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Beliefs of self-esteem, self-confidence, control, faith in therapy, optimism, will to live, and recovery… Kenworthy, Shirra 1989

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BELIEFS OF SELF-ESTEEM, SELF-CONFIDENCE, CONTROL, FAITH IN THERAPY, OPTIMISM, WILL TO LIVE, AND RECOVERY OF BACK AND NECK PATIENTS by SHIRRA KENWORTHY B.S.R., U n i v e r s i t y of B r i t i s h Columbia, 1970 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n THE FACULTY OF GRADUATE STUDIES Department o f C o u n s e l l i n g Psychology We accept t h i s t h e s i s as conforming t o the r e q u i r e d standard The U n i v e r s i t y o f B r i t i s h Columbia October, 1989 (c) SHIRRA KENWORTHY, 1989 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of C o u n s e l l i n g Psychology The University of British Columbia Vancouver, Canada Date Qr-.toher 8th. 1989 DE-6 (2/88) i i A b s t r a c t T h i s study examined the d i f f e r e n c e s i n b e l i e f s o f s e l f - e s t e e m , s e l f - c o n f i d e n c e , c o n t r o l , f a i t h i n therapy, optimism, and the w i l l t o l i v e between r e c o v e r y groups o f poor r e c o v e r y , moderate recovery, and good r e c o v e r y , i n back and neck p a t i e n t s . In a d d i t i o n , t h i s study examined how these b e l i e f s r e l a t e d t o the r a t e o f r e c o v e r y when p a t i e n t s were d i v i d e d i n t o t h r e e groups o f slow r a t e o f reco v e r y , moderate r a t e o f recovery, and h i g h r a t e o f re c o v e r y . I t was hy p o t h e s i z e d t h a t the p a t i e n t group w i t h a g r e a t e r degree of r e c o v e r y and a g r e a t e r r a t e o f re c o v e r y would be r e l a t e d t o s i g n i f i c a n t l y s t r o n g e r b e l i e f s o f s e l f - e s t e e m , s e l f - c o n f i d e n c e , l o c u s o f c o n t r o l , f a i t h i n therapy, optimism, and w i l l t o l i v e , compared t o the groups w i t h moderate r e c o v e r y degree and moderate r e c o v e r y r a t e , and these groups would be f o l l o w e d by the group w i t h a poor degree of re c o v e r y and a slower r a t e o f re c o v e r y . The s u b j e c t s were back and neck p a t i e n t s who were d i s c h a r g e d from the ph y s i o t h e r a p y department o f S t . V i n c e n t ' s H o s p i t a l d u r i n g the p e r i o d from January, 1986 t o December, 1988. A package c o n t a i n i n g a c o v e r i n g l e t t e r o f e x p l a n a t i o n and the q u e s t i o n n a i r e s was m a i l e d w i t h a response r a t e o f 45%. Respondents were men (n = 47) and women (n = 103) ran g i n g from 20 t o 89 y e a r s o f age (M = 52.7, SD = 16.89). Two m u l t i v a r i a t e a n a l y s i s o f v a r i a n c e s (MANOVAS) were i i i computed w i t h the dependent measures o f s e l f - e s t e e m , s e l f - c o n f i d e n c e , l o c u s o f c o n t r o l , f a i t h i n therapy, optimism, and w i l l t o l i v e , examining group d i f f e r e n c e s on degree o f r e c o v e r y and r a t e o f re c o v e r y . The r e s u l t s o f the MANOVA f o r degree o f re c o v e r y demonstrated s i g n i f i c a n t d i f f e r e n c e s f o r f a i t h i n therapy, F(2, 147) = 18.13, jo <.001, optimism, F(2, 147) = 7.24, E <.001, and s e l f - e s t e e m , F(2, 147) = 3.16, jo <.001. An examination o f the means and p o s t hoc S c h e f f e t e s t s (p_ <.05) r e v e a l e d t h a t those w i t h a good degree o f re c o v e r y h e l d s t r o n g e r b e l i e f s o f f a i t h i n therapy, than those w i t h a moderate degree o f recovery, f o l l o w e d by those w i t h poor r e c o v e r y . While those w i t h a good degree o f r e c o v e r y and a moderate degree o f re c o v e r y h e l d s t r o n g e r b e l i e f s o f optimism than the poor r e c o v e r y group, and those w i t h a good degree o f re c o v e r y h e l d s t r o n g e r b e l i e f s o f s e l f - e s t e e m than the poor r e c o v e r y group. No group d i f f e r e n c e s were found f o r r a t e o f r e c o v e r y . The importance o f the study as w e l l as i t s l i m i t a t i o n s , and the i m p l i c a t i o n s f o r f u t u r e r e s e a r c h a re d i s c u s s e d . i v T a b l e o f Contents ABSTRACT i i TABLE OF CONTENTS i v LIST OF TABLES v i i ACKNOWLEDGEMENTS i x INTRODUCTION 1 LITERATURE REVIEW 5 General B e l i e f s and A t t i t u d e s 7 The S a l u t o g e n i c Model 8 The Placebo 11 Co g n i t i v e - E m o t i o n a l Model 13 E x p e c t a n c y - A t t r i b u t i o n Theory 13 C o n d i t i o n i n g Theory 14 Secondary S u g g e s t i b i l i t y Theory 14 The H e a l t h B e l i e f Model 16 A Phenomological Approach 26 Measurement Issues 30 Summary 32 HYPOTHESES 38 Purpose 38 Hypotheses 38 METHOD 42 Su b j e c t s and Procedures 42 Instruments 46 The Rosenberg S e l f - E s t e e m S c a l e (RSE) 46 The I n t e r p e r s o n a l Dependency Inventory (IDI)....47 The H e a l t h R e l a t e d Hardiness S c a l e (HRHS) 48 V The C l i e n t Readiness f o r Therapy Inventory (CRTI) 48 The L i f e O r i e n t a t i o n T e s t (LOT) 49 The W i l l t o L i v e S c a l e (WLS) 50 Demographic and A n c i l l a r y Measures 50 Data A n a l y s i s 51 RESULTS 52 D e s c r i p t i v e Data 52 Recovery Degree 52 Recovery Rate 57 C o r r e l a t i o n M a t r i x 59 Hypotheses T e s t i n g .62 Degree of Recovery 62 Rate of Recovery 67 DISCUSSION 69 L i m i t a t i o n s 75 Recommendations f o r Future Research 78 C o n c l u s i o n s 79 REFERENCES 81 APPENDIX A 90 Purpose of Study L e t t e r 91 I n s t r u c t i o n Sheet 93 APPENDIX B 94 Rosenberg Self-Esteem S c a l e 95 Lack of S o c i a l S e l f - C o n f i d e n c e Subscale 96 C o n t r o l Subscale 98 F a i t h i n Therapy Subscale 99 v i L i f e O r i e n t a t i o n T e s t 100 W i l l t o L i v e S c a l e 101 Demographic and A n c i l l a r y Q u e s t i o n n a i r e 102 APPENDIX C 104 Comparing the Means 105 Rosenberg Se l f - E s t e e m Means and Standard D e v i a t i o n s 106 APPENDIX D 108 C o r r e l a t i o n M a t r i x f o r Dependent Measures, Treatment Measures, A n c i l l a r y Data, and Age 109 APPENDIX E I l l T a b l e s w i t h Portuguese P o p u l a t i o n Removed 112 v i i L i s t o f T a b l e s 1. H e a l t h B e l i e f Model Research 20 2. Comparisons o f Models/Theories 34 3. D e s c r i p t i v e I nformation f o r Respondents 45 4. Means and Standard D e v i a t i o n s on Treatment V a r i a b l e s f o r P e r c e i v e d Degree o f Recovery Groups 54 5. C h a r a c t e r i s t i c s o f the Poor Degree o f Recovery, Moderate Degree o f Recovery, and Good Degree of Recovery Groups 55 6. C h a r a c t e r i s t i c s o f the Slow Rate o f Recovery, Moderate Rate o f Recovery, and High Rate o f Recovery Groups 60 7. Means and Standard D e v i a t i o n s f o r Dependent Measures f o r the Degree o f Recovery 63 8. Summary of MANOVA and followup ANOVAS f o r the Degree o f Recovery Groups (n = 150) 64 9. C r i t i c a l V a l u e s ( S c h e f f e Tests) o f S i g n i f i c a n c e f o r t he Dependent Measures Between Groups f o r the Degree of Recovery 66 10. Means and Standard D e v i a t i o n s o f Dependent Measures f o r Rate o f Recovery 68 11. Means and Standard D e v i a t i o n s f o r Se l f - E s t e e m f o r t he Degree o f Recovery Groups 106 12. Summary o f MANOVA and followup ANOVA f o r the Degree o f Recovery Groups (n = 150) 107 v i i i 13. C o r r e l a t i o n M a t r i x f o r Dependent Measures, Treatment Measures, A n c i l l a r y Data, and Age...109 14. Means and Standard D e v i a t i o n s f o r Dependent Measures f o r the Degree of Recovery Groups w i t h no Portuguese 112 15. Summary of MANOVA and followup ANOVAS f o r the Degree o f Recovery Groups w i t h no Portuguese..113 16. C r i t i c a l V alues ( S c h e f f e Tests) of S i g n i f i c a n c e f o r the Dependent Measures Between Groups f o r the Degree o f Recovery wi t h no Portuguese 114 i x Acknowledgments I would l i k e t o f i r s t thank my s u p e r v i s o r Dr. B o n i t a Long, whose understanding, encouragement, and guidance has been a source o f s t r e n g t h and m o t i v a t i o n throughout t h e p r e p a r a t i o n of t h i s paper. I a l s o wish t o thank Dr. I s a b e l Dyck f o r her time and v a l u e d s u g g e s t i o n s , as w e l l as Dr. Stephen Marks. In a d d i t i o n I wish t o thank the s t a f f and a d m i n i s t r a t i o n o f S t . V i n c e n t ' s H o s p i t a l f o r t h e i r h e l p and a s s i s t a n c e throughout t h i s p r o c e s s . F i n a l l y t o my p a r e n t s B e t t y and Sam Kenworthy, a v e r y s p e c i a l thank-you f o r your encouragement, support, and b e l i e f i n my a b i l i t y t o succeed. 1 I n t r o d u c t i o n In our h e a l t h s e r v i c e s , back and neck problems a r e c o n s i d e r e d t o be major e n t i t i e s t h a t c o s t m i l l i o n s o f d o l l a r s t h r o u g h workdays l o s t and s e v e r a l b i l l i o n d o l l a r s t h r o u g h t r e a t m e n t a n n u a l l y (Saunders , 1983) . In r e c e n t y e a r s back c l i n i c s have emerged t o d e a l more s p e c i f i c a l l y w i t h t h e s e problems t h r o u g h a m u l t i d i s c i p l i n a r y team. D o c t o r s and t h e r a p i s t s , t h r o u g h the m e d i c a l mode l , s t r i v e t o maximize the h e a l i n g and r e c o v e r y o f p a t i e n t s b o t h w i t h t h e degree o f h e a l i n g t h a t t a k e s p l a c e , and i n the speed w i t h which t h i s h e a l i n g o c c u r s . Ye t t o d a y , even though our knowledge about neck and back i n j u r y and r e c o v e r y has i n c r e a s e d d r a m a t i c a l l y , we s t i l l a r e a t a l o s s t o e x p l a i n why some i n d i v i d u a l s r e c o v e r by r e t u r n i n g t o the p r e i n j u r y s t a t e and why some do n o t . The focus o f t h i s paper t h e n i s t o examine b e l i e f s and the r e l a t i o n s h i p s t h e y may have w i t h r e c o v e r y . The r o l e o f the mind i n h e a l i n g and r e c o v e r y has l o n g been r e c o g n i z e d . S o c r a t e s noted t h a t " there i s no i l l n e s s o f the body a p a r t from the mind" ( c i t e d i n M a r t u s , 1985) . W i t h the advent o f the new t e c h n o l o g i e s i n m e d i c i n e , t h e r e l a t i o n s h i p o f the mind and t h e body became d i v i d e d and d i s e a s e and i n j u r y were d e a l t w i t h as p h y s i o l o g i c a l e n t i t i e s (Ferguson , 1980) . More r e c e n t l y w i t h t h e development o f the h o l i s t i c approach i n m e d i c i n e t h e i n t e r a c t i o n o f the mind , the body, and the env ironment as i t i n f l u e n c e s our h e a l t h i s r e c o g n i z e d . 2 O r n s t e i n and S o b e l (1987) note t h a t i t i s t h e b r a i n t h a t "minds t h e body" (p. 40) , and t h a t t h e maintenance o f h e a l t h i s i t s p r i m a r y f u n c t i o n . The b r a i n t e l l s t h e body, where, when and how t o adapt i t s e l f based on the i n f o r m a t i o n i t r e c e i v e s and i n t e r p r e t s , i n o r d e r t o a v o i d t r o u b l e and s t a y w e l l . The c o n n e c t i o n s between our b e l i e f s and how t h e y i n f l u e n c e t h e body t h r o u g h the b r a i n a r e made by many a u t h o r s ( C o u s i n s , 1979; F r a n k , 1961; O r n s t e i n & S o b e l , 1987; S h a p i r o , 1964; S i e g e l , 1986). Much o f t h e l i t e r a t u r e however, r e l a t e s b e l i e f s t o t h e maintenance o f h e a l t h a g a i n s t t h e o n s l a u g h t o f germs and v i r u s e s and not n e c e s s a r i l y t o t h e degree o f r e c o v e r y and t h e r a t e o f r e c o v e r y from a s p e c i f i c i n j u r y . In a d d i t i o n t h e r e i s r e l a t i v e l y l i t t l e e m p i r i c a l da ta and r e s e a r c h t o s u p p o r t t h e i n f l u e n c e o f b e l i e f s . Antonovsky (1979, 1987) c o n c e p t u a l i z e s h e a l t h as b a l a n c e d on a cont inuum between the n e g a t i v e p u l l o f l i f e demands and the p o s i t i v e p u l l o f the i n d i v i d u a l ' s r e s o u r c e s which a r e a v a i l a b l e t o respond t o t h o s e demands. A l t h o u g h he does not s p e c i f i c a l l y addres s the i n d i v i d u a l ' s b e l i e f system, he t h e o r i z e s t h a t a s t r o n g sense o f s e l f - e f f i c a c y , a l o c u s o f c o n t r o l p l a c e d where t h e i n d i v i d u a l b e l i e v e s i t s h o u l d be p l a c e d , and a s t r o n g sense o f s e l f - i d e n t i t y , push the i n d i v i d u a l towards the h e a l t h end o f the cont inuum. The h e a l t h b e l i e f model (HBM) (Becker , 1974) 3 i d e n t i f i e s p e r c e p t i o n s o f s u s c e p t i b i l i t y , t h e s e v e r i t y o f a h e a l t h t h r e a t , t h e b e n e f i t s o f a s p e c i f i c p r e v e n t i v e c a r e , and b a r r i e r s t o t h i s a c t i o n such as c o s t and danger as i n f l u e n c i n g an i n d i v i d u a l s h e a l t h b e h a v i o r ( i . e . , c l i n i c u t i l i z a t i o n , v a c c i n a t i o n , c o m p l i a n c e w i t h a m e d i c a l r e g i m e n ) . R o b e r t s e t a l . (1984) used t h i s model t o examine r e c o v e r y from laminectomy s u r g e r y and i d e n t i f i e d b e l i e f s o f lower v u l n e r a b i l i t y , h i g h e r b e n e f i t s , lower b a r r i e r s , and lower resentment as r e p r e s e n t a t i v e o f the more improved g r o u p . However, because t h e HBM c l a s s i f i e s t h e b e l i e f s i n t o b r o a d subdomains i t l i m i t s our a b i l i t y t o s t u d y the s p e c i f i c t y p e o f b e l i e f s which may i n f l u e n c e the r e c o v e r y p r o c e s s . The p l a c e b o e f f e c t which has been s t u d i e d by many d i f f e r e n t a u t h o r s (Frank , 1961; J o s p e , 1978; Lundh , 1987; S h a p i r o , 1964) i d e n t i f i e s the e x p e c t a t i o n o f p o s i t i v e t r e a t m e n t e f f e c t s , f a i t h i n the e f f i c a c y o f t h e r a p y , and b e l i e f i n the p h y s i c i a n , as c o n t r i b u t o r y t o the r e l i e f o f p a i n o r r e c o v e r y . F i n a l l y an i m p o r t a n t c o n t r i b u t i o n t o the f i e l d i s a s tudy t h a t s p e c i f i c a l l y examined t h e e x p e r i e n c e o f b e l i e v i n g as i t i n f l u e n c e s r e c o v e r y . M a r t u s ' (1985) phenomeno log ica l s tudy o f 16 p a t i e n t s whose h e a l i n g showed a d r a m a t i c i n c r e a s e was a b l e t o i d e n t i f y such c e n t r a l b e l i e f s as opt imism, b e i n g i n c h a r g e , f a i t h i n t h e r a p y , s e l f - e s t e e m , and s e l f - c o n f i d e n c e . The purpose o f t h i s s tudy then i s t o examine whether 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 between i n d i v i d u a l s w i t h 4 g r e a t e r , compared t o l e s s r e c o v e r y , and t h e h e a l t h b e l i e f s o f s e l f - e s t e e m , s e l f - c o n f i d e n c e , c o n t r o l , f a i t h i n t h e r a p y , o p t i m i s m , and w i l l t o l i v e . R e c o v e r y , the r e t u r n t o the p r e - i n j u r y s t a t e o f back and neck f u n c t i o n was examined i n two ways. F i r s t s u b j e c t i v e l y by the degree o f r e c o v e r y t h a t p a t i e n t s i d e n t i f y t h e y have a c h i e v e d , and second by the r a t e o f r e c o v e r y , t h e l e n g t h o f t ime and the number o f t r ea tment s r e q u i r e d f o r t h i s h e a l i n g t o o c c u r . T h i s s tudy extends M a r t u s 1 q u a l i t a t i v e r e s e a r c h by examining whether b e l i e f s o f s e l f - e s t e e m , s e l f - c o n f i d e n c e , c o n t r o l , f a i t h i n t h e r a p y , opt imism, and w i l l t o l i v e a r e s i g n i f i c a n t t o t h e h e a l i n g p r o c e s s f o r back and neck p a t i e n t s . The r e c o g n i t i o n and s u b s t a n t i a t i o n o f b e l i e v i n g i n t h e h e a l i n g p r o c e s s c o u l d be a major s t e p f o r w a r d i n our u n d e r s t a n d i n g o f h e a l t h and h e a l i n g t o d a y . R e s u l t s o f t h i s s t u d y may p r o v i d e c o u n s e l l o r s w i t h i n f o r m a t i o n about the t y p e s and importance o f b e l i e f s t h a t a r e a s s o c i a t e d w i t h the h e a l i n g and r e c o v e r y p r o c e s s o f back and neck p a t i e n t s . I t s h o u l d a l s o be u s e f u l t o d o c t o r s , n u r s e s , and t h e r a p i s t s i n h e l p i n g them t o i d e n t i f y when c o u n s e l l i n g may be a u s e f u l a d j u n c t t o t h e i r p r e s c r i b e d t h e r a p i e s . 5 Review of L i t e r a t u r e The i s s u e o f concern i n t h i s study i s the h e a l i n g and re c o v e r y o f p a t i e n t s w i t h back and neck problems, and t h e i r a s s o c i a t i o n w i t h h e a l t h r e l a t e d b e l i e f s and a t t i t u d e s . T h i s s e c t i o n w i l l b r i e f l y d e s c r i b e the c h a r a c t e r i s t i c s o f neck and back p a t i e n t s and then review the r e l a t i o n s h i p o f b e l i e f s and a t t i t u d e s t o h e a l t h . More s p e c i f i c a l l y , the s a l u t o g e n i c model o f h e a l t h as developed by Antonovsky (1979, 1987), the pl a c e b o e f f e c t , and the h e a l t h b e l i e f model (HBM) are examined. F i n a l l y a phenomenological study which e x p l o r e d t h e h e a l i n g and re c o v e r y o f 16 p a t i e n t s i s examined i n depth. There i s a h i g h i n c i d e n c e o f back and neck problems. G r i e v e (1981) e s t i m a t e s t h a t i n any 2-week p e r i o d t h e r e are enough s t a t i s t i c s t o i n d i c a t e t h a t 20% o f the a d u l t p o p u l a t i o n w i l l be s u f f e r i n g from some form o f back p a i n . While o t h e r s t u d i e s i n d i c a t e an i n c i d e n c e o f approximately 30% t o 50% of the p o p u l a t i o n w i t h t h i s problem, t h e s e ranges are c o n s i s t e n t throughout the i n d u s t r i a l i z e d world, between the sexes, between the d i f f e r e n t r a c e s , and a c r o s s the d i f f e r e n t s o c i a l c l a s s e s . The i n c i d e n c e i s g e n e r a l l y lower i n the under 35 group (between 25% and 30%) and much g r e a t e r i n the over 55 group (55%) (Fairbank, 1986; Hay, 1974; H u l t , 1972; Nagi, R i l e y , & Newby, 1973). A Quebec t a s k f o r c e on s p i n a l d i s o r d e r s i n the worker (LaRocca, 1987) r e p o r t e d t h a t the frequency o f w o r k - r e l a t e d s p i n a l problems r e p r e s e n t e d 14.3% of a l l c l a i m s . These were 6 f u r t h e r broken down i n t o anatomical a r e a s . Seventy p e r c e n t o f the c l a i m s were f o r lumbar back i n j u r y , 11% were f o r t h o r a c i c back i n j u r i e s and 7% were neck i n j u r i e s . F a c t o r s c o n t r i b u t i n g t o and i n some cases c a u s i n g back and neck problems are many. G r i e v e (1981) i d e n t i f i e s these e t i o l o g i c a l f a c t o r s as i n c l u d i n g : (a) the aging p r o c e s s where the t i s s u e becomes l e s s supple due t o p h y s i o l o g i c a l changes; (b) being overweight which p l a c e s an a d d i t i o n a l s t r e s s on the s p i n a l weight b e a r i n g j o i n t s ; (c) poor p o s t u r e which may c o n t r i b u t e t o f u r t h e r more s p e c i f i c s t r e s s ; (d) o c c u p a t i o n a l s t r e s s such as r e g u l a r r e p e t i t i v e movements or a f i x e d p o s t u r a l p o s i t i o n f o r l o n g p e r i o d s o f time; (e) trauma; (f) the u n e x p l a i n a b l e tendency o f some i n d i v i d u a l s t o e x p e r i e n c e d e g e n e r a t i v e changes such as a r t h r i t i s a t an e a r l i e r age than o t h e r s ; (g) c o n g e n i t a l d e f e c t s or a d d i t i o n a l bony o r s o f t t i s s u e development; and (h) the presence of d i s e a s e . In a d d i t i o n p s y c h o l o g i c a l f a c t o r s such as a n x i e t y , d e p r e s s i o n , and p e r s o n a l i t y have been i d e n t i f i e d as c o n t r i b u t o r y f a c t o r s (Finneson, 1973; G r i e v e , 1981; Nagi e t a l . , 1973). A review o f h o s p i t a l r e c o r d s over the l a s t t h r e e y e a r s (1986 t o 1988) r e v e a l s t h a t back and neck p a t i e n t s a t t e n d i n g the p h y s i o t h e r a p y o u t p a t i e n t s a t S t . V i n c e n t ' s H o s p i t a l a r e l a r g e l y from Vancouver (90%), 5% from Burnaby and 5% from the lower mainland area. Of t h e 400 p a t i e n t s , (65.5%) were female and (35.5%) were male w i t h a 7 mean age of 49 y e a r s . General B e l i e f s and A t t i t u d e s I t s h o u l d be noted t h a t a review o f the l i t e r a t u r e r e l a t e d t o h e a l i n g and recovery r e v e a l s a p a u c i t y o f r e s e a r c h i n t h i s area ( O r n s t e i n & Sobel, 1987). The d i s e a s e and d i s e a s e process has been s t u d i e d r a t h e r than the a b i l i t y o f the body t o ma i n t a i n h e a l t h and t o h e a l . There i s some l i t e r a t u r e t h a t d i s c u s s e s the mind-body c o n n e c t i o n and a few of these readings s p e c i f i c a l l y comment on the e f f e c t s o f a t t i t u d e s and b e l i e f s . S i e g e l (1986) notes t h a t p o s i t i v e a t t i t u d e s and b e l i e f s i n c r e a s e the degree of h e a l i n g , w h i l e Johnson (1986) s t a t e s t h a t our p e r s o n a l b e l i e f system c o n t a i n s a s e l f - f u l f i l l i n g prophecy, and t h a t by changing our b e l i e f systems we can i n f l u e n c e our h e a l t h . O r n s t e i n and Sobel (1987) take t h i s one s t e p f u r t h e r when r e f e r r i n g t o a t t i t u d e s and b e l i e f s by n o t i n g t h a t the p o t e n t i a l f o r h e a l i n g through the m a n i p u l a t i o n o f the mind has gone u n n o t i c e d . What then are these b e l i e f s and a t t i t u d e s t h a t may i n f l u e n c e our h e a l t h ? S t e i n and Urdang (1966) note t h a t b e l i e f s a re " o p i n i o n s o r c o n v i c t i o n s " which are based on a "conf i d e n c e i n the t r u t h o r e x i s t e n c e o f something not immediately s u s c e p t i b l e t o r i g o r o u s p r o o f " (p. 135). Fleming (1976) r e p o r t s the need t o d i s t i n g u i s h between s e v e r a l types o f b e l i e f s which she i d e n t i f i e s as v a l u e s , a t t i t u d e s and knowledge. She d e s c r i b e s v a l u e s as " g e n e r a l i z e d c o n c e p t i o n s of what i s 'good' o r 'bad'"... 8 which " c l e a r l y r e f l e c t p e r s o n a l p r e f e r e n c e s " , a t t i t u d e s as " f e e l i n g s about p a r t i c u l a r o b j e c t s which 'flow from' v a l u e s " . She f u r t h e r s t a t e s t h a t a t t i t u d e s "are u s u a l l y c o n s i d e r e d l e s s s t a b l e than v a l u e s f o r t h a t r e a s o n , " and t h a t i t i s " p o s s i b l e t h a t what appears t o be an a t t i t u d e o f c e r t a i n i n d i v i d u a l s i s a ve r y deep s e a t e d v a l u e f o r o t h e r s . " Knowledge she d e f i n e s as " v e r i f i a b l e i n f o r m a t i o n a person has about a s u b j e c t , " and she notes t h a t knowledge i n c o r p o r a t e s " b e l i e f s which s o c i e t y a c c e p t s as f a c t s " (p. 4 ) . We know t h a t these a t t i t u d e s and b e l i e f s about h e a l t h are the r e s u l t o f c o g n i t i v e thought p r o c e s s e s which r e s u l t from an " i n t e r a c t i o n among the p a t i e n t , the environment, and c a r e g i v e r " (Genest & Genest, 1987, p. 34). These thought p r o c e s s e s i n f l u e n c e us i n what we ac c e p t t o be t r u e i n t h e world about us, they a l s o a re one of t h e p r o p e r t i e s o f our mental l i f e t h a t we are a b l e t o measure (Gazzaniga, 1985). The S a l u t o g e n i c Model Antonovsky (1979) p r e s e n t s an important concept o f h e a l t h c a l l e d "sense o f coherence" (SOC). He b e l i e v e s t h a t i n o r d e r t o understand h e a l t h we need t o understand s u r v i v a l and t h a t we can do so by s t u d y i n g those people who are h e a l t h y and w e l l throughout t h e i r l i v e s . Antonovsky (1987) maintains t h a t i n medicine t h e r e i s a pathogenic o r i e n t a t i o n which seeks t o e x p l a i n why people become i l l and focuses on the o r i g i n s o f d i s e a s e , w h i l e he 9 seeks t o e x p l a i n the o r i g i n s of h e a l t h w i t h h i s s a l u t o g e n i c o r i e n t a t i o n . He proposes t h a t both these concepts are l o c a t e d on a " h e a l t h e a s e / d i s - e a s e continuum" (p. 3) and t h a t t h e r e i s a p u l l t o the d i s e a s e end o f the continuum by g e n e r a l r e s i s t a n c e d e f i c i t s which he d e f i n e s as "demands t o which t h e r e are no r e a d i l y a v a i l a b l e or automatic a d a p t i v e r e s o u r c e s " (1979, p. 72). He b e l i e v e s t h a t t h i s p u l l i s o f f s e t and maintained c l o s e r t o the h e a l t h - e a s e end o f the continuum by the g e n e r a l r e s i s t a n c e r e s o u r c e s which he t h e o r i z e s are "any c h a r a c t e r i s t i c o f the person, the group, or the environment t h a t can f a c i l i t a t e e f f e c t i v e t e n s i o n management" (1979, p. 99). Antonovsky (1987) d e f i n e s the SOC as "a g l o b a l o r i e n t a t i o n t h a t expresses the e x t e n t t o which one has a p e r v a s i v e , enduring though dynamic f e e l i n g o f c o n f i d e n c e t h a t (a) the s t i m u l i d e r i v i n g from one's i n t e r n a l and e x t e r n a l environments i n the course of l i v i n g a r e s t r u c t u r e d , p r e d i c t a b l e , and e x p l i c a b l e ; (b) the r e s o u r c e s are a v a i l a b l e t o one t o meet the demands posed by t h e s e s t i m u l i ; and (c) these demands are c h a l l e n g e s , worthy o f investment and engagement" (1987, p. 19). The f i r s t component of t h i s d e f i n i t i o n Antonovsky (1987) r e f e r s t o as c o m p r e h e n s i b i l i t y , the second as m a n a g e a b i l i t y , and the t h i r d as meaningfulness. He uses these t h r e e components t o form h i s o r i e n t a t i o n t o l i f e i nstrument and notes t h a t these components a r e i n t e r t w i n e d and t h a t t h i s statement i s supported by d a t a t h a t 10 demonstrate a h i g h i n t e r c o r r e l a t i o n between the t h r e e components. He does not however d e s c r i b e the breakdown o f these t h r e e components though does d e s c r i b e v a r i o u s elements as they apply t o the model as a whole. In the SOC concept the i n d i v i d u a l i s not n e c e s s a r i l y viewed as b e i n g e i t h e r i n t e r n a l l y o r e x t e r n a l l y c o n t r o l l e d . The l o c u s of power may be w i t h i n t h e i n d i v i d u a l but may a l s o be w i t h the head o f t h e f a m i l y or a l e a d e r . What i s important i s t h a t t h e c o n t r o l i s where the i n d i v i d u a l b e l i e v e s i t should be, the r i g h t f u l n e s s o f t h i s a u t h o r i t y however i s c r i t i c a l because the i n d i v i d u a l must be a s s u r e d t h a t matters p e r t a i n i n g t o them w i l l be r e s o l v e d i n t h e i r own b e s t i n t e r e s t . Antonovsky (1987) b e l i e v e s t h a t i n d i v i d u a l s w i t h a s t r o n g SOC w i l l have: (a) a s t r o n g sense o f i d e n t i t y and s e l f ; (b) w i l l e x p e r i e n c e d i f f e r e n t t y pes and s t r e n g t h s of emotions, and w i l l be aware of and more a b l e t o t a k e r e s p o n s i b i l i t y f o r t h e i r emotions; and (c) w i l l have a s t r o n g e r sense of s e l f - e f f i c a c y . He (1979) a l s o d i s c u s s e s e x t e r n a l f a c t o r s t h a t he b e l i e v e s a c t as e i t h e r s t r e s s o r s o r r e s o u r c e s depending on t h e i r v a r i o u s c i r c u m s t a n c e s . Furthermore he suggests t h a t l i f e changes, c u l t u r a l changes, or changes i n i n t e r p e r s o n a l r e l a t i o n s are elements t h a t r e q u i r e a d a p t a b i l i t y on the p a r t o f the i n d i v i d u a l which lowers t h e i r r e s i s t a n c e and i n c r e a s e s t h e i r v u l n e r a b i l i t y . Antonovsky's model though u s e f u l f o r c l i n i c a l and 11 t h e o r e t i c a l purposes does not attempt t o i d e n t i f y those p a r t i c u l a r b e l i e f s and a t t i t u d e s of t h e i n d i v i d u a l which may i n f l u e n c e h e a l i n g and r e c o v e r y . I n s t e a d i t tends t o examine s t r e s s e s and r e s o u r c e s and where an i n d i v i d u a l might f a l l on the h e a l t h ease/dis-ease continuum i n response t o t h e s e . The Placebo The p l a c e b o n o t i o n o r i g i n a t e d i n medicine (Frank, 1961; S h a p i r o , 1971), and was r e l e g a t e d t o p s y c h o l o g y by p h y s i c i a n s f o r f u r t h e r study and r e s e a r c h (Katz, 1969). I n i t i a l l y i n psychology, as i n medicine, i t was regarded as a nuisance v a r i a b l e but with the development o f c o g n i t i v e b e h a v i o r a l models i t became acknowledged as a c o g n i t i v e v a r i a b l e i n i t s own r i g h t ( C r i t e l l i & Neumann, 1984) . The word "placebo" i s d e r i v e d from L a t i n and means "I s h a l l p l e a s e " ( O r n s t e i n & Sobel, 1987, p. 78). S h a p i r o and M o r r i s (1978) d e f i n e the placebo as "any t h e r a p y o r component o f therapy t h a t i s d e l i b e r a t e l y used f o r i t s n o n s p e c i f i c , p s y c h o l o g i c a l , p s y c h o p h y s i o l o g i c a l e f f e c t , o r t h a t i s used f o r i t s presumed s p e c i f i c e f f e c t , but i s without s p e c i f i c a c t i v i t y f o r the c o n d i t i o n b e i n g t r e a t e d " (p. 371). I t has been suggested t h a t h i s t o r i c a l l y the p l a c e b o may w e l l be the f o u n d a t i o n on which me d i c a l p r a c t i c e i s based. S h a p i r o (1971) b e l i e v e s t h a t a l l m e d i c a t i o n s u n t i l j u s t r e c e n t l y were i n f a c t p l a c e b o s . Cousins 12 (1971) expands on t h i s by d e s c r i b i n g the p l a c e b o as "the d o c t o r who r e s i d e s w i t h i n " (p. 69), and s t a t e s f u r t h e r t h a t what i s important i s the i n d i v i d u a l ' s " w i l l t o l i v e " . He a l s o d e s c r i b e s the placebo as a c a t a l y s t which enables us t o h e a l o u r s e l v e s w h i l e g i v i n g us a t a n g i b l e reason t o e x p l a i n t h i s h e a l i n g (1979). In p r e s e n t day medicine the placebo i s s t i l l viewed q u i t e n e g a t i v e l y as the " t r i c k " cure f o r those whose s u f f e r i n g i s seen as fake or imagined (Ferguson, 1980). A l s o d o c t o r s o f t e n view the use of the p l a c e b o as d e c e i t f u l and o f t e n disapprove of t r i c k i n g t h e i r p a t i e n t s i n t h i s manner (Frank, 1961). However the n o t i o n of the placebo has made some h i g h l y v a l u a b l e c o n t r i b u t i o n s , p a r t i c u l a r l y t o our understanding o f the h e a l i n g p r o c e s s . I t has demonstrated c l e a r l y the c o n n e c t i o n between the h e a l i n g mechanism of the body and the mind (Agras, 1984; Cousins, 1979; O r n s t e i n & Sobel, 1987). Research on the placebo has a l s o h e l p e d t o demonstrate t h a t i t i s the mind t h a t b r i n g s about h e a l i n g and r e c o v e r y (Cousins, 1979). The degree of e f f e c t i v e n e s s of the p l a c e b o however has prompted c o n s i d e r a b l e debate. Zimbardo (1969) c l a i m s t h a t the placebo i s the most e f f e c t i v e drug t o be produced by the p h a r m a c e u t i c a l l a b o r a t o r i e s , w h i l e Hamilton ( c i t e d i n R i c k e l s , 1968) b e l i e v e s t h a t the placebo o n l y p r o v i d e s s m a l l treatments f o r e q u a l l y s m a l l problems. R e g a r d l e s s of the d i f f e r e n c e s , q u a n t i t a t i v e r e s e a r c h has however 13 shown t h a t approximately o n e - t h i r d o f the people who r e c e i v e d p l acebos have r e p o r t e d a s a t i s f a c t o r y r e c o v e r y from t h e i r symptoms ( O r n s t e i n & Sobel, 1987). The mechanisms by which the placebo works, o r how i t s e f f e c t works i s not y e t understood, however s e v e r a l t h e o r i e s have been advanced. C o g n i t i v e - e m o t i o n a l model. Lundh (1987) has r e c e n t l y proposed a r e l a t i v e l y simple c o g n i t i v e - e m o t i o n a l model which he b e l i e v e s w i l l e f f e c t t he i n d i v i d u a l s e x p e r i e n c e o f h e a l t h . Lundh proposes t h a t i n d i v i d u a l ' s sense s i g n s o f i l l n e s s , i n t e r p r e t these s i g n s and respond t o them e m o t i o n a l l y . Moreover he suggests t h a t t h e s e emotions make people more a t t e n t i v e t o s i g n s o f improvement or t o evidence which i s c o n s i s t e n t w i t h t h e i r b e l i e f s o f improvement. These s i g n s a r e taken as p r o o f of the c o r r e c t n e s s o f t h e i r b e l i e f s , s e t t i n g up a p o s i t i v e c y c l e o f placebo b e l i e f s . He r a i s e s t h e q u e s t i o n o f whether t h e r e i s a p s y c h o p h y s i o l o g i c a l p l a c e b o e f f e c t as w e l l and supports t h i s p o s s i b i l i t y by c i t i n g Ader's 1981 study o f the p s y c h o l o g i c a l i n f l u e n c e s on t h e immune system, Imboden's 1972 study on how d e p r e s s i o n slows r e c o v e r y from i n f e c t i o n s , and G o t t s c h a l k ' s 1974 demonstration o f how hope i s c o r r e l a t e d w i t h the l e n g t h o f l i f e i n cancer. E x p e c t a n c y - a t t r i b u t i o n theory. Ross and Olse n (1981) have proposed the E x p e c t a n c y - A t t r i b u t i o n t h e o r y which d i f f e r e n t i a t e s between two l e v e l s o f p a t i e n t 14 assessment. They i d e n t i f y primary assessment which measures the s u b j e c t s e x p e c t a n c i e s of t h e treatment e f f e c t s , and secondary assessment which measures whether th e i n d i v i d u a l b e l i e v e s t h a t the c o n d i t i o n f o r which they were b e i n g t r e a t e d has been e f f e c t e d . They p o i n t out t h a t o f t e n the focus of the placebo i s on t h e symptoms, and the e v a l u a t i o n i s based on the p a t i e n t s ' b e l i e f s of whether t h e r e i s any change i n t h e i r u n d e r l y i n g c o n d i t i o n . The placebo however may be d i r e c t e d a t e i t h e r the symptom o r the u n d e r l y i n g cause. C o n d i t i o n i n g t h e o r y . Ullmann and Krasner (1969) have proposed a c o n d i t i o n i n g theory. They b e l i e v e the placebo i s the r e s u l t of c o n d i t i o n i n g e f f e c t s and t h a t c o n d i t i o n i n g responses t o s t i m u l i are p r e s e n t w i t h i n the m i l i e u o f the therapy or experiment. Voudouris, Peck, and Coleman (1985) found support f o r t h i s t h e o r y i n t h e i r study o f p a i n induced by noxious s t i m u l a t i o n and an a n a l g e s i c cream, however Swalm (1987) found no support f o r t h i s t h e o r y when conducting a s i m i l a r type o f study. Secondary s u g g e s t i b i l i t y t h e o r y . Secondary s u g g e s t i b i l i t y i s a theory t h a t emphasizes the i n d u c t i o n o f p e r c e p t i o n s and emotions as i n f l u e n t i a l i n the placebo e f f e c t (Eysenck & Furneaux, 1984). Jospe (1978) reviewed numerous s t u d i e s examining the r o l e of s u g g e s t i b i l i t y i n the placebo response and concluded t h a t s i g n i f i c a n t r e l a t i o n s h i p s o n l y seemed t o emerge when the s u b j e c t s were p a t i e n t s . 15 I t i s i n t e r e s t i n g t o examine the v a r i o u s f e a t u r e s o f the placebo e f f e c t . Frank (1961) d e s c r i b e s f o u r f e a t u r e s which he s t a t e s needs t o be i n p l a c e f o r h e a l i n g t o occur. These a r e : (a) the h e a l e r and p a t i e n t must have a good r e l a t i o n s h i p , one where the h e a l e r i s empathic and the p a t i e n t has t o t a l f a i t h i n the h e a l e r s a b i l i t y t o h e a l ; (b) the p l a c e o f h e a l i n g must be s o c i a l l y s a n c t i o n e d ; (c) the p a t i e n t must have a r a t i o n a l e t o e x p l a i n t h e i l l n e s s o r problem; and (d) t h e r e must be a treatment procedure. I n f o r m a t i o n about the e f f e c t expected from the pla c e b o was a l s o found t o be necessary. D i n n e r s t e i n and Halm (1970) found t h a t when p a t i e n t s were t o l d t o expect t o f e e l e n e r g i z e d o r t r a n q u i l i z e d f o l l o w i n g the a d m i n i s t r a t i o n o f a placebo t h a t t h e r e was a h i g h correspondence w i t h t h i s e f f e c t . The need f o r p h y s i c i a n enthusiasm has a l s o been confirmed ( F i s h e r , Cole, R i c k e l s , & Uhlenhuth, 1964; R i c k e l s , Baum, T a y l o r , & Raab, 1964; R i c k e l s , Boren, & S t u a r t , 1964; Uhlenhuth e t a l . , 1966). In a d d i t i o n , the t h e r a p i s t s a t t i t u d e towards the treatment and the treatment r e s u l t s s t r o n g l y i n f l u e n c e the outcome (Frank, 1973; S h a p i r o , 1971). On examining the a t t i t u d e s o f the s u b j e c t o r p a t i e n t t h a t must be p r e s e n t f o r the placebo e f f e c t t o occur, Frank (1961) and Shapi r o (1964) note t h a t a h i g h l e v e l o f a n x i e t y i s p r e s e n t w i t h a s u c c e s s f u l p lacebo response. A l s o noted was the importance o f f a i t h , hope and m o t i v a t i o n . Although they both d i s c u s s t h e s e elements 16 they do not suggest what t h e i r r o l e or f u n c t i o n might be. F o l l o w i n g a review of the placebo l i t e r a t u r e Swalm (1987) noted t h a t i t c o u l d be argued t h a t p a t i e n t 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 a r t i c u l a r l y those who were depressed and n e u r o t i c a l l y anxious responded b e s t t o p l a c e b o s . Lundh (1987) d i s c u s s e s the importance o f the p a t i e n t ' s b e l i e f i n the e f f i c a c y of treatment and bases h i s c o g n i t i v e - e m o t i o n a l model on the s u g g e s t i o n t h a t b e l i e f s have s t r o n g e f f e c t s on a person's h e a l t h . He b e l i e v e s t h a t what i s t h e r a p e u t i c about b e l i e f s o f hope and f a i t h i s t h e i r a b i l i t y t o c o u n t e r a c t those b e l i e f s which would seem t o produce a n x i e t i e s and d e p r e s s i o n . Although Lundh's model emphasizes the importance o f the i n d i v i d u a l ' s b e l i e f s , he o n l y examines one type o f b e l i e f and does not e x p l o r e or even suggest the p o s s i b i l i t y o f o t h e r p e r s o n a l b e l i e f s , a t t i t u d e s o r v a l u e s which may c o n t r i b u t e t o t h i s e f f e c t . The study of the placebo and i t s e f f e c t g i v e s us an important glimpse i n t o the power of the mind. Once the mechanism of the placebo i s understood we w i l l h o p e f u l l y have the means t o s t r e n g t h e n and r e i n f o r c e t h e h e a l i n g system of our b o d i e s . The H e a l t h B e l i e f Model There are many models t h a t have been used t o e x p l a i n h e a l t h b e h a v i o r ( A l l e n , 1988; Becker e t a l . , 1977; Janz, 1988; J e n k i n s , 1988; K i r s c h t , 1974; Maiman & Becker, 1974; M i l l e r , 1988; Pender, Walker, S e c h r i s t , & Stromberg, 17 1988). The most f r e q u e n t l y used and r e s e a r c h e d o f a l l of t h e s e i s the H e a l t h B e l i e f Model (HBM) as f o r m u l a t e d by Hochbaum, L e v e n t h a l , Kegeles, and Rosenstock ( L a n g l i e , 1977; Maiman & Becker, 1974; Rosenstock, 1974). T h i s model has been d e s c r i b e d as both a p s y c h o s o c i a l model (Janz & Becker, 1984) and a s o c i o b e h a v i o r a l compliance model (Becker & Maiman, 1975). The HBM i s based on the p s y c h o l o g i c a l and b e h a v i o r a l t h e o r i e s o f Lewin (1935) and Skinner (1938) and was developed t o i n v e s t i g a t e and e x p l a i n h e a l t h c a r e b e h a v i o r and compliance by i n d i v i d u a l s as these a c t i o n s r e l a t e d t o t h e t h r e a t of a s p e c i f i c d i s e a s e or problem (Becker e t a l . , 1977). More r e c e n t l y i t has been used t o i n v e s t i g a t e s i c k r o l e b e h a v i o r s , examining p o s s i b l e r e l a t i o n s h i p s between the HBM v a r i a b l e s and compliance w i t h the p r e s c r i b e d b e h a v i o r s (Becker, 1974; Becker e t a l . , 1977; Janz & Becker,1984); c l i n i c u t i l i z a t i o n , a response t o the symptoms of i l l n e s s (Janz & Becker, 1984) ; and r e c o v e r y , an examination o f a c t u a l improvement f o l l o w i n g m e d i c a l i n t e r v e n t i o n (Roberts e t a l . , 1984). The HBM i s based on f o u r b a s i c components; p e r c e i v e d s u s c e p t i b i l i t y or r e s u s c e p t i b i l i t y t o d i s e a s e o r t h r e a t , p e r c e i v e d s e v e r i t y of the d i s e a s e or t h r e a t , p e r c e i v e d b e n e f i t s of p r e v e n t i v e c a r e and p e r c e i v e d b a r r i e r s t o p r e v e n t i v e c a r e . The p e r c e i v e d s e v e r i t y o f the d i s e a s e or t h r e a t i n c l u d e s e v a l u a t i o n s of m e d i c a l and c l i n i c a l consequences of the a c t i o n . P e r c e i v e d b e n e f i t s of 18 p r e v e n t i v e c a r e i s dependent on the b e l i e f t h a t the a c t i o n i s f e a s i b l e , w h i l e p e r c e i v e d b a r r i e r s t o a p a r t i c u l a r h e a l t h a c t i o n would be elements such as c o s t , danger, unpleasantness and time (Becker, 1974; H i j e c k , 1984; Janz & Becker, 1984). A l s o the a d d i t i o n a l element "cues t o a c t i o n " , a s t i m u l u s t o t r i g g e r the d e c i s i o n t o take a c t i o n , i s i d e n t i f i e d as a component, however many s t u d i e s do not i n c l u d e t h i s element (Janz & Becker, 1984). The HBM emphasizes the need t o assess a t t i t u d e s and b e l i e f s and focuses on the v a l u e p l a c e d on a p a r t i c u l a r g o a l by the i n d i v i d u a l . Rosenstock (1974) r e f e r s t o t h i s as t h e m o t i v a t i o n of the i n d i v i d u a l and p o i n t s out t h a t t h i s i s c e n t r a l t o the f u n c t i o n i n g of the HBM. More r e c e n t l y , the HBM has been expanded t o i n c l u d e some a d d i t i o n a l v a r i a b l e s . A f t e r much debate, Rosenstock, S t r e c h e r , and Becker (1988) proposed t h a t s e l f - e f f i c a c y be i n c o r p o r a t e d i n t o the HBM as an ex p l a n a t o r y v a r i a b l e . They d e s c r i b e s e l f - e f f i c a c y as the c o n v i c t i o n by the i n d i v i d u a l t h a t s/he can s u c c e s s f u l l y perform the r e q u i r e d behavior i n order t o a c h i e v e the d e s i r e d outcome and p o i n t out t h a t t h i s o c c u r s p r i o r t o any a c t i o n b e i n g undertaken. A l s o F e u e r s t e i n and Linden (1984) have proposed a m o d i f i c a t i o n t o the HBM by su g g e s t i n g t h a t r i s k f a c t o r s i d e n t i f i e d as h a v i n g p s y c h o b i o l o g i c a l mechanisms, which may i n t e r f e r e w i t h h e a l t h b e h a v i o r maintenance, need t o be i n c o r p o r a t e d i n t o the model. They suggest t h a t these mechanisms need t o be 19 d i f f e r e n t i a t e d from those which may i n i t i a t e p o s i t i v e h e a l t h a c t i o n s and they b e l i e v e t h i s w i l l g i v e a more a c c u r a t e e v a l u a t i o n of the h e a l t h b e h a v i o r outcome. The HBM has been used t o i n v e s t i g a t e p a t i e n t h e a l t h care b e h a v i o r and compliance as these a c t i o n s r e l a t e t o the t h r e a t of s p e c i f i c d i s e a s e s or problems, th e t h r e a t of a d i s e a s e p r o g r e s s i o n , c l i n i c u t i l i z a t i o n , and r e c o v e r y . Many s t u d i e s have been conducted u s i n g the HBM. See T a b l e 1 f o r a summary of these s t u d i e s . Janz and Becker (1984) reviewed 46 s i m i l a r s t u d i e s which were conducted b e f o r e 1984. They determined a " s i g n i f i c a n c e r a t i o " by adding up the s i g n i f i c a n t f i n d i n g s f o r each dimension of the HBM and d i v i d i n g i t by the number o f s t u d i e s . They found t h a t the " b a r r i e r s " dimension, the n e g a t i v e aspect of a h e a l t h a c t i o n such as p o t e n t i a l c o s t , s i d e e f f e c t s , unpleasantness e t c . , was the most important w i t h a r a t i o of 89%, " s u s c e p t i b i l i t y " , the f e e l i n g s of v u l n e r a b i l i t y t o the t h r e a t , w i t h 81%, then " b e n e f i t s " , the b e l i e f t h a t a s p e c i f i c c ourse of a c t i o n w i l l reduce the t h r e a t , came next w i t h 78%, and f i n a l l y " s e v e r i t y " o f the t h r e a t w i t h 65%, and t h i s h e l d f o r both p r o s p e c t i v e and r e t r o s p e c t i v e d e s i g n s . " B a r r i e r s " i s s i g n i f i c a n t l y h i g h e r on the m a j o r i t y of the s t u d i e s , t h i s dimension was r e p o r t e d i n 31 of the s t u d i e s reviewed, i t was s i g n i f i c a n t i n 25, not s i g n i f i c a n t i n 3, and e i t h e r not r e p o r t e d o r not measured i n 18. S u s c e p t i b i l i t y was s i g n i f i c a n t i n 30, s i g n i f i c a n t i n the o p p o s i t e d i r e c t i o n 20 T a b l e 1 H e a l t h B e l i e f Model Research Type Authors H e a l t h b e h a v i o r i n the p r e v e n t i o n o f a t h r e a t Dental p r e v e n t i v e care - Haefner, 1974 V a c c i n a t i o n D i e t a r y & e x e r c i s e compliance B r e a s t s e l f examination Smoking Pregnancy - H a r r i s & Guten, 1979 - L a n g l i e , 1977 - Montano, 1986 - Becker, Maiman, K i r s c h t , Haefner, & Drachman, 1977. - O'Connell, P r i c e , Roberts, J u r s , & McKinley, 1985. - T i r r e l l & Hart, 1980. - Champion, 1985, 1987. - Rutledge & Davis, 1988. - Janz & Becker, 1984. - E i s e n & Zellman, 1986. - E i s e n , Zellman, & M c A l i s t e r , 1985. - H e s t e r & Macrina, 1985, D r i v i n g b e h a v i o r & 21 se a t b e l t usage - Beck, 1981. - L a n g l i e , 1977. H e a l t h b e h a v i o r t o prevent the p r o g r e s s i o n of a d i s e a s e . M e d i c a t i o n compliance - Becker, Drachman, & K i r s c h t , 1972. - Becker e t a l . , 1978. - Fincham & Wertheimer, 1985 - Jones, Jones, & Katz, 1988. - K e l l y , Mamon, & S c o t t , 1987. - K i r s c h t , Becker, & Eveland, 1976. Measuring d i a b e t i c b e l i e f s - Given, Given, G a l l i n , & Condon, 1983. - H a r r i s , L i n n , S k y l e r , & S a n d i f e r , 1987. C l i n i c u t i l i z a t i o n Mothers o b t a i n i n g s e r v i c e s f o r t h e i r c h i l d r e n - Becker, Maiman e t a l . , 22 1977. - K i r s e n t , Becker, & Eveland, 1976. Use of pre p a i d h e a l t h program - L e a v i t t , 1979. Recovery From back surgery - Roberts e t a l . , 1984. 23 i n 2, n o n s i g n i f i c a n t i n 5, and e i t h e r not r e p o r t e d or not measured i n 9. They b e l i e v e the HBM both e x p l a i n s and p r e d i c t s h e a l t h - r e l a t e d behavior and t h a t t h e s e s t u d i e s p r o v i d e v e r y s u b s t a n t i a l e m p i r i c a l support f o r t h e s e dimensions o f the model. I t i s i n t e r e s t i n g t h a t the " b a r r i e r s " dimension i s the most s i g n i f i c a n t . T h i s dimension c o n t a i n s b e l i e f s around a r e q u i r e d a c t i v i t y t h a t i s performed i n o r d e r t o reduce a t h r e a t ( i . e . , c o s t , danger of the a c t i o n , l a c k of t i m e ) . T h i s would seem t o suggest t h a t day t o day d i f f i c u l t i e s o f l i v i n g may take precedence over t h e o t h e r groups of b e l i e f s when the d e c i s i o n of whether t o a c t o r not i s a s sessed. However, almost as h i g h i n s i g n i f i c a n c e are the b e l i e f s o f " s u s c e p t i b i l i t y " and " b e n e f i t s " . Both o f these are dimensions t h a t are s t r o n g l y based on b e l i e f s , b e l i e f s of i n d i v i d u a l v u l n e r a b i l i t y , and b e l i e f s t h a t by t a k i n g a c e r t a i n a c t i o n the t h r e a t w i l l be reduced. Furthermore, s p e c i f i c i d e n t i f i c a t i o n o f the t y p es of b e l i e f s i n v o l v e d i n each of t h e s e c a t e g o r i e s would be o f g r e a t v a l u e , however t h i s i s not a v a i l a b l e as t h e authors do not r e p o r t t h e i r r e s u l t s a t t h e i n d i v i d u a l b e l i e f l e v e l , but l e a v e them c l u s t e r e d as dimensions. Only one study has been l o c a t e d t h a t has as i t s focus p a t i e n t s r e c o v e r y and b e l i e f s w i t h i n the HBM. Roberts e t a l . (1984) e v a l u a t e d r e t r o s p e c t i v e l y p a t i e n t b e l i e f s f o l l o w i n g laminectomy surgery and s u c c e s s f u l l y d e l i n e a t e d between th e b e l i e f s of those p a t i e n t s who do w e l l a f t e r 24 surgery and those who do not. The authors developed the A i r d a l e S p i n a l Surgery Q u e s t i o n n a i r e which measured v u l n e r a b i l i t y , b e n e f i t s of a c t i o n , b a r r i e r s t o a c t i o n , a t t i t u d e s towards h o s p i t a l s t a y , and g e n e r a l h e a l t h b e l i e f s . An a d d i t i o n a l s e t of s c a l e s was i n c l u d e d t o measure p r e - and p o s t - o p e r a t i v e l e v e l s of d i s a b i l i t y , p a i n , and the p a t i e n t ' s knowledge about t h e i r s u r g e r y and subsequent r e h a b i l i t a t i o n . S u b j e c t s were c l a s s i f i e d a c c o r d i n g t o improved or not improved on t h e above measures. T h i s study had 154 s u b j e c t s , 112 who r e p o r t e d they had improved, and 42 who r e p o r t e d they d i d not. A d i s c r i m i n a n t f u n c t i o n a n a l y s i s aimed a t maximally d i f f e r e n t i a t i n g between the improved and the not improved groups was conducted. T h e i r r e s u l t s demonstrated t h a t those p a t i e n t s who r e p o r t e d lower v u l n e r a b i l i t y , h i g h e r b e n e f i t s , lower b a r r i e r s , and lower resentment p o s t o p e r a t i v e l y were i n the improved group. T h i s improved group a l s o r e p o r t e d p r e o p e r a t i v e l y , fewer o p e r a t i o n s , s h o r t e r i l l n e s s e s , fewer o u t p a t i e n t v i s i t s , more p a i n , more d i s a b i l i t y , and a b e t t e r knowledge o f t h e i r i l l n e s s . I t i s i n t e r e s t i n g t h a t the improved group r e p o r t e d more p a i n and more d i s a b i l i t y p r i o r t o surgery, though t h i s i s not s p e c i f i c a l l y addressed by the authors, t h i s may i n d i c a t e t h a t s u r g e r y h e l p s those w i t h a more sev e r e problem compared t o those p a t i e n t s w i t h a m i l d e r one. The g e n e r a l h e a l t h b e l i e f s which were measured through i n d i c e s c o n s t r u c t e d by the authors were not s i g n i f i c a n t . 25 T h i s study i s not w e l l documented and i s d i f f i c u l t t o i n t e r p r e t . The q u e s t i o n n a i r e s used are not a v a i l a b l e so the b e l i e f s t e s t e d are u n i d e n t i f i a b l e , a l s o the data a re scanty and the a n a l y s i s u n c l e a r . C l e a r l y t he m a j o r i t y of the HBM s t u d i e s d e a l w i t h compliance and h e a l t h behavior and not r e c o v e r y , except f o r the study by Roberts e t a l . (1984). As such t h e m a j o r i t y o f t h e s e s t u d i e s are t a n g e n t i a l f o r they do not d e a l w i t h the p s y c h o b i o l o g i c a l changes o f h e a l i n g and rec o v e r y but s t r i c t l y b e h avior. In a d d i t i o n , a l t h o u g h t h e r e i s c o n s i d e r a b l e l i t e r a t u r e a v a i l a b l e on t h e HBM, t h e emphasis i s not on the type o f b e l i e f s and how they might be s i m i l a r , study t o study, and d i s e a s e t o d i s e a s e , o r on the b e l i e f s t h a t a re supported by the v a r i o u s p s y c h o l o g i c a l t h e o r i e s . The b e l i e f s and a t t i t u d e s examined w i t h i n the model are many. Each instrument c o n s t r u c t e d c o n t a i n s those b e l i e f s the d e s i g n e r views as r e l e v a n t t o examine or t o p r e d i c t a p a r t i c u l a r b e h a v i o r as lo n g as they f i t w i t h i n the f o u r p r e v i o u s l y d e s c r i b e d dimensions. Thus t h e r e i s no r e c o g n i z e d measurement t o o l f o r each type of b e l i e f , nor are attempts made t o ensure t h a t each q u e s t i o n i s c l e a r l y understood i n the same way by d i f f e r e n t i n d i v i d u a l s . The HBM i s l i m i t e d i n t h a t i t does not examine t h e spectrum of d i f f e r e n t b e l i e f s t h a t may i n f l u e n c e r e c o v e r y , but f o r c e s a mixed group o f b e l i e f s t o f i t i n t o i t s f o u r c a t e g o r i e s o f p e r c e i v e d s u s c e p t i b i l i t y , s e v e r i t y , e f f e c t i v e n e s s o f t h e p r e c a u t i o n 26 and b a r r i e r s t o a c t i o n . Another weakness i s t h e model's i n a b i l i t y t o determine the c a u s a l r o l e o f the v a r i o u s b e l i e f s (Rosenstock, 1974) and i t s i n a b i l i t y t o determine the comparative s t r e n g t h s of the d i f f e r e n t b e l i e f s (Martus, 1985). F i n a l l y as the c a t e g o r i e s are v e r y g l o b a l and s i n c e t h e r e are no content requirements t h e r e i s a l a c k o f r e p l i c a b i l i t y ( J e t t e , Cummings, Brock, Phelps, & Naessens, 1981). Through t h e c o n s t r u c t i o n and use o f an HBM instrument, a means of p r e d i c t i n g p a t i e n t b e h a v i o r , compliance and even outcome can be developed as shown by Roberts e t a l . (1984). However, as each subdomain of t h i s model i n v o l v e s v a r i o u s types o f b e l i e f s , which ones are s i g n i f i c a n t and how they may i n f l u e n c e r e c o v e r y i s not c l e a r . A Phenomenological Approach A l l o f the h e a l t h t h e o r i e s o r models examined so f a r have t o a c e r t a i n degree examined b e l i e f s as they i n f l u e n c e h e a l t h b e h a v i o r and h e a l t h . None o f them have examined i n depth which s p e c i f i c b e l i e f s may i n f l u e n c e r e c o v e r y and h e a l i n g . Martus (1985), u t i l i z i n g a phenomenological approach, examined the e x p e r i e n c e of b e l i e v i n g i n 16 i n d i v i d u a l s who had been s u c c e s s f u l l y h e a l e d o r who had experienced a marked improvement i n t h e i r c o n d i t i o n from major p h y s i c a l i l l n e s s e s of a r t h r i t i s , cancer, h i g h b l o o d p r e s s u r e , kidney d i s e a s e , o r tumors. He i d e n t i f i e d n i ne themes t h a t he b e l i e v e d c h a r a c t e r i z e d t h e i r experience. He o b t a i n e d t h e data 27 through 90 minute i n t e r v i e w s which were t a p e r e c o r d e d , and then t r a n s c r i b e d . Martus c i t e s Keen's 1975 model f o r a n a l y z i n g phenomenological data as the framework used f o r h i s a n a l y s i s . He d e s c r i b e s h i s p r o c e s s o f i d e n t i f y i n g the themes through e n t e r i n g i n t o the p r o c e s s o f "epoche" and immersing h i m s e l f "completely" i n the d a t a . He f u r t h e r used " b r a c k e t i n g " , " h o r i z o n t a l i z a t i o n " , " d e l i m i t i n g " , " c l u s t e r i n g " , " i m a g i n a t i v e v a r i a t i o n " and "thematic l i n k a g e s " , i n the process o f theme i d e n t i f i c a t i o n (Martus, 1985) . The nine themes he i d e n t i f i e d are: the c o m p a t i b i l i t y o r i n c o m p a t i b i l i t y of p r e v i o u s e x p e r i e n c e s , the need t o focus one's a t t e n t i o n on h e a l i n g , s i g n i f i c a n t changes, the acknowledgment of a r a t i o n a l e , an a c t i v e optimism, the r e c e i v i n g o f feedback from s e l f and o t h e r s , a s t r o n g sense of b e ing i n charge, the v i t a l presence o f support, and the presence o f s t r o n g f e e l i n g s . Although Martus examined the p r o c e s s of b e l i e v i n g r a t h e r than the types o f b e l i e f s , c e r t a i n types o f b e l i e f s are apparent. Both, however, ar e i n t e r t w i n e d making complete s e p a r a t i o n and d i v i s i o n i m p o s s i b l e . A f t e r s y n t h e s i z i n g Martus 1 n i n e themes, t h r e e domains of b e l i e f s are e v i d e n t , t h e s e are domains about the s e l f , b e l i e f s about the h e a l i n g p r o c e s s , and b e l i e f s about the p r e s e n t and f u t u r e . In a d d i t i o n t o these, t h r e e d i f f e r e n t themes not d e s c r i b e d i n t h e above t h r e e domains are a l s o e v i d e n t . These are b e l i e f s about s o c i a l support, n e g a t i v e l i f e changes, and the l o c a t i o n o f 28 the i n d i v i d u a l s focus on the i n j u r y t o f u l l h e a l t h continuum. F i r s t , a re those b e l i e f s r e l a t e d t o and about the s e l f . The "sense of b e i n g i n charge" f a l l s i n t o t h i s c ategory, here t h e i n d i v i d u a l d e c i d e s t o be i n c o n t r o l . T h i s d e c i s i o n i s based on p r e v i o u s e x p e r i e n c e , and promoted by the f a m i l y through s o c i a l support, b e h a v i o r s , and knowledge o f the h e a l i n g and b e l i e v i n g p r o c e s s e s . A l s o , Martus i d e n t i f i e s the theme of " s i g n i f i c a n t changes" (p. 89) as one where b e l i e f s are e i t h e r s t r e n g t h e n e d or changed. Here he d e s c r i b e s how t h i s p r o c e s s r e s u l t s i n an i n c r e a s e of t h e i n d i v i d u a l ' s s e l f - e s t e e m and s e l f - c o n f i d e n c e . Second, are those b e l i e f s about the i n j u r y and h e a l i n g p r o c e s s . H e a l i n g i s experienced by f o c u s i n g one's a t t e n t i o n away from the i l l n e s s on t o the h e a l i n g p r o c e s s or another s u b s t i t u t e , and power i s g i v e n t o the b e l i e f through t h e r e g u l a r and c o n s i s t e n t p r a c t i c e o f b e l i e v i n g i n t h i s p r o c e s s . A l s o support from f a m i l y , f r i e n d s and the r e a d i n g of l i t e r a t u r e may a s s i s t i n t h i s p r o c e s s . R e c e i v i n g feedback from the s e l f and o t h e r s ( i . e . , d o c t o r s , medical t e s t s ) i s an a d d i t i o n a l element t h a t a f f i r m s the h e a l i n g process and h e l p s t o f o c u s a t t e n t i o n . One can assume t h a t b e l i e f i n t h e e f f i c a c y of therapy i s one dimension of these b e l i e f s about the h e a l i n g p r o c e s s . T h i r d , are those b e l i e f s about the p r e s e n t and the 29 f u t u r e . A c c o r d i n g t o Martus the theme o f a c t i v e optimism i s e s s e n t i a l . He s t a t e s i t " o r i g i n a t e s from p o s i t i v e l i t e r a t u r e , f r i e n d s , and ones own sense o f humor" (p. 80), as w e l l as a c o n s c i o u s e f f o r t t o m a i n t a i n i t . A l s o i n t h i s domain are b e l i e f s about what i s happening, and the "acknowledgment of a r a t i o n a l e " (p. 81). Here th e i n d i v i d u a l develops a r a t i o n a l e e x p l a i n i n g t o themselves what i s happening. T h i s may be s p i r i t u a l , a p e r s o n a l i n s i g h t i n t o the l i f e they are l i v i n g o r s i m p l y becoming more i n touch w i t h themselves or t h e i r b o d i e s . T h i s i s u s u a l l y based on the i n f l u e n c e of p r e v i o u s b e l i e f s and the i n p u t o f t h e i r d o c t o r or s i g n i f i c a n t o t h e r s . Three a d d i t i o n a l domains of importance noted by Martus a r e the presence of s o c i a l support, s i g n i f i c a n t change, and t h e i n d i v i d u a l s ' need t o focus t h e i r a t t e n t i o n on h e a l i n g . When d i s c u s s i n g s o c i a l support Martus notes the s t r u c t u r e o f t h i s should be c o n t i n u a l emotional support f o r the i n d i v i d u a l and i n t e l l e c t u a l support f o r t h e i r r a t i o n a l e . I t may come from f a m i l y , f r i e n d s , the church, or the d o c t o r . There i s a l s o the c h a r a c t e r i s t i c o f " s i g n i f i c a n t change" t h a t was p r e s e n t when h e a l i n g o c c u r r e d . T h i s e x p e r i e n c e i n c r e a s e d the i n d i v i d u a l s s e l f - e s t e e m and s e l f - c o n f i d e n c e . In some cases b e l i e f s were strengthened and i n o t h e r s they were a c t u a l l y changed. An example o f t h i s was the i n d i v i d u a l becoming aware o f what was happening about them and what was happening w i t h i n 30 themselves, o r another example would be t h e g a i n i n g o f new knowledge. Martus s t a t e s t h i s change must be wanted and t h a t i t may be an i n t e r n a l or e x t e r n a l change and although i t may o n l y o c c u r on the p h y s i c a l l e v e l i t may a l s o i n v o l v e the emotions, the s p i r i t , and the b e h a v i o r a l p a t t e r n s . F u r t h e r , t h e need t o focus one's a t t e n t i o n on the h e a l i n g p r o c e s s , c h a r a c t e r i z e d by the need t o a v o i d f o c u s i n g one's a t t e n t i o n on the problem o r d i s e a s e , but i n s t e a d t o focus on one's h e a l i n g i s a l s o i d e n t i f i e d by Martus. Martus a l s o notes t h a t the "presence of s t r o n g f e e l i n g s " (p. 94) are important. These f e e l i n g s are more n e g a t i v e p r i o r t o the s t a r t of the h e a l i n g e x p e r i e n c e and they become more p o s i t i v e as h e a l i n g o c c u r s . Martus r e p o r t s t h a t p a t i e n t s , p r i o r t o recovery, express f e e l i n g s of "being s c a r e d s t i f f , ashamed, f r u s t r a t e d and f r i g h t e n e d " . L a t e r on as the h e a l i n g was i n p r o c e s s the f e e l i n g s were d e s c r i b e d as being " f u l l o f hope, c o n f i d e n t , e n e r g i z e d , t h a n k f u l , t o t a l l y s a t i s f i e d , and b l e s s e d " (p. 94) . Measurement Issues The v a l i d i t y o f s e l f - r e p o r t measures o f h e a l t h s t a t u s i s a concern. T i s s u e (1975) notes t h a t t h e s e l f - r a t i n g of h e a l t h i s dependent on the i n d i v i d u a l e v a l u a t i n g numerous h e a l t h areas both s u b j e c t i v e l y as w e l l as o b j e c t i v e l y and then i n t e r p r e t i n g these data through 31 h i s / h e r own p e r c e p t u a l framework. G o l d s t e i n , S i e g e l , and Boyer (1984) found t h a t n e i t h e r p o s i t i v e or n e g a t i v e changes i n p e r c e i v e d h e a l t h s t a t u s were s i g n i f i c a n t l y a s s o c i a t e d w i t h p h y s i c a l h e a l t h b e l i e f s o r p h y s i c a l h e a l t h s t a t u s . They measured t h i s w i t h q u e s t i o n s they c a t e g o r i z e d as c o v e r i n g the areas o f s a t i s f a c t i o n w i t h medical c a r e , a c c e s s i b i l i t y t o medical s e r v i c e s , s e r i o u s n e s s o f i l l n e s s , e f f i c a c y o f c a r e , and m o t i v a t i o n . T h e r e f o r e the s e l f - r a t i n g s of p e r c e i v e d h e a l t h s t a t u s o r r e c o v e r y are not always dependably r e l a t e d t o a c t u a l p h y s i c a l s t a t u s . T h i s study however, f a i l e d t o examine s p e c i f i c b e l i e f s . The m a j o r i t y of these c a t e g o r i e s , l i k e the HBM, are broad and encompass a l a r g e range o f p o s s i b l e areas. Furthermore, the b e l i e f s were not measured by a s t a n d a r d i z e d instrument c o n s t r u c t e d and t e s t e d f o r measuring t h a t s p e c i f i c b e l i e f . On the o t h e r hand Maddox (1964) when s t u d y i n g the s e l f - a s s e s s m e n t o f h e a l t h by the e l d e r l y noted t h a t they expressed a predominantly r e a l i s t i c o r i e n t a t i o n t o h e a l t h s t a t u s . J y l h a , Leskinen, Alanen, Leskinen, and Heikkinen (1986) when examining s e l f - r a t e d h e a l t h and a s s o c i a t e d f a c t o r s i n men o f d i f f e r e n t ages found t h a t those i n the 31 t o 35 age range e x p l a i n e d t h e i r h e a l t h more by symptoms and an index o f p h y s i c a l f i t n e s s , those i n the 51 t o 55 age range by symptoms and p s y c h i c w e l l - b e i n g , and those i n the 71 t o 75 y e a r s o f age range by c h r o n i c i l l n e s s . T h e r e f o r e the s e l f - a s s e s s m e n t of h e a l t h s t a t u s may measure d i f f e r e n t 32 elements of h e a l t h s t a t u s f o r the d i f f e r e n t age groups. Summary The review o f l i t e r a t u r e r e v e a l e d approaches which span s e v e r a l t h e o r e t i c a l areas. For example, the HBM was developed from p s y c h o l o g i c a l , h e a l t h c a r e , and e p i d e m i o l o g i c a l , and the medical d i s c i p l i n e s ; Antonovsky's (1979) s a l u t o g e n i c model was developed from s o c i o l o g i c a l , and p s y c h o l o g i c a l approaches. Because the dimensions o f the HBM, t h e s a l u t o g e n i c model, the placebo, and Martus' (1985) phenomenological study c r o s s t h e o r e t i c a l areas, they seem t o be the most comprehensive models a v a i l a b l e . The HBM, s a l u t o g e n i c model, and placebo a r e f r e q u e n t l y r e f e r r e d t o i n the l i t e r a t u r e . A l l of t h e s e models t e l l us something about h e a l i n g and r e c o v e r y . However none o f them s p e c i f i c a l l y e x p l o r e the i n f l u e n c e o f the v a r i o u s b e l i e f s on the h e a l i n g and r e c o v e r y p r o c e s s . Antonovsky (1979) i d e n t i f i e s t h a t a s t r o n g sense o f s e l f and s e l f - i d e n t i t y , and a s t r o n g sense o f s e l f - e f f i c a c y are necessary t o r e s i s t the e f f e c t s o f s t r e s s . He a l s o d i s c u s s e s the l o c u s of c o n t r o l c o n s t r u c t n o t i n g t h a t whether i t i s i n t e r n a l or e x t e r n a l does not matter, the c r i t i c a l i s s u e i s whether i t i s where i t i s supposed t o be a c c o r d i n g t o the i n d i v i d u a l ' s i n t e r p r e t a t i o n . The HBM which i d e n t i f i e s the f o u r areas o f b e l i e f s , p e r c e i v e d s u s c e p t i b i l i t y , p e r c e i v e d s e v e r i t y o f the t h r e a t , and b e n e f i t s and b a r r i e r s t o a c t i o n examine b e h a v i o r as a response t o these b e l i e f s and p e r c e p t i o n s . 33 The HBM does not however, i d e n t i f y s p e c i f i c i n d i v i d u a l b e l i e f s t h a t might i n f l u e n c e h e a l i n g and r e c o v e r y . Research and l i t e r a t u r e on the placebo e f f e c t i d e n t i f i e s t h a t many p a t i e n t - b e l i e f v a r i a b l e s such as s e l f - e f f i c a c y , f a i t h , hope, i n a d d i t i o n t o s e v e r a l o t h e r v a r i a b l e s a l l must be p r e s e n t f o r t h i s e f f e c t t o occur. Attempts a r e made t o d e s c r i b e these v a r i a b l e s but not n e c e s s a r i l y t o s p e c i f i c a l l y s u b s t a n t i a t e the types o f b e l i e f s i n v o l v e d . F u r t h e r the placebo e f f e c t has been predominantly examined i n terms of the i n d i v i d u a l s response t o s h o r t term p a i n o r unpleasant s t i m u l i and not n e c e s s a r i l y t o a group p a r t i c i p a t i n g i n the recover y p r o c e s s . Martus' (1985) n i n e themes though not s p e c i f i c t o b e l i e f s do d e s c r i b e components of b e l i e v i n g and t h e r e f o r e a re more c l o s e l y a l i g n e d t o the i n d i v i d u a l s p e r s o n a l b e l i e f system. T a b l e 2 summarizes the b e l i e f s i n h e r e n t i n t h e s e t h r e e approaches. An examination o f T a b l e 2 r e v e a l s t h a t s e l f - e s t e e m i s o n l y i d e n t i f i e d i n Martus 1 (1985) phenomenological approach, w h i l e s e l f - c o n f i d e n c e , a l s o i d e n t i f i e d by Martus, i s a core element i n Antonovsky's (1979) s a l u t o g e n i c model. The l o c u s o f c o n t r o l b e l i e f , i d e n t i f i e d as a c o r e theme by Martus, i s not c o n s i d e r e d a c r i t i c a l v a r i a b l e by Antonovsky because he p o s t u l a t e s t h a t i n t e r n a l i t y o r e x t e r n a l i t y o f c o n t r o l can v a r y . F a i t h i n therapy i s d e s c r i b e d i n d i r e c t l y by Martus, however i t i s a core element i n the placebo e f f e c t , w h i l e both Martus and the placebo e f f e c t i d e n t i f y optimism as T a b l e 2 Comparisons of M o d e l s / T h e o r i e s B e l i e f s P h e n o m e n o l o g i c a l S a l u t o g e n i c P l a c e b o H e a l t h B e l i e f Model S e l f E x p e r i e n c e o f b e l i e v - Not s p e c i f i c a l l y i n d e n t - Not i d e n t i f i e d Not i d e n t i f i e d , though Esteem i n g i n the h e a l i n g i f i e d , though may be c o u l d be a component o f p r o c e s s i n c r e a s e d s e l f c o n s i d e r e d as p a r t of " p e r c e i v e d v u l n e r a b i l -esteem ( i d e n t i f i e d the s t r o n g s e n s e of i t y " . i n t h e theme o f s i g n - i d e n t i t y and s e l f , n e c -i f i c a n t c h a n g e ) . e s s a r y f o r a s t r o n g s e n s e o f c o h e r e n c e . S e l f E x p e r i e n c e o f b e l i e v - C o re element o f A n t o n - Not i d e n t i f i e d Not s p e c i f i c a l l y i d e n t -C o n f i d e n c e i n g i n t h e h e a l i n g o v s k y 's s e n s e of c o h e r - i f i e d though the d e f i n -p r o c e s s i n c r e a s e d s e l f ence . i t i o n o f " s e l f e f f i c a c y " c o n f i d e n c e ( i d e n t i f i e d w ould a p p e a r t o i n c l u d e i n t h e theme of s i g n - s e l f c o n f i d e n c e as a i f i c a n t c h a n g e ) . p r i m a r y e l e m e n t . Locus of Core theme. "Sense I d e n t i f i e d as i m p o r t a n t Not i d e n t i f i e d . Not i d e n t i f i e d . c o n t r o l . of b e i n g i n c h a r g e " . however c o n t r o l need n o t be s e l f c o n t r o l and may be p l a c e d w i t h a n o t h e r as l o n g as t h i s i s where the i n d i v i d u a l b e l i e v e s i t s h o u l d be. B e l i e f s P h e n o m e n o l o g i c a l S a l u t o g e n i c P l a c e b o H e a l t h B e l i e f Model F a i t h i n Not s p e c i f i c a l l y i d e n - Not i d e n t i f i e d . C o re e l e m e n t Not i d e n t i f i e d , though Therapy t i f i e d , b u t a g e n e r a l c o u l d be a component of a s s u m p t i o n i n t h e " p e r c e i v e d b e n e f i t s " . themes " f o c u s on h e a l -i n g " , and " r e c e i v i n g f e e d b a c k f r o m s e l f and o t h e r s Optimism Core theme. Op t i m i s m . Not i d e n t i f i e d . C o r e element r e - Not i d e n t i f i e d , though l a t e d t o the h e a l - p o s s i b l y a component of i n g p r o c e s s ( the " p e r c e i v e d b e n i f i t s of b e l i e f t h a t h e a l - an a c t i o n " . i n g w i l l be a c h i e v -ed) . W i l l t o G e n e r a l a s s u m p t i o n Core element i n the G e n e r a l a s s u m p t i o n G e n e r a l a s s u m p t i o n L i v e made t h r o u g h o u t t h e O r i e n t a t i o n t o l i f e made t h r o u g h o u t made as p e o p l e r e s p o n d 9 themes though n o t which has as i t s comp- as p a t i e n t i s hop- t o and seek h e l p when s p e c i f i c a l l y i d e n t - o n e n t s , c o m p r e h e n s i b - i n g t h e r a p y w i l l f a c e d w i t h a t h r e a t . i f i e d . i l i t y , m a n a g e a b i l i t y , and m e a n i n g f u l n e s s . work. 36 core elements. The w i l l t o l i v e i s a g e n e r a l assumption made by a l l f o u r o f the models, although i t i s o n l y i d e n t i f i e d by Antonovsky i n h i s o r i e n t a t i o n t o l i f e . In o r d e r t o be c l o s e t o the p a t i e n t p e r s p e c t i v e , t h i s study focused on b e l i e f s i d e n t i f i e d from Martus' work which u t i l i z e d a phenomenological approach. These b e l i e f s a r e : (a) the b e l i e f s about the s e l f , t h e s e i n c l u d e b e l i e f s about s e l f - e s t e e m , s e l f - c o n f i d e n c e and c o n t r o l ; (b) the b e l i e f s about the h e a l i n g p r o c e s s where a t t e n t i o n i s focused on h e a l i n g and away from i l l n e s s ; and (c) b e l i e f s about the pr e s e n t and the f u t u r e , such as a c t i v e optimism. In a d d i t i o n t o these b e l i e f s , the i n d i v i d u a l s " f a i t h i n the r a p y " and the " w i l l t o l i v e " as b r o a d l y i d e n t i f i e d i n t h e placebo e f f e c t are i n c l u d e d . T h e r e f o r e t h i s study emphasizes s i x t y p e s o f b e l i e f s ; b e l i e f s o f s e l f - e s t e e m , s e l f - c o n f i d e n c e , c o n t r o l , f a i t h i n therapy, w i l l t o l i v e , and optimism. The t h r e e domains of s o c i a l support, s i g n i f i c a n t change, and the i n d i v i d u a l s focus on h e a l i n g which Martus a l s o i d e n t i f i e s a r e not s p e c i f i c a t t i t u d e s or b e l i e f s , but are more t a n g i b l e and t h e r e f o r e a st e p removed from the more i n t r a p s y c h i c h e a l t h b e l i e f s d i s c u s s e d above. T h i s study then, examines the i n f l u e n c e s o f s p e c i f i c b e l i e f s on the r e c o v e r y o f back and neck p a t i e n t s . The r e s u l t s may p r o v i d e c o u n s e l l o r s , t h e r a p i s t s , nurses and d o c t o r s w i t h i n f o r m a t i o n about the type and importance o f b e l i e f s t h a t may be a s s o c i a t e d w i t h the h e a l i n g and 37 r e c o v e r y p r o c e s s o f back and neck p a t i e n t s . 38 Hypotheses Purpose The purpose o f t h i s study i s t o examine whether 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 between both th e degree of r e c o v e r y and the r a t e of r e c o v e r y and the h e a l t h b e l i e f s o f s e l f - e s t e e m , s e l f - c o n f i d e n c e , c o n t r o l , f a i t h i n therapy, optimism and w i l l t o l i v e . Recovery, th e r e t u r n t o the p r e - i n j u r y s t a t e of back and neck f u n c t i o n was examined i n two ways: f i r s t , s u b j e c t i v e l y by the degree o f r e c o v e r y t h a t the p a t i e n t i d e n t i f i e s they have a c h i e v e d ; and second, by the r a t e of recovery, the l e n g t h o f time and the number o f treatments r e q u i r e d f o r t h i s h e a l i n g t o occur. T h i s study i s c o n s t r a i n e d i n the f o l l o w i n g ways: (a) s i x b e l i e f s of s e l f - e s t e e m , s e l f - c o n f i d e n c e , c o n t r o l , f a i t h i n therapy, optimism and w i l l t o l i v e were examined, whereas the more t a n g i b l e elements o f s o c i a l support, the s i g n i f i c a n c e of change, and the i n d i v i d u a l s f ocus o f a t t e n t i o n on b e i n g h e a l t h y from Martus' (1985) study were not i n c l u d e d ; (b) nor does t h i s study examine the more i n t e r p s y c h i c a s p e c t s of peoples s o c i a l l i v e s which may a l s o a f f e c t t h e i r a t t i t u d e s , b e l i e f s and response t o treatment. Hypotheses T h i s study t e s t e d the f o l l o w i n g hypotheses: 1. The p a t i e n t group e x h i b i t i n g a f u l l degree o f r e c o v e r y w i l l have s i g n i f i c a n t l y g r e a t e r s e l f - e s t e e m , compared 39 w i t h the group w i t h moderate r e c o v e r y , f o l l o w e d by the group w i t h no recovery, when s e l f - e s t e e m i s measured by the Rosenberg Self-Esteem S c a l e (RSE). 2. The p a t i e n t group e x h i b i t i n g the g r e a t e s t r a t e o f re c o v e r y w i l l have s i g n i f i c a n t l y g r e a t e r s e l f - e s t e e m , compared w i t h the group w i t h a moderate r a t e o f reco v e r y , f o l l o w e d by the group w i t h t h e l e a s t r a t e o f reco v e r y , when s e l f - e s t e e m i s measured by the Rosenberg Sel f - E s t e e m S c a l e (RSE). 3. The p a t i e n t group e x h i b i t i n g a f u l l degree o f r e c o v e r y w i l l have s i g n i f i c a n t l y g r e a t e r s e l f - c o n f i d e n c e , compared w i t h the group with moderate r e c o v e r y , f o l l o w e d by the group with no r e c o v e r y when s e l f - c o n f i d e n c e i s measured by t h e s u b s c a l e o f Lack o f S o c i a l S e l f - C o n f i d e n c e i n the I n t e r p e r s o n a l Dependency Inventory ( I D I ) . 4. The p a t i e n t group e x h i b i t i n g the g r e a t e s t r a t e o f re c o v e r y w i l l have s i g n i f i c a n t l y g r e a t e r s e l f - c o n f i d e n c e , compared w i t h the group w i t h a moderate r a t e o f recovery, f o l l o w e d by the group w i t h the l e a s t r a t e o f recovery, when s e l f - c o n f i d e n c e i s measured by the su b s c a l e of Lack of S o c i a l S e l f - C o n f i d e n c e i n the I n t e r p e r s o n a l Dependency Inventory ( I D I ) . 5. The p a t i e n t group e x h i b i t i n g a f u l l degree o f r e c o v e r y w i l l have s i g n i f i c a n t l y g r e a t e r c o n t r o l , compared w i t h the group with moderate r e c o v e r y , 40 f o l l o w e d by the group with the l e a s t r e c o v e r y , when c o n t r o l i s measured by the s u b s c a l e o f C o n t r o l i n the H e a l t h R e l a t e d Hardiness S c a l e (HRHS). 6. The p a t i e n t group e x h i b i t i n g the g r e a t e s t r a t e o f re c o v e r y w i l l have s i g n i f i c a n t l y g r e a t e r c o n t r o l , compared w i t h t h e group wi t h a moderate r a t e o f reco v e r y , f o l l o w e d by the group w i t h the l e a s t r a t e of r e c o v e r y , when c o n t r o l i s measured by t h e s u b s c a l e of C o n t r o l i n t h e H e a l t h R e l a t e d H a r d i n e s s S c a l e (HRHS). 7. The p a t i e n t group e x h i b i t i n g a f u l l degree o f r e c o v e r y w i l l have s i g n i f i c a n t l y g r e a t e r f a i t h i n therapy, compared w i t h the group with moderate r e c o v e r y , f o l l o w e d by group of the l e a s t degree o f r e c o v e r y , when f a i t h i n therapy i s measured by the s u b s c a l e o f F a i t h i n Therapy i n the C l i e n t Readiness f o r Therapy Inventory (CRTI). 8. The p a t i e n t group e x h i b i t i n g the g r e a t e s t r a t e o f re c o v e r y w i l l have g r e a t e r f a i t h i n therapy, compared wit h the group w i t h a moderate r a t e o f r e c o v e r y , f o l l o w e d by the group wi t h the l e a s t r a t e o f r e c o v e r y , when f a i t h i n therapy i s measured by the s u b s c a l e F a i t h i n Therapy, i n the C l i e n t Readiness f o r Therapy Inventory (CRTI). 9. The p a t i e n t group e x h i b i t i n g a f u l l degree o f r e c o v e r y w i l l have s i g n i f i c a n t l y g r e a t e r optimism, compared w i t h the group w i t h a moderate degree of r e c o v e r y , f o l l o w e d 41 by the group w i t h the l e a s t degree o f r e c o v e r y , when optimism i s measured by the L i f e O r i e n t a t i o n T e s t (LOT). 10. The p a t i e n t group e x h i b i t i n g the g r e a t e s t r a t e o f re c o v e r y w i l l have s i g n i f i c a n t l y g r e a t e r optimism, compared w i t h the group wi t h a moderate r a t e o f reco v e r y , f o l l o w e d by the group w i t h the l e a s t r a t e o f reco v e r y , when optimism i s measured by the L i f e O r i e n t a t i o n T e s t (LOT). 11. The p a t i e n t group e x h i b i t i n g a f u l l degree o f r e c o v e r y w i l l have a s i g n i f i c a n t l y g r e a t e r w i l l t o l i v e , compared w i t h the group with a moderate degree o f recovery, f o l l o w e d by the group w i t h the l e a s t degree of r e c o v e r y , when the w i l l t o l i v e i s measured by a w i l l t o l i v e s c a l e (WLS) which has been developed by the author. 12. The p a t i e n t group e x h i b i t i n g the g r e a t e s t r a t e o f re c o v e r y w i l l have a s i g n i f i c a n t l y g r e a t e r w i l l t o l i v e , compared wi t h the group w i t h a moderate r a t e o f reco v e r y , f o l l o w e d by the group w i t h the l e a s t r a t e o f reco v e r y , when the w i l l t o l i v e i s measured by a w i l l t o l i v e s c a l e (WLS) which has been developed by the author. 42 Method S u b j e c t s and Procedures The respondents were males (n = 47) and females (n = 103) r a n g i n g from (20 t o 89) years o f age (M = 52.9; SD = 17.14). Responses were s o l i c i t e d from the p o p u l a t i o n o f back and neck p a t i e n t s o f S t . V i n c e n t ' s p h y s i o t h e r a p y o u t p a t i e n t area over the years 1986, 1987, and 1988 (N = 400) . The o u t p a t i e n t s r e c e i v e d an assessment on t h e i r f i r s t v i s i t t o the h o s p i t a l which c o n s i s t e d o f a d e t a i l e d h i s t o r y i n c l u d i n g t h e i r p a s t and p r e s e n t m e d i c a l s i t u a t i o n , the h i s t o r y of t h e i r p r e s e n t i n g problem and the treatments attempted t o date, as w e l l as a p h y s i c a l o r t h o p e d i c examination o f the problem a r e a . The frequency o f the treatments t h a t f o l l o w e d were then determined by the t h e r a p i s t , o r arranged between t h e t h e r a p i s t and the p a t i e n t . These may have been d a i l y , t h r e e times weekly, two times weekly, and o c c a s i o n a l l y once a week. The most f r e q u e n t l y used p a t t e r n o f therapy was t o s t a r t the p a t i e n t e i t h e r d a i l y , o r t h r e e times a week and then decrease the frequency o f treatment as r e q u i r e d . Some of these treatments r e q u i r e d one s e s s i o n o n l y , w h i l e o t h e r p a t i e n t s came i n f o r one treatment and f o r reasons known o n l y t o them d i d not r e t u r n f o r more. More g e n e r a l l y , p a t i e n t s r e c e i v e 15 t o 20 treatments over a 6 t o 8 week p e r i o d of time. The need f o r treatments v a r i e s due to the a c u i t y o r c h r o n i c i t y o f t h e problem as 43 w e l l as t h e i n d i v i d u a l ' s l i f e demands. Sometimes f o l l o w i n g a s e r i e s o f treatments the p a t i e n t w i l l a t a l a t e r time exper i e n c e a r e c u r r e n c e of the problem and be r e - r e f e r r e d by t h e i r d o c t o r f o r more th e r a p y . The e n t i r e s e t of o u t p a t i e n t p h y s i o t h e r a p y r e c o r d s from January 1986 t o December 1988 were s c r u t i n i z e d t o i d e n t i f y a l l those p a t i e n t s who had r e c e i v e d t h e r a p y f o r back and neck problems. An a l p h a b e t i c a l l i s t i n g o f these p a t i e n t s were made n o t i n g b i r t h d a t e , address, phone number, type o f problem (back o r neck o r b o t h ) , number of treatments r e c e i v e d , and the dates o f admission and d i s c h a r g e . The i n i t i a l c o n t a c t w i t h the former p a t i e n t s was by phone t o inform them t h a t a q u e s t i o n n a i r e would be coming and t o c o n f i r m t h e i r address. Of t h e 400 p a t i e n t s , 23 were d e l e t e d as no c o n t a c t c o u l d be made and 7 s t a t e d e x p l i c i t l y t h a t they d i d not wish t o p a r t i c i p a t e . The q u e s t i o n n a i r e package with a c o v e r i n g l e t t e r and i n s t r u c t i o n sheet was then sent t o the remaining 370 p a t i e n t s . T h i s m a i l i n g i n c l u d e d the independent and dependent v a r i a b l e s as d e s c r i b e d below as w e l l as the demographics and a n c i l l a r y q u e s t i o n s . A s e l f - a d d r e s s e d envelope w i t h r e t u r n postage was a l s o i n c l u d e d . Three weeks a f t e r t he m a i l i n g , those who had not r e t u r n e d t h e i r q u e s t i o n n a i r e s were co n t a c t e d t o check t h a t they had r e c e i v e d the package and asked i f they had any q u e s t i o n s . Seventeen i n d i v i d u a l s had not r e c e i v e d the package and were m a i l e d a second one. One hundred e i g h t y 44 q u e s t i o n n a i r e s were r e t u r n e d f o r a response r a t e o f 48.7%. Of these 30 c o u l d not be used, 13 d i d not have da t a f o r the r a t e of r e c o v e r y , 8 d i d not have da t a f o r t h e degree of r ecovery, and 9 were f i l l e d out i n c o r r e c t l y . In a d d i t i o n 15 were r e t u r n e d , 12 n o t i n g t h a t t h e p a r t i c i p a n t s were no l o n g e r a t t h a t address, and 3 by p a r t i c i p a n t s who d i d not wish t o p a r t i c i p a t e . In g e n e r a l o f the respondents, 17% were s i n g l e , 61% were married, 10% were d i v o r c e d or separated, and 13% were widowed (See T a b l e 3). There were 4 6% who work f u l l time, 6.6% who work p a r t time, 6% who were unemployed, 13.3% who were homemakers, and 27.3% who were r e t i r e d . E t h n i c background was c l a s s i f i e d i n t o f i v e b a s i c c a t e g o r i e s . Of the 150 p a r t i c i p a n t s 138 responded t o t h i s q u e s t i o n . Twenty-two p e r c e n t were Portuguese (1 Spanish respondent was i n c l u d e d i n t h i s grouping), 14% i d e n t i f i e d themselves as Canadian, 22% were from the U n i t e d Kingdom, 24% were European, and 18% were from v a r i o u s d i f f e r e n t p a r t s of the world. Independent and Dependent V a r i a b l e s The independent v a r i a b l e s i n t h i s study were: the degree of re c o v e r y , and the r a t e of r e c o v e r y . The f i r s t v a r i a b l e , the degree of recovery, was measured by p a t i e n t s e l f - a s s e s s m e n t . The p a t i e n t s were asked t o r a t e t h e i r degree of r e c o v e r y on a 5-point s c a l e w i t h the anchors; "no r e c o v e r y " (1), "moderate r e c o v e r y " (3), and "good r e c o v e r y " (5). The t h e r a p i s t ' s r a t i n g a t the time o f 45 Tabl e 3 D e s c r i p t i v e I nformation f o r Back and Neck P a t i e n t s (n = 150) % E t h n i c group: Portuguese 21.7% U n i t e d Kingdom 21.7% Canadian 14.6% European 23.8% Other 18.2% Work S t a t u s : F u l l time 46.3% P a r t t i m e / c a s u a l 6.7% Unemp1oyed 6.1% Homemaker 13.4% R e t i r e d 27.5% M a r i t a l S t a t u s : S i n g l e 16.6% M a r r i e d 60.7% Divorced/Seperated 10.0% Widowed 12.7% 46 d i s c h a r g e was r e c o r d e d i n order t o s u b s t a n t i a t e the p a t i e n t ' s s e l f - e v a l u a t i o n . The t h e r a p i s t s used t h e f o l l o w i n g d e s c r i p t o r s " f u l l r e c o v e r y " or " p a i n f r e e " , "good" or "marked improvement", "improved", "some improvement" o r " s l i g h t improvement", and "no r e c o v e r y " o r "no improvement". However, the p a t i e n t ' s s e l f - r a t i n g was used as the independent v a r i a b l e . The second independent v a r i a b l e , the r a t e o f r e c o v e r y was measured by the time span i n v o l v e d ( i . e . , the number of days between the f i r s t treatment and t h e l a s t a t S t . V i n c e n t ' s H o s p i t a l ) . These data were f u r t h e r q u a l i f i e d by d i v i d i n g i t by the number of treatments r e c e i v e d over t h i s p e r i o d of time. The dependent v a r i a b l e s i n v e s t i g a t e d were the b e l i e f s o f s e l f - e s t e e m , s e l f - c o n f i d e n c e , c o n t r o l , f a i t h i n therapy, optimism, and the w i l l t o l i v e . Instruments The Rosenberg Self-Esteem S c a l e (RSE) (Robinson & Shaver, 1973). The RSE measures the i n d i v i d u a l ' s s e l f - e s t e e m . I t i s a 10-item q u e s t i o n n a i r e w i t h responses based on a 4-point L i k e r t s c a l e . The c a t e g o r i e s range from (1) " s t r o n g l y agree", t o (4) " s t r o n g l y d i s a g r e e " . There are two methods f o r s c o r i n g the RSE, the i n t e r v a l s c a l e method was used, however the second method was a l s o computed (See Appendix C ) . The s c a l e range i s from 10 t o 40. The lower the s c o r e the g r e a t e r the s e l f - e s t e e m . The r e l i a b i l i t y c o e f f i c i e n t o f 47 .92 was o b t a i n e d through the use of the Guttman s c a l e and a t e s t - r e t e s t c o r r e l a t i o n over two weeks was found t o be .85 (n=28). C o r r e l a t i o n s were c a l c u l a t e d w i t h s e v e r a l s i m i l a r measures and ranged from .56 t o .83 and adequate d i s c r i m i n a n t v a l i d i t y was e s t a b l i s h e d as w e l l (Robinson & Shaver, 1973). The 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 , f o r t h i s study was c a l c u l a t e d a t Cronbach's a l p h a = .79. The I n t e r p e r s o n a l Dependency Inventory ( I D I ) . The IDI was developed by H i r s c h f e l d e t a l . (1977) and i n c l u d e s the s u b s c a l e s o f emotional r e l i a n c e on another person, l a c k of s o c i a l s e l f - c o n f i d e n c e , and a s s e r t i o n o f autonomy. For the purposes of t h i s study o n l y the s u b s c a l e l a c k of s o c i a l s e l f - c o n f i d e n c e was used. H i r s c h f e l d e t a l . (1977) note t h a t the l a c k of s e l f - c o n f i d e n c e s u b s c a l e r e f l e c t s the " n o t i o n s of attachment and dependency i n n e a r l y equal p o r t i o n s " (p. 617). T h i s s u b s c a l e c o n t a i n s 15 items whose answers are based on a 4 - p o i n t s c a l e . The c a t e g o r i e s of t h i s s c a l e range from (1) "very c h a r a c t e r i s t i c o f me" t o (4) "not c h a r a c t e r i s t i c o f me". The s c a l e range i s from 15 t o 60. The lower th e s c o r e the g r e a t e r the l a c k of s o c i a l s e l f - c o n f i d e n c e . For the l a c k of s o c i a l c o n f i d e n c e s u b s c a l e the c o r r e c t e d s p l i t h a l f r e l i a b i l i t y i s .78 and s t r o n g evidence i s p r o v i d e d f o r c r o s s sample c o n s i s t e n c y of the f a c t o r s t r u c t u r e as w e l l as c r o s s v a l i d a t i o n of the f a c t o r t o s c a l e r e l a t i o n s h i p i n d i c a t i n g t h a t the composition o f the s c a l e i s s t a b l e ( H i r s c h f e l d e t a l . , 1977). The r e l i a b i l i t y , 48 i n t e r n a l c o n s i s t e n c y , f o r t h i s study was c a l c u l a t e d a t Cronbach's alpha = .81. The H e a l t h R e l a t e d Hardiness S c a l e (HRHS). The HRHS developed by P o l l o c k (1985, 1988, 1989) c o n t a i n s t h r e e s u b s c a l e s which measure c o n t r o l , commitment, and c h a l l e n g e F o r the purposes o f t h i s study o n l y the s u b s c a l e o f " c o n t r o l " was used. A c c o r d i n g t o P o l l o c k (1987) i n d i v i d u a l s h i g h i n c o n t r o l " b e l i e v e and a c t as i f they can i n f l u e n c e the events they e x p e r i e n c e " . T h i s s c a l e c o n t a i n s 14 items on a 6-point L i k e r t s c a l e . The c a t e g o r i e s range from (1) " s t r o n g l y d i s a g r e e " , t o (6) " s t r o n g l y agree". The s c a l e range i s from 14 t o 84. The lower the s c o r e the h i g h e r the c o n t r o l . P o l l o c k determined the i n t e r n a l c o n s i s t e n c y u s i n g Cronbach's alpha, the alpha f o r " c o n t r o l " was .82. Content v a l i d i t y f o r the s c a l e (37 items loaded on the t h r e e f a c t o r s ) was supported by a p r i n c i p a l component f a c t o r a n a l y s i s . The 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 , f o r t h i s study was c a l c u l a t e d a t Cronbach's alpha = .73. The C l i e n t Readiness f o r Therapy Inv e n t o r y (CRTI). The CRTI i s an instrument designed by B e r i s h (1987) t o measure the c l i e n t ' s r e a d i n e s s f o r therapy i n t h e p s y c h o l o g i c a l s e t t i n g . T h i s instrument c o n s i d e r s a c l i e n t ' s m o t i v a t i o n , r e s p o n s i b i l i t y , e x p e c t a t i o n s , and hope as important determinants. The s u b s c a l e " F a i t h i n Therapy" was a p p l i c a b l e t o the p h y s i o t h e r a p y s e t t i n g . The s u b s c a l e c o n s i s t s of a 24-item q u e s t i o n n a i r e used w i t h 49 a 7-point L i k e r t s c a l e , the anchors were (1) " s t r o n g l y agree", t o (7) " s t r o n g l y d i s a g r e e " Only t h e s t r o n g e s t f i v e items were used as these items b e s t measure the concept t o be t e s t e d , a l s o f o r pragmatic reasons t h e r e i s a need t o keep t h e number of q u e s t i o n s s h o r t . B e r i s h i d e n t i f i e d t h i s s u b s c a l e as r e f l e c t i n g a " f e e l i n g o r a t t i t u d e o f optimism, t r u s t , and hope on t h e p a r t o f the person i n r e g a r d t o the t h e r a p e u t i c e n t e r p r i s e " (p. 73). The range of the s c a l e i s 5 t o 35. The lower the s c o r e the g r e a t e r the f a i t h i n therapy. The Cronbach's a l p h a f o r the 24 items on t h i s s u b s c a l e i s .85. The f a c t o r l o a d i n g on the f i v e i n d i v i d u a l items ranges from .74 t o .51 with one n e g a t i v e l y loaded s c o r e of -.55. The 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 , f o r t h i s study was c a l c u l a t e d a t Cronbach's alpha = .55. The L i f e O r i e n t a t i o n T e s t (LOT). The LOT i s a t o o l designed by S c h e i e r and Carver (1985) t o measure optimism. S c h e i e r and Carver (1985) and S c h e i e r , Weintraub, and Carver (1986) d e s c r i b e optimism as the o u t l o o k p e o p l e have, the d i s p o s i t i o n a l t r a i t t h a t i s t h e i r approach t o the world. I t i s the "expectancy judgment" (1986, p. 1257) t h a t t h i n g s w i l l go t h e i r way and t h a t good not bad w i l l happen t o them. T h i s instrument examines an i n d i v i d u a l ' s l i f e approach, whereas B e r i s h ' s s u b s c a l e " F a i t h i n Therapy" examines the i n d i v i d u a l s approach s p e c i f i c t o therapy. T h i s t o o l c o n s i s t s of a 12-item q u e s t i o n n a i r e used w i t h a 5-item L i k e r t s c a l e . The 50 c a t e g o r i e s of t h i s s c a l e range from: (4) " s t r o n g l y agree", t o (0) " s t r o n g l y d i s a g r e e " . Four f i l l e r items were omitted thus t h e range of the s c a l e i s from 0 t o 32. The g r e a t e r the s c o r e the g r e a t e r the optimism. S c h e i e r and Carver (1985) demonstrated i n t e r n a l c o n s i s t e n c y w i t h a Cronbach's alpha o f .76, and a t e s t - r e t e s t r e l i a b i l i t y o f .79 f o r the LOT. As w e l l they e s t a b l i s h e d adequate convergent and d i s c r i m i n a n t v a l i d i t y through e v a l u a t i n g t h e LOT a g a i n s t 9 o t h e r s c a l e s . The 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 , f o r t h i s study was c a l c u l a t e d a t Cronbach's alpha = .79. The W i l l To L i v e S c a l e . An examination o f the l i t e r a t u r e found no a v a i l a b l e o p e r a t i o n a l i z a t i o n o f t h i s c o n s t r u c t t h e r e f o r e the author developed a s c a l e and p i l o t t e s t e d i t on e x p e r t s as w e l l as p a t i e n t s t y p i c a l o f those p a r t i c i p a t i n g i n t h i s study. I t i s a 7-item q u e s t i o n n a i r e developed t o examine an i n d i v i d u a l s d e s i r e and w i l l t o l i v e . Response c a t e g o r i e s range from (1) " s t r o n g l y agree" t o (4) " s t r o n g l y d i s a g r e e " . The range o f the s c a l e i s from 7 t o 28. The lower th e s c o r e the g r e a t e r the w i l l t o l i v e . The 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 , f o r t h i s study was c a l c u l a t e d a t Cronbach's alpha = .71. Demographic and A n c i l l a r y Measures. I n f o r m a t i o n on demographics and some a n c i l l a r y q u e s t i o n s i n c l u d e d : sex, age, m a r i t a l and work s t a t u s , e t h n i c background, type o f i n j u r y (back o r neck), any a d d i t i o n a l t h e r a p y r e c e i v e d 51 f o l l o w i n g d i s c h a r g e from St . V i n c e n t ' s H o s p i t a l , adherence t o a home e x e r c i s e program, emotional support, any major n e g a t i v e l i f e change experienced over the l a s t f i v e y e a r s , s e l f - h e a l t h assessment, focus of a t t e n t i o n (on b e i n g i n j u r e d or b e i n g h e a l e d ) , and maintenance o f p h y s i c a l h e a l t h and f i t n e s s . Data A n a l y s i s The hypotheses were t e s t e d by two m u l t i v a r i a t e a n a l y s i s of v a r i a n c e s (one-way) t o t e s t between group d i f f e r e n c e s on h e a l t h b e l i e f s ( s e l f - e s t e e m , s e l f - c o n f i d e n c e , c o n t r o l , f a i t h i n therapy, optimism, and w i l l t o l i v e ) . S i g n i f i c a n t o v e r a l l MANOVA was f o l l o w e d by c a l c u l a t i o n of u n i v a r i a t e F t e s t s and f o l l o w u p S c h e f f e p o s t hoc comparisons ( c i t e d i n Spatz & Johnston, 1976). An a c c e p t a b l e s i g n i f i c a n c e l e v e l of p_ <.05 was used. The f i r s t a n a l y s i s was conducted on the p a r t i c i p a n t s c l a s s i f i e d as good, moderate and poor degree o f r e c o v e r y . The second, on the g r e a t e s t , moderate, and s l o w e s t r a t e of r e c o v e r y . D e s c r i p t i v e s t a t i s t i c s (mean, s t a n d a r d d e v i a t i o n s and c o r r e l a t i o n s ) were a l s o c a l c u l a t e d . 52 R e s u l t s D e s c r i p t i v e Data The respondents were males (n = 47) and females (n = 103) r a n g i n g from (20 t o 89) years o f age (M = 52.9; SD = 17.1). T h i s sample of respondents c o n t a i n e d 58.7% w i t h a d i a g n o s i s o f back problems, 28.7% w i t h a d i a g n o s i s o f neck problems, and 12.7% w i t h both back and neck problems. The average number o f p h y s i o t h e r a p y treatments r e c e i v e d a t S t . V i n c e n t ' s H o s p i t a l (SVH) was 15.3 (SD = 14.7) and ranged from 1 t o 93. These treatments o c c u r r e d over v a r y i n g p e r i o d s o f time ranging from 1 t o 352 days (M = 57.0; SD = 56.2 d a y s ) . Recovery Degree. The degree o f r e c o v e r y was d i v i d e d i n t o t h r e e c a t e g o r i e s i n order t o a n a l y z e t h e d a t a . The s c a l e s were c o l l a p s e d , anchors one and two becoming one, and b e i n g named the "poor r e c o v e r y " group, anchors t h r e e and f o u r becoming two, and being c a l l e d the "moderate r e c o v e r y " group, and anchor f i v e becoming t h r e e , and s t a y i n g as the "good r e c o v e r y " group. The "poor r e c o v e r y " group c o n t a i n e d 22.0% o f respondents, t h e "moderate r e c o v e r y " group c o n t a i n e d 47.3%, and t h e "good r e c o v e r y " group c o n t a i n e d 30.6%. The mean age was 49.5 (SD =17.49) i n the "poor r e c o v e r y " group, a mean o f 50.5 (SD = 17.79) on the "moderate r e c o v e r y " group, and a mean of 54.2 (SD = 18.45) i n the "good r e c o v e r y " group. The sexes were d i s t r i b u t e d w i t h 17% o f the males and 24.3% o f the females i n the "poor re c o v e r y " group; 48.9% o f the 53 males and 46.6% of the females i n the "moderate r e c o v e r y " group; and 34.0% of the males and 29.1% o f the females i n the "good r e c o v e r y " group. On examining the treatment c h a r a c t e r i s t i c s i n Tab l e 4, of the t h r e e r e c o v e r y degree groups "moderate r e c o v e r y " had c o n s i s t e n t l y h i g h e r means and standar d d e v i a t i o n s when compared t o the o t h e r groups f o r the number o f SVH treatments r e c e i v e d and the t o t a l number o f days over which the SVH treatments o c c u r r e d . The i n t e n s i t y , the number o f days over which the SVH treatments o c c u r r e d d i v i d e d by the number of SVH treatments had a lower mean v a l u e f o r the "good r e c o v e r y " group i n d i c a t i n g t h e y had r e c e i v e d more treatments i n a s h o r t e r p e r i o d o f time than t h e "poor r e c o v e r y " group. A p r e l i m i n a r y a n a l y s i s was conducted t o determine whether the "poor r e c o v e r y " group and the "good r e c o v e r y " group d i f f e r e d i n treatment i n t e n s i t y , t - t e s t s were computed; the i n t e n s i t y o f treatment was s i g n i f i c a n t , t(77) = 2.62, p. <.05; i n d i c a t i n g t h a t the "good re c o v e r y " group had more treatments per number of days than the "poor r e c o v e r y " group. The number of treatments, and the number o f days over which the treatments o c c u r r e d a t SVH were not s i g n i f i c a n t when the "good r e c o v e r y " and the "poor r e c o v e r y " groups were analyzed. Examining the a n c i l l a r y c h a r a c t e r i s t i c s i n T a b l e 5, f o r the degree o f recovery, 60.9% of the "good r e c o v e r y " 54 Ta b l e 4 Means and Standard D e v i a t i o n s on Treatment V a r i a b l e s f o r  P e r c e i v e d Degree of Recovery Groups PR group MR group GR group (n = 33) (n = 71) (n = 46) M SD M SD M SD Number of treatments a t SVH 13.5(13.1) 16.8(15.9) 14.4(13.7) Number of treatments a t SVH & elsewhere 20.9(21.7) 23.5(23.5) 16.2(16.2) T o t a l days of SVH Treatments 53.1(44.4) 62.1(60.4) 52.1(57.4) T o t a l days between a l l treatments 155.2(263.9) 137.0(200.3) 103.4(210.6) I n t e n s i t y o f t r e a t -ment a t SVH 4.2(1.9) 3.7(1.4) 3.2(1.3) I n t e n s i t y o f t o t a l treatments 8.8(10.5) 10.6(29.7) 12.4(49.6) Note. PR = poor r e c o v e r y ; MR = moderate r e c o v e r y ; GR = good r e c o v e r y ; and SVH = S t . V i n c e n t ' s H o s p i t a l ; I n t e n s i t y = number of days over which treatment o c c u r r e d d i v i d e d by the number of treatments. 55 T a b l e 5 C h a r a c t e r i s t i c s o f the Poor Degree of Recovery. Moderate Degree  of Recovery, and Good Degree of Recovery Groups PR group MR group GR group (n = 33) (n = 71) (n = 46) % % % P r e s c r i b e d home e x e r c i s e s : Yes 39.4% 67.6% 48.9% No 60.6% 32.4% 51.1% Complied w i t h home e x e r c i s e s • 1. not a t a l l 15.4% 2.1% 13.6% 2. — % 6.3% 9.1% 3. moderately 46.1% 56.3% 54.6% 4. 23 .1% 20.8% 13.6% 5. v e r y r e g u l a r l y 15.4% 14.5% 9.1% Emotional support: 1. no support — % 4.2% 4.3% 2. 15.2% 7.0% 4.3% 3. moderate support 45.4% 21.2% 8.8% 4. 12.1% 26.8% 21.7% 5. g r e a t support 27.3% 40.8% 60.9% Negative L i f e Impact: 1. somewhat - 11.1% 20.5% 57.1! 2. 11.1% 15.9% 9.5% 3. moderately - 33.4% 38.6% 4.9% M(SD) 1.4(0.5) 3.3(1.0) 4.0(1.1) 2.8(1.4) 56 4. 5. extremely -S e l f H e a l t h A p p r a i s a l : 1. not v e r y h e a l t h y 2. 3. moderate h e a l t h 4. 5. v e r y h e a l t h y Focus of t h i n k i n g : 1. b e i n g i n j u r e d 2. 3. somewhat improved 4. 5. b e i n g h e a l e d Maintenance of f i t n e s s : 1. not a t a l l 2. 3. moderate f i t n e s s 4. 5. f u l l f i t n e s s 33.3% 13.6% 9.5% 11.1% 11.4% 19.0% 21.2% 8.6% — % 9.1% 4.3% 2.2% 45.4% 37.1% 30.4% 9.1% 25.7% 26.1% 15.2% 24.3% 41.3% 15.6% 8.7% 2.2% 6.3% 4.3% 4.3% 37.5% 26.1% 6.6% 15.6% 29.0% 13.0% 25.0% 31.9% 73 .9% 21.2% 1.4% 6.5% 15.2% 8.6% 8.7% 39.3% 65.7% 58.7% 18.2% 18.6% 15.2% 6.1% 5.7% 10.9% 3.9(1.3) 3.1(0.9) Note. PR = poor degree of rec o v e r y ; MR = moderate degree of r e c o v e r y ; GR = good degree of recov e r y . 57 group had " g r e a t emotional support" w h i l e o n l y 27.3% of t h e "poor r e c o v e r y " group r e p o r t e d they had " g r e a t support". In e v a l u a t i n g t h e i r own h e a l t h ( s e l f - h e a l t h a p p r a i s a l ) , when compared t o o t h e r s t h e i r age, 41.3% i n the "good r e c o v e r y " group r e p o r t e d they were "very h e a l t h y " w h i l e o n l y 15.2% i n the "poor r e c o v e r y " group r e p o r t e d they were "very h e a l t h y " . When asked where t h e i r f o cus o f t h i n k i n g was i n r e g a r d t o t h e i r i n j u r y , 73.9% i n the "good r e c o v e r y " group noted i t was on "being healed", w h i l e 25.0% i n the "poor r e c o v e r y " group r e p o r t e d i t was on "being h e a l e d " . t - t e s t s were computed f o r the above v a r i a b l e s between the "poor r e c o v e r y " and "good r e c o v e r y " groups, s i g n i f i c a n c e was determined f o r support, t(77) = 3.20, p_ < .002; f o r s e l f - r a t i n g o f h e a l t h , t(77) = 4.80, p_ <.001; and f o r focus of t h i n k i n g , t(76) = 4.75, jo <.001. T h e r e f o r e , those i n d i v i d u a l s who r a t e d themselves as having g r e a t e r emotional support, as h a v i n g b e t t e r h e a l t h , and p l a c i n g the focus of t h e i r a t t e n t i o n on b e i n g h e a l e d e x p e r i e n c e d a g r e a t e r degree of r e c o v e r y . Recovery Rate. The number of days between th e f i r s t treatment and the l a s t a t SVH as w e l l as any a d d i t i o n a l p h y s i o t h e r a p y , c h i r o p r a c t i c , n a t u r o p a t h i c , accupuncture or o t h e r treatments the p a t i e n t r e c e i v e d f o r t h e i r neck or back f o l l o w i n g t h e i r l a s t SVH treatment, was c a l c u l a t e d as the independent v a r i a b l e r e c o v e r y r a t e . However a d d i t i o n a l therapy was recorded by o n l y a t o t a l o f 36 respondents. A few o f them t r i e d s e v e r a l d i f f e r e n t types 58 o f treatment, 20 had a d d i t i o n a l p h y s i o t h e r a p y , 17 had c h i r o p r a c t i c treatments, 2 had accupuncture, and 6 t r i e d a v a r i e t y o f d i f f e r e n t treatments. As thes e d a t a r e s u l t e d i n m i s s i n g i n f o r m a t i o n which p r e c l u d e d a n a l y s i s ( i . e . , respondents were o f t e n v e r y vague, "many" treatments over s e v e r a l years") i t was i n a p p r o p r i a t e t o i n c l u d e t h e s e d a t a i n the a n a l y s i s . T h e r e f o r e the S t . V i n c e n t ' s H o s p i t a l treatment time was examined i n p l a c e o f the t o t a l treatment time. The r a t e o f re c o v e r y was d i v i d e d i n t o t h r e e groups t o ana l y z e the data, 34.0% of respondents were i n the "slow r a t e o f r e c o v e r y " group, 32.7% i n the "moderate r a t e o f re c o v e r y " group, and 33.3% i n the "high r a t e o f r e c o v e r y " group. T h i s v a r i a b l e was measured by the number o f days and the d i v i s i o n between the f i r s t and second group o c c u r r e d between the 22nd and 23rd days, and the d i v i s i o n between the second and t h i r d group o c c u r r e d between the 61st and 62nd days. The mean age was 55.9 i n the "slow r a t e o f r e c o v e r y " group, 53.2 i n the "moderate r a t e o f r e c o v e r y " group, and 48.9 i n the "high r a t e o f re c o v e r y group". The sexes were d i s t r i b u t e d so t h a t 8.0% of the males and 26.0% o f the females were i n the "slow r a t e o f r e c o v e r y " group, 13.3% o f the males and 19.3% of the females were i n the "moderate r a t e o f re c o v e r y " group, and 10.0% o f the males and 23.3% of the females were i n the "high r a t e o f re c o v e r y " group. 59 Reviewing the c h a r a c t e r i s t i c s o f the a n c i l l a r y data w i t h the t h r e e r a t e of recovery groups i n T a b l e 6 showed no major d i f f e r e n c e s i n the data d i s t r i b u t i o n . C o r r e l a t i o n matrix. A c o r r e l a t i o n m a t r i x f o r a l l the dependent measures, treatment measures, and a n c i l l a r y d ata were used t o examine the r e l a t i o n s h i p s among thes e v a r i a b l e s (See Appendix D). G r e a t e r degree of recover y showed moderate t o low c o r r e l a t i o n s w i t h g r e a t e r f a i t h i n therapy ( r = -.44), g r e a t e r optimism ( r = .29), b e t t e r h e a l t h ( r = .36), and the respondents focus of a t t e n t i o n on b e i n g h e a l e d ( r = .37) . Low t o moderate c o r r e l a t i o n s were found among the dependent v a r i a b l e s , the h i g h e s t b e i n g g r e a t e r optimism r e l a t i n g t o g r e a t e r s e l f - e s t e e m , ( r = -.52). No c o r r e l a t i o n s were noted between s e l f - e s t e e m and l o c u s o f c o n t r o l , between s e l f - c o n f i d e n c e and f a i t h i n therapy, and between f a i t h i n therapy and w i l l t o l i v e . The a n c i l l a r y data have s i g n i f i c a n t c o r r e l a t i o n s w i t h the dependent measures as w e l l . G r e a t e r s e l f - h e a l t h a p p r a i s a l has a moderate t o low c o r r e l a t i o n w i t h g r e a t e r optimism ( r = .35), g r e a t e r f a i t h i n the r a p y ( r = .27), and g r e a t e r s e l f - e s t e e m , and h i g h l o c u s o f c o n t r o l ( r = .28). The focus o f a t t e n t i o n on b e i n g h e a l e d has a low c o r r e l a t i o n w i t h g r e a t e r f a i t h i n therapy ( r = .31), w h i l e g r e a t e r p h y s i c a l f i t n e s s has a low c o r r e l a t i o n w i t h 60 T a b l e 6 C h a r a c t e r i s t i c s o f the Slow Rate o f Recovery, Moderate Rate o f  Recovery, and High Rate o f Recovery Groups SR group MR group HR group (n = 51) (n = 49) (n = 50) % % % P r e s c r i b e d home e x e r c i s e s : Yes 64.7% 64. 6% 39. 0% No 35.3% 35.4% 61. 0% Complied w i t h home e x e r c i s e s 1. not a t a l l 6.1% 6.5% 10. 5% 2. 3.0% 9.7% 5. 3% 3. moderately 54.5% 48. 3% 63. 1% 4. 18.2% 22.6% 15. 8% 5. v e r y r e g u l a r l y 18.2% 12.9% 5. 3% Emotional support: 1. no support 7.8% 2.0% — -% 2. 7.8% 12.2% 4 . 0 3. moderate support 21.7% 26.6% 20. 0% 4. 23.5% 18.4% 24. 0% 5. g r e a t support 39.2% 40.8% 52 . 0% Negative L i f e Impact: 1. somewhat - 32.0% 25.0% 26. 5% 2. 8.0% 12.5% 17. 6% 3. moderately - 36.0% 20.8% 29. 4% M(SD) 1.4(0.5) 3.3(1.0) 4.0(1.1) 2.8(1.4) 61 4. 12. 0% 29. 2% 11. 8% 5. extremely - 12. 0% 12. 5% 14. 7% S e l f H e a l t h A p p r a i s a l : 1. not v e r y h e a l t h y 6. 0% 8. 2% 12. 0% 2. 2. 0% 8. 2% 4. 0% 3 . moderate h e a l t h 48. 0% 34. 6% 28. 0% 4. 22. 0% 16. 3% 28. 0% 5. v e r y h e a l t h y 22. 0% 32. 7% 28. 0% Focus of t h i n k i n g : 1. being i n j u r e d 12. 2% 6. 1% 6. 1% 2. 4. 1% 4. 1% 6. 1% 3. somewhat improved 26. 5% 20. 4% 20. 0% 4. 18. 4% 26. 5% 18. 4% 5. being h e a l e d 38. 8% 42 . 9% 49. 0% Maintenance of f i t n e s s : 1. not a t a l l 4. 0% 12. 2% 6. 0% 2. 14. 0% 4. 1% 12. 0% 3. moderate f i t n e s s 64. 0% 57. 1% 52 . 0% 4. 12. 0% 18. 4% 22 . 0% 5. f u l l f i t n e s s 6. 0% 8. 2% 8. 0% 3.6(1.2) 3.9(1.3) 3.1(0.9) Note. SR = slow r a t e of recovery; MR = moderate r a t e o f r e c o v e r y ; HR = h i g h r a t e of r e c o v e r y . 62 g r e a t e r w i l l t o l i v e (r = .27). A l s o g r e a t e r emotional support by important people as above w i t h g r e a t e r optimism (r = .27). Some h i g h c o r r e l a t i o n s were noted among the d i f f e r e n t treatment parameters and these support t h e p a t t e r n o f therapy as d e s c r i b e d ( i . e . , between the number o f days over which the treatments o c c u r r e d and the number o f treatments, r = .95). Hypotheses T e s t i n g Degree of Recovery. The degree of r e c o v e r y t e s t s hypotheses 1, 3, 5, 7, 9, and 11. The s e l f - e s t e e m , s e l f - c o n f i d e n c e , l o c u s of c o n t r o l , f a i t h i n therapy, optimism, and w i l l t o l i v e v a r i a b l e s were examined by computing a one-way MANOVA. Means and s t a n d a r d d e v i a t i o n s f o r the dependent v a r i a b l e s are found i n T a b l e 7. D i f f e r e n c e s were examined between the "poor r e c o v e r y " , t h e "moderate r e c o v e r y " and the "good r e c o v e r y " groups. The m u l t i v a r i a t e group e f f e c t was s i g n i f i c a n t , F(12,284) = 3.89, p_ <.001. An examination of the u n i v a r i a t e F t e s t s r e v e a l e d s i g n i f i c a n t group d i f f e r e n c e s f o r s e l f - e s t e e m , F (2,147) = 3.16, p_ <.05; f a i t h i n therapy, F (2,147) = 18.13, p_ <.001; and optimism, F (2,147) = 7.24, p_ <.001. Lack of s e l f - c o n f i d e n c e , l o c u s of c o n t r o l , and w i l l t o l i v e s c a l e s were not s i g n i f i c a n t , F < 1.0 (See T a b l e 8 ) . Followup S c h e f f e p o s t hoc comparisons between the groups o f "poor rec o v e r y " , "moderate r e c o v e r y " , and "good 63 Tab l e 7 Means and Standard D e v i a t i o n s f o r Dependent Measures f o r  the Degree of Recovery Groups. PR group MR group GR group (n = 33) (n = 71) (n = 46) V a r i a b l e s M SD M SD M SD s e l f esteem 18. 0(4. 7) 16 .4(3.9) 15 .7(4. 0) l a c k o f s o c i a l s e l f c o n f i d e n c e 32. 0(8. 3) 28 .8 (7.2) 29 .5(6. 9) l o c u s o f c o n t r o l 45. 1(8. 9) 42 .6(10.1) 40 .2 (12 .0) f a i t h i n therapy 17. 5(3. 2) 14 .5(4.1) 12 .2 (4. 0) optimism 18. 1(6. 6) 21 .0(4.8) 22 .5(4. 4) w i l l t o l i v e 15. 5(3. 5) 14 .4(3.0) 14 .4(3. 7) Note. PR = poor r e c o v e r y ; MR = moderate r e c o v e r y ; GR = good r e c o v e r y . Low sc o r e s on s e l f - e s t e e m , l a c k o f s o c i a l s e l f - c o n f i d e n c e , l o c u s o f c o n t r o l , f a i t h i n therapy, optimism, and w i l l t o l i v e i n d i c a t e ; more s e l f - e s t e e m , more s e l f - c o n f i d e n c e , more i n t e r n a l c o n t r o l , more f a i t h i n therapy, l e s s optimism, and a g r e a t e r w i l l t o l i v e . 64 Tabl e 8 Summary of MANOVA and followup ANOVAS f o r the Degree o f  Recovery Groups (n - 150) . Source SS d f F p_< Between Groups m u l t i v a r i a t e 12,284 3.65 .001 U n i v a r i a t e s e l f - e s t e e m 106. 07 2, 147 3 . 16 . 045 s e l f - c o n f i d e n c e 232 . 61 2, 147 2. 14 . 121 l o c u s o f c o n t r o l 455. 71 2, 147 2. 06 . 131 f a i t h i n therapy 554. 51 2, 147 18. 13 .001 optimism 378. 62 2, 147 7. 24 .001 w i l l t o l i v e 28. 61 2, 147 1. 31 .273 65 r e c o v e r y " were conducted on s i g n i f i c a n t u n i v a r i a t e F t e s t s f o r s e l f - e s t e e m , f a i t h i n therapy, and optimism, i n o r d e r t o determine group d i f f e r e n c e s (See Tab l e 9 ) . F o r s e l f - e s t e e m , the "poor r e c o v e r y " group d i f f e r e d s i g n i f i c a n t l y from the "good r e c o v e r y " group, p_ <.05. An examination o f the means i n d i c a t e s t h a t t h e "poor r e c o v e r y " group had l e s s s e l f - e s t e e m than t h e "good r e c o v e r y " group. The "moderate r e c o v e r y " group d i d not d i f f e r s i g n i f i c a n t l y from the "poor r e c o v e r y " o r "good r e c o v e r y " groups. For f a i t h i n therapy, the "poor r e c o v e r y " and "good r e c o v e r y " groups d i f f e r e d s i g n i f i c a n t l y , p_ <.05, the "poor r e c o v e r y " and "moderate r e c o v e r y " groups d i f f e r e d , p. <.05; and the "moderate r e c o v e r y " and "good r e c o v e r y " groups d i f f e r e d , p_ <.05. From an examination o f t h e means i t appears the "poor r e c o v e r y " group had p o o r e r f a i t h i n therapy than the "moderate re c o v e r y " group, and the "moderate r e c o v e r y " group poorer f a i t h i n t h e r a p y than t h e "good r e c o v e r y " group. With r e g a r d t o optimism, the "moderate r e c o v e r y " and "good r e c o v e r y " groups d i f f e r e d s i g n i f i c a n t l y , p_ <.05, the "poor r e c o v e r y " and "moderate r e c o v e r y " group d i f f e r e d s i g n i f i c a n t l y , p_ <.05, but the "moderate r e c o v e r y " and "good r e c o v e r y " group d i d not. An examination o f the means i n d i c a t e s t h a t the "poor r e c o v e r y " group showed l e s s optimism than the "moderate re c o v e r y " and "good r e c o v e r y " groups. 66 T a b l e 9 C r i t i c a l V alues ( S c h e f f e Tests) of S i g n i f i c a n c e f o r the  Dependent Measures Between Groups f o r the Degree o f  Recovery PR & GR PR & MR MR .& GR group group group s e l f esteem 6.21* 3.43 0.91 f a i t h i n therapy 36.39* 13.97* 9.66* optimism 14.36* 7.00* 2.36 Note. PR = poor r e c o v e r y group; MR = moderate r e c o v e r y group; GR = good r e c o v e r y group; (*) denotes p a i r s of groups s i g n i f i c a n t l y d i f f e r e n t a t the p_ <.05 l e v e l . 67 T h e r e f o r e , h y p o t h e s i s number 1 was p a r t i a l l y supported as the d i f f e r e n c e s between one o f t h e groups was s i g n i f i c a n t . Hypotheses numbers 3, and 5, were not supported. Hypothesis number 7 was supported by t h i s study as the d i f f e r e n c e s between a l l t h r e e o f t h e groups were s i g n i f i c a n t . While h y p o t h e s i s number 9 was p a r t i a l l y supported as two out of the t h r e e groups d i f f e r s i g n i f i c a n t l y , and h y p o t h e s i s number 11 was not supported. Rate of Recovery. Hypotheses 2, 4, 6, 8, 10, and 12, were t e s t e d u s i n g a MANOVA on the r a t e o f r e c o v e r y . T h i s r e v e a l e d no s i g n i f i c a n t d i f f e r e n c e s among the slow, moderate, and h i g h r a t e s of recov e r y groups (see T a b l e 10 f o r means and standa r d d e v i a t i o n s ) , when examined w i t h the dependent measures of s e l f - e s t e e m , s e l f - c o n f i d e n c e , l o c u s of c o n t r o l , f a i t h i n therapy, optimism, and w i l l t o l i v e . The m u l t i v a r i a t e group e f f e c t was not s i g n i f i c a n t , F < 1.0. 68 T a b l e 10 Means and Standard D e v i a t i o n s of Dependent Measures f o r  Rate of Recovery SR group MR group HR group (n = 51) (n = 49) (n = 50) V a r i a b l e s M SD M SD M SD s e l f esteem 17. 1(4.1) 15 .9(4.4) 16. 6(4.0) Lack of s o c i a l 30. 0(7.2) 29 .5(7.4) 29. 8(7.2) s e l f - c o n f i d e n c e l o c u s of c o n t r o l 43 . 2 (10.1) 41 .4(10.3) 42. 6(11.5) f a i t h i n therapy 14. 8(4.5) 14 .6(4.3) 14. 0(4.3) optimism 20. 7(5.7) 20 .6(5.3) 21. 2(5.1) w i l l t o l i v e 14. 9(2.8) 14 .2(3.5) 14. 8(3.6) Note. SR = slow r a t e of recovery; MR = moderate r a t e r e c o v e r y ; HR = h i g h r a t e of recov e r y . 69 D i s c u s s i o n The hypotheses t h a t the p a t i e n t group e x h i b i t i n g a "good degree o f r e c o v e r y " would have s i g n i f i c a n t l y s t r o n g e r s e l f - e s t e e m , f a i t h i n therapy, and optimism compared w i t h the groups wi t h moderate r e c o v e r y , f o l l o w e d by the groups w i t h no r e c o v e r y was supported by t h i s study. The f i n d i n g s suggest t h a t s e l f - c o n f i d e n c e , l o c u s o f c o n t r o l , and w i l l t o l i v e were not s i g n i f i c a n t l y r e l a t e d t o the degree of recovery, nor were any of the b e l i e f s s i g n i f i c a n t l y r e l a t e d t o the r a t e o f r e c o v e r y . With r e g a r d t o degree of r e c o v e r y ( s e l f - r a t i n g of r e c o v e r y ) , t h e r e were s i g n i f i c a n t d i f f e r e n c e s among a l l t h r e e groups f o r f a i t h i n therapy, between the "poor r e c o v e r y " and "good r e c o v e r y " groups as w e l l as between the "poor r e c o v e r y " and "moderate r e c o v e r y " groups f o r optimism, and between the "poor r e c o v e r y " and "good r e c o v e r y " group f o r s e l f - e s t e e m . The f a i t h i n therapy b e l i e f i n d i c a t e d t h a t t h e s t r o n g e r the b e l i e f s were t h a t the t h e r a p i s t would be a b l e h e l p them and t h a t they would have a p o s i t i v e outcome the g r e a t e r was the degree of rec o v e r y a c h i e v e d . T h i s supports Frank's (1961) d e s c r i p t i o n of t h e p l a c e b o e f f e c t i n t h a t f a i t h i n the t h e r a p i s t i s a c o r e element, and Lundh's (1987) c o n t e n t i o n t h a t the p a t i e n t s b e l i e f s i n the e f f i c a c y of therapy are tantamount. The optimism v a r i a b l e i n d i c a t e d t h a t the more o p t i m i s t i c an i n d i v i d u a l was the g r e a t e r t h e degree o f 70 r e c o v e r y a t t a i n e d . T h i s supports Martus' (1987) phenomenological r e s u l t s t h a t a c t i v e optimism i s e s s e n t i a l i n the h e a l i n g p r o c e s s . The s e l f - e s t e e m v a r i a b l e i n d i c a t e d t h a t the s t r o n g e r t h e s e b e l i e f s the b e t t e r the r e c o v e r y a t t a i n e d . T h i s f i n d i n g concurs w i t h t h a t of Martus (1985) where he d e s c r i b e d how the p r o c e s s of " s i g n i f i c a n t change" l e a d t o an i n c r e a s e o f s e l f - e s t e e m through the s t r e n g t h e n i n g o f the i n d i v i d u a l s b e l i e f s . These f i n d i n g s f o r f a i t h i n therapy, optimism, and s e l f - e s t e e m p r o v i d e support f o r the placebo e f f e c t and moderate support f o r Martus' phenomenological r e s u l t s . F a i t h i n therapy and optimism are core elements i n the placebo e f f e c t , no o t h e r s p e c i f i c b e l i e f s were i d e n t i f i e d . In Martus' study the l o c u s of c o n t r o l and optimism were co r e themes w h i l e s e l f - e s t e e m was one o f t h e elements i d e n t i f i e d i n h i s theme of s i g n i f i c a n t change. No support was found f o r Antonovsky's (1979) s a l u t o g e n i c model, the c o r e elements are s e l f - c o n f i d e n c e and w i l l t o l i v e , w h i l e i n the HBM no s p e c i f i c b e l i e f elements are addressed and f o u r t o f i v e broad headings are used i n t o which a l l the b e l i e f s must f i t . The e t h n i c groups represented i n t h i s sample, people from P o r t u g a l , the U n i t e d Kingdom, Europe, Canada, and t h e r e s t o f the world, p r o v i d e d a unique m u l t i c u l t u r a l n a t u r e t o the r e s e a r c h . There was concern t h a t the Portuguese may have had E n g l i s h language d i f f i c u l t i e s , and a MANOVA 71 f o r r a t e o f r e c o v e r y and degree o f r e c o v e r y was computed w i t h t h i s group removed (See Appendix E ) . There were no marked changes i n the a n a l y s i s , although t h e s e l f - e s t e e m v a l u e s d i d drop s l i g h t l y . I t i s i n t e r e s t i n g t h a t f o r back and neck p a t i e n t s s i m i l a r b e l i e f s seem t o go a c r o s s t h e s e d i f f e r e n t c u l t u r a l groups f o r s e l f - p e r c e i v e d degree o f r e c o v e r y . The c o r r e l a t i o n between the p a t i e n t s s e l f - r a t i n g o f t h e i r r e c o v e r y degree a t the p r e s e n t time and t h a t done by the p h y s i o t h e r a p i s t a t the time o f d i s c h a r g e i s p o s i t i v e and s i g n i f i c a n t ( r = .35, p_ <.001). The c o r r e l a t i o n i s however, r e l a t i v e l y low and may r e f l e c t t he d i s c r e p a n c y i n time between the two e v a l u a t i o n s , i n some cases t h i s d i s c r e p a n c y i s up t o t h r e e y e a r s , d u r i n g which t h e p a t i e n t may have s u f f e r e d f u r t h e r i n j u r y , o r may have r e c e i v e d a d d i t i o n a l treatments. The comparison of the means i n t h i s study w i t h the means o f the same instruments r e p o r t e d elsewhere i s d i f f i c u l t because few s t u d i e s had s i m i l a r p o p u l a t i o n s . Mahon and Y a r c h e s k i (1988) r e p o r t e d a mean o f 30.13 (SD = 4.9) f o r e a r l y a d o l e s c e n t s , boys and g i r l s 12 t o 14 y e a r s o f age on the Rosenberg Self-Esteem S c a l e , a l s o Mechanic and H a n s e l l (1987) r e p o r t e d a mean of 3 0.07 (SD = 4.67) f o r a d o l e s c e n t s i n grades 7, 9, and 11 on t h e Rosenberg Se l f - E s t e e m S c a l e . A f t e r a d j u s t i n g the means so t h a t they were s c o r e d i n the same d i r e c t i o n ( g r e a t e r s c o r e = g r e a t e r s e l f - e s t e e m ) , the means i n t h i s study were s i m i l a r 72 t o those o f the a d o l e s c e n t s (M = 33.47). With r e g a r d t o l a c k of s o c i a l s e l f - c o n f i d e n c e , H i r s c h f e l d e t a l . (1977) r e p o r t e d means of 29.8 (SD = 6.4) and 34.3 (SD = 7.5) f o r c o l l e g e s tudents and p s y c h i a t r i c p a t i e n t s r e s p e c t i v e l y . T h i s study had a mean of 29.8, s i m i l a r t o the c o l l e g e s t u d e n t s . Sangster (1988) used the LOT t o examine rheumatoid a r t h r i t i s p a t i e n t s w i t h a mean age o f 56.2 ye a r s , and r e p o r t s a mean of 20.5 (SD = 5.7). T h i s study r e p o r t e d a mean of 20.8 which i s c o n s i s t e n t w i t h s i m i l a r s t u d i e s . The instruments used were s e l e c t e d p r i m a r i l y because they covered most of the b e l i e f s i d e n t i f i e d by Martus and a l s o f o r t h e i r s i m p l i c i t y and ease of use. On examining how these d i f f e r e n t s c a l e s c o r r e l a t e d w i t h one another, some moderate c o r r e l a t i o n s were found. The h i g h e s t o f these were s e l f - e s t e e m c o r r e l a t i n g w i t h optimism ( r = -.52, p_ <.001), and s e l f - e s t e e m c o r r e l a t i n g w i t h s e l f - c o n f i d e n c e (r = .51, p_ <.001). The f i n d i n g s o f Smith, Pope, Rhodewalt, and Po u l t o n , (1989) i n d i c a t e t h a t optimism r e f l e c t s the i n f l u e n c e o f n e u r o t i c i s m . They d e s c r i b e n e u r o t i c i s m as both a broad and s t a b l e dimension and have s t u d i e d i t p a r t i c u l a r l y i n r e l a t i o n t o the L i f e O r i e n t a t i o n T e s t (LOT). They suggest t h a t elements of n e u r o t i c i s m and n e g a t i v e a f f e c t p e r t a i n t o a dimension of p e r s o n a l i t y which c o n s i s t s o f c h r o n i c a l l y n e g a t i v e emotions " i n c l u d i n g sadness, a n x i e t y , g u i l t , and anger, as w e l l as c o g n i t i v e and b e h a v i o r a l 73 c h a r a c t e r i s t i c s such as low s e l f - e s t e e m , p r e - o c c u p a t i o n , and i n s e c u r i t y " . They conclude t h a t the LOT does not d i s t i n g u i s h optimism from measures of n e u r o t i c i s m o r n e g a t i v e a f f e c t i v i t y , and t h e r e f o r e has l i m i t e d d i s c r i m i n a n t v a l i d i t y . I t i s i n t e r e s t i n g though t h a t one o f the elements noted i n the d e f i n i t i o n o f n e u r o t i c i s m i s a n x i e t y , and t h a t a h i g h l e v e l of a n x i e t y was a l s o noted by Frank (1973) and Shapiro (1971) as b e i n g n e c e s s a r y f o r t h e placebo e f f e c t t o occur. Smith e t a l . (1989) f u r t h e r suggest t h a t the LOT's c o r r e l a t i o n w i t h c o p i n g and symptom r e p o r t i n g may be caused by n e u r o t i c i s m , however, a l s o under the d e f i n i t i o n of n e u r o t i c i s m they noted the presence of the b e h a v i o r a l c h a r a c t e r i s t i c , low s e l f - e s t e e m . For t h i s study optimism and s e l f - e s t e e m a l s o c o r r e l a t e but o n l y moderately (r = .52), t h e r e f o r e t h e r e i s evidence t h a t the optimism s c a l e i s not measuring o n l y n e g a t i v e a f f e c t or n e u r o t i c i s m . As t h i s study i s r e t r o s p e c t i v e i n d e s i g n i t can be argued t h a t those i n d i v i d u a l s who p e r c e i v e themselves as having a good r e c o v e r y , a l s o p e r c e i v e the t h e r a p y o r treatment as b e i n g e f f e c t i v e and thus f a i t h i n t h e r a p y may have developed p o s t treatment, r a t h e r than p r i o r t o treatment. The f i n d i n g s from the s e l f - c o n f i d e n c e , l o c u s o f c o n t r o l , and the w i l l t o l i v e instruments do not d i s t i n g u i s h among the degree of r e c o v e r y groups. A c c o r d i n g t o Martus (1985) i n c r e a s e d s e l f - c o n f i d e n c e was 74 developed i n the same manner as s e l f - e s t e e m and a s t r o n g i n t e r n a l l o c u s o f c o n t r o l or sense of b e i n g i n charge was one of h i s n i n e themes, however t h i s study does not support the a s s o c i a t i o n of e i t h e r of these v a r i a b l e s w i t h the degree of r e c o v e r y . Likewise the s e l f - c o n f i d e n c e and w i l l t o l i v e expressed i n Antonovsky's (1979) o r i e n t a t i o n t o l i f e concept and the s a l u t o g e n i c model i s not supported by these r e s u l t s . However Antonovsky d e f i n e s the l o c u s of c o n t r o l as the need t o have the power o f the c o n t r o l p l a c e d where i t r i g h t f u l l y should be, and t h i s may be w i t h the husband, the mother, or a church l e a d e r , and need not n e c e s s a r i l y be i n t e r n a l l y l o c a t e d . He f u r t h e r suggests t h a t t h i s may e x p l a i n the v a r i e t y of r e s u l t s t h a t a r e o b t a i n e d i n the d i f f e r e n t l o c u s of c o n t r o l s t u d i e s . I t may a l s o o f f e r an e x p l a n a t i o n f o r the r e s u l t s here. The placebo t h e o r y and HBM l i t e r a t u r e s do not i d e n t i f y these t h r e e v a r i a b l e s as b e i n g r e l a t e d t o r e c o v e r y . The r a t e of r e c o v e r y was examined t o f u r t h e r q u a l i f y and d e s c r i b e the degree of re c o v e r y . The f i n d i n g s here do not d i s t i n g u i s h among any of the r a t e o f r e c o v e r y groups f o r s e l f - e s t e e m , s e l f - c o n f i d e n c e , l o c u s o f c o n t r o l , f a i t h i n therapy, optimism, or w i l l t o l i v e . There are two e x p l a n a t i o n s t h a t may address t h i s . F i r s t the measure used may tap d i f f e r e n t elements than the r a t e o f r e c o v e r y , such as d i f f e r e n t t h e r a p i s t s p r a c t i c e s on the l e n g t h of time a treatment program should take, o r the i n d i v i d u a l s l i f e demands t h a t may i n t e r f e r e w i t h treatment 75 c o n t i n u a t i o n . Second, perhaps the r a t e t h a t p e o p l e r e c o v e r from back and neck i n j u r i e s i s not r e l a t e d t o b e l i e f s , t h a t i s , our e x p e c t a t i o n s and b e l i e f s do not h e l p us t o r e c o v e r f a s t e r . The r a t e or speed w i t h which people r e c o v e r does not c o r r e l a t e w i t h the degree or amount o f r e c o v e r y a t t a i n e d ( r = -.02). T h e r e f o r e no support was found f o r an a s s o c i a t i o n between the degree and the r a t e of r e c o v e r y . A n c i l l a r y data was examined i n an e x p l o r a t o r y f a s h i o n . Martus (1985) i d e n t i f i e d the " f o c u s on h e a l i n g " as a core theme, and some support f o r t h i s n o t i o n was found as "good" and "poor re c o v e r y " groups d i f f e r e d s i g n i f i c a n t l y on focus of h e a l i n g ; the "good r e c o v e r y " group h a v i n g a g r e a t e r focus. T h i s i s a l s o c o n s i s t e n t w i t h Lundh*s c o g n i t i v e - e m o t i o n a l model where b e l i e f s o f improvement s e t up a p o s i t i v e c y c l e of p l a c e b o b e l i e f s . Another a n c i l l a r y measure was the s e l f - r a t i n g of p h y s i c a l h e a l t h . Some support f o r t h i s n o t i o n was a l s o found as the "good" and "poor r e c o v e r y " groups d i f f e r e d s i g n i f i c a n t l y , the "good re c o v e r y " group c o n s i d e r i n g themselves t o be g e n e r a l l y h e a l t h i e r than those who d i d not achieve a good degree of re c o v e r y . L i m i t a t i o n s The most s e r i o u s l i m i t a t i o n i s the measurement of the r a t e of r e c o v e r y . T h i s measure c o n s i s t e d of t h e number of days between the f i r s t and l a s t treatments p r o v i d e d by the SVH p h y s i o t h e r a p y . As i t was important t o e x p l o r e 76 whether s e l f - e s t e e m , s e l f - c o n f i d e n c e , c o n t r o l , f a i t h i n therapy, optimism, and w i l l t o l i v e r e l a t e d w i t h t h e r a t e as w e l l as the degree o f recovery, the l e n g t h o f time over which the treatments o c c u r r e d were examined. However, an assumption was made t h a t r e c o v e r y happened over t h i s p e r i o d o f time when i t d i d not f o r 22% o f t h e respondents who f e l l i n t o the "poor r e c o v e r y " group, and second the assumption t h a t the rec o v e r y stopped on t h e l a s t day o f treatment. Another l i m i t a t i o n i s t h a t although t h e p o p u l a t i o n i s d e s c r i b e d as b e i n g made up of p a t i e n t s w i t h back and or neck problems, w i t h i n t h i s very broad c l a s s i f i c a t i o n , t h e r e a re many d i f f e r e n t types o f i n j u r i e s and problems. In a d d i t i o n , these i n j u r i e s o r problems v a r y c o n s i d e r a b l y i n t h e i r s e v e r i t y , as w e l l as t h e i r acuteness o r c h r o n i c i t y . A l s o t h e r e were d i f f e r e n t t h e r a p i s t s i n v o l v e d as w e l l as a c o n s i d e r a b l e a r r a y o f d i f f e r e n t t h e r a p i e s p r o v i d e d . As a r e s u l t i t was not p o s s i b l e t o q u a l i f y t he s p e c i f i c medical problems i n v o l v e d o r t h e treatments p r o v i d e d . The treatment l e n g t h and frequency a l s o v a r i e d depending on the s e v e r i t y and acuteness o f the problems i n a d d i t i o n t o the i n d i v i d u a l s l i f e s t y l e and l i f e commitments. T h e r e f o r e i t was a l s o not p o s s i b l e t o q u a n t i f y the treatments a c c u r a t e l y e i t h e r . These l i m i t a t i o n s may w e l l t o some exte n t account f o r the f i n d i n g s . A f u r t h e r l i m i t a t i o n i s wit h the f a i t h i n t h e r a p y 77 s u b s c a l e o f the C l i e n t Readiness f o r Therapy Inventory, T h i s i n v e n t o r y had a low Cronbach's alpha o f .54 i n d i c a t i n g a low 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 ) . In a d d i t i o n t h i s study does not show cause and e f f e c t , o n l y r e l a t i o n s h i p s among the b e l i e f s and the re c o v e r y degree and r a t e as onl y c r o s s s e c t i o n a l data were used. S e l f - r e p o r t and age b i a s were f u r t h e r l i m i t a t i o n s t h a t must be c o n s i d e r e d as t h i s study was mostly comprised of s e l f - r e p o r t data and the age range o f the s u b j e c t s was from 20 t o 89 y e a r s . From J y l h a e t a l . (1986) i n t h e i r study o f men onl y , we know t h a t the younger p a t i e n t s are more l i k e l y t o e x p l a i n t h e i r h e a l t h by symptoms and p h y s i c a l f i t n e s s , the middle age group by symptoms and p s y c h i c w e l l b e i n g and the more e l d e r l y group be c h r o n i c i l l n e s s . In t h i s study the p o p u l a t i o n i s w e l l d i s t r i b u t e d over the d i f f e r e n t age groups, the young a d u l t 20 t o 45 ye a r s o f age (n = 51), those i n middle age 46 t o 65 years o f age, (n = 60), and the more e l d e r l y those 66 t o 92 y e a r s o f age, (n = 39). T h e r e f o r e d i f f e r e n t h e a l t h v a l u e s may be expressed i n t h i s study. Another l i m i t a t i o n may be t h a t the s c a l e o f s o c i a l s e l f - c o n f i d e n c e o n l y examines the s o c i a l a s p e c t o f s e l f - c o n f i d e n c e where t h i s v a r i a b l e may need t o be asses s e d more comprehensively. F i n a l l y , t h i s study was r e t r o s p e c t i v e i n d e s i g n and some respondents were f i l l i n g out the q u e s t i o n n a i r e two or 78 even t h r e e y e a r s a f t e r the experience. Recommendations f o r Future Research Future r e s e a r c h i s needed t o f u r t h e r e x p l o r e the p r e s e n t f i n d i n g s w i t h a concurrent study r a t h e r than a r e t r o s p e c t i v e study. A l s o t h e r a p i s t s e x p e c t a t i o n s f o r r e c o v e r y f o l l o w i n g assessment need t o be e v a l u a t e d and compared t o the a c t u a l r e c o v e r y degree o b t a i n e d t o see i f t h e r e i s a s e l f - f u l f i l l i n g prophecy e f f e c t o c c u r r i n g . F u r t h e r , s t u d i e s are needed t h a t w i l l compare r e c o v e r y groups of p a t i e n t s , one group r e c e i v i n g t h e s t a n d a r d course of p h y s i o t h e r a p y , and the o t h e r r e c e i v i n g p h y s i o t h e r a p y p l u s c o u n s e l l i n g and group work aimed a t i n c r e a s i n g f a i t h i n therapy, optimism and s e l f - e s t e e m . As w e l l , a n e u r o t i c i s m s c a l e should be used both t o s u b s t a n t i a t e the a s s o c i a t i o n of n e u r o t i c i s m w i t h symptoms as w e l l t o r u l e out the i n f l u e n c e of t h i s e f f e c t , both p r i o r t o treatment s t a r t i n g as w e l l as a t t h e time o f d i s c h a r g e . In a d d i t i o n , s i m i l a r s t u d i e s need t o be done w i t h d i f f e r e n t c o n d i t i o n s t o determine i f t h e f i n d i n g s observed i n t h i s study g e n e r a l i z e t o o t h e r groups o r are s p e c i f i c o n l y t o back and neck p a t i e n t s . There a r e a l s o o t h e r b e l i e f v a r i a b l e s t h a t need t o be examined as w e l l such as s e l f - e f f i c a c y and a good h e a l t h m o t i v a t i o n . F u r t h e r a model needs t o be e s t a b l i s h e d t h a t e x p l a i n s t h e a s s o c i a t i o n s of s p e c i f i c b e l i e f s i n the r e c o v e r y p r o c e s s . T h i s study does not p r o v i d e enough i n f o r m a t i o n t o p r e s e n t a model but does l e n d credence t o the p l a c e b o 79 t h e o r y and p a r t i a l l y support the f i n d i n g s o f Martus. C o n c l u s i o n s In c o n c l u s i o n then, t h i s was an e x p l o r a t o r y study i n t h a t i t attempted t o i d e n t i f y those s p e c i f i c i n d i v i d u a l b e l i e f s o f s e l f - e s t e e m , s e l f - c o n f i d e n c e , c o n t r o l , f a i t h i n therapy, optimism, and w i l l t o l i v e t h a t were r e l a t e d t o the p e r c e i v e d degree of recover y and the r a t e o f r e c o v e r y . The h y p o t h e s i s f o r f a i t h i n therapy was supported, and the hypotheses f o r optimism and s e l f - e s t e e m were p a r t i a l l y supported, i n the s e l f - r e p o r t e d degree of r e c o v e r y groups. The study found s i g n i f i c a n t group d i f f e r e n c e s among a l l t h r e e r e c o v e r y groups f o r f a i t h i n therapy, s i g n i f i c a n t d i f f e r e n c e s between the "poor r e c o v e r y " and "good r e c o v e r y " groups as w e l l as between the "poor r e c o v e r y " and "moderate r e c o v e r y " groups f o r optimism, and between the "poor r e c o v e r y " and "good r e c o v e r y " groups f o r s e l f - e s t e e m . These f i n d i n g s support the t h e o r y advanced by r e s e a r c h on the placebo e f f e c t , as w e l l as support some of Martus 1 f i n d i n g s . The i m p l i c a t i o n s o f t h e s e r e s u l t s suggest t h a t p h y s i c a l t h e r a p i s t s when t r e a t i n g back and neck p a t i e n t s may improve recove r y degree through f o s t e r i n g an awareness and co n f i d e n c e by the p a t i e n t i n the t h e r a p i s t s knowledge, s k i l l s , and a b i l i t i e s , as w e l l as the e f f e c t i v e n e s s o f the treatment p r o v i d e d . 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V i n c e n t s H o s p i t a l . In order t o b e t t e r understand the h e a l i n g p r o c e s s I am s o l i c i t i n g your support i n p r o v i d i n g us w i t h i n f o r m a t i o n about your ex p e r i e n c e . The r e s u l t s o f t h i s study may h e l p us i n our approach t o other p a t i e n t s . T h i s w i l l i n v o l v e you f i l l i n g i n the e n c l o s e d q u e s t i o n n a i r e s and m a i l i n g them back t o me i n t h e s e l f addressed, stamped envelope t h a t i s i n c l u d e d . I f you have o n l y had a s h o r t bout o f d i s c o m f o r t , o r o n l y one treatment t h i s i n f o r m a t i o n w i l l s t i l l be ve r y h e l p f u l . I am conducting t h i s study as p a r t i a l f u l f i l l m e n t o f the requirements f o r a masters degree i n the department of C o u n s e l l i n g Psychology i n the F a c u l t y o f E d u c a t i o n a t the U n i v e r s i t y of B r i t i s h Columbia. My s u p e r v i s o r i s Dr. B. Long. Your p a r t i c i p a t i o n i n t h i s study w i l l be most a p p r e c i a t e d . A l l the i n f o r m a t i o n c o l l e c t e d w i l l be kept s t r i c t l y c o n f i d e n t i a l and used f o r r e s e a r c h purposes o n l y . When the study i s f i n i s h e d a l l the data w i l l be d e s t r o y e d . In keeping w i t h the c o n f i d e n t i a l i t y p l e a s e do not put your name or any i d e n t i f i c a t i o n on the q u e s t i o n n a i r e s . P a r t i c i p a t i o n i n t h i s p r o j e c t i s e n t i r e l y v o l u n t a r y . In no way w i l l your p a r t i c i p a t i o n , or l a c k o f p a r t i c i p a t i o n , have any e f f e c t on your r e l a t i o n s h i p w i t h S t . V i n c e n t s H o s p i t a l o r the U n i v e r s i t y of B r i t i s h Columbia. Participating in the Healing Ministry 93 PLEASE NOTE; T h i s q u e s t i o n n a i r e w i l l t a k e b e t w e e n 2 0 m i n u t e s a n d 1 h o u r t o f i l l i n . 1. P l e a s e r e a d t h e i n s t r u c t i o n s c a r e f u l l y . 2. P l e a s e c o m p l e t e t h e e n c l o s e d q u e s t i o n n a i r e s a n s w e r i n g a l l t h e q u e s t i o n s y o u c a n , t r y i n g n o t t o l e a v e a n y o u t . 3. P l e a s e r e t u r n t h e c o m p l e t e d q u e s t i o n n a i r e s , p a g e s 3 t o 1 1 , i n t h e a d d r e s s e d a n d s t a m p e d e n v e l o p e . I f y o u w i s h t o r e c e i v e a c o p y o f t h e r e s u l t s o f t h e s t u d y p l e a s e f i l l o u t t h e i n f o r m a t i o n b e l o w , a n d r e t u r n a t a l a t e r d a t e . Name: A d d r e s s : P l e a s e r e t u r n t o : S h i r r a K e n w o r t h y D i r e c t o r o f R e h a b i l i t a t i o n M e d i c i n e . S t . V i n c e n t ' s H o s p i t a l 749 West 3 3 r d A v e . V a n c o u v e r , B. C. V5Z 2K4 94 APPENDIX B Rosenberg Self-Esteem S c a l e Lack of S o c i a l S e l f - C o n f i d e n c e S u b s c a l e C o n t r o l Subscale F a i t h i n Therapy s u b s c a l e L i f e O r i e n t a t i o n T e s t W i l l t o L i v e S c a l e Demographic and A n c i l l a r y Q u e s t i o n a i r e 95 Each item i s a b e l i e f statement w i t h which you may agree or d i s a g r e e . C i r c l e the number t h a t r e p r e s e n t s the exte n t t o which you agree or d i s a g r e e w i t h the statement. The more s t r o n g l y you agree w i t h a statement, then the lower w i l l be the number you c i r c l e . The more s t r o n g l y you d i s a g r e e w i t h a statement, the the h i g h e r w i l l be the number you c i r c l e . Please make sure you answer every item and t h a t you c i r c l e o n l y one number per item. Response c a t e g o r i e s : 1. S t r o n g l y agree. 2. Agree. 3. Disagree. 4. S t r o n g l y d i s a g r e e . 1. I f e e l t h a t I'm a person of worth, a t l e a s t on an equal plane w i t h o t h e r s . 1. 2. 3. 4. 2. I f e e l t h a t I have a number of good q u a l i t i e s . 1. 2. 3. 4. 3. A l l i n a l l , I am i n c l i n e d t o f e e l t h a t I am a f a i l u r e . 1. 2. 3. 4. 4. I am a b l e t o do t h i n g s as w e l l as most o t h e r people. 1. 2. 3. 4. 5. I f e e l I do not have much t o be proud o f . 1. 2. 3. 4. 6. I take a p o s i t i v e a t t i t u d e toward myself. 1. 2. 3. 4. 7. On the whole I am s a t i s f i e d w i t h myself. 1. 2. 3. 4. 8. I wish I c o u l d have more r e s p e c t f o r myself. 1. 2. 3. 4. 9. I c e r t a i n l y f e e l u s e l e s s a t times. 1. 2. 3. 4. 10. At times I t h i n k I am no good a t a l l . 1. 2. 3. 4. 96 Each item i s a statement which you may b e l i e v e t o be v e r y c h a r a c t e r i s t i c o f you, q u i t e c h a r a c t e r i s t i c o f you, somewhat c h a r a c t e r i s t i c o f you, or not c h a r a c t e r i s t i c o f you. C i r c l e the number t h a t b e s t r e p r e s e n t s t h e l e v e l t o which the statement i s c h a r a c t e r i s t i c o f you. The more c h a r a c t e r i s t i c you b e l i e v e the statement t o be o f you, then the lower w i l l be the number you c i r c l e . The more the c h a r a c t e r i s t i c i s not what you c o n s i d e r y o u r s e l f t o be, then the h i g h e r w i l l be the number you c i r c l e . P l e a s e make sure you answer every item and t h a t you c i r c l e o n l y one number per item. Response c a t e g o r i e s : 1. Very C h a r a c t e r i s t i c . 2. Qui t e C h a r a c t e r i s t i c . 3. Somewhat C h a r a c t e r i s t i c . 4. Not C h a r a c t e r i s t i c . 1. When I have a d e c i s i o n t o make, I always ask f o r a d v i c e . 1. 2. 3. 4. 2. I would r a t h e r be a f o l l o w e r than a l e a d e r . 1. 2. 3. 4. 3. I f e e l c o n f i d e n t of my a b i l i t y t o d e a l w i t h most of the p e r s o n a l problems I am l i k e l y t o meet i n l i f e . 1. 2. 3. 4. 4. I am q u i c k t o agree w i t h the o p i n i o n s expressed by o t h e r s . 1. 2. 3. 4. 5. I t i s hard f o r me t o ask someone f o r a f a v o r . 1. 2. 3. 4. 6. In an argument, I g i v e i n e a s i l y . 1. 2. 3. 4. 7. When I go t o a p a r t y I expect t h a t the o t h e r people w i l l l i k e me. 1. 2. 3. 8. I t i s hard f o r me t o make up my mind about a T.V. show or movie u n t i l I know what o t h e r people t h i n k . 1. 2. 3. 9. In s o c i a l s i t u a t i o n s I tend t o be ve r y s e l f - c o n s c i o u s . 1. 2. 3. 10.I have a l o t o f t r o u b l e making d e c i s i o n s by myself. 1. 2. 3. 4. 9 Response c a t e g o r i e s : 1. Very C h a r a c t e r i s t i c . 2. Quite C h a r a c t e r i s t i c . 3. Somewhat C h a r a c t e r i s t i c . 4. Not C h a r a c t e r i s t i c . 11. I don't l i k e t o buy c l o t h e s by myself. 1. 2. 3. 12. When I meet new people, I'm a f r a i d t h a t I won't do the r i g h t t h i n g . 1. 2. 3. 13. I would r a t h e r s t a y f r e e of involvements w i t h o t h e r s than t o r i s k disappointments. 1. 2. 3. 14. I am v e r y c o n f i d e n t about my own j udgement. 1 . 2 . 3 . 15. I don't have what i t takes t o be a good l e a d e r . 1. 2. 3. 98 I n s t r u c t i o n s : T h i s i s a q u e s t i o n n a i r e designed t o determine the way i n which d i f f e r e n t people view c e r t a i n important i s s u e s r e l a t e d t o t h e i r h e a l t h . Each item i s a b e l i e f statement w i t h which you may agree or d i s a g r e e . Beside each statement i s a s c a l e which ranges from s t r o n g l y d i s a g r e e (1) t o s t r o n g l y agree (6). For each item we would l i k e you t o c i r c l e the number t h a t r e p r e s e n t s the e x t e n t t o which you agree or d i s a g r e e w i t h the statement. P l e a s e make sure t h a t you answer every item and t h a t you c i r c l e o n l y one number per item. Disagree Agree s M S S M S T 0 L L 0 T R D I I D R 0 E G G E 0 N R H H R N G A T T A G L T L L T L Y E Y Y E Y L L Y Y 1. When I get s i c k I am t o blame. 1 2 3 4 5 6 2. I can a v o i d i l l n e s s , i f I take c a r e o f myself. 1 2 3 4 5 6 3. Luck p l a y s a b i g p a r t i n det e r m i n i n g how soon I w i l l r e c o v e r from an i l l n e s s . 1 2 3 4 5 6 4. I am i n c o n t r o l o f my h e a l t h . 1 2 3 4 5 6 5. My good h e a l t h i s l a r g e l y a matter o f good f o r t u n e . 1 2 3 4 5 6 6. No matter what I do I'm l i k e l y t o get s i c k . 1 2 3 4 5 6 7. The main t h i n g which a f f e c t s my h e a l t h i s what I myself do. 1 2 3 4 5 6 8. Most t h i n g s t h a t a f f e c t my h e a l t h happen t o me by a c c i d e n t . 1 2 3 4 5 6 9. I f I get s i c k , i t i s my own be h a v i o r which determines how soon I get w e l l again. 1 2 3 4 5 6 99 Disagree Agree s M S S M S T 0 L L 0 T R D I I D R 0 E G G E 0 N R H H R N G A T T A G L T L L T L Y E L Y Y Y E L Y Y 10. I w i l l s t a y h e a l t h y i f i t ' s meant t o be. 1 2 3 4 5 6 11. No matter what I do, i f I am going t o get s i c k , I w i l l g et s i c k . 1 2 3 4 5 6 12. I f I take the r i g h t a c t i o n s , I can s t a y h e a l t h y . 1 2 3 4 5 6 13. I can be as h e a l t h y as I want t o be. 1 2 3 4 5 6 14. I have l i t t l e i n f l u e n c e over my h e a l t h . 1 2 3 4 5 6 Answer each item by c i r c l i n g the number which b e s t i n d i c a t e s how you f e e l / t h i n k . The numbers r e p r e s e n t the same p o i n t s from S t r o n g l y Agree t o S t r o n g l y Disagree throughout the q u e s t i o n n a i r e . Do not leav e out any q u e s t i o n s . STRONGLY AGREE DISAGREE STRONGLY AGREE DISAGREE 1. I b e l i e v e t h a t a t h e r a p i s t w i l l be a b l e t o h e l p me s o l v e my problems. 1 2 3 4 5 6 7 2. I am o p t i m i s t i c t h a t the outcome of my therapy w i l l be p o s i t i v e . 1 2 3 4 5 6 7 3. I f a f e e was charged f o r therapy I would be w i l l i n g t o pay. 1 2 3 4 5 6 7 4. I don't expect t o f e e l b e t t e r when I've f i n i s h e d therapy.1 2 3 4 5 6 7 5. I expect t o be somewhat changed a f t e r therapy. 1 2 3 4 5 6 7 100 Please i n d i c a t e the extent t o which you agree w i t h each o f the f o l l o w i n g items. C i r c l e the response t h a t most c l o s e l y matches how you f e e l . P l e a s e be as a c c u r a t e and honest as you can throughout and t r y not t o l e t your answers t o one q u e s t i o n i n f l u e n c e your answers t o o t h e r q u e s t i o n s . There i s no c o r r e c t or i n c o r r e c t answer. S t r o n g l y S t r o n g l y Agree Agree N e u t r a l D i s a g r e e Disagree 1. In u n c e r t a i n times I u s u a l l y expect the b e s t . 4 3 2 1 0 2. I t ' s easy f o r me t o r e l a x . 4 3 2 1 0 3. I f something can go wrong f o r me, i t w i l l . 4 3 2 1 0 4. I always l o o k on the b r i g h t s i d e of t h i n g s . 4 3 2 1 0 5. I'm always o p t i m i s t i c about my f u t u r e . 4 3 2 1 0 6. I enjoy my f r i e n d s a l o t . 4 3 2 1 0 7. I t s important f o r me t o keep busy. 4 3 2 1 0 8. I h a r d l y ever expect t h i n g s t o go my way. 4 3 2 1 0 9. Things never work out the way I want them t o . 4 3 2 1 0 10. I don't get upset too e a s i l y . 4 3 2 1 0 11. I'm a b e l i e v e r i n the i d e a t h a t "every c l o u d has a s i l v e r l i n i n g " . 4 3 2 1 0 12. I r a r e l y count on good t h i n g s happening t o me. 4 3 2 1 0 101 T h i s i s a q u e s t i o n n a i r e designed t o determine t h e way i n which people view a c e r t a i n l i f e i s s u e . Each item i s a b e l i e f statement w i t h which you may agree o r d i s a g r e e . C i r c l e the number t h a t r e p r e s e n t s the e x t e n t t o which you agree o r d i s a g r e e w i t h the statement. The more s t r o n g l y you agree w i t h the statement then the lower w i l l be the number you c i r c l e . The more s t r o n g l y you d i s a g r e e w i t h the statement, then the h i g h e r w i l l be the number you c i r c l e . P l e a s e make sure t h a t you answer every item. Response c a t e g o r i e s : 1. S t r o n g l y agree. 2. Agree. 3. Disagree. 4. S t r o n g l y d i s a g r e e . 1. I b e l i e v e I have a s t r o n g w i l l t o l i v e . 1 2 3 4 2. L i v i n g t o 100+ years has no g r e a t appeal f o r me. 1 2 3 4 3. I w i l l make my l i f e l a s t as long as I p o s s i b l y can under any circumstances. 1 2 3 4 4. I am f r u s t r a t e d w i t h l i f e and don't wish t o l i v e t o a v e r y o l d age. 1 2 3 4 5. I b e l i e v e I w i l l l i v e t o 100+ y e a r s . 1 2 3 4 6. My d e s i r e t o l i v e a long l i f e i s not ver y s t r o n g . 1 2 3 4 7. I enjoy l i v i n g and want t o make the most out o f every minute. 1 2 3 4 102 APPENDIX I The f o l l o w i n g i n f o r m a t i o n w i l l be used simply t o d e s c r i b e the respondents t o t h i s survey. BACKGROUND INFORMATION ON INJURY. 1. Please c i r c l e the a p p r o p r i a t e l e v e l o f your r e c o v e r y a t the pr e s e n t time as i t compares t o your c o n d i t i o n on your f i r s t day of treatment. _ _ _ __ _^  no moderate good re c o v e r y r e c o v e r y r e c o v e r y BACKGROUND INFORMATION ON TREATMENT. 2. Have you r e c e i v e d a d d i t i o n a l treatment f o r your neck o r back, s i n c e you l a s t had phy s i o t h e r a p y treatments a t S t . V i n c e n t s H o s p i t a l ? P l e a s e t i c k one. a) . yes b) . no c ) . I f "yes" p l e a s e i n d i c a t e ; i ) the type, i i ) the number of treatments and i i i ) the approximate p e r i o d o f time over which these treatments o c c u r r e d . i ) type i i ) no. of treatments i i i ) time p e r i o d phys i o t h e r a p y i i ) i i i ) c h i r o p r a c t e r i i ) i i i ) naturopathy i i ) i i i ) accupunctur e _ _ i i ) i i i ) o t h e r (please d e s c r i b e ) 11) hi) 3. Si n c e i n j u r y i n g your neck or back, have you been on a p r e s c r i b e d home e x e r c i s e program? P l e a s e t i c k one. a) . Yes. b) . No. 4. I f the answer t o q u e s t i o n number 3 was "yes", p l e a s e c i r c l e the a p p r o p r i a t e l e v e l t h a t r e p r e s e n t s how r e g u l a r l y you f o l l o w e d your home e x e r c i s e program. 1 • 2 • 3 • 4 • 5 • not a t moderately v e r y a l l r e g u l a r l y 5. To what degree do you f e e l e m o t i o n a l l y supported by the people important t o you. Please c i r c l e the a p p r o p r i a t e number. 1L • 2 • 3* 4 • 5 • no moderate g r e a t support support support 103 6. Major l i f e events sometimes b r i n g about changes i n the l i v e s of those who e x p e r i e n c e them. Sometimes we p e r c e i v e these e x p e r i e n c e s as b e i n g n e g a t i v e . Please i n d i c a t e i f you have experienced such an event s i n c e you f i r s t sought treatment a t St . V i n c e n t ' s Physiotherapy Department. B r i e f l y d e s c r i b e t h i s event. I n d i c a t e on the f o l l o w i n g s c a l e , the e x t e n t o f n e g a t i v e impact on your l i f e t h a t the event had. T~. T. 37, 47. 5. somewhat moderately extremely n e g a t i v e n e g a t i v e n e g a t i v e 7. When you t h i n k about y o u r s e l f do you t h i n k of y o u r s e l f as being v e r y h e a l t h y or not v e r y h e a l t h y when comparing y o u r s e l f t o your own age group? Please c i r c l e the a p p r o p r i a t e l e v e l . 1 • 2 • 3 • 4 • 5 • not v e r y moderate v e r y h e a l t h y h e a l t h h e a l t h y 8. When you t h i n k about your back or neck i n j u r y do you focus your a t t e n t i o n more on being i n j u r e d or more on b e i n g healed? Pleas e c i r c l e the a p p r o p r i a t e l e v e l of your f o c u s . T. 2~7 3~7 4~7 5. b e i n g b e i n g b e i n g i n j u r e d somewhat improved h e a l e d 9. To what degree do you m a i n t a i n your p h y s i c a l h e a l t h and f i t n e s s through e x e r c i s e and a c t i v i t i e s ? P l e a s e c i r c l e the a p p r o p r i a t e l e v e l . T7 2~7 3~7 4~7 5. not a t moderate f u l l a l l f i t n e s s f i t n e s s BACKGROUND DEMOGRAPHICS. 10. Sex. . 11. Age y e a r s . 12. M a r i t a l S t a t u s . ( T i c k one). 13. Work S t a t u s . ( T i c k one). S i n g l e . F u l l time M a r r i e d . P a r t t i m e / c a s u a l Divorced/Separated . Unemployed Widowed . Housewife 14. E t h n i c background. R e t i r e d Thankyou. 104 APPENDIX C Rosenberg S e l f - E s t e e m S c o r i n g 105 The Rosenberg S e l f - E s t e e m S c a l e (RSE). T h i s s c a l e s c o r e d a c c o r d i n g t o Rosenberg's o r i g i n a l i n s t r u c t i o n s has a range of -6 t o +6. The h i g h e r the sc o r e the g r e a t e r the s e l f - e s t e e m . Comparison o f the means i s d i f f i c u l t as the samples s t u d i e d elsewhere w i t h the same instruments a r e not s i m i l a r . In t h i s study the RSE had a mean of 4.72 (SD = 1.91). (See Tab l e 11). T h i s i s h i g h e r than the mean ob t a i n e d by Mahard (1988) with an e l d e r l y (age M = 64.7, SD = 6.2) Puerto R i c a n p o p u l a t i o n (M = 3.13, SD = .60), and the mean o b t a i n e d by W i l l i a m s and Thorn (1989) w i t h WCB c h r o n i c p a i n p a t i e n t s who had an average age o f 37.6 yea r s (M = 1.78, SD = 1.44). T h i s suggests t h a t t h e p a r t i c i p a n t s i n the SVH study had h i g h e r s e l f - e s t e e m than those p a r t i c i p a n t s i n the above two s t u d i e s . A n a l y s i s o f degree of recover y w i t h the r e s c o r e d s c a l e r e s u l t e d i n s i g n i f i c a n t m u l t i v a r i a t e group e f f e c t , F(12,284) = 3.83, p_ <.001, and an examination o f t h e u n i v a r i a t e F t e s t s r e v e a l e d s i g n i f i c a n t group d i f f e r e n c e s f o r s e l f - e s t e e m , F(2,147) = 3.64, p_ <.029. See T a b l e 12. 106 T a b l e 11 Means and Standard D e v i a t i o n s f o r S e l f - E s t e e m f o r the Degree of Recovery Groups. PR group MR group GR group (n = 33) (n = 71) (n = 46) V a r i a b l e s M SD M SD M SD s e l f esteem 4.0(2.5) 5.0(1.6) 4.8(1.7) Note. PR = poor r e c o v e r y ; MR = moderate r e c o v e r y ; GR = good r e c o v e r y . High s c o r e s on s e l f - e s t e e m i n d i c a t e more s e l f - e s t e e m . 107 T a b l e 12 Summary of MANOVA and followup ANOVAS f o r the Degree of  Recovery Groups (n = 150)• Source SS d f F p_< Between Groups m u l t i v a r i a t e 12,284 3.83 .001 U n i v a r i a t e s e l f - e s t e e m 25. 64 2, 147 3 . 64 .029 s e l f - c o n f i d e n c e 232. 61 2, 147 2 . 14 . 121 l o c u s o f c o n t r o l 455. 71 2, 147 2. 06 . 131 f a i t h i n therapy 554. 51 2, 147 18. 13 .001 optimism 378. 62 2, 147 7. 24 . 001 w i l l t o l i v e 28. 61 2, 147 1. 31 .273 108 APPENDIX D C o r r e l a t i o n M a t r i x f o r Dependent Measures, Treatment Measures, A n c i l l a r y Data, and Age. Table 13 C o r r e l a c l o n M a t r i x f o r Dependent Measures, Treatment Measures, A n c i l l a r y Data, and Age ATOT ATOT 1.0000 BTOT . 5 0 7 5 CTOT . 1 380 DTOT . 2370 E TOT -.5170 FTOT . 2464 INTENS .0282 INTENS2 .0514 G2 - .0735 G3 .0598 G4 . 0 8 6 8 H1 • . 1964 H 19 -.0651 H20 -.1693 H22 .0823 H23 -.2796 H24 -.17 40 H25 -.1911 H27 . 0602 TXNIO -.0210 TXDAYS .0230 BTOT CTOT . 5 0 7 5 ' ' . 1380 .0000 . 3 7 5 9 " . 3759* * 1.0000 .14 14 .2313* .4767 1 • - . 3 2 2 8 ' ' . 2 5 3 9 " .2383* .0606 .0241 .0886 . 1 330 . 1336 -.1039 .0124 .0386 .0477 .0749 . 1084 -.1652 .0183 - .0553 .1015 - .0608 .0414 .0267 . 1950* - .2748' ' . 1 166 -.1890 . 1901 -. 2 2 3 8 * . 2 3 2 5 ' .2506 * • .0967 -.0436 .0123 - . 0 1 6 5 DTOT ETOT .2370* - . 5 1 7 0 ' * .14 14 - . 4 7 6 7 " .2313* - . 3 2 2 8 * ' 1.0000 - . 2 9 5 2 " - . 2 9 5 2 * * 1.0000 .0468 - .2831 " .2338* -.0136 -.0334 .0727 -.1426 .0925 -.0196 - .0105 .0339 - .0325 - . 4 4 2 5 " . 2 9 3 4 " -.2458 . 1629 - . 1360 . 2 6 6 9 " .0598 -.1556 - . 2 6 5 8 * ' .3532* ' - . 3 0 5 4 " .2393* -.1821 . 1920* - . 2 0 1 5 * .0477 -.0219 .0516 - .0373 .0886 FTOT INTENS .2464* .0282 . 2 5 3 9 " .0606 . 2 3 8 3 ' .0241 .0468 . 2 3 3 8 ' -.2831 " -.0136 1.0000 -.0782 -.0782 1.0000 .0196 -.0235 -.0808 -.2214* -.0224 .0374 -.0237 .2547 " -.110 0 - . 2 2 1 9 * - . 0 7 5 5 .1413 -. 1829 - . 1698 .0828 .2237 - . 2 0 2 2 * -.1184 - . 1723 -.1 1 14 -.273 1 " .0530 .0578 -.0454 -.0526 .1763 -.02 2 5 .2270* INTENS2 G2 0 5 1 4 - .0735 0 8 8 6 -.1336 1330 -.1039 0 3 3 4 - . 1426 07 2 7 .0925 0 1 9 6 - .0808 0 2 3 5 - . 2 2 1 4 " 0 0 0 0 .0285 0 2 8 5 1.0000 0 4 3 9 -.0189 0 4 0 4 - .0368 0 3 7 8 . 3 5 0 5 ' 1848 -.2586 0 6 3 3 .0225 2359 -.1909 0 7 2 8 .0314 0 2 7 2 .0337 0 4 3 4 .0429 0 8 4 0 .0265 0 6 0 9 - .054 1 6 0 3 6 " - .0633 G3 G4 .0598 .0868 .0124 .0477 .0386 .0749 .0196 .0339 .0105 -.0325 .0224 - .0237 .0374 . 2 5 4 7 " .0439 -.0404 .0189 - .0368 .0000 .9478'* . 9 4 7 8 " 1.0000 .0112 -.0161 . 2329 . 2349 .0047 - .0657 .0057 .0308 .0103 - .0527 .0913 -.1396 .0186 -.0082 . 1507 .14 17 . 7 0 7 4 " . 6 9 2 6 " .2287' .2606* ' O ATOT BTOT C T O T DTOT ETOT FTOT INTENS INTENS2 G2 G3 G4 H1 H19 H20 H22 H23 H24 H25 H27 TXNO TXDAYS H1 • .1964 ' - .1084 •.1652 - . 4 4 2 5 ' .2934 ' •.1100 - .2219" .0378 .3505" .01 12 - .0161 1.0000 -. 1 176 .2499* •.2473 .3578 ' . 3 6 7 1 ' . 1505 . 1 120 - .0934 - .0879 H19 • .0651 .0183 • .0553 •.2458 . 1629 •.0755 .14 13 . 1848 •.2586 . 2329 . 2349 • . 1 176 1.0000 . 1032 - .0115 . 1796 . 3 3 6 6 ' .3846* . 1996 . 3 2 6 1 ' . 2845' H20 - . 1693 - . 1015 •.0608 •.1360 . 2669* * - . 1 8 2 9 - . 1698 .0633 .0225 - .0047 - .0657 .2499* . 1032 1.0000 •.0644 .2408* . 1328 . 1569 .0252 - .0327 • .0544 H22 H23 H24 H25 H27 TXNO TXDAYS .0823 - . 2 7 9 6 " - . 1 7 4 0 - . 1 9 1 1 * .0602 - . 0 2 1 0 .0230 - . 0 4 1 4 - . 1950* - . 1 166 - .1901 . 2 3 2 5 ' - .0967 - .0123 .0267 - . 2 7 4 8 * * -. 1890 - . 2 2 3 8 * . 2 5 0 6 " - .0436 - .0165 .0596 - . 2 6 5 8 * ' - . 3 0 5 4 ' ' - . 1 8 2 1 - . 2015' - .0219 - .0373 - . 1 5 5 6 . 3 5 3 2 ' ' .2393* . 1 9 2 0 ' .0477 .0516 .0886 .0828 - . 2 0 2 2 * - . 1 7 2 3 - .2731 " .0578 - . 0 5 2 6 - . 0 2 2 5 .2237 - . 1 1 8 4 - . 1 1 1 4 .0530 - .0454 . 1763 .2270* . 2359 .0728 .0272 .0434 .0840 .0609 .6036* * - . 1 9 0 9 .0314 .0337 .0429 .0265 - .0541 - . 0 6 3 3 - . 0 0 5 7 - .0103 - .0913 .0186 . 1507 . 7 0 7 4 " .2287* .0308 - . 0 5 2 7 - . 1396 - .0082 .1417 . 6 9 2 6 " . 2 6 0 6 " - .2473 .3578* * .367 1 " . 1505 . 1 120 - .0934 - . 0 8 7 9 - . 0 1 1 5 . 1796 . 3 3 6 6 " . 3 8 4 6 " . 1996 . 3 2 6 1 ' . 2845 ' - .0644 .2408* . 1328 . 1569 .0252 - . 0 3 2 7 - .0544 1 .0000 - . 1045 - . 2 9 1 9 ' .0024 - .2594* .0737 .2553* - . 1045 1.0000 . 2 8 9 5 " . 4 3 3 0 " .0432 .0026 .0103 - . 2 9 1 9 ' . 2 8 9 5 " ' 1.0000 . 1785 .1312 - .0885 .0242 .0024 . 4 3 3 0 " . 1785 1 .0000 .0280 .1313 .1511 - . 2 5 9 4 ' .0432 .1312 .0280 1.0000 .0337 .0016 .0737 .0026 - . 0 8 8 5 .1313 .0337 1.0000 .6600* ' . 2 5 5 3 ' .0103 .0242 .1511 .0016 . 6 6 0 0 ' ' 1 .0000 Note. ATOT - Rosenberg Self-Esceem Scale; BTOT - Lack of S o c i a l Self-Confidence subscale of I n t e r p e r s o n a l Dependency Inventory; CTOT - subscale of Control i n Che Healch Related Hardiness Scale; DTOT - subscale F a i t h i n Therapy i n Che C l i e n t Readiness f o r Therapy Inventory; ETOT - the L i f e O r i e n t a t i o n Test; FTOT - W i l l to L i v e Scale; INTENS - Che number of days over which treatment at St. Vincent's H o s p i t a l occurred d i v i d e d by che number of creacmencs r e c e i v e d at St. Vincent's H o s p i t a l ; INTENS2 - the number of days over which t o t a l treatments occurred d i v i d e d by the cecal number of creacmencs; G2 - the t h e r a p i s t s r a t i n g of the degree of recovery; C3 - the number of St. Vincent's H o s p i t a l treatments; G4 - che number of days over which che Sc. VincenCs H o s p i c a l creacmencs occurred; HI - the p a t i e n t ' s s e l f - r a t i n g of recovery; H19 - the amount the pacienc complied with Che home e x e r c i s e program; H20 - Che amount of emotional support r e c e i v e d ; H22 - negative l i f e impact; H23 - s e l f - r a c i n g of healch; H24 - focus of accencion on being i n j u r e d or healed; H25 - degree of p h y s i c a l f i t n e s s maintained; H27 - age; TXNO - t o t a l number of creacments; TXDAYS - t o c a l treacmenc days. • - SIGNIF. LE .01 " - SIGNIF. LE .001 I l l APPENDIX E Data A n a l y s i s with the Portuguese P o p u l a t i o n Removed 112 Ta b l e 14 Means and Standard D e v i a t i o n s f o r Dependent Measures f o r  the Degree of Recovery Groups wi t h no Portuguese. PR group MR group GR group (n = 20) (n = 51) (n = 38) V a r i a b l e s M SD M SD M SD s e l f - e s t e e m 18. 4 (5. 1) 16 .6(3.8) 16 .0(4.1) l a c k o f s o c i a l s e l f - c o n f i d e n c e 29. 2 (6. 5) 28 .5(7.0) 29 .5(6.6) l o c u s o f C o n t r o l 42. 0(8. 1) 43 .2(10.4) 39 .1(11.3) f a i t h i n therapy 16. 9(3. 1) 14 .1(4.2) 12 .1(3.9) optimism 20. 2 (5. 7) 20 .4(4.8) 22 .8(4.4) w i l l t o l i v e 15. 0(3. 8) 14 .8(2.5) 14 .4(3.5) Note. PR = poor r e c o v e r y ; MR = moderate r e c o v e r y ; GR = good r e c o v e r y . Low sc o r e s on s e l f esteem, l a c k o f s o c i a l s e l f - c o n f i d e n c e , l o c u s o f c o n t r o l , f a i t h i n therapy, optimism, and w i l l t o l i v e i n d i c a t e ; more s e l f esteem, more s e l f - c o n f i d e n c e , h i g h e r c o n t r o l , more f a i t h i n therapy, l e s s optimism, and a g r e a t e r w i l l t o l i v e . 113 Tab l e 15 Summary of MANOVA and followup ANOVAS f o r the Degree of  Recovery Groups w i t h no Portuguese (n = 109). Source SS d f F p< Between Groups M u l t i v a r i a t e 12,202 2.59 .004 U n i v a r i a t e s e l f - e s t e e m 78. 73 2, 106 2. 28 . 107 s e l f - c o n f i d e n c e 20. 58 2, 106 0. 22 .800 l o c u s o f c o n t r o l 382. 54 2, 106 1. 78 . 173 f a i t h i n therapy 306. 60 2, 106 9. 95 . 001 optimism 154. 12 2, 106 3. 31 .041 w i l l t o l i v e 5. 51 2 . 106 0. 28 .758 114 Ta b l e 16 C r i t i c a l V alues ( S c h e f f e Tests) of S i g n i f i c a n c e f o r the Dependent Measures Between Groups f o r the Degree o f  Recovery w i t h no Portuguese. PR & GR PR & MR MR . & GR group group group s e l f esteem 4.40 3.02 0.45 f a i t h i n therapy 19.61* 6.85* 6.12 optimism 3.86 0.03 5.57 Note. PR = poor r e c o v e r y group; MR = moderate r e c o v e r y group; GR = good r e c o v e r y group; (*) denotes p a i r s o f groups s i g n i f i c a n t l y d i f f e r e n t a t the p_ <.05 l e v e l . 

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