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Locus of control and psychosocial adjustment to chronic pain Hooge, Brenda Lee Sawyer 1983

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LOCUS OF CONTROL AND PSYCHOSOCIAL ADJUSTMENT TO CHRONIC P A I N  by  BRENDA L E E SAWYER HOOGE B.A., U n i v e r s i t y o f S a s k a t c h e w a n , 1968 M.Sc, Simmons C o l l e g e , 1974  A THESIS SUBMITTED I N P A R T I A L FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS  in  THE FACULTY OF GRADUATE (Department  STUDIES  of Counselling Psychology)  We a c c e p t t h i s  t h e s i s as c o n f o r m i n g  to t h e r e q u i r e d  standard  THE UNIVERSITY OF B R I T I S H COLUMBIA O c t o b e r 1983  © B r e n d a L e e S a w y e r H o o g e , 1983  In  presenting  an  advanced degree at  the  Library  further  this  thesis  this  agree that  University  of B r i t i s h  be  for financial  g r a n t e d by  shall  permission.  Department of C o u n s e l l i n g  Psychology  The U n i v e r s i t y o f B r i t i s h V a n c o u v e r , Canada V6T 1Y3  Columbia  Date  requirements  Columbia, I agree  c o p y i n g of  t h e H e a d o f my  I t i s understood gain  the  a v a i l a b l e f o r r e f e r e n c e and  permission for extensive  representatives.  thesis  f u l f i l m e n t of  s h a l l make i t f r e e l y  s c h o l a r l y p u r p o s e s may or her  the  in partial  not  that be  this  that  study. thesis  Department or  c o p y i n g or  for  I for  by  his  publication  a l l o w e d w i t h o u t my  written  of  ABSTRACT  This control, pain  study  sought  psychosocial  t o examine t h e r e l a t i o n s h i p s between l o c u s o f adjustment  to chronic  p a i n , and r e p o r t e d  f o r c h r o n i c p a i n p a t i e n t s who h a d c o m p l e t e d  m u l t i d i s c i p l i n a r y p a i n treatment program. one  i n d i v i d u a l s drawn from B r i t i s h  all  o f whom had c o m p l e t e d a p a i n  Columbia  during  an i n - p a t i e n t ,  The sample  t r e a t m e n t program  Locus o f C o n t r o l S c a l e ,  ( A C P S ) , and t h e M c G i l l P a i n  British  A l l i n d i v i d u a l s completed the  the Adjustment  Questionnaire,  to Chronic  Pain  Scale  Questionnaire.  F i v e hypotheses were t e s t e d . tested  Saskatchewan  i n Vancouver,  f o l l o w i n g q u e s t i o n n a i r e s : a B i o g r a p h i c a l ^Information Rotter's  consisted of f o r t y  C o l u m b i a , A l b e r t a , and  t h e y e a r s 1979-1982.  levels of  Hypotheses  One, Two, a n d T h r e e  were  u s i n g P e a r s o n Product-Moment c o r r e l a t i o n c o e f f i c i e n t s t o  establish  the r e l a t i o n s h i p s between v a r i a b l e s .  were t e s t e d u s i n g  independent  groups  t-tests  Hypotheses  Four  f o r the d i f f e r e n c e between  means t o d e t e r m i n e i f t h e r e was a s t a t i s t i c a l l y s i g n i f i c a n t b e t w e e n t h e means o f t h e two g r o u p s p s y c h o s o c i a l adjustment Significant the Locus  to chronic  negative  on d i f f e r e n t  difference  variables of  pain.  c o r r e l a t i o n s were found f o r f e m a l e s  of Control scores  and t h e ACPS s c o r e s  relationship  b e t w e e n an i n t e r n a l  adjustment.  Similarly,  and F i v e  suggesting  l o c u s o f c o n t r o l and poor  a significant  i n t e r a c t i o n was f o u n d  between  a psychosocial between  - iii  internality  and h i g h  significant  c o r r e l a t i o n was  high  of r e p o r t e d  levels  curvilinear high  levels  pain f o r females.  found between e x t e r n a l l o c u s  pain.  A secondary  e x t e r n a l s ) and  poor  For males,  significant  of l o c u s of c o n t r o l ( i . e .  p s y c h o s o c i a l adjustment  to  pain.  I m p l i c a t i o n s f o r the c o n s t r u c t i v e use of the l o c u s of c o n t r o l m e a s u r e as a t h e r a p e u t i c i n t e r v e n t i o n s t r a t e g y i n c o u n s e l l i n g c h r o n i c p a i n p a t i e n t s are  discussed.  a  of c o n t r o l and  a n a l y s i s found a  r e l a t i o n s h i p between the extremes  i n t e r n a l s and h i g h  chronic  of reported  -  - iv -  TABLE OF CONTENTS PAGE Abstract  i  Table of Contents List  of Tables  List  of Figures  i iv  v i i viii  Acknowledgements  i x  Dedication  x  CHAPTER I INTRODUCTION Statement of the Problem  1  Objectives  6  of the Study  S i g n i f i c a n c e of the Study  7  Limitations  8  Overview of the Study  8  CHAPTER I I REVIEW OF THE L I T E R A T U R E Introduction  10  Chronic  10  Pain - A Societal Perspective  Pain Perception  and Measurement  13  Treatment S t r a t e g i e s  15  E v a l u a t i o n of Adjustment  19  Gender D i f f e r e n c e s  i n Chronic  Pain  20  - v -  TABLE OF CONTENTS c o n t i n u e d PAGE Locus of Control - T h e o r e t i c a l Context  23  Locus of C o n t r o l - Conceptual Assumptions  28  L o c u s o f C o n t r o l - Gender D i f f e r e n c e s  30  Summary  31  CHAPTER I I I METHODOLOGY Sample C h a r a c t e r i s t i c s  33  Instrumentation  34  Data C o l l e c t i o n  43  R e s e a r c h H y p o t h e s e s and Method o f T e s t i n g  44  Summary  46  CHAPTER I V RESULTS H y p o t h e s e s , Method o f T e s t i n g  and R e s u l t s  47  Secondary A n a l y s i s  58  Summary o f R e s u l t s  59  CHAPTER V SUMMARY, CONCLUSIONS AND DISCUSSION Summary  61  C o n c l u s i o n s and D i s c u s s i o n  63  Limitations  73  of the Study  - vi -  TABLE OF  CONTENTS c o n t i n u e d PAGE  I m p l i c a t i o n s of the Study  75  Suggestions  79  Conclusion  f o r Future Research  81  References  83  Appendices  90  - v i i -  L I S T OF  TABLES  TABLE  PAGE  I n t e r n a l c o n s i s t e n c y scores f o r the Adjustment to Chronic P a i n S c a l e (ACPS).  38  Item a n a l y s i s r e s u l t s P a i n Scale (ACPS).  f o r the A d j u s t m e n t t o C h r o n i c  39  P e a r s o n Product-Moment C o r r e l a t i o n C o e f f i c i e n t s f o r m a l e s and f e m a l e s u s i n g t o t a l s c o r e s f o r e a c h s e x on L o c u s o f C o n t r o l and MPQ.  54  T - t e s t u s i n g Adjustment to Chronic t o compare m a l e s and females.  55  Pain Scale  Means and S t a n d a r d D e v i a t i o n s o f ACPS s c o r e s two a d j u s t e r g r o u p s o f m a l e s and females. T - t e s t u s i n g Locus of C o n t r o l s c o r e s and p o o r a d j u s t e r s .  scores  for  t o c o m p a r e good  56  57  - viii  -  L I S T OF FIGURES  FIGURE  3  PAGE  L o c u s o f C o n t r o l s c o r e s a n d ACPS s c o r e s subjects.  fora l l  49  Locus of C o n t r o l scores male s u b j e c t s .  a n d ACPS s c o r e s  for  51  Locus of C o n t r o l scores female s u b j e c t s .  a n d ACPS s c o r e s f o r  53  -  ix -  Acknowledgements  I would l i k e Dr.  t o express  my a p p r e c i a t i o n t o my c h a i r p e r s o n , •  M a r v W e s t w o o d , a n d t o my c o m m i t t e e member, D r . S h a r o n K a h n , f o r  their  supervision, patience,  support,  f e e d b a c k a n d humour.  B o t h have  i n f l u e n c e d my p r o f e s s i o n a l d e v e l o p m e n t a s a c o u n s e l l o r a n d r e s e a r c h e r and  I am g r a t e f u l f o r t h e i r  unavailable during assistance  during To  I  expertise.  the l a t t e r  stages  D r . J i m V a r g o was  o f my t h e s i s , I a p p r e c i a t e h i s  the p r e l i m i n a r y stages  o f my  research.  my h u s b a n d , J o h n , a n d t o o u r c h i l d r e n , A n d r e a a n d S a m u e l ,  am e s p e c i a l l y t h a n k f u l f o r t h e i r  ongoing support,  e n c o u r a g e m e n t t h r o u g h t h e many y e a r s degree.  Although  To my p a r e n t s ,  l o v e , and  i t t o o k me t o c o m p l e t e  this  M i l d r e d a n d J o h n S a w y e r , I am g r a t e f u l f o r  t e a c h i n g me p e r s e v e r a n c e a n d f o r v a l u i n g my s p i r i t . s u s t a i n s me w i t h u n f a i l i n g  good a d v i c e ,  generosity,  My s i s t e r , S i d , and c a r i n g .  I w a n t t o t h a n k my many f r i e n d s a t S y n e r g y who h e l p me without  bumping on t h e w a l l s . Finally,  and  dance  Sharon f o r t h e i r  I would  like  t o t h a n k my d e a r f r i e n d s C a r e n ,  l o v e and u n d e r s t a n d i n g .  I would n o t have had t h e m o t i v a t i o n  Without  to complete t h i s  their thesis.  Muff,  inspiration  - x -  DEDICATION  This  thesis  i s dedicated  Shari a f r i e n d who h e l p e d  t o t h e memory o f  Podersky-Cannon,  me t o l i v e ,  a n d t o know how and why.  CHAPTER  ONE  Introduction  Chronic  p a i n i s one o f t h e most p r e v a l e n t  problems p h y s i c i a n s  treat.  Chronic  chronic,  payments ( N a g i , R i l e y , afflicts  each year. and  entity with  with  & Newby, 1 9 7 3 ) . of the p o p u l a t i o n  s e r i o u s i n d i v i d u a l and s o c i e t a l  pain behaviors  medical  c o s t s , and  P a i n , both acute  and  of the U n i t e d  States  cause o f  y e t i t i s o n l y now c o m i n g t o be r e c o g n i z e d  as a  impact (Lorenz,  appear t o share c e r t a i n important  disability disease  1981).  commonalities  addictive states, including self-destructive features,  intractability of  hospitalization,  I t r a n k s a s p e r h a p s t h e most f r e q u e n t  suffering,  Chronic  about o n e - t h i r d  difficult  p a i n r a n k s among t h e l e a d i n g  problems i n terms o f p h y s i c i a n v i s i t s , disability  and  to treatment,  iatrogenesis.  psychological, closely severity  Seres,  social,  frequency  of r e c u r r e n c e ,  incidence  P a i n t e r , and Newman ( 1 9 8 1 ) made t h e p o i n t  and e n v i r o n m e n t a l  that  f a c t o r s a p p e a r t o be more  r e l a t e d t o p a i n and t o p a i n r e l i e f of i n j u r y ,  and h i g h  than a r e such f a c t o r s as  number o f s u r g e r i e s , o r r a d i o g r a p h i c f i n d i n g s .  Statement o f the Problem The  cognitive, overt  seen i n c h r o n i c  b e h a v i o r a l , and p h y s i o l o g i c a l r e s p o n s e s  p a i n p a t i e n t s a r e t h e e n d p r o d u c t s of an e x t e n d e d  l e a r n i n g h i s t o r y (Keefe,  1982).  A t the "acute  stage"  of coping  with  - 2 -  pain, this  p a t i e n t s d i s p l a y pain behavior stage,  decreases  i n activity  p r o m o t e h e a l i n g o f t i s s u e damage. and  at least  begins  M u s c l e s p a s m may  stage  typically  financial likely  t o become p a i n f r e e .  exacerbating  leads  t o g r a d u a l l y resume a c t i v i t y a r e  f o r developing  chronic  this  i n p a i n and r e v e r t t o p a i n b e h a v i o r s  once a g a i n  t o these  maladaptive.  often experience  a  s u c h a s r e l i a n c e on  t o resume a c t i v i t y and a s t i m e  the pain behaviors  that  continues  fails  and i f  become s t r o n g e r a n d  that lead to a shortening of muscles,  m u s c l e s p a s m , and f a t i g u e . is little  cognitive  pain.  P a t i e n t s may become c a u t i o u s a n d g u a r d e d i n t h e i r  movements - p a t t e r n s  there  Each attempt  pain behaviors,  pattern i s repeated,  pain are  P a t i e n t s who a r e u n a b l e b e c a u s e o f  c o n s i d e r a t i o n s or u n w i l l i n g  and p a i n m e d i c a t i o n .  The  t a s k may be c r i t i c a l .  P a t i e n t s who a b r u p t l y r e s u m e a c t i v i t y  bedrest  Patients at  a t t e m p t t o r e t u r n t o a more a c t i v e l i f e s t y l e .  t o be a t h i g h r i s k  flalr-up  f o r some  i n which  entrenched.  P a t i e n t s who g r a d u a l l y r e s u m e a c t i v i t y w i t h o u t more l i k e l y  As h e a l i n g  (2-6 months p o s t - i n j u r y ) p a i n p e r s i s t s  manner i n w h i c h t h e p a t i e n t a p p r o a c h e s t h i s  may  joints  from r e i n j u r y .  p a t t e r n s may become more f i r m l y  At  intake  immobilize  T h e s e p a t i e n t s may e n t e r a " p r e - c h r o n i c " s t a g e  pain-behavior this  place  that are adaptive.  and i n c r e a s e s i n m e d i c a t i o n  i n i t i a l l y p r o t e c t the i n d i v i d u a l  to take  patients.  patterns  t h a t they  distortions  increased  P a t i e n t s may a l s o become c o n v i n c e d  that  c a n do t o c o n t r o l p a i n and may become p r o n e t o  serving to increase depression  and d r u g  dependency. As they w i l l  these  pain behavior  lead to p o s i t i v e  social  patterns recur, the l i k e l i h o o d  that  consequences i s a l s o i n c r e a s e d .  That  - 3 -  is,  s p o u s e a n d f a m i l y members may become q u i t e c o n c e r n e d a n d t a k e  many o f t h e p a t i e n t ' s r e s p o n s i b i l i t i e s and  pain medication  intake.  At the "chronic  p o s t - i n j u r y ) evidence f o r underlying is  o f t e n absent or minimal.  solicitous  and a c t u a l l y pain  enforce  stage"  inactivity  (6 m o n t h s  Powerful  p o s i t i v e consequences such as  o r home r e s p o n s i b i l i t i e s ,  and f i n a n c i a l  c o m p e n s a t i o n , h o w e v e r , may  t o r e i n f o r c e and m a i n t a i n  pain behavior  patterns.  chronic  p a i n syndrome.  considerable modalities  these  perpetuation  have d e s c r i b e d  nature  i n the treatment behaviors  of c h r o n i c  Specifically,  process  are required.  pain.  This  failure  from an i n a b i l i t y  to recognize the  on t h e outcome o f  treatment.  t h e c o n c e p t o f l o c u s o f c o n t r o l ( R o t t e r , 1966)  t o o r management o f p a i n a f t e r The l o c u s  individuals  perceive  of c o n t r o l construct the events i n t h e i r  their  own a c t i o n s , a n d t h e r e b y  being  unrelated  to their  Failure to  or lack of adjustment t o  be a p p l i e d t o a n a n a l y s i s o f c h r o n i c p a i n p a t i e n t s '  program.  of the  o f t e n h a s as t h e c o n s e q u e n c e t h e  consequences o f one's b e h a v i o r  adjustment  serve  To be s u c c e s s f u l i n t e r m s o f p a i n management  p a i n management c o u l d r e s u l t  can  the s t r e s s f u l  work  s e l f - d i s c i p l i n e on t h e p a r t o f t h e p a t i e n t and adherence t o  learned  incorporate  plus  t i s s u e damage r e s p o n s i b l e f o r p a i n  a t t e n t i o n from f a m i l y or spouse, a v o i d a n c e o f unwanted  Many o b s e r v e r s  over  control  (external control).  control  tend  an i n - p a t i e n t p a i n  treatment  r e f e r s to the degree to which lives  as b e i n g  controllable (internal  own b e h a v i o r s  psychosocial  a consequence o f  control),  and, t h e r e f o r e , beyond  I n d i v i d u a l s w i t h an i n t e r n a l  or as personal  locus of  t o b e l i e v e t h a t e v e n t s and rewards a r e c o n t i n g e n t  upon  -  their  own  believe or  behavior,  that  while  e v e n t s and  -  individuals with  rewards are  an  external  l a r g e l y the  locus  r e s u l t of  of  control  luck,  chance,  fate. According  subject's  locus  be  to Phares  of  These c o n d i t i o n s  n a r r o w , and  c o n t r o l can  p r o g r a m s , and  behavior.  exerted,  a v a r i e t y of  e x p e c t a n c y or a very  stated  the  successfully,  situation, that  or  a range of  Some o f  be  one  conditions.  these forces  but  a l t e r e d by include  or n a t i o n a l e v e n t s ,  that w i l l  must i n f l u e n c e  be  factors certainty  techniques. as  a very  specific  i n e i t h e r case i t i s important As  generalized  a somewhat n a r r o w e x p e c t a n c y a r i s i n g  the  expectancy  out  world  for  control  of a  v i e w e d as a r e l a t i v e l y  stable characteristic  persons carry with  them f r o m s i t u a t i o n t o  situation.  control  chronic  f r a m e w o r k as  Harrow & F e r r a n t e ,  pain  patients  are  viewed  f r o m an  some a u t h o r s h a v e s u g g e s t e d  1969;  external  (Abramowitz,  Skevington, 1979), then f a i l u r e  may  specific  be  If  to  Phares  to cope w i t h  Phares suggested f u r t h e r that perceived  i t may  a  special training  affect i t s strength.  their  may  pervasive,  that a f f e c t a subject's  construed  one,  the  i n f l u e n c e s whose e f f e c t s  to enhance i n d i v i d u a l s ' c a p a c i t y  internal control. v i e w e d as  (reflecting  L o c u s of c o n t r o l can  therapeutic  general  conditions  i n order  specific  world  I n t e r n a l c o n t r o l can  understand  a l t e r e d by  changes, c o n d i t i o n s  be  scores  a l s o c h a n g e s t h a t h a v e more  of e n v i r o n m e n t a l f o r c e s .  t h a t a c c o m p a n y age that  be  include both very  t r a n s i t o r y and  variety  ( 1 9 7 6 ) I-E  c o n t r o l ) can  p e r m a n e n t e f f e c t s on  be  4  locus  of  1969;  t o manage o n e ' s  p a i n w e l l a f t e r treatment probably r e s u l t s from a view p o i n t  of  the  - 5 -  patients point  that  their  actions  do n o t a f f e c t t h e i r m e d i c a l c o n d i t i o n .  of view suggests that  pain  process i t s e l f  locus  of c o n t r o l .  the h i g h l y  stressful  nature of the chronic  t e n d s t o make i n d i v i d u a l s more e x t e r n a l Therefore,  i t could  i n their  be i m p o r t a n t t o know  p r e - t r e a t m e n t whether an i n d i v i d u a l has an i n t e r n a l o r e x t e r n a l control.  I f t h e f e e l i n g o f c o n t r o l were a b s e n t  e f f e c t i v e n e s s o f many b e h a v i o r a l motivational  This  locus of  (high E score) then the  i n t e r v e n t i o n s t r a t e g i e s on t h e  components o f p a i n c o u l d  b e e x p e c t e d t o be s u b s t a n t i a l l y  reduced. Changes i n l o c u s  o f c o n t r o l o c c u r as a r e s u l t o f n a t u r a l  events or a d e l i b e r a t e e f f o r t Examples o f t h i s recovery  a r e found i n s t u d i e s  internality  personal  p s y c h o t h e r a p y , where  in internality  control of t h e i r world.  i s a sign of  Patients'  of the i n d i v i d u a l s concerned.  of s u c c e s s f u l  i s a c c o m p a n i e d by a n i n c r e a s e  take greater  with  on t h e p a r t  so t h a t  patients  H e r e , an i n c r e a s e i n  recovery.  b e l i e f s about t h e i r  chronic  pain,  and t h e i r  coping  p a i n , may b e d e t e r m i n e d b y a c o g n i t i v e s t y l e s u c h a s l o c u s o f  control rather strategies  t h a n by t h e a c t u a l s e v e r i t y o f t h e i r  a r e d e t e r m i n e d by a n i n d i v i d u a l ' s b a s i c  Locus of c o n t r o l i s a p e r s o n a l i t y v a r i a b l e that individual  behaves w i t h i n a s o c i a l  externally  oriented  treatments that sought s o c i a l  system  r e q u i r e autonomous b e h a v i o r . from e x t e r n a l  personality  Coping style.  e l u c i d a t e s how an  ( L e f c o u r t , 1976).  i n d i v i d u a l may h a v e t r o u b l e  reinforcement  disability.  complying  with  I n d i v i d u a l s who  f a c t o r s may  find  The  have  - 6 -  rehabilitation difficult. difficulty Hence,  coping  with  The i n t e r n a l l y  l o c a t e d i n d i v i d u a l may  the dependent nature  of c e r t a i n  the role of a p e r s o n a l i t y v a r i a b l e l i k e  interacting with chronic  have  treatments.  locus of c o n t r o l i n  p a i n management seems t o w a r r a n t  further  investigation.  Objectives  o f the Study It  interest  i s c l e a r from the l i t e r a t u r e  that  i n f a c t o r s which i n f l u e n c e chronic  management.  This  study  i s designed  there  pain  to explore  i s wide-spread  treatment  and  the i n t e r n a l - e x t e r n a l  l o c u s o f c o n t r o l d i m e n s i o n and i t s ' r e l a t i o n s h i p t o t h e p s y c h o s o c i a l a d j u s t m e n t o f c h r o n i c p a i n p a t i e n t s who h a v e c o m p l e t e d an i n - p a t i e n t , multidisciplinary  pain  answer t h e f o l l o w i n g  treatment  program.  The s t u d y  will  attempt to  questions:  1.  I s t h e r e a r e l a t i o n s h i p between l o c u s o f c o n t r o l ( R o t t e r ' s i n t e r n a l - e x t e r n a l ) and p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n f o r c h r o n i c p a i n p a t i e n t s who h a v e c o m p l e t e d a n i n - p a t i e n t pain treatment program?  2.  I s t h e r e a r e l a t i o n s h i p between l o c u s o f c o n t r o l and a d j u s t m e n t t o c h r o n i c p a i n f o r m a l e s a n d f o r f e m a l e s who h a v e c o m p l e t e d an i n - p a t i e n t p a i n t r e a t m e n t program?  3.  I s locus of c o n t r o l o r i e n t a t i o n r e l a t e d to reported f o r p a t i e n t s f o l l o w i n g an i n - p a t i e n t p a i n treatment program?  4.  Are t h e r e gender d i f f e r e n c e s i n t h e p s y c h o s o c i a l adjustment to chronic pain?  5.  Do t h e good a d j u s t e r s d i f f e r terms o f l o c u s of c o n t r o l ?  pain  from the poor a d j u s t e r s i n  - 7 -  S i g n i f i c a n c e of t h e Study In order  to better understand  the question  i n t e r v e n t i o n w o r k s b e s t f o r whom, i n f o r m a t i o n control  o r i e n t a t i o n of i n d i v i d u a l chronic  important. different  Interventions individuals.  For instance,  not  comply w i t h  findings w i l l  treatment  i n d i v i d u a l s do  f a t e , and t h e r e f o r e  tend  t h e need f o r t h e  strategies for patients.  t o r e s p o n d more f a v o r a b l y  own r e s p o n s i b i l i t y  may  behavior.  (1978) concluded a f t e r a r e v i e w o f t h e l i t e r a t u r e  differentially or  their  be v i e w e d a s s u p p o r t i n g  s t r u c t u r e , whereas i n t e r n a l s p r e f e r their  p a t i e n t s may b e  t r e a t m e n t s t h a t r e q u i r e more a u t o n o m o u s  a p p l i c a t i o n of d i f f e r e n t i a l  externals  pain  the locus of  externally oriented  see t h e m s e l v e s as h a v i n g c o n t r o l over  Strickland  regarding  may be more e f f e c t i v e i f t h e y a r e t a i l o r e d t o  not  The  of which  that  to interventions with  imposed  those i n which they can e x e r c i s e  or s e l f - c o n t r o l .  H e n c e , i n t e r v e n t i o n s may b e  e f f e c t i v e f o r p a t i e n t s depending on t h e i r  coping  styles  personality predispositions. It  well  i s postulated  providers  of pain  t r e a t m e n t w o u l d do  t o d e t e r m i n e t h e p o s t u r e o f t h e p a t i e n t s on t h e l o c u s  dimension, i n order participating staff  that  t o make a v a i l a b l e a more n o n d i r e c t i v e ,  program t o i n t e r n a l l y  c o n t r o l l e d and s t r u c t u r e d  individuals. enrolled  oriented  that  oriented  perhaps i n t e r n a l s c a n be  i n more i n d e p e n d e n t , s e l f - r e g u l a t e d p r o g r a m s w h i l e  w o u l d p r o f i t most f r o m p r o g r a m s t h a t support from  others.  rely  patient  i n d i v i d u a l s , and a more  program f o r e x t e r n a l l y  P h a r e s ( 1 9 7 6 ) made t h e p o i n t  of control  externals  on p r e s t i g e , s u g g e s t i o n ,  or  - 8  Existing  data provide  -  a very  s t r o n g b a s i s f o r the  systematic  i n c o r p o r a t i o n o f v a r i o u s means o f e v a l u a t i n g l o c u s o f c o n t r o l into  d i a g n o s t i c and  patients' those  therapeutic efforts.  locus of c o n t r o l b e l i e f s  persons  and  could (if  apply  the  techniques  the i n d i v i d u a l  desired  C a r e f u l e v a l u a t i o n of  c a n be  a real help  to planning a s e n s i b l e , e f f i c i e n t  about d e s i r e d changes i n b e h a v i o r .  behaviors)  Alternately,  t h a t w o u l d e n h a n c e an  lacks sufficient  to  understanding  program to b r i n g  pain treatment  control  s e l f - c o n f i d e n c e to mediate  certain  overwhelming  internal  programs  l o c u s of  o r t h a t w o u l d r e d u c e an  i n d i v i d u a l experiences  beliefs  internal  locus of c o n t r o l ( i f  guilt).  Limitations The s u b j e c t s who r e s u l t s may may  not  be  r e s e a r c h sample used i n t h i s agreed  be  s t u d y was  restricted  to  t o p a r t i c i p a t e on a v o l u n t e e r b a s i s , t h e r e f o r e  considered  r e l e v a n t o n l y to the i n d i v i d u a l s  g e n e r a l i z e d to other  chronic pain patients.  studied  had  in-patient  pain treatment  three years.  s a m p l e may  respond  differently  and  A l l subjects  w e r e r e s i d e n t s o f a W e s t e r n C a n a d i a n p r o v i n c e and program w i t h i n the past  the  completed  f r o m an i n v o l u n t a r y c h r o n i c  an Such  a  pain  population.  Overview of the This and  appendices.  study. and  Chapter  Study t h e s i s was The two  first  organized chapter  provides  contains a review  into  five  provided  the conceptual  an  chapters  plus  references  i n t r o d u c t i o n to  the  foundation for this  of the r e l e v a n t l i t e r a t u r e .  Chapter  Three  research  - 9  describes  the methodology of the s t u d y .  method of t e s t i n g  in this  chapter.  Four  Chapter  t e s t s of hypotheses. and  -  study  presents Chapter  and  suggestions  tested  are s t a t e d at the c o n c l u s i o n of the r e s u l t s  of the d a t a a n a l y s e s  and this and  F i v e p r o v i d e s the c o n c l u s i o n s , d i s c u s s i o n  summary o f t h e r e s u l t s , a s w e l l a s  findings  H y p o t h e s e s t o be  for further  implications arising  research.  out  of  these  - 10 -  CHAPTER  TWO  Review o f t h e L i t e r a t u r e  Introduction The organized issues  into  of the l i t e r a t u r e  relevant to this  two m a i n a r e a s o f i n t e r e s t .  The f i r s t  i n v o l v i n g the concept of chronic p a i n .  overall  societal  strategies, second  review  perspective, pain perception  s e c t i o n concerns  Included  here i s an  and measurement,  e v a l u a t i o n o f a d j u s t m e n t , and gender d i f f e r e n c e s .  section presents  Included  study i s  the research  here i s the t h e o r e t i c a l  treatment The  related to locus of control.  context  of the c o n s t r u c t ,  conceptual  a s s u m p t i o n s , and a d i s c u s s i o n o f gender d i f f e r e n c e s .  Chronic  Pain - A Societal Perspective Pain  t o be a d i r e c t  i s a u n i v e r s a l human e x p e r i e n c e  that i s u s u a l l y thought  c o n s e q u e n c e o f b o d i l y damage o r p h y s i o l o g i c a l  dysfunction.  As M e l z a c k ( 1 9 7 3 ) s t a t e d , h o w e v e r , t h e r e  evidence that  the report  i s over-whelming  o f p a i n does n o t have a s i m p l e  one-to-one  r e l a t i o n s h i p w i t h e i t h e r b o d i l y damage o r p h y s i o l o g i c a l d y s f u n c t i o n . Extreme i l l u s t r a t i o n s pain of  of this  i n s p i t e of i n j u r y  a r e t h e p e r s o n who shows no e v i d e n c e o f  a n d t h e p e r s o n who r e p o r t s p a i n i n t h e a b s e n c e  injurious stimuli. The  indication  current  abundance o f l i t e r a t u r e  t h a t i t i s a common c l i n i c a l  on c h r o n i c  pain  i s one  problem which remains  poorly  - 11 -  understood. from acute  Chronic pain.  physiologists,  p a i n h a s become r e c o g n i z e d  Among  as a c o n d i t i o n  the neurosurgeons, a n e s t h e s i o l o g i s t s ,  psychologists, psychiatrists,  p r o f e s s i o n a l s who h a v e d e a l t w i t h c h r o n i c  and o t h e r  pain, there  agreement as t o t h e n a t u r e  and t r e a t m e n t  pain  by M e l z a c k , a p u z z l e .  r e m a i n s , as d e s c r i b e d  classical  specificity  distinct  of this  health i s limited  condition.  Chronic  Melzack noted that the  and p a t t e r n t h e o r i e s o f p a i n l a c k u n i t y , f a i l t o  i n t e g r a t e d i v e r s e t h e o r e t i c a l m e c h a n i s m s , and h a v e n o t r e c e i v e d substantial empirical verification. To a v o i d c o n f u s i o n  t h o u g h t o f as a metaphor f o r  all  types  the  I n t e r n a t i o n a l A s s o c i a t i o n f o r the Study of P a i n  as  of anguish  between p a i n  "an u n p l e a s a n t  and p a i n w h i c h i s f e l t  sensory  and e m o t i o n a l  a t a l o c a t i o n i n t h e body,  experience  a c t u a l o r p o t e n t i a l t i s s u e damage, o r d e s c r i b e d (p. 250). the  chronic  complaints existing this  Few w o u l d  disagree  with Black's  p a i n p a t i e n t as h a v i n g f o r at least  (1979) d e f i n e d associated  with  i n t e r m s o f s u c h damage"  (1975) c h a r a c t e r i z a t i o n o f  intractable,  often m u l t i p l e , pain  s i x months w h i c h a r e u s u a l l y i n c o n g r u e n t  somatogenic problems.  Black  f u r t h e r noted  that patients  c h r o n i c p a i n syndrome o f t e n r e v e a l : a h i s t o r y of m u l t i p l e physician contacts nonproductive  d i a g n o s t i c procedures;  preoccupation  with  behavior  excessive  p a t t e r n w i t h some o f t h e f e a t u r e s o f  depression,  a n x i e t y , and n e u r o t i c i s m ;  particular,  no r e a l i s t i c  (p. 1000)  and many  t h e p a i n p r o b l e m ; an a l t e r e d  plans  pain  and, i n  f o r the distant future,  with with  - 12 -  Fordyce variety  (1976),  of psychosocial  expression  Sternbach  systematic  of chronic pain. social  expressions b)  systematic  of d i s a b i l i t y  of s u f f e r i n g (pain  environmental (anxiety,  d)  reinforcement  and d i s a b i l i t y  a  both the  These f a c t o r s i n c l u d e : and  behavior);  monetary compensation f o r p a i n litigation  c)  have s u g g e s t e d  f a c t o r s that can exaggerate or prolong  and e x p e r i e n c e a)  ( 1 9 6 8 ) and o t h e r s  through personal  injury  claims;  stresses leading to a f f e c t i v e d i s t r e s s  depression); a s s o c i a t i o n between p a i n b e h a v i o r  from s t r e s s or from unpleasant  and t i m e o u t  vocational or family  responsibilities; e)  c h r o n i c p a i n as j u s t i f i c a t i o n  of f a i l u r e s  s e l f - e x p e c t a t i o n s or the expectations f)  pain providing j u s t i f i c a t i o n  of  to l i v e  up t o  others;  o f dependence on  analgesics  and/or a l c o h o l ; g)  h)  past  and p r e s e n t  care  system;  lack of prospects the  Typically,  for satisfying  somatic  with  the h e a l t h  one's needs o u t s i d e  of  role.  the chronic pain patient i s f i r m l y  has a s t r i c t l y other  pain patient  i a t r o g e n i c experiences  convinced  t h a t he o r s h e  p h y s i c a l p r o b l e m and h e n c e s e e k s o u t t h e s u r g e o n and specialists  but shuns t h e p s y c h i a t r i s t  or p s y c h o l o g i s t .  c o m b i n e d c o n s i d e r a t i o n o f b o t h t h e p h y s i c a l and p s y c h o l o g i c a l f a c t o r s , however, a l l o w s disorder.  a v i e w o f c h r o n i c p a i n as a s p e c i f i c  psychobiological  A  -  Aronoff  and  psychosomatic process behavior.  the  sensory  as  pain  s u f f e r i n g as  and  A c e n t r a l goal  emotional  s u c h , i t i s t h o u g h t t o be  pain treatment  the highest  of l i f e  P a i n P e r c e p t i o n and One investigators pain.  As  t h a t may  cognitions  pain  sensory  on  behavior spouse or  tasks  facing both  suffering.  research  continue  clinical  experience  reactions,  1979).  p a t i e n t ' s report of pain experiences First,  p a t i e n t s who  t o c o m p l a i n o f p a i n may reverse  o f t e n a s s o c i a t e d w i t h poor outcome.  is  show i m p r o v e m e n t s i n elicit  responses  therapeutic benefits.  u n d e r g o m u l t i p l e d i a g n o s t i c and  which  and  Study of P a i n ,  p e r s i s t e n t r e p o r t of pain a l s o i n c r e a s e s the  factors  an  a c t u a l o r p o t e n t i a l t i s s u e damage, and  f a m i l y members t h a t may  p a i n p a t i e n t s may  function.  approaches i s  i s a s u b j e c t i v e , unpleasant  f o r several reasons. who  chronic  self-reliance,  r e s i d u a l p a i n and  ( I n t e r n a t i o n a l A s s o c i a t i o n f o r the  but  teaching  emotional  treatment  information, affective  Assessment of the important  pain  Comprehensive,  h e a l t h p r o f e s s i o n a l s i s the measurement o f  associated with  d e t e r m i n e d by  goal directed  Measurement  noted e a r l i e r , be  p o s s i b l e p h y s i c a l and  o f the most d i f f i c u l t and  and  a m e n a b l e t o c h a n g e e v e n when  programs a l l focus  i n s p i t e o f any  a complex  r e a c t i o n to  p a i n remains unchanged.  i n most m u l t i d i s c i p l i n a r y  improved q u a l i t y  the  the  s u f f e r e r s ways t o manage p a i n w h i l e m a i n t a i n i n g  self-control  is  c h r o n i c p a i n as  i n which s u f f e r i n g i s a learned  q u a l i t y of the  multidisciplinary  -  Evans (1982) see  They r e g a r d  s e n s a t i o n and,  13  likelihood surgical  T h i r d , and  that  from  Second, chronic  treatment,  p e r h a p s most  - 14 -  important,  the perception  of pain  i s often the patient's  primary  concern. The clear. that  meaning o f c o n t r o l i n p a i n p e r c e p t i o n  Averill  ( 1 9 7 3 ) i n an a n a l y s i s o f c o n t r o l a s a v a r i a b l e , showed  i t has been used t o r e f e r t o b e h a v i o r a l c o n t r o l ,  or d e c i s i o n a l c o n t r o l . handling  Not a l l i n d i v i d u a l s f e e l  the r e s p o n s i b i l i t y  provider. occurs  For instance, with  by t h e d e m o n s t r a t i o n  placebo  medication  anxiety  that something i s being  done t o c o n t r o l  pain  i s important  when i t i s c o m b i n e d w i t h a p e r s o n ' s f e e l i n g o f  H i s a n a l y s i s i m p l i e s t h a t a n x i e t y r e d u c t i o n s t r a t e g i e s such as  the person a f e e l i n g  that the pain w i l l  someone, w h e t h e r t h e p a t i e n t h i m s e l f  tolerance  t o p a i n by  and c a n be c o n t r o l l e d b y  or a trusted other  h a s y i e l d e d h i s own power o f c o n t r o l .  feeling  some  control.  d e s e n s i t i z a t i o n , m o d e l i n g , and r e l a x a t i o n i n c r e a s e giving  of  reduction  (1980) s t a t e d t h a t a n x i e t y r e d u c t i o n  i n pain perception mainly control.  Clinically,  control,  c o n t r o l to the health-care  e v e n i f i t i s n o t t h e p a t i e n t who i s e x e r t i n g Weisenberg  cognitive  e q u a l l y capable  that control implies.  p a t i e n t s may be b e t t e r o f f y i e l d i n g  he  i s not e n t i r e l y  He p r o p o s e d  p e r s o n t o whom  t h a t when t h e  o f c o n t r o l i s a b s e n t , t h e e f f e c t i v e n e s s o f many  behavioral  i n t e r v e n t i o n s o n t h e m o t i v a t i o n a l component o f p a i n w o u l d be substantially  reduced.  This  behavior  regulation of pain  i s an e s s e n t i a l  part of the c o n t r o l of pain. Traditionally, verbal, or visual  rating  o r a word t o d e s c r i b e  p a i n r e p o r t has been assessed scales.  using  numerical,  P a t i e n t s a r e a s k e d t o s e l e c t a number  the i n t e n s i t y of t h e i r  pain.  A variation of this  -  15 -  approach, the v i s u a l analogue s c a l e (Huskisson, used t o assess Rating these  pain intensity  i n c h r o n i c pain treatment  widely  programs.  s c a l e s h a v e two m a j o r p r o b l e m s ( L o d g e a n d T u r s k y , 1 9 8 1 ) . s c a l e s measure o n l y one d i m e n s i o n , i n t e n s i t y ,  phenomenon t h a t i s m u l t i d i m e n s i o n a l . responses on these statistically 1982).  aspects  (Tursky,  between  Jamner, and F r i e d m a n ,  have r e c e n t l y devoted major e f f o r t s t o  p a i n p e r c e p t i o n measures t h a t assess  of pain report  probably  perceptual  Second, t h e d i s t a n c e s  as though they were e q u a l  Pain Questionnaire  of a  First,  s c a l e s a r e unknown b u t a r e u s u a l l y t r e a t e d  Pain researchers  developing  i n a valid  (Melzack,  the multidimensional  and q u a n t i f i a b l e m a n n e r .  1 9 7 5 ) i s one r e s u l t  of this  t h e most commonly u s e d m e a s u r e o f p a i n r e p o r t  f r o m many o f t h e d i f f i c u l t i e s visual  1974), has been  The M c G i l l  research  and i s  since i ti s free  associated with numerical,  v e r b a l and  analogue s c a l e s .  Treatment S t r a t e g i e s Recognition behavioral,  a n d p s y c h o l o g i c a l phenomenon h a s l e d t o t h e d e v e l o p m e n t o f  i n n o v a t i v e treatment assumption. combination patients.  t h a t c h r o n i c p a i n i s a complex n e u r o p h y s i o l o g i c a l ,  programs.  Specifically, of treatment  T h e s e p r o g r a m s s h a r e one common  i fchronic pain  techniques  i s complex, then a  i s needed t o s u c c e s s f u l l y t r e a t  T h e r e h a s b e e n a r a p i d g r o w t h i n t h e number o f p a i n  around t h e world  since the concept of a m u l t i d i s c i p l i n a r y  p a i n p r o b l e m s was f i r s t  introduced  t h e r e have been c o m p a r a t i v e l y  (Bonica  few r e p o r t e d  & Black,  1974).  clinics  approach to However,  studies of the effectiveness  -  of  such c l i n i c s .  H a l l e t t and  w h i c h have been p u b l i s h e d available  16  -  Pilowsky  and  (1982) reviewed  concluded  that  Pain  clinics  vary  in their  the  importance of p s y c h o l o g i c a l  has  become i n c r e a s i n g l y r e c o g n i z e d t h i s has  ( 1 9 7 4 ) has  evolved  argued  d a i l y monitoring  the  that  r e h a b i l i t a t i o n of  the and  behavioral  and  considerably.  notably as  First, the  pain  supervision  patient  of  the  pain  psychiatric  close  behavior.  control,  particularly  mainly  i n f l u e n c e of contemporary c o n c e p t s of  sensory components.  (medical  by  and  the  i n t e r a c t i o n of  methods.  surgical) therapies  to  p a t i e n t s , many o f whom do 1980).  not  pain  cognitive,  Second, the  pain failure  i n adequately  p a i n p a t i e n t s , as w e l l as  s i d e - e f f e c t s due  (Merskey,  most  1975), which views  the  such treatments  s u b s t a n t i a l evidence of p s y c h o l o g i c a l  techniques  pain,  for  Such c o n c e p t s emphasize t h a t  psychological  f o r many c h r o n i c  o c c u r r e n c e of d e b i l i t a t i n g  pain  the  responsible  and  chronic  adequate f o r  because they provide  (Melzack & Wall,  and  Sternbach  T h r e e r e l a t e d f a c t o r s seem t o be  gate c o n t r o l theory  Third,  in-patient units.  patient's  approaches f o r pain  pain  Sternbach, 1968),  increased  the  1973).  However,  c o g n i t i v e i n t e r v e n t i o n s , have r e c e n t l y  somatic  alleviating  approaches.  ( F o r d y c e , 1976; of  and  syndromes.  i n - p a t i e n t programs are  chronic  potentially modifiable  of p u r e l y  far  personality factors i n chronic  a c o m p l e x phenomenon r e s u l t i n g f r o m t h e  motivational is  and  pain  emphases and  establishment  only  Psychological  this.  evidence thus  s u g g e s t s t h a t m u l t i d i s c i p l i n a r y p a i n c l i n i c s make a u s e f u l  i m p o r t a n t c o n t r i b u t i o n t o t h e management o f  with  the  those r e s u l t s  (Melzack,  illness  respond w e l l to  in  traditional  - 17 -  T r a d i t i o n a l management o f c h r o n i c encompassed such o p t i o n s medications, the  as bed r e s t ,  nerve b l o c k s , surgery,  c e n t r a l nervous system.  ameliorating cancer  uncomplicated  pain, their  p a i n has g e n e r a l l y  p h y s i c a l therapy,  and, at times,  Although  these  operative  techniques  c h r o n i c p a i n , acute  effectiveness i s marginal  potent  may be u s e f u l i n  p a i n , and t e r m i n a l  i n dealing with  p a i n s y n d r o m e s most o f t e n e n c o u n t e r e d i n p a i n c e n t e r s . demonstrated  the importance of the m u l t i d i s c i p l i n a r y  Pain centers treatments  diagnosis 1981).  p h y s i c a l and  w i t h t h e p a t i e n t as a t o t a l  medical being.  T h e r e a r e f e a t u r e s w h i c h a r e common t o most c h r o n i c p a i n c l i n i c s differing  emphases o n c e r t a i n a s p e c t s .  this  to posture  m e c h a n i c s and t o d a i l y  i s p h y s i c a l therapy,  therapy.  Psychotherapy i n groups, i n d i v i d u a l l y ,  provide  skills  or strategies.  hypnosis,  reasonable  are  used as a p p r o p r i a t e  therapies available.  i n drug withdrawal  Included i n  e x e r c i s e s , a n d movement and w i t h  the spouse include  m o d e l i n g , and c o g n i t i v e  D a i l y l e c t u r e s and d i s c u s s i o n groups  patients with information regarding  the  exercise  p a r t o f most p r o g r a m s a n d m i g h t  operant c o n d i t i o n i n g techniques, coping  activities.  r e c r e a t i o n a l and p o o l  and/or f a m i l y i s an important  with  P a t i e n t s a r e i n v o l v e d i n an  a c t i v e program s t r e s s i n g e x e r c i s e and a p p l i c a t i o n o f p r o p e r principles  has  team a p p r o a c h t o  methods ( L o r e n z ,  u s u a l l y combine t r a d i t i o n a l  i n t o a model t h a t d e a l s  the chronic  Experience  c h r o n i c p a i n , p a r t i c u l a r l y when t h e p a i n p r o b l e m h a s e l u d e d a n d / o r a d e q u a t e management v i a c o n v e n t i o n a l  lesions to  the source  Biofeedback  to the p a t i e n t ' s needs.  and d a i l y m o n i t o r i n g  o f t h e p a i n and  and r e l a x a t i o n t r a i n i n g Patients are assisted  of medical  problems.  Vocational  - 18 -  rehabilitation counselling role  of the pain  center  i s part  o f any c o m p r e h e n s i v e p r o g r a m .  as a t u r n i n g  point  i n the p a t i e n t ' s  The  life is  stressed. The e m p h a s i s i n t h e s e c e n t e r s and  functioning  often  i n s p i t e of p h y s i c a l  an u n r e a l i s t i c g o a l  histories  symptoms.  certain basic  Total  to emotional relief  as e v i d e n c e d by t h e p a t i e n t s '  of p r i o r treatment f a i l u r e .  approach pain with  i s on r e t u r n  Most p a i n  health  of pain i s  extensive  clinics,  therefore,  t h e c o n c e p t o f c o n t r o l and management, and t h e r e  and c h a r a c t e r i s t i c g o a l s w h i c h t h e y h a v e i n common.  are These  include: a)  e l i m i n a t i n g t h e s o u r c e o f p a i n when f e a s i b l e ;  b)  teaching  c)  improving pain  the p a t i e n t  psychological  to function w i t h i n pain l i m i t a t i o n s ;  c o n t r o l through p h y s i c a l  therapy  and  methods;  d)  r e l i e v i n g drug  dependence;  e)  treating underlying  f)  addressing  g)  improving family  h)  providing  d e p r e s s i o n and  secondary gain  insomnia;  issues;  and c o m m u n i t y  access to vocational  support and  systems;  occupational  rehabilitation; i)  returning  the patient  t o a f u n c t i o n a l and  productive  lifestyle; j)  stopping  patients'  symptomatic  relief.  'doctor shopping'  i n search of  - 19 -  Evaluation  o f Adjustment Long term f o l l o w - u p  adjustment of the chronic reported  pain  i n the l i t e r a t u r e .  psychological  studies  o f t h e p h y s i c a l and  patient  A few s t u d i e s  Newman, S e r e s , Y o s p e , & G a r l i n g t o n , treatment  have r e p o r t e d  1978) i n p a t i e n t s  of m u l t i p l e  of improvement i n t h e i r  Taylor,  and C a r r o n ( 1 9 8 2 ) i n t h e i r  pain  multiple,  measures of improvement. abilities  Included  (e.g. a b i l i t y  c h a n g e s i n r e c r e a t i o n and s o c i a l behaviors  f o r pain  variables  to patients' Toomey,  pain  p a t i e n t s , noted the  ratings  and  functional-behavior  i n t h e l a t t e r w o u l d be c h a n g e s i n t o w a l k and b e n d , amount o f t i m e  activities,  rehabilitation  reflief).  status,  S e l f - r a t i n g s of pain  f r e q u e n c y and  r e s u l t s suggest  patients  functioning.  This  that  to pain-related  behaviors  are inclined  as w e l l as  lends support to b e h a v i o r a l l y  t r e a t m e n t programs which emphasize i n c r e a s e d inattention  spent  and changes i n  judge improvement i n terms o f reduced exposure t o p a i n  enhanced p h y s i c a l  response to  ( e . g . a b s e n c e o f d r u g m i s u s e , no a d d i t i o n a l  i n t e n s i t y w o u l d be u s e d s i n c e to  pain  techniques to  i n assessing  down due t o p a i n ) , c h a n g e s i n v o c a t i o n a l  surgeries  pain  study of the s t a b i l i t y o f  functional criteria  treatment, i n c l u d i n g both g l o b a l  health-seeking  following  condition.  s e l f - r e p o r t measures of improvement i n c h r o n i c  lying  (Cairns,  S t e r n b a c h , & Timmermans, 1 9 7 7 ;  self-perceptions  physical  function  have employed s t a t i s t i c a l  examine t h e s e p a r a t e c o n t r i b u t i o n s  Skelton,  improvement i n  programs.  V e r y few s t u d i e s  need f o r u s i n g  treatment are r a r e l y  ( S t e r n b a c h , 1974) as w e l l as p h y s i c a l  Thomas, Mooney, & P a c e , 1976; I g n e l z i ,  clinic  following  psychosocial  l e v e l s of functioning  (Fordyce, 1976).  Other  based and  factors  - 20 -  which contribute to successful or unsuccessful pain  adjustment t o chronic  i n c l u d e changes i n p s y c h o l o g i c a l measures ( e . g .  anxiety,  self-esteem)  above c r i t e r i a  and g e n e r a l  life  outlook  of depression,  and a t t i t u d e .  A l l ofthe  a r e t h e ones w h i c h p a t i e n t s u s u a l l y a s s o c i a t e  improvement o r nonimprovement o f t h e i r  chronic  with  p a i n o v e r an e x t e n d e d  period of time.  Gender D i f f e r e n c e s i n Chronic It  i s interesting  c h r o n i c p a i n seems t o f o c u s  Pain  t o n o t e t h a t most o f t h e l i t e r a t u r e o n on men.  T h i s may be a p p r o p r i a t e  since  r e p r e s e n t a t i o n i n Worker's C o m p e n s a t i o n programs and r e h a b i l i t a t i o n services males.  for chronic  pain patients involves higher  H o w e v e r , women do u s e t h e s e  notwithstanding chronic pain. from c h r o n i c  the dearth Likely  proportions of  programs and s e r v i c e s ,  o f l i t e r a t u r e w h i c h d e a l s w i t h women a n d  i t w o u l d be c o r r e c t t o s a y t h a t women  pain face d i f f e r e n t  personal,  a d j u s t m e n t s t h a n do men w i t h c h r o n i c Crook (1982) d i s c u s s e d socioeconomic perspectives  social,  suffering  and c u l t u r a l  pain.  the h i s t o r i c a l ,  o f women w i t h  social  r o l e , and  c h r o n i c p a i n and c o n c l u d e d  that  women do h a v e d i f f e r e n t n e e d s t h a n men t h a t , i n g e n e r a l , a r e n o t b e i n g recognized  by h e a l t h p r o f e s s i o n a l s l a r g e l y b e c a u s e o f unexamined  assumptions regarding complaining  what t h e s e  needs a r e .  of pain often the f i r s t  Historically,  explanations  given  t o women  a r e based on t h e  assumption of the f r a i l i t y  o f t h e f e m a l e body and t h e h e a l t h  throughout  cycle.  the female l i f e  prescriptions  These e x p l a n a t i o n s  f o r symptom management ( e . g .  bed r e s t ,  problems  and t h e curtailing or  - 21 -  d i s c o n t i n u i n g p h y s i c a l a c t i v i t i e s a n d w o r k , and l i m i t i n g a n y a c t i v i t i e s which cause d i s c o m f o r t )  do n o t h i n g  to allay  fears but rather  reinforce  helplessness. Women and men a r e o f t e n o f f e r e d p s y c h o l o g i c a l e x p l a n a t i o n s o f their  chronic  That  p a i n , b u t women s u f f e r a d o u b l e l i a b i l i t y  i s , women a r e more l i k e l y  psychologically  to interpret their  and t o p r e s e n t  interpretations of pain into  psychological categories  regard.  symptoms  them i n t h i s way, and a r e most  a c c e p t p s y c h o l o g i c a l i n t e r p r e t a t i o n s and t r e a t m e n t Splitting  pain  i n this  (Chesler,  likely to 1972).  e x c l u s i v e b i o l o g i c a l and  t e n d s t o be a p o w e r f u l  means o f p l a c i n g t h e  blame on t h e p a t i e n t . A n o t h e r way o f e x a m i n i n g t h e e x p e r i e n c e pain  i s t o understand  roles.  bound  often think that climate  perceive  the world  the  nurturant  guilt this  primary  of the family.  An i m p o r t a n t  of others  resulting  differ  function.  i n their  illness beliefs  Briscoe dissatisfaction  As B r i s c o e  tested  with  d e t e r m i n a n t o f how women  f o r others  pain  others  within  becomes a p a r t o f  i n f e e l i n g s of l o s s , i f s h e i s no l o n g e r  a n x i e t y and able  to f u l f i l  ( 1 9 7 8 ) s t a t e d m a l e s a n d f e m a l e s do regarding  the hypothesis  their  i s to maintain the  o f women t o s e r v e  The c a r i n g a n d d o i n g  f o r t h e women w i t h c h r o n i c role  social  r o l e s a r e much more  functions  i s the s o c i a l i z a t i o n  role.  expectations  chronic  t o t h e f e m a l e t h a n t h e y a r e t o t h e m a l e , a n d women  one o f t h e i r  emotional  their  t h e d i f f e r e n c e between male and female  U n d e n i a b l y , f a m i l y and c a r e t a k i n g  specifically  o f women w i t h  health  behavior  and e x p e c t a t i o n s .  t h a t women e x p r e s s  greater  t h a n men a n d f o u n d no d i f f e r e n c e i n  -  expressed  satisfaction,  o r i n number o r s e v e r i t y o f symptoms  However, t h e r e s u l t s o f t h a t more s o c i a l l y research stated  acceptable  services morbidity  research  apart  appear t o i n d i c a t e that  Contrary  to Briscoe's  from the increased  around r e p r o d u c t i o n statistics  and a n a t o m i c a l  i n d i c a t e that while  f o r b o t h a c u t e and c h r o n i c data must, however, take i n social  utilization  disease.  illness  that males a r e ,  and d i a g n o s e d i n fact,  ( d u e t o b o t h i n h e r i t e d and a c q u i r e d  and  p s y c h o l o g i c a l f a c t o r s enhance female r e p o r t s  female excess appears o v e r a l l .  with  rates  one s h o u l d  illness.  Thus,  the p h y s i c a l l y sicker  h e a l t h r i s k s ) but that  social  t o such an extent  The r e a s o n s f o r t h e g r e a t e r  that  morbidity  l e s s e r m o r t a l i t y f o r women a r e n o t r e a d i l y a p p a r e n t , a r e s u b j e c t t o  much s p e c u l a t i o n , a n d a r e i m p o r t a n t  to consider  i n v i e w o f how t h e  c h a n g i n g r o l e s o f women may i n f l u e n c e t h e s e i l l n e s s Some o f t h e u s u a l morbidity and  illness  i l l n e s s may be  t e r m s , and t h a t  sex  a  expectation  An adequate i n t e r p r e t a t i o n o f t h e s e  account o f the f a c t that  d i s t i n g u i s h between e x p e r i e n c e d  of health  d i f f e r e n c e s , h e a l t h and  the female l i f e  as w e l l as i n c l i n i c a l  Verbrugge has suggested  illness i s  view, Verbrugge  e x c e e d s t h a t o f m a l e s a t e v e r y a g e , women e x h i b i t h i g h e r  regarded  reported.  i n women t h a n i n men, a v i e w s u p p o r t e d b y o t h e r  (Verbrugge, 1976).  f u r t h e r that  22 -  rate of i l l n e s s  a culturally  accepted  possible explanations. distribution physician  explanations  put f o r t h  statistics. to explain the higher  f o r women a r e f e m a l e d e p e n d e n c y , p a s s i v i t y , sick role.  The f i r s t  o f some d i s e a s e s .  One must a l s o c o n s i d e r  three  other  i s t h e gender p r e f e r e n c e i n  The s e c o n d i s a n i a t r o g e n i c c o m p o n e n t o f  judgement o f t h e i l l n e s s  t h a t d e t e r m i n e s how women a s p a t i e n t s  - 23 -  are  v i e w e d and t r e a t e d .  illness  The t h i r d  i s the different  r o l e s o f women a s c o m p a r e d w i t h men.  As C r o o k ( 1 9 8 2 ) n o t e d i t  i s more commonly e n c o u n t e r e d a n d more s o c i a l l y abandon h i s f a m i l y r e s p o n s i b i l i t i e s  perception of  accepted  f o r a man t o  on a c c o u n t o f s i c k n e s s  and c h r o n i c  p a i n t h a n f o r a woman t o do t h e same t h i n g .  Women, i n g e n e r a l , do n o t  relinquish  and t h i s  conflict  their  caretaking  between t h e i r  responsibilities  illness  r o l e s and t h e i r o t h e r  I f a woman a l s o h a s a n o c c u p a t i o n a l complicated  further.  chronic pain  there  role  results roles.  the s i t u a t i o n i s  F o r women who d r o p o u t o f t h e w o r k f o r c e due t o  a r e u s u a l l y two a l t e r n a t i v e s b o t h o f w h i c h  women p o w e r l e s s .  I f she i s m a r r i e d  by  I f she i s s i n g l e , widowed o r d i v o r c e d  someone e l s e .  relegated  ina  to poverty  she r e t u r n s  t o t h e home,  render supported  she i s o f t e n  u n s u p p o r t e d by a d e q u a t e r e h a b i l i t a t i o n o r  compensation s e r v i c e s . An i n v e s t i g a t i o n i n t o pain  the psychosocial adjustment of chronic  p a t i e n t s needs t o a d d r e s s a l l o f these  factors discussed  above.  T h e s e a r e some o f t h e v a r i a b l e s w h i c h i n f l u e n c e t h e f e m a l e e x p e r i e n c e chronic  p a i n and d i f f e r e n t i a t e  i t from t h e male  of  experience.  Locus o f C o n t r o l - T h e o r e t i c a l Context The of  phrase "locus of c o n t r o l "  c o n t r o l over one's b e h a v i o r .  control  refers to the perceived  According  to the concept of locus o f  ( R o t t e r , 1 9 6 6 ) , when i n d i v i d u a l s c h a r a c t e r i s t i c a l l y  reinforcers  as n o n c o n t i n g e n t l y  source  r e l a t e d to t h e i r behavior  perceive  the occurrence  - 24  of  reinforcement  o t h e r s and  is attributed  -  to l u c k ,  such i n d i v i d u a l s are  said  chance, f a t e  t o be  or  externally  to  powerful  oriented.  C o n v e r s e l y , when i n d i v i d u a l s c h a r a c t e r i s t i c a l l y p e r c e i v e r e i n f o r c e r s  as  d e p e n d e n t e n t i r e l y u p o n t h e i r own  to  be  internally oriented.  m a g n i t u d e of  introduction  development of a s c a l e Locus of  demonstrated individual 1971;  that  1966,  but 1976;  f r e q u e n c y and be  described  one  l e v e l of  anticipated  to  control  has  as more p a s s i v e ,  their ability  (Joe, 1966,  and  as  manipulate  (Lefcourt,  1976;  events, a  externals  anxious, less  to  higher  overall general a c t i v i t y  contrast,  to c o n t r o l  events  an  t o e x p e c t a n c i e s as  over important l i f e  apathetic,  o n l y how  Rotter,  control  refers  c o p i n g e f f o r t s and  and  has  have been d e s c r i b e d  persons  the  orientation  1975;  to  oriented  control  In  to  c o n c e p t and  d e t e r m i n e not  situations  i n attempting  often  might  have been  self-confident,  events happening to  them  and or  them. A n o t h e r a p p r o a c h t o l o c u s of  Levenson (1973).  She  reasoned that  might respond d i f f e r e n t l y according or  locus of  individuals often  from i n t e r n a l s .  l e s s c o n f i d e n t of around  reacts  Because l o c u s of control  the  Procuik & Lussier,  direct  respect  1966), c o n s i d e r a b l e r e s e a r c h  environments than e x t e r n a l l y  amount o f  exist with  said  orientations.  in orientation  also  Internally oriented  Phares, 1976). the  of  Scale,  differences  more a c t i v e , a l e r t and their  differences  to measure i n t e r n a l - e x t e r n a l  Control  perceives,  Lefcourt,  1975).  Individual  i n t e r n a l versus external  S i n c e the  (Rotter's  e f f o r t s , such i n d i v i d u a l s are  c h a n c e as  responsible  for  control  externally  (LOC)  was  oriented  t o w h e t h e r t h e y saw  t h e i r behavior.  She  taken  by  individuals powerful  expanded  others  Rotter's  - 25  concept  -  to produce a t h r e e - d i m e n s i o n a l  instrument  i n a d d i t i o n to i n t e r n a l c o n t r o l (LOC-I), powerful  others  (LOC-PO) and  L e v e n s o n ' s d i s t i n c t i o n may nature  of  by  be  the  and  demonstrated  dimensions of  that,  c o n t r o l by  c h a n c e (LOC-C) w e r e c o n s i s t e n t f a c t o r s .  important  to the  understanding  of  the  externality. L o c u s o f c o n t r o l seems e s p e c i a l l y r e l e v a n t t o a d i s c u s s i o n o f  treatment who  of  chronic pain patients.  According  t o Bowers (1968) p e o p l e  b e l i e v e themselves unable to r e l i e v e or avoid p a i n or  more t h a n t h o s e Attribution  who  theory  perceive  t h e m s e l v e s to have c o n t r o l a v a i l a b l e .  s t a t e s that people seek causes or e x p l a n t i o n s  observed events that take theory  place  d e r i v a t i o n , D a v i s o n and  a r o u n d them.  t o t h e i r own  efforts  as  treatment patients  of p a t i e n t s w i t h c h r o n i c low  and  that helplessness  and  d e p e n d e n c y on  p a i n and  their  program, these regulation  situation.  p a t i e n t s are  for dealing with The  a significant  They f e e l  taught their  unpredictability  As  the  attribution tolerance  to  changes i n p a i n  e f f e c t s of a  factor in  pill.  back p a i n .  He  as a r e s u l t  the  found t h a t  of  their  unable to e x e r t  such  disability  t e n d s t o become r e i n f o r c e d by m a s s i v e  others.  living  helplessness  for  to i n t e r n a l rather than e x t e r n a l  b e e n u s e d by G o t t l i e b ( 1 9 7 7 ) as a k e y  e x h i b i t a learned  an  to a t t r i b u t e  opposed to the  A t t r i b u t i o n o f c o n t r o l a s due f a c t o r s has  Using  V a l i n s ( 1 9 6 9 ) showed how  p a i n i n c r e a s e d when s u b j e c t s w e r e t a u g h t tolerance  stress suffer  medication  c o n t r o l over  p a r t of a comprehensive  their  treatment  s e l f - r e g u l a t i o n rather than  drug  pain.  o f c h r o n i c p a i n m i g h t l e a d one  r e l a t i o n s h i p between l e a r n e d  helplessness  and  to  locus  suppose of  - 26  control.  A study  convincing studies  depression  and  n e e d t o be  reinforcement  & D a w e s , 1974;  1975;  1980;  controlled  scores).  p a t i e n t s e x h i b i t an  and  functioning found  the  research  provide  no  college-age  Becker & L e s i a k ,  belief  of  the  may  e x t e r n a l locus of  evidence l i n k i n g  locus  of  depression  Calhoun,  Cheney,  Emmelkamp & Harrow &  Ferrante,  chronic  c o n t r o l and  depression  F i r s t , most s t u d i e s u s e d  evidence that depression p e o p l e i s on  that  control.  l o c u s of  i n otherwise  a continuum w i t h Second, those  mental h o s p i t a l i z a t i o n  the  i s o f t e n at l e a s t  normally  depression  studies that  as H a r r o w and  college  used  Ferrante partly  w e l l produce a sense of u n c o n t r o l l a b i l i t y i r r e s p e c t i v e  patient's disorder.  seldom i s considered. social  and  t h a t outcomes are e x t e r n a l l y  p a t i e n t s h a v e u s e d h o s p i t a l i z e d p a t i e n t s and  c o e r c i v e and  1977;  I t i s therefore conceivable  i n a psychiatric population.  (1969) p o i n t out,  1978)  symptoms o f  and  However,  a s s o c i a t i o n between p e r c e i v e d  f a r from c l e a r f o r s e v e r a l reasons. and  area.  a  These s t u d i e s r e p o r t a c o n s i s t e n t a s s o c i a t i o n  symptoms and  students  l o c u s of c o n t r o l  F o g g , K o h a u t , & G a y t o n , 1977;  between d e p r e s s i v e (high E  to demonstrate  pain patients (Sternbach,  contingencies  Archer,  Lamont, 1972).  The  and  D i s t e f a n o , P r y e r , & S m i t h , 1971;  Cohen-Kettenis,  is  helplessness  s t u d i e s have examined the  ( A b r a m o w i t z , 1969;  pain  Seligman (1973) f a i l e d  done w i t h p a i n p a t i e n t s i n t h i s  i s common i n c h r o n i c  c o n t r o l of  1969;  Miller  l i n k between l e a r n e d  still  several  by  -  T h i r d , the  Because R o t t e r  l e a r n i n g t e r m s as a r e s u l t  of  effect  (1966) d e f i n e d  will  on  locus  i t i s at l e a s t  change i n the  course  of c o n t r o l  locus of c o n t r o l i n  subjective probability  o u c o m e c o n t i n g e n c i e s b a s e d on e x p e r i e n c e , l o c u s of c o n t r o l s c o r e s  o f age  estimates  possible  of one's  life.  that  of  - 27 -  Costello and  externality,  (1982) found a h i g h  controlling  psychiatric outpatients. of d e p r e s s i o n ,  f o r age and u s i n g  This  both students  helplessness  1 9 7 8 ) , w h i c h makes e x t e n s i v e  t o argue t h a t c l i n i c a l  responsibility  depression  f o r outcome c o n t i n g e n c i e s  s t a t e d , however, t h a t u n t i l  depression and  i s o f some s i g n i f i c a n c e f o r c a u s a l  such as t h e r e v i s e d l e a r n e d  Seligman, & Teasdale, students  c o r r e l a t i o n between  model  (Abramson,  use o f data  i s a result  from  of a t t r i b u t i n g  to external factors.  l o n g i t u d i n a l data  u n c e r t a i n whether e x t e r n a l i t y has a t r u l y  models  Costello  are c o l l e c t e d i t i s  causal r e l a t i o n s h i p to  depression. I n view o f t h e dependence o f c h r o n i c and  p r o f e s s i o n a l s , and S t e r n b a c h ' s  p a i n p a t i e n t as a " p e t i t i o n e r might take  (1978) d e s c r i p t i o n of the c h r o n i c  for aid", externality  the form of a b e l i e f  i n "powerful  p a t i e n t s who f e e l h e l p l e s s a n d h a v e l o s t may be more i n c l i n e d Skevington three and  p a i n p a t i e n t s on f a m i l y  others".  faith  t o b e l i e v e i n chance  for this  population  Alternatively,  i n the medical  community  happenings.  (1979) s t u d i e d l o c u s o f c o n t r o l w i t h r e s p e c t t o  c a t e g o r i e s of p a i n p a t i e n t s - low back p a i n , psychosomatic  rheumatoid a r t h r i t i s  p a i n - and found t h a t b e l i e f s  pain,  about t h e  c o n t r o l l a b l i t y of events i n f l u e n c e the r e p o r t i n g of pain w i t h both the low  back p a i n and r h e u m a t o i d a r t h r i t i s  dimension of locus of c o n t r o l , p a t i e n t s would have h i g h e r indicated chronic  a substantive  pain patients.  patients.  Skevington's  On t h e c h a n c e  hypothesis  e x t e r n a l i t y was c o n f i r m e d .  belief  that  pain  This  study  i n a n e x t e r n a l l o c u s o f c o n t r o l among  - 28 -  Beliefs likelihood  that the world  i s g o v e r n e d by c h a n c e may i n c r e a s e t h e  o f h e l p l e s s n e s s more t h a n a b e l i e f  "powerful  others"  uncontrollable.  s i n c e chance happenings a r e T h i s may s h e d  some l i g h t  b e t w e e n l o c u s o f c o n t r o l and l e a r n e d identifiable  "powerful  a s " o t h e r s " may be p r e v e n t e d  c o n t r o l l e d by  completely  on t h e l a c k o f r e l a t i o n s h i p  helplessness.  others" controlling  s i t u a t i o n may a p p e a r more h o p e f u l over,  i n a world  Where t h e r e a r e  the world,  changing the  t h a n i n s i t u a t i o n s where chance  takes  from e x e r c i s i n g c o n t r o l .  Locus of c o n t r o l - Conceptual Assumptions A p r o b l e m i n c o n c e p t u a l i z a t i o n i s t h e i n t r u s i o n o f a good/bad dichotomy.  T h r o u g h o u t much o f t h e l o c u s o f c o n t r o l r e s e a r c h  t o be a t a c i t while  seems  assumption that i n t e r n a l locus of c o n t r o l i s d e s i r a b l e  a n e x t e r n a l one i s n o t .  Rotter  (1975) d i s c u s s e s  f e a r s and e v e n w a r n i n g s t o t h e c o n t r a r y , assume t h a t i t i s good t o be i n t e r n a l course,  there  i n some s e n s e s ,  how i n s p i t e o f  some p s y c h o l o g i s t s q u i c k l y  and b a d t o be e x t e r n a l .  Of  t h i s may be t r u e , b u t t h e p r o b l e m t h e n l i e s i n  a s s u m i n g t h a t a l l good t h i n g s a r e c h a r a c t e r i s t i c o f i n t e r n a l s and a l l bad  things are characteristic  liberal,  more s o c i a l l y  of externals.  skilled,  be more  b e t t e r a d j u s t e d , more e f f i c i e n t , e t c .  Aside  from the p e c u l i a r i t i e s  basis  t o assume any r e l a t i o n s h i p . Rotter  I n t e r n a l s should  o f one t e s t o r a n o t h e r t h e r e  i s no  logical  (1975) a l s o noted t h a t the problem o f t h e r e l a t i o n s h i p  b e t w e e n s u c h a g e n e r a l i z e d e x p e c t a n c y a s l o c u s o f c o n t r o l and a d j u s t m e n t is  complicated.  Adjustment i s only a value  c o n c e p t , and a n y  - 29  -  r e l a t i o n s h i p must d e p e n d u p o n t h e d e f i n i t i o n o f a d j u s t m e n t . clear  that  s e l f - r e p o r t locus of c o n t r o l s c a l e s c o r r e l a t e w i t h  self-report  s c a l e s of a n x i e t y , adjustment, or s c a l e s i n v o l v i n g  s e l f - d e s c r i p t i o n s o f symptoms.  However, t h e r e  K o l s t o e , James & R a n d a l l , 1968;  P h a r e s , 1968)  typical  (or forget) f a i l u r e s  of i n t e r n a l s to repress  experiences. fewer  Consequently  t h e y may  symptoms, e t c . , and  internality  and  are t r y i n g  patients,  report  be b e t t e r f o r p e o p l e who  to cope w i t h f a i l i n g  to have a g r e a t e r  (i.e.  feel  that  extreme  strong  o f t h e I-E  o u t , but  adjustment respond  are i n obvious  t h e f a u l t may  t h e y may  basis, w i l l w i l l not.  pointed  that  The  be  pain  c o n t r o l what  Many p e o p l e , h o w e v e r ,  e x p e r i e n c e ( o r have they cannot  reality  experienced)  c o n t r o l some  early hypothesis  may  things  ( R o t t e r , 1966)  relationship with  has not  been  i n t h e methods o f measurement o f  fashion.  That  i s , some s i t u a t i o n s ,  seem l a r g e l y w i t h i n t h e i n d i v i d u a l s ' To be  out perhaps  be  able  the  more r e s e a r c h  should  As  be d e v o t e d  on  who a  control,  to d i s t i n g u i s h between these  t h e most e f f e c t i v e mode.  that  both  I n t h i s view, i t i s people nearer the middle  c l a s s e s of s i t u a t i o n s might (1976)  such as c h r o n i c  dimension r e f l e c t i n g maladjustment  variable.  others  difficulties,  that they can, i n f a c t ,  have a c u r v i l i n e a r  i n a more r e a l i s t i c  realistic while  and  or disease.  l o c u s of c o n t r o l would  borne  unpleasant  (or admit) l e s s a n x i e t y ,  abilities,  feeling  when t h e y d i s c o v e r  s u c h as a c c i d e n t s  extremes  and  that i t i s  t h e y h a v e more c o n t r o l t h a n i s w a r r a n t e d by  internals),  trauma  that suggest  (Lipp,  thereby c r e a t e a p o s i t i v e r e l a t i o n s h i p between  h a p p e n s t o them ( i . e . be more i n t e r n a l ) . already  are s t u d i e s  adjustment.  I t may who  I t seems  two  Phares t o t h e means  -  of  teaching  the  i n d i v i d u a l s when one  more u s e f u l .  30  or  -  the  other  locus  Probably people would b e n e f i t  d i s c r i m i n a t e among s i t u a t i o n s as  r e g a r d s an  of c o n t r o l b e l i e f  f r o m l e a r n i n g how  appropriate  locus  is  to  of  control  belief.  Locus o f C o n t r o l - Gender It there  appears from a r e v i e w of  w e r e few  Scale.  Differences  reported do  not  and  a large majority  of  studies  the  I-E  that be  sex  b e t w e e n men  d i f f e r e n c e s on  minimal, studies  females earned  that  and  the  I-E  has  differences  a l t h o u g h a s t u d y of  over h e a l t h feel  women r a t e d  t h e n men,  less helpless  belief  population  sex  and  the  that  (1966)  in five  in  stated  students appeared  scores  than  be  c o n t r o l of countries  to  that  males. related  identification.  in external  females  differences  d i f f e r e n c e s may  sex-role  to  I t seems  their  lives,  indicated  that  c u l t u r e (McGinnies, Nordholm,  and  t h e m s e l v e s as  with  recently  Control  M a r k s ( 1 9 7 2 ) showed  T a i t , DeGood, and  a finding  Gruen, Korte,  Although Rotter  sex  i n t h e U.S.  i n dealing  significant  external  that  i n externality varied with  both c o u n t r i e s  find  ( 1 9 6 8 ) and  college students  low-back p a t i e n t s  the Locus of  s c a l e among c o l l e g e  as w e l l as  Ward, & Bhanthumnavin, 1 9 7 4 ) . chronic  d i d not  higher  suggested  on  that u n t i l  s e p a r a t e means f o r m a l e s and  women.  Feather  f e m a l e s have a h i g h e r  belief  report  significantly  Rotter geographical  by  literature  gender d i f f e r e n c e s  Many s t u d i e s  scores  the  New  Carron  Z e a l a n d and  in  control  indicates that  men  pain.  Baum ( 1 9 7 4 ) f o u n d  d i f f e r e n c e s were r e v e r s e d ,  studied  found t h a t  having less personal  they suggest  their  (1982)  with  that  i n the  girls  black  significantly  more  - 31 -  internal  than boys.  control reflect of  differences i n locus of  r e a l d i f f e r e n c e s i n o p p o r t u n i t i e s to c o n t r o l the r e s u l t s  one's b e h a v i o r  connection  I t may be t h a t i n d i v i d u a l  and, i n g e n e r a l ,  between t h e i r b e h a v i o r  females are s o c i a l i z e d and i t s ' c o n s e q u e n c e s .  power-helplessness  f a c t o r may h a v e some v a l i d i t y  female e x t e r n a l i t y  and p e r h a p s e x t e r n a l i t y  t o make l e s s A  i n a discussion of  f o r a l l chronic  pain  patients. Further relationships treatment.  research  i s needed t o u n d e r s t a n d b e t t e r t h e  between gender, p e r c e p t i o n s  However, i t i s l i k e l y  control beliefs  i f a n d when t h e y  of c o n t r o l ,  t h a t gender d i f f e r e n c e s i n l o c u s o f occur,  are accounted  b i o l o g i c a l v a r i a b l e s t h a n by s o c i a l i z a t i o n definitions,  and/or d i f f e r e n t  and r e s p o n s e t o  perceptions  f o r l e s s by  patterns, different  sex-role  of control.  Summary In this and  the l i t e r a t u r e  psychosocial adjustment to chronic  literature of  chapter  review  relevant to locus of c o n t r o l  p a i n was r e v i e w e d .  underlies the i n t e r e s t  This  i n and i m p o r t a n c e o f t h e l o c u s  c o n t r o l c o n s t r u c t and i t s ' a p p l i c a t i o n t o t h e p s y c h o s o c i a l  adjustment of chronic investigation  i s just  pain p a t i e n t s , but demonstrates that the beginning.  I t was n o t e d t h a t t h e p r o b l e m o f c h r o n i c p a i n f o r i n d i v i d u a l s is  very  complex.  personality differently.  trait  I t may be t h a t t h e s t a b i l i t y as i m p l i e d i n e a r l i e r  o f l o c u s o f c o n t r o l as a  research  must be l o o k e d a t  P e r h a p s , f o r c h r o n i c p a i n p a t i e n t s one n e e d s t o be a w a r e  -  of  a more t r a n s i e n t  environmental This relationships chronic  and  32  a t t r i b u t i o n about c o n t r o l ,  individual  present  study  present  g o v e r n e d by  social,  factors. i s concerned w i t h e x p l o r i n g  between l o c u s of c o n t r o l ,  p a i n , and  -  pain  ratings.  the  psychosocial adjustment  to  - 33 -  CHAPTER THREE  Methodology  This instruments, analyses  chapter  presents  t h e sample, d e s c r i p t i o n of the  data c o l l e c t i o n procedures,  used t o t e s t  and t h e h y p o t h e s e s w i t h t h e  the hypotheses.  Sample C h a r a c t e r i s t i c s F o r t y one s u b j e c t s p a r t i c i p a t e d were t w e n t y e i g h t m a l e s and t h i r t e e n Columbia, A l b e r t a or Saskatchewan. multidisciplinary w i t h i n the past For  pain treatment  3-1/2  The s u b j e c t s  i n British  A l l h a d c o m p l e t e d an i n - p a t i e n t ,  program i n Vancouver, B r i t i s h  Columbia  years.  a l l s u b j e c t s , 1 9 . 5 % w e r e i n t h e a g e r a n g e 20-40 y e a r s a n d  w e r e i n t h e age r a n g e 41-61+ y e a r s .  still  e x p e r i e n c i n g some p a i n .  chronic pain five  years  A l l participants reported  For the females,  or longer, while  53.8% had  None o f t h e  c h r o n i c pain f o r l e s s than  on p a i n - r e l a t e d s u r g e r y  prior  experienced  f o r t h e males 78.6% had  chronic pain f o r that period of time.  p a r t i c i p a n t s had e x p e r i e n c e d Reporting  study.  females r e s i d i n g  80.5%  experienced  i n this  two y e a r s .  to the r e s i d e n t i a l  treatment  p r o g r a m , t h e f i g u r e s w e r e 7 8 . 6 % f o r t h e m a l e s and 6 4 . 3 % f o r t h e females. completion  Two m a l e s r e p o r t e d of the treatment  recent h o s p i t a l  admissions  a d d i t i o n a l p a i n - r e l a t e d surgery p r o g r a m and 1 6 . 7 % o f t h e s a m p l e  f o r p a i n - r e l a t e d problems.  since reported  Reporting  on  - 34 -  medication 43.9%  u s e f o r p a i n , 5 3 . 6 % i n d i c a t e d t h e same a s b e f o r e  or less  now,  i n d i c a t e d no u s a g e now, and 2.4% i n d i c a t e d more u s a g e now.  Reporting either  on time  spent i n bed o r l y i n g  t h e same a s b e f o r e  ability  o r more t i m e  down due t o p a i n , 4 6 . 3 % r e p o r t e d than  before.  t o bend o r w a l k , 3 4 . 1 % r e p o r t e d e i t h e r  treatment  or worse s i n c e  Reporting  on  t h e same a s b e f o r e  treatment.  Instrumentation THE LOCUS OF CONTROL SCALE Rotter's I n t e r n a l - E x t e r n a l (I-E) Scale of a 29-item intended  S i x o f the items  are  "fillers"  and p u r p o s e o f t h e s c a l e .  Scoring  t o 1 p o i n t f o r each endorsement o f an e x t e r n a l c o n t r o l  Scores  internal  test.  to d i s g u i s e the nature  corresponds item.  forced choice  ( R o t t e r , 1966) c o n s i s t s  may r a n g e f r o m 0 ( a n i n d i v i d u a l w i t h b e l i e f  c o n t r o l ) t o 23 ( a n i n d i v i d u a l w i t h b e l i e f  external control).  i n completely  The P e r s o n a l L o c u s o f C o n t r o l s u b s c a l e  2,6,11,15,16,23,25), a measure o f p e r s o n a l S o c i o - p o l i t i c a l Locus of C o n t r o l subscale measure o f c o n t r o l over manner a s t h e f u l l  i n completely  socio-political  s c a l e I-E ( M i r e l s ,  C o n t r o l S c a l e i s found i n Appendix  control, (items  and t h e  3,12,17,20,22,29), a  f o r c e s , are scored  1970).  (items  i n t h e same  A copy o f t h e L o c u s o f  D.  Reliability: Internal of  .70.  consistency a n a l y s i s (Kuder-Richardson)  Test-retest r e l i a b i l i t y  coefficients  y i e l d e d a _r  of the s c a l e range  .60 t o  - 35  .83 a f t e r  one m o n t h , a n d f r o m  speculates  .49  t o .61 a f t e r  t h a t the low r e l i a b i l i t y  differences i n a group  i n test  administration.  situation,  the second  method of a d m i n s t r a t i o n  -  two m o n t h s .  f o r the l a t t e r The  first  p e r i o d may  r e t e s t was  individually.  i s suggested  Rotter to  administered  H o w e v e r , no  (Rotter,  be due  specific  1966).  Validity: Content V a l i d i t y . Locus  of C o n t r o l Scale  multidimensional  1973;  Construct construct v a l i d i t y  (Joe,  1971;  Schluderman,  M i r e l s , 1970;  Validity.  Reid  & Ware,  1966;  1966).  CHRONIC P A I N SCALE  (ACPS)  to Chronic Pain Scale  t o c h r o n i c p a i n was (ACPS).  to I l l n e s s  This  patients' opinions  Scale  c o n s i s t s o f 27 i t e m s ,  on t h e i r  'no  disturbance'  m e a s u r e d by  (Derogatis,  own  t o 3 'marked d i s t u r b a n c e ' .  the  modelled  1975).  The  to gather  adjustment.  each composed o f f o u r  u s e d as a 4 - p o i n t s c a l e w h e r e t h e s u b j e c t ' s  of c o n t r o l  i n s t r u m e n t was  ACPS i s a s e l f - r e p o r t q u e s t i o n n a i r e w h i c h c a n be u s e d  questionnaire  1973; K l e i b e r ,  predicted differences i n  Rotter,  P s y c h o s o c i a l adjustment  i n f o r m a t i o n about  and i s  Numerous s t u d i e s h a v e e s t a b l i s h e d t h e  P h a r e s , 1976;  on t h e P s y c h o s o c i a l A d j u s t m e n t  Rotter  1973).  p e r s o n a l i t y d i m e n s i o n s on t h e b a s i s o f l o c u s Lefcourt,  the  & Schlederman,  of the s c a l e s u p p o r t i n g  ADJUSTMENT TO  Adjustment  i n d i c a t e d that  c o n s i s t s o f a number o f s u b f a c t o r s  (Abrahamson,  Vedman, & M e n a k e r ,  b e h a v i o r and  R e s e a r c h has  r e s p o n s e may  The  ACPS  statements range  Thus, the lower  from scores  0  - 36 -  indicate  b e t t e r adjustment  adjustment.  and h i g h e r s c o r e s i n d i c a t e  A c o p y o f t h e ACPS i s f o u n d  E a c h o f t h e 27 i t e m s an a s p e c t as (1)  of adjustment  i n Appendix  contained i n this  poorer E.  instrument pertain to  and c a n be g r o u p e d a c c o r d i n g t o s e v e n  subtests  follows: H e a l t h c a r e : I t e m numbers 1,2, and 3.  The i t e m s a r e c o n c e r n e d  t h e c u r r e n t h e a l t h c a r e p o s t u r e and w h e t h e r i t i s c o n d u c i v e positive (2)  adjustment  V o c a t i o n a l environment: this  or  this  Environment:  i s attributable  to chronic pain  I t e m s n u m b e r s 8, 9, 1 0 , and 1 1 .  i n t h e home o r u s u a l f a m i l y  environment.  The i t e m s i n which  I t i s designed  i n response  to the subject's chronic pain.  S e x u a l R e l a t i o n s h i p s : I t e m s numbers 12, 13, 14, and 15. in  arise  a s s e s s p r o b l e m s i n a d a p t a t i o n e x p e r i e n c e d by t h e p a t i e n t a n d t h e  family unit  this  s u b t e s t a s s e s s any s h i f t s  relationship (5)  which  job  subtest assess chronic pain induced d i f f i c u l t i e s  primarily  (4)  i n job performance,  The i t e m s i n  disability.  Domestic  to  and a d j u s t m e n t  to  treatement.  I t e m n u m b e r s 4, 5, 6, and 7.  subtest assess d i s r u p t i o n  satisfaction,  (3)  to c h r o n i c pain a f t e r  with  Extended items  attributable  subtest r e f l e c t  w i t h i n the extended indirect  effects  family  items  of sexual behavior or  to chronic pain.  Family Relationships:  i n this  i n quality  The  I t e m s n u m b e r s 1 6 , 1 7 , and 1 8 . any d i f f i c u l t i e s  constellation  of the c h r o n i c p a i n .  The  i n relationships  t h a t a r i s e as d i r e c t  or  - 37  (6)  -  S o c i a l E n v i r o n m e n t : I t e m s numbers 19, this the  (7)  subtest  assess  21,  and  the degree t o w h i c h c h r o n i c  s u b j e c t s ' s o c i a l and  Psychological Distress: items  20,  i n t h i s subtest  leisure  The  p a i n has  24,  25,  the degree to which  26  of c h r o n i c  of  impaired  and  27.  The  pertinent  p s y c h o l o g i c a l d i f f i c u l t i e s have r i s e n a s s o c i a t e d w i t h occurrence  items  activities.  I t e m s numbers 2 3 ,  cover  22.  the  pain.  Instrument A n a l y s i s  Reliability: Reliability Educational an  of  t h e ACPS was  Research Test  internal consistency  Internal  i s an  item  taps whatever the  test  i t e m as a s a m p l e t e s t  pairs  of  weighting  i s roughly  items. of t e s t  algebraically and  test  technique  estimate  1.  This  of  for Likert-type the e x t e n t  item i s measuring. from the  equivalent  total  program  of uses  items  equivalent  and  to which each  I f one  considers  h e n c e has  each  between a l l  differential  some a d v a n t a g e o v e r  other  p r o c e d u r e s s u c h as K u d e r - R i c h a r d s o n The  test  internal  to the average c o r r e l a t i o n f o r the  is  scales.  domain t h e n the  Hoyt's anova approach a l l o w s  Cronbach's c o e f f i c i e n t alpha.  in Table  the L a b o r a t o r y  m e t h o d b a s e d on H o y t ' s ( 1 9 4 1 ) p r o c e d u r e and  analytic  consistency  using  A n a l y s i s Package (LERTAP).  t h e most a p p r o p r i a t e consistency  assessed  summary o f r e s u l t s  is  formulas presented  - 38 -  TABLE 1 Internal Consistency  Scores  Subtest  f o r t h e ACPS  Hoyt E s t i m a t e  of R e l i a b i l i t y  1  0.83  2  0.48  3  0.35  4  0.83  5  0.57  6  0.83  7  0.85  Total  Test  0.89  Item A n a l y s i s . inclusion item.  I t e m a n a l y s i s i s t h e s e l e c t i o n o f an i t e m f o r  i n one's s c a l e based on t h e r e l i a b i l i t y  A s t r a i g h t f o r w a r d item a n a l y s i s procedure  correlation  technique.  (Pearson's)  with the t o t a l  0.50 w i t h t o t a l greater  test  LERTAP c a l c u l a t e d  i n Table  item  correlations  I t e m c o r r e l a t i o n s o f 0.30 t o  superior items.  good, w h i l e  coefficients  The summary o f r e s u l t s i s  2.  Another procedure standard  scores.  of the  i s the i t e m - t o - t o t a l  individual  scores are considered  t h a n 0.50 i n d i c a t e  presented  test  and v a l i d i t y  f o r i t e m a n a l y s i s c a n be t h e s i z e o f t h e  d e v i a t i o n c a l c u a t e d f o r each item.  For a 4-point  scale  (such  - 39 -  TABLE 2 Item A n a l y s i s  ACPS I t e m  Results  Standard  f o r t h e ACPS  Deivation  T o t a l Test Correlations  Subtest 1 1 2 3  0.84 1.03 0.87  0.46 0.54 0.54  Subtest 2 4 5 6 7  0.94 1.35 1.04 1.19  0.32 0.51 0.30 0.21  Subtest 3 8 9 10 11  0.71 0.95 1.01 0.83  0.55 0.32 0.31 0.45  Subtest 4 12 13 14 15  0.88 0.99 0.86 0.76  0.69 0.62 0.55 0.55  Subtest 5 16 17 18  0.78 0.75 0.75  0.57 0.30 0.61  Subtest 6 19 20 21 22  1.04 1.01 0.88 1.03  0.55 0.63 0.76 0.65  Subtest 7 23 24 25 26 27  0.94 0.91 0.81 1.07 0.99  0.53 0.70 0.58 0.62 0.70  - 40  as  t h e ACPS) a s t a n d a r d  good, w h i l e a standard superior  items.  w o u l d be  d i s p e r s e d by  summary o f t h e s e  -  d e v i a t i o n o f 0.80  t o 1.00  d e v i a t i o n g r e a t e r than  w o u l d be  1.00  would  In other words, the degree of response at l e a s t  results  one  indicate to these  s c a l e s t e p on a 4 - p o i n t  i s presented  i n Table  considered  items  scale.  The  2.  Validity: Content v a l i d i t y m e a s u r e m e n t , and represents  to  the concepts  about w h i c h g e n e r a l i z a t i o n s are shows c o n t e n t v a l i d i t y  from the domain of content  the degree t h a t items  within  each of these  w h i c h can  be  areas.  T h e r e i s no  used to determine  whether or not  validity a)  The  procedure  statistical  one  has  The  i n m i n d as  domain of c o n t e n t  was  ACPS was  that and  of meaning criterion  p r o p e r l y sampled can  take s e v e r a l  the r e p r e s e n t a t i o n of the v a r i o u s  of meaning from w i t h i n the domain. content  single  made.  of a l l s t r a t a  subtleties  However, the r e s e a r c h e r  to help guarantee  t o be  to the degree  i s representative  c o n s t r u c t e d tap the  from the domain of c o n t e n t . precautions  in attitude  r e f e r s t o the degree t h a t the s c o r e or s c a l e used  One's m e a s u r i n g i n s t r u m e n t sampling  i s o f t e n the main concern  constructed  shades  with  follows: identified  a d j u s t m e n t t o c h r o n i c p a i n ) and  ( i . e . psychosocial  arranged  into  seven major  components; b)  S e v e r a l i t e m s w e r e w r i t t e n and  r e - w r i t t e n , or adapted  from  existing scales; c)  The  ACPS was  then designed,  modified with respect  c r i t i c a l l y analyzed,  to format,  content,  and  and  vocabulary.  - 41 -  Validity consistency  approach i n v o l v i n g item  High i n t e r n a l aspect  o f t h e ACPS was f u r t h e r a s s e s s e d  consistency  using  an i n t e r n a l  a n a l y s i s as d i s c u s s e d  previously.  between items  o n t h e ACPS i l l u s t r a t e  this  of v a l i d i t y .  Comment: The administered initial  i m p l i c a t i o n of these w i t h an a c c e p t a b l e  measure o f c o n f i d e n c e  t i o n t h a t an instrument  f i n d i n g s i s t h a t t h e ACPS c a n be  degree of r e l i a b i l i t y  in its'  validity.  possesses v a l i d i t y  and w i t h an  Conclusive  increases  demonstra-  over time as i t i s  u s e d i n a number o f s t u d i e s a n d i s shown t o b e h a v e i n a c o n s i s t e n t manner. With minor e x p e c t a t i o n s , independent of each other score.  This  finding  the contention  Family of  this  subscales,  s t r u c t u r e f o r a s s e s s i n g m u l t i p l e domains  subsumed  R e v i s i o n o f items  i n the Domestic  i n t h e V o c a t i o n a l and E x t e n d e d  further strengthen  the psychometric  properties  instrument.  MCGILL P A I N QUESTIONNAIRE The  McGill Pain Questionnaire  p e r c e p t i o n measure t h a t a s s e s s e s report.  to the t o t a l appears  a s w e l l as t h o s e  could  are r e l a t i v e l y  that the instrument  w i t h i n psychosocial adjustment. Environment subscale,  subtests  and c o n t r i b u t e s i g n i f i c a n t l y  supports  to have a s a t i s f a c t o r y  the separate  (MPQ)  (Melzack,  1975) i s a p a i n -  the multidimensional  aspects  A s s u c h i t i s f r e e f r o m many o f t h e d i f f i c u l t i e s  of pain-  associated  -  with numerical,  v e r b a l and v i s u a l analogue s c a l e s .  20  category  be  r e p r e s e n t a t i v e of the sensory,  of p a i n  (Melzack,  1975).  and i s designed  of p a i n .  This  affective,  questionnnaire  and e v a l u a t i v e i s probably  both  the q u a l i t y  (Dubuisson & Melzack,  the f u n c t i o n a l s t a t u s of p a i n  p e r f o r m as a d e p e n d e n t m e a s u r e i n p a i n 1976).  t h e most  (Leavitt  treatment  research  and t h e i n t e n s i t y  The MPQ h a s b e e n shown t o d i s t i n g u i s h d i f f e r e n t  determining  dimensions  c u r r e n t l y used i n c h r o n i c p a i n  to evaluate  c o n d i t i o n s w i t h 77% e f f i c i e n c y  Melzack,  T h e MPQ c o n s i s t s o f  scales of a d j e c t i v e pain d e s c r i p t o r s that are considered t o  common m e a s u r e o f p a i n r e p o r t studies  42 -  pain  1976), a s s i s t i n  & Garron,  evaluations  1980), and (Fox&  A c o p y o f t h e MPQ i s f o u n d i n A p p e n d i x F.  Reliability: T h r e e i n v e s t i g a t i o n s o f t h e MPQ's r e l i a b i l i t y published and  (Fox& Melzack,  a l l yield  1976; M e l z a c k ,  evidence suggesting  s c a l e s a p p e a r t o be a d e q u a t e l y  1975; M e l z a c k & P e r r y , 1975)  that i n d i v i d u a l s '  consistent across  choices  t h e MPQ a t 4 s u c c e s s i v e w e e k l y i n t e r v a l s  consistency highly  r a t i n g s o f 75.0%,  and found  66.0%, and 80.4%.  c o m p a r a b l e m e a s u r e s when a d m i n i s t e r e d  of  one week t i m e  Graham, B o n d , G e e k o v i c h a n d C o o k e ( 1 9 8 0 ) t e s t e d c a n c e r with  have been  pain  periods.  patients  consecutive  T h u s , t h e MPQ  more t h a n  category  yields  once.  Validity: Content and Construct Melzack,  Validity.  1976; a n d M e l z a c k & P e r r y ,  Several  i n v e s t i g a t i o n s (Fox &  1975) have p r o v i d e d  c o n s i s t e n t and  - 43 -  positive MPQ.  evidence regarding  the content  P r i e t o , Hopson, B r a d l e y ,  (1980) found  s o l e l y of sensory,  scales, respectively.  This  latter  the construct v a l i d i t y  of the  t o t h e MPQ  affective  study  produced  and e v a l u a t i v e  as w e l l as R e a d i n g ' s  (1979) f a c t o r a n a l y s i s of p a t i e n t s ' responses p r o v i d e concerning  of the  B y r n e , G e i s i n g e r , M i d o x and M a r c h i s e l l o  t h a t low back p a i n p a t i e n t s ' responses  3 f a c t o r s t h a t w e r e composed category  and c o n s t r u c t v a l i d i t y  f u r t h e r evidence  MPQ.  Data C o l l e c t i o n Initial ( A p p e n d i x A) s e n t treatment table  contact  mailing  t h e s u b j e c t s was made b y a  t o one h u n d r e d  program.  i n d i v i d u a l s who  They were a s i m p l e  o f random numbers.  return  with  Included  had c o m p l e t e d  the pain  random s a m p l e s e l e c t e d by u s i n g  i n t h e m a i l i n g were t h e f o l l o w i n g :  a)  I n s t r u c t i o n Sheet (Appendix B ) ;  b)  Biographical Information  c)  R o t t e r ' s Locus of C o n t r o l  d)  Adjustment to Chronic  e)  M c G i l l Pain Questionnaire  (Appendix F ) ;  f)  A stamped, s e l f  return  All  s u b j e c t s were asked  them b y m a i l  letter  Questionnaire Scale  Pain  addressed  (Appendix E ) ;  envelope.  out the q u e s t i o n n a i r e s  i n the envelope provided.  a l l s u b j e c t s were c o n t a c t e d  (Appendix D);  Scale  to f i l l  (Appendix C);  and  Two w e e k s a f t e r t h e  by t e l e p h o n e  followup.  a  - 44  -  R e s e a r c h H y p o t h e s e s and Method o f T e s t i n g  Hypothesis  1.  There w i l l  be a s t a t i s t i c a l l y  locus of c o n t r o l ,  significant linear relationship  as m e a s u r e d on R o t t e r ' s L o c u s o f C o n t r o l S c a l e ,  p s y c h o s o c i a l adjustment to chronic to Chronic  Pain Scale  in-patient,  m u l t i d i s c i p l i n a r y pain  scores  each s u b j e c t  c o e f f i c i e n t was  f o r each s u b j e c t on l o c u s o f c o n t r o l on a d j u s t m e n t t o c h r o n i c  2.  There w i l l  be a s t a t i s t i c a l l y  locus of c o n t r o l ,  Pain  ( A C P S ) , f o r m a l e s who  scores f o r  pain.  relationship  between and  p a i n , a s m e a s u r e d on t h e A d j u s t m e n t t o C h r o n i c have c o m p l e t e d an i n - p a t i e n t  t r e a t m e n t p r o g r a m and f o r f e m a l e s who  '  pain  h a v e c o m p l e t e d an i n - p a t i e n t  pain  program.  P e a r s o n Product-moment  correlation  c o e f f i c i e n t s were c a l c u l a t e d ,  m a l e s and one f o r f e m a l e s , u s i n g t o t a l f e m a l e on l o c u s female.  using  as measured on R o t t e r ' s Locus o f C o n t r o l S c a l e ,  to c h r o n i c  treatment  computed  and t o t a l  significant positive  adjustment Scale  have c o m p l e t e d an  treatment program.  correlation  Hypothesis  and  p a i n , as measured on t h e A d j u s t m e n t  ( A C P S ) , f o r p a t i e n t s who  A P e a r s o n Product-moment total  between  of c o n t r o l  scores  f o r e a c h male and  and t o t a l ACPS s c o r e s  one f o r each  f o r e a c h m a l e and  each  - 45 -  Hypothesis  3.  There w i l l  be a s t a t i s t i c a l l y  the  t o t a l scores  Pain Questionnaire  in-patient,  multidisciplinary  total for  pain treatment  on  an  program.  coefficient  f o r e a c h s u b j e c t on l o c u s o f c o n t r o l  was c o m p u t e d  using  a n d t o t a l MPQ  scores  4.  Mean A d j u s t m e n t t o C h r o n i c significantly The  different  P a i n Scores  t h a n mean ACPS s c o r e s  independent groups t - t e s t determine  (ACPS) f o r males w i l l  Hypothesis  f o r t h e d i f f e r e n c e b e t w e e n means was u s e d  i f t h e r e was a s t a t i s t i c a l l y  significant  d i f f e r e n c e between  significance.  5.  T h o s e s u b j e c t s who r e p o r t g o o d a d j u s t m e n t o n t h e ACPS ( l o w e r will  score  those  be  f o r females.  t h e means o f t h e two g r o u p s a t t h e .05 l e v e l o f  significantly different  scores)  on t h e L o c u s o f C o n t r o l S c a l e  s u b j e c t s who r e p o r t p o o r a d j u s t m e n t o n t h e ACPS.  groups t - t e s t  than  The i n d e p e n d e n t  f o r t h e d i f f e r e n c e b e t w e e n means was u s e d t o d e t e r m i n e i f  t h e r e was a s t a t i s t i c a l l y the  between  each s u b j e c t .  Hypothesis  to  relationship  (MPQ) f o r p a t i e n t s f o l l o w i n g  Product-moment c o r r e l a t i o n  scores  linear  on R o t t e r ' s L o c u s o f C o n t r o l S c a l e a n d t o t a l s c o r e s  the M c G i l l  A Pearson  significant  significant  two g r o u p s a t t h e .05 l e v e l o f  d i f f e r e n c e b e t w e e n t h e means o f  significance.  - 46  -  Summary In  t h i s c h a p t e r a d e s c r i p t i o n o f t h e s a m p l e was  presented,  f o l l o w e d by a d e s c r i p t i o n o f t h e i n s t r u m e n t s , d a t a c o l l e c t i o n procedures, following  and  t h e r e s e a r c h h y p o t h e s e s and  chapter presents  the methods of t e s t i n g .  the r e s u l t s of the data  analyses.  The  - 47  -  CHAPTER FOUR  Results  In collection  the preceding  and  restatement, hypothesis  chapter,  a n a l y s i s were p r e s e n t e d .  f o r the convenience  out  Hypothesis  research  a summary o f t h e  the Adjustment  h a v e c o m p l e t e d an  results  hypothesis.  be  a statistically  significant  r e l a t i o n s h i p b e t w e e n l o c u s o f c o n t r o l , a s m e a s u r e d on  m e a s u r e d on  a  Results  1 stated that there w i l l  L o c u s o f C o n t r o l S c a l e , and  who  each  data  c o n s i s t s of  of the r e a d e r , of each  to t e s t  H y p o t h e s e s , M e t h o d o f T e s t i n g and  f o r both  This chapter  a l o n g w i t h t h e m e t h o d o f t e s t i n g and  of the a n a l y s i s c a r r i e d  linear  the procedure  Rotter's  p s y c h o s o c i a l adjustment to chronic p a i n , to Chronic  as  P a i n s c a l e (ACPS), f o r p a t i e n t s  in-patient, multidisciplinary  pain  treatment  program. In coefficient  a n a l y z i n g the data a Pearson was  calculated  of c o n t r o l  and  pain.  results  The  statistically b e t w e e n how self-ratings  total of  scores  on  linear  r a t e themselves  t h e ACPS.  scores  correlation  f o r e a c h s u b j e c t on  f o r e a c h s u b j e c t on a d j u s t m e n t  the s t a t i s t i c a l  significant  people  using t o t a l  Product-moment  a n a l y s i s on 41  relationship on  L o c u s o f C o n t r o l S c a l e ( e x t e r n a l ) do  to chronic  subjects reveal  ( r = - 0 . 0 5 , _p =  not  no  0.39)  the Locus of C o n t r o l S c a l e  T h a t i s , p a r t i c i p a n t s who  locus  and  s c o r e h i g h on  the  n e c e s s a r i l y s c o r e h i g h on  the  - 48 -  ACPS ( p o o r  adjustment).  The p r o b a b i l i t y  (0.39) and t h e r e f o r e i t i s l i k e l y Locus of c o n t r o l scores  nonsignificant  that the n u l l  hypothesis  i s true.  and a d j u s t m e n t t o c h r o n i c p a i n s c o r e s  subjects are presented While  o f a Type I e r r o r i s q u i t e h i g h  graphically  for a l l  i n F i g u r e 1.  the correlation coefficient  i s low and appears  according to the s t a t i s t i c a l  test,  the graphic  r e p r e s e n t a t i o n of t h e data i n d i c a t e s a t r e n d i n t h e d i r e c t i o n o f an inverse  relationship  chronic  pain scores.  between l o c u s of c o n t r o l  t h a t p a r t i c i p a n t s who s c o r e d  = 7.44) i n d i c a t i n g  l o w on t h e L o c u s o f C o n t r o l  ( i n t e r n a l ) may s c o r e h i g h o n t h e ACPS ( p o o r presence  o f two o u t l i e r s  two r e s e a r c h s u b j e c t s d i f f e r  e s t a b l i s h e d by o t h e r individual of  scores  scale.  Their scores  the data  pattern  Closer i n s p e c t i o n of the the extremes  c o u l d be v i e w e d a s  analysis.  correlation coefficient,  contaminated  The s c o r e s o f  from the g e n e r a l  Product-moment c o r r e l a t i o n c o e f f i c i e n t  the o u t l i e r s  correlation  remarkably  i n the s t a t i s t i c a l  may r e v e a l a d i f f e r e n t that  contamination.  r e v e a l e d t h a t t h e two s u b j e c t s r e p r e s e n t  deviants or o u t l i e r s the Pearson  Scale  adjustment).  s u b j e c t s i n t h e sample.  the i n t e r n a l - e x t e r n a l  perhaps  i n d i c a t e s that the s t a t i s t i c a l  a n a l y s i s may h a v e b e e n a f f e c t e d by o u t l i e r these  and a d j u s t m e n t t o  More of t h e d a t a p o i n t s a r e i n Quadrants 1 and 3  (X o f ACPS s c o r e s = 3 6 . 5 9 ; X o f LOC s c o r e s  The  scores  A r e c a l c u l a t i o n of on t h e "trimmed"  data  since i ti s possible  resulting  i n a highly  suspect  coefficient.  A r e c a l c u l a t i o n of the Pearson  Product-moment  correlation  c o e f f i c i e n t was d o n e , o m i t t i n g t h e two s u b j e c t s d e f i n e d a b o v e a s outliers,  using total  s c o r e s f o r each s u b j e c t on l o c u s o f c o n t r o l and  - 49 -  20 19 18 17 16 15 14 13 12 11 10 <D  u  o o  9  o +-> c o  8  %  6|  u  7  CJ  10 O  5  o 4 3 2 1 0l  10  20  30  Adjustment to C h r o n i c  F i g u r e 1.  40  50  60  P a i n Scores  Locus of c o n t r o l scores and Adjustment to c h r o n i c s c o r e s f o r 41 s u b j e c t s , r = -0.05.  pain  70  -  total  scores  results  of  f o r each s u b j e c t  this  statistically b e t w e e n how self-ratings  perhaps a trend Scale  Hypothesis 2 stated  that  high  on  Locus of C o n t r o l S c a l e , m e a s u r e d on  and  f e m a l e s s e p a r a t e l y who  ary  pain  treatment  sex  the  data  on a d j u s t m e n t t o c h r o n i c  pain.  f o r each sex  f o r 28 m a l e s u b j e c t s (_r = 0.25,  _p = 0.10) and  Adjustment to Chronic  Scale.  of  control scale  ACPS ( p o o r a d j u s t m e n t ) . chronic Figure  pain 2.  scores  on  0.33)  Control  adjustment). significant Rotter's  adjustment to chronic Scale  and  the L o c u s of  statistically  Pain  pain,  (ACPS), f o r males  as and  in-patient, multidisciplin-  Pain  P e a r s o n Product-moment c o r r e l a t i o n  f o r m a l e s and of  how  one  c o n t r o l and  The  r e v e a l no  the L o c u s of C o n t r o l S c a l e  locus  no  indicates  o f c o n t r o l , as m e a s u r e d on  two  locus  relationship  r value  low  h a v e c o m p l e t e d an  on  analysis  be a  psychosocial  c o e f f i c i e n t s w e r e c a l c u l a t e d , one scores  reveal  programs.  In analyzing  total  score  the Adjustment to Chronic  for  negative  t h e ACPS ( p o o r  there w i l l  r e l a t i o n s h i p between l o c u s  subjects  The  the Locus of C o n t r o l S c a l e  However, the  score  39  pain.  r e l a t i o n s h i p (r_ = - 0 . 0 7 , jo =  t h a t p a r t i c i p a n t s who  ( i n t e r n a l ) may  linear  inverse  t h e ACPS.  to c h r o n i c  a n a l y s i s on  p e o p l e r a t e t h e m s e l v e s on on  -  on a d j u s t m e n t  second s t a t i s t i c a l  significant  50  f o r females,  total  r e s u l t s of  the  statistically  b e t w e e n how they r a t e  not  are  statistical significant  t h e m s e l v e s on score  n e c e s s a r i l y score  Locus of c o n t r o l s c o r e s  f o r male s u b j e c t s  f o r each  linear  males r a t e themselves  T h a t i s , m a l e s who  ( e x t e r n a l ) do  scores  using  and  presented  on  the high  on  high  on  adjustment  to  graphically in  the the  - 51 -  20 19 18 17 16 15 14 13 12 11 m U  10  o o  9  o u +-> c o o  8 7 6  m O  5  o 4 3 2 1 01  10  20  30  Adjustment to C h r o n i c  F i g u r e 2.  40  50  60  P a i n Scores  Locus of c o n t r o l s c o r e s and Adjustment to c h r o n i c s c o r e s f o r 28 male s u b j e c t s , r = 0.25.  pain  70  - 52  The  r e s u l t s of the s t a t i s t i c a l  reveal a s t a t i s t i c a l l y 0.002) between how and  how  they  females r a t e themselves on the Locus of C o n t r o l  r a t e themselves on the ACPS.  (good adjustment).  ( e x t e r n a l ) a l s o score and  Scale  score  low on the ACPS  psychosocial  f o r female s u b j e c t s are presented  adjustment  graphically in  3.  H y p o t h e s i s 3 s t a t e d that there w i l l  be a s t a t i s t i c a l l y  l i n e a r r e l a t i o n s h i p between the t o t a l C o n t r o l S c a l e and (MPQ)  That i s , females who  Locus of c o n t r o l scores  c h r o n i c p a i n scores  Figure  a n a l y s i s f o r 13 female s u b j e c t s  s i g n i f i c a n t i n v e r s e r e l a t i o n s h i p (r_ = -0.74, p_ =  h i g h on the Locus of C o n t r o l S c a l e  to  -  the t o t a l scores  scores  significant  on R o t t e r ' s Locus of  on the M c G i l l P a i n  Questionnaire  f o r p a t i e n t s f o l l o w i n g an i n p a t i e n t , m u l t i d i s c i p l i n a r y  pain  treatment program. In a n a l y z i n g c o e f f i c i e n t was of c o n t r o l and no MPQ 40  0.04,  c a l c u l a t e d using t o t a l f o r MPQ.  score was  subjects  One  available.  r a t i n g of p a i n s c o r e s .  f o r each s u b j e c t f o r l o c u s  dropped from the a n a l y s i s s i n c e  r e s u l t s of the s t a t i s t i c a l significant  linear  a n a l y s i s on  r e l a t i o n s h i p (r =  That i s , p a r t i c i p a n t s who  ( e x t e r n a l ) do not  their  score high  n e c e s s a r i l y score high  on on  MPQ. It  i s p o s s i b l e t h a t a r e l a t i o n s h i p between the v a r i a b l e s of  locus of c o n t r o l and the  The  correlation  between i n d i v i d u a l s ' l o c u s of c o n t r o l scores and  the Locus of C o n t r o l S c a l e the  scores  s u b j e c t was  r e v e a l no s t a t i s t i c a l l y  jo = 0.39)  present  the data a Pearson Product-moment  two  r e p o r t e d p a i n may  genders as a homogenous group.  have been obscured by t r e a t i n g Pearson Product-moment  c o r r e l a t i o n c o e f f i c i e n t s were c a l c u l a t e d f o r males and  females  - 53 -  10  20  30  Adjustment to C h r o n i c  F i g u r e 3.  40  50  60  Pain Scores  Locus of c o n t r o l s c o r e s and Adjustment to c h r o n i c s c o r e s f o r 13 female s u b j e c t s , r = 0.74.  pain  70  separately using t o t a l MPQ.  The r e s u l t s  Table  3.  scores  of these  f o r each s e x f o r l o c u s of c o n t r o l and  statistical  analyses  are presented i n  TABLE 3 P e a r s o n Product-Moment C o r r e l a t i o n C o e f f i c i e n t s F o r Males and F emales U s i n g T o t a l S c o r e s F o r E a c h S e x on L o c u s o f C o n t r o l a n d MPQ  Males n = 27  Females n = 13  r  0.33  -0.74  p_  0.05  0.00  F o r m a l e s , t h e r e a p p e a r s t o be a s t a t i s t i c a l l y linear  relationship  (r_ = 0.33) b e t w e e n how t h e y  of c o n t r o l and t h e i r p r e s e n t high  on l o c u s o f c o n t r o l  rating  of p a i n ) .  significant themselves is, on  females t h e MPQ  Hypothesis  r a t i n g of pain.  r a t e themselves  on l o c u s  T h a t i s , m a l e s who  score  ( e x t e r n a l ) a l s o s c o r e h i g h on t h e MPQ  For females,  t h e r e a p p e a r s t o be a  inverse relationship  l o w on l o c u s o f c o n t r o l  (high  statistically  Or = - 0 . 7 4 ) b e t w e e n how t h e y  on l o c u s o f c o n t r o l a n d t h e i r p r e s e n t who s c o r e  significant  rating  rate  of pain.  That  ( i n t e r n a l ) also score  high  (high r a t i n g of p a i n ) . 4 s t a t e d t h a t t h e mean ACPS ( a d j u s t m e n t  scores  f o r male s u b j e c t s w i l l  female  subjects.  be d i f f e r e n t  than  to chronic  pain)  t h e mean ACPS s c o r e s f o r  - 55  I n a n a l y z i n g the g r o u p s was  done t o d e t e r m i n e t h e  t h e means on was  set at  t-test Table  data,  t h e m a l e and  .05.  using  The  the  -  a t w o - t a i l e d t - t e s t f o r independent significance  female groups.  means, s t a n d a r d  of The  the  l e v e l of  d e v i a t i o n s and  t h e ACPS t o c o m p a r e t h e  two  d i f f e r e n c e between  the  significance  results  groups are presented  of  in  4.  TABLE T-test Using  4  Adjustment to Chronic P a i n Scores Compare M a l e s and F e m a l e s  Variable  Mean  Males n = 28  38.11  Standard Deviation  to  g_  t_  13.03  1.07 Females n = 13  33.31  The  hypothesis  of males i s d i f f e r e n t  pain  of females i s not after  an  significant  than the  supported  in-patient,  of  the  by  ACPS.  to  p s y c h o s o c i a l adjustment the  results  m u l t i d i s c i p l i n a r y pain  d i f f e r e n c e s are  t h e mean s c o r e s  0.29  14.03  that the p s y c h o s o c i a l adjustment  pain  is,  the  chronic to  chronic  of the a n a l y s i s .  That  treatment  no  f o u n d b e t w e e n t h e m a l e and  program  female groups  on  -  Hypothesis 5 stated that a d j u s t m e n t on scores  on  The s a m p l e o f 41  t h e ACPS ( l o w e r  adjusters  a d j u s t m e n t on  scores)  the b a s i s  ( n = 9) the  4 4 - 6 3 on  t h e ACPS.  deviations  of  poor a d j u s t e r s  f o r the  i s presented  on  The  g o o d and  i n Table  report  poor  scores).  the ACPS.  consisted  distribution.  f o r ACPS s c o r e s sex  scores  15)  different  females s e l e c t e d from the  These groups r e p r e s e n t e d  t h e ACPS s c o r e  b r e a k d o w n by  (n =  psychosocial  t h a n t h o s e s u b j e c t s who  m a l e s and  their  good  have s i g n i f i c a n t l y  c o n s i s t e d o f p a r t i c i p a n t s who  ACPS and  of  will  reported  t h e ACPS ( h i g h e r  s u b j e c t s w e r e 24 on  -  t h o s e s u b j e c t s who  the L o c u s of C o n t r o l S c a l e  psychosocial  thirds  56  scored of  The  roughly  the  means and  good  f r o m 10-24  t h o s e who  total  on  scored  l o w e r and  the  from upper  standard  poor a d j u s t e r s w i t h  a  5.  TABLE 5 Means and S t a n d a r d D e v i a t i o n s o f ACPS S c o r e s f o r Two A d j u s t e r G r o u p s o f M a l e s and F e m a l e s  Good A d j u s t e r s Variable  N Mean Standard Deviation  Poor  Males  Females  Total  4  5  9  14.50  19.80  17.44  5.45  3.70  5.08  Males  11  Adjusters Females  4  50.46  50.00  4.00  8.68  Total  15 50.33 5.26  -  In analyzing g r o u p s was  the  2 groups.  means, s t a n d a r d  locus  data  of c o n t r o l  The  s i g n i f i c a n c e of level  d e v i a t i o n s , and  scores  -  a two-tailed t-test  done t o d e t e r m i n e the  t h e means o f The  the  57  of  for  the  independent  difference  s i g n i f i c a n c e was  the  results  of  the  to compare the 2 g r o u p s a r e  set at  t-test  presented  between .05-  using i n Table  6.  TABLE 6 T-test  Variable  Using  Locus of C o n t r o l Scores to Good and P o o r A d j u s t e r s  Standard Deviation  Mean  Good a d j u s t e r s n = 9  Compare  8.22  2.73  0.27 Poor a d j u s t e r s n = 15  The psychosocial control  7.80  hypothesis  4.21  that  t h o s e s u b j e c t s who  adjustment to c h r o n i c  scores  s u p p o r t e d by  significant  d i f f e r e n c e s are  psychosocial  a d j u s t m e n t and  a d j u s t m e n t on  pain w i l l  t h a n t h o s e s u b j e c t s who  adjustment i s not  0.79  the  report  results  of  report  good  have d i f f e r e n t poor the  locus  psychosocial analysis.  No  f o u n d b e t w e e n t h o s e s u b j e c t s who those subjects  t h e mean s c o r e s  of  who  of  report  the Locus of C o n t r o l  poor  report  good  psychosocial  Scale.  -  58  -  Secondary A n a l y s i s I n a d d i t i o n to the was  performed to explore  Hypothesis  above f i v e  analyses,  another possible  a secondary a n a l y s i s  relationship.  1 examined the c o r r e l a t i o n between l o c u s  p s y c h o s o c i a l adjustment to chronic p a i n . scatterplot  of the  research  data  Further  of c o n t r o l  examination  i n d i c a t e d that the  and  of  the  r e l a t i o n s h i p between  t h e v a r i a b l e s l o c u s o f c o n t r o l and  p s y c h o s o c i a l adjustment to  p a i n m i g h t be  i n s t a n c e s where t h e r e l a t i o n s h i p  nonlinear.  I n those  between v a r i a b l e s i s markedly n o n l i n e a r correlation coefficient  the P e a r s o n Product-moment  i s i n a p p r o p r i a t e , and  s t r e n g t h of a s s o c i a t i o n .  Rotter  support  of a c u r v i l i n e a r  f o r the  e x t r e m e s of  locus  To ( e t a ) was  existence  test  of the  subjects  ACPS.  The  total  results  reveal a s t a t i s t i c a l  s q u a r e d = 0.39)  and  curvilinearity  calculated using  c o n t r o l and  ( 1 9 6 6 ) and  c o n t r o l scores  b e t w e e n how  scores  the L o c u s of C o n t r o l S c a l e  score  low  pain.  t h e ACPS.  the L o c u s of C o n t r o l S c a l e  a c c o u n t e d f o r by chronic  on  the  A b o u t 39%  on  the  ratio  locus  a n a l y s i s on  p e o p l e r a t e t h e m s e l v e s on  high  adjustment).  a correlation  from l i n e a r i t y  score  t h e ACPS ( p o o r  data  statistical  departure  self-ratings  the  ( 1 9 7 6 ) i n d i c a t e d some  f o r each s u b j e c t  and  on  Phares  r e l a t i o n s h i p between  the  Control Scale on  would underestimate  maladjustment.  of  of the  chronic  of  41  ( e t a = 0.62, the Locus  eta  of  That i s , p a r t i c i p a n t s  who  ( e x t e r n a l ) and  participants  who  ( i n t e r n a l ) tend  to score high  on  of  the  t o t a l variance  is  independent v a r i a b l e , p s y c h o s o c i a l adjustment  to  - 59 -  Summary o f R e s u l t s This  study  concerned with adjustment testing  was d e s i g n e d  to i n v e s t i g a t e f i v e hypothesis  each  t h e v a r i a b l e of l o c u s o f c o n t r o l and p s y c h o s o c i a l  to chronic pain.  of each  The summary p r e s e n t s  the r e s u l t s  of t h e  hypothesis.  Hypotheses 1.  T h e r e a p p e a r s t o be no s t a t i s t i c a l l y  significant  linear  r e l a t i o n s h i p b e t w e e n how p a r t i c i p a n t s r a t e t h e m s e l v e s o n l o c u s o f c o n t r o l and s e l f - r a t i n g s adjustment t o chronic 2.  pain.  T h e r e a p p e a r s t o be no s t a t i s t i c a l l y relationship  chronic pain. significant  T h e r e a p p e a r s t o be a  inverse  linear  and  of c o n t r o l and  on p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c  rating  of pain.  a p p e a r s t o be a s i g n i f i c a n t  present a  significant  between p a r t i c i p a n t s ' l o c u s  t h e i r present  how t h e y  statistically  r e l a t i o n s h i p b e t w e e n how  T h e r e a p p e a r s t o be no s t a t i s t i c a l l y relationship  linear  on p s y c h o s o c i a l a d j u s t m e n t t o  f e m a l e s r a t e t h e m s e l v e s on l o c u s self-ratings  significant  b e t w e e n how m a l e s r a t e t h e m s e l v e s o n l o c u s o f  c o n t r o l and s e l f - r a t i n g s  3.  on p s y c h o s o c i a l  linear  r a t e t h e m s e l v e s on l o c u s r a t i n g of p a i n .  statistically  scores  there  r e l a t i o n s h i p between o f c o n t r o l and t h e i r  For females,  significant  linear  of c o n t r o l  F o r males,  pain.  there  a p p e a r s t o be  i n v e r s e r e l a t i o n s h i p between  -  how  they  present 4.  60  -  r a t e t h e m s e l v e s on r a t i n g of  locus  o f c o n t r o l and  pain.  T h e r e a p p e a r s t o be  no  significant  difference in  p s y c h o s o c i a l adjustment to chronic pain m a l e s and 5.  T h e r e a p p e a r s t o be  no  significant  between those  p s y c h o s o c i a l a d j u s t m e n t and psychosocial  1.  scores  the  (ACPS) of  females.  of c o n t r o l s c o r e s  Supplementary  their  d i f f e r e n c e i n the  s u b j e c t s who  those  report  s u b j e c t s who  locus good  report  poor  adjustment.  Analysis T h e r e a p p e a r s t o be a s t a t i s t i c a l l y curvilinear control  r e l a t i o n s h i p between the  (internals  and  adjustment to chronic  e x t e r n a l s ) and pain.  significant extremes of poor  locus  psychosocial  of  - 61 -  CHAPTER V  Summary, C o n c l u s i o n  The hypothesis analysis  preceding  chapter  and D i s c u s s i o n  presented  a restatement  o f each  a l o n g w i t h t h e method o f t e s t i n g and t h e r e s u l t s o f t h e  carried  out to test  summary, c o n c l u s i o n s investigation,  each h y p o t h e s i s .  and d i s c u s s i o n .  This  chapter  presents  In addition, limitations  i m p l i c a t i o n s and s u g g e s t i o n s  a  of the  f o r future research are  discussed.  Summary Chronic  p a i n p a t i e n t s c o n s t i t u t e a p o p u l a t i o n where t h e i s s " e  of c o n t r o l over reinforcement their  t o be a n i m p o r t a n t  r e h a b i l i t a t i o n or psychosocial adjustment t o chronic  Regardless be,  i s likely  o f how p h y s i c a l l y o r m e d i c a l l y  i f they  are not perceived  advisable  may f a i l  pain.  some a c t i v i t i e s  and i n t e r p r e t e d as b e n e f i c i a l  one's c o n t r o l t h e n t h e impact o f treatment  factor i n  may  or within  on p s y c h o l o g i c a l  grounds. The  v a r i a b l e s involved i n p s y c h o s o c i a l adjustment  p a i n a r e numerous.  I n an e f f o r t  to chronic  t o better understand c e r t a i n f a c t o r s  w h i c h c o n t r i b u t e t o p o o r and good p s y c h o s o c i a l  adjustment, t h i s  study  sought t o examine t h e r e l a t i o n s h i p between i n t e r n a l - e x t e r n a l l o c u s o f control  and p s y c h o s o c i a l a d j u s t m e n t .  whether there control  i s any v a l i d i t y  The r e s e a r c h  i n applying  to the concepts of psychosocial  was i n t e n d e d  the construct  adjustment  t o see  of locus of  to chronic  p a i n and  -  reported  pain  treatment exists  program.  b e t w e e n an  contingent related that the  f o r s u b j e c t s who The  to v a r i o u s  d e g r e e o f an  questions  and  f o r m a l e s and  there  pain  f o r females.  for chronic  Fifth,  do  study, Canada.  a sample of A l l forty  multidisciplinary w i t h i n the  past  there  questions.  c o n t r o l and  forty one pain  one  answer the  r e l a t i o n s h i p between the  to  chronic  Fourth,  adjustment  from the  to  chronic  developed  extreme scores  the  mailed  study  the  significant of  in the  Western  residential,  program i n Vancouver, B r i t i s h  a statistically  for  drawn from t h r o u g h o u t  E a c h s u b j e c t was  are  poor a d j u s t e r s  completed a six-week  the o b j e c t i v e s of  a p p e a r s t o be  Second, i s  adjustment  questions  s u b j e c t s was  treatment  completed  T h i r d , i s l o c u s of c o n t r o l r e l a t e d to  s u b j e c t s had  three years.  e x t e r n a l s ) and  To  psychosocial  have  program?  pain patients post-treatment?  control?  I n terms of  and  treatment  t h e good a d j u s t e r s d i f f e r  terms of l o c u s of  that  p a i n p a t i e n t s who  pain  by  post-treatment.  gender d i f f e r e n c e s i n the p s y c h o s o c i a l  pain?  reflected  were to answer f i v e  pain for chronic  t h e r e a r e l a t i o n s h i p between l o c u s of  reported  pain  as  reasoned  a r e l a t i o n s h i p b e t w e e n l o c u s o f c o n t r o l and  in-patient, multidisciplinary  pain  good p s y c h o s o c i a l a d j u s t m e n t  as a p e r s o n a l i t y m e a s u r e , w o u l d be  study  are  F u r t h e r m o r e , i t was  i n d i v i d u a l ' s reported  pain  assumed t h a t a r e l a t i o n s h i p  t h a t d e s i r e d outcomes  a r e a s of one's l f e .  adjustment to chronic an  completed a m u l t i d i s c i p l i n a r y  behavior  o b j e c t i v e s of the  i s there  -  individual's belief  l o c u s of c o n t r o l ,  First,  research  u p o n h i s / h e r own  The  had  62  Columbia  questionnaires. results  indicate  curvilinear  l o c u s of c o n t r o l  poor p s y c h o s o c i a l adjustment to c h r o n i c  (internals pain.  The  - 63 -  study  f u r t h e r demonstrates a strong c o r r e l a t i o n  internality  and poor p s y c h o s o c i a l a d j u s t m e n t  c o r r e l a t i o n was f o u n d b e t w e e n r e p o r t e d scores  when t h e s e x e s w e r e a n a l y z e d  significant control  and h i g h  internal  scores  However, t h e r e  levels  were  of locus of between  of reported  pain.  d i f f e r e n c e s e x i s t e d between males and  psychosocial adjustment t o chronic  t h e r e w e r e no s i g n i f i c a n t  good a d j u s t e r s and t h e r e p o r t e d  No  and l o c u s o f c o n t r o l  p a i n , and f o r f e m a l e s  o f l o c u s o f c o n t r o l and h i g h  females i n t h e i r reported Additionally,  pain scores  between e x t e r n a l scores  levels of reported  I t was n o t e d t h a t no s i g n i f i c a n t  to chronic pain.  together.  c o r r e l a t i o n s f o r males  f o r females between  pain.  d i f f e r e n c e s between t h e r e p o r t e d  poor a d j u s t e r s  i n their  locus of c o n t r o l  scores.  Conclusions  and D i s c u s s i o n  Locus o f C o n t r o l and P s y c h o s o c i a l There appears  Adjustment  t o be no s i g n i f i c a n t  how s u b j e c t s ' r a t e t h e m s e l v e s on t h e L o c u s self-ratings  o n t h e ACPS.  are  supportive  and  p s y c h o s o c i a l adjustment  support  both very  that  e x t e r n a l and v e r y  psychosocial  adjustment  r e l a t i o n s h i p between  o f C o n t r o l S c a l e and  However, t h e r e s u l t s  of a c u r v i l i n e a r  the contention  linear  of a secondary a n a l y s i s  r e l a t i o n s h i p between l o c u s o f c o n t r o l  f o r a l lsubjects. there might internal  to chronic  There  i s some e v i d e n c e t o  be a U - s h a p e d  subjects  relationship with  indicating  pain.  A p o s s i b l e e x p l a n a t i o n m i g h t be t h a t e x t r e m e l y individuals  poor  c o u l d be so overwhelmed w i t h a sense o f  internal  personal  - 64 -  responsibility  over each f a i l u r e  and  very  hence f e e l  unpredictable react  with  helpless.  uncertainty  cope s u c c e s s f u l l y w i t h instance  resistant the  regarding  management  these extreme i n t e r n a l s might  their  own i n s t r u m e n t a l i t y .  The  very  s i t u a t i o n s enhances i n d i v i d u a l s ' c a p a c i t y t o  the world  ( i . e . an i n t e r n a l l o c u s  difficult.  i t i s possible  to influence  ( S t r i c k l a n d , 1978) t h e y m i g h t have responded t o  reluctance.  t h o s e who s c o r e  high  more p r o d u c t i v e l y , Doctor, 1971). psychosocial  since  i n t e r n a l s a r e more  There i s evidence to suggest  success i n dealing with  on e x t e r n a l i t y .  Since  I n t e r n a l s tend  success i n a pain  compliance to behavioral  that  t h e i r environments to use  and a r e l e s s m a n i p u l a t e d o r c o e r c e d  adjustment i n t h i s  than  information  ( L e f c o u r t , 1966;  treatment program ( i . e . b e t t e r  study) i s dependent, at l e a s t i n p a r t ,  interventions  t h e i n d i v i d u a l s who r e p o r t e d  to i n s t r u c t i o n .  that  of c o n t r o l ) i n  Alternately,  treatment with  that  pain,  pain  f r u s t r a t i n g and  may make a d j u s t m e n t o r a d a p t a t i o n  i n t e r n a l s have g r e a t e r  on  own r e g a r d i n g  Due t o t h e v e r y  nature of chronic  a t t r i b u t e which i n other  this  of t h e i r  high  i t i s possible  i n t e r n a l i t y were v e r y  T h a t i s , t h e y may h a v e h a d d i f f i c u l t y  dependent nature o f c e r t a i n treatments.  to  There i s a l s o  coping  speculate resistant with the  the p o s s i b i l i t y  that  i n t e r n a l s , f e e l i n g more i n c o n t r o l , may i n e f f e c t h a v e l e s s o f a  need  to a c t i v e l y respond If  control  chronic  pain  to therapeutic  p a t i e n t s are viewed  f r a m e w o r k a s some r e s e a r c h  Ferrante,  interventions.  suggests  ( A b r a m o w i t z , 1969; Harrow &  1969; S k e v i n g t o n , 1979) t h e n f a i l u r e  psychosocial  dimensions a f t e r a pain  from an e x t e r n a l l o c u s o f  to adjust  w e l l on t h e  t r e a t m e n t p r o g r a m may r e s u l t f r o m  - 65 -  a viewpoint  of the i n d i v i d u a l  t h a t o n e ' s a c t i o n do n o t a f f e c t  condition.  The e x t r e m e e x t e r n a l s ' i n a b i l i t y  m i g h t i n f l u e n c e p a i n management, may  result  one's  t o s e e how t h e i r i n passivity  pain  behavior  and l o s s o f  initiative. As  discussed  i n the review  of the l i t e r a t u r e  there  i s some  s p e c u l a t i o n about b o t h e x t r e m e s o f l o c u s o f c o n t r o l and t h e r e l a t i o n s h i p to maladjustment is  found  (Phares,  1976; R o t t e r , 1 9 7 5 ) .  i n b o t h p e o p l e who p o s s e s s a s t r o n g  o u t c o m e s a r e t h e i r own r e s p o n s i b i l i t y a t t a i n valued internals  goals  or outcomes.  expectancies  show p o o r a d j u s t m e n t . their  chronic  feel  both very  i n attaining  The e x t e r n a l s t h i n k t h e y  p a i n and a r e p o o r l y  i n t e r n a l s may be p o o r l y a d j u s t e d they  generalized expectancy  Thus, a p o p u l a t i o n  f o r success  over i n a b i l i t y  adjustment that  a n d p e o p l e who do n o t e x p e c t t o  and extreme e x t e r n a l s , h a v i n g  generalized  Perhaps, poor  adjusted  high  and v e r y  important  low  goals,  c a n n o t do a n y t h i n g  psychosocially.  because of g u i l t  t o cope w e l l w i t h  of extreme  their  and  may about  The  responsibility  chronic  pain.  L o c u s o f C o n t r o l and P s y c h o s o c i a l A d j u s t m e n t f o r M a l e s and Females The r e s u l t s  of the s t a t i s t i c a l  a n a l y s i s appear t o i n d i c a t e a  gender d i f f e r e n c e between t h e r e l a t i o n s h i p o f l o c u s o f c o n t r o l and  adjustment to chronic pain scores.  external  locus of c o n t r o l a l s o tended  adjustment  to chronic  scores  F e m a l e s who i n d i c a t e d a n to i n d i c a t e better  psychosocial  pain.  One p o s s i b l e e x p l a n a t i o n good a d j u s t m e n t i s t h a t they  f o r the e x t e r n a l females  may h a v e u n d e r p l a y e d  their  indicating  symptoms  - 66 -  r e s p o n d i n g o n t h e ACPS i n the' d i r e c t i o n o f l e s s d i s t r e s s . is  s u p p o r t e d by P h a r e s  able  ( 1 9 7 6 ) who s t a t e d  to handle threatening  c o n v e n i e n t mode o f a n x i e t y potentially and  threatening  one w o u l d  material  that  externals  because t h e i r  reduction,  Perhaps t h e female externals  seen i n a s o c i a l l y  acceptable  light  may be b e t t e r  In this  i na  a  case t h e  or personal  respond t o i t e m s on t h e q u e s t i o n n a i r e  d e s i r a b l e way.  thinking  e x t e r n a l i t y provides  namely d e n i a l .  s t i m u l i w o u l d be f a i l u r e  This  inadequacy,  socially  had a greater  n e e d t o be  and thus were l e s s w i l l i n g  (or able)  t h a n t h e f e m a l e i n t e r n a l s and t h e males t o acknowledge t h e e x t e n t of their  difficulties. Perhaps an e x p l a n a t i o n  better psychosocial  compliant (Eagly, the  A recent  center  i n group s i t u a t i o n s as they a r e u s u a l l y p o r t r a y e d They a r e , h o w e v e r , more l i k e l y  conformity,  as  being  t o c o n f o r m t h a n men when  o r when t h e i r  i n t h e presence of a male expert  popultion  behavior  i s being  a s was t h e c a s e f o r t h e p a i n  f r o m w h i c h t h e s a m p l e was d r a w n .  In view of the better the externally oriented  responsive  on  i n d i c a t e s t h a t women a r e n o t a s  s i t u a t i o n i n v o l v e s male e x p e r t i s e  evaluated  by  survey of the l i t e r a t u r e  and i n f l u e n c e a b i l i t y  1978).  reporting  adjustment i s s t r i c t l y a matter of hgher l e v e l s o f  compliance i n females. persuadability  f o r f i n d i n g female e x t e r n a l s  a d j u s t m e n t w h i c h a p p e a r s t o be  females, i tappears that  t o t h e more p r e s t i g i o u s  within a structured  situation.  s u g g e s t i o n s and d i r e c t i o n s given  sources  reported  externals are  of t h e r a p e u t i c  influence  That i s , they a r e r e c e p t i v e t o by p r o f e s s i o n a l s , a v i e w s u p p o r t e d b y  Abramowitz, Abramowitz, Roback, and J a c k s o n  (1974), Balch  and Ross  - 67 -  (1975), if  and K i l m a n n , A l b e r t , and S o t i l e  the treatment  (1975).  strategies are closely  This  controlled, externals  d e m o n s t r a e more t h e r a p e u t i c r e s p o n s i v e n e s s  than i n t e r n a l s .  a p p e a r e d t o be so f o r t h e f e m a l e s i n t h e p r e s e n t For  not  sufficient.  help  F o r women c o p i n g  t o have a b e l i e f  lives  as b e i n g  d i f f i c u l t y with their pain.  The v e r y  and  relief  reality,  perceive  the events  own a c t i o n s , a n d  f e m a l e s may e x p e r i e n c e  i s  i n their  thereby  tremendous  o f c h r o n i c p a i n makes a d j u s t m e n t h a r d .  t h a t outcome i s c o n t i n g e n t  sense of h e l p l e s s n e s s  i n d i v i d u a l s may f e e l  psychosocial  c h r o n i c p a i n i t d o e s n o t seem t o  from c h r o n i c p a i n i s e l u s i v e .  a heightened  This  s e n s e o f i n s t r u m e n t a l i t y r e g a r d i n g management o f  nature  their perception total  with  system i n which they  Perhaps, these  should  one c o n t r o l s o n e ' s r e i n f o r c e m e n t  a consequence of t h e i r  controllable.  that  study.  t h e female i n t e r n a l s r e p o r t i n g poor  adjustment i t appears that f e e l i n g  view suggests  that they  and e x p e r i e n c e  great  c a n n o t c o n t r o l some t h i n g s  upon t h e i r  own  Despite  control,  F r u s t r a t i o n i s experienced,  and h o p e l e s s n e s s .  These  h a v e more c o n t r o l t h a n i s w a r r a n t e d b y difficulty  when t h e y  such as c h r o n i c  pain.  discover In fact,  that  they  the female  i n t e r n a l s who t e n d e d t o r e p o r t p o o r p s y c h o s o c i a l a d j u s t m e n t may be more representative given  of c h r o n i c p a i n p a t i e n t s i n g e n e r a l .  some s u p p o r t  by t h e e v i d e n c e p r e v i o u s l y d i s c u s s e d  U-shaped r e l a t i o n s h i p w i t h both very individuals  This  indicating  e x t e r n a l and v e r y  poor p s y c h o s o c i a l adjustment  I n a l a r g e number o f s t u d i e s L e f c o u r t persons h o l d i n g an i n t e r n a l  notion i s  supporting  a  internal  to chronic  (1976) found  locus of c o n t r o l can withstand  pain.  that pressures  - 68 -  directing  them t o b e h a v e i n c e r t a i n c i r c u m s c r i b e d  t r u e i n a l l i n s t a n c e s , as i n t e r n a l s do y i e l d same p r e s s u r e s  as e x t e r n a l s .  seem t o i m p r e s s  internals,  arguments r e g a r d l e s s their  prestigious  1968).  an  internal  be  circumspect  of the s t a t u s of the source. when a l l o w e d  to externals  t o more  (Johnson, Ackerman,  For chronic pain patients, p a r t i c u l a r l y  i n the face  to chronic pain.  variables.  of pressure  to y i e l d  the very  of c o n t r o l  Frank,  f o r females,  to influence. linear  and p s y c h o s o c i a l  The a b s e n c e o f any s i g n i f i c a n t r e l a t i o n s h i p strong  c o r r e l a t i o n f o r f e m a l e s between  require different  patterns  adjustment c r i t e r i a  That i s , s i n c e t r a d i t i o n a l l y  defined  these  o f male and f e m a l e  f o r males and  f e m a l e r o l e s may  imply  c o n c e r n w i t h e m o t i o n s and f e e l i n g s , w h i l e male r o l e s  traditionally instrumental  have been a s s o c i a t e d w i t h g r e a t e r a c t s , the notions  of p s y c h o s o c i a l  h e r e m i g h t make more s e n s e a s c r i t e r i a for  scores  Perhaps, the generally d i f f e r e n t  socialization  greater  and  l o c u s o f c o n t r o l seems t o be a s s o c i a t e d w i t h a t e n d e n c y t o  puzzling given  females.  shift  more a c t i v e  o f i n f l u e n c e , and t h e d e s i r e f o r a f f i l i a t i o n  r e l a t i o n s h i p between l o c u s  is  but not t o t h e  Internals also  F o r m a l e s , t h e r e a p p e a r s t o be no s i g n i f i c a n t  adjustment  i s not  by a u t h o r i t i e s do n o t  E x t e r n a l s a p p e a r t o be more r e s p o n s i v e  sources  This  b u t i n t e r n a l s do r e s p o n d t o r e a s o n e d  d e p e n d e n c e may be more i m p o r t a n t & Fionda,  to pressures  Statements presented  own a t t i t u d e s and b e h a v i o r s  participation.  manners.  overt  a c t i v i t y and  adjustment as  presented  f o r adjustment f o r females  than  males. Alternately,  research  h a s shown t h a t p e o p l e i n many m i n o r i t y  - 69 -  and  disadvantaged  perceiving 1974).  their  life  In general  individuals what  groups tend  they  t o score  situations realistically  b l a c k s , women, a n d l o w e r  h a v e more r e s t r i c t i o n s  do o r do n o t d o .  on t h e i r  Perhaps those  p s y c h o s o c i a l a d j u s t m e n t and s c o r e d a realistic  i n the external  perception of t h e i r  direction,  (Gruen, K o r t e ,  socioeconomic  class  own s u c c e s s e s  regardless of  f e m a l e s who r e p o r t e d  In the d i r e c t i o n  restraints.  c o n t r o l and s i t u a t i o n a l  instrumentality i n this  coping  (i.e. a situation  Pain  r e l a t i o n s h i p between l o c u s  subjects.  statistically  of p a i n ) .  significant  results  are obtained.  on t h e MPQ  hypothesis  fora  scores f o r  separately  M a l e s who s c o r e d o n t h e MPQ  (high  high rating  l o w on l o c u s of c o n t r o l ( i n t e r n a l ) s c o r e d  (high r a t i n g of p a i n ) .  f i n d i n g s f o r the females i s c o n s i s t e n t with  two s i n c e t h e f e m a l e i n t e r n a l s r e p o r t i n g h i g h  reported  earlier,  high  support  a n d MPQ  H o w e v e r , when t h e two s e x e s a r e t r e a t e d  F e m a l e s who s c o r e d  The  statistical  of c o n t r o l scores  on l o c u s of c o n t r o l ( e x t e r n a l ) a l s o s c o r e d  also  o f an i n d i v i d u a l  Ratings  T h e r e a p p e a r s t o be no s i g n i f i c a n t  high  locus of  of gender.  Locus o f C o n t r o l and P r e s e n t  all  socially  w i t h c h r o n i c p a i n ) may be m e d i a t e d i n p a r t a t l e a s t by t h e  variable  linear  have  situation.  The r e l a t i o n s h i p b e t w e e n p e r c e i v e d powerlessness  good  of e x t e r n a l i t y  M a l e s , on t h e o t h e r h a n d a r e n o t a f f e c t e d i n t h e same way by determined  Baum, &  poorer  psychosocial adjustment to t h e i r  i t i s p o s s i b l e that these  the r e s u l t s of levels  pain.  f e m a l e s may e x p e r i e n c e  of pain  As n o t e d  frustration i n  - 70 -  dealing with difficulty  the v a r i a b l e nature  with  their  sense of i n s t r u m e n t a l i t y .  helplessness  do n o t p r e c l u d e  management.  Logically,  i f i n d i v i d u a l s r e p o r t poor  to c h r o n i c pain those  experience  high  The r e s u l t s reported  pain  over t h e i r  tend  pain  on  f o r t h e m a l e s seem t o s u g g e s t  t o see t h e m s e l v e s as h a v i n g For these  (1980) supports  this  less personal  i n d i v i d u a l s who  pain.  an  of c o n t r o l .  males the e x p e r i e n c e  reduced.  that  anxiety  when i t i s c o m b i n e d  M a l e s w i t h an e x t e r n a l less personal  locus  c o n t r o l over  o f c h r o n i c p a i n may  of an a t t i t u d e of h e l p l e s s n e s s , p r e c l u d i n g , as w i t h response to pain  experience  n o t i o n by f u r t h e r s t a t i n g  see t h e m s e l v e s as h a v i n g  F o r these  high  control  substantially  i n pain perception mainly  w i t h an i n d i v i d u a l ' s f e e l i n g c o n t r o l may  t h a t males w i t h  t h e e f f e c t i v e n e s s o f many b e h a v i o r a l i n t e r v e n t i o n s  reduction i s important  of  psychosocial  same i n d i v i d u a l s w o u l d be e x p e c t e d t o  t h e m o t i v a t i o n a l component o f p a i n i s l i k e l y  Weisenberg  and p a i n  of p a i n .  (external).  absence of c o n t r o l ,  experience  These f e e l i n g s of  good r e s p o n s e t o t r e a t m e n t  adjustment  levels  o f c h r o n i c p a i n and hence  occasion  the females,  their more  good  management.  P s y c h o s o c i a l Adjustment f o r Males and Females T h e r e was no s i g n i f i c a n t differences findings  statistical  i n p s y c h o s o c i a l adjustment  o f Toomey, T a y l o r , S h e l t o n ,  males a r e d e c i d e d l y  more c o n s e r v a t i v e  support  to chronic pain  and C a r r o n  f o r gender contrary  ( 1 9 8 2 ) who f o u n d  to the that  than females i n r e p o r t i n g  improvement i n a wide spectrum of a r e a s .  P o s s i b l y the f i n d i n g s of the  - 71 -  present  research  w e r e a f f e c t e d by t h e v a l i d i t y  measuring instrument. speculative,  W h i l e any e x p l a n a t i o n  same m e a n i n g f o r m a l e s a n d f e m a l e s .  for  t h e l a c k of gender d i f f e r e n c e s i s t h a t  of  of these  i t may be t h a t t h e s e v e n s u b t e s t s  the  o f t h e ACPS as a results i s  o f t h e ACPS do n o t h a v e  Another p o s s i b l e t h e ACPS f a i l s  explanation t o measure a l l  t h e c o m p l e x and m u l t i p l e f a c t o r s i n p s y c h o s o c i a l a d j u s t m e n t t o  c h r o n i c p a i n which would have d i f f e r e n t Although  importance f o r each s e x .  t h e r e was no s i g n i f i c a n t  d i f f e r e n c e i n the  p s y c h o s o c i a l a d j u s t m e n t t o c h r o n i c p a i n o f males and f e m a l e s u s i n g ACPS s c o r e s , seven items  subsequent t - t e s t s revealed  some s i g n f i c a n t d i f f e r e n c e s .  Environment, revealed females w i t h  significant  i ti s likely  that i f the r e l i a b i l i t y  Two i t e m s  and  of w o r r y i n g  Males they  for this  s u b t e s t was l o w  of t h e s u b t e s t were  improved  7, P s y c h o l o g i c a l D i s t r e s s , ( w i t h a h i g h  revealed  significant  d i f f e r e n c e s between males  i n d i c a t e d more d i s t r e s s t h a n f e m a l e s i n t h e amount  do s i n c e t h e d e v e l o p m e n t o f t h e i r  males a l s o experience experience  2, V o c a t i o n a l  decrease.  i n Subtest  of r e l i a b i l i t y ) ,  females.  Subtest  d i f f e r e n c e s between t h e males and  of r e l i a b i l i t y  t h e mean d i f f e r e n c e w o u l d  estimate  and on t h e t w e n t y  the females r e p o r t i n g b e t t e r adjustment than the males.  However, t h e Hoyt e s t i m a t e and  on t h e s e v e n s u b t e s t s  total  more d e p r e s s i o n  of c h r o n i c p a i n .  c h r o n i c p a i n , and  than females r e l a t e d t o the  Litigation,  m a l e a n d f e m a l e r o l e s may e x p l a i n t h e s e  c o m p e n s a t i o n , and results.  The  traditional  cultural  stereotype  r e q u i r i n g m a l e s t o be more p h y s i c a l l y s t r o n g  productive  t h a n f e m a l e s may  and v o c a t i o n a l l y  c a u s e m a l e s t o w o r r y more a n d b e more  -  72  d e p r e s s e d t h a n f e m a l e s when f a c e d w i t h vocational Appendix  disruption.  The  results  chronic pain, d i s a b i l i t y ,  of t h e s e  Good a n d  Poor P s y c h o s o c i a l  T h e r e a p p e a r s t o be c o n t r o l scores results  hypothesis, adjustment  than those  for reported  call  no  significant  into question  the  theoretical  i n d i v i d u a l s who The  l a c k of  small  Moreover, the  report poorer  generalizability  of  to t h i s hypothesis  difference i n locus  results  was  the  one  to  The  subject  are  these  dubious.  concept  that  supported  there would subjects  those  e x t e r n a l and  results  very  be who  subjects of  (that there  poor p s y c h o s o c i a l a d j u s t m e n t ) then the i s moot.  events  may  B o t h of  I f however, the  r e l a t i o n s h i p with both very  addressed i n t h i s hypothesis  of  f i f t e e n poor a d j u s t e r s ) .  t o c h r o n i c p a i n and  supplementary a n a l y s i s to hypothesis  indicating  life  adjustment  considerations.  the  r e p o r t good p s y c h o s o c i a l a d j u s t m e n t .  a curvilinear  this  levels  have over t h e i r  of c o n t r o l o r i e n t a t i o n between t h o s e  r e p o r t poor p s y c h o s o c i a l adjustment  of  psychosocial  s u b j e c t s p a r t i c i p a t i n g were v o l u n t e e r s .  Pivotal  subjects  rationale for  psychosocial  locus  poor a d j u s t e r s .  s u b s t a n t i a t i o n f o r the h y p o t h e s i s  ( n i n e g o o d a d j u s t e r s and  f a c t o r s make t h e  be  reported  to have d i f f e r e n t  t o t h e amount o f c o n t r o l t h e y  p o s s i b l y have r e s u l t e d from m e t h o d o l o g i c a l  who  in  Adjustment  r e p o r t good  t o c h r o n i c p a i n a r e more l i k e l y  chronic pain.  a  are presented  d i f f e r e n c e i n the  good a d j u s t e r s and  n a m e l y , t h a t i n d i v i d u a l s who  e x p e c t a n c y as  p o o l was  analyses  and  G.  L o c u s o f C o n t r o l and  The  -  the  might  internal  question  -  In fact, the  two  t h e r e was  may  external.  reported  The  reported  locus  i n T a b l e 6.  reflect  homogeneous i n t h e i r of  -  a marked d i f f e r e n c e i n the v a r i a b i l i t y  g r o u p s as p r e s e n t e d  extreme scores  73  their  The  tendency  reported  t o be  poor  of  adjusters  either internal  or  good a d j u s t e r s , i n c o n t r a s t , w e r e more  responses r e f l e c t i n g  control  a commonality i n  their  scores.  L i m i t a t i o n s of the I n v e s t i g a t i o n The agreed  current  research  s a m p l e was  t o p a r t i c i p a t e on a v o l u n t e e r  restricted  basis.  T h i s may  to s u b j e c t s have b i a s e d  s a m p l e t o w a r d s i n c l u d i n g c h r o n i c p a i n p a t i e n t s whose e x p e r i e n c e s the  chronic pain treatment  i n d i v i d u a l s who g e n e r a l l y may  consented to p a r t i c i p a t e i n t h i s  have e x p e r i e n c e d  p a i n than those  who  generalizability is  no way  differ  of  d i d not the  participate.  f i n d i n g s to the  i n some s y s t e m a t i c  which are  study  subject  way  This  research  project  i s b a s e d e x c l u s i v e l y on  t o d i s t o r t i o n by  the  population  since  respond to followup who  with  chronic  a f f e c t s the  general  from those  the  The  b e t t e r p s y c h o s o c i a l adjustment to  o f k n o w i n g w h e t h e r s u b j e c t s who  This  Sanders  c e n t r e were g e n e r a l l y p o s i t i v e .  who  do  there  assessment  not.  self-report  individual  (Keefe,  techniques 1982).  (1980) found t h a t c h r o n i c low-back p a i n p a t i e n t s c o n s i s t e n t l y  distorted  their  reports  of a c t i v i t y  might have been s t r e n g t h e n e d s u b j e c t s b e e n a t t e m p t e d and  had  i n a negative  face  to face  o b s e r v a t i o n a l data  direction.  interviews with collected.  The the  design  -  This control,  was  adjustment  These r e l a t i o n s h i p s s u r f a c e d  the  and  study.  Control  reliability  validity  of  and  r e l a t i o n s h i p s between l o c u s  to c h r o n i c  with  of  A l t h o u g h the  Scale  -  a study to observe the  psychosocial  validity  74  the  the  pain,  reported  instruments applied  instruments  researcher  and  has  confidence  the M c G i l l P a i n Q u e s t i o n n a i r e ,  the Adjustment to C h r o n i c P a i n  the  crucial  i n Rotter's the  Scale  pain.  and  i s , therefore,  yet  to  Locus  reliability  have not  of  of  and  been w e l l  established. Relationships treating divided the  the the  two  attain  s e x e s as a homogenous g r o u p .  small  results.  between v a r i a b l e s perhaps were o b s c u r e d  sample of  f e m a l e s made i t d i f f i c u l t  sexes were  to generalize  A much l a r g e r s a m p l e w o u l d h a v e b e e n n e c e s s a r y  i n d i c a t e that  different  level  advisable  to t a k e sex This  of  the  locus  complexity  of  specificity  o r i e n t a t i o n lead  e x t r e m e e x t e r n a l and  research c a u s e and  familial,  does n o t ,  effect  and  lead  to h i g h l y  e x t r e m e s of  adjustment?  personal  These are by  question.  The  a be  i t i s impossible Does  Or  external  locus do  of  the  lead to  important questions,  i t s nature,  poor  c o r r e l a t e s ) that  extreme i n t e r n a l b e l i e f s a l s o  adjustment?  cited  the  to poor p s y c h o s o c i a l  (social,  psychosocial  pain  s y s t e m s o r do  to  account.  d e f i n i t i v e way.  adjustment to chronic  internal belief  conditions  into  Hence, i t would  s t u d y i s c o r r e l a t i o n a l i n n a t u r e and  s e p a r a t e c a u s e f r o m e f f e c t i n any psychosocial  c o n t r o l concept might have  f o r each sex.  from  i n order  a more a d e q u a t e number o f f e m a l e s f r o m w h i c h t o g e n e r a l i z e .  results  highly  Once t h e  by  allow  us  and  control same  lead  to  poor  but  the  to i n v e s t i g a t e  the  to  -  No  e f f o r t was  made by  75  the  researcher  those  subjects  not.  I t i s possible that l i t i g a t i o n  regarding control,  involved i n l i t i g a t i o n  and  responses to pain.  individuals' efforts This  may  value.  not  I t was  p s y c h o s o c i a l dimensions, the  I t m i g h t be  and  individual  f o r those  I m p l i c a t i o n s of the The  This  different  locus  was  perhaps not  f o r males and or  the  same f o r  f o r females,  and  compensation  interesting  strategies for chronic pain to change l o c u s  o f c o n t r o l and  poor p s y c h o s o c i a l  In general  of  i n this investigation.  of  patients  control  seems t o i n d i c a t e b o t h a c u r v i l i n e a r r e l a t i o n s h i p  extremes of  and  concept  on a v a r i e t y o f  s t u d y w o u l d a p p e a r t o be  treatment  a d j u s t m e n t t o c h r o n i c p a i n , and, internality  punish  involved.  s t r a t e g i e s designed study  systems  conditions.  being w e l l adjusted  i m p l i c a t i o n s of t h i s  of t r e a t m e n t  of  Study  terms of d i f f e r e n t i a l  between the  on  reinforcement  so  to  locus  i n v e s t i g a t e d the  involved i n l i t i g a t i o n  not  legal  d e p e n d e n c y and  reinforcement  all  beliefs.  c o m p e n s a t i o n have i m p l i c a t i o n s  c o m p e n s a t i o n and  and  those  assumed t h a t i n d i v i d u a l s e x p e r i e n c i n g  of  and  and  have a d e q u a t e l y  However, the v a l u e  a l s o f o r those  this  between  o r c o m p e n s a t i o n c a s e s and  c o n t r o l over t h e i r p a i n  chronic pain place a high value  participants.  The  behaviors  to exert  study  reinforcement  in  to d i f f e r e n t i a t e  gender d i f f e r e n c e s i n adjustment to c h r o n i c p a i n ,  appear to reward i l l n e s s  disputes  -  past  f o r females,  poor  psychosocial  a r e l a t i o n s h i p between  adjustment.  studies report  that i n d i v i d u a l s with  an  -  internal  locus  and  social  external  l o c u s of c o n t r o l .  with  literature  relationship  between l o c u s  regarding and  the  counsellors,  the  results  t h e r a p i s t s , and  research  be  and  s i n c e the  results  of  establish  The  results  treatment  expectancies could help  regarding  separately.  are  the  to i n c r e a s e  t h e r a p i s t e s t a b l i s h goals  the  scores  carried  those  assessment p r i o r  appear to suggest  goals. out  then help  Similarly,  Not  in this  a great and  to  poorer  the  therapist  generalized  these  measures  f o r change w i t h t h e i r  clients better  pain.  internal  area  of  extreme  to i n d i v i d u a l s '  i n d i v i d u a l s reporting high  e n c o u r a g i n g an  treatment  locus  i n d i v i d u a l s s e n s e of i n s t r u m e n t a l i t y l e a d i n g t o  p s y c h o s o c i a l adjustment to For  treating  t o measure the  of t h i s m e a s u r e c o u l d  l o c u s of c o n t r o l .  pain  have i m p l i c a t i o n s f o r  study  strategies tailored  to  interesting  p s y c h o s o c i a l a d j u s t m e n t f o r b o t h e x t r e m e e x t e r n a l s and internals.  the  for  appear  of c o n t r o l f o r c h r o n i c  beneficial  this  examine  study  raise  o r i e n t a t i o n of i n d i v i d u a l s upon i n i t i a l  treatment  study  p s y c h o s o c i a l adjustment  h e a l t h p r o f e s s i o n a l s who  I t may  an  this  reports  findings in this  locus  of  female c h r o n i c p a i n p a t i e n t s  findings i n this  chronic pain patients.  individuals with  done s i n c e few  literature  c o n c e p t of  f u n c t i o n more s u c c e s s f u l l y  t h a n do  o f c o n t r o l and  However, the  f o r m a l e and  The  control  readily  the p r e v i o u s l y c i t e d  questions patients  areas  A c o m p a r i s o n of  c a n n o t be  chronic pain patients. contradict  -  of c o n t r o l p e r f o r m b e t t e r and  i n numerous p e r s o n a l  the  76  locus deal  the  of  external locus  c o n t r o l w o u l d be  of s y s t e m a t i c  f i n d i n g s are  research  still  one has  sketchy.  of c o n t r o l of  the  been However,  -  Phares  (1976) n o t e d t h a t what r e s e a r c h  reported  seems c o n s i s t e n t w i t h  c o n t r o l may coping  be  one  -  has  been a c c o m p l i s h e d  t h e v i e w t h a t an  internal  p r e r e q u i s i t e of competent b e h a v i o r  forms, but  one  expectancies change.  should  are  only  training  f o r the  and  enhanced  add  change d a t a  to understanding  Thus, use  of a  locus  of  of  desired i s not the  treatment  programs f o r c h r o n i c The  responsible  professionals actions  of  their  maintain  concepts:  that  heightened  own  (based  on  p a i n management.  and the  MacDonald,  (4) p e r s o n a l experience  1977).  He  training  recognize resource,  should  the  evaluate  but  sound a d v i c e )  be  to  train  need t o use who will  will be  health  a l s o see  necessary  causation  training.  (3)  Other  r a i s e i n t e r n a l b e l i e f s was  revealed  i n d i c a t e d t h a t b o t h a c t i o n - o r i e n t e d and internal  scores.  obtain  major  realistic researchers to  f o r s e l f - d e t e r m i n a t i o n groups effectively  that to  DeCharms ( 1 9 6 8 ) e m p h a s i z e d f o u r  Support f o r the n o t i o n t h a t  l e d to i n c r e a s e d  of  c o n t r o l measure i s  of p r o b l e m c o n f r o n t a t i o n l e a d s  in internality  one's problems can (1970).  behavior  f e e l i n g of i n t e r n a l c o n t r o l ( G o t t e s f e l d & D o z i e r ,  i s a shit  therapy  appropriate  or  change or l a c k  (1) s e l f - c o n c e p t , (2) achievement m o t i v a t i o n ,  goal-setting, suggest  as an  will  many  pain patients.  g o a l of i n t e r n a l i t y  i n t e r n a l s who  take  always p o s s i b l e  recommended i n c o n j u n c t i o n w i t h b e h a v i o r a l m e a s u r e s t o  Dua  of  extreme e x t e r n a l s c o u l d  r e l e v a n t i f a c c o m p a n i e d by  expectancy data w i l l  there  locus  keep i n mind t h a t changes i n b e l i e f s  However, o b t a i n i n g b e h a v i o r  change i n b e h a v i o r s .  and  and  efforts. Internality  and  77  a 1966),  and  (Tobias  &  coping  with  i n the work reeducative  of  - 78 -  It provide  i s c l e a r that b e l i e f  i n d i v i d u a l s with a greater  potential  f o r power and e f f i c a c y .  powerlessness, training. extent  i n an i n t e r n a l  hopelessness  Discussions  Reduction  and b e h a v i o r  those  The  an  i n c o n t r o l of t h e i r  i n d i v i d u a l s who r e p o r t e d  to increase the environment  extreme i n t e r n a l  locus of  females r e p o r t i n g i n t e r n a l i t y , the  f o r c o u n s e l l o r s and t h e r a p i s t s a r e of a d i f f e r e n t  therapeutic goals  expectations  i s t h e a i m on i n t e r n a l i t y  procedures.  c o n t r o l s c o r e s , and a l s o f o r those implications  greater  of the e x t e r n a l s ' sense of  assignments designed  to which the i n d i v i d u a l s f e e l  For  of c o n t r o l can  s e n s e of c o n t r o l and t h u s a  and h e l p l e s s n e s s  o u g h t t o be u s e f u l t h e r a p e u t i c  locus  f o r these  regarding  personal  nature.  i n d i v i d u a l s i s t o change one's responsibility.  Since  o v e r w h e l m i n g s e n s e o f power o r c o n t r o l o v e r one's  environment,  techniques  c o u l d be u s e d t o r e d u c e t h e i n t e r n a l  is  guilt,  helplessness,  f r u s t r a t i o n and f e e l i n g s o f d e f e a t i n  p a i n management.  These c l i e n t s  n e e d t o l e a r n t h a t some o f t h e c o n t r o l  causing  which they that  experience  i s unrealistic  i t i s appropriate  some c o n t r o l . enhanced.  equals  of c o n t r o l which  i n d e a l i n g w i t h c h r o n i c p a i n , and  i n c e r t a i n s i t u a t i o n s t o d i s c r i m i n a t e and g i v e up  I n t h i s way t h e i r  As M a c D o n a l d  expectancy equals  locus  the issue here i s  expectancy f o r success  (1971) noted m o t i v a t i o n  optimism; m o t i v a t i o n  coupled  coupled  w o u l d be with p o s i t i v e  with negative  expectancy  despair. Counsellors  d i f f e r e n c e s may e x i s t  a n d t h e r a p i s t s n e e d a l s o t o be a w a r e t h a t regarding  chronic  p a t i e n t s ' experiences  meanings of p a i n , p s y c h o s o c i a l adjustment  gender  of p a i n ,  t o p a i n , and l o c u s of c o n t r o l  -  beliefs.  Further  preliminary treatment training  results  to a l t e r  right  the  locus  be  appropriate  to r e a l i z e  technique  should  different  be  the  techniques  will  systematic  his  internality  w a r m t h , a c c e p t a n c e and utilize  Similarly,  constraints, while  construct success  be  treatment  Then one  individual  one  internal  the  Suggestions  f o r Future  subsequent  in a  could attempt to approach  increase  encompassing should  encouraged to p a r t i c i p a t e i n  s u b j e c t i n g them t o f e w e r  or support  from others.  the  environmental  most f r o m t r e a t m e n t s I n these ways,  e x t e r n a l l o c u s o f c o n t r o l as  outcome  control  of  their  m i g h t be  find  technqiues.  an  relying the  expectancy  for  and  research.  Research  Research dealing with and  as  Rather,  effect  o p e r a t i o n a l i z e d as m e a s u r e s f o r i n - p a t i e n t  treatment  construct  pain.  to  effects.  o f p a t i e n t s and  e x t e r n a l s might p r o f i t  out-patient  control  s o l u t i o n i s not  l i s t e n i n g , w h i l e f o r a n o t h e r p a t i e n t one  o f i n t e r n a l and  could  s e x e s as w e l l  have a p p r o p r i a t e  i n t e r n a l s c o u l d be  on p r e s t i g e s u g g e s t i o n  the  by means of a R o g e r i a n  a c t i v e , manipulatory  management of t h e i r  that  with various kinds  t o s t a t e t h a t f o r one  or her  but  differential  f o r t h e two  i n v e s t i g a t i o n of  p s y c h o s o c i a l adjustment to c h r o n i c position  areas,  to enhance a p p r o p r i a t e  Many s u c h t e c h n i q u e s  goal  done i n t h e s e  of c o n t r o l b e l i e f s .  i s important  therapeutic  beliefs.  n e e d s t o be  -  appear to i n d i c a t e that perhaps  s t r a t e g i e s may  It the  research  79  the  r e l a t i o n s h i p between the  psychosocial adjustment  locus  of  to c h r o n i c p a i n appears  to  - 80 -  be  a new a r e a o f i n v e s t i g a t i o n .  future  research  larger  sample. The  might f i r s t  current  Based on t h e r e s u l t s o f t h i s  consider  r e p l i c a t i o n of the study w i t h  i n v e s t i g a t i o n was f u r t h e r l i m i t e d i n t h a t  psychosocial  v a r i a b l e s were used t o p r e d i c t a d j u s t m e n t .  psychosocial  variables are only  adjustment  to chronic  been i n c r e a s e d  pain,  only  Since the  one s e t o f f a c t o r s i n f l u e n c i n g  had v a r i a b l e s been i n c l u d e d  of s u r g e r i e s  such as e v a l u a t i o n s  taking  o f m e d i c a t i o n o r a l c o h o l usage, and  and t r e a t m e n t  the p o s s i b i l i t y  since  discharge.  of gender d i f f e r e n c e s  t h e ACPS d o e s n o t a p p e a r t o a p p l y generally require  d i f f e r e n t patterns  more c r i t i c a l l y  adjustment to chronic  pain without  of a d j u s t m e n t .  may  understanding  Specifically,  and t h e i r  It  experienced  and t h e gender d i f f e r e n c e s  to illuminate patterns  The  adjustment f o r males.  t h e more i n t e r n a l f e m a l e s  m u s t be w e i g h e d more c o m p l e t e l y  since  f o r males and f e m a l e s , s i n c e t h e  ACPS d o e s n o t a p p e a r t o p r e d i c t p s y c h o s o c i a l  w h i c h f e m a l e s and what k i n d s  i n t o account  t o b o t h s e x e s i n t h e same way.  d i f f e r e n t adjustment c r i t e r i a  poorer psychosocial  also  o f m a s c u l i n e and f e m i n i n e e x p e r i e n c e  may n o t b e e n o u g h t o s a y t h a t  have  of  R e f i n e m e n t o f t h e ACPS a s a m e a s u r i n g i n s t r u m e n t w o u l d include  a  t h e p r e d i c t i v e power o f t h e s t u d y w o u l d  functional status, evaluations evaluations  study,  the variables looked  at  interplay with  personality. Similarly,  a f a c t o r a n a l y s i s of the locus  might i n d i c a t e that w h i l e  s i m i l a r f o r the sexes  of c o n t r o l  the locus  c o n c e p t might have a d i f f e r e n t l e v e l o f c o m p l e x i t y  scale  of c o n t r o l  f o r each sex.  Hence,  - 81 -  sex  specificity  should  be c o n s i d e r e d  i n future studies using  the locus  of c o n t r o l c o n s t r u c t . The  hypothesis  psychosocial  adjustment  investigated  further.  it  appears  that a c u r v i l i n a r  t o c h r o n i c p a i n and l o c u s Accepting  between  of c o n t r o l should  be  t h e n o t i o n o f a U-shaped r e l a t i o n s h i p  t h a t b o t h t h e extreme e x t e r n a l s and extreme i n t e r n a l s a r e  more p o o r l y  adjusted  psychosocially.  from the middle of the d i s t r i b u t i o n , i n f l e x i b l e way a f t e r middle should research  relationship exists  Since  each i s r e l a t i v e l y  e a c h seems l i k e l y  categorizing situations.  t o respond i n an  The p e o p l e n e a r e r t h e  r e s p o n d t o s i t u a t i o n s i n a more r e a l i s t i c  fashion.  might a l s o i n v e s t i g a t e the r e l a t i o n s h i p of other  as a g e , s e x , c h r o n i c i t y ,  removed  Future  v a r i a b l e s such  e t c . t o good and p o o r p s y c h o s o c i a l  adjustment  t o c h r o n i c p a i n and t o l o c u s o f c o n t r o l o r i e n t a t i o n .  Conclusion B a s e d on t h e m e a s u r e s u s e d i n t h i s analyses  a p p l i e d , t h e r e l a t i o n s h i p s between l o c u s  p s y c h o s o c i a l adjustment the  subjects  s u b j e c t s who scored  to chronic  s t u d i e d were d i f f e r e n t reported  females,  a  there  of c o n t r o l ,  poor p s y c h o s o c i a l adjustment.  curvilinear  pain ratings f o r  f o r males and f e m a l e s ,  or h i g h l y i n t e r n a l ) reported  suggesting  and t h e s t a t i s t i c a l  p a i n , and p r e s e n t  a t both extremes of the l o c u s  external  study  of c o n t r o l s c a l e poorer  and f o r those  Those s u b j e c t s  who  ( i . e . highly  psychosocial  adjustment  r e l a t i o n s h i p between t h e v a r i a b l e s .  a p p e a r s t o be a s u b s t a n t i a l r e l a t i o n s h i p b e t w e e n  For poorer  - 82 -  p s y c h o s o c i a l adjustment t o c h r o n i c p a i n and i n t e r n a l i t y , internality  and h i g h  levels  of r e p o r t e d  pain.  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I n t e r n a l - e x t e r n a l locus of c o n t r o l : A n a l y s i s a n d b i b l i o g r a p h y o f two y e a r s r e s e a r c h ( 1 9 7 3 - 1 9 7 4 ) . P s y c h o l o g i c a l R e p o r t s , 1975, 37, 1323-1337. R e a d i n g , A . E . The i n t e r n a l s t r u c t u r e o f t h e M c G i l l p a i n i n d y s m e n o r r h o e a p a t i e n t s . P a i n , 1 9 7 9 , 4_, 2 8 3 - 2 9 2 .  questionnaire  -  Reid,  88 -  D.W., & Ware, E . E . M u l t i d i m e n s i o n a l i t y o f i n t e r n a l - e x t e r n a l control: I m p l i c a t i o n s f o r past and f u t u r e r e s e a r c h . Canadian J o u r n a l o f B e h a v i o r a l S c i e n c e , 1973, _5, 2 6 4 - 2 7 1 .  Revill, of 1  1  S.F., R o b i n s o n , J.O., R o s e n , M., & H o g g , M . I . J . The r e l i a b i l i t y the l i n e a r analogue f o re v a l u a t i n g p a i n . A n a e s t h e s i a , 1976, 3 1 , 1  R o t t e r , J.B. Generalized expectancies f o r i n t e r n a l versus e x t e r n a l c o n t r o l of reinforcement. P s y c h o l o g i c a l M o n o g r a p h s , 1 9 6 6 , 80_ (whole no. 6 0 9 ) . R o t t e r , J . B . Some p r o b l e m s a n d m i s c o n c e p t i o n s r e l a t e d to the construct of i n t e r n a l v e r s u s e x t e r n a l r e i n f o r c e m e n t . Journal of Consulting and C l i n i c a l P s y c h o l o g y , 1975, 4 3 , 56-67. S a n d e r s , S. T o w a r d a p r a c t i c a l i n s t r u m e n t s y s t e m f o r t h e a u t o m a t e d m e a s u r e m e n t o f " u p t i m e " i n c h r o n i c p a i n p a t i e n t s . P a i n , 1 9 8 0 , 9_, 103-109. S e r e s , J . , P a i n t e r , J . R . , & Newman, R . I . M u l t i d i s c i p l i n a r y t r e a t m e n t o f chronic pain a t the Northwest P a i n Centre. I n L o r e n z , K y Ng ( E d . ) New A p p r o a c h e s t o T r e a t m e n t o f C h r o n i c P a i n . R o c k v i l l e , MD.: NIDA R e s e a r c h Monograph 36, 1981. S k e v i n g t o n , S.M. P a i n a n d l o c u s o f c o n t r o l - A s o c i a l a p p r o a c h . I n O b o r n e , D . J . , G r u n e b e r g , M.M., & E i s e r , J . R . ( E d s . ) R e s e a r c h i n Psychology and Medicine. V o l u m e 1. L o n d o n : A c a d e m i c P r e s s , 1 9 7 9 . S t e r n b a c h , R.A. P a i n : A Psychophysiological Analysis. Academic P r e s s , 1968. S t e r n b a c h , R.A. P a i n p a t i e n t s : Academic P r e s s , 1974. Sternbach, 1978.  T r a i t s and treatment.  R.A. ( E d . ) The P s y c h o l o g y o f P a i n .  New Y o r k :  New Y o r k :  New Y o r k :  Raven  Press,  S t r i c k l a n d , B.R. I n t e r n a l - e x t e r n a l e x p e c t a n c i e s a n d h e a l t h - r e l a t e d behaviors. J o u r n a l o f C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1978, 46, 1192-1211. Tait,  R., DeGood, D., & C a r r o n , H. A c o m p a r i s o n o f h e a l t h l o c u s o f c o n t r o l b e l i e f s i n l o w - b a c k p a i n p a t i e n t s f r o m t h e U.S. a n d New Zealand. P a i n , 1982, JL4, 5 3 - 6 1 .  T o b i a s , L . L . , & M a c D o n a l d , M.L. I n t e r n a l l o c u s of c o n t r o l and weight loss: An i n s u f f i c i e n t c o n d i t i o n . J o u r n a l o f C o n s u l t i n g and C l i n i c a l P s y c h o l o g y , 1977, 45, 647-653. Toomey, T.C., T a y l o r , A.G., S k e l t o n , J . A . , & C a r r o n , H. S t a b i l i t y o f s e l f - r e p o r t measures of improvement i n c h r o n i c p a i n : A five-year follow-up. P a i n , 1982, ]2, 2 7 3 - 2 8 3 .  - 89  -  T u r s k y , B., J a m n e r , L., & F r i e d m a n , R. The p a i n p e r c e p t i o n p r o f i l e : A p s y c h o p h y s i c a l a p p r o a c h to the assessment of p a i n r e p o r t . Behavior T h e r a p y , 1982, _13» 3 7 6 - 3 9 4 . V e r b r u g g e , L.M. F e m a l e s and i l l n e s s . Recent trends i n sex d i f f e r e n c e s i n the U n i t e d S t a t e s . J o u r n a l o f H e a l t h and S o c i a l B e h a v i o r , 1976, 17, 3 8 7 - 4 0 3 . W e i s e n b e r g , M. The r e g u l a t i o n o f p a i n . I n F l o r e n c e , L., ( E d . ) , Psychology: The L e a d i n g E d g e . V o l u m e 340. New Y o r k : The Y o r k Academy o f S c i e n c e s , 1980.  New  - 90 -  APPENDIX A  L E T T E R OF CONTACT  - 91 T H E U N I V E R S I T Y O F BRITISH C O L U M B I A F A C U L T Y OF  EDUCATION  D E P A R T M E N T OF COUNSELLING 5780 T O R O N T O  PSYCHOLOGY  ROAD  VANCOUVER, V6T 1L2  B.C.  May  PROJECT:  What e f f e c t  does a  chronic  pain  31,  t r e a t m e n t p r o g r a m h a v e on  individual's  adjustment to  I am  your involvement i n a study  1983  an  pain?  Dear  myself at  and  Dr.  seeking  M a r v Westwood of  carried  the Department of C o u n s e l l i n g  out  by  Psychology  UBC. I am  aspects  interested  of y o u r l i f e  program at  the  in finding  s i n c e you  out  how  finished  Columbia Centre.  This  the  included with  this letter.  your  be  The  time w i l l  helpful  pain.  required.  some i n t e r e s t i n g yourself  as y o u  things  respond to  Approximately  complete the  voluntary.  a b o u t y o u r s e l f and  four  1-1/2  hours  from t h i s study  questionnaires, a b o u t how  you  people  from may  of will  chronic discover  like  pain.  H o w e v e r , I want t o e m p h a s i z e A l l information  used f o r research  gained  various  treatment  the  patients suffering  Your p a r t i c i p a t i o n i n t h i s study appreciated.  residential pain  information  to p r o f e s s i o n a l s working with  In addition,  y o u ' v e managed i n  involves answering  questionnaires  be  being  gathered w i l l  p u r p o s e s o n l y , and  will  w o u l d be  very  much  that p a r t i c i p a t i o n i s be k e p t e n t i r e l y be  destroyed  totally  confidential,  when t h e  study  is  - 93 -  APPENDIX B  INSTRUCTION SHEET  - 95 -  APPENDIX C  BIOGRAPHICAL INFORMATION QUESTIONNAIRE  - 96 -  PART A  BIOGRAPHICAL INFORMATION  Your cooperation i n p r o v i d i n g t h i s information i s appreciated. be a s s u r e d  of s t r i c t  confidentiality  Please  and do n o t w r i t e y o u r name on t h e  questionnaire.  AGE  20-30 31-40 41-50 51-60 61+  SEX  Female Male  HOW  LONG AGO  d i d you complete the r e s i d e n t i a l  pain treatment  program?  months years  I f y o u no l o n g e r FREE ( o m i t  experience  i f you s t i l l  p a i n , i n d i c a t e how  ago ago  l o n g you have been PAIN  h a v e some p a i n ) .  weeks months years  DO NOT  WRITE BELOW THIS L I N E :  (FOR TABULATING  USE)  - 97 -  HOW  LONG h a v e y o u e x p e r i e n c e d  chronic  1 year  or l e s s  2 years 2-5  pain?  or less  years  more t h a n 5 y e a r s  PRIOR t o t h e r e s i d e n t i a l p a i n t r e a t m e n t pain-related  p r o g r a m d i d y o u have any  surgery? yes no  ADDITIONAL p a i n - r e l a t e d treatment  surgery  since completion  of the r e s i d e n t i a l  pain  program? yes  more t h a n one  no  H a v e y o u h a d any r e c e n t h o s p i t a l a d m i s s i o n s  f o r p a i n - r e l a t e d problems?  yes no  Have you sought o t h e r t r e a t m e n t r e s i d e n t i a l p a i n treatment  f o r pain r e l i e f  since completion  program?  yes no  If  y e s , what?  How much m e d i c a t i o n  do y o u t a k e f o r y o u r  pain?  no m e d i c a t i o n f o r p a i n l e s s than before same a s b e f o r e more t h a n b e f o r e  (indicate now  treatment  treatment treatment  one)  of the  - 98 -  Has pain  t h e amount o f t i m e w h i c h y o u s p e n d changed s i n c e you completed  program?  Has  the r e s i d e n t i a l  pain  down b e c a u s e o f treatment  ( i n d i c a t e one)  spend  no t i m e i n b e d o r l y i n g  spend  less  down due t o p a i n  spend  t h e same amount o f t i m e a s b e f o r e  spend  more t i m e  time i n bed or l y i n g  t h e r e been a change i n your  completed  i n bed o r l y i n g  than before  ability  t o bend o r w a l k  the r e s i d e n t i a l p a i n t r e a t m e n t program?  function  completely improved  function slightly  down due t o p a i n  better  ( i n d i c a t e one)  or restored  than before  f u n c t i o n t h e same as b e f o r e f u n c t i o n worse than b e f o r e  s i n c e you  treatment treatment  treatment  - 99 -  APPENDIX D  LOCUS OF CONTROL SCALE (ROTTER, 1 9 6 6 )  -  100  -  PART B ~ OPINION QUESTIONNAIRE  DIRECTIONS  I  am  trying  I want you  to find  o u t w h a t men  t o answer the f o l l o w i n g q u e s t i o n s  are  no r i g h t o r w r o n g  One  of your concerns d u r i n g  should my the  that  t h e way  certain things.  you  feel.  There  answers.  I do i f b o t h ( a ) a n d  opinon?" one  a n d women t h i n k a b o u t  this  part  ( b ) e x p r e s s my  I t ' s not unusual f o r that i s more n e a r l y  of the q u e s t i o n n a i r e  may  be,  opinion or i f n e i t h e r  t o happen.  true i n your opinion.  I f i t does,  "What  express  select  Try not t o l e a v e  any  blank.  For  each q u e s t i o n  circle  s e l e c t which statement i s c l o s e r to your o p i n i o n  e i t h e r (a) or ( b ) .  and  - 101 -  PART B ~ OPINION QUESTIONNAIRE  C h i l d r e n get i n t o much.  t r o u b l e because t h e i r  p a r e n t s p u n i s h them t o o  The t r o u b l e w i t h m o s t c h i l d r e n n o w a d a y s i s t h a t t h e i r a r e t o o e a s y w i t h them. Many o f t h e u n h a p p y t h i n g s i n p e o p l e ' s bad l u c k . People's  misfortunes results  from  lives  parents  are partly  the mistakes  they  due t o  make.  One o f t h e m a j o r r e a s o n s why we h a v e w a r s i s b e c a u s e don't t a k e enough i n t e r e s t i n p o l i t i c s .  people  There w i l l always p r e v e n t them.  try to  be w a r s , no m a t t e r how h a r d p e o p l e  In the long run people world.  get the r e s p e c t they deserve  U n f o r t u n a t e l y , an i n d i v i d u a l ' s worth no m a t t e r how h a r d one t r i e s . The  idea that teachers are u n f a i r  o f t e n passes  the r i g h t  breaks  unrecognized  to students i s nonsense.  Most s t u d e n t s don't r e a l i z e t h e e x t e n t t o which a r e i n f l u e n c e d by a c c i d e n t a l h a p p e n i n g s . Without  i n this  one c a n n o t  their  be an e f f e c t i v e  grades  leader.  C a p a b l e p e o p l e who f a i l t o become l e a d e r s h a v e n o t t a k e n advantage of t h e i r o p p o r t u n i t i e s . No m a t t e r  how h a r d y o u t r y some p e o p l e  P e o p l e who c a n ' t g e t o t h e r s t o l i k e to g e t a l o n g w i t h o t h e r s . H e r e d i t y p l a y s the major r o l e  have o f t e n found  don't  them d o n ' t  which  determine  l i k e you.  understand  i n d e t e r m i n i n g one's  I t i s one's e x p e r i e n c e s i n l i f e like. I  just  how  personality.  what  they're  t h a t what i s g o i n g t o happen w i l l  happen.  T r u s t i n g t o f a t e h a s n e v e r t u r n e d o u t as w e l l f o r me a s m a k i n g a d e c i s i o n t o take a d e f i n i t e course of a c t i o n .  - 102 -  10.  11.  12.  13.  14.  15.  16.  17.  18.  a.  I n the case of the w e l l prepared student t h e r e i s r a r e l y i f e v e r s u c h a t h i n g a s an u n f a i r t e s t .  b.  Many t i m e s exam q u e s t i o n s t e n d t o be s o u n r e l a t e d t o c o u r s e work t h a t s t u d y i n g i s r e a l l y u s e l e s s .  a.  Becoming a success i s a matter n o t h i n g t o do w i t h i t .  b.  G e t t i n g a good j o b depends m a i n l y at the r i g h t time.  a.  The a v e r a g e decisions.  b.  T h i s w o r l d i s r u n by t h e f e w p e o p l e i n p o w e r , a n d t h e r e i s n o t much t h e l i t t l e guy c a n do a b o u t i t .  a.  When I make p l a n s , I am a l m o s t work.  b.  I t i s n o t a l w a y s w i s e t o p l a n t o o f a r a h e a d b e c a u s e many t h i n g s t u r n o u t t o be a m a t t e r o f g o o d o r b a d f o r t u n e a n y w a y .  a.  t h e r e a r e c e r t a i n p e o p l e who a r e j u s t no g o o d ,  b.  T h e r e i s some g o o d i n e v e r y b o d y .  a.  I n my c a s e g e t t i n g w h a t I w a n t h a s l t t l e luck.  b.  Many t i m e s we m i g h t j u s t a coin.  a.  Who g e t s t o be t h e b o s s o f t e n d e p e n d s on who was l u c k y e n o u g h t o be i n t h e r i g h t p l a c e f i r s t .  b.  G e t t i n g p e o p l e t o do t h e r i g h t h a s l i t t l e t o do w i t h i t .  a.  As f a r a s w o r l d a f f a i r s a r e c o n c e r n e d , m o s t o f u s a r e t h e v i c t i m s o f f o r c e s we c a n n e i t h e r u n d e r s t a n d n o r c o n t r o l .  b.  By t a k i n g a n a c t i v e p a r t i n p o l i t i c a l people can c o n t r o l world events.  a.  Most people controlled  19.  citizen  don't  There r e a l l y  a.  One s h o u l d a l w a y s  b.  I t i s usually  on b e i n g i n t h e r i g h t  c a n have an i n f l u e n c e  realize  i s no s u c h  and s o c i a l  flipping  t h i n g as " l u c k " . mistakes,  b e s t t o c o v e r up o n e ' s m i s t a k e s .  luck  a f f a i r s the  their  happenings.  t o admit  them  depends upon a b i l i t y ;  the extent to which  be w i l l i n g  place  o r n o t h i n g t o do w i t h  d e c i d e what t o do by  thing  or  i n government  c e r t a i n t h a t I c a n make  as w e l l  by a c c i d e n t i a l  b.  of hard work, l u c k has l i t t l e  lives are  - 103 -  It  i s h a r d t o know w h e t h e r o r n o t a p e r s o n  really  l i k e s you.  How many f r i e n d s y o u h a v e d e p e n d s u p o n how n i c e a p e r s o n y o u are. In t h e l o n g r u n t h e bad t h i n g s t h a t happen t o us a r e b a l a n c e d by t h e good o n e s . Most m i s f o r t u n e s a r e t h e r e s u l t laziness, or a l l three. With  of l a c k of a b i l i t y ,  e n o u g h e f f o r t we c a n w i p e o u t p o l i t i c a l  It i s d i f f i c u l t f o r people p o l i t i c i a n s do i n o f f i c e .  ignorance,  corruption.  t o h a v e much c o n t r o l  over  the things  S o m e t i m e s I c a n ' t u n d e r s t n d how t e a c h e r s a r r i v e a t t h e g r a d e s they g i v e . There i s a d i r e c t grades I g e t .  c o n n e c t i o n b e t w e e n how h a r d I s t u d y a n d t h e  A good l e a d e r e x p e c t s p e o p l e s h o u l d do.  to decide f o r themselves  A g o o d l e a d e r makes i t c l e a r  to everybody  Many t i m e s I f e e l t h a t I h a v e l i t t l e t h a t h a p p e n t o me. I t i s i m p o s s i b l e f o r me t o b e l i e v e i m p o r t a n t r o l e i n my l i f e . People  are lonely  i n f l u e n c e over  they  jobs a r e . the things  t h a t chance o r l u c k p l a y s an  because they don't  T h e r e ' s n o t much u s e i n t r y i n g they l i k e you, they l i k e you.  what t h e i r  what  t r y t o be  too hard  T h e r e i s t o o much e m p h a s i s o n a t h l e t i c s  friendly.  to please people, i f  i n high school.  Team s p o r t s a r e a n e x c e l l e n t way t o b u i l d c h a r a c t e r . What h a p p e n s t o me i s my own d o i n g . Sometimes I f e e l t h a t I don't d i r e c t i o n my l i f e i s t a k i n g .  have enough c o n t r o l o v e r t h e  Most of t h e time I can't u n d e r s t a n d way t h e y d o .  why p o l i t i c i a n s  behave t h e  In t h e l o n g r u n t h e p e o p l e a r e r e s p o n s i b l e f o r bad government on a n a t i o n a l as w e l l a s o n a l o c a l l e v e l .  - 104 -  APPENDIX E  ADJUSTMENT TO CHRONIC P A I N SCALE  -  PART C I and  time a c t i v i t i e s  Please you  1.  think or  you t o answer these and y o u r f a m i l y  questions  about your work,  pain  spare  life.  t h e one s t a t e m e n t w h i c h b e s t  states  how  feel.  treatments  you have r e c e i v e d f o r  very p o s i t i v e w i t h h i g h l e v e l s of c o n f i d e n c e g e n e r a l l y p o s i t i v e w i t h some r e s e r v a t i o n s somewhat n e g a t i v e w i t h c y n i c i s m n e g a t i v e w i t h a l a c k of c o n f i d e n c e  How do y o u f e e l a b o u t t h e l e v e l o f c o m p e t e n c e o f t h e d o c t o r s have t r e a t e d you f o r y o u r c h r o n i c p a i n ?  who  very p o s i t i v e w i t h h i g h l e v e l s of c o n f i d e n c e g e n e r a l l y p o s i t i v e w i t h some r e s e r v a t i o n s somewhat n e g a t i v e w i t h c y n i c i s m n e g a t i v e w i t h a l a c k of c o n f i d e n c e  Do y o u b e l i e v e y o u w e r e g i v e n e n o u g h i n f o r m a t i o n a b o u t y o u r p a i n c o n d i t i o n t o make a d i f f e r e n c e i n y o u r d a i l y l i v i n g ? 0 1 2 3  4.  FAMILY L I F E QUESTIONNAIRE  How do y o u f e e l a b o u t t h e v a r i o u s your chronic pain?  0 . 1 2 3  3.  -  y o u h a v e b e e n a f f e c t e d by y o u r c h r o n i c  C I R C L E t h e number b e s i d e  0 1 2 3  2.  WORK, L E I S U R E AND  am I n t e r e s t e d i n how  I would l i k e  105  chronic  c o m p l e t e i n f o r m a t i o n f o r my p u r p o s e s a d e q u a t e , b u t I c o u l d h a v e u s e d more l e s s than adequate no i n f o r m a t i o n t o make a d i f f e r e n c e  Have y o u h a d t o c h a n g e t h e k i n d o f w o r k y o u do as a r e s u l t o f y o u r c h r o n i c p a i n , by f i n d i n g new e m p l o y m e n t o r by c h a n g i n g t h e n a t u r e of your work? 0 1 2 3  unchanged slight modification significant modification completely different  - 106 Has t h e amount o f s a t i s f a c t i o n y o u g e t f r o m y o u r you have e x p e r i e n c e d c h r o n i c p a i n ? 0 1 2 3  none l e s s than 1 year more t h a n 1 y e a r b u t l e s s 1-1/2 y e a r s o r more  f r o m t h e j o b as a r e s u l t  t h a n 1-1/2  or anger, of your  never rarely often always  How w o u l d y o u c h a r a c t e r i z e y o u r r e l a t i o n s h i p w i t h y o u r f a m i l y member? 0 1 2 3  of your  years  How o f t e n do y o u e x p e r i e n c e d i f f i c u l t i e s ( e . g . h o s t i l i t y r e s e n t m e n t , e t c . ) on t h e j o b w i t h c o - w o r k e r s a s a r e s u l t chronic pain? 0 1 2 3  since  more s a t i s f a c t i o n now same s a t i s f a c t i o n now a s b e f o r e l e s s s a t i s f a c t i o n now no s a t i s f a c t i o n now o r b e f o r e  The amount o f t i m e y o u h a v e l o s t c h r o n i c p a i n has been 0 1 2 3  j o b changed  closest  v e r y good adequate somewhat i n a d e q u a t e very inadequate  Has i t b e e n d i f f i c u l t f o r t h e p e r s o n o r p e o p l e y o u l i v e w i t h t o t a l k about o r adapt t o any changes r e s u l t i n g f r o m y o u r c h r o n i c pain? 0 1 2 3  not d i f f i c u l t at a l l mildly difficult moderately d i f f i c u l t extremely d i f f i c u l t  Have y o u r f i n a n c i a l experience? 0 1 2 3  r e s o u r c e s b e e n a f f e c t e d by y o u r c h r o n i c  no a f f e c t slightly affected moderately a f f e c t e d drastically affected  pain  - 107 Do y o u d e p e n d on t h e p e r s o n o r p e o p l e y o u l i v e w i t h f o r a n y h e l p o r a s s i s t a n c e because of your c h r o n i c pain? 0 1 2 3  t o t a l l y independent m i l d l y dependent moderately dependent t o t a l l y dependent  S i n c e you've e x p e r i e n c e d c h r o n i c p a i n , has t h e r e been any change i n the p l e a s u r e o r s a t i s f a c t i o n you d e r i v e from s e x u a l a c t i v i t i e s ? 0 1 2 3  no c h a n g e i n s e x u a l p l e a s u r e o r s a t i s f a c t i o n s l i g h t reduction i n sexual pleasure or s a t i s f a c t i o n moderate r e d u c t i o n i n s e x u a l p l e a s r e or s a t i s f a c t i o n no s e x u a l p l e a s r e o r s a t i s f a c t i o n  S i n c e you've e x p e r i e n c e d c h r o n i c p a i n has t h e r e been any change i n your i n t e r e s t i n sexual a c t i v i t i e s ? 0 1 2 3  no c h a n g e i n i n t e r e s t s l i g h t change i n i n t e r e s t moderate change i n i n t e r e s t no i n t e r e s t  Have y o u h a d any p r o b l e m s d u r i n g s e x u a l i n t e r c o u r s e ( e . g . d i s c o m f o r t or d i f f i c u l t r e a c h i n g c l i m a x ) s i n c e the development of your chronic pain? 0 1 2 3  never rarely often always  Has t h e r e b e e n a n y c h a n g e i n t h e f r e q u e n c y s i n c e you've experienced c h r o n i c pain? 0 1 2 3  of your sexual a c t i v i t y  no c h a n g e i n f r e q u e n c y s l i g h t reduction i n frequency moderate r e d u c t i o n i n frequency no s e x u a l a c t i v i t y  How w o u l d y o u c h a r a c t e r i z e y o u r r e l a t i o n s h i p w i t h y o u r r e l a t i v e s ( i . e . y o u r p a r e n t s , b r o t h e r s , s i s t e r s , i n - l a w s , and c h i l d r e n n o t l i v i n g a t home) s i n c e t h e d e v e l o p m e n t o f y o u r c h r o n i c p a i n ? 0 1 2 3  v e r y good adequate somewhat inadequate very inadequate  - 108 -  Do y o u d e p e n d on y o u r r e l a t i v e s who do n o t l i v e w i t h y o u f o r a n y help or a s s i s t a n c e because of your c h r o n i c pain? 0 1 2 3  t o t a l l y independent m i l d l y independent moderately dependent t o t a l l y dependent  Are you i n t e r e s t e d i n spending time w i t h and t a l k i n g t o y o u r r e l a t i v e s s i n c e the development of your c h r o n i c pain? 0 1 2 3  very interested moderately i n t e r e s t e d somewhat i n t e r e s t e d not at a l l i n t e r e s t e d  Have you m a i n t a i n e d y o u r i n t e r e s t i n s o c i a l a c t i v i t i e s ( e . g . s o c i a l c l u b s , e n t e r t a i n i n g , church groups, going t o the movies, going to s p o r t s events, e t c . ) s i n c e t h e development of your c h r o n i c pain? 0 1 2 3  same l e v e l o f i n t e r e s t a s p r e v i o u s l y s l i g h t l y less i n t e r e s t than before s i g n i f i c a n t l y l e s s i n t e r e s t than before l i t t l e o r no i n t e r e s t r e m a i n i n g  Have y o u m a i n t a i n e d y o u r p a r t i c i p a t i o n i n s o c i a l o r l e i s u r e a c t i v i t i e s ( e . g .s o c i a l clubs, e n t e r t a i n i n g , church groups, going to the movies, going t o s p o r t s e v e n t s , e t c . ) s i n c e t h e development of y o u r c h r o n i c p a i n ? 0 1 2 3  same l e v e l o f p a r t i c i p a t i o n a s p r e v i o u s l y s l i g h t l y less p a r t i c i p a t i o n than before s i g n i f i c a n t l y l e s s p a r t i c i p a t i o n than b e f o r e l i t t l e o r no p a r t i c i p a t i o n now  Have y o u m a i n t a i n e d y o u r p a r t i c i p a t i o n i n i n d i v i d u a l l e i s u r e a c t i v i t i e s (e.g. sports, gardening, dancing, other hobbies, e t c . ) s i n c e the development of your c h r o n i c pain? 0 1 2 3  same l e v e l o f p a r t i c i p a t i o n as p r e v i o u s l y s l i g h t l y less p a r t i c i p a t i o n than before s i g n i f i c a n t l y less p a r t i c i p a t i o n than before l i t t l e o r no p a r t i c i p a t i o n now  -  109  -  Have you m a i n t a i n e d y o u r i n t e r e s t i n i n d i v i d u a l l e i s u r e (e.g. s p o r t s , g a r d e n i n g , o t h e r h o b b i e s , e t c . ) s i n c e the of your c h r o n i c pain? 0 1 2 3  same l e v e l o f i n t e r e s t a s p r e v i o u s l y s l i g h t l y l e s s i n t e r e s t than before s i g n i f i c a n t l y less i n t e r e s t than before l i t t l e o r no i n t e r e s t r e m a i n i n g  Have y o u b e e n f e e l i n g a n x i o u s o r n e r v o u s 0 1 2 3  recently?  not at a l l mildly moderately extremely  Has t h e amount o f w o r r y i n g y o u do c h a n g e d your chronic pain state? 0 1 2 3  d i d n ' t w o r r y b e f o r e and s t i l l w o r r y l e s s now w o r r y t h e same now as b e f o r e w o r r y more now  s i n c e the development  I I I I  of  don't  Do y o u t h i n k , a b o u t y o u r body d i f f e r e n t l y s i n c e your chronic pain? 0 1 2 3  activities development  l i k e my body more now l i k e my body t h e same now as b e f o r e l i k e my body l e s s now d i d n ' t l i k e my body b e f o r e and I d o n ' t  the development  like  of  i t now  Has t h e r e b e e n any c h a n g e i n t h e amount o f a n g e r y o u f e e l t o w a r d s f r i e n d s or r e l a t i v e s s i n c e the development of your c h r o n i c p a i n ? 0 1 2 3  I I I I  f e e l l e s s a n g e r now f e e l t h e same amount o f a n g e r now as b e f o r e f e e l more a n g r y now n e v e r g o t a n g r y b e f o r e a n d I d o n ' t now  Has t h e r e b e e n any c h a n g e i n t h e amount o f d e p r e s s i o n y o u s i n c e t h e development of your c h r o n i c p a i n ? 0 1 2 3  I I I I  g e t d e p r e s s e d l e s s o f t e n now t h a n b e f o r e g e t d e p r e s s e d now a b o u t t h e same as b e f o r e f e e l more d e p r e s s e d now n e v e r g o t d e p r e s s e d b e f o r e and I d o n ' t now  feel  - 110 -  APPENDIX F  MCGILL P A I N QUESTIONNAIRE ( M e l z a c k , 1975)  -  PART D  DIRECTIONS  Ill  -  P A I N QUESTIONNAIRE  What D o e s Y o u r P a i n F e e l  Some o f t h e w o r d s b e l o w d e s c r i b e  Like?  your present  pain.  C i r c l e ONLY t h o s e w o r d s t h a t b e s t d e s c r i b e i t . L e a v e o u t a n y c a t e g o r y that i s not s u i t a b l e . Use o n l y a s i n g l e word i n each a p p r o p r i a t e c a t e g o r y - t h e one t h a t a p p l i e s b e s t .  Flickering Quivering Pulsing Throbbing Beating Pounding  2 Jumping Flashing Shooting  6 Tugging Pulling Wrenching  Pricking Boring Drilling Stabbing Laciniating  4 Sharp Cutting Lacerating  Hot Burning Scalding Searing  8 Tingling Itchy Smarting Stinging  10 Tender Taut Rasping Splitting  11 Tiring Exhausting  12 Sickening Suffocating  13 Fearful Frightful Terrifying  14 Punishing Gruelling Cruel Vicious Killing  15 Wretched Blinding  16 Annoying Troublesome Miserable Intense Unbearable  17 Spreading Radiating Penetrating Piercing  18 Tight Numb Drawing Squeezing Tearing  19 Cool Cold Freezing  20 Nagging Nauseating Agonizing Dreadful Torturing  Pinching Pressing Gnawing Cramping Crushing  9 D  u  l  1  Sore Hurting Aching Heavy  - 112 -  APPENDIX G  T-TESTS USING ADJUSTMENT TO CHRONIC P A I N SCORES TO COMPARE MALES AND FEMALES  -  113  -  T-Tests Using Adjustment to Chronic P a i n Scores t o Compare M a l e s and F e m a l e s  Variables  Mean  Standard Deviation  S u b t e s t 2, V o c a t i o n a l Environment Males n = 28  7.64  2.33  Females n = 13  5.85  2.08  Males n = 28  2.39  0.83  Females n = 13  1.69  0.95  Males n = 28  1.43  1.00  Females n = 13  0.69  0.86  2.38  0.02  2.40  0.02  2.30  0.03  S u b t e s t 7, P s y c h o l o g i c a l Distress Worrying:  Depression:  

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