Psychotherapy Research 12(3) 339–354, 2002© 2002 Society for Psychotherapy Research

CHRONIC PAIN PATIENTS: PATTERNS OF CHANGEIN INTERPERSONAL PROBLEMS, PAIN INTENSITY,AND DEPRESSION-ANXIETY

Kirsti MonsenJon T. MonsenUniversity of Oslo

Martin SvartbergNorwegian University of Science and Technology

Odd E. HavikUniversity of Bergen

This work was supported by Norwegian Research Council, Medicine and Health, Grant 120349, Nor-wegian Hydro A/S, and Confederation of the Norwegian Business and Industry.

The authors are indebted to Michael Seltzer for helpful advice on data analysis and to Trine Eklundfor administering the collection of follow-up data.

Correspondence concerning this article should be addressed to Kirsti Monsen, Melkevn.24, 07790,Oslo, Norway. E-mail: jon.monsen@psykologi.uio.no.

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Patients with pain disorder were treated using psychotherapy, with aspecific focus on affect experience and interpersonal problems. Usinghierarchical linear modeling, growth curve analyses were performed toexamine the patterns of change in interpersonal problems, pain intensity,and depression-anxiety according to specific and general change mod-els. A 3-piece linear model was used to analyze the individual rates ofchange during the 1st and 2nd halves of the treatment period and duringfollow-up. The mean rates of change were congruent with the specificchange model in that interpersonal problems decreased significantly dur-ing all 3 phases, whereas pain intensity and depression-anxiety changedsignificantly during the 2nd phase only. Correlational analyses of indi-vidual rates of change indicated that improvement in depression-anxietywas a strong predictor of subsequent improvement in interpersonal prob-lems and a lesser degree of pain, supporting the general change model.

The current study is part of a study of chronic pain disorder. Previous articles havereported the effects of psychotherapy for this group of patients (Monsen & Monsen,2000), and the relationships among psychological factors, bodily conditions, and painintensity have been analyzed and discussed (Monsen & Havik, 2001). In this study,we explore some questions related to patterns of change in psychotherapy.

In the literature, several models of change processes in psychotherapy have beendescribed. Kolden (1996) classified these into general change models and specificchange models according to their levels of generalization. At a generic level, we findmodels describing change processes that are assumed to be common across differ-ent theories of psychotherapy. Frank (1973) and Frank and Frank (1991) suggested

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that all effective treatments comprise two sets of components: those aimed at cor-recting specific pathological processes and those aimed at counteracting the demor-alization associated with specific symptoms or problems. Others also suggested asimilar two-phase model of symptomatic relief, involving a nonspecific phase ofimproved well-being followed by a decline in specific symptoms (Uhlenhuth &Duncan, 1968). This model has been expanded into a three-phase model of psycho-therapy change with a fixed sequence of improvement, starting with subjectivelyexperienced states of well-being facilitating symptom improvement, which in turnfacilitates improvement in different areas of life functioning: family life, interpersonalrelationships, work, and so on (Howard, Lueger, Maling, & Martinovitch, 1993). Thesegeneral change models highlight the importance of improved subjective well-beingand increased hope—what Frank (1973) termed remoralization—as the commonstarting point for all therapeutic change. In Howard et al.’s (1993) phase model,remoralization is followed by remediation focused on resolution of specific symp-toms, life problems, or both followed by rehabilitation emphasizing the unlearningof long-standing, maladaptive patterns. Several studies involving psychodynamictherapy with depressed and anxious outpatients lend general support to the validityof this three-phase model (Howard et al., 1993; Kopta, Howard, Lowry, & Beutler,1994). Others, however, reported parallel reduction of symptoms and interpersonalproblems during the first half of brief dynamic psychotherapies (Horowitz, Rosenberg,Baer, Ureño, & Villasenor, 1988). In addition to the ordered sequence of change, thegeneral change model also assumes that most of the improvement occurs very earlyin treatment (Howard et al., 1993, Kopta et al., 1994). Ilardi and Craighead (1994),after reviewing eight controlled studies of cognitive–behavioral treatment of depres-sion, showed that the major part of the improvement in depressive symptoms oc-curred during the first weeks of treatment. They concluded that there is strong evidencethat “improvement in clinical symptoms, especially depression and anxiety, takesplace in the first weeks of treatment across a broad spectrum of psychotherapeuticapproaches” (p. 140).

Some reservations about the basic assumptions in Howard et al.’s (1993) generalchange model can be voiced. The model has mainly been tested in samples of pa-tients presenting with depression and anxiety as their target problems. Demoraliza-tion on the one side and depression-anxiety on the other share several aspects (Frank& Frank, 1991; Kopta et al., 1994). It is, therefore, possible that rapid initial improve-ment and decline in distress before symptom improvement are more typical for thisgroup of patients than for others. It is thus critical to test the model in patient groupspresenting less psychological distress and symptoms with less manifest psychologi-cal content such as those with pain and somatization problems. Second, the supportin favor of the three-phase model of psychotherapy change is based on the assump-tion that the average severity time course is representative of an individual patient’stime course patterns. Tang and DeRubeis (1999) argued that quite different combi-nations of heterogeneous individual time courses can give the same mean grouptime course. A better approach to exploring patterns of change would, therefore, beto complement mean level analyses with analyses of individual rates of change overtime.

In contrast to the general model of therapeutic change, particular theories ofpsychotherapy describe specific change processes regarding both the interventionsthat promote change as well as the sequences of change. According to the specificmodels, psychotherapy is expected to produce changes congruent with the goals ofthe interventions and the main focus of the treatment. As an example, Socratic dia-

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logue in cognitive therapy should identify and correct automatic dysfunctional atti-tudes, which in turn should lead to a decrease in depressive symptoms (Beck, Rush,Shaw, & Emery, 1979), whereas a focus on negative interpersonal cycles in briefdynamic therapy should give rise to improved interpersonal relationships (Strupp &Binder, 1988). At a more general level, it is assumed that treatments produce resultscongruent with their main focus (Hogdson & Rachman, 1974). In line with this, it ispossible that some of the findings supporting the three-phase model (i.e., Howardet al., 1993, and Kopta et al., 1994) may reflect the possibility that the therapies inthese studies did not have a consistent and common focus because they were notconducted according to one specific therapeutic model. However, studies that haveexamined specific effects derived from specific therapy ingredients have failed toprovide empirical support to the specific change model (Imber et al., 1990; Jacobsonet al., 1996; Wampold, 2001). Most of these studies were based on cognitive thera-pies on patients with depression and anxiety problems, and less is known aboutother therapy models and about patients with other problems.

In the current study, the therapeutic model regards interpersonal conflicts andthemes, both present and past, as important factors in the development and mainte-nance of chronic psychogenic pain and somatization. In a previous study, we foundthat these patients were characterized by an interpersonal style with problems re-lated to being overly nurturant, exploitable, nonassertive, and socially avoidant(Monsen & Havik, 2001). The therapeutic interventions focused mainly on theseinterpersonal themes and conflicts and how the particular interpersonal problemsmanifested themselves in the perception and expression of affect experiences in sig-nificant interpersonal relationships (see Monsen & Monsen, 1999, 2000). The focuswas only indirectly related to specific symptoms (i.e., pain problems), and moregeneral symptoms, such as depression and anxiety, are not granted specific atten-tion. If the impact of the specific therapeutic focus is stronger than the common fac-tors, one would expect that changes in interpersonal problems at a mean group levelprecede improvement in specific pain symptom. The same pattern would be expectedat an individual level of analysis. Because the treatment model did not focus on generalsymptoms of depression and anxiety, one would expect that these symptoms wouldexhibit an even slower change course at both the group and individual levels.

To summarize, according to the general change model, changes in general symp-toms (depression and anxiety) should precede changes in specific symptoms (e.g.,pain intensity) followed by improvement in interpersonal problems both at a grouplevel and at an individual level. In contrast, if the pattern of change is consistentwith the theoretical and technical focus of the treatment, improvement in interper-sonal problems should precede and predict later improvement in pain intensity andgeneral symptoms on both a group level and an individual level.

Because the sample in the current study was relatively homogeneous and thefocus of the specific treatment model was highly consistent, our hypothesis was thatthe patterns of change would follow the specific change model.

Method

Subjects, Setting, and Procedure

Our patients constitute the treatment group in a controlled psychotherapy study(Monsen & Monsen, 2000). The patients were employees in a large Norwegian com-

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pany and recruited from 88 patients who participated anonymously in a pilot studyof associations between musculoskeletal pain and psychosocial factors (Monsen,Eklund & Hals, 1995). These 88 patients were offered to participate in a treatmentstudy free of charge during their working hours. Forty-three patients wished to takepart in the treatment study. Forty patients, 35 women and 5 men, met the inclusioncriteria for the diagnosis of Pain Disorder Associated with Psychological Factors ac-cording to the Diagnostic and Statistical Manual of Mental Disorders (4th edition;DSM-IV; American Psychiatric Association, 1994). This diagnosis is a subtype ofsomatoform disorders in which psychological factors are judged to play a major rolein the onset, severity, exacerbation, or maintenance of the pain. The somatoformmodule of Axis I of the DSM-IV was used to screen all patients before therapy. Thediagnoses were made by the chief physician of the company’s health service on thebasis of patient records and long treatment responsibility for all patients involved.The patients had all been thoroughly physically examined, and no pathophysiologywas found that could explain their pain problems. Psychiatric comorbidity was notsystematically checked on other modules of the DSM-IV, Axis I, or Axis II. However,the chief physician’s thorough knowledge of the patients enabled him to evaluatewhether the pain disorder would be better accounted for by a mood, anxiety, or apsychotic disorder or whether the criteria for dyspareunia were met (see Criterion E,DSM-IV, 1994, p. 461). All patients gave signed informed consent to participate ineither the treatment or the control group.

Before therapy, the 40 patients were matched in 20 pairs according to profilesimilarity of the Minnesota Multiphasic Personality Inventory. Matching was basedon correlations as estimates of profile similarity (mean r = .71, range = .32–.89). These20 pairs were then randomly assigned to the treatment group and control group,respectively. Only data from the treatment group were used in the current study.One patient moved to another part of the country after the 15th session and was notincluded in this study.

The group of treatment completers (N = 19) constituting the sample in this studyranged in age from 29 to 56 years (M = 42.8 years, SD = 8.1), 89% (17) were females,12 patients (63%) were married or cohabitants, and 7 (37%) were divorced or single.Fifty-three percent of the patients had a medium high level of education (13–17 years),and 37% had a high level of education (>17 years). Mean duration of pain complaintsbefore therapy was 12.8 years (SD = 7.4). Their pain problems were mainly locatedin the head, neck, shoulder, and lower part of the back. Patients could have morethan one pain location (M = 2.2). All patients were full-time employees, and 90%had participated in regular physical training during the year before the project started.In sum, the sample was composed of rather well-functioning individuals with amedium-high level of education and a high working capacity despite their long-lastingpain problems.

Psychological characteristics of the sample are presented in Table 1. The treat-ment group’s average global Inventory of Interpersonal Problems (IIP-C) score washigher than for a Norwegian reference sample1 (Monsen & von der Lippe, 1999),and 47% of the patients had a global IIP score higher than 1 standard deviation ofthe reference sample. A specific interpersonal style of being overly nurturant, ex-

1The Norwegian reference sample consisted of 304 individuals (186 women and 118 men) ranging inage from 18 to 68 years (M = 31, SD = 10.9); 151 were married or cohabitants, 13 were divorced, 138were single, 1 was a widow (missing marital status for 1 person). Most of the sample (n = 285) had amedium to high level of education; 135 were students and 150 were full-time employees.

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ploitable, nonassertive, and socially avoidant has been demonstrated to uniquelycontribute to the variation of pain intensity problems (Monsen & Havik, 2001). Themean value of a combined IIP-C index representing these problems was higher forthe treatment group than for the reference sample, and 63% were about 1 standarddeviation above the reference sample.

The treatment group’s average level on the global symptom index (GSI) on theSymptom Checklist-90-Revised (SCL-90-R) was also higher than the reference sample.Forty-seven percent had a GSI score above 1 standard deviation of the normal refer-ence sample, and 42% had a GSI score above 0.97, which is considered a cut-off scorefor severe symptoms (Tingey, Lambert, Burlingame, & Hansen, 1996). In this study, acombined index of the Depression and Anxiety subscales of the SCL-90-R was used asan indicator of general symptoms. We used this because depression and anxiety symp-toms are frequently reported across a wide variety of diagnoses in general psychiatricoutpatient samples as well as in studies of chronic pain patients (Gamsa, 1994). Thecontent of these symptom scales of the SCL-90-R is close to what Frank (1973) termeddemoralization, and they have been empirically grouped and used as indicators of themost acute distress symptoms together with the Somatization subscale (Kopta et al.,1994). Because somatization symptoms are conceptually confounded with pain symp-toms, this scale was not included in the general symptom index used in this study.

Because the distributions for the Anxiety and Depression subscales on the SCL-90-R are quite similar to the GSI (Derogatis, 1992), the cut-off scores for the GSIwere also used to characterize the initial level of the depression-anxiety. Tingey et al.(1996), using multiple normative samples, established three cut-off scores for theGSI: severe/moderate (0.97), moderate/mild (0.51), and mild/asymptomatic (0.23).Two-thirds of the sample in this study was within the severe or moderate level ofdisease on the depression-anxiety index, whereas one-third was in the mild categoryand only 1 patient (5%) was in the asymptomatic range.

Treatment

The treatment approach used in this study, psychodynamic body therapy (PBT),is a variant of the affect consciousness treatment model (ACT; Monsen & Monsen,

TABLE 1. Psychological Characteristics of the PBT Group(N = 19) and a Norwegian Reference Sample (n = 304)

PBT group Reference sample

Variable M SD M SD F p

Global IIP-Ca 1.34 .39 .97 .44 12.80 .0004IIP-C indexb 1.81 .57 1.14 .55 26.54 .0000GSIc .86 .53 .45 .40 18.06 .0000D-A indexd 1.00 .74 .47 .48 20.12 .0000

Note. PBT = psychodynamic body therapy.aMean value of 64 items of the global index of the Inventory of Interpersonal Prob-lems-Circumplex version. bMean value for the index comprising the subscales OverlyNurturant, Exploitable, Non-assertive and Socially Avoidant of the IIP-C. cGlobalsymptom index of the Symptom Checklist-90-R. dMean value for the index com-prising the Depression and Anxiety subscales of the SCL-90-R.

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1999). The ACT is based on an integration of Tomkins’s (1995) affect and script theorywith contemporary self-psychology (see, e.g., Stolorow & Atwood, 1992; Stolorow,Brandchaft, & Atwood, 1987). The theoretical basis and the psychological interven-tions of the ACT have been described elsewhere (Monsen & Monsen, 1999); there-fore, only a brief outline is given here. At a general level, the therapeutic interventionsinvolve a continued exploration of affect experiences related to self and others. Thetherapist systematically tries to read affect information and invites the patient to exploretheir affect experiences and to start the process called personal reflection. The psy-chological interventions during this process are adapted to whether and how thepatients recognize their affects (awareness), allow themselves to be moved by theaffects, and reflect on their content and context of activation (tolerance), withthe goal of being able to use affects as meaningful self-signals. Steady decoding ofaffect information promotes acquisition of interpersonal knowledge and maturation.The process of personal reflection further includes continued exploration of expres-sive manners, aimed at achieving more direct, differentiated, and avowed expres-sions in relation to significant others. It also includes explorations of how long-standingmaladaptive patterns of experiencing or expressing affects are linked to other peopleand to the representations of significant others. Most often this contextualization ofaffects and their maladaptive organizing patterns (scripts) elicit repeated transforma-tions of parental images or the self-image. Through a process of mourning, or disil-lusionment, the patients will gradually tolerate seeing the weaker attributes of theirsignificant attachment figures. The goal of these processes is to facilitate a percep-tion of themselves and others as more demarcated or separate individuals and to beable to represent a wider range of their self-experiences interpersonally.

In addition to the psychological interventions of the ACT, PBT also applies bodilyinterventions based on the Norwegian tradition of psychomotor physiotherapy(Thornquist & Bunkan, 1991). Bodily techniques, such as massage grips and spe-cific exercises, are performed to accelerate the psychotherapeutic process by mak-ing affects more accessible to conscious awareness (Monsen, 1989). The use of bodilyinterventions are indicated when the patient’s affect experience during the processof personal reflection is either absent, remote, or vague or is present only on a cog-nitive level. The amount or dosage of bodily interventions will vary among patientsbased on the therapist’s and patient’s appraisal of the situation. In the current sample,all patients have received bodily techniques to various degrees, but only one patientwith great difficulties in experiencing her own affects received bodily interventionsin every session.

Given that appropriate self-object ties to the therapist are established, the directloosening of muscular stiffness or restricted respiratory patterns may allow the pa-tients to be moved and let affects impact them. Such movements tend to have a vi-talizing effect and most often develop into more direct and clear expressions.

The treatment was conducted by Kirsti Monsen, who is both a clinical psycholo-gist and a physiotherapist. The patients received an average of 33 individual 1-hrsessions (SD = 4.36, range = 30–41) during a period of about 10 months. None of thepatients received medication during treatment and follow-up.

Process and Outcome Measures

Assessments were carried out at intake, at Sessions 15, 21, and 29, at the end oftherapy, and four times during follow-up, constituting a total of nine assessmentoccasions.

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Interpersonal problems. The circumplex version of the IIP (64 items) was usedto measure outcome of interpersonal problems. The IIP-C (Alden, Wiggins, & Pincus,1990) is a subset of Horowitz et al.’s (1988) original 127-item IIP. The 64 self-ratingitems are responded to on a 5-point scale and scored on eight subscales, each witheight items: Domineering (PA), Intrusive (NO), Overly Nurturant (LM), Exploitable(JK), Nonassertive (HI), Socially Avoidant (FG), Cold (DE), and Vindictive (BC). Thesubscales Overly Nurturant, Exploitable, Nonassertive, and Socially Avoidant werecombined into one index with high internal consistency (a = .85).

Pain intensity. On a visual analogue scale (VAS) registering the individual’s sub-jective experience of pain intensity, patients rated their pain intensity, ranging from1 (no pain) to 10 (the most intense pain possible).

Depression and anxiety. The SCL-90-R, a questionnaire assessing the intensityof 90 self-reported common psychological symptoms during the last week on a5-point scale, was used (Derogatis, Rickles & Rock, 1976). Nine subscales can becalculated: Somatization, Obsession, Sensitivity, Depression, Anxiety, Anger, Pho-bia, Paranoia, Psychoticism, along with the GSI, an average score of the 90 items.The subscales of Depression and Anxiety were combined and used as a general symp-tom index (a = .90).

Statistical Analyses

Descriptive statistics were used to report the mean group level on the IIP-C, theVAS pain intensity scale, and the SCL-90-R on the different measurement occasions.The relative amount of change in each phase of treatment was calculated as a per-centage of the total improvement, in line with Ilardi and Craighead (1994).

To estimate individual changes in interpersonal problems, pain intensity, andgeneral symptoms over the course of treatment and the follow-up period, a growthmodeling approach was used. This involved the application of hierarchical linearmodels (HLM; Bryk & Raudenbush, 1987; Svartberg, Seltzer, Choi, & Stiles, 2000).HLMs consist of two models. The within-patient model (Level 1) captures individualrates of change over time as well as initial status on the various measures. This modelenables us to estimate an average rate of change for interpersonal problems, painintensity, and depression-anxiety within the various time periods and to assess theextent to which patients vary in their rates of change in these areas. These estimatesof variability are called variance component estimates. In the between-patient model(Level 2), differences between patients in their rates of change and their initial statuscan be modeled as a function of differences in various patient, therapist, or relation-ship characteristics, thereby providing a means of identifying key correlates of changeand initial status. In this study, only the within-patient model (Level 1) was used.The analyses were conducted using the program HLM/2L, Version 5.01 (Bryk, Rauden-bush, & Congdon, 1996).

We used a three-piece linear model to capture the course of change for a givenpatient during three continuous phases. There were both empirical and conceptualreasons for choosing a three-piece linear model. First, the plots of the individual timeseries revealed an overall nonlinear change pattern, leaving us in practice with twomodel options: a quadratic model and a piecewise model. We decided in favor ofthe latter model because scores on the various nuances tended to drop in a differentmanner as observed over the two phases of therapy. Second, we explicitly wanted

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to study the pattern of change in different phases of therapy. This warranted break-ing up the treatment period into two separate phases, each with a sufficient numberof assessments to allow for growth modeling. The model consisted of the followingthree continuous phases: Phase 1, comprising assessments made pretherapy, afterSession 15, and after Session 21; Phase 2, comprising assessments after Session 21,after Session 29, and after the final therapy session; and Phase 3, comprising assess-ments made after the final therapy session and 6 months, 8 months, 10 months, and14 months after the termination. In this model, the end point of Phase 1 (Session 21)was also the starting point of Phase 2, and the end point of Phase 2 (the final therapysession) was also the starting point of Phase 3. Phase 1 lasted an average of 5.2 months;Phase 2, 4.7 months; and Phase 3, 14 months.

The associations between the slope coefficients representing individual rates ofchange of the IIP-C index, the subjective experiences of pain intensity and anxiety-depression in the three phases were analyzed by product–moment correlations. Thesestatistical analyses were performed by using the Statistical Package for the SocialSciences (SPSS for Windows, version 6.1.3, 1995).

Results

Average Group Changes Based on Raw Scores

Mean scores and standard deviations of the IIP-C index, pain intensity, and thedepression-anxiety index at each measurement occasion are presented in Table 2.Based on the relative amount of change in average raw scores within and over thethree phases, the three outcome measures showed an average change pattern consis-tent with the specific change model described early in this article. The first phaseof treatment was mainly characterized by improvement in interpersonal problemsand, to a lesser degree, pain intensity and depression-anxiety. Half of the total

TABLE 2. Means and Standard Deviations of the IIP-C Index,Pain, and Depression-Anxiety Index on Various MeasurementOccasions (N = 19)

IIP-C indexa Pain D-A indexb

Occasion M SD M SD M SD

Pretherapy 1.75 .56 4.42 2.12 1.00 .74Session 15 1.60 .61 4.05 2.63 .96 .79Session 21 1.32 .75 3.68 2.36 .87 .71Session 29 1.35 .79 3.26 2.26 .78 .70End of therapy 1.21 .67 2.00 1.53 .39 .346-mo follow-up .98 .60 2.74 1.59 .48 .588-mo follow-up .79 .63 2.44 1.76 .39 .4910-mo follow-up .76 .61 2.79 1.81 .36 .4214-mo follow-up .94 .59 2.05 1.31 .33 .30

aMean value for the index comprising the subscales Overly Nurturant, Exploitable,Non-assertive, and Socially Avoidant of the Inventory of Interpersonal Problems-Circumplex version. bMean value for the index comprising the Depression and Anxi-ety subscales of the Symptom Checklist-90-R.

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improvement in interpersonal problems (53%), followed by one third of the total im-provement in pain intensity (31%) and one fifth of the improvement in depression-anxiety (19%), occurred in this phase (Figure 1).

The major part of the total group improvement in pain intensity (71%) anddepression-anxiety (72%) occurred in the second part of the treatment, whereas onlya small part (14%) of the total change in interpersonal problems was reported in thisphase. One third of the improvement in the IIP-C index (33%) occurred duringfollow-up, whereas no further improvement in pain intensity and a just smaller partof the total improvement in depression-anxiety (9%) were observed.

Average Group Changes Based on Individual Ratesof Change (HLM Analyses)2

In accordance with the findings based on the change in the average raw scores,Table 3 reveals that the mean rates of individual change of the IIP-C index werenegative in all phases, indicating declining scores. The average decline was signifi-cantly larger than zero in all phases.

On average, the patients’ scores on the IIP-C index decreased .07 points/monthduring the first phase of therapy, .06 points/month during the second phase of therapy,and .02 points/month during follow-up. Thus, the average patient with a treatmentlength of 33 sessions would be expected to improve by a total of .63 IIP-C indexpoints (.36 points plus .27 points) during therapy and .34 points during the 14 monthsof follow-up.

Consistent with the average group change in raw scores (see Figure 1), the meanrate of change in individual slopes for pain intensity and depression-anxiety was

2The estimates of the individual rate of change correspond to the slope of the individual growth curvefrom the HLM analyses.

FIGURE 1. Percentage of total improvement based on mean values for the raw scoresfrom the Inventory of Interpersonal Problems (IIP) index, pain, and the depression-anxiety index.

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significantly different from zero in the second phase only. One should note, how-ever, that the average rate of individual change in depression-anxiety approachedstatistical significance (p = .11) in Phase 1, and the corresponding effect size was ata medium level.

Correlation Analyses Based on Individual Rates of Change(HLM Analyses)

Correlation analyses of the relationships between measures and between phasesbased on the individual rates of change are shown in Table 4 (see footnote 2). Basedon individual rates of change, initial improvement in the IIP-C index did not predictsubsequent improvement in pain intensity and depression-anxiety. Contrary to whatwe had expected, initial improvement in the IIP-C index was followed by less im-provement in pain intensity and depression-anxiety. However, improvement in theIIP-C index during the latter part of therapy (Phase 2) was associated with improve-ment in pain intensity and depression-anxiety during follow-up. Inspection of thescatter plots showed that improvement in the IIP-C index in Phase 1 was not associ-ated with an increase in pain or depression-anxiety during the subsequent phasesbut rather with less improvement or no change at all.

Based on the individual rates of change, improvement in depression-anxiety,both during the first and second treatment phases, was a very strong predictor oflater improvement in the IIP-C index in the subsequent phases. It is noteworthy thatimprovement in depression-anxiety during the second treatment phase also predictedimprovement during follow-up regardless of outcome criteria. This is consistent withthe predictions from the general change model.

Discussion

In relation to the specific and general models of change, we found that patientson average improved substantially and to a statistically significant degree with re-spect to the IIP-C index during the first phase of therapy, the final phase of therapy,

TABLE 3. Mean Levels of Individual Rates of Change in a Three-PieceLinear Model (N = 19)

Phase 1 Phase 2 Phase 3

Effect Effect EffectMeasure Coefficient (SE) size Coefficient (SE) size Coefficient (SE) size

IIP-Ca –.069** (.022) .60 –.058* (.020) .59 –.024** (.008) .59Painb –.140 (.111) .29 –.276*** (.074) .74 .001 (.029) .01D-Ac –.022 (.015) .37 –.083** (.024) .64 –.011 (.005) .41

Note. Effect sizes are expressed in the r statistic (r > .50 = large; r > .30 = medium).aMean value of the individual rates of change for the index comprising the subscales Overly Nurturant,Exploitable, Non-assertive and Socially Avoidant of the Inventory of Interpersonal Problems-Circumplexversion. bMean score of the individual rates of change for the pain visual analog scale. cMean value ofthe individual rates of change for the index comprising the Depression and Anxiety subscales of theSymptom Checklist-90-R.*p < .05. **p < .01. ***p < .001.

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and the 14-month follow-up period. With respect to pain intensity and depression-anxiety, patients improved on the average significantly, both substantially and statis-tically during the final phase of therapy only. In addition, we found a strong correlationbetween changes in depression-anxiety during the first phase and changes in theIIP-C index during the second phase and follow-up.

The mean level analyses referred to previously speak to the central tendency ofthe sample (i.e., how the average patient in the sample fares with respect to the IIP-C index, pain intensity, and depression-anxiety). Instead of dealing with the averageimprovement of the sample, the correlation findings in Table 4 address the extent towhich, for example, individual rates of changes in depression-anxiety symptoms covarywith and predict later individual changes in the IIP-C index. This finding implies thatthose patients who experienced the largest change in depression-anxiety over thefirst 21 sessions are quite likely to demonstrate the largest changes in their friendly/submissive interpersonal style beyond the 21 sessions.

How do these findings fit with the specific and general models of change? Theresults reported in Table 3 seem to lend support to the specific model of therapeuticchange with reference to both the point in time when the different changes weresupposed to occur and the expected sequence of change. The rapid and steady changein the IIP-C index and slower changes in pain intensity and in depression-anxietyare consistent with the focus of the specific treatment approach. Thus, at a grouplevel, the patterns of change in the current study are in agreement with the specificmodel and in line with findings from Horowitz et al. (1988) and Horowitz, Rosenberg,and Bartholomew (1993), indicating that problems most frequently focused on intherapy improve more readily than others.

There are, however, some reservations and alternative explanations of the find-ings in Table 3. First, the rather long observation phases and infrequent measurementsin the initial phase of treatment preclude the possibilities of detecting an early re-moralization effect, often reported to occur between the first 3 to 12 sessions. The design

TABLE 4. Individual Rates of Change: Correlations BetweenMeasures and Between Phases (N = 19)

Phase 2 Phase 3

IIP-C D-A IIP-C D-APhase index index index Pain index index Pain

Phase 1IIP-Ca — –.84*** –.45 — –.69*** –.59**D-Ab .81*** — .13 .74*** — .28Painc –.21 –.61** — –.21 –.48* —

Phase 2IIP-C — — — — .89*** .50*D-A — — — .84*** — .70***Pain — — — .26 .40 —

Note. IIP-C = Inventory of Interpersonal Problems-Circumplex version; D-A = depres-sion-anxiety.aIndividual rates of change for the index comprising the subscales Overly Nurturant,Exploitable, Non-assertive and Socially Avoidant of the Inventory of InterpersonalProblems-Circumplex version. bIndividual rates of change for the index comprisingDepression and Anxiety subscales of the Symptom Checklist-90-R. cIndividual ratesof change for the pain visual analog scale.*p > .05. **p < .01. ***p < .001.

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of this study, therefore, limited the possibilities of performing a true test of the generalchange model. Nevertheless, a closer inspection of the scores of depression-anxietyshowed that 68% of the sample was unchanged or slightly more symptomatic at Ses-sion 15 compared with pretherapy. One implication of this may be that if a very earlyremoralization and remediation effect actually had occurred (i.e., depression-anxietysymptom decrease) in the current sample without being detected, it must have beencounterbalanced by symptom increase by the 15th session. In our opinion, such a processwould not be consistent with the general change model because sustained remoralizationis assumed to be a necessary condition for later improvement in life functioning, in-cluding interpersonal and personality functioning.

A second alternative explanation of the small initial changes in depression-anxietycould be attributed to low starting values giving a floor effect with little room forpatients to change. However, such an explanation is less likely because significantand large changes were seen in the second phase of treatment.

A third alternative explanation is that certain patient characteristics might haveinfluenced the observed patterns of change. The relatively high level of functioningof the current sample (full-time employed, low level of sick leave, regular physicalactivity) despite the long-lasting pain problems suggests that the patients might havebeen less demoralized at the start of therapy than other general outpatient samples.High motivation and optimistic expectations toward psychotherapy may have mobi-lized the patients’ own resources, enabling them to pass over the remoralization phaseand begin therapy in the remediation phase (Phase 2 in Howard et al.’s three-phasemodel). Another characteristic of the sample that may support this assumption is theirspecific pattern of interpersonal problems. Elevated scores on the “friendly submis-siveness” segment of the IIP-C have earlier been shown to improve most readily(Horowitz et al., 1993). The course of improvement among the patients in this samplemay reflect a real effect of patient characteristics such as high motivation and a friendlysubmissive interpersonal style on their readiness to change, making them start therapyin the remediation phase.

Despite these reservations, the group-level findings from the current study andfrom Horowitz et al. (1988, 1993) suggest possible limitations of the general changemodel, which until now mainly has been tested in large samples characterized bydepression and anxiety and by using treatment models with a less specified focus(Howard et al., 1993; Ilardi & Craighead, 1994). Under such conditions, mean ef-fects of therapies may overestimate the influence of common factors such as thequality of the therapeutic relationship, optimism, and the like and thereby lendtoo strong support to the general model of change. In our opinion, the viability ofthe general model of change rests on being tested in homogenous samples, in whichdifferences in the presented problems and the treatment models used should bemaximized.

On the other hand and contrary to our expectations, the correlation analysesindicated that the individual rates of change in depression-anxiety symptoms consis-tently predicted subsequent individual rates of change in the IIP-C index and thatindividual rates of change in depression-anxiety in Phase 2 also predicted changesduring follow-up. This sequence of change supports Frank’s (1973) and Howard et al.’s(1993) general change models.

Inspections of the plots on which the correlation analyses were based revealedthat all patients had declining rates of change on depression-anxiety in Phase 1 (i.e.,showing some improvement). The variation in individual rates of change in depres-

PATTERNS OF CHANGE IN CHRONIC PAIN PATIENTS 351

sion-anxiety in Phase 1, however, was moderate (SD = .015), and the rates of changewere also small to moderate and within the rather tight range of –.01 to –.04. It issurprising that such a moderate variation in individual rates of change in depression-anxiety in Phase 1 should be a very strong predictor of changes in the IIP-C index inPhases 2 and 3. One may speculate whether a relatively small change in depression-anxiety may be experienced as vital signals of improvement that, in turn, increasemotivation and optimism and further encourage the patient to a more active partici-pation in the treatment process, in line with the predictions from the general modelof change.

The small sample size and certain characteristics of the sample restrict the exter-nal validity of the findings. One concern relates to the question of whether a samplesize of 19 yields enough power to detect differences between change and no changewhen in reality such differences exist. On the basis of power calculations (Cohen,1988) and the fact that we used a repeated measures design (Maxwell, 1998), thepower to detect large differences was acceptable.3 Not only are small samples typi-cally associated with lowered power and increased likelihood of Type II errors, butthey also produce relatively large standard errors when parameters (e.g., rates ofchange) are estimated. Consequently, as the confidence band tends to widen, theless certain can we be that the findings are true findings and not merely a reflectionof error or noise. Thus, generalizability of the current findings, based as they are ona small sample, may be lowered. Another limitation is that adherence to the treat-ment model was not empirically controlled. Because only one therapist conductedall treatments, possible therapist effects cannot be excluded. Bearing these reserva-tions in mind, the findings of the current study should be considered with caution,and replication in larger samples of patients is clearly necessary because this willproduce more precise estimates of the change rates.

Conclusions

Depending on the level of analyses, the findings from the current study lead toquite different conclusions. At a group level of analyses the specific change model issupported, whereas at an individual level of analysis the general change model issupported. These inconsistent findings may be related to the small sample size andthe restrictions mentioned previously. However, following Tang and DeRubeis’s (1999)suggestion, the results emphasize the necessity of including both levels of analysesin future research on models of change in psychotherapy.

3Under the assumptions of a one-tailed t test with p = .05 (i.e., a two-tailed with p = .10) and a sampleof 19, the power to detect a large difference (i.e., r > .50 or Cohen’s d > .80) was 78% (Cohen, 1988).That is, with such power four of five differences of this size would be detected with our sample. Inreality, power is even stronger in that the use of repeated measures designs tends to increase powerfurther (Maxwell, 1998). Additionally, power to detect differences of moderate size was found to be45%, which is considered unacceptably low. In the current study, it is reasonable to expect large differ-ences because the null hypothesis is one of no treatment effects, and the general outcome literatureclearly shows that psychotherapy overall effects sizable changes in patients. In comparative group designs,however, it would, based on the literature, have made more sense to expect differences of moderate orsmall size.

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ZusammenfassungPatienten mit Schmerzsymptomen wurden mit Psychotherapie behandelt, wobei der Behandlungs-schwerpunkt auf affektiven Erfahrungen und interpersonellen Problemen lag. Mit Hilfe von hierarchischenlinearen Modellen wurden Wachstumskurvenanalysen durchgeführt, um Veränderungsmuster bei inter-personellen Problemen, Schmerzintensität, und Depression/Angst im Hinblick auf die Tragfähigkeit einesspezifischen und allgemeinen Modells der Veränderung zu untersuchen. Es wurde ein 3-stufiges linearesModell benutzt, um individuelle Veränderungsraten während der ersten und der zweiten Hälfte derBehandlung, sowie in der Zeit danach, zu analysieren. Mit der Abnahme interpersoneller Probleme währendaller 3 Phasen zeigte sich eine Übereinstimmung der durchschnittlichen Veränderungsraten mit demspezifischen Veränderungsmodell, während Schmerzintensität und Depression/Angst sich nur währendder zweiten Phase signifikant veränderten. Korrelationsanalysen individueller Veränderungsraten deutetendarauf hin, dass die Verbesserung von Depressions-/Angstsymptomen ein guter Prädiktor für die nachfol-gende Verbesserung bei interpersonellen Problemen und die Abnahme von Schmerz war, was alsUnterstützung für das allgemeine Veränderungsmodell zu werten ist.

RésuméDes patients à douleur chronique ont été traités par des psychothérapies ayant comme focus spécifiquesl’expérience affective et les problèmes interpersonnels. A l’aide du modèle hiérarchique linéaire, desanalyses de courbes de croissance étaient appliquées pour identifier des patterns de changementconcernant les problèmes interpersonnels, l’intensité de la douleur, et la dépression/ l’anxiété en fonctiond’un modèle de changement spécifique et général. Un modèle linéaire en 3 pièces était utilisé pouranalyser les taux de changement individuels au cours de la première et deuxième moitié du traitementet de la catamnèse. Les taux de changement moyens étaient congruents avec le modèle de changementspécifique, les problèmes interpersonnels ayant diminué de façon significative au cours des 3 phases,alors que l’intensité de la douleur et la dépression/l’anxiété changeaient uniquement dans la 2e phase.Des analyses de corrélation des taux individuels de changement indiqaient que l’amélioration de ladépression/l’anxiété prédisait de façon robuste d’un changement consécutif des problèmes inter-personnels et, à un moindre degré, de la douleur, ce qui soutient le modèle de changement général.

ResumenSe trataron pacientes con desorden debido a dolor por medio de psicoterapia focalizada específicamenteen la experiencia afectiva y en problemas interpersonales. Usando una modelización jerárquica lineal,se efectuaron análisis de las curvas de crecimiento para ver los patrones de cambio en problemasinterpersonales, intensidad del dolor y depresión/ansiedad de acuerdo con un modelo de cambio gen-eral y específico. Se utilizó un modelo lineal de 3 fases para analizar las tasas individuales de cambio

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tanto durante la primera y la segunda mitad del tratamiento como durante el seguimiento. Las mediasde las tasas de cambio fueron congruentes con el modelo de cambio específico ya que los problemasinterpersonales disminuyeron significativamente durante las tres fases, mientras que la intensidad deldolor y la relación depresión/ansiedad cambiaron significativamente solo durante la segunda fase. Losanálisis de correlación de tasas de cambio individuales indican que la mejoría en la relación depresión/ansiedad fue un fuerte predictor de la mejoría subsiguiente en problemas interpersonales y algo másdébil del dolor, lo cual apoya el modelo general de cambio.

ResumoPacientes com perturbação de dor foram tratados usando psicoterapia, com um foco específico nasexperiências afectivas e problemas interpessoais. Usando um modelo hierárquico linear, foram realizadasanálises de curvas de crescimento para examinar os padrões de mudança em problemas interpessoais,intensidade da dor, e depressão/ansiedade de acordo com um modelo de mudança específica e geral.Um modelo linear de 3 partes foi usado para analisar os índices individuais de mudança durante a 1ªe 2ª metades do período de tratamento e durante o seguimento (follow-up). Os índices médios demudança foram congruentes com o modelo de mudança específica no qual os problemas interpessoaisdecresceram significativamente durante todas as três fases, enquanto a intensidade da dor e a depressão/ansiedade alteram-se significativamente apenas durante a 2ª fase. As análises correlacionais dos índicesindividuais de mudança indicaram que as melhorias na depressão/ansiedade eram um forte preditorde melhorias subsequentes nos problemas interpessoais e um menor nível de dor, suportando o modelode mudança geral.

SommarioPazienti con disturbi dolorosi sono stati trattati utilizzando la psicoterapia con un’attenzione specificasull’esperienza affettiva e i problemi interpersonali. Utilizzando una modellazione gerarchica lineare,sono state effettuate analisi della curva di crescita per esaminare degli schemi di cambiamento neiproblemi interpersonali, nell’intensità del dolore e nella depressione/ansia secondo un modello dicambiamento specifico e uno generale. Per analizzare i singoli indici di cambiamento nella 1ª e 2ª partedel periodo di trattamento e durante gli incontri successivi di verifica si è usato un modello linearetripartito. Gli indici medi di cambiamento sono stati congruenti con lo specifico modello di cambiamentoin quanto i problemi interpersonali sono diminuiti in maniera significativa durante tutte e e 3 le fasi,mentre l’intensità del dolore e la depressione/ansia hanno presentato modifiche soltanto durante la 2ªfase. Analisi correlazionali dei singoli indici di cambiamento hanno indicato che il miglioramento nelladepressione/ansia rappresenta un significativo indicatore del successivo miglioramento nell’ambito deiproblemi interpersonali e del grado più basso di dolore, sostenendo così il modello generale dicambiamento.

Received February 23, 2001Revision received December 11, 2001

Accepted February 14, 2002