Pain, 38 (1989) 123-135 123

Elsevier

PAIN 01438

Clinical Section

Review A rticle
The utility of cognitive coping strategies
for altering pain perception: a meta-analysis

Ephrem Fernandez * and Dennis C. Turk **

* Dept. of Clinical Psychology. Ohio State University, Columbus, OH 43210 (U.S.A.), and * * Pain Evaluation and Treatment Institute,
University of Pittsburgh School of Medicine, Pittsburgh, PA 15123 (U.S.A.)

(Received 28 December 1988, revision received and accepted 16 March 1989)

Summary The literature on the utility of cognitive coping strategies in pain control has been unclear because of 2 principal
limitations: the lack of a validated classification system, and reliance on qualitative and quasi-statistical reviews. In this study, an
empirically based multidimensional taxonomy was employed to categorize the variety of cognitive coping strategies into 6 major
classes: external focus of attention, neutral imaginings, pleasant imaginings, dramatized coping, rhythmic cognitive activity and pain
acknowledging. Meta-analytic techniques were introduced to evaluate the overall efficacy of cognitive strategies (in comparison to
no-treatment controls), the relative efficacy of these strategies (how the different groups of strategies compare with one another), and
the substantive efficacy of such strategies (how cognitive strategies fare against placebo/expectancy conditions). Results revealed
that, in general, cognitive coping strategies are’ more effective in alleviating pain as compared to either no-treatment or expectancy
controls. Each individual class of strategies significantly attenuates pain although the imagery methods are the most effective whereas
pain acknowledging is the least effective. Positive expectancy is no better than no treatment. These findings stand in contrast with
previous reviews that have not assigned prime importance to imagery or for that matter have not shown cognitive strategies to be
particularly effective. Results are discussed with reference to attentional models and methodological issues,

Key words: Cognitive coping strategies; Pain perception; Meta-analysis

Introduction tive events altered may include an individual’s

attentional processes, images and/or self-state-
The use of cognitive coping strategies to in- ments.
fluence the experience of pain has had a long
history [46,86]. The term ‘cognitive’ implies that
these are techniques that covertly influence pain Classification of cognitive coping strategies
through the medium of one’s thoughts, as dis-
tinguished from behavioral techniques that modify Terminological inconsistency
overt behavior or physical intervention. The cogni- A major difficulty in reviewing the literature on
cognitive strategies for control of pain is termino-
logical inconsistency. Several authors have em-
Correspondence to: Ephrem Fernandez, Pain Evaluation
and Treatment Institute, University of Pittsburgh School of
ployed different terms for what are apparently the
Medicine, Baum Boulevard at Craig Street, Pittsburgh, PA same strategies. For example, the strategy of iso-
15213, U.S.A. lating a non-painful feature of a noxious stimulus
0304-3959/89/$03.50 0 1989 Elsevier Science Publishers B.V. (Biomedical Division)
upon which to focus (e.g., focusing on the thermal [X1,X2]. Sub.jects categorized the 30 strategies into
properties of cold pressor pain) has been referred groups, using the method of subjective grouping
to as ‘dissociation’ by Blitz and Dinnerstein [ll], [52]. The data were found to be ordered along 3
‘focused’ attention by Craig et al. [19], and ‘soma- dimensions identified as ‘sensation acknowledg-
tization’ by Rybstein-Blinchik [56]. Similarly, what ing’ (dimension I) characterized at the negative
Jaremko [35] calls ‘rationalization,’ is termed ‘cog- end by an active denial of sensations associated
nitive reappraisal’ by Langer et al. [39]. And, what with pain and at the positive end by an acknowl-
Beers and Karoly [6] label ‘incompatible imagery’ edgement of noxious sensations with a view to
is classed as ‘selective attention’ by Thelen and transforming them, ‘coping relevance’ (dimension
Fry [78] and as a ‘strategy inconsistent with pain’ II) ranging from strategies relevant to the manage-
by Spanos et al. [65]. ment of nociceptive stimulation at the negative
These differences in terminology compound the end to strategies of little coping utility at the
task of integrating findings across studies and positive end, and the ‘cognitive-behavioral’ dimen-
assessing the differential effectiveness of various sion (dimension 111) distinguished at its negative
strategies. Clearly, a standardized classification pole by strategies based on mental fantasy. and at
system for grouping and categorizing cognitive its positive pole by those strategies involving be-
coping strategies is necessary before a systematic havioral activity.
review of the literature can proceed. Subsequently, a cluster analysis was employed
to identify categories of coping strategies and to
A priori tuxonomies fit these within the coordinate space produced by
Several intuitive taxonomies have been devel- the multidimensional scaling. Eight categories of
oped to enable the classification of cognitive cop- coping strategies were identified and these were
ing strategies [15,21,71,83]. Although these serve labeled: (a) pleasant imaginings, (b) rhythmic cog-
as interesting points of departure, they may be nitive activity, (c) external focus of attention, (d)
criticized as being idiosyncratic and hence open to pain acknowledging, (e) dramatized coping, (f)
disagreement [80]. The nomenclature issue may be neutral imaginings, (g) breathing activity, and (h)
more amicably settled by a taxonomy derived behavioral activity. The above findings were repli-
from the perceptions of a number of subjects and cated in a second experiment by Wack and Turk
amenable to replication and cross-validation across [XX exp. 21 in which a new sample of subjects
multiple populations. The perceptions of these made similarity ratings for 120 pairwise compari-
subjects who actually use cognitive strategies must sons of 16 coping strategies randomly sampled as
be pertinent to the classification process. to be representative of the initial list of 250.
For the purposes of this paper, the first 6 of the
An empiricult) derived taxonomy’ above categories were used to group cognitive
Wack and Turk [88] used the statistical ap- strategies (the last 2 categories relating to non-
proach of multidimensional scaling (MDS) to de- cognitive techniques). This is not to suggest that
velop a subject-based taxonomy of cognitive the Wack and Turk [88] taxonomy is the only one
strategies. This approach entails a spatial repre- that could be developed; however, it does serve a
sentation of ‘psychological closeness’ between heuristic function of permitting systematic organi-
stimuli - so that, in this case, cognitive strategies zation of the literature.
would be arranged as points on meaningful di-
mensions, the distance between points reflecting
the degree of perceived similarity between the Previous literature reviews on cognitive strategies
corresponding strategies. influencing pain
In the first of 2 experiments, Wack and Turk
[SS] randomly sampled 30 coping strategies from a Having decided upon an appropriate classifica-
list of over 250 strategies spontaneously used by tion system, the next step is to consider the avail-
subjects in laboratory pain induction experiments able methods for integrating this body of litera-
 125

ture. A variety of descriptive and simple quantita- are omitted [e.g., 62,681. In short, the conclusions
tive approaches have been used to review the of M&au1 and Malott stem from a non-uniform
studies on cognitive strategies influencing pain pool of studies, not to mention the fact that these
perception. These include narrative, summary ta- studies were not always confined to pain but also
ble, ‘box-score,’ rank-ordering, and ‘ vote-count’ embraced research on stress [e.g., 17,181.
methods. This section will briefly outline the re- Taking a quantitative direction, Turk et al. [86]
sults of these approaches. introduced what was called ‘ box-score analyses’
Adopting a narrative approach, Tan 1771 re- (p. 96) for synthesizing diverse findings of the
viewed the available literature on the efficacy of literature in this area. This included features of
cognitive coping strategies for pain in both clinical the ‘vote-count method’ to be described later.
and laboratory contexts. He concluded that the Cognitive strategies labeled according to an a priori
effectiveness of cognitive strategies had yet to be system [83] were compared with one another and,
demonstrated - since only about half the number for each study, the efficacy of any strategy in
of studies had found such strategies to be better relation to another was represented by a set of
than control conditions. Tan also noted that the symbols (> , = , or <) denoting whether the
results regarding the superiority of any particular strategy was more effective, equal to, or less effec-
strategy compared to another were equivocal. tive than another condition. A frequency count of
These conclusions are consistent with an earlier these results showed that 64% of studies unequiv-
review on laboratory pan-induction studies [84]. ocally favored cognitive strategies over control
In considering clinical pain alone, Tan also noted conditions with regard to attenuating pain, whereas
that the efficacy of cognitive strategies was rather 37% unequivocally showed cognitive strategies to
meager. be equal to control groups. A third summary table
McCaul and Malott [45], who also used a nar- of laboratory studies directly comparing one or
rative approach, singled out one class of cognitive more strategies, seemed to indicate some superior-
strategies for review - ‘distraction.’ Studies com- ity of imagery strategies, but an overall lack of
paring distraction techniques with control condi- support for any particular category over any other.
tions or distraction with another group of strate- Consistent with Tan [77], Turk et al. [86] hence
gies labeled ‘sensation redefinition’ were critically concluded: ‘The data . . . do not convincingly estab-
evaluated. The authors concluded that distraction lish the efficacy of any cognitive coping strategy
was more effective than no treatment or placebo relative to the strategies that subjects bring to ex-
controls in coping with noxious stimulation. The periments, nor is there sufficient evidence to support
comparison with placebo controls, however, was the use of any one strategy compared to any other’
based on only one study. The fact that the authors (p. 96, original emphasis).
included studies in which distraction was only one Fernandez [22] grouped all cognitive strategies
component in a package of multiple strategies according to the 6 dasses of cognitive coping
[e.g., 551 is also problematic. Imagery techniques techniques discerned by Wack and Turk [88] and
as well as ‘counting’ and ‘focusing on visual outlined earlier. Every condition within a study
stimuli’ were all subsumed under distraction. On was assigned an ordinal ranking, a numerically
the other hand, distracting procedures such as higher ranking indicating significantly greater ef-
listening to music [47] or pursuit-rotor tracking ficacy and equal rankings indicating no significant
[68] were excluded. Similar criticisms apply to the difference in efficacy. Mean efficacy rankings were
authors’ attempts to compare distraction with then calculated (from multiple investigations) for
‘sensation redefinition.’ Whereas some studies in- each condition. Results of this method (updated
volving this kind of reappraisal are included [e.g., to incorporate studies published since 1986) are
41,441 others reporting on similar comparisons are shown in Table I.
excluded [e.g., 57,691. Inconsistencies also exist In interpreting the above results, a few caveats
with regard to studies employing suggestion, some are in order. First, the DC strategy was based on
of which are reviewed [e.g., 14,401 whereas others only 2 studies. Caution must also be exercised in
126

TABLE 1 based on too few observations. Therefore, the

RESULTS OF RANK-ORDERING APPROACH TO focus will be on the last column of the table which
ASSESSING THE EFFICACY OF COGNITIVE STRATE- lists comparisons between cognitive strategy and
GIES FOR PAIN
no-treatment control. The percentages reported
,Yote: EFA = external focus of attention; Nl = neutral imag- there accord greatest efficacy to the PA group of
inga; DC = dramatized coping; RCA = rhythmic cognitive ac-
strategies and least efficacy to the NI group (in
tivity: PA = pain acknowledging; PI = pleasant imagings; EC
= expectancy control: NTC = no-treatment control.
exact agreement with the rank-ordering method).
Both rank-order and vote-count methods also sug-
Experimental Number of Mean gest that cognitive strategies, in general. are supe-
condition observations efficacy ranking rior to no-treatment controls and to expectancy
EFA 25 1.57 effects in enhancing tolerance for nociceptive
NI 13 1.38 stimulation.
DC‘ 2 2.00 In summary, there are problems associated with
RCA 13 1.54
each of the previous reviews in this area: many are
PA 30 1.67
PI 42 1 .h4 inherent limitations in the methodology employed,
EC 17 1.12 while some are problems introduced in the review
NT< 80 1.04 process. To recount some of these, Tan [77] tends
to be more descriptive than analytic. McCaul and
Malott [45] combine critical evaluation with
interpreting the mean rankings for the remaining summary tables but use inconsistent selection
conditions, since these means were based on un- criteria for studies and do not analyze the data
equal numbers of observations, and also because quantitatively. The first quantitative integration ol
each observation typically related to a different the literature begins with Turk et al.‘s [86]
subset of strategies. Nevertheless, it appears that box-score analysis. Related to the vote-count ap-
EFA and PA were among the more effective proach, this analysis treats frequencies as the basic
strategies whereas RCA and NI were among the dependent measure and overlooks highly informa-
less effective strategies, PI being intermediate in tive data contained within each study. Such a
efficacy. box-score approach does not permit statistical in-
In an attempt to overcome the above-men- ferences to be made regarding any of the issues
tioned limitation of comparisons between differ- under investigation. These same criticisms apply
ent subsets of strategies, a ‘vote-count’ method to the rank-ordering and vote-count methods em-
was used to make more direct comparisons among ployed by Fernandez [22].
various strategies and control conditions. This
method entails the organization of studies into
various categories of outcome, a simple tally count Meta-analysis of cognitive coping strategies
being made of the number of studies falling into
each category, and the modal category then be- In pursuit of more objectivity in the review
coming the ‘winner’ [34,42]. In the present con- process, a group of techniques collectively known
text, the vote-count method entailed counting the as ‘meta-analysis’ was developed [26]. Meta-analy-
number of studies in which a cognitive strategy sis consists of ‘the integration of research through
was significantly more effective than, less effective statistical analysis of the analyses of individual
than, or equal to, another cognitive strategy or studies’ [61, p. 7521. It is an off-shoot of survey
control group. This was done for all possible methodology [49] that incorporates many of the
pairwise comparisons among the 6 classes of cog- standards of current empirical research.
nitive strategies [88] and no-treatment controls. Meta-analysis has gained widespread use re-
The outcome was a 6 X 7 matrix (Table II). cently in a number of diverse areas - for exam-
As can be seen in Table II, the matrix is only ple, headaches [9], coping with aversive situations
partially filled and many of the comparisons are [76], and non-medical treatments for chronic pain
 127

[43]. A thorough discussion of the value of meta-
analysis is beyond the scope of this paper; there-
fore, brief mention will be made of its relevant
features, as part of the rationale for this study.
Meta-analysis reduces the subjectivity that nec-
essarily characterizes narrative reviews. It is also
an advance in statistical sophistication, compared
to other quantitative techniques outlined earlier,
inasmuch as it makes use of the original data in
each study (typically measures of dispersion and
central tendency). Mathematical formulae are used
to convert these into an index of the strength of
relationship (effect size) between the variables un-
der study, Indi~du~ effect sizes can be averaged
across studies to provide a global picture of the
relationship, or else they can be further examined
as a dependent variable moderated by type of
treatment in question, or a host of other method-
ological variables.
Perhaps the most innovative aspect of meta-
TABLE II
analytic applications, as emphasized by Mintz (491,
is that they afford the use of inferential statistics
in a domain where conclusions formerly rested on
opinion, counting, and other simple statistical op-
erations. Using meta-analysis, probabilistic state-
ments may be made and specific hypotheses tested,
about the phenomena under study.
Method
Studies. The population of studies for the
meta-analysis, conducted in this paper, consisted
of all articles on the topic of cognitive strategies
for modifying pain, published between 1960 and
August 1988. Studies in which stress or discomfort
rather than nociception were being investigated
and studies in which a cognitive strategy was
presented in combination with other strategies or
treatments were excluded.
Perusal of Psychology Abstracts and secondary
sources resulted in the identification of 51 perti-

RESULTS OF VOTE-COUNT METHOD OF ASSESSING EFFICACY OF COGNITIVE STRATEGIES FOR PAIN

Note: The symbols > , = , < , refer to ‘significantly better than,’ ‘ not significantly different from,’ and ‘significantly worse than,’
the compared condition, respectively. The rightmost column gives percentage of comparisons, in which treatment was significantly
better than its control counterpart. EFA = external focus of attention; NI = neutral ima~~ngs; DC = dramatized coping; RCA =
rhythmic cognitive activity; PA = pain acknowledging; PI = pleasant imaginings; EC = expectancy control; NTC = no-treatment
control.

EFA NI DC RCA PA PI EC NTC Superior

to NTC

EFA > 3 11
=i 2 1 2 5 10 52%
< 1 1
NI > 1 5
= 2 6 7 42%
< 2 2
DC > 2
z% 100%
<
RCA z 1 1 3 4
= 4 1 I 4 44%
< 1 3 1
PA > 1 2 1 3 17
= 1 2 4 3 2 6 71%
< 3 1
PI > 1 2 3 6 21
= 2 6 1 3 4 20 51%
< 1
EC > 2
X.? 4 1 1 4 9 17%
< 1 3 3 5 1
nent studies that met the inclusion criteria. Of denominator represents a pooled standard devia-
these. 4 were suitable only for the examination of tion for the groups. However, not all research
expectancy effects [8,20,25,66]. leaving a total of reports furnished the necessary information for
47 studies in which one or more cognitive strate- this purpose. Thus. where studies reported dif-
gies had been individually compared with a no- ferences in terms of the I statistic. non-parametric
treatment control group. These studies permitted statistics, exact P values, or where they merely
61 separate observations (analyses). Every cogni- indicated the sample size and whether or not a
tive strategy reported was classified according to mean difference was statistically significant at a
the 6 categories of the Wack and Turk [88] taxon- customary level, special formulae derived by Glass
omy, by referring to the illustrative examples pro- et al. [27] were used to obtain estimates of effect
vided and the guidelines given for positioning size from the particular information provided.
each strategy along the 3 dimensions (i.e.. sensa- Where results were reported in terms of the F
tion acknowledging, coping relevance, and cogni- statistic, or where they pertained to changes within
tive/behavioral). groups over time, the formulae proposed by
Strategies involving a redirection of attention Nicholson and Berman [51] were employed to
away from the site of stimulation. for example, estimate effect size. Finally, when results were
viewing slides of landscapes [7], were classified as reported as non-significant and no other informa-
EFA: strategies involving imagery of neither a tion was supplied, effect size was conservatively
pleasant nor unpleasant quality, for example, the estimated as d = 0 [51]. In 84% of cases. effect
imagined attendance of a lecture by one’s instruc- sizes were calculated from the means and standard
tor [35], were classified as NI: strategies involving deviations reported. To avoid the problem of
a dramatized reconstruction of the context in non-independence of data. multiple (correlated)
which nociception occurs, for example, imagining effect sizes were averaged to yield a single d foi
the pain as arising from an injury sustained during each study within a group.
a football game [39], were classed as DC; strate- The procedures of Rosenthal (551 were adopted
gies involving cognitive activity of a repetitive or to weight each effect size according to the sample
systematized nature, for example, counting back- size of each study and then to derive a weighted
wards from 100 by 3 [6], were classed as RCA: mean effect size for each group of studies. For
strategies involving a reappraisal of the nocicep- each mean, 95% confidence intervals were delin-
tive stimulation in terms of objective sensations, eated. As proposed by Rosenthal, a xL‘ test of
for example. concentration on the sensation of heterogeneity of variance within each set of effect
dullness associated with nociception induced by sizes was computed. Each mean effect size was
cold water [6X] were classed as PA: and finally, compared with 0 using a l-sample t test. while
strategies centering around the use of pleasant pairwise comparisons between means were
imagery, for example imagining oneself sitting in achieved by independent-groups t tests; a-tailed
comfort and listening to music [53], were classed levels of significance were used. Finally, to address
as PI. Two independent judges agreed on the the file-drawer problem that (published) studies
classification of 98% of the strategies. reviewed might represent a biased sample from a
Deriving effect sizes. Each comparison between larger population of studies dominated by non-
cognitive strategy and control condition was ex- significant (unpublished) results, a fail-safe N was
pressed in terms of a standardized mean dif- calculated using a counting procedure proposed
ference or effect size: by Rosenthal [55]: if the obtained statistic
exceeded a value of 5 times the number of studies
reviewed plus 10, the meta-analytic findings could
be regarded as robust.

where d is effect size, M, is mean of the treatment Results

group. MZ is mean of the control group, and the A total of 150 effect sizes was computed. Aver-
 129

TABLE III revealed that more than 85% of the time, cognitive
NEUTRAL IMAGININGS strategies had a positive effect in enhancing pain
tolerance/threshold or attenuating pain ratings as
Study N d compared to no-treatment, there being only 6
Neufeld [50] 4 0.00 cases with negative effect sizes and 3 cases in
Spanos et al. [65] 32 1.99 which effect size was conservatively estimated as
Grimm and Kanfer [30] 24 1.55
0. As Smith and Glass [61] argue, ‘if therapies of
Westcott and Horan [90] 20 0.48
Jaremko [35] 20 0.67
any type were ineffective and design and measure-
Worthington 1911 20 0.28 ment flaws were immaterial, one would expect
Spanos and Brazil [63] 40 0.19 half the effect size measures to be negative’ (p.
Weighted mean d 0.74
755). Effect size ranged from -0.66 to 1.99, with
95% confidence intervals 0.41-1.07 a grand weighted mean of 0.51. This is signifi-
d compared with 0 1 tailed f (6) = 2.61, P < 0.25 cantly different from 0, z = 10.64, P < 0.0001,
Heterogeneity of d’s x2 (6) = 16.10,O.Ol i P i 0.02 and there is a 95% chance that the true mean lies
Fail-safe N 88
between 0.42 and 0.60. The fail-safe N of 1093 is
much greater than the minimal criterion of 315,
making this a robust finding. There is consider-
aging multiple (correlated) effect sizes to yield a able variability, however, among the 61 indepen-
single d per study within a group led to a final
figure of 82 independent effect sizes: of these 61
pertained to comparisons of treatment with no- TABLE IV
treatment controls. The results are presented in
PLEASANT IMAGININGS
Tables III-VII. Each effect size reflects the mag-
nitude of the difference between the (coping Study N d
strategy) treatment condition and the control con- Barber and Hahn [5] 24 0.64
dition, and this becomes the ‘dependent variable’ Blitz and Dinnerstein [ll] 24 0.51
for the meta-analysis. As will be noted from the Strassberg and Klinger [75] 16 0.51
tables, effect sizes range from negative values in Chaves and Barber [14] 30 0.75
Horan and Dellinger [32] 24 0.98
cases where the treatment condition experienced
Spanos et al. [65] 32 1.57
more pain than its control counterpart, through 0 Horan et al. [33] 27 0.44
where no difference in pain was found between Scott and Barber [58] 40 0.36
treatment and control, and positive values where Stone et al. [74] 20 0.47
treatment led to less pain than the no-treatment Westcott and Horan [90] 20 0.63
Jaremko [35] 20 0.85
control. A further point to note is that since the
Worthington [91] 20 0.48
‘dramatized coping’ category contained only one Beers and Karoly (61 38 0.64
study [39], it is not included in the meta-analyses. Avia and Kanfer [3] 39 0.45
The 3 principal purposes of the meta-analysis Rosenbaum [53] 40 0.68
were: first, to determine whether cognitive strate- Thelen and Fry [78] 28 0.43
Worthington and Shumate [92] 24 2.50
gies as a group have an effect on perception of
Clum et al. [16] 60 0.53
pain (the overall efficacy question), second, to Holmes et al. [31] 12 0.44
determine if these strategies are superior to ex- Ladoucer and Carrier [38] 20 0.00
pectancy (placebo) manipulations (the substantive
Weighted mean d 0.64
efficacy question), and third, to ascertain whether 95% confidence intervals 0.47-0.81
there are differences among the various categories d compared,with 0 l-tailed r (19) = 5.93,
of cognitive strategies (the relative efficacy ques- P < 0.0005
tion). Heterogeneity of d’s x2 (19) = 21.77.
0.30 < P < 0.50
Beginning with the first of these questions, a
Fail-safe N 379
meta-analysis of 61 independent investigations
1x1

TABLE V
EXTERNAL FOCUS OF A7TENTION

_~
stuliq N d Study N d
Melzack et al. [47] 24 0.77 Kanfer and Goldfoot [36] - 0.43
Kanfer and Goldfoot [36) 24 0.93 Blitz and Dinnerstein [IO] 1.95
Walker [ES] 4x 0.07 Blitz and Dinnerstein [ll] 0.43
Barber and Cooper [4] 28 0.78 Chuves and Barber [14] 0.75
Kanfer and Seidner [37] 30 0.52 Spanos et al. [62J 0.45
Berger and Kanfer [7] 30 0.x1 sco1t [S7] 0.00
Lavinc et al. 1401 20 0.47 Lcvrnthal et al. [41] 0.67
Stevens [72] 17 1.07 Stam and Spanos 1691 0.29
Stevens and Heide [73] lb 1.39 Spanoa et al. 1681 .- 0.44
Stone et al. [74] 20 -- 0.14 McCaul and Haugvedt 1441 - 0.63
Spanos et al. [6X] 20 .- 0.44 Ahles et al. 121 0.34
McCaul and Haugvedt 1441 35 0.95 Spanos and Brazil 1631 0.79
<;recnstein [29] 36 0.43 Spanox et al. [67] 1.41
Fowier-Kerry and Lander [24] 120 0.38 Stevens [70] 0.79
Spanos et al. [64] -- 0.66
Weighted mean d 0.49
9S%>confidence intervals 0.31-0.6X Weighted mean d 0.34
d compared with 0 l-tailed f(13) = 4.32. 95% confidence intervals 0.16-0.52
P < 0.0005 d compared with 0 l-tailed t (14) = 1.99.
Heterogeneity of d’s xZ (13) =16.X5. 0.025 < P < 0.05
0.20 < f r; 0.30 Heterogeneity of d’s x1 (14) = 43.36.
Fail-aafe N 199 P < 0.001
Fail-safe N 336

dent effect sizes, x2 (60) = 104.53. P c 0.005, to

warrant the question of how effect sizes might be size was highest for ‘neutral imaginings’ (0.74)
related to type of strategy used. followed by ‘pleasant imaginings’ (O&4), ‘external
This question of relative efficacy is answered in focus of attention’ (0.49), ‘rhythmic cognitive ac-
Tables III-VII that summarize results of separate tivity’ (0.44) and lowest for ‘pain acknowledging’
meta-analyses for each of the 5 classes of cognitive (0.34). All means, however, were significantly dif-
strategies. As indicated, the weighted mean effect ferent from 0 at an alpha of 0.05 or less. An
omnibus F test revealed no significant difference
among strategy categories, F (4, 56) = 0.74, P >
TABLE VI 0.25. and t tests of pairwise comparisons between
RHYTHMIC COGNITIVE ACTIVITY means confirmed the absence of any significant
differences among classes of cognitive strategies.
Study N d
For each group of studies, the fail-safe N was high
Barber and Cooper [4] 28 0.39 enough to make sampling bias related to pub-
Horan and Dellinger 1321 24 0.48
lished versus unpublished studies improbable. Sig-
Beers and Karoly [6] 3x 0.52
Ahles et al. (‘2.1 52 0.12
nificant heterogeneity of variance in effect sizes
Spanos et al. [67] 28 1.04 was found only for ‘neutral imaginings’ and ‘pain
acknowledging,’ and because of relatively small
Weighted mean d 0.44
95% confidence intervals 0.14-0.75
n’s in these cases, the idea of exploring further
d compared with 0 l-tailed t (4) = 3.41. relationships between effect sizes and other depen-
0.01 i P i 0.025 dent variables was abandoned.
Heterogeneity of d’s x’ (4) = 3.61, Turning now to the question of substantive
0.30 < P c 0.50
efficacy, a separate body of 12 investigations com-
Fail-safe N 91
paring cognitive strategies with expectancy con-
 131

TABLE VIII for each study to ensure independent data. Results

COGNITIVE STRATEGIES VERSUS EXPECTANCY are summarized in Table VIII. As shown, 83% of
CONTROL the effect sizes were positive. The mean weighted
effect size was 0.35 which is significantly different
Study N d
from 0, t (11) = 2.13, P -c 0.05. The fail-safe N of
Melzack et al. [47] 24 0.85 133 suggests this is a robust effect.
Chaves and Barber [14] 30 0.88
To further explicate the effects of expectancy, a
Grimm and Kanfer [30] 24 1.55
Stone et al. (741 20 0.41 final meta-analysis was carried out on studies
Beers and Karoly [6] 38 0.53 comparing positive expectancy with no-treatment
Thelen and Fry [78] 28 0.14 control conditions. As shown in Table IX, the
Farthing et al. [20] 24 -0.91 mean weighted effect size was 0.03, which does
Gill&an et al. [25] 16 1.04
not depart significantly from 0. The fail-safe N of
Stevens [70] 40 0.54
Berntzen [8] 20 1.37 67 is only slightly above criterion; this is expected,
Fowler-Kerry and Lander [24] 80 0.22 since there is a preponderance of small effect sizes
Spanos et al. [64] 40 - 0.91 raising the possibility of even more non-significant
Weighted mean d 0.35 findings that are unpublished.
95% confidence intervals 0.14-0.56 In comparing cognitive strategies with no-treat-
d compared with 0 l-tailed t (11) = 2.13, ment controls, the meta-analytic results are based
P < 0.05 on the same set of (approximately 2000 subjects
Heterogeneity of d’s x* (11) = 39.45,
distributed across) 46 different published studies
P < 0.005
Fail-safe N 133 that were subjected to the rank-ordering and
vote-count methods. Yet, the outcome differs
markedly. Both the quasi-statistical methods
agreed on ‘pain acknowledging’ as the most effica-
trols was meta-analyzed using the procedures cious strategy and ‘neutral imagining’ as the least
described above. All categories of cognitive coping efficacious. Meta-analysis, however, revealed the
strategies were represented. As in the earlier
opposite. That is, ‘neutral imagining’ was shown to
analyses, a single (averaged) effect size was used
be the most effective whereas ‘pain acknowledg-
ing’ turned out the least effective. All 3 methods,
TABLE IX
however, agreed that ‘expectancy controls’ were
less effective than any of the cognitive strategies,
EXPECTANCY VERSUS NO-TREATMENT CONTROLS
when compared to no-treatment controls.
Study N d

Melzack et al. [47] 24 0.00

Chaves and Barber [14] 30 0.88 Summary and conclusions
Grimm and Kanfer [30] 24 0.00
Stone et al. [74] 20 -0.79 Three questions that have occupied most re-
Beers and Karoly [6] 38 0.07 search reviews in this area are, as stated earlier,
Thelen and Fry [78] 28 0.57
that of the overall efficacy, substantive efficacy,
Spanos et al. [66] 45 -1.18
Fowler-Kerry and Lander [24] 120 0.13
and relative efficacy of cognitive coping strategies
Spanos et al. [64] 40 0.33 in influencing reports of pain. The meta-analytic
aggregation of data from 51 relevant research
Weighted mean d 0.03
95% confidence intervals -0.18-0.24 studies sheds new light on these questions.
d compared with 0 l-tailed t (8) = 0.005, Regarding the overall efficacy issue, 85% of the
P < 0.10 investigations showed cognitive strategies to have
Heterogeneity of d’s x2 (8) = 25.10, a positive effect in enhancing pain tolerance/
P i 0.005
threshold or attenuating pain ratings as compared
Fail-safe N 67
to no-treatment; this greatly exceeds the figure of
I??

50%~reported by Tan [77] or 64% reported by Turk ods. The differences are not attributable to sam-
et al. [86]. The average study meta-analyzed pling variations since the same pool of studies was
showed a 0.51 standard deviation superiority of used in all 3 methods. They are more likely related
cognitive strategy to no-treatment. It should be to the fact that traditional approaches were based
mentioned at this juncture that, in many studies, on the gross outcomes of significance tests. On the
control groups were not prevented from the spon- other hand. meta-analytic procedures utilize more
taneous use of cognitive strategies [e.g., 3.30.321. information in the form of means and standard
This disturbs the comparability between treatment deviations which are synthesized into standardized
and control groups (as pointed out by Barber and indices of the magnitude of difference between
Cooper [4] and discussed by Turk et al. [86]). It conditions.
may be further noted that in some instances. the Interpreting the 3-fold conclusions of this study
insufficiency of data reported in studies necessi- is a speculative exercise. Limited-capacity models
tated conservative estimates of effect size. Both of attention [12.60,79] provide one plausible
these factors would, if anything, have deflated the explanation for the results of the meta-analysis.
derived effect size resulting in some underestima- These models posit that attention is finite in
tion of the utility of cognitive coping strategies. In capacity. and that given competing stimuli. atten-
any case, these findings are much more encourag- tion becomes selective by filtering out (excluding)
ing about the efficacy of cognitive strategies than part of the incoming information. Cognitive cop-
previous reviews have suggested. ing strategies may thus be seen as impinging on
The substantive efficacy question was raised to the amount of attention available for nociception:
determine whether cognitive strategies provide any that is. distraction displaces the processing of
advantage over expectancy (placebo) manipula- nociceptive information. thereby attenuating per-
tions. Meta-analysis of those studies directly com- ceived pain. This reasoning has only recently been
paring cognitive strategies with expectancy control formulated as a major principle governing the
groups found the former to be better by more than effects of cognitive strategies on pain [45].
l/3 of a standard deviation. This is especially The differential efficacy of types of strategies
significant clinically. Furthermore, a separate can also be explained in terms of the same atten-
analysis of studies comparing expectancy groups tional models that point to varying demands on
with no-treatment controls revealed no significant attentional capacity. In other words. imagery
departure of the mean effect size from 0. Clearly, strategies were generally superior to pain acknowl-
cognitive strategies, whether in comparison to no- edging strategies because they produce greater dis-
treatment or positive expectancy alone. reduce traction from pain. Pain acknowledging was
pain significantly. and this effect is a substantive limited in its distraction potential inasmuch as it
one. To our knowledge. this is the first unequiv- requires paying attention to the ‘objective sensa-
ocal demonstration of the utility of cognitive tions’ of the noxious experience. Similarly.
strategies in reducing reports of pain. rhythmic cognitive activity might not have been
As for relative efficacy, each individual class of sufficiently effective possibly because of its repe-
strategies attenuated pain significantly. with no titive and monotonous quality that is not ideal for
significant differences emerging in any of the pair- capturing attention.
wise comparisons between strategies. The imagery The above-mentioned attentional processes may
strategies tended to be most effective. whereas also be accompanied by unique patterns of physic
strategies involving repetitive cognitions or ac- logical activity. Melzack and Wall [46] postulate
knowledgement of sensations associated with pain that attention exerts its modulating effect on pain
were among the least effective. This agrees with by way of descending cortical influences upon a
results obtained from a glassian meta-analysis of ‘gate’ in the dorsal horns of the spinal cord.
much of the same data by Fernandez and Turk Scholars of imagery [e.g.. l] concede that higher
[23], but is almost diametrically opposite to the brain centers are active during imaging and these
findings from vote-count and rank-ordering meth- in turn may exert inhibitory effects on the gate
 133

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