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n , and p r e s e n t p a i n r a t i n g s f o r

t h e s u b j e c t s s t u d i e d were d i f f e r e n t f o r males and f e m a l e s , and f o r t h o s e

s u b j e c t s who r e p o r t e d poor p s y c h o s o c i a l a d j u s t m e n t . Those s u b j e c t s who

s c o r e d a t b o t h extremes of the l o c u s of c o n t r o l s c a l e ( i . e . h i g h l y

e x t e r n a l o r h i g h l y i n t e r n a l ) r e p o r t e d p o o r e r p s y c h o s o c i a l a d j u s t m e n t

s u g g e s t i n g a c u r v i l i n e a r r e l a t i o n s h i p between t h e v a r i a b l e s . F o r

f e m a l e s , t h e r e appears t o be a s u b s t a n t i a l r e l a t i o n s h i p between p o o r e r

- 82 -

p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n and i n t e r n a l i t y , and between

i n t e r n a l i t y and h i g h l e v e l s of r e p o r t e d p a i n . F o r males, i t seems t h e

more e x t e r n a l t h e l o c u s of c o n t r o l o r i e n t a t i o n the h i g h e r t h e r e p o r t e d

p a i n . More r e s e a r c h i s n e c e s s a r y t o e s t a b l i s h any c a u s a l r e l a t i o n s h i p s

between t h e s e v a r i a b l e s .

- 83 -

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Graham, C , Bond, S.S., G e e k o v i c h , M., & Cook, M.R. Use of the M c G i l l P a i n Q u e s t i o n n a i r e i n the assessment of c a n c e r p a i n : r e p l i c a b i l i t y and c o n s i s t e n c y . P a i n , 1980, 8, 377-387.

Gruen, G.E., K o r t e , J.R., & Baum, J.R. Group measure of l o c u s of c o n t r o l . D e v e l o p m e n t a l P s y c h o l o g y , 1974, 10_, 683-686.

H a l l e t t , E.C., & P i l o w s k y , I . The r e s p o n s e to t r e a t m e n t i n a m u l t i d i s c i p l i n a r y p a i n c l i n i c . P a i n , 1982, 12, 365-374.

Harrow, M., & F e r r a n t e , A. Locus of C o n t r o l i n p s y c h i a t r i c p a t i e n t s . J o u r n a l of C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1969, 33_, 582-589.

Hoy t , C. T e s t r e l i a b i l i t y e s t i m a t e d by a n a l y s i s of v a r i a n c e . P s y c h o m e t r i c a , 1941, JS, 153-160.

H u s k i s s o n , E.C. Measurement of p a i n . L a n c e t , 1974, l_y 1127-1131.

I g n e l z i , R . J . , S t e r n b a c h , R.A. & Timmermans, G. The p a i n ward f o l l o w - u p a n a l y s i s . P a i n , 1977, 3_, 277-285.

I n t e r n a t i o n a l A s s o c i a t i o n f o r the Study of P a i n . Subcommittee on Taxonomy. P a i n t e r m s : A l i s t w i t h d e f i n i t i o n s and n o t e s on usage. P a i n , 1979, 6, 249-252.

J o e , V.C. Review of the i n t e r n a l - e x t e r n a l c o n t r o l c o n s t r u c t as a p e r s o n a l i t y v a r i a b l e . P s y c h o l o g i c a l R e p o r t s , 1971, 28, 619-640.

J o h n s o n , R.C., Ackerman, J.M., F r a n k , H., & F i o n d a , A . J . R e s i s t a n c e t o t e m p t a t i o n and g u i l t f o l l o w i n g y i e l d i n g and p s y c h o t h e r a p y . J o u r n a l of C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1968, 32, 169-175.

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K e e f e , F . J . B e h a v i o r a l assessment and t r e a t m e n t of c h r o n i c p a i n : c u r r e n t s t a t u s and f u t u r e d i r e c t i o n s . J o u r n a l of C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1982, 50, 896-911.

K i l m a n n , P.R., A l b e r t , B.M., & S o t i l e , W.M. R e l a t i o n s h i p between l o c u s of c o n t r o l , s t r u c t u r e of t h e r a p y and outcome. J o u r n a l of C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1975, 27_y 588.

K l e i b e r , D., Veldman, D.J., & Menaher, S.L. The m u l t i d i m e n s i o n a l i t y of l o c u s of c o n t r o l . J o u r n a l o f C l i n i c a l P s y c h o l o g y , 1973, 29, 411-416.

Lamont, J . D e p r e s s i o n , l o c u s of c o n t r o l and mood r e s p o n s e s e t . J o u r n a l of C l i n i c a l P s y c h o l o g y , 1972, 28, 342-345.

L e a v i t t , F., & G a r r o n , D.C. V a l i d i t y of a back p a i n c l a s s i f i c a t i o n s c a l e f o r d e t e c t i n g p s y c h o l o g i c a l d i s t u r b a n c e as measured by the MMPI. J o u r n a l o f C l i n i c a l P s y c h o l o g y , 1980, 36_, 186-189.

L e f c o u r t , H.M. I n t e r n a l v e r s u s e x t e r n a l c o n t r o l of r e i n f o r c e m e n t : A r e v i e w . P s y c h o l o g i c a l B u l l e t i n , 1966, j>5, 206-220.

L e f c o u r t , H.M. Locus of c o n t r o l : C u r r e n t t r e n d s i n t h e o r y and r e s e a c h . New Y o r k : John W i l e y , 1976.

L e v e n s o n , H. M u l t i d i m e n s i o n a l l o c u s of c o n t r o l i n p s y c h i a t r i c p a t i e n t s . J o u r n a l o f C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1973, 41, 397-404.

L i p p , L., K o l s t o e , R., James, W., & R a n d a l l , H. D e n i a l of d i s a b i l i t y and i n t e r n a l c o n t r o l of r e i n f o r c e m e n t : A s t u d y u s i n g p e r c e p t u a l d e f e n s e paradigm. J o u r n a l of C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1968, 32, 72-75.

Lodge, M., & T u r s k y , B. The workshop on the magnitude of s c a l i n g of p o l i t i c a l o p i n i o n i n s u r v e y r e s e a r c h . A m e r i c a n J o u r n a l o f P o l i t i c a l S c i e n c e , 1981, 25, 225-227.

L o r e n z , Ky Ng ( E d . ) . New approaches t o t r e a t m e n t o f c h r o n i c p a i n : A r e v i e w o f m u l t i d i s c i p l i n a r y p a i n c l i n i c s and p a i n c e n t r e s . R o c k v i l l e , MD.: NIDA R e s e a r c h Monograph 36, 1981.

MacDonald, A.P., J r . I n t e r n a l - e x t e r n a l l o c u s of c o n t r o l : A p r o m i s i n g r e h a b i l i t a t i o n v a r i a b l e . J o u r n a l o f C l i n i c a l P s y c h o l o g y , 1971, 18, 111-116.

M c G i n n i e s , E., Nordholm, L.A., Ward, C D . , & Bhanthumnavin, D.L. Sex and c u l t u r a l d i f f e r e n c e s i n p e r c e i v e d l o c u s of c o n t r o l among s t u d e n t s i n f i v e c o u n t r i e s . J o u r n a l o f C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1974, 42^ 451-455.

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M a r k s , E. Sex, b i r t h o r d e r , and b e l i e f s about p e r s o n a l power. D e v e l o p m e n t a l P s y c h o l o g y , 1972, 6̂ , 184.

M e l z a c k , R. The M c G i l l P a i n Q u e s t i o n n a i r e : M a j o r p r o p e r t i e s and s c o r i n g methods. P a i n , 1975, _1, 277-299.

M e l z a c k , R. The p u z z l e o f p a i n . London: P e n g u i n , 1973.

M e l z a c k , R., & P e r r y , C. S e l f - r e g u l a t i o n of p a i n : t h e use of a l p h a f e e d b a c k and h y p n o t i c t r a i n i n g f o r the c o n t r o l of c h r o n i c p a i n . E x p e r i m e n t a l N e u r o l o g y , 1975, 46, 452-469.

M e l z a c k , R., & W a l l , P.D. P a i n mechanisms: A new t h e o r y . S c i e n c e , 1965, 150, 971-979.

Me r s k e y , H. The r o l e of the p s y c h i a t r i s t i n the i n v e s t i g a t i o n and t r e a t m e n t o f p a i n . I n B o n i c a , J . J . (Ed.) P a i n . New Y o r k : Raven P r e s s , 1980.

M i l l e r , R.W., & S e l i g m a n , M.E.P. D e p r e s s i o n and t h e p e r c e p t i o n o f r e i n f o r c e m e n t . J o u r n a l o f Abnormal P s y c h o l o g y , 1973, 82, 62-73.

M i r e l s , H.L. Dimensions of i n t e r n a l v e r s u s e x t e r n a l c o n t r o l . J o u r n a l o f C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1970, 34, 226-228.

N a g i , S.Z., R i l e y , L.E., & Newby, L.G. A s o c i a l e p i d e m i o l o g y of back p a i n i n g e n e r a l p o p u l a t i o n . J o u r n a l o f C h r o n i c D i s e a s e , 1973, 26, 769-779.

Newman, R . I . , S e r e s , J . L . , Yospe, L.P., & G a r l i n g t o n , B. M u l t i d i s c i p l i n a r y t r e a t m e n t of c h r o n i c p a i n : l o n g term f o l l o w - u p of low back p a i n p a t i e n t s . P a i n , 1978, 4-, 283-292.

P h a r e s , E . J . D i f f e r e n t i a l u t i l i z a t i o n of i n f o r m a t i o n as a f u n c t i o n o f i n t e r n a l - e x t e r n a l c o n t r o l . J o u r n a l o f P e r s o n a l i t y , 1968, 36, 649-662.

P h a r e s , E . J . L ocus o f C o n t r o l i n P e r s o n a l i t y . M o r r i s t o w n , N.J.: G e n e r a l L e a r n i n g P r e s s , 1976.

P r i e t o , E . J . , Hopson, L., B r a d l e y , L.A., B y r n e , M., G e i s i n g e r , K.F., Mi d a x , D., & M a r c h i s e l l o , P . J . The language of low back p a i n : f a c t o r s t r u c t u r e of the M c G i l l P a i n Q u e s t i o n n a i r e . P a i n , 1980, J3, 11-19.

P r o c i u k , T . J . , & L u s s i e r , R . J . I n t e r n a l - e x t e r n a l l o c u s of c o n t r o l : A n a l y s i s and b i b l i o g r a p h y of two y e a r s r e s e a r c h (1973-1974). P s y c h o l o g i c a l R e p o r t s , 1975, 37, 1323-1337.

R e a d i n g , A.E. The i n t e r n a l s t r u c t u r e of the M c G i l l p a i n q u e s t i o n n a i r e i n dysmenorrhoea p a t i e n t s . P a i n , 1979, 4_, 283-292.

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R e i d , D.W., & Ware, E.E. M u l t i d i m e n s i o n a l i t y of i n t e r n a l - e x t e r n a l c o n t r o l : I m p l i c a t i o n s f o r pa s t and f u t u r e r e s e a r c h . C a n a d i a n J o u r n a l o f B e h a v i o r a l S c i e n c e , 1973, _5, 264-271.

R e v i l l , S.F., R o b i n s o n , J.O., Rosen, M., & Hogg, M . I . J . The r e l i a b i l i t y of the l i n e a r analogue f o r e v a l u a t i n g p a i n . A n a e s t h e s i a , 1976, 31, 1 1 1

R o t t e r , J.B. G e n e r a l i z e d e x p e c t a n c i e s f o r i n t e r n a l v e r s u s e x t e r n a l c o n t r o l of r e i n f o r c e m e n t . P s y c h o l o g i c a l Monographs, 1966, 80_ (whole no. 6 0 9 ) .

R o t t e r , J.B. Some problems and m i s c o n c e p t i o n s r e l a t e d t o the c o n s t r u c t of i n t e r n a l v e r s u s e x t e r n a l r e i n f o r c e m e n t . J o u r n a l o f C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1975, 43, 56-67.

S a n d e r s , S. Toward a p r a c t i c a l i n s t r u m e n t system f o r the automated measurement of "u p t i m e " i n c h r o n i c p a i n p a t i e n t s . P a i n , 1980, 9_, 103-109.

S e r e s , J . , P a i n t e r , J.R., & Newman, R . I . M u l t i d i s c i p l i n a r y t r e a t m e n t of c h r o n i c p a i n a t the N o r t h w e s t P a i n C e n t r e . I n L o r e n z , Ky Ng (Ed.) New Approaches t o Treatment o f C h r o n i c P a i n . R o c k v i l l e , MD.: NIDA R e s e a r c h Monograph 36, 1981.

S k e v i n g t o n , S.M. P a i n and l o c u s of c o n t r o l - A s o c i a l a p p r o a c h . I n Oborne, D.J., Grunebe r g , M.M., & E i s e r , J.R. ( E d s . ) R e s e a r c h i n P s y c h o l o g y and M e d i c i n e . Volume 1. London: Academic P r e s s , 1979.

S t e r n b a c h , R.A. P a i n : A P s y c h o p h y s i o l o g i c a l A n a l y s i s . New Y o r k : Academic P r e s s , 1968.

S t e r n b a c h , R.A. P a i n p a t i e n t s : T r a i t s and t r e a t m e n t . New Y o r k : Academic P r e s s , 1974.

S t e r n b a c h , R.A. (Ed.) The P s y c h o l o g y o f P a i n . New Y o r k : Raven P r e s s , 1978.

S t r i c k l a n d , B.R. I n t e r n a l - e x t e r n a l e x p e c t a n c i e s and h e a l t h - r e l a t e d b e h a v i o r s . J o u r n a l o f C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1978, 46, 1192-1211.

T a i t , R., DeGood, D., & C a r r o n , H. A c o m p a r i s o n of h e a l t h l o c u s of c o n t r o l b e l i e f s i n low-back p a i n p a t i e n t s from the U.S. and New Z e a l a n d . P a i n , 1982, JL4, 53-61.

T o b i a s , L.L., & MacDonald, M.L. I n t e r n a l l o c u s of c o n t r o l and w e i g h t l o s s : An i n s u f f i c i e n t c o n d i t i o n . J o u r n a l o f C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1977, 45, 647-653.

Toomey, T.C., T a y l o r , A.G., S k e l t o n , J.A., & C a r r o n , H. S t a b i l i t y of s e l f - r e p o r t measures of improvement i n c h r o n i c p a i n : A f i v e - y e a r f o l l o w - u p . P a i n , 1982, ]2, 273-283.

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T u r s k y , B., Jamner, L., & F r i e d m a n , R. The p a i n p e r c e p t i o n p r o f i l e : A p s y c h o p h y s i c a l approach to the assessment of p a i n r e p o r t . B e h a v i o r T h e r a p y , 1982, _13» 376-394.

V e r b r u g g e , L.M. Females and i l l n e s s . Recent t r e n d s i n sex d i f f e r e n c e s i n the U n i t e d S t a t e s . J o u r n a l o f H e a l t h and S o c i a l B e h a v i o r , 1976, 17, 387-403.

W e i s e n b e r g , M. The r e g u l a t i o n of p a i n . I n F l o r e n c e , L., ( E d . ) , P s y c h o l o g y : The L e a d i n g Edge. Volume 340. New Y o r k : The New Y o r k Academy of S c i e n c e s , 1980.

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APPENDIX A

LETTER OF CONTACT

- 91 -T H E UNIVERSITY O F BRITISH C O L U M B I A

F A C U L T Y O F E D U C A T I O N

D E P A R T M E N T O F C O U N S E L L I N G P S Y C H O L O G Y

5780 T O R O N T O R O A D

VANCOUVER, B.C. V6T 1L2

May 31, 1983

PROJECT: What e f f e c t does a c h r o n i c p a i n t r e a t m e n t program have on an

i n d i v i d u a l ' s a d j u s t m e n t t o p a i n ?

Dear

I am s e e k i n g y o u r i n v o l v e m e n t i n a s t u d y b e i n g c a r r i e d out by

m y s e l f and Dr. Marv Westwood of the Department of C o u n s e l l i n g P s y c h o l o g y

a t UBC.

I am i n t e r e s t e d i n f i n d i n g out how you've managed i n v a r i o u s

a s p e c t s of y o u r l i f e s i n c e you f i n i s h e d t h e r e s i d e n t i a l p a i n t r e a t m e n t

program at the Columbia C e n t r e . T h i s i n v o l v e s a n s w e r i n g the f o u r

q u e s t i o n n a i r e s i n c l u d e d w i t h t h i s l e t t e r . A p p r o x i m a t e l y 1-1/2 h o urs of

y o u r time w i l l be r e q u i r e d . The i n f o r m a t i o n g a i n e d from t h i s s t u d y w i l l

be h e l p f u l t o p r o f e s s i o n a l s w o r k i n g w i t h p a t i e n t s s u f f e r i n g from c h r o n i c

p a i n . I n a d d i t i o n , as you complete the q u e s t i o n n a i r e s , you may d i s c o v e r

some i n t e r e s t i n g t h i n g s about y o u r s e l f and about how p e o p l e l i k e

y o u r s e l f r e s p o n d t o p a i n .

Your p a r t i c i p a t i o n i n t h i s s t u d y would be v e r y much

a p p r e c i a t e d . However, I want t o emphasize t h a t p a r t i c i p a t i o n i s t o t a l l y

v o l u n t a r y . A l l i n f o r m a t i o n g a t h e r e d w i l l be k e p t e n t i r e l y c o n f i d e n t i a l ,

used f o r r e s e a r c h purposes o n l y , and w i l l be d e s t r o y e d when the s t u d y i s

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APPENDIX B

INSTRUCTION SHEET

- 95 -

APPENDIX C

BIOGRAPHICAL INFORMATION QUESTIONNAIRE

- 96 -

PART A BIOGRAPHICAL INFORMATION

Y o u r c o o p e r a t i o n i n p r o v i d i n g t h i s i n f o r m a t i o n i s a p p r e c i a t e d . P l e a s e be a s s u r e d of s t r i c t c o n f i d e n t i a l i t y and do not w r i t e y o u r name on the q u e s t i o n n a i r e .

AGE 20-30

31-40 41-50 51-60 61+

SEX Female Male

HOW LONG AGO d i d you complete the r e s i d e n t i a l p a i n t r e a t m e n t program?

months ago y e a r s ago

I f you no l o n g e r e x p e r i e n c e p a i n , i n d i c a t e how l o n g you have been PAIN FREE ( o m i t i f you s t i l l have some p a i n ) .

weeks months y e a r s

DO NOT WRITE BELOW THIS LINE: (FOR TABULATING USE)

- 97 -

HOW LONG have you e x p e r i e n c e d c h r o n i c p a i n ? 1 y e a r or l e s s 2 y e a r s or l e s s 2-5 y e a r s more t h a n 5 y e a r s

PRIOR t o the r e s i d e n t i a l p a i n t r e a t m e n t program d i d you have any p a i n - r e l a t e d s u r g e r y ?

yes no

ADDITIONAL p a i n - r e l a t e d s u r g e r y s i n c e c o m p l e t i o n of the r e s i d e n t i a l p a i n t r e a t m e n t program?

yes more tha n one no

Have you had any r e c e n t h o s p i t a l a d m i s s i o n s f o r p a i n - r e l a t e d problems? yes no

Have you sought o t h e r t r e a t m e n t f o r p a i n r e l i e f s i n c e c o m p l e t i o n of the r e s i d e n t i a l p a i n t r e a t m e n t program?

yes no

I f y e s , what?

How much m e d i c a t i o n do you t a k e f o r you r p a i n ? ( i n d i c a t e one) no m e d i c a t i o n f o r p a i n now l e s s t h a n b e f o r e t r e a t m e n t same as b e f o r e t r e a t m e n t more tha n b e f o r e t r e a t m e n t

- 98 -

Has the amount of time w h i c h you spend i n bed o r l y i n g down because of p a i n changed s i n c e you completed the r e s i d e n t i a l p a i n t r e a t m e n t program? ( i n d i c a t e one)

spend no time i n bed or l y i n g down due t o p a i n spend l e s s time i n bed or l y i n g down due t o p a i n spend the same amount of time as b e f o r e spend more time than b e f o r e

Has t h e r e been a change i n you r a b i l i t y t o bend or walk s i n c e you co m p l e t e d the r e s i d e n t i a l p a i n t r e a t m e n t program? ( i n d i c a t e one)

f u n c t i o n c o m p l e t e l y improved o r r e s t o r e d f u n c t i o n s l i g h t l y b e t t e r t h a n b e f o r e t r e a t m e n t f u n c t i o n the same as b e f o r e t r e a t m e n t f u n c t i o n worse t h a n b e f o r e t r e a t m e n t

- 99 -

APPENDIX D

LOCUS OF CONTROL SCALE

(ROTTER, 1966)

- 100 -

PART B ~ OPINION QUESTIONNAIRE

DIRECTIONS

I am t r y i n g t o f i n d out what men and women t h i n k about c e r t a i n t h i n g s .

I want you t o answer the f o l l o w i n g q u e s t i o n s the way you f e e l . There

a r e no r i g h t o r wrong answers.

One of y o u r c o n c e r n s d u r i n g t h i s p a r t of t h e q u e s t i o n n a i r e may be, "What

s h o u l d I do i f b o t h ( a ) and (b) e x p r e s s my o p i n i o n o r i f n e i t h e r e x p r e s s

my o p i n o n ? " I t ' s not u n u s u a l f o r t h a t t o happen. I f i t does, s e l e c t

the one t h a t i s more n e a r l y t r u e i n y o u r o p i n i o n . T r y not t o l e a v e any

b l a n k .

F o r each q u e s t i o n s e l e c t w h i c h s t a t e m e n t i s c l o s e r t o y o u r o p i n i o n and

c i r c l e e i t h e r (a) or ( b ) .

- 101 -

PART B ~ OPINION QUESTIONNAIRE

C h i l d r e n get i n t o t r o u b l e because t h e i r p a r e n t s p u n i s h them t o o much.

The t r o u b l e w i t h most c h i l d r e n nowadays i s t h a t t h e i r p a r e n t s a r e too easy w i t h them.

Many of the unhappy t h i n g s i n p e o p l e ' s l i v e s a r e p a r t l y due t o bad l u c k .

P e o p l e ' s m i s f o r t u n e s r e s u l t s from the m i s t a k e s t h e y make.

One of the major r e a s o n s why we have wars i s because p e o p l e don't t a k e enough i n t e r e s t i n p o l i t i c s .

T here w i l l a lways be wars, no m a t t e r how h a r d p e o p l e t r y t o p r e v e n t them.

I n t h e l o n g r u n p e o p l e get the r e s p e c t they d e s e r v e i n t h i s w o r l d .

U n f o r t u n a t e l y , an i n d i v i d u a l ' s w o r t h o f t e n p a s s e s u n r e c o g n i z e d no m a t t e r how h a r d one t r i e s .

The i d e a t h a t t e a c h e r s a r e u n f a i r t o s t u d e n t s i s nonsense.

Most s t u d e n t s don't r e a l i z e t he e x t e n t t o w h i c h t h e i r grades a r e i n f l u e n c e d by a c c i d e n t a l h a p p e n i n g s .

W i t h o u t the r i g h t b r e a k s one cannot be an e f f e c t i v e l e a d e r .

Capable p e o p l e who f a i l t o become l e a d e r s have not t a k e n advantage of t h e i r o p p o r t u n i t i e s .

No m a t t e r how h a r d you t r y some p e o p l e j u s t don't l i k e you.

P e o p l e who c a n ' t get o t h e r s t o l i k e them don't u n d e r s t a n d how to get a l o n g w i t h o t h e r s .

H e r e d i t y p l a y s the major r o l e i n d e t e r m i n i n g one's p e r s o n a l i t y .

I t i s one's e x p e r i e n c e s i n l i f e w h i c h d e t e r m i n e what t h e y ' r e l i k e .

I have o f t e n f o u n d t h a t what i s g o i n g t o happen w i l l happen.

T r u s t i n g t o f a t e has never t u r n e d out as w e l l f o r me as making a d e c i s i o n t o t a k e a d e f i n i t e c o u r s e of a c t i o n .

- 102 -

10. a. I n the case of the w e l l p r e p a r e d s t u d e n t t h e r e i s r a r e l y i f ev e r such a t h i n g as an u n f a i r t e s t .

b. Many t i m e s exam q u e s t i o n s t e n d t o be so u n r e l a t e d t o c o u r s e work t h a t s t u d y i n g i s r e a l l y u s e l e s s .

11. a. Becoming a s u c c e s s i s a m a t t e r of h a r d work, l u c k has l i t t l e o r n o t h i n g t o do w i t h i t .

b. G e t t i n g a good j o b depends m a i n l y on b e i n g i n the r i g h t p l a c e a t t he r i g h t t i m e .

12. a. The average c i t i z e n can have an i n f l u e n c e i n government d e c i s i o n s .

b. T h i s w o r l d i s r u n by the few p e o p l e i n power, and t h e r e i s not much the l i t t l e guy can do about i t .

13. a. When I make p l a n s , I am a l m o s t c e r t a i n t h a t I can make them work.

b. I t i s not always w i s e t o p l a n too f a r ahead because many t h i n g s t u r n out t o be a m a t t e r of good o r bad f o r t u n e anyway.

14. a. t h e r e a r e c e r t a i n p e o p l e who a r e j u s t no good,

b. There i s some good i n everybody.

15. a. I n my case g e t t i n g what I want has l t t l e o r n o t h i n g t o do w i t h l u c k .

b. Many t i m e s we might j u s t as w e l l d e c i d e what t o do by f l i p p i n g a c o i n .

16. a. Who g e t s t o be the boss o f t e n depends on who was l u c k y enough to be i n the r i g h t p l a c e f i r s t .

b. G e t t i n g p e o p l e t o do the r i g h t t h i n g depends upon a b i l i t y ; l u c k has l i t t l e t o do w i t h i t .

17. a. As f a r as w o r l d a f f a i r s a r e c o n c e r n e d , most of us a r e the v i c t i m s of f o r c e s we can n e i t h e r u n d e r s t a n d nor c o n t r o l .

b. By t a k i n g an a c t i v e p a r t i n p o l i t i c a l and s o c i a l a f f a i r s t he p e o p l e can c o n t r o l w o r l d e v e n t s .

18. a. Most p e o p l e don't r e a l i z e t he e x t e n t t o w h i c h t h e i r l i v e s a r e

c o n t r o l l e d by a c c i d e n t i a l h a p p e n i n g s .

b. There r e a l l y i s no such t h i n g as " l u c k " .

19. a. One s h o u l d always be w i l l i n g t o admit m i s t a k e s ,

b. I t i s u s u a l l y b e s t t o c o v e r up one's m i s t a k e s .

- 103 -

I t i s h a r d t o know whether or not a p e r s o n r e a l l y l i k e s you.

How many f r i e n d s you have depends upon how n i c e a p e r s o n you a r e .

I n the l o n g r u n the bad t h i n g s t h a t happen t o us a r e b a l a n c e d by the good ones.

Most m i s f o r t u n e s a r e the r e s u l t of l a c k of a b i l i t y , i g n o r a n c e , l a z i n e s s , o r a l l t h r e e .

W i t h enough e f f o r t we can wipe out p o l i t i c a l c o r r u p t i o n .

I t i s d i f f i c u l t f o r pe o p l e t o have much c o n t r o l o v e r the t h i n g s p o l i t i c i a n s do i n o f f i c e .

Sometimes I c a n ' t u n d e r s t n d how t e a c h e r s a r r i v e a t t h e grades they g i v e .

There i s a d i r e c t c o n n e c t i o n between how h a r d I s t u d y and the grades I g e t .

A good l e a d e r e x p e c t s p e o p l e t o d e c i d e f o r t h e m s e l v e s what they s h o u l d do.

A good l e a d e r makes i t c l e a r t o everybody what t h e i r j o b s a r e .

Many tim e s I f e e l t h a t I have l i t t l e i n f l u e n c e o v e r the t h i n g s t h a t happen t o me.

I t i s i m p o s s i b l e f o r me t o b e l i e v e t h a t chance o r l u c k p l a y s an i m p o r t a n t r o l e i n my l i f e .

P e o p l e a r e l o n e l y because they don't t r y t o be f r i e n d l y .

T h e r e ' s not much use i n t r y i n g t o o h a r d t o p l e a s e p e o p l e , i f the y l i k e y ou, they l i k e you.

There i s too much emphasis on a t h l e t i c s i n h i g h s c h o o l .

Team s p o r t s a r e an e x c e l l e n t way t o b u i l d c h a r a c t e r .

What happens t o me i s my own d o i n g .

Sometimes I f e e l t h a t I don't have enough c o n t r o l o v e r the d i r e c t i o n my l i f e i s t a k i n g .

Most of the time I c a n ' t u n d e r s t a n d why p o l i t i c i a n s behave t h e way they do.

I n t h e l o n g r u n t h e p e o p l e a r e r e s p o n s i b l e f o r bad government on a n a t i o n a l as w e l l as on a l o c a l l e v e l .

- 104 -

APPENDIX E

ADJUSTMENT TO CHRONIC PAIN SCALE

- 105 -

PART C WORK, LEISURE AND FAMILY L I F E QUESTIONNAIRE

I am I n t e r e s t e d i n how you have been a f f e c t e d by y o u r c h r o n i c p a i n and I w o u l d l i k e you t o answer t h e s e q u e s t i o n s about y o u r work, spare t i m e a c t i v i t i e s and y o u r f a m i l y l i f e .

P l e a s e CIRCLE t h e number b e s i d e t h e one s t a t e m e n t w h i c h b e s t s t a t e s how you t h i n k or f e e l .

1. How do you f e e l about the v a r i o u s t r e a t m e n t s you have r e c e i v e d f o r y o u r c h r o n i c p a i n ?

0 v e r y p o s i t i v e w i t h h i g h l e v e l s of c o n f i d e n c e 1 g e n e r a l l y p o s i t i v e w i t h some r e s e r v a t i o n s 2 somewhat n e g a t i v e w i t h c y n i c i s m 3 n e g a t i v e w i t h a l a c k of c o n f i d e n c e

2. How do you f e e l about the l e v e l of competence of the d o c t o r s who have t r e a t e d you f o r y o u r c h r o n i c p a i n ?

0 v e r y p o s i t i v e w i t h h i g h l e v e l s of c o n f i d e n c e . 1 g e n e r a l l y p o s i t i v e w i t h some r e s e r v a t i o n s 2 somewhat n e g a t i v e w i t h c y n i c i s m 3 n e g a t i v e w i t h a l a c k of c o n f i d e n c e

3. Do you b e l i e v e you were g i v e n enough i n f o r m a t i o n about y o u r c h r o n i c p a i n c o n d i t i o n t o make a d i f f e r e n c e i n y o u r d a i l y l i v i n g ?

0 c o m plete i n f o r m a t i o n f o r my purposes 1 adequate, but I c o u l d have used more 2 l e s s t h a n adequate 3 no i n f o r m a t i o n t o make a d i f f e r e n c e

4. Have you had t o change t h e k i n d of work you do as a r e s u l t of y o u r c h r o n i c p a i n , by f i n d i n g new employment or by c h a n g i n g the n a t u r e of y o u r work?

0 unchanged 1 s l i g h t m o d i f i c a t i o n 2 s i g n i f i c a n t m o d i f i c a t i o n 3 c o m p l e t e l y d i f f e r e n t

- 106 -

Has the amount of s a t i s f a c t i o n you get f r o m y o u r j o b changed s i n c e you have e x p e r i e n c e d c h r o n i c p a i n ?

0 more s a t i s f a c t i o n now 1 same s a t i s f a c t i o n now as b e f o r e 2 l e s s s a t i s f a c t i o n now 3 no s a t i s f a c t i o n now or b e f o r e

The amount of time you have l o s t from the j o b as a r e s u l t of y o u r c h r o n i c p a i n has been

0 none 1 l e s s t h a n 1 y e a r 2 more t h a n 1 y e a r but l e s s t h a n 1-1/2 y e a r s 3 1-1/2 y e a r s or more

How o f t e n do you e x p e r i e n c e d i f f i c u l t i e s ( e . g . h o s t i l i t y o r anger, r e s e n t m e n t , e t c . ) on the j o b w i t h c o - w o r k e r s as a r e s u l t of yo u r c h r o n i c p a i n ?

0 n e v e r 1 r a r e l y 2 o f t e n 3 always

How would you c h a r a c t e r i z e y o u r r e l a t i o n s h i p w i t h y o u r c l o s e s t f a m i l y member?

0 v e r y good 1 adequate 2 somewhat i n a d e q u a t e 3 v e r y i n a d e q u a t e

Has i t been d i f f i c u l t f o r the p e r s o n or p e o p l e you l i v e w i t h t o t a l k about or adapt t o any changes r e s u l t i n g f r o m y o u r c h r o n i c p a i n ?

0 not d i f f i c u l t a t a l l 1 m i l d l y d i f f i c u l t 2 m o d e r a t e l y d i f f i c u l t 3 e x t r e m e l y d i f f i c u l t

Have yo u r f i n a n c i a l r e s o u r c e s been a f f e c t e d by y o u r c h r o n i c p a i n e x p e r i e n c e ?

0 no a f f e c t 1 s l i g h t l y a f f e c t e d 2 m o d e r a t e l y a f f e c t e d 3 d r a s t i c a l l y a f f e c t e d

- 107 -

Do you depend on the p e r s o n or p e o p l e you l i v e w i t h f o r any h e l p o r a s s i s t a n c e because of y o u r c h r o n i c p a i n ?

0 t o t a l l y i n d e p e n d e n t 1 m i l d l y dependent 2 m o d e r a t e l y dependent 3 t o t a l l y dependent

S i n c e you've e x p e r i e n c e d c h r o n i c p a i n , has t h e r e been any change i n t h e p l e a s u r e o r s a t i s f a c t i o n you d e r i v e f r o m s e x u a l a c t i v i t i e s ?

0 no change i n s e x u a l p l e a s u r e o r s a t i s f a c t i o n 1 s l i g h t r e d u c t i o n i n s e x u a l p l e a s u r e or s a t i s f a c t i o n 2 moderate r e d u c t i o n i n s e x u a l p l e a s r e o r s a t i s f a c t i o n 3 no s e x u a l p l e a s r e or s a t i s f a c t i o n

S i n c e you've e x p e r i e n c e d c h r o n i c p a i n has t h e r e been any change i n y o u r i n t e r e s t i n s e x u a l a c t i v i t i e s ?

0 no change i n i n t e r e s t 1 s l i g h t change i n i n t e r e s t 2 moderate change i n i n t e r e s t 3 no i n t e r e s t

Have you had any problems d u r i n g s e x u a l i n t e r c o u r s e ( e . g . d i s c o m f o r t or d i f f i c u l t r e a c h i n g c l i m a x ) s i n c e the development of y o u r c h r o n i c p a i n ?

0 n e v e r 1 r a r e l y 2 o f t e n 3 always

Has t h e r e been any change i n the f r e q u e n c y of y o u r s e x u a l a c t i v i t y s i n c e you've e x p e r i e n c e d c h r o n i c p a i n ?

0 no change i n f r e q u e n c y 1 s l i g h t r e d u c t i o n i n f r e q u e n c y 2 moderate r e d u c t i o n i n f r e q u e n c y 3 no s e x u a l a c t i v i t y

How would you c h a r a c t e r i z e y o u r r e l a t i o n s h i p w i t h y o u r r e l a t i v e s ( i . e . y o u r p a r e n t s , b r o t h e r s , s i s t e r s , i n - l a w s , and c h i l d r e n n o t l i v i n g a t home) s i n c e the development of y o u r c h r o n i c p a i n ?

0 v e r y good 1 adequate 2 somewhat i n a d e q u a t e 3 v e r y i n a d e q u a t e

- 108 -

Do you depend on y o u r r e l a t i v e s who do not l i v e w i t h you f o r any h e l p o r a s s i s t a n c e because of y o u r c h r o n i c p a i n ?

0 t o t a l l y i n d e p e n d e n t 1 m i l d l y i n d e p e n d e n t 2 m o d e r a t e l y dependent 3 t o t a l l y dependent

Are you i n t e r e s t e d i n s p e n d i n g time w i t h and t a l k i n g t o y o u r r e l a t i v e s s i n c e the development of y o u r c h r o n i c p a i n ?

0 v e r y i n t e r e s t e d 1 m o d e r a t e l y i n t e r e s t e d 2 somewhat i n t e r e s t e d 3 not a t a l l i n t e r e s t e d

Have you m a i n t a i n e d y o u r i n t e r e s t i n s o c i a l a c t i v i t i e s ( e . g . s o c i a l c l u b s , e n t e r t a i n i n g , c h u r c h g r o u p s , g o i n g t o the mo v i e s , g o i n g t o s p o r t s e v e n t s , e t c . ) s i n c e t h e development of y o u r c h r o n i c p a i n ?

0 same l e v e l of i n t e r e s t as p r e v i o u s l y 1 s l i g h t l y l e s s i n t e r e s t t h a n b e f o r e 2 s i g n i f i c a n t l y l e s s i n t e r e s t t h a n b e f o r e 3 l i t t l e o r no i n t e r e s t r e m a i n i n g

Have you m a i n t a i n e d y o u r p a r t i c i p a t i o n i n s o c i a l o r l e i s u r e a c t i v i t i e s ( e . g . s o c i a l c l u b s , e n t e r t a i n i n g , c h u r c h g r o u p s , g o i n g t o the mo v i e s , g o i n g t o s p o r t s e v e n t s , e t c . ) s i n c e t h e development of y o u r c h r o n i c p a i n ?

0 same l e v e l of p a r t i c i p a t i o n as p r e v i o u s l y 1 s l i g h t l y l e s s p a r t i c i p a t i o n t h a n b e f o r e 2 s i g n i f i c a n t l y l e s s p a r t i c i p a t i o n than b e f o r e 3 l i t t l e o r no p a r t i c i p a t i o n now

Have you m a i n t a i n e d y o u r p a r t i c i p a t i o n i n i n d i v i d u a l l e i s u r e a c t i v i t i e s ( e . g . s p o r t s , g a r d e n i n g , d a n c i n g , o t h e r h o b b i e s , e t c . ) s i n c e the development of y o u r c h r o n i c p a i n ?

0 same l e v e l of p a r t i c i p a t i o n as p r e v i o u s l y 1 s l i g h t l y l e s s p a r t i c i p a t i o n t h a n b e f o r e 2 s i g n i f i c a n t l y l e s s p a r t i c i p a t i o n t h a n b e f o r e 3 l i t t l e o r no p a r t i c i p a t i o n now

- 109 -

Have you m a i n t a i n e d y o u r i n t e r e s t i n i n d i v i d u a l l e i s u r e a c t i v i t i e s ( e . g . s p o r t s , g a r d e n i n g , o t h e r h o b b i e s , e t c . ) s i n c e the development o f y o u r c h r o n i c p a i n ?

0 same l e v e l of i n t e r e s t as p r e v i o u s l y 1 s l i g h t l y l e s s i n t e r e s t than b e f o r e 2 s i g n i f i c a n t l y l e s s i n t e r e s t t h a n b e f o r e 3 l i t t l e or no i n t e r e s t r e m a i n i n g

Have you been f e e l i n g a n x i o u s or nervous r e c e n t l y ?

0 n o t a t a l l 1 m i l d l y 2 m o d e r a t e l y 3 e x t r e m e l y

Has the amount of w o r r y i n g you do changed s i n c e t h e development of y o u r c h r o n i c p a i n s t a t e ?

0 d i d n ' t w o r r y b e f o r e and s t i l l don't 1 worry l e s s now 2 w o r r y the same now as b e f o r e 3 w o r r y more now

Do you think, about y o u r body d i f f e r e n t l y s i n c e the development of y o u r c h r o n i c p a i n ?

0 I l i k e my body more now 1 I l i k e my body the same now as b e f o r e 2 I l i k e my body l e s s now 3 I d i d n ' t l i k e my body b e f o r e and I don't l i k e i t now

Has t h e r e been any change i n t h e amount of anger you f e e l towards f r i e n d s or r e l a t i v e s s i n c e the development of your c h r o n i c p a i n ?

0 I f e e l l e s s anger now 1 I f e e l t h e same amount of anger now as b e f o r e 2 I f e e l more angry now 3 I n e v e r got angry b e f o r e and I don't now

Has t h e r e been any change i n the amount of d e p r e s s i o n you f e e l s i n c e t h e development of y o u r c h r o n i c p a i n ?

0 I get d e p r e s s e d l e s s o f t e n now t h a n b e f o r e 1 I get d e p r e s s e d now about the same as b e f o r e 2 I f e e l more d e p r e s s e d now 3 I never got d e p r e s s e d b e f o r e and I don't now

- 110 -

APPENDIX F

MCGILL PAIN QUESTIONNAIRE

( M e l z a c k , 1975)

- I l l -

PART D PAIN QUESTIONNAIRE

DIRECTIONS What Does Your P a i n F e e l L i k e ?

Some of the words below d e s c r i b e your p r e s e n t p a i n .

C i r c l e ONLY thos e words t h a t b e s t d e s c r i b e i t . Leave out any c a t e g o r y t h a t i s not s u i t a b l e . Use o n l y a s i n g l e word i n each a p p r o p r i a t e c a t e g o r y - the one t h a t a p p l i e s b e s t .

F l i c k e r i n g Q u i v e r i n g P u l s i n g T h r o b b i n g B e a t i n g P o u n d i n g

2 Jumping F l a s h i n g S h o o t i n g

P r i c k i n g B o r i n g D r i l l i n g S t a b b i n g L a c i n i a t i n g

4 Sharp C u t t i n g L a c e r a t i n g

P i n c h i n g P r e s s i n g Gnawing Cramping C r u s h i n g

6 Tu g g i n g P u l l i n g W renching

Hot B u r n i n g S c a l d i n g S e a r i n g

8 T i n g l i n g I t c h y S m a r t i n g S t i n g i n g

9 10 11 12 D u l 1 Tender T i r i n g S i c k e n i n g S o re Taut E x h a u s t i n g S u f f o c a t i n g H u r t i n g R a s p i n g A c h i n g S p l i t t i n g Heavy

13 F e a r f u l F r i g h t f u l T e r r i f y i n g

14 P u n i s h i n g G r u e l l i n g C r u e l V i c i o u s K i l l i n g

15 Wretched B l i n d i n g

16 A n n o y i n g Troublesome M i s e r a b l e I n t e n s e U n b e a r a b l e

17 S p r e a d i n g R a d i a t i n g P e n e t r a t i n g P i e r c i n g

18 T i g h t Numb Drawing S q u e e z i n g T e a r i n g

19 C o o l C o l d F r e e z i n g

20 N a g g i n g N a u s e a t i n g A g o n i z i n g D r e a d f u l T o r t u r i n g

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APPENDIX G

T-TESTS USING ADJUSTMENT TO CHRONIC

PAIN SCORES TO COMPARE MALES AND FEMALES

- 113 -

T-Tests U s i n g A d j u s t m e n t t o C h r o n i c P a i n S c o r e s t o Compare Mal e s and Females

V a r i a b l e s S t a n d a r d

Mean D e v i a t i o n

S u b t e s t 2, V o c a t i o n a l E n v i r o n m e n t

M a l e s n = 28

Females n = 13

7.64

5.85

2.33

2.08 2.38 0.02

S u b t e s t 7, P s y c h o l o g i c a l D i s t r e s s

W o r r y i n g :

M a l e s n = 28

Females n = 13

2.39

1.69

0.83

0.95 2.40 0.02

D e p r e s s i o n :

M a l e s n = 28

Females n = 13

1.43

0.69

1.00

0.86 2.30 0.03