Changes in Beliefs, Catastrophizing, and Coping Are ... · pain-related beliefs, Catastrophizing, and coping responses were associated with changes in physical disability, depression,

Journal of Consulting and Clinical Psychology2001, Vol. 69, No. 4, 655-662

Copyright 2001 by the American Psychological Association, Inc.0022-006X/01/J5.00 DOI: 10.1037//0022-006X.69.4.655

Changes in Beliefs, Catastrophizing, and Coping Are Associated WithImprovement in Multidisciplinary Pain Treatment

Mark P. Jensen, Judith A. Turner, and Joan M. RomanoUniversity of Washington

To examine the associations between changes in cognitions and coping and multidisciplinary paintreatment outcomes, the authors had 141 patients with chronic pain complete measures of adjustment,beliefs, Catastrophizing, and coping; in addition, their significant others rated patient physical functioningat pretreatment, posttreatment, and 6- and 12-month follow-ups. Decreases in guarding and resting andin the belief that pain signals damage were associated with decreases in patient disability. Increases inperceived control over pain and decreases in Catastrophizing and in the belief that one is disabled wereassociated with decreases in self-reported patient disability, pain intensity, and depression. The results areconsistent with the hypothesis, derived from cognitive—behavioral models of chronic pain, that theoutcomes of multidisciplinary pain treatment are associated with changes in patient cognitions andcoping responses.

Multidisciplinary pain treatment programs are based, in largepart, on cognitive—behavioral models that hypothesize a centralrole for cognitions and coping responses in the adjustment tochronic pain (Loeser & Egan, 1989). Such programs include avariety of interventions focused on altering patient cognitiveand behavioral responses to pain under the assumption thatthese changes will lead to better functioning. Although researchsupports the effectiveness of multidisciplinary treatment pro-grams in improving physical and psychological functioning andin reducing medication use (Flor, Fydrich, & Turk, 1992), fewstudies have tested the hypothesized associations between cog-nitions, coping responses, and improvement in multidisci-plinary pain treatment outcome. In a previous study, we exam-ined whether pretreatment to 3-6 month follow-up changes inpain-related beliefs, Catastrophizing, and coping responses wereassociated with changes in physical disability, depression, andnumber of physician visits over this same time period amongmultidisciplinary pain-program participants (Jensen, Turner, &Romano, 1994). Although changes in beliefs were associated

Mark P. Jensen, Department of Rehabilitation Medicine, Universityof Washington School of Medicine, and Multidisciplinary Pain Center,University of Washington; Judith A. Turner, Department of Psychiatryand Behavioral Sciences, and Department of Rehabilitation Medicine,University of Washington School of Medicine; Joan M. Romano, De-partment of Psychiatry and Behavioral Sciences, University of Wash-ington School of Medicine, and Multidisciplinary Pain Center, Univer-sity of Washington.

This research was supported by Grant NS 31638 from the NationalInstitutes of Health-National Institute of Neurological Disorders andStroke. We thank Teresa Chen, Shannon Fogh, Christopher Gaunya, Chris-tina Jackson, Jackie Kellogg, Elise Leaf, Trey Power, Braia Weiss, and inparticular, Susan Strom, for their assistance with the study.

Correspondence concerning this article should be addressed to Mark P.Jensen, Department of Rehabilitation Medicine, Box 356490, University ofWashington School of Medicine, Seattle, Washington 98195-6490. Elec-tronic mail may be sent to [email protected].

with decreases in depression and patient-reported disability,changes in several coping responses specifically targeted inmultidisciplinary treatment (e.g., the use of exercise and relax-ation) were not associated with improvement. Limitations of thestudy included a short follow-up period, the use of unvalidatedsingle-item rating scales to measure behavioral coping re-sponses, and the reliance solely on patient self-report for out-come assessment.

Our purpose for the present study was to examine furtherwhether changes in beliefs, Catastrophizing, and coping areassociated with improvement in multidisciplinary pain treat-ment. We sought to improve on previous studies' methodolo-gies by (a) examining the association between process andoutcome variables over a longer time period (1 year), (b)including a reliable and valid multiple-item measure of behav-ioral pain-coping strategies, and (c) obtaining observer (signif-icant other) ratings of outcome. Consistent with cognitive-behavioral theory and with previous research, we hypothesizedthat pre- to posttreatment and pretreatment to follow-upchanges in measures of patient adjustment would be associatedwith changes in pain-related beliefs, Catastrophizing, and cop-ing strategies over the same time periods. We also sought toexamine whether previous findings concerning the strength anddirection of these associations would be replicated in a newsample of patients and over a longer follow-up period.

Method

Participants

Among 283 patients who participated in the University of Washington(Seattle, WA) outpatient multidisciplinary pain program during the studyenrollment period, 197 (70%) enrolled in the study and 86 (30%) declined toparticipate. Of the 197 patients who enrolled, 141 (72%) provided posttreat-ment and 6- and 12-month follow-up data and thus composed the sample forthis study. In addition, 109 significant others of these patients enrolled and

655

656 JENSEN, TURNER, AND ROMANO

provided pretreatment data; 72 (66%) provided data at all assessment pointsand thus composed the significant-other sample for the study. Criteria foradmission to the program included significant pain-related disability, specificbehavioral and functional goals that could be addressed in treatment, andfunding for the program. Program exclusion criteria included current alcoholor substance abuse, conditions requiring other medical interventions, comor-bidity that would prohibit participation in a physical reactivation program,dementia, and major psychopathology. To be included in the study, patientshad to meet criteria for program admission, be 18 years of age or older, and beable to read and write in English.

Of the 141 patient participants, 51% were female, and the mean agewas 44.7 years (range = 21-78 years). Median pain duration was 3.2 years(range, 4 months—48 years). The majority (90%) of the patient participantsdescribed their ethnicity as Caucasian. The primary site of pain varied andincluded the low back (34%), neck (18%), shoulder or arm (13%), leg (12%),head (9%), and other sites (14%). Twenty-nine percent of the patient partici-pants were working either full time (18%) or part time (11%), 60% werereceiving pain-related disability compensation, and 12% had litigation pendingregarding their pain problem at the time of study enrollment.

Measures

Process VariablesBeliefs. Patient participants completed the Survey of Pain Attitudes2

(SOPA; Jensen, Turner, Romano, & Lawler, 1994) and the Pain Beliefsand Perceptions Inventory (PBPI; Williams & Thorn, 1989). The SOPAincludes seven scales that assess beliefs that (a) one has control over pain(Pain Control), (b) one is unable to function because of pain (Disability),(c) pain signifies damage and that activity should be avoided (Harm), (d)emotions influence pain (Emotion), (e) medications are an appropriatetreatment for chronic pain (Medication), (f) others should respond solici-tously to pain behaviors (Solicitude), and (g) a medical cure exists for one'spain (Medical Cure). The PBPI has four scales: (a) Pain as a Mystery (painis mysterious/poorly understood), (b) Pain Permanence (pain is permanentand will not be cured), (c) Pain Constancy (there are no pain-free periods),and (d) Self-Blame (pain is caused or maintained by the patient). (Wil-liams, Robinson, & Geisser, 1994).

Catastrophizing. Patient participants completed the Catastrophizingscale of the Coping Strategies Questionnaire (CSQ; Rosenstiel & Keefe,1983).

Coping. Patient participants completed the Chronic Pain Coping In-ventory (CPCI; Jensen, Turner, Romano, & Strom, 1995) and the CSQ.The CPCI includes eight scales: (a) Guarding, (b) Resting, (c) Asking forAssistance, (d) Relaxation, (e) Task Persistence, (f) Exercise/Stretch, (g)Seek Support, and (h) Coping Self-Statements. The CSQ contains sixscales (in addition to Catastrophizing): (a) Diverting Attention, (b) Rein-terpreting Pain Sensations, (c) Ignoring Pain, (d) Praying and Hoping, (e)Coping Self-Statements, and (f) Increasing Behavioral Activities.

Outcome VariablesDepression. Patient participants completed the Center for Epidemic-

logical Studies—Depression Scale (CES-D; Radloff, 1977), a measure ofdepressive symptoms with high internal consistency, adequate test-retestreliability, and validity. It has been shown to be a valid screening instru-ment for depression in patients with chronic pain (Turk & Okifuji, 1994).

Physical functioning. The Roland Scale (Roland & Morris, 1983) wasadministered to both the patient and the significant-other study participants,with the significant-other version modified to allow assessment of patientdisability by the significant others. Posttreatment significant-other ratingsof patient disability were not obtained because few significant others spentsufficient time with the patients during their last week of treatment to beable to make such ratings.

Health care use. Patient participants were asked the number of pain-related visits they made to health care providers during the 3 months beforeeach assessment, except posttreatment.

Pain intensity. Patients rated their current pain and their average, least,and worst pain intensity (over the past week) on 0-10 scales, from 0 (nopain) to 10 (pain as intense as you could imagine). These measures wereaveraged into a single index of pain intensity (cf. Jensen, Turner, Romano,& Fisher, 1999).

Procedure

Patient and significant-other study participants completed telephoneinterview versions of the process and outcome measures at the beginningof treatment, after treatment, and at 6- and 12-month follow-ups.3 The painprogram is a 3-week,4 5.5 days per week, outpatient treatment programaimed at improving patient pain-management skills and physical andpsychological functioning. It includes quota-based physical and occupa-tional therapy, individual cognitive-behavioral psychotherapy, vocationalcounseling (if appropriate), group pain education and coping-skills train-ing, and the tapering of opioid and sedative—hypnotic medications whenindicated (cf. Loeser & Egan, 1989).

Results

Data Preparation and Reduction

Measures with skewness > 1.0 were transformed for use in dataanalysis. Repeated measures analysis of variance (ANOVAs) wereperformed to identify the process and outcome measures that changedfrom pretreatment to posttreatment and to follow-up (Table 1). Therewere significant (p < .Ol)5 pretreatment-to-posttreatment changes,with maintenance of significant differences through the 6- and 12-month follow-ups, in 8 of the 11 Belief scales, in the CSQ Catastroph-izing scale, and in 8 of 14 coping measures. All 5 outcome measuresshowed significant (p < .001) improvement from pretreatment toposttreatment and through both follow-ups.

1 Of these 72 significant-other participants, the majority (88%) weremarried to and living with the patient. Three (8%) were not married to butwere cohabiting with the patient, and the remainder (6%) were friends orrelatives with whom the patient lived.

2 Twenty-three items were reworded slightly for increased clarity. Forexample, Item 2, "The pain I usually experience is a signal that damage isbeing done," was reworded as "The pain I feel is a sign that damage isbeing done," and Item 20, "My pain is not emotional, it is purely physical,"was reworded as "My pain is physical, not emotional."

3 We interviewed a random sample of 78% of the study participants 2weeks, 1 month, 2 months, and 3 months after treatment to test hypothesesrelated to maintenance of gains after treatment. These data will be pre-sented in a separate article.

4 Some patients may participate for more than 3 weeks if they requireadditional time to reach maximum gains and have funding for the addi-tional time. Twenty-eight (20%) of the 141 study participants participatedin treatment for more than 3 weeks; almost all of these patients (25/28)completed treatment in 4 weeks.

5 Potential Type I error in testing for changes in the process and outcomevariables was controlled by (a) setting the alpha level at .01 for theseanalyses and (b) requiring that all three changes tested (pretreatment toposttreatment and pretreatment to the 6- and the 12-month follow-uppoints) be statistically significant to conclude that the change was real andconsistent through 1 year posttreatment for the sample as a whole.

BELIEFS, CATASTROPHIZING, AND COPING 657

Table 1Process and Outcome Measure Scores at Pretreatment, Posttreatment, and 6- and 12-MonthFollow-Up

Pretreatment

Scale

Process variablesSOPA subscales (beliefs)

Pain ControlDisabilityHarmEmotionMedicationSolicitudeMedical Cure

PBAPI subscales (beliefs)MysteryPain PermanencePain ConstancySelf-Blame

CSQ CatastrophizingCSQ subscales (coping)

Reinterpret PainIgnore PainCoping Self-

StatementsPray/HopeDivert AttentionIncrease Activities

CPCI (coping)GuardingRestingAsk for AssistanceRelaxationTask PersistenceExercise/StretchSeek Social SupportCoping Self-

StatementsOutcome variables

Patient-RolandSignificant other-RolandDepression (CES-D)Health care visits'*Average pain intensity

M

1.88a2.48a1-70.1.96a2.30a1-31.1.81.

0.57a0.37a1.28a

-1.14.2.47a

0.96a2.19a

3.73a3-14.2.79a3.04a

4.43a4.32a3.24a2.40a4.21a3-31.3.05a

3.68a

15.10.15.77a25.11.

8.77a6-15.

(SD)

(0.82)(0.78)(0.74)(0.80)(0.95)(0.95)(0.80)

(0.96)(0.97)(0.71)(0.89)(1.49)

(1.09)(1.39)

(1.26)(1.52)(1.38)(1.23)

(1.76)(1.63)(2.32)(1.50)(1.65)(1.92)(1.68)

(1.87)

(4.94)(4.57)

(12.86)(11.60)

(1.51)

Posttreatment

M

2.72b1.69b0.82b2.31b1.50b0.98b1.19b

-0.22b0.54b0.80b

-1.15.1.49b

1.74b3.04b

4.50b2.89a3.60b3.71b

2.02b2.83b1.20b4.72b5.34b6.62b3.48b

9.73b

9.12b

16.47b

5.50b

(SD)

(0.85)(0.83)(0.61)(0.65)(0.98)(0.80)(0.78)

(1.01)(0.92)(1.03)(0.90)(1.37)

(1.60)(1.52)

(1.08)(1.67)(1.33)(1.10)

(1.88)(1.75)(1.73)(1.30)(1.44)(1.01)(1.54)

(1.58)

(5.70)

(10.88)

(1.65)

6-monthfollow-up

M

2.23C2.10C1.24C2.07a2.19a0.99b1.26b

-0.09b0.68b0.96b

-1.08.1.83C

1.59b2.83b

3.99a2.44b2.92a3.20a

2.69C2.62b1.97C3.12C4.94C4.59C2.40C

3.38a

10.82C11.53b21.01,4.96b5.64b

(SD)

(0.98)(0.93)(0.74)(0.81)(1.08)(0.87)(0.77)

(1.10)(0.90)(1.01)(1.01)(1.49)

(1.60)(1.60)

(1.24)(1.51)(1.42)(1.13)

(2.10)(1.71)(2.05)(1.67)(1.67)(1.72)(1.81)

(1.96)

(6.03)(6.05)

(12.27)(8.89)(1.95)

12-monthfollow-up

M

2.29C2.05C1.26C2.03a2.23a1.02b1.33b

-0.27b0.65b0.94b

-1.19.1.73b,c

1.70b2.97b

3.96a2.43b3.07a3.28a

2.73C2.73b2.04C3.10.4.97c,b4.59C2.27C

3.39a

10.93C12.00b19.34C4.32b5.46b

(SD)

(1.00)(1.00)(0.80)(0.78)(1.04)(0.89)(0.83)

(1.08)(0.93)(1.00)(0.90)(1.45)

(1.71)(1.60)

(1.22)(1.58)(1.48)(1.17)

(2.19)(1.97)(2.06)(1.58)(1.77)(1.83)(1.73)

(1.98)

(6.51)(6.16)

(11.48)(7.82)(2.15)

f*

41.6945.3569.6015.0141.3110.9436.02

34.966.40

13.710.46

23.73

16.4618.82

18.6621.6921.2416.72

83.1258.9946.60

117.6218.53

118.2526.90

34.61

69.9424.5028.1630.9910.71

Note, n = 141 for the patient-rated measures; n = 72 for the significant other Roland scores. Means withdifferent subscripts are significantly different from one another (p < .01). SOPA = Survey of Pain Attitudes;PBAPI = Pain Beliefs and Perceptions Inventory; CSQ = Coping Strategies Questionnaire; CPCI = ChronicPain Coping Inventory; CES-D = Center for Epidemiologic Studies—Depression Scale." dft, = 3, 420 for all F tests except Significant other-Roland, dfo = 2, 142; p < .001 for all Fs except Self-Blameon the PBAPI.b Number of pain-related health care visits in the past 3 months.

Change scores were calculated for the belief, catastrophizing,and coping strategy scales that demonstrated significantpretreatment-through-follow-up changes. The belief and copingscale change scores were then subjected to two principal compo-nents analyses (PCAs; one for the changes in the belief scalescores and one for the changes in the coping scale scores) for eachof the three time intervals (pretreatment to posttreatment, pretreat-ment to 6-month follow-up, and pretreatment to 12-month follow-up) to reduce the number of predictor variables. If more than onefactor emerged, the factors were rotated using an oblique rotation.

The PCA of the pretreatment to posttreatment belief changescores resulted in a single factor, which we labeled Change in PainBeliefs. The PCAs of the pretreatment through the 6- and the12-month belief change scores resulted in two-factor solutions,with the SOPA Control (negative loading), Disability, and Harm,and the PBAPI Mystery and Constancy scales loading on the firstfactor (labeled Change in Pain as Illness Beliefs), and with SOPASolicitude and Medical Cure loading on the second factor (labeledChange in Responsibility Beliefs). Three factors emerged fromeach of the PCAs of pretreatment-to-posttreatment and


pretreatment-to-6- and 12-month Coping change scores. In each ofthe three PCAs, the same scales loaded on the same factors. Onefactor was Change in Passive Coping (made up primarily of CPCIGuarding, Resting, and Asking for Assistance change scores). Thesecond factor was Change in Active Coping, with CPCI Relaxationand CPCI Exercise/Stretch having the highest loadings on thisfactor. The third factor was Change in Attention to Pain, with CSQIgnore Pain, CSQ Reinterpret Pain, and CPCI Task Persistencehaving the highest loadings on this factor.

Associations Between Changes in Outcome Measures andChanges in Process Measures

We then performed regression analyses to examine the extent towhich treatment outcomes were associated with the changes in theprocess variables (see Table 2, Table 3, and Table 4). Demo-graphic or pain-related variables were entered in the first step onlyif they demonstrated significant zero-order relationships with im-provement. Separate regressions were conducted for each outcomemeasure for each time period (pre—post, pre—6 month follow-up,and pre—12 month follow-up). We used an alpha level of .01 tobalance control for alpha inflation with ability to detect reliableassociations. The process variables explained 45%, 42%, and 45%,respectively (all ps < .001), of the variance in improvement inpatient self-rated disability from pre- to posttreatment and frompretreatment to 6- and 12-month follow-ups; 45%, 41%, and 35%,respectively (all ps < .001), of the variance in change in depres-sive symptoms; and 20%, 27%, and 31%, respectively, (all ps <.01) of the variance in change in average pain intensity across the

three time intervals. They explained 13% (ns) and 26% (p < .01)of the variance in improvement in significant-other-rated patientphysical disability and 12% (p < .01) and 7% (ns) of the variancein change from pretreatment to 6-month and pretreatment to 12-month health care visits for pain, respectively.

To better understand the relative strengths of the associationsbetween specific process and outcome measures and to help inter-pret the findings from the regression analyses, we calculated thecorrelations between the pretreatment-to-follow-up change scoresof the individual process measures (Beliefs, Catastrophizing, andcoping) and the change scores for the outcome variables. Wecontrolled for alpha inflation by setting the alpha level at .001. Sixof the process measures (SOPA Solicitude and Medical Cure, CSQReinterpret Pain and Ignore Pain, and CPCI Relaxation and Exer-cise/Stretch) that changed pre- to posttreatment and throughfollow-up were weakly (r < .30) associated with all outcomemeasures across the assessment intervals. Three process measures(PBAPI Mystery and CPCI Ask for Assistance and Task Persis-tence) showed a moderately strong (IH > .30) association with atleast one outcome measure change score, but these associationswere not consistent across all three assessment intervals. Thestrongest (IH > .30) consistent associations are presented in Ta-ble 5. Changes in SOPA Control, SOPA Disability, and CSQCatastrophizing were consistently associated with changes in de-pression, pain, and patient-reported physical disability. SOPAHarm and CPCI Rest were consistent predictors of patient-reportedphysical disability, and PBAPI Mystery was a consistent predictorof pain intensity. CPCI Guarding predicted patient-reported dis-

Table 2Multiple Regression Analyses Predicting Pretreatment to Posttreatment Outcome MeasureChanges From Changes in Belief Factors, Catastrophizing, and Coping Factors

TotalMeasure step and variable R2

Self-rated patient disability (Roland Scale)Step 1. Cognitions and coping .45

Change in Pain BeliefsChange in CatastrophizingChange in Attention to PainChange in Passive CopingChange in Active Coping

Depression (CES-D)Step 1. Control variable (pretreatment pain) .03Step 2. Cognitions and coping .48


Pain intensityStep 1. Cognitions and coping .20


Change

R2 F /3

.45 21.90*** a

.31***

.16-.20**

.25**-.14

.03 4.95* a .13*

.45 23.37*** ».21*.44***

-.13.08.00

.20 6.81*** ".24*.19

-.12-.02-.06

Note, n = 141. CES-D = Center for Epidemiological Studies-—Depression Scale."dfs = 1, 139. cdjs = 2, 138.*p<.05. **/?<.01. ***p<.001.


Table 3Multiple Regression Analyses Predicting Pretreatment to 6-Month Follow-Up Outcome MeasureChanges From Changes in Belief Factors, Catastrophizing, and Coping Factors

Measure step and variableTotal

R2

Change

R2 F ft

Self-rated patient disability (Roland Scale)Step 1. Cognitions and coping .42 .42

Change in Pain as Illness BeliefsChange in Responsibility BeliefsChange in CatastrophizingChange in Attention to PainChange in Passive CopingChange in Active Coping

Significant-other-rated patient disability (Roland Scale)Step 1. Cognitions and coping .13 .13


Depression (CES-D)Step 1. Cognitions and coping .41 .41


Health care visits for painStep 1. Control variable (pain site) .03 .03Step 2. Cognitions and coping .15 .12


Pain intensityStep 1. Control variable (employment status) .05 .05Step 2. Cognitions and coping .32 .27


16.12*** a

1.57"

15.36*** a

4.40*2.99*

6.82* a

11.13***'

.38***

.07

.11-.01-.29***-.04

.21

.00

.02

.04-.21.10

.20*

.07

.48***-.03.01

-.01

.15

.21

.12-.10-.14-.13.16

.14

.40***-.06.25**.01.03.03

Note, n = 141 for statistics related to the association between predictors and patient-rated outcomes; n = 72for statistics related to the association between predictors and the significant other-rated outcome. CES-D =Center for Epidemiological Studies—Depression Scale.*dfi = \, 139. bdfs = 1, 70. crf/s = 2, 138.*p<.05. ** /><.01 . ***/>< .001.

ability and depression across all three assessment intervals andalso predicted significant-other-reported patient disability pretreat-ment to both follow-ups. Across every assessment interval, de-creases in SOPA Disability and Harm, PBAPI Mystery, CSQCatastrophizing, and CPCI Guarding and Rest were associatedwith improvement, whereas an increase in SOPA Control wasassociated with improvement.

DiscussionCurrent cognitive—behavioral models of pain posit that pain

programs are effective, at least in part, because they alter patients'

cognitive and behavioral responses to pain. If this is true, thenimprovement after treatment outcome should be associated withchanges in pain-related cognitions and coping responses. Theresults of this study support this model. Pretreatment-to-posttreatment and pretreatment-to-follow-up changes in cognitionsand coping accounted for large and statistically significant portionsof the variance in changes in patient self-reported physical disabil-ity, depressive symptoms, and pain intensity. Changes in cogni-tions and coping were less consistent predictors of changes insignificant-other-reported patient disability (statistically signifi-cant only for the pretreatment to 12-month follow-up interval) and


Table 4Multiple Regression Analyses Predicting Pretreatment to 12-Month follow-Up OutcomeMeasure Changes From Changes in Belief Factors, Catastrophizing, and Coping Factors

TotalChange

Measure step and variable

6.60* b

4J4**c

Self-rated patient disability (Roland Scale)Step 1. Cognitions and coping .45 .45 18.35*


Significant-other-rated Patient Disability (Roland Scale)Step 1. Control variable (pain duration) .09 .09Step 2. Cognitions and coping .34 .26

Change in Pain as Illness BeliefsChange in Responsibility BeliefsChange in CatastrophizingChange in Attention to PainChange in Passive Coping

Depression (CES-D)Step 1. Cognitions and coping .35 .35 11.84***'


Health care visits for painStep 1. Cognitions and coping .07 .07 1.75a


Pain intensityStep 1. Cognitions and coping .31 .31 9.95***'


.25**

.08

.08-.14.46***

-.05

.26*

.11-.08-.03-.25.49***

.18

.14

.38**-.07.10.03

.06

.11

.01-.14*.18.02

.36***

.01

.11

.01

.20*

.17*

Note, n = 141 for statistics related to the association between predictors and patient-rated outcomes; n — 72for statistics related to the association between predictors and the significant other-rated outcome. CES-D =Center for Epidemiological Studies—Depression Scale.ad/s = 1, 139. bdft, = 1, 70. cdfa = 2, 69.*p<.05. **p<.01 . ***/?<.001.

patient-reported number of health care visits for pain (statisticallysignificant only for the pretreatment to 6-month follow-up inter-val). Although correlational findings do not shed light on causalrelationships, they do suggest specific cognitions and coping re-sponses that are likely to be important in patient improvement withmultidisciplinary pain treatment. Moreover, it appears that specificcognitions and coping responses may be uniquely associated withspecific outcomes.

Decreases in patient-rated disability were most strongly and con-sistently associated with an increase in the belief that one has controlover pain and decreases in the beliefs that one is disabled by pain andthat pain signals damage. These findings replicate those of our pre-

vious study (Jensen, Turner, & Romano, 1994). However, somefindings differed, including associations between changes in somecoping responses and change in patient self-reported disability. In thepresent study, decreases in patient self-reported disability were moststrongly associated with decreases in coping responses that involvedactivity restriction, such as guarding and resting. In the previousstudy, no behavioral-coping responses were associated with patientdisability. The differences in results between the two studies may bedue, in part, to a more detailed and comprehensive assessment ofcoping in the present study.

The associations between changes in the process measures andchanges in significant-other ratings of patient disability are of


Table 5Correlations Between Changes in Outcome and Changes in Process Measures That WereConsistent From Pretreatment to Posttreatment and Pretreatment to 6- and 12-Month Follow-Up

Assessment interval

Process/outcome change measure

SOPA Pain Control/Patient-RolandSOPA Pain Control/CES-DSOPA Pain Control/Pain IntensitySOPA Disability/Patient-RolandSOPA Disability/CES-DSOPA Disability/Pain IntensitySOPA Harm/Patient-RolandPBAPI Mystery/Pain IntensityCSQ Catastrophizing/Patient-RolandCSQ Catastrophizing/CES-DCSQ Catastrophizing/Pain IntensityCPCI Guarding/Patient-RolandCPCI Guarding/CES-DCPCI Guarding/Significant Other-RolandCPCI Rest/Patient-Roland

Pretreatment-posttreatment

-.46-.45-.32

.67

.50

.33

.42

.45

.52

.64

.38

.55

.43

.31

Pretreatment-6-month follow-up

-.47-.44-.47

.53

.48

.43

.45

.54

.47

.61

.48

.64

.39

.30

.36

Pretreatment-1 2-month follow-up

-.38-.33-.34

.53

.41

.36

.32

.47

.39

.53

.35

.66

.45

.55

.43

Note, n = 141 for coefficients related to the association between predictors and patient-rated outcomes; n = 72for coefficients related to the association between predictors and the significant-other-rated outcome. Changescores for both process and outcome measures were calculated by subtracting follow-up measure scores frompretreatment measure scores. Thus, positive coefficients indicate that a decrease in the predictor (process)variable is positively associated with improvement (decrease in the outcome variable), and negative coefficientsindicate that an increase in the predictor variable is associated with improvement. These correlations andsignificance levels are presented for descriptive purposes. Only coefficients with significance levels less than.001 are presented. SOPA = Survey of Pain Attitudes; CES-D = Center for Epidemiologic Studies—DepressionScale; PBAPI = Pain Beliefs and Perceptions Inventory; CSQ = Coping Strategies Questionnaire; CPCI =Chronic Pain Coping Inventory.

particular interest, because these associations are not biased byshared method variance. Changes in cognitions and coping re-sponses, as a group, were strongly associated with changes insignificant-other-rated patient physical disability only for the pre-treatment to 12-month follow-up interval. Change in passive cop-ing (guarding, resting, asking for assistance) made the greatestcontribution to this association. Examination of the correlationcoefficients suggests that decreases in guarding accounted formuch of this effect.

The process measures, as a group, were also strongly associatedwith decreased depressive symptoms. The single process variablemost responsible for this was catastrophizing; those patients whoreported the greatest decreases in catastrophizing also had thegreatest decreases in depressive symptoms. However, the correla-tion analyses suggested that changes in several other beliefs (e.g.,increases in perceived pain control and decreases in the beliefs thatone is necessarily disabled) were at least moderately associatedwith change in depression symptoms. These findings generallyreplicate those of our previous study (Jensen, Turner, & Romano,1994), which also found changes in pain-control beliefs, disabilitybeliefs, and catastrophizing to be associated with change in de-pressive symptoms.

No single process variable made a significant independent con-tribution to the prediction of change in number of health care visitsat either assessment interval. This finding suggests that changes inthe cognitions and coping responses assessed in this study aremore strongly associated with improvements in physical disability,depression, and pain after multidisciplinary pain treatment than

they are with decreases in self-reported health care utilization forpain.

As a group, the process variables accounted for a large amountof the variance in changes in pain intensity across all three timeintervals. The individual process-measure change scores that ap-peared to account for decreases in pain intensity were increases ina belief in control over pain and decreases in the beliefs that oneis necessarily disabled by pain, that pain represents a mystery, andin catastrophizing. No coping measure was associated with changein pain intensity consistently across all three intervals. This sug-gests that the decreases in pain intensity found, pretreatment toposttreatment and through follow-up, cannot be explained bychanges that occurred in the pain-coping responses measured inthis study.

The findings of this study are consistent with previous researchand with the hypothesis that belief in control over pain is adaptiveand that other cognitions and coping responses (e.g., the beliefsthat one is disabled and that pain is a signal of damage, catastroph-izing, guarding, and resting) are not adaptive. The findings supportthe continued use of interventions that increase perceived controlover pain and decrease maladaptive patient cognitions and copingresponses. However, to determine whether a specific process vari-able is responsible for treatment benefits, experimental studies areneeded to test the effects of interventions that focus on alteringspecific cognitions and coping responses, with the goal of deter-mining whether changes in these process variables improve patientphysical and psychological functioning.


Several limitations of the study should be noted. First, given thatthis study was performed in the context of an existing treatmentprogram, the inclusion of a control condition was not practical.Thus, it is not possible to determine whether the changes observedin the process variables and outcome measures were the directresult of treatment. Second, the correlational nature of the datadoes not allow for conclusions regarding sequential or causalrelations among the process and outcome variables. Third, al-though the inclusion of significant-other observations of patientdisability is a strength of the study, only 72 participants had asignificant other who was willing to participate in all assessments.This limits the generalizability and statistical power of the analysesinvolving the significant-other data. Fourth, conclusions regardingthe generalizability of the current study are further complicated bythe facts that only 70% of patients who were eligible enrolled inthe study and only 72% of these completed all posttreatmentmeasures. Generalizability of the current findings is supported bythe similarity to findings in our previous process analysis (Jensen,Turner, & Romano, 1994), but the previous study was also per-formed at the same pain center. Despite these limitations, thisstudy provides additional support for a cognitive-behavioralmodel of the effects of multidisciplinary pain treatment on thefunctioning of individuals with chronic pain.

ReferencesFlor, H., Fydrich, T., & Turk, D. C. (1992). Efficacy of multidisciplinary

pain treatment centers: A meta-analytic review. Pain, 49, 221-230.Jensen, M. P., Turner, J. A., & Romano, J. M. (1994). Correlates of

improvement in multidisciplinary treatment of chronic pain. Journal ofConsulting and Clinical Psychology, 62, 172-179.

Jensen, M. P., Turner, J. A., Romano, J. M., & Fisher, L. (1999). Com-parative reliability and validity of chronic pain intensity measures. Pain,83,157-162.

Jensen, M. P., Turner, J. A., Romano, J. M., & Lawler, B. K. (1994).Relationship of pain-specific beliefs to chronic pain adjustment. Pain,57, 301-309.

Jensen, M. P., Turner, J. A., Romano, J. M., & Strom, S. E. (1995). TheChronic Pain Coping Inventory: Development and preliminary valida-tion. Pain, 60, 203-216.

Loeser, J. D., & Egan, K. J. (1989). Managing the chronic pain patient:Theory and practice at the University of Washington MultidisciplinaryPain Center. New York: Raven Press.

Radloff, L. (1977). The CES-D scale: A self-report depression scale forresearch in the general population. Applied Psychological Measurement,1, 385-401.

Roland, M., & Morris, R. (1983). A study of the natural history of backpain. Part I. Development of a reliable and sensitive measure of disabil-ity in low-back pain. Spine, 8, 141-144.

Rosenstiel, A. K., & Keefe, F. J. (1983). The use of coping strategies inchronic low back pain patients: Relationship to patient characteristicsand current adjustment. Pain, 17, 33-44.

Turk, D. C., & Okifuji, A. (1994). Detecting depression in chronic painpatients: Adequacy of self-reports. Behaviour Research and Therapy,32, 9-16.

Williams, D. A., & Thorn, B. E. (1989). An empirical assessment of painbeliefs. Pain, 36, 351-358.

Williams, D. A., Robinson, M. E. & Geisser, M. E. (1994). Pain beliefs:Assessment and utility. Pain, 59, 71-78.

Received May 9, 2000Revision received October 10, 2000

Accepted October 10, 2000

Low Publication Prices for APA Members and Affiliates

Keeping you up-to-date. All APA Fellows, Members, Associates, and Student Affiliatesreceive—as part of their annual dues—subscriptions to the American Psychologist andAPA Monitor. High School Teacher and International Affiliates receive subscriptions tothe APA Monitor, and they may subscribe to the American Psychologist at a significantlyreduced rate. In addition, all Members and Student Affiliates are eligible for savings of upto 60% (plus a journal credit) on all other APA journals, as well as significant discounts onsubscriptions from cooperating societies and publishers (e.g., the American Association forCounseling and Development, Academic Press, and Human Sciences Press).

Essential resources. APA members and affiliates receive special rates for purchases ofAPA books, including the Publication Manual of the American Psychological Association,and on dozens of new topical books each year.

Other benefits of membership. Membership in APA also provides eligibility forcompetitive insurance plans, continuing education programs, reduced APA convention fees,and specialty divisions.

More information. Write to American Psychological Association, Membership Services,750 First Street, NE, Washington, DC 20002-4242.

Documents

Changes in Beliefs, Catastrophizing, and Coping Are ... · pain-related beliefs, Catastrophizing, and coping responses were associated with changes in physical disability, depression,