Treatment Outcomes Vary by Coping Styles in Rehabilitation Settings

Treatment Outcomes Vary by Coping Styles in Rehabilitation Settings Daisha J. Cipher, University of Texas at Arlington, USA Abstract: Patients undergoing rehabilitation have been evidenced to improve in different ways depending on their coping styles. Amplifiers, Repressors, and Social Copers are examples of patients who present differently in rehabilitation settings and tend to have differing levels of success in their response to treatment. The current study examined the differential treatment outcomes of three coping style groups undergoing multidisciplinary rehabilitation at two clinic sites. A sample of 123 patients suffering from chronic pain was assessed repeatedly during the course of treatment using the Beck Depression Inventory and the Multidimensional Pain Inventory. Coping style groups derived from the Millon Behavioral Medicine Diagnostic consisting of Amplifiers, Repressors, and Social Copers were compared with regard to reductions in depression, anxiety, pain, functional impairment, and associated outcomes. Results revealed differing outcomes by the coping style groups on depression and affective distress. There were no differences between the coping style groups on changes in pain or functional impairment. These findings support prior research emphasizing the value of tailoring treatments in rehabilitation settings toward patients coping styles in order to maximize outcomes, particularly outcomes associated with emotional distress. Keywords: coping style, treatment outcome, rehabilitation Introduction Research on the influence of personality on treatment outcomes indicates that persons suffering from injuries associated with chronic pain are quite heterogeneous in their personalities, symptom presentation, psychopathology, and social milieu (Cipher, Clifford, & Schumacker, 2002; Cipher & Clifford, 2003; Cipher, Kurian, Fulda, Snider & Van Beest, 2007). While the goals of most pain management and work hardening programs are to reduce the patient s emotional distress and increase functional capacity, the methods by which these goals are accomplished vary widely due to the complex biopsychosocial nature of the chronic pain experience. The efficacy of multidisciplinary treatment for persons rehabilitating from a painful injury is well-documented (Flor, Fydrich, & Turk, 1992; Cutler, Fishbain, Rosomoff, Abdel- Moty, Khalil, & Rosomoff, 1994; Turk, 1996; Cipher, Fernandez, & Clifford, 2001). Research on factors affecting treatment outcomes in rehabilitation has recently focused on the influences of patient characteristics on treatment improvement. The extent to which certain patients respond to treatment more (or less) successfully than other patients has become particularly important. One emerging research focus is the study of patients differences in coping style that is, how patients personality styles affect how they cope with their pain condition and their effects on outcomes in health settings (Cipher & Clifford, 2003; Persson,

Rivano-Fischer, & Eklund, 2004; Watten, Vassend, Myhrer, & Syversen, 1997; Goldstein & Antoni, 1989; Wilcoxen, Zook, & Zarski, 1988; Kleinke, 1992). Cipher et al. (2002) identified distinct coping style groups within the chronic pain population using the Millon Behavioral Health Inventory (Millon, Green, & Meagher, 1979). These coping style groups were derived from a hierarchical cluster analysis of the eight MBHI coping scales followed with cluster comparisons on the MMPI-2, Multidimensional Pain Inventory, Beck Depression Inventory, and Chronic Illness Problem Inventory. Cipher & Clifford s analyses revealed three distinct clusters that differed substantially in levels of personality styles, psychopathology and emotional distress. The first group, deemed Amplifiers, reported the highest overall levels of psychopathology and emotional distress, and the lowest levels of perceived control over their life situation, levels of social satisfaction, and treatment compliance. The second group, deemed Repressors, were more emotionally stable than the Amplifiers. However, they tended to be psychologically defensive and scored highest on scales measuring repression (MMPI K and L scales), indicating a risk of underreporting psychosocial problems. The third group, deemed Social Copers, reported the highest levels of functional capacity, but above-average levels of emotional distress. This group reported higher levels of sociability, forcefulness, narcissism, and interpersonal success. The coping style groups were subsequently replicated by Cipher et al (2007), using the newer revised version of the MBHI, called the Millon Behavioral Medicine Diagnostic (MBMD; Millon, Antoni, Millon, Meagher, & Grossman, 2001). In both studies from Cipher and colleagues (2002 and 2007), these coping style groups look virtually the same in terms of demographics such as ethnicity, gender, age, and marital status, as well as pain duration and pain condition. In addition, these coping groups do not differentiate between the MPI taxonometric groups of Turk and Rudy (1988); that is, the coping style groups generated from the Millon inventories were distinctly different from those generated from the MPI taxonomy. The implications of Cipher and colleagues (2002; 2003; 2007) are that patients who possess certain coping styles are likely to progress through treatment differently, and exhibit varying levels of success in the rehabilitation treatment setting. The purpose of this study was to examine the extent to which patients in each of the coping style classifications demonstrate differing outcomes over the course of treatment. Methods Subjects Participants were 123 consecutive outpatients who were treated for a painful injury at one of two rehabilitation clinics. Patients average age was 49 (SD = 11.3), with 44 males and 79 females. Eighty-six percent of patients were White/Caucasian, 12.4% were African-American, and 1.6% were of Hispanic/Latino origin. Procedures During their evaluation at the rehabilitation center, all patients completed an informed consent form, the MBMD, the MPI, and the BDI. Once patients were admitted into the treatment program, the MPI and BDI were administered again during the second and third weeks of the

treatment program. The rehabilitation centers, which were accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF), applied a multidisciplinary treatment approach that involved physical therapy, biofeedback, relaxation training, psychological group counseling, and vocational counseling. All patients received physical therapy every day of their treatment program. They received individual biofeedback sessions 2 to 3 times per week by a certified biofeedback technician. Measures Millon Behavioral Medicine Diagnostic (MBMD; Millon, Antoni, Millon, Meagher, & Grossman, 2001). The MBMD was designed to provide information on patients biopsychosocial health, and is a revised version of the Millon Behavioral Health Inventory (Millon et al., 1979). The MBMD was normed on patients with chronic medical conditions and consists of 165 true/false items. The MBMD scoring system generates 11 scales that assess coping styles, as well as 27 other scales. The 11 coping scales were included in this study. They were introversive, inhibited, dejected, cooperative, sociable, confident, nonconforming, forceful, respectful, oppositional, and denigrated. When our coping style classification procedure (the cross-validation procedure described in the Results section) was tested for reliability, on average, the procedure misclassified cases less than 6% of the time. This means that the procedure correctly classified an Amplifier, Repressor, or Social Coper 94% of the time. The authors of the MBMD conducted reliability and validity studies and reported test retest reliability coefficients that ranged from.71 to.90 for the 11 coping scales, and internal consistency coefficient alphas that ranged from.54 to.85 for 11 coping scales (Millon, Antoni, Millon, Meagher, & Grossman, 2001). Multidimensional Pain Inventory (MPI; Kerns et al, 1985). The West Haven-Yale Multidimensional Pain Inventory (MPI) is a comprehensive, psychometrically sound instrument which is composed of three sections with a total of 12 empirically derived scales. This study focused on eight of the 12 scales: Pain Severity, Life Interference, Affective Distress, Distracting Responses, Punishing Responses, Solicitous Responses, Life Control, and Social Support. Higher scores indicate higher levels of the subscale s construct. For example, higher scores on the Pain Severity scale are indicative of more/higher pain, and higher scores on the Life Control and Social Support scales are indicative of a stronger sense of control of one s life and support from others, respectively. Published subscale internal consistency coefficients have ranged from.62 to.91 (Jamison, Rudy, Penzien, & Mosley, 1994). Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock,& Erbaugh, 1961). The BDI contains 21 items assessing levels of depression experienced in the past week. Sample items are I blame myself for everything bad that happens and I have lost all of my interest in other people. Internal consistency coefficient alphas for the BDI have been found to range from.76 to.95 (Beck, Steer, & Garbin, 1988). Statistical Analyses The formulas from Cipher et al. (2007) were applied to patients MBMD data to determine each patient s coping style classification (Amplifier, Repressor, or Social Coper). Dichotomized outcomes were created from the patients change in the BDI and MPI subscales over time, with a 1 representing improvement over time, and a 0 representing no change or deterioration.

Continuous parameters were reported as mean ± SD, and discrete parameters were reported as a percent (%). Continuous parameters were compared with one-way ANOVA and discrete parameters were compared with the Pearson chi-square test. Logistic regression analysis was used to evaluate associations between coping style classifications and dichotomized outcomes, adjusting for clinic site. Statistical significance was determined a priori at p 0.05. All analyses were conducted using SPSS 18.0 for Windows and SAS 9.1 for Windows. Results When the coping style classification formulas were applied, the results revealed that 27 (22%) patients were Amplifiers, 48 (39%) were Repressors, and 48 (39%) were Social Copers (see Table 1). The coping style classifications did not significantly differ by gender ( ²(2) = 4.36, p=.11), nor race ( ²(4) = 2.83, p=.58). The coping style classifications also did not significantly differ on patients age (F(2,106) = 1.17, p =.31). Table 1. Means and Standard Deviations for Outcome Variables Amplifiers Repressors Social Copers Mean SD Mean SD Mean SD BDI Baseline 24.9 8.4 16.9 8.6 15.1 8.5 BDI Post-Treatment 16.2 7.7 14.7 9.1 10.5 7.0 MPI Life Interference Baseline 4.7 1.1 4.5 1.4 4.2 1.3 MPI Life Interference Post-Treatment 4.1 1.4 4.0 1.5 3.7 1.7 MPI Social Support Baseline 3.2 2.1 3.9 1.9 4.2 1.6 MPI Social Support Post-Treatment 2.7 2.1 3.7 2.4 3.9 1.7 MPI Pain Severity Baseline 4.6 1.1 4.7 1.0 4.2 1.2 MPI Pain Severity Post-Treatment 4.1 1.6 4.1 1.2 3.9 1.4 MPI Life Control Baseline 2.3 1.2 3.5 1.5 3.9 1.3 MPI Life Control Post-Treatment 2.9 1.1 3.8 1.3 3.8 1.5 MPI Affective Distress Baseline 4.2 1.0 3.3 1.1 3.0 1.2 MPI Affective Distress Post- Treatment 3.8 1.0 2.6 1.3 2.9 1.2 MPI Punishing Responses Baseline 2.7 1.9 1.8 1.6 1.8 1.6 MPI Punishing Responses Post- Treatment 2.5 2.1 1.7 1.5 1.9 1.6 MPI Solicitous Responses Baseline 2.8 1.9 3.2 1.7 3.3 1.7

MPI Solicitous Responses Post- Treatment 2.2 1.9 3.0 1.6 3.3 1.9 MPI Distracting Responses Baseline 1.6 1.4 2.2 1.6 2.5 1.5 MPI Distracting Responses Post- Treatment 1.8 1.5 2.4 1.6 2.7 1.6 BDI : Beck Depression Inventory MPI : Multidimensional Pain Inventory Mixed factorial analyses of variance with Clinic Site as the between subjects factor and Time (Pre vs. Post-Treatment) as the within subjects factor were computed on the outcome variable set (BDI and MPI subscales). With the exception of three MPI subscales (Life Interference, Pain Severity, and Solicitous Responses), there was no significant interaction between Time and Clinic Site for the outcome variables. Therefore, subsequent mixed factorial analyses of variance were computed with Coping Style Classification as the between subjects factor and Time (Pre vs. Post-Treatment) as the within subjects factor. There was a significant interaction between Coping Style and Time on BDI (F(2,120) = 8.33, p<.001). Amplifiers made significantly more reductions in depression over time than the other two coping style groups (see Figure 1). There were no significant interactions between Coping Style and Time on the MPI subscales: Life Control, Social Support, Affective Distress, Punishing Responses, or Distracting Responses. Figure 1 Changes Over Time in Depression by Coping Group

For the three MPI subscales that yielded a significant interaction between Time and Clinic Site (as described above), mixed factorial analyses of variance with Coping Style Classification as the between subjects factor, Time (Pre vs. Post-Treatment) as the within subjects factor, and Clinic Site as the covariate were computed. There were no significant interactions between Coping Style and Time on the MPI subscales Life Interference, Pain Severity, and Solicitous Responses, after controlling for Clinic Site. Logistic regression analyses on the dichotomized outcomes were performed with coping style classifications as the predictors and clinic site as the covariate. Amplifiers were over three times more likely to make improvements in depression, even after controlling for clinic site (OR = 3.3, p=.04; see Figure 2). Social Copers were 54% less likely to make improvements in MPI Affective Distress, even after controlling for clinic site (OR =.46, p =.04). No other significant associations emerged. Figure 2. Improvement in Beck Depression Inventory by Coping Group Discussion The findings of this study indicate that the coping style groups differed in their improvements in emotional distress over time, but not other treatment outcomes. Analyses revealed that

Amplifiers exhibited the largest improvements in depression and emotional distress over the treatment span. Just as Cipher and colleagues (2002; 2003) reported, Amplifiers started treatment with the highest levels of emotional distress, and revealed the largest changes as treatment progressed. Repressors and Social Copers, on the other hand, started with moderate levels of emotional distress and exhibited modest improvements over the treatment span. Contrary to the findings of Cipher et al (2002; 2003), the coping style groups did not differ in improvements in pain and functional impairment over time. The implications of these findings are that Amplifiers engage in a different treatment response pattern than do other coping style groups. They may be most responsive to treatments designed to alleviate depression, such as the cognitive-behavioral therapies incorporated in this study. On the other hand, Repressors did not respond to depression-focused therapy. Since persons in this group are most likely to be defensive in self-reporting and introversive in their interpersonal styles, they may respond positively to other modes of multidisciplinary treatment such as biofeedback. In a previous study by the authors (Cipher et al. 2003), we found that chronic pain patients with Repressor characteristics were most compliant with multidisciplinary treatment. Repressors were most successful when performing objective tasks and homework assignments through the course of treatment. It was noted that they were least successful in therapies involving talking about thoughts and feelings. The findings from our collective studies indicate that individualized treatment methods designed to help Repressors, Amplifiers, and Social Copers manage their injuries and associated chronic pain, in modalities that are suited to their particular coping style, are likely to maximize patients response to treatment. Moreover, the ability for clinicians to identify the particular coping style of the patient through a psychometric assessment process is an important part of the treatment plan. Administering the MBMD to patients during the initial evaluation, classifying their coping styles, and using this classification as a consideration in developing an individualized treatment plan, may increase the likelihood of treatment success especially in the area of emotional distress. References Beck, A.T, Epstein, N., Brown, G., Steer, R.A. (1988). An inventory for measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology, 56, 893-897. Beck A.T., Steer R.A., Garbin M.G. (1988). Psychometric properties of the Beck Depression Inventory: Twenty-five years of evaluation. Clinical Psychology Review, 8, 77-100. Beck, A. T., Steer, R. A., & Brown, G.K. (1996). Beck Depression Inventory-Second Edition Manual. San Antonio: The Psychological Corporation. Beck A.T., Ward C.H., Mendelson M., Mock J., Erbaugh J. (1961). An inventory for measuring depression. Archives of General Psychiatry, 4, 53-63.

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