the impact of psychosocial features of employment status on emotional distress in chronic pain and...

Journal of Behavioral Medicine, Vol 20. No. 3, 1997

The Impact of Psychosocial Features ofEmployment Status on Emotional Distress inChronic Pain and Healthy Comparison Samples

Todd Jackson,1-3 Anthony Iezzi,1 and Kathryn Lafreniere2

Accepted for publication: September 1, 1996

This study examined the extent to which measures of psychosocial features ofemployment status predict emotional distress in chronic pain (n = 83) andhealthy comparison (n = 88) samples. Participants completed measures ofemotional distress, pain severity, psychosocial features of employment status,and demographic data. After controlling for length of current unemployment,number of pain sites, and level of current pain severity, psychosocial measures(structured and purposeful time use, perceived financial security, skill use,social support from formal sources) were significant predictors of emotionaldistress in the chronic pain sample. Similar results were obtained for thehealthy comparison sample. Structured and purposeful time use emerged asthe most significant individual predictor of emotional distress for both samples.Findings are discussed in terms of their potential implications for treatingchronic pain patients and the need to develop multidimensional measures thatassess features of employment status within chronic pain samples.KEY WORDS: employment; emotional distress; chronic pain.

INTRODUCTION

While considerable empirical support has been obtained for links be-tween chronic pain and emotional distress (e.g., Gamsa and Vikis-Freibergs,

1Department of Psychology, Victoria Hospital, 370 South Street, London, ON, N6B IBS,Canada

2Department of Psychology, University of Windsor, 401 Sunset Avenue, Windsor, ON, N9B3P4, Canada.

3To whom correspondence should be addressed.

Z41

O160-7715/97/0600-0241$12.50/0 C 1997 Plenum Publishing Corporation

1990; Melzack and Wall, 1988; Polatin et al., 1993) as well as pain andwork disability (e.g., Frymoyer, 1991; Gallagher et al., 1989; Gatchel et al.,1995; McGill, 1968), little theory-driven research has examined how psy-chosocia! features of employment status affect the emotional well-being ofchronic pain patients. Nonetheless, theory and research on nonclinical sam-ples have identified several correlates of employment status that maymoderate emotional distress (e.g., Banks, 1995; Feather, 1990; Fineman,1979; Fryer and Payne, 1986; Jahoda, 1982; O'Brien, 1986; Warr, 1987; Warret al., 1988).

One recent approach explains the impact of employment and unem-ployment on emotional distress on the basis of differences in ninepsychosocial features of the environment (Banks, 1995; Warr, 1987; Warret al., 1988). According to Warr (1987), the negative psychological impactof unemployment and employment results largely from reduced opportu-nities for control, skill use, task variety, environmental clarity, externallygenerated goals, income/financial strain, physical security, social status, andinterpersonal contact. Conversely, employment has detrimental conse-quences for emotional distress when job environments provide excessivelylow levels of these features or excessively high levels of particular features(demands for control, skill use, task variety, environmental clarity, exter-nally generated goals, interpersonal contact).

Research on Warr's nine-factor model indicates that reductions inmoney, externally generated demands such as the imposition of structuredand purposeful time use, social contact and support, control, skill use, taskvariety, and environmental clarity are associated with heightened affectivedistress within employed and unemployed groups (e.g., Bolton and Oatley,1987; Broman et al., 1990; Dew et al., 1991; Gore, 1978; Graetz, 1993; Hep-worth, 1980; Jackson, 1988; Jones, 1991; Kilpatrick and Trew, 1985; Ullah,1990; Winefield et al., 1992).

While Warr's nine-factor model has not been assessed comprehensivelyin chronic pain patients, there is some research support for relations be-tween isolated aspects of the model and measures of physical andpsychological adjustment For example, related to purposeful activity, jobduties that are perceived to be boring and monotonous have been linkedto reports of increased pain severity and emotional distress (e.g., Svenssonand Andersson, 1983, 1989). At the other extreme, excessively high levelsof responsibility during the job are associated with increased work pressure(Beals and Hickman, 1972; Bigos et al., 1992) and job dissatisfaction (Bigoset al., 1991). The absence of financial support may be linked to deteriora-tions in emotional status and a decreased likelihood of returning to work

242 Jackson, Iezzi, and Lafreniere

among injured workers who perceive they are entitled to compensation(Gallagher et al., 1995). Supportive job environments are related to in-creased job satisfaction (Crates, 1993) and reduced pain intensity(Feuerstein et al., 1985; Feuerstein and Thebarge, 1991; Svensson and An-dersson, 1983) for workers with various disabilities. Adversarial relationswith formal systems are associated with exacerbations in pain severity, pro-longed unemployment, and heightened emotional distress (e.g., Carron etal, 1985; Guest and Drummond, 1992). High levels of perceived controland autonomy in the workplace may be associated with reduced pain in-tensity (e.g., Beals and Hickman, 1972; Parkes, 1973).

Unfortunately, few studies have assessed how a combination of thesepsychosocial features affect the emotional status of chronic pain patients(e.g., Feuerstein et al., 1985; Feuerstein and Thebarge, 1991). Furthermore,research on chronic pain samples has assessed the impact of work-relatedpredictors on work-related outcomes such as job satisfaction and return towork as opposed to more general outcomes such as emotional distress.

This study evaluates the impact of measures based on specific featuresof Warr's nine-factor model in predicting emotional distress for chronicpain and healthy comparison samples. An investigation of these featuresis important because injured workers are at risk for vocational dysfunctionand job loss and the successful maintenance of, and return to, employmentcould depend, in part, on optimal levels of these psychosocial features. Fur-thermore, evaluating measures based upon several features of thenine-factor model can aid in identifying psychosocial experiences that aremost predictive of emotional distress, understanding which individuals withchronic pain are most at risk for experiencing emotional maladjustment,and suggesting treatment strategies for specific areas of vulnerability.

On the basis of past research, measures based on six features of Warr'snine-factor model (externally generated demands, financial strain, control,skill use, variety, and social contact) were expected to emerge as significantpredictors of emotional distress for both chronic pain and healthy com-parison samples. Measures based on the other three features of Warr'smodel—physical security, status, and environmental clarity—were not in-cluded because of the absence of psychometrically sound measuresapplicable to contexts of both employment and unemployment. Even aftercontrolling for statistically significant demographic variables and level ofcurrent para severity for the pain sample, measures of externally generateddemands, financial strain, control, skill use, variety, and social contact wereexpected to make contribute significantly to the prediction of emotionaldistress.

Employment Status and Emotional Distress 243

Participants

Employed and unemployed participants with chronic pain were re-cruited from various services at a general medical hospital in London,Ontario. Subjects from both samples were also recruited through adver-tisements posted at government and community agencies in London andWindsor, Ontario. The advertisements requested volunteers for researchon the impact of conditions of employment and unemployment among per-sons with and without chronic pain conditions. To assess eligibility for thestudy, all community and patient volunteers were initially screened in abrief phone interview by the first author.

Inclusion criteria included age between 18 and 60 years, a report ofeither chronic benign pain (ongoing pain for at least 6 months in the back,neck, limbs, or face) or good physical health, and consistent with conven-tions of unemployment research (e.g., Feather, 1990), employment statusof either employed (i.e., earning a wage for performance of job duties) orunemployed (i.e., wanting but unable to obtain suitable employment). Ex-clusion criteria included a primary complaint of chronic episodic pain (e.g.,migraine headaches), previous history of psychosis or major depression notsecondary to chronic pain, and/or head injury concurrent with chronic pain.Adults below the age of retirement who were voluntarily caring for chil-dren, employed fewer than 20 hr per week, involved in full-time educationor retraining, or otherwise unavailable for employment were also excludedfrom the research.

One hundred eighty-three persons volunteered for the study, of whomeight did not meet inclusion criteria (one of whom was age 17, four ofwhom were in retraining, and three who were employed less than 20 hrper week). In addition, four questionnaires were excluded from analysesbecause of excessive missing data. The chronic pain sample consisted of40 unemployed (20 females) and 43 employed (22 females) participantsand the healthy comparison sample consisted of 43 unemployed (22 fe-males) and 45 employed (23 females) respondents.

Within the entire sample, a majority of subjects reported being eithersingle (34.5%) or married (36.4%) and a minority of participants reportedcohabiting (9.1%), marital separation (5.5%), divorce (13.9%), or deceasedspouse (.6%). In the pain sample, 53.0% of respondents reported a primarycomplaint of low back pain. For the rest of this sample, the primary painsite was reported as follows: mid or upper back (16.8%), neck or shoulders(8.2%), arms or legs (19.5%), or face (3.5%). Also, within the pain sample,41.8% of participants were obtained from a pain clinic and 58.2% of re-

METHODS

Jackson, Iezzi, and Lafreniere244


spondents were community volunteers. Finally, 24% of the pain sample re-ported current litigation.

A decision was made a priori to equate samples for age, sex, and yearsof education. Table I presents the means and t values on a number of demo-graphic variables, Although groups did not differ on most other backgroundvariables, the chronic pain sample reported more medical problems priorto pain onset [f(l,164) = 4.42, p < .03] and more other family memberswith chronic pain, [f(l,164) = 7.85, p < .001] than the healthy comparisonsample.

Measures

Emotional Distress. The 12-item General Health Questionnaire (GHQ-12; Goldberg, 1972), a measure of general psychological distress, was usedto assess current emotional distress. The GHQ-12 is recommended for usein occupational research (Banks et al., 1980) and Iss; been widely employedin research on the psychological impact of unemployment. Subjects wererequired to rate the frequency of occurrence of symptoms of psychological

Table I. Means and t-Test Values of Demographic Variables for Chronic Pain andHealthy Comparison Samples

GroupChronic

Age (in years)Years of educationOccupational statusIncome (thousands)Total past medical problemsTotal prior medical interventionsTotal times helped by menial

health professionalsMonths of treatmena from

mental health professionalsTotal family members with

chronic painMonths in labor forceTotal jobs heldMonths at past or current jobHours at past or current job

an - 83.bn - 88.

PMean

36.9013.3619.9437.10

.961.41.46

3.90

.82

231.067.59

92.4036.35

aina

SD

(8.85)(2.15)(9.32)

(23.60)(1.23)(1.67)(.72)

(7.85)

(.98)

(115.06)(7.68)

(99.70)(11.14)

Healthycom]

Mean

35.1813.9521.7634.09

.631.36.36

4.49

.44

198.387.12

76.6437.04

parisonb

SD

(10.35)(2.15)(9.89)

(23.00)(.85)

(1.68)(.76)

(19.12)

(.77)

(132.16)(5.86)

(104.41)(12.15)

t test

1.171.801.24.85

2.08.18.83

.26

2.78

1.73.44

1.1339

P

n.S.

n.s.n.s.n.s..03n.s.n.s.

n.s.

.001

II.S.

n.s.n.s.n.s.

distress on 4-point Likert scales ranging between "not at all" and "most ofthe time." Alpha coefficients for the GHQ-12 have ranged from .82 to .95for four samples (Banks et al, 1980; Feather, 1989).

Measures Based on Nine-Factor Model Features. Participants also com-pleted several self-report measures based on specific features of Warr'snine-factor model (i.e., externally generated demands, financial strain, op-portunities for control, skill use, variety, and social contact). Consistent withWarr's (1987) conceptualization, externally generated demands were as-sessed with the 26-item Time Structure Questionnaire (TSQ; Bond andFeather, 1988), which evaluates the degree to which time spent on dailyactivities is planned, purposeful, and routinized. Bond and Feather (1988)found the TSQ to have high internal consistency, with coefficient alphasbetween .88 and .92 for three samples. Financial strain was measured withthe seven-item Financial Stress Scale [FSS (Feather, 1989)], which assessesfinancial strain in various significant areas of life. Opportunities for controlwere measured by the six-item Personal Control subscale of the Multidi-mensional Health Locus of Control Scale (Wallston et al., 1978), whichfocuses on perceptions of health behavior as being the result of internalcontrol. Opportunities for skill use and for variety were measured by fouritem skill use (e.g., "I have adequate opportunities to use my specializedskills and training") and task variety (e.g., "I am able to vary the pace atwhich I complete tasks") scales developed on the basis of O'Brien's (1983)research. The scales had adequate internal consistencies, .84 for skill useand .78 for task variety. Finally, three measures evaluated quality and quan-tity of social contact. The 12-item Multidimensional Scale of PerceivedSocial Support (Zimet et al., 1988) evaluated perceived social support re-ceived from family, friends, and significant other. The alpha coefficient forthe total scale is .88. The 12 items of the Supervisor Availability and PeerAvailability subscales of the Multidimensional Support Scale (Winefield etal., 1992) assessed adequacy and frequency of supportive behaviors receivedfrom one's peer group and individuals in positions of authority. These itemswere evaluated on 6-point Likert scales ranging from "strongly disagree"to "strongly agree." Alpha coefficients for these scales range from .81 to.90 (Winefield et al., 1992). Finally, a single item ("How much time do youspend alone?") was created to assess quantity of social contact.

Pain-Related Variables. Pain experiences assessed included duration ofpain, primary pain site, number of pain sites, total compensation sourcesat pain onset, and current litigation status. In addition, six items from theChronic Pain Grade (Von Korff et al., 1992) assessed current pain severityand dysfunction in various areas of life. The items, which examine current,average, and worst intensity of pain as well as interference in daily activitiesdue to pain, were rated on 10-point Likert scales ranging from "no pain


at ail" to "extreme pain." Internal consistences for the Chronic Pain Gradeare adequate, ranging between .73 and .80 for three samples (Von Korff* al., 1992).

Background Variables. A brief questionnaire was designed by theauthors to assess background functioning. Demographic data (age, sex,years of education, income, occupational status, and marital status), labormarket experiences (duration in labor market, durations of current or pastemployment, total jobs held, hours at past or current job), and previousadaptation (numbers of medical problems, medical interventions, and psy-chological problems unrelated to a current pain problem, total familymembers with chronic pain, duration of non-pain-related psychological in-terventions) were assessed by the questionnaire.

Procedure

Appointments were set up with the principal investigator for volunteerswho met inclusion criteria. After the provision of informed consent, par-ticipants completed the questionnaire packet which included a briefstatement of the general research purposes and the measures describedabove. Volunteers were paid $25.00 for completing the research. On aver-age, respondents took about 90 min to complete the survey. There werefew reports of fatigue associated with the test session. Written feedbackdisclosing the general purposes and research findings was mailed to re-spondents following data analyses.

Data Analyses

Preliminary analyses assessed bivariate correlations between subjectbackground characteristics, measures of Warr's nine factor model, and themeasure of emotional distress. Given the relatively large ratio of measuresto subjects, only measures having statistically significant bivariate correla-tions with emotional distress (p < .01) were included in further analyses.Subsequently, hierarchical regression analyses were conducted separatelyfor the chronic pain and healthy comparison samples. For the healthy com-parison group, significant background characteristics were entered in thefirst step and scores of significant measures of nine-factor model featureswere entered in the second step of each regression equation. For thechronic pain group, significant background variables were entered in thefirst step, followed by current pain-related severity and impairment in thesecond step, and significant measures of nine factor model features in thethird step of regression equations.


248

RESULT S

Preliminary Analyses

SPSS for Windows (Version 6.0) was used for all analyses. Data screen-ing procedures (Tabachnick and Fidell, 1989) identified no violations ofassumptions of multivariate statistics. Table II summarizes the correlationcoefficients demographic variables, psychosocial measures related to fea-

Table II. Correlation Coefficients Between Background and Psychosocial Variables andEmotional Distress (GHQ Score) for Healthy Comparison and Chronic Pain Samples

Age (in years)Years of educationOccupational statusIncome (in thousands)Total prior medical problemsTotal prior medical interventionsTimes help sought from mental health professionalsMonths of treatment from mental health professionalsTotal family members having sought help from

mental health professionalsTotal family members with chronic painTotal months in labor forceTotal of jobs heldMonths of current unemploymentMonths since pain onsetTotal of pain sitesTotal compensation sources at pain onsetCurrent pain severityTime structurePerceived financial strainPerceived skill usePerceived task varietyPersonal control of healthAmount of time spent alonePerceived support from close relations (family, friends,

significant other)Perceived support from formal relations (peers,

supervisors, employment staff)

*p < .05.**p < .01.

*** < .001.

GHQ score

Chronicpain sample

(n = 83)

.03

.07-.20-.22*.14

-.00.23*.23*

.15-.20

.00-.02.35***

-.19.28".10.51"

-.67".56***

-.54***-.32**-.49***-.42"

-.48***

-.48***

Healthycomparison

sample(n = 88)

-.21-.22*-.17-.32".17.01.12.01

.04

.13-.19.10.10

———.19

-.66***.32**

-.32**-.19-.03-.19

-.48***

-.35***

Jackson, Iezzi, and Lafreniere


tures of Warr's nine-factor model, and emotional distress for chronic painand healthy comparison groups, respectively. In general, a greater numberof psychosocial measures had bivariate correlations with emotional distressfor the chronic pain than the healthier sample. In addition, bivariate asso-ciations between psychosocial measures and emotional distress werestronger in the chronic pain sample compared to the healthier sample.

Primary Analyses

For the chronic pain sample, measures of nine-factor model featuresmade significant contributions to the prediction of emotional distress be-yond background functioning and pain-related severity and impairment (seeTable III). While pain-related severity and impairment accounted for ap-proximately 20% of the variance in emotional distress, measures ofexternally generated demands (i.e., time structure), financial strain, skill

Table III. Demographic and Psychosocial Predictors of Emotional Distress for theChronic Pain Sample (n = 83)

Step

1

2

3

Total

Predictor

Length of current unemploymentNumber of pain sites

Pain severity/impairment

Time structureFinancial strainSkill useTask varietyPersonal control of healthAmount of time spent aloneTotal close supportTotal formal support

P

-.04-.03

.24

-.43.20

-.08.02

-.21.15.01

-.16

sr2

-.03-.03

Multiple R = .40R2 = .16P<.003

.20

R2 change = .17P < .0001

-.36.15

-.05.01

-.19.12.01

-.12

R2 change = .38p < .0001

Multiple R= .85R2 = .71

Adjusted R2 = .67F(10.72) = 17.83

p < .0001

use, control (personal health locus of control), and social contact (i.e., timespent alone, perceived close support, and perceived formal support) com-bined to predict an additional r2 — .38 of variance in the regression model(Table III). The strongest individual predictor, time structure, sr2 = -.36,indicated that more structured and purposeful time use was associated withreduced emotional distress.

A similar pattern of findings was found for the healthy comparisonsample. Measures of nine-factor mode! features (structured and purposefultime use, financial strain, skill use, perceived close and formal support)accounted for 40% of the variance in emotional distress, after controllingfor the lone significant background factor (income level). Again, structuredand purposeful time use emerged as the strongest individual predictor ofemotional distress, sr2 =-.45 (Table IV).

DISCUSSION

The main finding of this study was that psychosocial measures basedon Warr's (1987) nine-factor model added substantially to the predictionof emotional distress for both chronic pain and healthy comparison sam-ples, even after controlling for significant background factors. Furthermore,

Table IV. Demographic and Psychosocial Predictors of EmotionalDistress for the Healthy Comparison Sample (n = 83)


Step

1

2

Predictor

Income level

Time structureFinancial strainSkill useTotal dose supportTotal formal support

Total

P sr2

-.08 -.06

Multiple R = .32R2 = .10p < .01

-.59 -.45-.08 -.05.12 .10

-.23 -.20-.10 -.08

R2 change = .40p < .0001

Multiple R = .71R2 = .50

Adjusted R2 = .46F(6,81) - 13.44

p < .0001

the measure of structured and purposeful time use emerged as the mostsignificant individual predictor of emotional distress in both samples.

The pattern of results suggests that while pain-related factors are im-portant predictors of emotional distress for chronic pain patients, specificpsychosocial experiences related to employment status also moderate cur-rent emotional distress among individuals reporting chronic pain. Forexample, the imposition of externally generated demands as measured bystructured and purposeful time use implies that interventions aimed at de-veloping a rewarding, structured, and personally meaningful routine maybe especially associated with the alleviation of emotional distress. Consis-tent with the recent work of Jensen et al. (1994), our findings suggest thatactivity per se may be less important than how activity is viewed in com-bating affective disturbances.

Aside from having a structured and purposeful routine, perceiving thatone has adequate financial resources, engaging in activities that use an in-dividual's unique skills, and opportunities to enhancing one's sense ofcontrol over his/her health may be important in reducing or preventing dis-tress for both chronic pain patients and physically healthy persons, andespecially for those who are unemployed. While these treatment strategiesare commonly found in behavioral and cognitive-behavioral interventionsrelated to chronic pain (e.g., Keefe et al, 1992), they also have potentialbenefits for non-clinical samples.

Given the current state of the economy, opportunities to acquire suchexperiences through traditional avenues of employment have become in-creasingly restricted, especially for disabled workers (e.g., Employment andImmigration Canada, 1992; Haworth, 1986). Yet engaging in a routine thatis personally fulfilling, and having a sense of financial security, opportuni-ties to use specialized skills, and contact and support within and beyondthe realm of family appear to be intimately linked to both employmentstatus and emotional well-being. Consequentty, creating alternatives to em-ployment that promote such experiences, especially during times of highunemployment, remains an important and necessary challenge for sustain-ing the emotional well-being for major segments of the population whoseopportunities for employment are restricted.

Furthermore, bivariate correlations obtained in this research are con-sistent with past studies that illustrate the importance of social support fromclose relationships (e.g., Faucett and Levine, 1990; Flor et al., 1987; Gil etal, 1987; Jamison and Virts, 1990). However, results of regression analysessuggest that perceptions of support from sources outside of family (e.g.,employers, health-care providers, compensation sources) are also importantmoderators of emotional distress among chronic pain patients. Given thefrequency with which many chronic pain patients interact with these


sources, the extent to which such contacts are viewed as being supportivewould have an expected relationship with their emotional status.

Despite these possible implications, methodological limitations of thisresearch must be acknowledged. Regarding the sample, generalizations be-yond volunteer groups must be made with caution. In addition, the painsample was composed of patients and community volunteers, groups thatmay be distinct in important respects (e.g., Crook et al., 1986). Thus, com-munity and patient volunteers may have differed on measures assessed inthis research. Furthermore, healthy and chronic pain samples differed notonly in terms of pain status but also on certain background variables (num-bers of previous medical problems, family members with chronic pain);consequently, they were not completely equivalent in terms of functioningprior to pain onset. Measurement limitations include an exclusive relianceupon self-report measures to assessing participant functioning and inclusioninto one's respective sample on the sole basis of identifying oneself as hav-ing chronic pain or good physical health. Although subjects were carefullyscreened before they were allowed to participate, the inclusion of medicalexamination data would have been useful to supplement the "healthy com-parison" and "chronic pain" distinctions. Finally, the cross-sectional designof this investigation constrains the extent to which causa! relations can bedrawn from prediction models. That is, the study does not indicate howmuch independent variables actually "cause" emotional distress versus howmuch emotional distress causes responses such as having poor time struc-ture and spending more time in isolation. Nonetheless, the strength of ourcross-sectional findings encourages the use of longitudinal research withprocedures such as path analysis to clarify the strength and directions ofcausation between features of employment status, emotional distress, andphysical status.

These limitations aside, this study suggests that while level of pain se-verity is a prominent predictor of emotional distress among persons withchronic pain conditions, psychosocial variables also contribute significantlyto emotional well-being for both chronic pain and healthier groups. In ad-dition, our research provides an important corollary to Fordyce's (1988)contention that people suffer less when they have something better to do:people who have more structured and subjectively meaningful pursuits ex-perience less emotional distress.

Future studies should attempt to replicate the current findings in largerhomogeneous and heterogeneous pain samples. Inquiries can also be ex-tended to patients with acute pain, patients being retrained, and part-timeemployees to aid in identifying how contexts other than employment andunemployment affect emotional distress. In addition, given the predictivepower of psychosocial measures in this study, new measures of facets of

252 Jackson, lezzi, and Lafreniere

employment status should be established for chronic pain patients. Multi-dimensional measures with psychosocial, ergonomic, and physicaldimensions of employment and unemployment may prove to be useful inidentifying injured individuals who are more likely to develop chronic painproblems, vocational dysfunction, and associated difficulties.

ACKNOWLEDGMENTS

This paper was prepared with the financial support of Grant 08719from the Victoria Hospital Health Research Fund. Special thanks go toDrs. Eldon Tunks, Stewart Page, Shelagh Towson, and Kay Fawdry for theircomments on the manuscript from which this research is based.

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