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

Transcription

1 Journal of Consulting and Clinical Psychology 2001, Vol. 69, No. 4, Copyright 2001 by the American Psychological Association, Inc X/01/J5.00 DOI: // X Changes in Beliefs, Catastrophizing, and Coping Are Associated With Improvement in Multidisciplinary Pain Treatment Mark P. Jensen, Judith A. Turner, and Joan M. Romano University of Washington To examine the associations between changes in cognitions and coping and multidisciplinary pain treatment 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 functioning at pretreatment, posttreatment, and 6- and 12-month follow-ups. Decreases in guarding and resting and in the belief that pain signals damage were associated with decreases in patient disability. Increases in perceived control over pain and decreases in Catastrophizing and in the belief that one is disabled were associated with decreases in self-reported patient disability, pain intensity, and depression. The results are consistent with the hypothesis, derived from cognitive behavioral models of chronic pain, that the outcomes of multidisciplinary pain treatment are associated with changes in patient cognitions and coping responses. Multidisciplinary pain treatment programs are based, in large part, on cognitive behavioral models that hypothesize a central role for cognitions and coping responses in the adjustment to chronic pain (Loeser & Egan, 1989). Such programs include a variety of interventions focused on altering patient cognitive and behavioral responses to pain under the assumption that these changes will lead to better functioning. Although research supports the effectiveness of multidisciplinary treatment programs in improving physical and psychological functioning and in reducing medication use (Flor, Fydrich, & Turk, 1992), few studies have tested the hypothesized associations between cognitions, coping responses, and improvement in multidisciplinary pain treatment outcome. In a previous study, we examined whether pretreatment to 3-6 month follow-up changes in pain-related beliefs, Catastrophizing, and coping responses were associated with changes in physical disability, depression, and number of physician visits over this same time period among multidisciplinary pain-program participants (Jensen, Turner, & Romano, 1994). Although changes in beliefs were associated Mark P. Jensen, Department of Rehabilitation Medicine, University of Washington School of Medicine, and Multidisciplinary Pain Center, University of Washington; Judith A. Turner, Department of Psychiatry and Behavioral Sciences, and Department of Rehabilitation Medicine, University of Washington School of Medicine; Joan M. Romano, Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, and Multidisciplinary Pain Center, University of Washington. This research was supported by Grant NS from the National Institutes of Health-National Institute of Neurological Disorders and Stroke. We thank Teresa Chen, Shannon Fogh, Christopher Gaunya, Christina Jackson, Jackie Kellogg, Elise Leaf, Trey Power, Braia Weiss, and in particular, Susan Strom, for their assistance with the study. Correspondence concerning this article should be addressed to Mark P. Jensen, Department of Rehabilitation Medicine, Box , University of Washington School of Medicine, Seattle, Washington Electronic mail may be sent to mjensen@u.washington.edu. with decreases in depression and patient-reported disability, changes in several coping responses specifically targeted in multidisciplinary treatment (e.g., the use of exercise and relaxation) were not associated with improvement. Limitations of the study included a short follow-up period, the use of unvalidated single-item rating scales to measure behavioral coping responses, and the reliance solely on patient self-report for outcome assessment. Our purpose for the present study was to examine further whether changes in beliefs, Catastrophizing, and coping are associated with improvement in multidisciplinary pain treatment. We sought to improve on previous studies' methodologies by (a) examining the association between process and outcome variables over a longer time period (1 year), (b) including a reliable and valid multiple-item measure of behavioral pain-coping strategies, and (c) obtaining observer (significant other) ratings of outcome. Consistent with cognitivebehavioral theory and with previous research, we hypothesized that pre- to posttreatment and pretreatment to follow-up changes in measures of patient adjustment would be associated with changes in pain-related beliefs, Catastrophizing, and coping strategies over the same time periods. We also sought to examine whether previous findings concerning the strength and direction of these associations would be replicated in a new sample 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 study enrollment period, 197 (70%) enrolled in the study and 86 (30%) declined to participate. Of the 197 patients who enrolled, 141 (72%) provided posttreatment and 6- and 12-month follow-up data and thus composed the sample for this study. In addition, 109 significant others of these patients enrolled and 655

2 656 JENSEN, TURNER, AND ROMANO provided pretreatment data; 72 (66%) provided data at all assessment points and thus composed the significant-other sample for the study. Criteria for admission to the program included significant pain-related disability, specific behavioral and functional goals that could be addressed in treatment, and funding for the program. Program exclusion criteria included current alcohol or substance abuse, conditions requiring other medical interventions, comorbidity that would prohibit participation in a physical reactivation program, dementia, and major psychopathology. To be included in the study, patients had to meet criteria for program admission, be 18 years of age or older, and be able to read and write in English. Of the 141 patient participants, 51% were female, and the mean age was 44.7 years (range = years). Median pain duration was 3.2 years (range, 4 months 48 years). The majority (90%) of the patient participants described their ethnicity as Caucasian. The primary site of pain varied and included the low back (34%), neck (18%), shoulder or arm (13%), leg (12%), head (9%), and other sites (14%). Twenty-nine percent of the patient participants were working either full time (18%) or part time (11%), 60% were receiving pain-related disability compensation, and 12% had litigation pending regarding their pain problem at the time of study enrollment. Process Variables Measures Beliefs. Patient participants completed the Survey of Pain Attitudes 2 (SOPA; Jensen, Turner, Romano, & Lawler, 1994) and the Pain Beliefs and Perceptions Inventory (PBPI; Williams & Thorn, 1989). The SOPA includes 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 appropriate treatment for chronic pain (Medication), (f) others should respond solicitously to pain behaviors (Solicitude), and (g) a medical cure exists for one's pain (Medical Cure). The PBPI has four scales: (a) Pain as a Mystery (pain is mysterious/poorly understood), (b) Pain Permanence (pain is permanent and 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). (Williams, Robinson, & Geisser, 1994). Catastrophizing. Patient participants completed the Catastrophizing scale of the Coping Strategies Questionnaire (CSQ; Rosenstiel & Keefe, 1983). Coping. Patient participants completed the Chronic Pain Coping Inventory (CPCI; Jensen, Turner, Romano, & Strom, 1995) and the CSQ. The CPCI includes eight scales: (a) Guarding, (b) Resting, (c) Asking for Assistance, (d) Relaxation, (e) Task Persistence, (f) Exercise/Stretch, (g) Seek Support, and (h) Coping Self-Statements. The CSQ contains six scales (in addition to Catastrophizing): (a) Diverting Attention, (b) Reinterpreting Pain Sensations, (c) Ignoring Pain, (d) Praying and Hoping, (e) Coping Self-Statements, and (f) Increasing Behavioral Activities. Outcome Variables Depression. Patient participants completed the Center for Epidemiclogical Studies Depression Scale (CES-D; Radloff, 1977), a measure of depressive symptoms with high internal consistency, adequate test-retest reliability, and validity. It has been shown to be a valid screening instrument for depression in patients with chronic pain (Turk & Okifuji, 1994). Physical functioning. The Roland Scale (Roland & Morris, 1983) was administered to both the patient and the significant-other study participants, with the significant-other version modified to allow assessment of patient disability by the significant others. Posttreatment significant-other ratings of patient disability were not obtained because few significant others spent sufficient time with the patients during their last week of treatment to be able to make such ratings. Health care use. Patient participants were asked the number of painrelated visits they made to health care providers during the 3 months before each 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 (no pain) to 10 (pain as intense as you could imagine). These measures were averaged into a single index of pain intensity (cf. Jensen, Turner, Romano, & Fisher, 1999). Procedure Patient and significant-other study participants completed telephone interview versions of the process and outcome measures at the beginning of treatment, after treatment, and at 6- and 12-month follow-ups. 3 The pain program is a 3-week, days per week, outpatient treatment program aimed at improving patient pain-management skills and physical and psychological functioning. It includes quota-based physical and occupational therapy, individual cognitive-behavioral psychotherapy, vocational counseling (if appropriate), group pain education and coping-skills training, and the tapering of opioid and sedative hypnotic medications when indicated (cf. Loeser & Egan, 1989). Results Data Preparation and Reduction Measures with skewness > 1.0 were transformed for use in data analysis. Repeated measures analysis of variance (ANOVAs) were performed to identify the process and outcome measures that changed from pretreatment to posttreatment and to follow-up (Table 1). There were 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 Catastrophizing scale, and in 8 of 14 coping measures. All 5 outcome measures showed significant (p <.001) improvement from pretreatment to posttreatment and through both follow-ups. 1 Of these 72 significant-other participants, the majority (88%) were married to and living with the patient. Three (8%) were not married to but were cohabiting with the patient, and the remainder (6%) were friends or relatives with whom the patient lived. 2 Twenty-three items were reworded slightly for increased clarity. For example, Item 2, "The pain I usually experience is a signal that damage is being done," was reworded as "The pain I feel is a sign that damage is being 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 2 weeks, 1 month, 2 months, and 3 months after treatment to test hypotheses related to maintenance of gains after treatment. These data will be presented in a separate article. 4 Some patients may participate for more than 3 weeks if they require additional time to reach maximum gains and have funding for the additional time. Twenty-eight (20%) of the 141 study participants participated in 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 outcome variables was controlled by (a) setting the alpha level at for these analyses and (b) requiring that all three changes tested (pretreatment to posttreatment and pretreatment to the 6- and the 12-month follow-up points) be statistically significant to conclude that the change was real and consistent through 1 year posttreatment for the sample as a whole.

3 BELIEFS, CATASTROPHIZING, AND COPING 657 Table 1 Process and Outcome Measure Scores at Pretreatment, Posttreatment, and 6- and 12-Month Follow-Up Pretreatment Posttreatment 6-month follow-up 12-month follow-up Scale M (SD) M (SD) M (SD) M (SD) f* Process variables SOPA subscales (beliefs) Pain Control Disability Harm Emotion Medication Solicitude Medical Cure PBAPI subscales (beliefs) Mystery Pain Permanence Pain Constancy Self-Blame CSQ Catastrophizing CSQ subscales (coping) Reinterpret Pain Ignore Pain Coping Self- Statements Pray/Hope Divert Attention Increase Activities CPCI (coping) Guarding Resting Ask for Assistance Relaxation Task Persistence Exercise/Stretch Seek Social Support Coping Self- Statements Outcome variables Patient-Roland Significant other-roland Depression (CES-D) Health care visits'* Average pain intensity 1.88 a 2.48 a a 2.30 a a 0.37 a 1.28 a a 0.96 a 2.19 a 3.73 a a 3.04 a 4.43 a 4.32 a 3.24 a 2.40 a 4.21 a a 3.68 a a a (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) 2.72 b 1.69 b 0.82 b 2.31 b 1.50 b 0.98 b 1.19 b b 0.54 b 0.80 b b 1.74 b 3.04 b 4.50 b 2.89 a 3.60 b 3.71 b 2.02 b 2.83 b 1.20 b 4.72 b 5.34 b 6.62 b 3.48 b 9.73 b 9.12 b b 5.50 b (0.85) (0.83) (0.61) (0.65) (0.98) (0.80) (0.78) (1) (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) (1.54) (1.58) (5.70) (10.88) (1.65) 2.23 C 2.10 C 1.24 C 2.07 a 2.19 a 0.99 b 1.26 b b 0.68 b 0.96 b C 1.59 b 2.83 b 3.99 a 2.44 b 2.92 a 3.20 a 2.69 C 2.62 b 1.97 C 3.12 C 4.94 C 4.59 C 2.40 C 3.38 a C b 21, 4.96 b 5.64 b (0.98) (0.93) (0.74) (0.81) (1.08) (0.87) (0.77) (1.10) (0.90) (1) (1) (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) 2.29 C 2.05 C 1.26 C 2.03 a 2.23 a 1.02 b 1.33 b b 0.65 b 0.94 b b, c 1.70 b 2.97 b 3.96 a 2.43 b 3.07 a 3.28 a 2.73 C 2.73 b 2.04 C c, b 4.59 C 2.27 C 3.39 a C b C 4.32 b 5.46 b (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) Note, n = 141 for the patient-rated measures; n = 72 for the significant other Roland scores. Means with different subscripts are significantly different from one another (p < ). SOPA = Survey of Pain Attitudes; PBAPI = Pain Beliefs and Perceptions Inventory; CSQ = Coping Strategies Questionnaire; CPCI = Chronic Pain 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-Blame on 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 significant pretreatment-through-follow-up changes. The belief and coping scale change scores were then subjected to two principal components analyses (PCAs; one for the changes in the belief scale scores and one for the changes in the coping scale scores) for each of the three time intervals (pretreatment to posttreatment, pretreatment to 6-month follow-up, and pretreatment to 12-month followup) to reduce the number of predictor variables. If more than one factor emerged, the factors were rotated using an oblique rotation. The PCA of the pretreatment to posttreatment belief change scores resulted in a single factor, which we labeled Change in Pain Beliefs. The PCAs of the pretreatment through the 6- and the 12-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 first factor (labeled ), and with SOPA Solicitude and Medical Cure loading on the second factor (labeled ). Three factors emerged from each of the PCAs of pretreatment-to-posttreatment and

4 658 JENSEN, TURNER, AND ROMANO pretreatment-to-6- and 12-month Coping change scores. In each of the three PCAs, the same scales loaded on the same factors. One factor was (made up primarily of CPCI Guarding, Resting, and Asking for Assistance change scores). The second factor was, with CPCI Relaxation and CPCI Exercise/Stretch having the highest loadings on this factor. The third factor was, with CSQ Ignore Pain, CSQ Reinterpret Pain, and CPCI Task Persistence having the highest loadings on this factor. Associations Between Changes in Outcome Measures and Changes in Process Measures We then performed regression analyses to examine the extent to which treatment outcomes were associated with the changes in the process variables (see Table 2, Table 3, and Table 4). Demographic or pain-related variables were entered in the first step only if they demonstrated significant zero-order relationships with improvement. Separate regressions were conducted for each outcome measure for each time period (pre post, pre 6 month follow-up, and pre 12 month follow-up). We used an alpha level of to balance control for alpha inflation with ability to detect reliable associations. The process variables explained 45%, 42%, and 45%, respectively (all ps <.001), of the variance in improvement in patient self-rated disability from pre- to posttreatment and from pretreatment to 6- and 12-month follow-ups; 45%, 41%, and 35%, respectively (all ps <.001), of the variance in change in depressive symptoms; and 20%, 27%, and 31%, respectively, (all ps < ) of the variance in change in average pain intensity across the three time intervals. They explained 13% (ns) and 26% (p < ) of the variance in improvement in significant-other-rated patient physical disability and 12% (p < ) and 7% (ns) of the variance in 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 associations between specific process and outcome measures and to help interpret the findings from the regression analyses, we calculated the correlations between the pretreatment-to-follow-up change scores of the individual process measures (Beliefs, Catastrophizing, and coping) and the change scores for the outcome variables. We controlled for alpha inflation by setting the alpha level at.001. Six of the process measures (SOPA Solicitude and Medical Cure, CSQ Reinterpret Pain and Ignore Pain, and CPCI Relaxation and Exercise/Stretch) that changed pre- to posttreatment and through follow-up were weakly (r <.30) associated with all outcome measures across the assessment intervals. Three process measures (PBAPI Mystery and CPCI Ask for Assistance and Task Persistence) showed a moderately strong (IH >.30) association with at least one outcome measure change score, but these associations were not consistent across all three assessment intervals. The strongest (IH >.30) consistent associations are presented in Table 5. Changes in SOPA Control, SOPA Disability, and CSQ Catastrophizing were consistently associated with changes in depression, pain, and patient-reported physical disability. SOPA Harm and CPCI Rest were consistent predictors of patient-reported physical disability, and PBAPI Mystery was a consistent predictor of pain intensity. CPCI Guarding predicted patient-reported dis- Table 2 Multiple Regression Analyses Predicting Pretreatment to Posttreatment Outcome Measure Changes From Changes in Belief Factors, Catastrophizing, and Coping Factors Total Measure step and variable R 2 Self-rated patient disability (Roland Scale) Step 1. Cognitions and coping.45 Change in Pain Beliefs Depression (CES-D) Step 1. Control variable (pretreatment pain).03 Step 2. Cognitions and coping.48 Change in Pain Beliefs Pain intensity Step 1. Cognitions and coping.20 Change in Pain Beliefs Change R 2 F / *** a.31*** **.25** * a.13* ***».21*.44*** *** ".24* Note, n = 141. CES-D = Center for Epidemiological Studies- Depression Scale. "dfs = 1, 139. c djs = 2, 138. *p<.05. **/?<. ***p<.001.

5 BELIEFS, CATASTROPHIZING, AND COPING 659 Table 3 Multiple Regression Analyses Predicting Pretreatment to 6-Month Follow-Up Outcome Measure Changes From Changes in Belief Factors, Catastrophizing, and Coping Factors Measure step and variable Total R 2 Change R 2 F ft Self-rated patient disability (Roland Scale) Step 1. Cognitions and coping Significant-other-rated patient disability (Roland Scale) Step 1. Cognitions and coping Depression (CES-D) Step 1. Cognitions and coping Health care visits for pain Step 1. Control variable (pain site) Step 2. Cognitions and coping Pain intensity Step 1. Control variable (employment status) Step 2. Cognitions and coping *** a 1.57" 15.36*** a 4.40* 2.99* 6.82* a 11.13***'.38*** *** *.07.48*** *** ** Note, n = 141 for statistics related to the association between predictors and patient-rated outcomes; n = 72 for statistics related to the association between predictors and the significant other-rated outcome. CES-D = Center for Epidemiological Studies Depression Scale. *dfi = \, 139. b dfs = 1, 70. c rf/s = 2, 138. *p<.05. **/><. ***/><.001. ability and depression across all three assessment intervals and also predicted significant-other-reported patient disability pretreatment to both follow-ups. Across every assessment interval, decreases in SOPA Disability and Harm, PBAPI Mystery, CSQ Catastrophizing, and CPCI Guarding and Rest were associated with improvement, whereas an increase in SOPA Control was associated with improvement. Discussion Current 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, then improvement after treatment outcome should be associated with changes in pain-related cognitions and coping responses. The results of this study support this model. Pretreatment-toposttreatment and pretreatment-to-follow-up changes in cognitions and coping accounted for large and statistically significant portions of the variance in changes in patient self-reported physical disability, depressive symptoms, and pain intensity. Changes in cognitions and coping were less consistent predictors of changes in significant-other-reported patient disability (statistically significant only for the pretreatment to 12-month follow-up interval) and

6 660 JENSEN, TURNER, AND ROMANO Table 4 Multiple Regression Analyses Predicting Pretreatment to 12-Month follow-up Outcome Measure Changes From Changes in Belief Factors, Catastrophizing, and Coping Factors Measure step and variable Total Change Self-rated patient disability (Roland Scale) Step 1. Cognitions and coping * Significant-other-rated Patient Disability (Roland Scale) Step 1. Control variable (pain duration) Step 2. Cognitions and coping Depression (CES-D) 6.60* b 4J4**c Step 1. Cognitions and coping ***' Health care visits for pain Step 1. Cognitions and coping a Pain intensity Step 1. Cognitions and coping ***'.25** *** * *** ** * ***.11.20*.17* Note, n = 141 for statistics related to the association between predictors and patient-rated outcomes; n 72 for statistics related to the association between predictors and the significant other-rated outcome. CES-D = Center for Epidemiological Studies Depression Scale. a d/s = 1, 139. b dft, = 1, 70. c dfa = 2, 69. *p<.05. **p<. ***/?<.001. patient-reported number of health care visits for pain (statistically significant only for the pretreatment to 6-month follow-up interval). Although correlational findings do not shed light on causal relationships, they do suggest specific cognitions and coping responses that are likely to be important in patient improvement with multidisciplinary pain treatment. Moreover, it appears that specific cognitions and coping responses may be uniquely associated with specific outcomes. Decreases in patient-rated disability were most strongly and consistently associated with an increase in the belief that one has control over pain and decreases in the beliefs that one is disabled by pain and that pain signals damage. These findings replicate those of our previous study (Jensen, Turner, & Romano, 1994). However, some findings differed, including associations between changes in some coping responses and change in patient self-reported disability. In the present study, decreases in patient self-reported disability were most strongly associated with decreases in coping responses that involved activity restriction, such as guarding and resting. In the previous study, no behavioral-coping responses were associated with patient disability. The differences in results between the two studies may be due, in part, to a more detailed and comprehensive assessment of coping in the present study. The associations between changes in the process measures and changes in significant-other ratings of patient disability are of

7 BELIEFS, CATASTROPHIZING, AND COPING 661 Table 5 Correlations Between Changes in Outcome and Changes in Process Measures That Were Consistent From Pretreatment to Posttreatment and Pretreatment to 6- and 12-Month Follow-Up Assessment interval Process/outcome change measure Pretreatmentposttreatment Pretreatment- 6-month follow-up Pretreatment- 1 2-month follow-up SOPA Pain Control/Patient-Roland SOPA Pain Control/CES-D SOPA Pain Control/Pain Intensity SOPA Disability/Patient-Roland SOPA Disability/CES-D SOPA Disability/Pain Intensity SOPA Harm/Patient-Roland PBAPI Mystery/Pain Intensity CSQ Catastrophizing/Patient-Roland CSQ Catastrophizing/CES-D CSQ Catastrophizing/Pain Intensity CPCI Guarding/Patient-Roland CPCI Guarding/CES-D CPCI Guarding/Significant Other-Roland CPCI Rest/Patient-Roland Note, n = 141 for coefficients related to the association between predictors and patient-rated outcomes; n = 72 for coefficients related to the association between predictors and the significant-other-rated outcome. Change scores for both process and outcome measures were calculated by subtracting follow-up measure scores from pretreatment 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 coefficients indicate that an increase in the predictor variable is associated with improvement. These correlations and significance 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 Depression Scale; PBAPI = Pain Beliefs and Perceptions Inventory; CSQ = Coping Strategies Questionnaire; CPCI = Chronic Pain Coping Inventory. particular interest, because these associations are not biased by shared method variance. Changes in cognitions and coping responses, as a group, were strongly associated with changes in significant-other-rated patient physical disability only for the pretreatment to 12-month follow-up interval. Change in passive coping (guarding, resting, asking for assistance) made the greatest contribution to this association. Examination of the correlation coefficients suggests that decreases in guarding accounted for much of this effect. The process measures, as a group, were also strongly associated with decreased depressive symptoms. The single process variable most responsible for this was catastrophizing; those patients who reported the greatest decreases in catastrophizing also had the greatest decreases in depressive symptoms. However, the correlation analyses suggested that changes in several other beliefs (e.g., increases in perceived pain control and decreases in the beliefs that one is necessarily disabled) were at least moderately associated with change in depression symptoms. These findings generally replicate those of our previous study (Jensen, Turner, & Romano, 1994), which also found changes in pain-control beliefs, disability beliefs, and catastrophizing to be associated with change in depressive symptoms. No single process variable made a significant independent contribution to the prediction of change in number of health care visits at either assessment interval. This finding suggests that changes in the cognitions and coping responses assessed in this study are more 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 for pain. As a group, the process variables accounted for a large amount of the variance in changes in pain intensity across all three time intervals. The individual process-measure change scores that appeared to account for decreases in pain intensity were increases in a belief in control over pain and decreases in the beliefs that one is necessarily disabled by pain, that pain represents a mystery, and in catastrophizing. No coping measure was associated with change in pain intensity consistently across all three intervals. This suggests that the decreases in pain intensity found, pretreatment to posttreatment and through follow-up, cannot be explained by changes that occurred in the pain-coping responses measured in this study. The findings of this study are consistent with previous research and with the hypothesis that belief in control over pain is adaptive and that other cognitions and coping responses (e.g., the beliefs that one is disabled and that pain is a signal of damage, catastrophizing, guarding, and resting) are not adaptive. The findings support the continued use of interventions that increase perceived control over pain and decrease maladaptive patient cognitions and coping responses. However, to determine whether a specific process variable is responsible for treatment benefits, experimental studies are needed to test the effects of interventions that focus on altering specific cognitions and coping responses, with the goal of determining whether changes in these process variables improve patient physical and psychological functioning.

8 662 JENSEN, TURNER, AND ROMANO Several limitations of the study should be noted. First, given that this study was performed in the context of an existing treatment program, the inclusion of a control condition was not practical. Thus, it is not possible to determine whether the changes observed in the process variables and outcome measures were the direct result of treatment. Second, the correlational nature of the data does not allow for conclusions regarding sequential or causal relations among the process and outcome variables. Third, although the inclusion of significant-other observations of patient disability is a strength of the study, only 72 participants had a significant other who was willing to participate in all assessments. This limits the generalizability and statistical power of the analyses involving the significant-other data. Fourth, conclusions regarding the generalizability of the current study are further complicated by the facts that only 70% of patients who were eligible enrolled in the study and only 72% of these completed all posttreatment measures. Generalizability of the current findings is supported by the similarity to findings in our previous process analysis (Jensen, Turner, & Romano, 1994), but the previous study was also performed at the same pain center. Despite these limitations, this study provides additional support for a cognitive-behavioral model of the effects of multidisciplinary pain treatment on the functioning of individuals with chronic pain. References Flor, H., Fydrich, T., & Turk, D. C. (1992). Efficacy of multidisciplinary pain treatment centers: A meta-analytic review. Pain, 49, Jensen, M. P., Turner, J. A., & Romano, J. M. (1994). Correlates of improvement in multidisciplinary treatment of chronic pain. Journal of Consulting and Clinical Psychology, 62, Jensen, M. P., Turner, J. A., Romano, J. M., & Fisher, L. (1999). Comparative reliability and validity of chronic pain intensity measures. Pain, 83, Jensen, M. P., Turner, J. A., Romano, J. M., & Lawler, B. K. (1994). Relationship of pain-specific beliefs to chronic pain adjustment. Pain, 57, Jensen, M. P., Turner, J. A., Romano, J. M., & Strom, S. E. (1995). The Chronic Pain Coping Inventory: Development and preliminary validation. Pain, 60, Loeser, J. D., & Egan, K. J. (1989). Managing the chronic pain patient: Theory and practice at the University of Washington Multidisciplinary Pain Center. New York: Raven Press. Radloff, L. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, Roland, M., & Morris, R. (1983). A study of the natural history of back pain. Part I. Development of a reliable and sensitive measure of disability in low-back pain. Spine, 8, Rosenstiel, A. K., & Keefe, F. J. (1983). The use of coping strategies in chronic low back pain patients: Relationship to patient characteristics and current adjustment. Pain, 17, Turk, D. C., & Okifuji, A. (1994). Detecting depression in chronic pain patients: Adequacy of self-reports. Behaviour Research and Therapy, 32, Williams, D. A., & Thorn, B. E. (1989). An empirical assessment of pain beliefs. Pain, 36, Williams, D. A., Robinson, M. E. & Geisser, M. E. (1994). Pain beliefs: Assessment and utility. Pain, 59, Received May 9, 2000 Revision 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 Affiliates receive as part of their annual dues subscriptions to the American Psychologist and APA Monitor. High School Teacher and International Affiliates receive subscriptions to the APA Monitor, and they may subscribe to the American Psychologist at a significantly reduced rate. In addition, all Members and Student Affiliates are eligible for savings of up to 60% (plus a journal credit) on all other APA journals, as well as significant discounts on subscriptions from cooperating societies and publishers (e.g., the American Association for Counseling and Development, Academic Press, and Human Sciences Press). Essential resources. APA members and affiliates receive special rates for purchases of APA 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 for competitive 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