THE EFFECTS OF COVERT POSITIVE REINFORCEMENT IN MODIFYING COLD-PRESSOR PAIN A Dissertation Presented to the Faculty of the Graduate School University of Missouri-Columbia In Partial Fulfillment of the Requirements for the Degree Doctor of Philosophy RRR by Michael Jonathan Stevens Frank E. Wellman Dissertation Supervisor July 1981The undersigned, appointed by the Dean of the Graduate Faculty, have examined a thesis entitled THE EFFECTS OF COVERT POSITIVE REINFORCEMENT IN MODIFYING COLD-PRESSOR PAIN presented by Michael Jonathan Stevens a candidate for the degree of Doctor of Philosophy and hereby certify that in their opinion it is worthy of acceptance. Roba | ae—THE EFFECTS OF COVERT POSITIVE REINFORCEMENT IN MODIFYING COLD-PRESSOR PAIN Michael Jonathan Stevens Frank E. Wellman Dissertation Supervisor ABSTRACT Purpose: The primary purpose of this study was to investigate the effectiveness of covert positive reinforcement (CPR) in modifying cold pressor pain responses and to examine the conceptual foundation of the technique. A secondary purpose was to explore the ability of CPR to facilitate imagery involvement. A third objective was to define the re~ Lationships of imagery involvement and image clarity to changes in the targeted pain responses. The experimental procedures were designed to compare competing conceptualizations of CPR. CPR consisted of presenting pleasant images contingent upon the imagination of hand insensitivity. Reversed-contingency covert positive reinforcement (r-CPR) reversed the two sets of images. Covert rehearsal (CR) involved imagining only the scenes of hand insensitivity. An expectancy (E) condition assessed the effects of expectancy without specific coping instructions. These inter~ ventions were hypothesized to impact differentially upon behavioral and self-report pain responses. Method: Ninety females between 18 and 35 years were screened as Potential subjects. The,screening criteria included various nedical conditions and failure to exceed the pretest pain tolerance ceiling.it Eighty subjects were accepted for treatment and randomly assigned to four conditions (CPR, r-CPR, CR, and E). The dependent variables in~ cluded behavioral tolerance, self-rated pain, and imagery involvement. Behavioral tolerance was measured by the duration of ice water exposure. Subjective pain was measured by an 1l-point rating scale. Both pain responses were assessed at pretreatment and posttreatment. Imagery involvement was operationalized as the proportion of coping time during the posttest used to imagine the scenes of hand insensitivity. Another variable, image clarity, was measured by a S-point rating scale at post~ treatment. Resulte: One-way analyses of variance were used to test ‘the hypo- thesized effects of the four interventions on the three dependent meas— ures. A prior! comparisons were tested with the LSD test. Pearson cor- relation coefficients were used to test the hypothesized relationships of inagery involvement and image clarity to changes in the targeted pain responses. Contrasts between the comparison groups on the three dependent measures, were tested using t tests. The alpha level was set at .05 throughout. CPR failed to produce a significantly greater increase in behavioral tolerance and decrease in self-rated pain than the comparison interven~ tions. CPR did not facilitate significantly more imagery {avolvenent than the other imagery conditions, Inagery involvement was not corre- lated with changes in behavioral tolerance and self-rated pain. Image clarity was positively correlated with increases in behavioral tolerance and negatively correlated with decreases in self-rated pain. A sizeableaii number of subjects reported using self-generated strategies to endure the cold stimulation. The variances of both pain responses increased sharply after treatment. Conclusions: The results of this study supported three conclusion: (1) GPR ds not superior to comparison treatments in modifying cold- pressor pain responses and in facilitating imagery involvement. (2) The operant sequencing of adaptive and reinforcing images is not critical to the ability of CPR to modify cold-pressor pain responses and to facilitate imagery involvement. (3) The modification of cold-pregsor responses is not associated with imagery involvement, but is associated with image clarity.TABLE OF CONTENTS LIST OF TABLES - 2. +. LIST OF FIGURES. +--+ ee eee ee eee Chapter . . “INTRODUCTION. © ee pe ee eee ee ee ee ee eee Purpose of the Study+ +++ eee eee Statement of the Problems ++ +e ee eee eee eee Research Questions» + +--+ + ee ee eee ee ee eee Hypotheses se pe ee ee ee et eee Research Design. ss ee se ee ee ee eee eens Limitations of the Study. +--+ eee ee te ee eee REVIEW OF THE LITERATURE. 2 ee ee ee ee ee ee Covert Positive Reinforcement - +++ +++ eee eee THEOL 0 oa oe i we set to ee Fos one ne ale Technique «sere ee eee rie hee eens Research Literature +++ eee eee ee ee ee eee Single Case Studies. . +--+. --- Controlled Experiments with Clinically Irrelevant Target Behaviors +--+ eee eres Controlled Experiments with Clinically 3 Relevant Target Behaviors - +--+ +e eee ee Covert Positive Reinforcement and Pain. +. +++. +s Cognitive Pain Control Strategies - +++ +++ eee ee Information Supply s+ +e + ee ee eee et ee eee Stimulus Information - ++ e+e eee eee eee Response Information +++ +e eee eee eee Self-Verbalization. +--+ ee ee ee eee ee eee Adaptive Attention Focusing -- +--+ eee eee eee Consunmatory Properties of Pain-Irrelevant Stimuli . E Non-Consunmatory Properties of Pain-Relevant Stimuli Imagined Numbness - +--+ ee ee ee ee Transformation of Sensations.» ++ +++ see 5 Dissociation. + see ee ee ee ee ee Consummatory Properties of Pain-Relevant Stimuli « Non-Consummatory Properties of Pain-Irrelevant [BUSI gogo ccucoddeusGoad00 Shiimaty so ST he oiled Wiahistlet eli Bg eve Summnryiene et vi Page ix xi ql 13 19 21 22 25 25 25 28 30 31 37vit Chapter Page 3. METHOD eee ee ee eee eee ee ee WL Subjectessis stewie lec eee tee ee eee eo LE Apparatus sve eee ee ee eee ee ee WD Neutral Stimulus. see eee eee ee eee ee ee 1 i Pain Stimlus see eee ee eee ee eee ee ee 122 4 Instrumentation ss eee ee eee ee eee ene Mh Dependent Measures . vse ee ee ee eee 12h ‘ Othe: Measure: a 6.0. oie Sone oe siacere tee ee © 127; i Procedure see ee eee te eee sete eee tees 128 Phase 1: Pretest Assessment» +++ eevee eee ee + 129 Phase 2: Interventions». secrete eee eee LL Covert Positive Reinforcement (CPR) +++ +++ +++ + 13L ; Reversed-Contingency Covert Positive i Reinforcement (r-CPR) se eee ee eee ee ee 18h i Covert Rehearsal (CR) eee eee eee ee ee ee 135 i Bupectancy (BE) pees cc ccc encesecee LF i Phase 3: Posttest Assessment +s see eee ee ees 137 j Predictions. vec en eee eee ene LB | Statistical Analysis. +++ eee eee eee ee ee ee LAL i hy RESULTS oe eee eee ee eee ee ee ee 16 i Hypothesis 1. ee t eee eee eee tee ee s 16 i Hypothesis 2s sce cece eee eee eet eet e 18 Hypothesis 3s cece ee ete eee eee eee eo EL Hypothesis 4s see ee ee ee ee ee tee ee 163 Ancillary Predictions sss eee eee ee eee eee eo 165 Self-Generated Coping Strategies «+++ e+e eee + + 168 Miscellaneous Findings. e+ ee ee ee ee ee ee ee 169 iDiacoee toa eer Recs eer) 1) 22 5. SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS 2. + +e + + + 185 Summary Crees 6 oe otete ee sects cele tere ce eel oa 18) Hypothesis Le eee ee ee ee ee te ee ee ee 189 flypothesda:2 «cue } ee en aha te sige gee ee eee 10 Hypothesie 30. eee ee ee ee ete et eee es 190 Hypothesis 4... ee ee ee ee eee ee ee eee IM Ancillary Predictions s+ eee eee ee eee eee ee UL Conclusions. ss ee cee eee er te re wees 192 Recommendations for Future Research - ++ +++ eee ee + 192 REFERENCES 6c 0s ole ce ce net ee eee ee tooo 9 0 196 APPENDIX A. RATIONALE AND DESCRIPTION OF THE EXPERIMENT . . . «+ 212 APPENDIX B. CONSENT FORM se ee ee ee ee eee ee ee eee 2hChapter APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX APPENDIX c D Ee rR G. a it Je K Le Me VERBATIM PRETEST INSTRUCTIONS . . . - SUBJECT DATA SHEET... +--+ + PAIN THERMOMETER 6.2 ee ee ee ee VERBATIM INSTRUCTIONS FOR EACH GROUP . EXPECTANCY-FOR-IMPROVEMENT QUESTIONNAIRE REINFORCEMENT SURVEY SCHEDULE . « IMAGERY RATING FORM see eee ee IMAGES OF HAND INSENSITIVITY 6. es PERSONAL DATA FORM eee ee ee ee VERBATIM POSTTEST INSTRUCTIONS . . - « POST-EXPERIMENTAL QUESTIONNAIRE. « « TABLES ss ee eee et ee eee vidi Page 216 218 220 222 233 235 2ah 247 249 251 253 255185 CHAPTER FIVE Summary, Conclusions, and Recommendations Sunmar; ‘The primary purpose of this study was to investigate the effective- ness of covert positive reinforcement (CPR) in modifying responses to cold-pressor pain and to examine the conceptual model upon which the technique was based. Whereas one published study assessed the effects of CPR in raising pain threshold (Scott & Leonard, 1978), this research focused on pain tolerance and subjective discomfort responses. The secondary purpose of this study was to explore the ability of CPR to facilitate imagery involvement and the conceptual foundations for this effect. Lastly, this study vas intended to examine the relationships of imagery involvement and image clarity to changes in the targeted pain responses over times CPR is a covert conditioning technique in which imagined reinfor- cers (e.g., pleasant images) are self-administered contingent upon imagined adaptive behavior. The technique is grounded on the operant principle that a reinforcing stimulus, presented immediately following a response, will increase the frequency of occurrence of that response. ‘The cold pressor test usually consists of submerging the hand into a container of circulated ice water maintained at 2-3 degrees Centigrade. ‘The procedure is one of several designed to induce moderate levels of pain and has been used in the laboratory studies of pain. A total of 90 subjects from the University of Missouri-Columbia and Stephens College were screened for participation. Only femaleseee i eee 186 between the ages of 18 and 35 with no known history of heart disease, high blood pressure, or disease and/or injury to the left hand were ta~ vited to participate. In addition, only subjects who failed to exceed the 360-second pretest tolerance ceiling were allowed to continue in the experiment. Ten women were excused from the study on the basis of their pretest tolerance times. The remaining 80 subjects were accepted for treatement and randonly assigned to one of, four experimental condi~ tions (covert positive reinforcement, reversed-contingency covert posi- tive reinforcement, covert rehearsal, and expectancy). The mean age of the subjects was 25.3 years (standard deviation = 5e2)e Nine graduate students in the Department of Counseling and Person nel Services were enlisted as co-examiners in this study. They were responsible for the posttest adninistration of the cold pressor test and the Post-Experimental Qustionnaire. They were trained individually prior to the implementation of the study and were kept “blind” as to the group assignment of subjects whom they tested- ‘The experimental conditions were designed to coupare alternate con ceptualizationa of CPR. The CPR treatment consisted of the tdentifica- tion, guided practice, and evaluation of pleasant images for later use as covert peiacoréert (see Cautela, 1970a; Tondo & Cautela, 1974). Three prescribed adaptive images of hand insensitivity were also practiced and evaluated. With the determination of three pleasant images and three adaptive images, subjects were trained to imagine the pleasant scenes contingent upon clear visualization of the adaptive images. At the con~ clusion of training, subjects were instructed to use just the adaptive187 images during the posttest. The reversed-contingency covert positive reinforcement (r-CPR) treatment was identical to CPR except that the two sets of images were combined in reverse sequence (i-e+, adaptive images followed pleasant images). This condition was intended to test the va~ “Mldity of the covert operant paradigm. The covert rehearsal (CR) treat~ ment consisted of the selection of pleasant images although these were not practiced and evaluated. This segment of the procedure along with the subsequent gathering of demographic data served to equate subjects on experimenter contact. The three adaptive images were then practiced and evaluated. Because these images were not combined with pleasant scenes, an equivalent number of additional trials of the adaptive images was practiced. This condition was intended to examine the tmportance of using pleasant images in CPR. The expectancy (&) intervention con- sisted, in part, of identifying pleasant images and in eliciting demo~ graphic data in order to equate the content and duration of experimenter contact. Subjects then listened to a brief audiotaped account of why they would experience less pain during the posttest application of ice water. This condition sought to evaluate the pain modification capacity of expectancy without instructing subjects to employ a particular coping strategy (Scott & Barber, 1977a; Scott & Leonard, 1978). Each subject received the identical pretreatment rationale for the study, consent form, medical screening, and exposure to ice water stimulation. All subjects were administered the cold pressor test and Post-Experimental Questionnarie at posttreatment, were debriefed, and received $5.00 or course credit for their participation. The entire experiment required approximately one hour for each subject188 Pain was conceptualized as a multidimensional constructs The de~ pendent measures were selected to assess two response classes: beha~ vioral and self-report. The behavioral meagure vas operationalized as the length of time that the subject voluntar{ly immersed her left hand tn the dce water. The self-report instrument consisted of the sub- Ject's verbal response to the Pain Thermometer, an LI-point graphic rating ne ————— at pretest and posttest. A third dependent vartable, inagery Lavolve- nent, was assessed by self-report at posttreatement. Imagery involve nent was operationalized as the retrospective estinate of the proportion of coping tine used to imagine the adaptive scenes. Expected tnprovenent in behavioral tolerance was assessed with a single Likert-type item imediately before the treatment administration proper The clarity of the adaptive imagery used during the posttest was measured by the sub- ject's response to a 5-point rating scale. The clarity and/or pleasant ness of the imagery practiced during training was also evaluated on 5+ rola mideth aeadekc AG ee, cancluaign $6:-tnaka pyaidcinatdony, out Jects were invited to record any self-generated strategies used to cope with colé-pressor pain. One hypothesis was formulated to examine the differential effec~ tiveness of the four experimental interventions in aoditying behavioral tolerance and self-rated pain responses. A second hypothesis was gener~ ated to determine the differential inpact of the four conditions in pro~ noting imagery involvement. Both hypotheses were tested using a one-way analysis of variance (treatment) on each dependent measure. A priori189 conparisons were tested with the LSD test. A third and fourth hypothesis were formulated to investigate the. relationships of imagery involvement and image clarity to changes in behavioral tolerance and self-rated pain. ‘These hypotheses were tested with Pearson product-moment correlation com efficients. A number of ancillary predictions, contrasting the compari son groups on the three dependent measures, were tested using t tests for independent samples. AL groups were initially comparable on pre~ treatment measures of behavioral tolerance and self-rated pains ALL groups were also initially comparable on expected Improvement in be~ havioral tolerance with treatment. The +05 alpha level was used as the criterion for statistical significance throughout this investigation. The hypotheses and results of the statistical analyses were as follow: Hypothesis 1. There are no differences in pain modification among subjects receiving CPR, r-CPR, CR, and E was measured by behavioral tol~ erance and self-rated pain indices. Prediction 1: Subjects receiving CPR will- manifest greater increases im behavioral tolerance than subjects receiving E. (Not significant) Prediction 2: Subjects receiving CPR will manifest greater de~ creases in self-rated pain than subjects receiving E. (Not significant) Prediction 3: Subjects receiving CPR will manifest greater increases in behavioral tolerance than subjects receiving r-CPR. (Not significant) Prediction 4: Subjects recetving CPR will manifest greater decreases in self-rated pain than subjects receiving r-CPR. (Not significant) Prediction 5: Subjects receiving CPR will manifest greater increases jin behavioral tolerance than subjects receiving CR. (Not significant)190 prediction 6: Subjects receiving CPR wilt manifest greater decreases TLL”: (Wot significant) Hypothesis 1.was not rejected: Predictions 1-6 were not accepted+ there are no differences in imagery involvement among Hypothesis gubjects receiving CPR, F-CPR, and OR a8 measured by the self-estinated proportion of coping tine during vnich the assigned inagery vas tuagineds prediction 7: Subjects receiving CPR wilt report higher proportions ercopiugit inatinvsived 1m thevanstanad: S=nt 7 during the posttest than gubjects who receive F-CPR. (NOE significant) prediction 8: Subjects receiving CPR will report higher proportions of coping time 1avolved in the assigned nssery during the posttest than subjects who receive OR (Significant) Hypothesis 2 vas not rejecteds Predictions 7 and 8 were not accepted+ Hypothesis 3, There ts no relationship between pain modification as measured by behavioral tolerance and self-rated pain indices and imagery involvenent as measured by the ‘self-estimated proportion of coping tiwe during which the asstgned imagery was imagined+ Prediction 9: Subjects receiving imagery training who manifest greater increases in behavioral tolerance will report higher proportions of coping time involved tn the assigned imagery during the posttest+ (Not significant) prediction 10: Subjects receiving imagery training who manifest greater decreases in self-rated paln will report higher proportions of coping tine involved in the assigned tnagery during the posttest. (Not significant) Hypothesis 3 was not rejected predictions 9 and 10 were not accepted:ceo smtp 191 Hypothesis 4. There is no relationship between pain modification as measured by behavioral tolerance and self-rated pain indices and the clarity of the assigned imagery used during the posttest. Prediction 1l: Subjects receiving imagery training who manifest greater increases in behavioral tolerance will report greater clarity of the {magery used during the posttest. (Significant) Prediction 12: Subjects receiving imagery training who manifest greater decreases in self-rated pain will report greater clarity of the assigned imagery used during the posttest. (Significant) Hypothesis 4 was rejected. Predictions 11 and 12 were accepted. Ancillary predictions Prediction 13: Subjects receiving comparison treatments (r-CPR and CR) will manifest greater increases in behavioral tolerance than subjects receiving E. (Not significant) Prediction 13 was not accepted. Prediction 14: Subjects receiving comparison treatments (r-CPR and CR) will manifest greater decreases in self-rated pain than subjects receiving E. (Significant) Prediction 14 was accepted. Prediction 15: Subjects receiving r-CPR will manifest equal increases in behavioral tolerance to subjects receiving CR. (Not significant) Prediction 15 was not rejected. Prediction 16: Subjects receiving r-CPR will manifest equal decreases in self-rated pain to subjects receiving CR. (Not significant) Prediction 16 was not rejected.192 Prediction 17: Subjects receiving r-CPR will report equal propor~ tions of coping time involved in the assigned imagery during the posttest to subjects who receive CR. (Significant) Prediction 17 was rejected. Conclusions Previous research has shown that covert positive reinforcement is an effective procedure for modifying cold-pressor pain responses (Scott & Leonard, 1978). This study was designed to evaluate the efficacy of covert positive reinforcement relative to competing imagery techniques (reversed-contingency covert positive reinforcement and covert rehearsal) and to an expectancy condition. The results of this research warrant the following conclusions: (1) Covert positive reinforcement is not superior to comparison treatments in modifying cold-pressor-pain responses and in facilitating imagery involvement. (2) The operant contingency arrangenent of the adaptive and rein forcing images is not critical to the ability of covert positive rein- forcement to modify cold-pressor pain responses and to facilitate imagery involvenent. (3) The modification of cold-pressor pain responses 1s not re~ lated to imagery involvement, but is associated with image clarity. Recomendations for Future Research The results of this experiment suggest several approaches for future research. Although the operant conceptualization of covert positive reinforcement ts no longer considered to be useful or valid,193 alternative models have not been investigated. Several models have been proposed which require experimental validation such as conditioned inhibition, response prevention, and self-efficacy. In addition, fur ther research is needed to ascertain the extent to which the pain modi- fication which follows instructions to use a cognitive strategy is due to (a) the success of the strategy per se, (b) the expectation of pain re~ lief implicit in the instruction, and (c) the demand to show pain relief conveyed by the experimenter. In view of the unanticipated increases in the variances of behavioral and self-report pain responses observed within all experimental conditions, future investigations should directly examine that subpopulation which exhibits such response variability. This research should focus on the relationship and role of individual dif- ferences and population characteristics in determining and modifying pain response variability. A growing number of {nvestigators have re~ ported that subjects engage in their own coping strategies. These self- generated coping responses must be classified with effective techniques distinguished from ineffective ones. To what extent do instructions to use a specific coping strategy interfere with more effective spontaneous strategies? Can naturally occurring coping strategies be further refined in order to maximize their efficacy? What personality and situational variables determine which coping strategies are selected and which ones work? Clearly, each of these research questions should be investigated using various forms of experimentally induced pain with greater focus placed on clinical pain. Because experimentally induced pain is not characterized by the affective-motivational component of clinical pain,ie ee nee tie 194 studies in which such artificial stimuli are used lack external validity. ‘Thus, naturalistic research is recommended in which various forms of clinical pain (e.g., arthritis, cancer, childbirth, dental discomfort, headache, etc.) are targeted for practical, realistic research. Methodo~ logically, future research should assess as many pain response domains as possible. Far too many studies have neglected the measurement of various classes of phystological responding. Methods for more accu rately assessing imagery involvenent, image clarity, and other cogni- tions are also needed. Such measurement techniques should intrude minimally upon ongoing covert activity. The validity and reliability of all assessment devices used in the measurement of pain must be guaranteed if research results are to be meaningful. In addition, laboratory and clinical studies of pain must make use of more stringent control procedures, and many more follow-up assessments are needed to determine the long-term impact of pain-control treatments, Finally, single subject research designs (e.g-, ABA and multiple baseline de~ signs) merit more frequent application to the study of pain. With the increased recognition that individual differences are often obscured by traditional group research, single subject designs would further facili~ tate the exploration of these differences along with effective, naturally occurring coping techniques.