goal specification in cognitive-behavioral therapy for chronic headache pain

BEHAVIOR THERAPY 24, 305-320, 1993

Goal Specification in Cognitive-Behavioral Therapy for Chronic Headache Pain

L. DENISE JAMES

BEVERLY E. THORN

University of Alabama

DAVID A. WILLIAMS

Georgetown University Medical Center

Setting goals for coping that are based on time enhances subjects' ability to withstand painful stimuli in laboratory analog studies. This study sought to deter- mine whether explicit time goals for using coping strategies would enhance treatment outcome in a clinical population. Subjects were 33 patients with chronic headache assigned to one of three 6-week groups: a goal group, given specific time goals for using coping strategies; an open group, given instructions to use strategies for as long as possible; and a waiting-list control group. Both treatment groups showed greater use of pain coping skills at posttreatment than the control group. Subjects with time goals reported lower headache activity and reported reductions in nonnarcotic medication use, whereas the control and open groups did not. The study suggests that goal specification can enhance the general efficacy of cognitive-behavioral therapy for treatment of chronic headache pain.

Cognitive-behavioral therapy (CBT) has been shown to be an effective treatment for chronic pain (Turk, Meichenbaum, & Genest, 1983). However, the mechanism of effect is not clear, nor is it understood why it works better for some patients than for others. Response patterns vary among individuals within a given program and across programs with ostensibly similar treatment pro- tocols (Malone, Strube, & Scogin, 1988). This suggests that there may be in- dividuai differences among patients that have not been explicitly defined, or that there may be treatment parameters within CBT that have not been syste- matically manipulated to maximize treatment outcome. The present study at-

The authors would like to acknowledge the assistance of Ms. Nicki Burst in the management of the dataset, Dr. Bill Chaplin for statistical consultation, and the contributions of the graduate student therapists Dr. Lorne Dann, Jennifer Wilson, David Nowell, and Anita Cates. Correspon- dence concerning this article should be addressed to David A. Williams, Ph.D., Department of Psychiatry, Georgetown University Medical Center, 3750 Reservoir Rd., N.W., Washington, DC 20007.

305 0005-7894/93/0305-032051.00/0 Copyright 1993 by Association for Advancement of Behavior Therapy

All rights of reproduction in any form reserved.

3 0 6 JAMES ET AL.

tempts to refine cognitive-behavioral treatment for headaches through examination of a single treatment parameter, the setting of time-based goals for use of coping strategies.

Historically, investigations of CBT outcome variability have focused on empirical identification of patient subgroups with similar responses to treatment. Predictors have included age, gender, and prior addiction to analgesics (Dia- mond, Medina, Diamond-Falk, & DeVeno, 1979); MMPI profiles (Werder, Sar- gent, & Coynes, 1981; Blanchard et al., 1982); duration of pain episodes (Bakal, Demjen, & Kaganov, 1981; Thorn, Williams, & Johnson, 1986); patient pain beliefs (Williams & Thorn, 1989); and coping strategies (Keefe, Caldwell, Wil- liams, Gil, Mitchell, Robertson, Martinez, Nunley, Beckham, Crisson, & Helms, 1990). Measures, such as the West Haven-Yale Multidimensional Pain Inven- tory (WHYMPI; Kerns, Turk, & Rudy, 1985), have been designed to provide comprehensive assessment of pain patients and should further our under- standing of how individual differences among pain patients influence treatment outcome (Turk & Rudy, 1990).

Variability in treatment outcome may also be due to differences in specific treatment parameters such as length and frequency of treatment, amount of therapist contact, relative emphasis on stress reduction versus pain coping skills, techniques used to teach skills, and instructions for use of coping strategies.

Mitchell and White (1977) were among the first to examine the role of various treatment components in CBT for headache pain; subjects asked to record pain or monitor stressors showed no change in frequency of headaches, whereas those given relaxation training or relaxation plus coping skills training had reductions in headache frequency of 55 and 83%, respectively. Holroyd and Andrasik (1978) compared the relative benefits of coping skills training, coping skills plus relaxation training, and insight-oriented therapy. All groups were taught to self-monitor dysfunctional thoughts and headache pain, and all groups showed significant improvement. Holroyd and Andrasik (1978) suggested that it may not be the specific skills that are taught, but rather training to increase awareness of maladaptive thoughts that contributes to a favorable outcome. With regard to how the skills are taught, investigations of the relative efficacy of biofeedback versus relaxation training suggest that both techniques are effective in teaching the relaxation response (Holroyd & Andrasik, 1982). Likewise, Attanasio, Andrasik, and Blanchard (1987) were unable to document a significant effect of therapist contact time on headache activity or medication intake following home- and office-based CBT for tension headache pain.

Although the technique used to teach coping skills may not be critical to outcome, several recent observations suggest that the instructions given to patients about use of coping skills may make a difference in response to therapy. For example, Edelson and Fitzpatrick (1983) compared cognitive strategy training with and without hypnotic induction; only subjects treated without induction showed significant improvements in pain and activity at posttreatment. Dolce, Crocker, Moletteire, and Doleys (1986) found that quotas for exercise resulted in systematic increases in exercise and self-efficacy for a mixed group of chronic pain patients. As the authors note, quotas may work "as

COALS, COPIUO, AND mskoAcI-mS 307

a desensitization process rather than as a strict reinforcement paradigm" (p. 371). If so, the act of setting and achieving goals may be sufficient for adopting more favorable health behaviors. This is suggested in the results of a related study. Williams and Steig (1987) examined the effects of goal setting for drug use, family interactions, household chores, recreation, and sexual activity in a group of chronic pain patients. Goal-setting was a significant predictor of treatment outcome, accounting for almost one fourth of total improvement following treatment.

Laboratory analog studies suggest that goal setting may also influence perception and tolerance to aversive stimulation. Stevenson, Kanfer, and Higgins (1984) reported that subjects given a time-based goal for tolerance of the cold- pressor task were able to withstand the pain longer than subjects not given a goal. Likewise, Dolce, Doleys, Raczynski, Lossie, Poole, and Smith (1986) showed that a quota for doubling baseline cold-pressor time led to increased endurance. Williams and Thorn (1986) extended these findings in a study designed to examine the effects of cognitive strategy training and instructional set on pain perception and tolerance in the cold-pressor task. Subjects were told to endure the pain for a fixed period of time (fixed-time group) or for as long as possible (open-ended group) in a baseline cold-pressor trial. Each group was then subdivided to receive either cognitive strategy training or no training prior to a second trial with the same instructions to cope for a fixed or indefinite period of time. Subjects in the open-ended groups responded to cognitive strategy training with increased tolerance but no change in pain rating. In contrast, subjects in the fixed-time groups showed longer baseline tolerance and decreased pain ratings following cognitive strategy training. Cogni- tive strategy training merely brought subjects in the open-ended groups up to the level of tolerance of untrained subjects in the fixed-time groups. Similar findings were subsequently reported using an ischemic pain-induction technique (Thorn & Williams, 1989).

Goal setting has traditionally been considered an integral part of behavior therapy. However, the specificity of goals provided for use of coping strategies varies among treatment programs. Despite converging evidence that specific goals for coping enhance treatment outcome, there have been no controlled trials of goal setting with use of cognitive-behavioral strategies in a chronic pain population. The present study provides a comparison of treatment outcome for patients with chronic headache pain who were given explicit goals for use of coping strategies (goal group) or instructions to use strategies for as long as possible (open group).

Method Subjects

Subjects were 33 patients who met criteria for diagnosis of migraine or tension-type headache as per the Headache Classification Committee of the International Headache Society (1988). Subjects were recruited through local media announcements and physician referrals. To be accepted into the study

308 JAMES ET AL

subjects needed to be at least 18 years of age and without evidence of major psychotic or affective disorders. All subjects had a medical evaluation and obtained permission for participation from their personal physicians prior to beginning therapy. Of the 139 individuals screened, 60 were seen for a clinical interview. Nine subjects elected not to participate, and three failed to meet diagnostic criteria. Forty-eight subjects attended the initial orientation session; 13 were lost to follow-up. Two additional subjects were identified as sample outliers and were subsequently dropped from analysis. Starting with the 48 who attended the initial orientation session, this resulted in a loss of 4 out of 11 control subjects, 5 out of 18 goal subjects, and 6 out of 19 open-group subjects. Reasons for loss to follow-up included unanticipated scheduling conflicts, family illness, group anxiety, other medical problems, relocation, and loss of interest. The pattern of loss appeared random and unrelated to group assignment, with the exception of the 2 control-group subjects who reported loss of interest as a reason for withdrawal from the study.

The sample on which analyses were performed (n = 33) were all Caucasian and included 5 males and 28 females with a mean age of 38.9 years (SD = 10.6 yrs). Nineteen of the patients were married, 9 were single, and 5 were divorced. Twenty-five were employed; 3 were students; and 5 were either un- employed, retired, or disabled. The mean years of education for the sample was 14.4 (SD = 2.0 yrs). The mean pain duration for the sample was 219 months (18 years, SD = 141 months). Eighteen subjects were diagnosed with mixed tension-type/migraine headaches, 9 with migraine headaches, and 6 with tension-type headaches. There were no evident differences in the distribution of headache type or gender among groups, ;~2 (4) = 4.27, p = .37; Z2 (2) = .005, p = .997).

Dependent Measures

Two types of dependent measures were used: measures derived from daily self-monitoring during three weeks pre- and posttreatment, and measures from self-report questionnaires administered immediately before and after treatment.

Self-monitoring measures were computed from a modified version of the headache diary (Blanchard & Andrasik, 1985). The diary included a recording of headache intensity (0-5 scale) four times daily. The headache diary is a reliable instrument for measurement of migraine and tension headache over time (r = .86 and r = .92, respectively) (Blanchard & Schwartz, 1988). It has also been shown to correlate with other measures of headache activity (e.g., peak headache intensity, headache-free days) (Blanchard & Andrasik, 1985) and with reports of change in headaches by a significant other (Blanchard, Andrasik, Neff, Jurish, & O'Keefe, 1981). The Pain Index was calculated as the sum of all ratings for the week divided by the number of ratings made during the week. Medications were categorized into 6 types of drugs as per the methodology of Karoly and Jensen (1987): nonnarcotic analgesics (including anti-inflammatory drugs), narcotic analgesics, muscle relaxants, anxiolytics, antidepressants, and sedative-hypnotics. The summary measure was per- cent of the maximum recommended intake of medications in each category. Downtime was derived from the daily self-rating of time spent in a supine

COALS, COPING, AND HEADACHES 309

position due to pain, excluding regular sleep time. Summary scores represented the average daily downtime for the 3-week pre- and posttreatment periods. Coping time was derived from the daily self-rating of time spent in active use of session-trained coping behaviors. Subjects were asked to specify separately the time used for practice, time used for coping with stressors, and time used for coping with pain. Two measures were calculated: (a) average daily time practicing and using strategies to cope with stressors, and (b) average daily time spent coping with pain. Pain behavior was measured using the Pain Be- havior Questionnaire (PBQ; Appelbaum, Radnitz, Blanchard, & Prins, 1988). The PBQ is a self-report measure of pain behavior in which patients are asked to record on a daily basis whether they engaged in each of 19 behaviors during periods of headache pain. A weekly average was computed for each of 4 subscales; verbal complaints, nonverbal complaints, avoidance behaviors, and medication intake.

Pre- and posttreatment assessment included 6 additional measures. Self- efficacy for prevention of pain was assessed using a 5-point rating scale on which subjects indicated how confident they were that they could prevent a headache in any of 29 stressful situations (Holroyd et al., 1984). The summary score was derived by summing all 29 ratings. Psychological distress was assessed using the Symptom Checklist 90 revised (SCL-90-R; Derogatis, 1977). The SCL-90-R is a self-administered questionnaire composed of 90 items that assesses psychological distress across 9 dimensions: (1) somatization, (2) ob- sessive-compulsive symptoms, (3) interpersonal sensitivity, (4) depression, (5) anxiety, (6) hostility, (7) phobic anxiety, (8) paranoid ideation, and (9) psy- choticism. Each item is rated along a 0-4 point scale indicating the degree to which the individual has been distressed by the symptom in the past week. A composite score labeled the Global Severity Index (GSI) was obtained based on the responses to all 90 items. Disability was measured using the Sickness Impact Profile (SIP, Bergner, Bobbit, Carter, & Gibson, 1981). The SIP con- tains 136 items describing limitations in self-care, work, and leisure behaviors associated with poor health. This instrument yields a summary measure identified as the SIP score. Depression was measured using the Beck Depres- sion Inventory (BDI; Beck, Rush, Shaw, & Emery, 1979). The BDI is a 21-item self-report measure of depressive symptomatology. A total score is derived by summing the responses to all items. Anxiety was measured using the State Trait Anxiety Inventory (STAI; Spielberger, 1983). Using a 4-point scale, subjects were asked to respond to 20 items describing how they felt at that mo- ment (state anxiety) and to 20 items describing how they generally feel (trait anxiety). The summary scores for state and trait anxiety were derived by summing endorsements for each scale. Adaptive coping was assessed using the Cognitive Coping Index (CCI) of the Cognitive Coping Strategies Inventory (CCSI, Butler, Damarin, Beaulieu, Schwebel, & Thorn, 1989). The CCSI is a 70-item list of behaviors used to cope with pain. Subjects were asked to indicate on a 5-point scale (ranging from "never" to "all of the time") how often they used each strategy to cope with pain. Items were grouped into the following subscales: imaginative inattention, imaginative transformation/con- text, imaginative transformation/sensation, attention diversion/external, at-

310 J ~ s Er At .

tention diversion/internal, somatization, and catastrophizing. The CCI was calculated as the sum of scores for the first 6 subscales minus the sum of scores for the catastrophizing subscale.

Clinical significance. As recommended by Blanchard and Schwartz (1988), ratings from pre- and posttreatment headache diaries were used to assess the clinical significance of treatment effects. This is a more conservative approach than use of global self-ratings, which may overestimate treatment effects (Cahn & Cram, 1980; Blanchard et al., 1981). A reduction of 50°70 or more in the headache pain index was considered to represent clinically significant improvement.

Procedures Three separate recruitment efforts were made over an 18-month period. Each

set of eligible volunteers was scheduled for a group orientation, during which the basic principles of cognitive-behavioral therapy were reviewed. Subjects were instructed to begin recording headache activity, medication intake, downtime, and pain behavior in a weekly headache diary.

Headache diaries were returned to the clinic on a weekly basis and were kept for a total of 3 weeks prior to completion of the pretreatment assessment battery. Subjects were randomly assigned to one of 3 groups: One was provided explicit time-limited goals for use of coping strategies (goal group); a second was given instructions to use coping strategies as much as possible for as long as possible (open group); and a third served as a delayed treatment control group. 1 Subjects assigned to the control group were instructed to continue to keep records over the next 6 weeks, returning them to the clinic on a weekly basis. Subjects assigned to the goal or open groups began treatment immediately and continued to keep records throughout the 6-week program. All subjects (including controls) then returned to the clinic to complete the posttreatment assessment battery and continued to keep records for 3 additional weeks.

Diagnostic interviewers and therapists were graduate students in clinical psychology. They were trained and supervised by a licensed clinical psychologist with experience in cognitive-behavioral therapy for pain management. Ther- apists were aware of differences in the instructional sets for groups but were not informed of the experimental hypotheses. To avoid potential confounding effects of differential therapist skill levels, goal and open treatment sessions within the recruitment set were conducted by the same therapists. All sessions were audiotaped and rated for fidelity to both the basic cognitive-behavioral treatment protocol and the prescribed instructional set (independent variable) by one of the authors (BET) using an expanded version of the Cognitive Therapy Rating Scale (Young & Beck, 1980). Because only one individual made these ratings, no reliability data are available.

' Subjects in the second and third recruitments were first blocked by headache diagnosis then randomly assigned within blocks to one of the groups. All subjects in the third recruitment were assigned to either goal or open conditions. Several individuals requested that they be assigned to different groups because of a preexisting relationship with other group members or a conflict with their work schedule.

GOALS, COPING, AND HEADACHES 311

Treatment General aspects. The cognitive-behavioral training strategy used for all groups

consisted of six weekly 90-minute sessions (Thorn, 1988). Each session was divided into three segments. The first segment was devoted to a review and discussion of pain activity recorded for the prior week. Following this, didactic information was provided. Topics included discussion of the nature of chronic headache pain and the gate control theory, the role of stressors in the pain response, coping versus catastrophizing, developing and using appropriate images and self talk, and maintaining and generalizing skills to other settings. The last 30 minutes of each session were used to teach the relaxation response. The series began with passive muscle relaxation. Subsequent sessions included imagery techniques, autogenic relaxation, and deepening strategies combined with cognitive restructuring of sensory experiences.

All sessions followed the guidelines of a treatment manual (Thorn, 1988) 2. Two versions of this manual were prepared. One highlighted instructions to be delivered to the goal groups, and the other provided instructions for the open groups. With the exception of instructions for use of coping strategies, the manuals were identical. All subjects were fully debriefed after completion of posttreatment assessments.

Operationalization of the independent variable. The treatment variable of interest, goal specificity, was operationalized as follows: At each treatment session the goal group received oral and written instructions to (a) practice coping strategies for a period of 20 minutes per day; (b) take three 10-minute breaks each day to use strategies for coping with daily stressors; and (c) use strategies for a period of 30 minutes when they experience pain. At each treatment session subjects in the open group were given oral and written instructions to (a) practice strategies as much and as often as possible; (b) use strategies as much as possible to cope with daily stressors; and (c) use the session-trained coping behaviors for as long as possible when they experience pain. Subjects in the delayed treatment groups were given no instructions for coping, but were asked to continue to record headache activity, pain behavior, medication intake, and downtime. A formal manipulation check was performed at the final treatment session to assess (a) the extent to which subjects guessed the hypothesis of the study (i.e., that goals affect response to treatment), and (b) the extent to which subjects used time goals for coping.

Data Analyses Data analyses followed the recommendations of Tabachnick and Fidell

(1989). Preliminary analyses included: (a) data screening for multivariate outliers, (b) examination of subject attendance, (c) evaluation of therapists' adherence to the treatment protocol, (d) analysis of pretreatment differences between subjects included in analyses and those considered lost to follow-up, (e) examination of data for pretreatment group differences on dependent

2 The treatment manual is available upon request from the second author, B. E. Thorn, Ph.D., Department of Psychology, University of Alabama, P.O. Box 870348, Tuscaloosa, AL 35487.

312 JAMES ET AL.

measures, and (f) evaluation of the effectiveness of the experimental manipulation.

Treatment effects were evaluated using multivariate analyses of covariance (MANCOVA) with pretreatment scores on each dependent variable serving as covariates for the respective posttreatment scores. This use of MANCOVA is an appropriate alternative to repeated measures MANOVA. While randomi- zation helps to minimize pretreatment differences between groups, using pretreatment scores as covariates lends statistical assurance to the researcher of pretreatment equality (Tabachnick & Fidell, 1989). Compared to multiple univariate ANCOVAs, MANCOVA has the added advantage of grouping dependent variables of interest and assessing differences at posttreatment while remaining a conservative statistical test. When MANCOVA was not possible or the dependent variables did not meet the assumptions for MANCOVA, MANOVA or appropriate nonparametric tests were used. Paired comparisons between treatment group means were made with Bonferroni's adjustments to the alpha level.

Results Preliminary Analyses

Data screening of bivariate plots of pre- and posttreatment scores revealed two subject outliers. Both showed marked deviation from the predictive model; Z scores of residuals were significant atp < .05 on five key dependent measures. One of the subjects was a member of the control group and reported having a dental procedure during the control (waiting) period with immediate reductions in headache activity. The other subject, a member of the goal group, reported several major psychosocial stressors that developed concomitant with treatment. These two subjects were deleted, resulting in a final study sample of 33 subjects, 7 in the delayed-treatment control group and 13 in each treatment group.

Subject attendance in the final study sample of n = 33 was high. Eleven of the 13 goal subjects and 12 of the 13 open subjects attended at least five of the six treatment sessions. The average number of sessions attended by both goal and open subjects was 5.3.

Therapist adherence to protocol was considered essential to maintaining the integrity of the design as a test of the independent effects of goal specificity on treatment outcome. Interventions were rated to be of high quality for all groups. On the Cognitive Therapy Rating Scale of 0 (poor) to 6 (excellent) therapists 1, 2, and 3 had ratings (X +_ SEM) of 5.6 (0.23), 5.3 (0.18), and 5.1 (0.18) for goal groups and scores of 5.5 (0.20), 5.3 (0.18), and 5.1 (0.18) for open groups, respectively. ANOVAs revealed no significant differences between goal and open groups in (a) degree of therapist adherence to the general treatment protocol, (b) degree of therapist adherence to the correct instructional set, or (c) level of group difficulty.

One way ANOVAs or appropriate nonparametric tests were used was to assess whether any systematic differences existed between the subjects who remained in the study (regardless of group assignment, n = 33) and those lost to follow-

COALS, COPING, AND m~ADACrmS 313

up (n = 15). The only difference identified was a tendency for the study participants to have a higher initial CCI score than subjects lost to follow-up, F(1,45) = 11.98, p < .05.

In the posttreatment manipulation check none of the participants reported knowledge of the research project prior to interviewing. When asked about the purpose of the research, none of the subjects were able to articulate the hypothesis that time goals for use of coping skills would influence treatment outcome. Responses to questions on use of time goals for coping were used to evaluate the effectiveness of experimental manipulations. When subjects were asked how they had decided on when and for how long to practice relaxation exercises, 11 of 13 goal subjects (85%o) reported use of time goals consistent with instructions to practice 20 minutes dally. In contrast, only 1 of the 13 open-group subjects reported using a time goal, ~2 (25) = 15.48, p < .01. When subjects were asked how they decided when and for how long to use strategies to cope with daily stressors and to cope with pain, 11 of 13 goal (85%) and 2 of 13 open subjects (15%) reported using a time goal, ~2 (25) = 12.46, p < .01.

Treatment Effects It was predicted that cognitive-behavioral therapy would facilitate acquisi-

tion of adaptive coping strategies and that provision of goals for use of strategies would result in improved treatment outcome, as measured by pain levels, medication intake, and other concomitants of chronic pain. Table 1 provides pre- and posttreatment cell means and standard deviations for all raw data by group.

Pain, adaptive coping, and self-efficacy for preventing pain. MANCOVA was used to identify differences among groups on reported headache pain, use of adaptive coping, and self-efficacy to prevent headaches following treatment. This analysis revealed a significant treatment group main effect, Wilks' lambda F(6,50) = 3.2, p < .01. Univariate ANCOVAs revealed that there were significant differences among the 3 treatment groups for headache pain index, F(2,29) = 3.68, p < .03 for logarithm of the pain index, and for the Cognitive Coping Index (CCI), F(2,29) = 9.54, p < .001. No significant differences were found among groups for reported self-efficacy to prevent headaches.

One-tailed paired comparisons were made between treatment group means using least squares means comparisons with Bonferroni's adjustment to the alpha level (i.e., alpha' = .05/3 = .017). These comparisons showed the goal group to report significantly lower headache pain ratings than the control group, t(19) = 2.7, p < .017. The open group was not significantly different from the control group. Paired comparisons between the treatment groups revealed that both the goal and open treatment groups had significantly higher scores on the Cognitive Coping Index at posttreatment than did controls, t(19) = 3.8, p < .001 and t(19) = 4.1,p < .001, respectively. The two treatment group means did not differ statistically.

Coping time. MANOVA was used to compare treatment groups on the variables of time spent coping with hassles and time spent coping with pain. No statistical differences were identified.

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TABLE 1 CELL MEANS AND STANDARD DEVIATIONS OF RAW DATA BY GROUP

AT PRE- AND POSTTKEATMENT

Group

Control Goal Open

Measure Pre Post Pre Post Pre Post

Age 43.14 36.46 39.00 (9.87) (12.00) (12.00)

Pain index la .22 .26 0.34 0.23 0.35 0.28 (0.12) (0.17) (0.20) (0.23) (0.15) (0.19)

Medication intake b Nonnarcotic 12.93 20.09 18.19 9.37 14.50 16.26

analgesics (9.71) (22.33) (12.44) (12.91) (18.25) (16.67)

Narcotic analgesics 1.87 2.25 6.01 4.28 2.29 3.29 (2.19) (3.09) (10.56) (12.75) (3.11) (7.79)

Muscle relaxants 3.97 6.92 8.12 1.86 5.62 3.11 (3.27) (12.75) (16.40) (4.54) (9.92) (5.99)

Anxiolytics 3.57 2.29 4.01 9.28 2.10 .82 (9.45) (6.07) (12.33) (27.66) (4.85) (2.63)

Antidepressants 2.38 1.52 2.17 3.81 8.61 8.42 (6.30) (4.03) (7.46) (8.88) (19.48) (20.10)

Sedative/hypnotics 0.34 2.43 3.39 0.96 0.12 1.06 (0.90) (4.58) (3.39) (1.77) (0.44) (1.97)

Cognitive Coping Index c 77.86 68.00 88.46 120.92 87.62 126.00 (21.00) (18.68) (24.01) (23.55) (30.75) (37.13)

Downtime a 14.32 13.44 28.96 22.11 34.01 42.27 (16.86) (18.90) (42.53) (62.51) (38.42) (62.18)

Self-efficacy 88.14 89.43 92.61 100.54 96.77 100.08 (17.18) (23.94) (32.71) (18.24) (21.75) (24.29)

Pain behavior e Avoidance 5.43 5.00 8.24 3.61 10.00 7.64

(4.07) (5.60) (9.82) (3.54) (8.85) (5.64)

Verbal complaint 1.29 1.33 2.10 0.74 2.46 1.82 (1.42) (1.35) (1.57) (1.16) (1.86) (1.46)

Nonverbal complaint 2.86 3.29 5.00 1.28 6.12 4.26 (3.92) (3.51) (4.03) (1.34) (6.45) (5.00)

Medication intake 5.33 5.48 6.44 4.64 5.80 5.12 (4.08) (4.10) (3.18) (4.33) (3.76) (2.74)

Disability f 6.15 4.15 7.38 4.62 4.52 3.60 (6.50) (6.71) (8.17) (5.97) (4.74) (5.49)

Depression s 12.43 7.86 10.15 9.31 9.77 7.77 (9.02) (6.28) (8.83) (8.76) (6.75) (6.00)

continued

GOALS, COPING, AND HEADACHES

TABLE 1 (continued)

315

Group

Control Goal Open

Measure Pre Post Pre Post Pre Post

Distress h 0.75 0.64 0.81 0.65 0.67 0.50 (0.65) (0.64) (0.63) (0.68) (0.41) (0.59)

Trait Anxiety i 43.86 38.86 40.23 40.08 43.85 33.69 (16.71) (12.97) (12.51) (12.26) (11.71) (13.93)

State Anxiety i 38.86 35.43 34.31 32.62 35.23 34.08 (15.52) (15.55) (34.31) (10.78) (10.17) (10.19)

Coping with pain i - - - 9.19 - 11.31 (14.71) - (13.81)

Coping with stressors Ik - - - 1.56 - 1.24 (0.32) - (0.48)

Note. Dash indicates data are not available. i Data are t ransformed using logl0 transformation. a Range of 0-low to 5-high. b Range of 0% to 100% of recommended maximum daily intake from each category. c Higher scores indicate use of more adaptive coping strategies. d Average number min /day reclining due to pain. e Average number of behaviors per week. f Higher scores indicate greater disability. s Higher scores indicate more symptoms of depression. h Range of 1-5, with higher scores indicating higher levels of distress. i Higher scores reflect higher levels of anxiety. J Average daily minutes using coping strategies for pain management . k Average daily minutes practicing and using strategies to cope with stressors.

Medication intake. ANCOVA revealed a significant group effect for nonnarcotic analgesics, F(2,29) = 5.72; p < .01 One-tailed paired comparisons revealed that, compared to both the control and the open group, goal group subjects reported significantly lower intake of nonnarcotic analgesics, t(19) = 3.1, p < .01, and t(25) = 2.5, p < .01 respectively. Due to the distribution of the data, Kruskal-Wallis tests with Bonferroni's adjustment were used to analyze all other forms of medication use. No significant differences among groups were found for intake of narcotic analgesics, muscle relaxants, anxiolytics, antidepressants, or sedative-hypnotics at posttreatment.

Pain behavior, downtime, and disability. MANCOVA revealed no significant differences among groups on the basis of self-reported pain behavior (PBQ), downtime, or disability as assessed by the SIP.

Psychological distress. A MANCOVA with depression (BDI), distress (GSI of the SCL-90-R), and anxiety (State and Trait Scales of STAI) was not significant.

Summary of statistically significant findings. Compared to controls, both treatment groups reported more frequent use of adaptive coping strategies.

316 JA~ES ET At.

The goal group reported lower levels of headache pain pre- to posttreatment. Compared to both the open-group and control subjects, goal-group subjects had a significantly lower intake of nonnarcotic analgesics at posttreatment.

Clinical significance. Clinically significant improvement was defined as a reduction of 500/0 or more in outcome as measured by pre- and posttreatment headache diaries. Seven of 13 goal (54°/0) and 4 of 13 open-group subjects (37070) reported clinically significant decreases in headache pain.

By far, the most frequently reported type of medications used by the sample were nonnarcotic and narcotic analgesics. Two of 7 control (290/0), 4 of 13 goal (310/0), and 5 of 13 openrgroup subjects (380/0) reported substantial reductions in narcotic analgesic intake. For nonnarcotic analgesics, a marked difference in response was evident, with 9 of 13 goal subjects (69070) reporting reductions of 50°70 or more pre- to post treatment. This is compared to only 1 of 7 control subjects (14°/0) and 1 of 13 open-group subjects (8o7o).

Discussion Goal-setting is a well-established motivational tool in industrial and aca-

demic pursuits (Locke, Shaw, Saari, & Latham, 1981). Recent laboratory analog studies suggest that time goals for coping may help individuals cope with a painful stimulus (Williams & Thorn, 1986; Thorn & Williams, 1989). The present study sought to evaluate the efficacy of goal-setting as an integral part of cognitive-behavioral treatment for chronic headache pain. It was hypothe- sized that provision of specific time goals for coping would improve treatment outcome, as defined by measures of coping, pain intensity, medication intake, and psychological distress. Results provide partial support for this hypothesis and suggest that goals for using coping strategies may enhance treatment outcome.

Goal and open-group subjects scored higher on the CCI than controls at posttreatment, reflecting the efficacy of CBT in teaching adaptive coping strategies. The reduction in pain reported by the open group approached significance. That reported by the goal group was both clinically and statistically significant, suggesting that CBT may be enhanced by the inclusion of concrete time-limited goals for practice and use of coping strategies.

Further support for the impact of goal setting was found in the data on medication intake. Reductions in headache pain observed in this study are not likely attributable to increases in mediation consumption, as intake from the six categories of pain-related medications remained statistically unchanged or decreased following treatment. It may be noted that goal subjects reported slightly increased mean levels of anxiolytic and antidepressant medication at posttreatment. Although it is possible that an increase in these medications might reduce headache pain, this seems an unlikely confound for these data. First, the observed increases are not statistically significant and second, the increase is almost entirely attributable to changes in medication made by 2 individuals. For example, I goal subject decreased intake of sedative hypnotics by 50% and increased intake of anxiolytics by a similar amount. In contrast, the pattern of improvement in pain ratings across the goal group more closely


resembles the pattern of consistent reductions observed for nonnarcotic analgesics. Thus, it appears that goal subjects were able to achieve reductions in headache pain with concomitant reductions in analgesic medication intake.

A second potential confound for the interpretation of these data is the ques- tion of the possible role of rebound headaches. It might be argued that goals work to reduce pain by selectively decreasing medication intake and that subsequent improvement in pain is due to a reduced risk of rebound phenomena. Although goals may work quite well in helping patients to delay use of drugs and to rely on self-coping strategies, careful scrutiny of the data does not suggest a selective effect for rebound headaches. Only 3 subjects were consuming an average of over 50°70 of the maximum recommended intake of narcotic and nonnarcotic analgesics. For these 3 subjects (1 in each of the three groups) medication intake remained essentially unchanged pre- to post treatment. Er- gotamine intake was quite low throughout the study in each of the three groups.

Results of this study do not provide direct evidence of an effect of goals on posttreatment self-efficacy to prevent headache pain. However, recent reports (Blanchard, Appelbaum, Guarnieri, Morrill, & Dentinger, 1987; Keefe, Cald- well, Williams, Gil, Mitchell, Robertson, Martinez, Nunley, Beckham, & Helms, 1990) suggest that certain treatment gains may not appear until posttreatment follow-up after the individual has had sufficient time to practice and fully incorporate cognitive-behavioral strategies into his or her daily repertoire. In the present study, when compared to control subjects, both treatment groups reported using more coping strategies and were able to exert good control over their headaches. The goal group did so with less reliance on nonnarcotic medication. Future investigations may be developed to examine the possibility that goals for coping lead to greater self-efficacy to prevent headaches after individuals have had longer periods of time to incorporate strategies into daily routines. Also, it should be noted that the self-efficacy measure used in this study examines only self-efficacy to prevent headaches in specific situations, not self-efficacy to cope with stressors or reduce headache pain once it emerges. More comprehensive measures might reveal treatment differences in self-efficacy to control tension and self-efficacy to cope with pain when and if it does occur.

The current study represented a laboratory-based clinical trial in which most subjects were self-referred volunteers. Effect sizes for this study were modest (e.g., f = .61 for nonnarcotic analgesic analysis) to low. Such effect sizes are consistent with or slightly lower than those published with other pain populations (e.g., Malone et al. 1988). Given that this study represents a treatment dismantling strategy where two viable forms of treatment are being compared, lower effect sizes in comparing the two groups should be expected (Strayhorn, 1987). Subject attrition was higher than what has been noted in some pre- viously published studies (e.g., Holroyd, Andrasik, & Westbrook, 1977) but generally consistent with others (e.g., Blanchard et al., 1985). Subjects lost to follow-up differed statistically from study participants on only one measure. The unexpected finding of a less adaptive coping style among subjects lost to follow-up may reflect the need for a certain minimal level of adaptive coping in order to benefit from cognitive-behavioral group treatment. If so, subjects who present with relatively lower levels of baseline coping may need

318 JA_~S ET At.

additional support or individual work to identify and circumvent potential difficulties in subsequent group treatment.

Failure to document significant treatment effects from measures of psy- chopathology (distress, anxiety, and depression) and disability (downtime and impairment) may be secondary to floor effects, as pretreatment levels were relatively low. Most subjects in the sample were self-referred and may represent a healthier segment of the population than those typically referred from physicians at the peak of distress. Thus, inferences from this study may be limited to self-referred individuals who are relatively well-adjusted and who are willing to seek help on their own. Replication and extension of the goal-open protocol with hospital-based populations would be necessary to define the extent to which these results may generalize to more dysfunctional headache patients.

In summary, results of this study suggest that cognitive-behavioral therapy results in greater use of coping strategies. Provision of explicit time goals for coping-strategy use was associated with decreased pain intensity and medication intake at posttreatment. That significant goal effects were documented with rather inexperienced therapists, a small number of relatively healthy subjects, and a small number of treatment sessions suggests a potentially powerful treatment component that can be readily incorporated into almost any cognitive-behavioral program.

Further investigation of coping style and self-efficacy for coping as predictors of adherence to treatment may provide information needed to minimize loss to follow up during treatment. Future efforts might also be directed toward replication of this protocol in other settings and with other pain populations. Variations in the efficacy of subject-set goals versus therapist-set goals could be examined to further define the most effective operationalization of goal- setting for coping strategy use with various groups of chronic pain patients. Such efforts may be strengthened by refinements in methodology, such as the inclusion of direct observation of pain behavior and the use of a more comprehensive measure of self-efficacy for coping with stressors and pain. Finally, with all such clinical trials, long-term follow-up is needed to examine the extent to which treatment gains are maintained or enhanced over time.

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RECEIVED: April 27, 1992 ACCEPTED: September 11, 1992

goal specification in cognitive-behavioral therapy for chronic headache pain

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