Cognitive Therapy and Research, Vol. 21, No. 5, 1997, pp. 525-534

Effects of Manipulated Cognitiveand Attributional Set on Pain Tolerance

Joel Goldberg,1,3 Matisyohu Weisenberg,1 Sergio Drobkin,1Mordechai Blittner,1 and K. Gunnar Gotestam2

The effects of cognitive set and attributional set on cold-pressor paintolerance were investigated. Fifty subjects were given a series of projectivetests that were used to manipulate the feedback they received concerningtheir ability to control their pain. The cognitive set was manipulated bytelling the positive groups (Pos) that they had the ability to deal withexternal stress while the negative groups (Neg) were informed that they haddifficulty dealing with external stress. The attributional set was manipulatedby telling subjects that the task they were about to perform depended onthe person performing it (Int) or on external factors (Ext). The resultsindicated that the Pos groups showed a longer duration in cold water anda strong tendency to rate the pain as less compared to the Neg groups. Intalso yielded greater pain tolerance than Ext. The discussion focuses on theimportance of mental attitude above and beyond any specific copingtechniques.

Cognitive perception has been shown to influence how a person copes witha threat in a given situation (cf. Lazarus, 1991), including pain perception(Manning & Wright, 1983; Weisenberg, 1989, 1994). Many of the pain con-trol strategies relate to how the person perceives, interprets, and relates to

1Bar-Ilan University, Ramat-Gan, Israel.2University of Trondheim, Trondheim, Norway.3Address all correspondence to Joel Goldberg, Bar-Ilan University, Department of Psychology,Ramat-Gan, Israel.

KEY WORDS: cognitive set; pain tolerance; attributions; coping skills.

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0147-5916/97/1000-0525$12.50/0 C 1997 Plenum Publishing Corporation

the pain more than to the pain stimulus itself. The individual's cognitions,especially the meaning assigned to the pain situation, can be the importantingredient involved in reacting to the pain and in controlling it. Staub, Tursky,and Schwartz (1971), as well a many others (cf. Weisenberg, 1987), haveshown that control and predictability can reduce the tension and interfer-ence of aversive stimulation on a person's behavior. At the other extreme,signified by lack of control, a person's self-perception could even lead tofeelings of learned helplessness (Maier & Seligman, 1976; Peterson, Maier,& Seligman, 1993).

To explain the positive aspects of control, Thompson (1981) haspresented Miller's (1979) minimax hypothesis. According to this view,perceived control means that the individual feels able to minimize themaximum future danger — that is to say, feels that the situation willnot get out of hand beyond the person's tolerance. It is thus the per-son's perception rather than the actual, objective situation that is im-portant.

This study assumed that the way a person copes with his/her paindepends on his/her cognitive perception of the situation along with the ap-propriate internal/external attributions. Differential cognitive conditionshad been created in a previous study by Blittner and Goldberg (1978). Inthis smoking cessation study, false feedback from a projective test was usedto create a positive cognitive set that reinforced the person's beliefs inhis/her ability to reduce smoking. This situation was compared to a condi-tion that focused only on practicing stimulus control. The findings indicatedgreater smoking reduction among subjects who were given an internal ex-pectation of ability to control as opposed to those trained in actual stimuluscontrol. Using a similar experimental paradigm, Goldberg, Weller, andBlittner (1982) demonstrated increased self-control of electromyography(EMG) biofeedback by subjects for whom a positive expectation of abilityto control was created as compared to those not so treated.

Internal or external attributions have also been shown to influencethe way an individual relates to aversive situations (Abramson, Garber, &Seligman, 1980; Weiner & Sierad, 1975). Attributing unpleasant outcomesto internal factors has been shown to lead to less effective taskperformance on new tasks, to negative feelings, and to a lowered self-evaluation (Maier & Seligman, 1976; Mikulincer, 1986). In terms of painperception, it was thus postulated that a positive cognitive set with internalattribution would lead to a high level of pain tolerance. A negativecognitive set with internal attribution, in turn, would lead to a low levelof pain tolerance.

526 Goldberg et al.

METHOD

Participants

Fifty female students ages 18 to 40 (mean = 26) participated in thestudy. To limit the influence of external factors the following criteria wereused for inclusion: (1) at least 8 years of schooling, (2) not students ofpsychology or related areas, (3) not currently taking any pain medication,and (4) not currently menstruating. Four additional women were excludedfrom the study since they had reached the 300-s limit on the premanipu-lation cold-pressor task and would have shown no effect. All subjects werevolunteers who were not paid for their participation.

Of the 50 women, 56% were single, 36% were married, and 8% weredivorced. Ninety percent were Israeli born and lived in an urban setting.In terms of educational level, 6% had completed only primary school, 60%high school, 26% some higher education, and 8% were unknown.

Overall Design

Subjects were divided into five groups, 10 per group:

1. Negative cognitive set, internal attribution (Neg-Int)2. Positive cognitive set, internal attribution (Pos-Int)3. Positive cognitive set, external attribution (Pos-Ext)4. Negative cognitive set, external attribution (Neg-Ext)5. Nonintervention control (Control)

The cognitive set was created by providing false feedback on theresults of a projective test that either supported or negated the person'sability to cope with external stress. The attribution was created by stress-ing that task success was dependent on the person carrying out the taskor that task success was not dependent on the person but on externalfactors.

Measures

Pain duration was assessed by the time in seconds that the subjectkept her dominant hand in a cold-pressor bath maintained at 0° to 2°C.Water temperature was measured prior to the start of each session for eachsubject.

Manipulated Pain Tolerance 527

Verbal pain ratings were obtained by use of a 100-mm line, visualanalogue scale (VAS) going from 0 (no pain at all) to 100 (extremely severepain) (Huskisson, 1974). Each subject was asked to make a mark along theline to indicate the intensity of the pain that she felt.

The measure of attribution for success on the assigned tasks wasassessed by a subject rating on a scale from 1 to 7 (1 = personal, 1 = si-tuational) that asked to what extent the subject's performance was con-nected with personal factors or with situational factors (Mikulincer,1986).

Perceived self-efficacy in pain control was assessed by a five-itemquestionnaire used by Weisenberg, Wolf, Mittwoch, Mikulincer, and Aviram(1985). The subject was asked to indicate on a scale from 0 to 7 (0 = notat all, 1 = a great deal) to what extent she felt she could cope with the painunder a number of different conditions, e.g., when she received a warningthat she was about to be given a pain stimulus.

Procedure

Subjects were individually tested. Each subject was told that the studyassessed the correlation between personal characteristics and mental andphysical function. The subjects were asked to volunteer and they signedinformed consent forms. The subjects were also asked to indicate if they hadtaken medications of any sort prior to the start of the study.

The premanipulation measure of pain tolerance followed. Each sub-ject was asked to insert her dominant hand into the bucket such that herhand touched the bottom and to keep it there as long as she could. Thetime was limited to 300 s. Duration in the cold water was measured by astop watch.

Upon completion of the cold-pressor task, the subject was asked torate the intensity of the pain she felt on the VAS.

The subject was next presented with two Bender cards that shewas asked to copy. When she completed that task, she was shown twoRorschach cards and asked to indicate what associations these cardsbrought up.

The subject was then moved to a different place where she was givena number of questionnaires to complete. She was informed that, while sheworked on the forms, the experimenter would go to the neighboring roomto score the tests that were just given. After 15 min the experimenter re-turned and by means of a fictitious graph provided the subject withfeedback according to condition.

528 Goldberg et al.

For the Neg groups, the subject was informed that: "The tests indicatethat you have a tendency to give-up when you have to cope with an un-pleasant situation." For the Pos groups the subject was informed that "thetests indicate that you have strong will power and ability to cope with anunpleasant situation."

The Int groups were informed: "The results of this task depend onyou. They don't depend on outside factors. Most previous research withthis task has indicated that the outcomes reflect very basic personal traitsof the person carrying it out."

The Ext groups were told: "The results of this task depend on outsidefactors. They do not depend on your ability or on the amount of effortthat you invest. Most previous research with this task has indicated thatthe outcomes do not reflect any personal traits of the person carrying itout."

The Control subjects were told that the test results were inconclusiveand one cannot predict from them how a person would react to an unpleas-ant stimulus.

The cold-pressor stimulation was repeated once more followed by an-other VAS measurement, the measure of self-efficacy, and the measure ofattribution.

A debriefing followed in which each subject was told that the resultsthat were given to her were fictitious. The study was explained to her andshe was assured that her performance was satisfactory. The subject's ques-tions were answered.

RESULTS

Measure of Take

An assessment of the attribution measure by one-way analysis of vari-ance (ANOVA) yielded a significant difference between the five groupson the measure of internal-external attribution [F(4, 45) = 2.46, p = .05].Multiple comparisons by way of the Duncan new multiple-range test indi-cated that the two external groups scored significantly higher in the externaldirection than the other groups (M = 3.40, M = 4.60 for the Pos-Ext andNeg-Ext, respectively, vs. M = 2.80, M = 2.60, M = 2.50 for the Neg-Int,Pos-Int, and Control, respectively). These data would support the appro-priate creation of the internal-external orientation.

Manipulated Pain Tolerance 529

Table I. Duration (Seconds) in Cold Water for Each Experimental Groupa

Group

Neg-IntPost-IntPost-ExtNeg-ExtControl

Beforemanipulation

(Time 1)

34.124.938.730.340.0

Aftermanipulation

(Time 2)

36.641.049.624.840.0

Time 2minus

Time 1

2.516.110.9-5.50.0

t

0.444.392.941.600.00

P

0.670.0020.020.141.00

a Neg-Int = negative cognitive set, internal attribution; Pos-Int = positive cognitive set,internal attribution; Pos-Ext = positive cognitive set; external attribution;Neg-Ext = negative cognitive set, external attribution.

Duration

A 2 x 2 x 2 (Attribution x Cognitive Set x Time) ANOVA in whichtime was a repeated value indicated significant differences for time [F(l,74) = 8.08, p < .007] and for the interaction of Time x Cognitive Set [F(1,74) = 12.62, p < .001]. Follow-up analysis by f-test for all five groups in-dicated that both the Pos-Int and the Pos-Ext yielded increased tolerancewhen going from Time 1 to Time 2. No other differences between groupsyielded significance. See Table I.

Pain Rating

In regard to the rating of pain for the premanipulation cold-pressortask, no significant differences between groups could be shown. Therefore,difference scores (see Table II) were analyzed. A one-way ANOVA forthe five groups of the postmanipulation pain rating minus the premanipu-lation pain rating for the cold water only yielded a group effect that wassignificant at the p = .10 level [F(4, 45) = 2.03, p = .10]. As there wereprior hypotheses as to effects, multiple comparisons were carried out fol-lowing Rosenthal and Rosnow (1985). The Duncan indicated that thePos-Int and the Pos-Ext groups significantly differed from the other groups(p < .05).

530 Goldberg et al.

Manipulated Pain Tolerance 531

Perceived Self-Efficacy

The scores of the self-efficacy ratings were divided at the median tocreate high and low self-eff icacy groups. Examination of thepremanipulation duration and VAS scores did not yield any differencesfor self-efficacy.

However, an ANOVA for the postmanipulation self-efficacy data forduration scores indicated a significant difference for self-efficacy [F(1,48) = 4.13, p < .05], a significant main effect for time [F(l, 48) = 5.65,p < .05], as well as a significant Self-Efficacy x Time interaction [F(1,48) = 4.23, p < .05]. An examination of the data indicated that the highself-efficacy group yielded a longer duration than the low self-efficacy group(mean = 44.28, mean = 27.01 for high and low self-efficacy, respectively).The duration scores for the postmanipulation time were higher than forthe premanipulation time (M = 44.28, M = 27.01 for postmanipulationand premanipulation, respectively). However, the significant interaction in-dicated that the main difference for the greater postmanipulation increasein duration was attributable to the high self-efficacy group (M = 39.96,M = 48.61 for the high self-efficacy pre- and postmanipulation, respectivelyvs. M - 26.70, M = 27.33 for the low self-efficacy pre- and postmanipu-lation, respectively).

The postmanipulation self-efficacy scores did not differ significantlyfor the VAS.

Table II. Mean Pain Rating (VAS) of Cold Water forEach Experimental Groupa

Group

Neg-IntPos-IntPos-ExtNeg-ExtControl

Beforemanipulation

(Time 1)

3.13.03.22.83.2

Aftermanipulation

(Time 2)

3.22.52.73.23.0

Time 2minus

Time 1

0.1-0.5-0.5

0.4-0.2

a VAS = visual analogue scale; Neg-Int = negative cognitiveset, internal attribution; Pos-Int = positive cognitive set,internal attribution; Pos-Ext = positive cognitive set, externalattribution; Neg-Ext = negative cognitive set, externalattribution.

DISCUSSION

The assumptions of this study were based on differences in copingwith pain as a function of the cognitive (positive-negative) and attribu-tional (internal-external) sets that subjects had. The assumptions werethat the type of cognitive set would result in different reactions to thepain stimulus. It was felt that the internal set would combine with thepositive set to increase pain tolerance while the external set would reducethe benefit of the positive set. The two dependent measures were toler-ance time and pain rating. In accordance with the initial assumptionsand with earlier research (Blittner & Goldberg, 1978; Goldberg et al.,1982; Shaw & Blanchard 1983), subjects who experienced a positive cog-nitive control in their ability to cope with the task at hand did experiencea higher level of tolerance and a strong tendency to rate the pain as less.Although no specific measures were used in this study, it can be arguedthat the results obtained when combined with the previous evidence sup-port outcomes that go beyond simple demand characteristics. Sherif hasargued that one of the important means of validating results is via similarfindings that are obtained under somewhat different conditions (cf.Sherif, 1966). Demand characteristics also cannot that easily influencesmoking behavior or biofeedback performance (Blittner & Goldberg,1978; Goldberg et al., 1982).

The positive cognitive set may be added to the accumulating evidencefor the effectiveness of cognitive techniques for increasing pain tolerance(Berntzen, 1985; Holzman, Turk, & Kerns, 1986; Turk, Meichenbaum, andGenest, 1983; Weisenberg, 1994). The findings of the present study em-phasize the importance of the mental attitude aside from any specificcognitive technique as no specific techniques were taught. Berntzen (1985),similarly, has argued that the specific techniques are of lesser importance.What basically counts is the mental attitude that the subjects use in ap-proaching the task at hand.

The second hypothesis related to attributional set. Although not asstrong an effect as the cognitive set mentioned earlier, the internals didshow greater pain tolerance than the externals. Weiner and his colleagues(1971) have theorized that attributing success to internal factors increasesfeelings of self-esteem, self-pride, and belief in the person's ability to dealwith future situations of a similar nature. The present study is a behavioralexample that supports the thinking of Weiner et al. (1971).

Mikulincer (1986) has theorized that in the aftermath of failure ob-tained following a learned helplessness manipulation internals are morefocused on the impression they make. As a consequence attention becomesnot task-focused. It is possible that, in this study, the positive cognitive set

532 Goldberg et al.

encouraged subjects to remain task-focused while the reverse may have oc-curred for subjects with a negative set. Negative set subjects may have beenmore concerned with problems of approval and as a consequence becamediscouraged and felt it may not have been worthwhile investing greater ef-fort.

It was hypothesized that the group receiving the negative cognitiveset with the internal attribution would yield the shortest tolerance timeand the highest pain ratings. This hypothesis did not receive statisticalsupport. These findings, however, are similar to the results obtained earlierby Goldberg et al. (1982), who manipulated subjects' expectations ofautonomic control in a biofeedback situation. Contrary to expectations,the negative cognitive set did not lead to a poorer performance in termsof muscle control. One possible explanation may follow the approach ofWeiner and Sierad (1975) and Mikulincer (1989), who theoreticallydescribed the consequences of negative outcomes on subsequent performanceas dependent on the level of achievement aspirations of the individual.Subjects who aspire to higher levels of achievement may try even harderafter negative evaluations. Meyer (1970) did indeed find that subjects withhigh achievement aspirations tend to attribute failure to lack of adequateeffort. It is possible that in our study most subjects were of medium tohigh levels of achievement aspiration and consequently may have triedeven harder after receiving negative evaluations.

The result of what may incorrectly appear to be opposing tendenciesmay have been functioning in this study. On the one hand, as Mikulincer(1986) has argued, subjects may have invested energy to foster a positiveimpression. On the other hand, the negative feedback received may haveproduced a challenge to show the experimenter that he was not correctand could therefore have led to increased effort to perform well. The latterapproach is somewhat similar to the counter-control phenomenon reportedby therapists who report that patients will often do just the opposite ofwhat they are asked to do as a way of asserting "I'll show the therapist"(Kanfer & Schefft, 1988).

REFERENCES

Abramson, L. Y., Garber, J., & Seligman, M. E. P. (1980). Learned helplessness in humans:An attributional analysis, In J. Garber & M. E. P. Seligman (Eds.), Human helplessness:Theory and application (pp. 3-34). New York: Academic Press.

Berntzen, D. (1985). Effects of multiple cognitive coping strategies on laboratory pain. In D.Berntzen (Ed.), Analysis and management of experimental and clinical pain. Trondheim,Norway: Tapir Forlag, pp. 11-15.

Blittner, M., & Goldberg, J. (1978) Cognitive self-control: Factors in the reduction ofsmoking-behaviour. Behaviour Therapy, 9, 553-561.

Manipulated Pain Tolerance 533

Goldberg, J., Weller, L., & Blittner, M. (1982). Cognitive self-control factors in EMGbiofeedback. Biofeedback and Self-Regulation, 7, 545-551.

Holzman, A. D., Turk, D. C, & Kerns, R. D. (1986). The cognitive-behavioral approach tothe management of chronic pain. In A. D. Holzman & D. C. Turk (Eds.), Painmanagement: A handbook of psychological treatment approaches (pp. 31-50). New York:Pergaraon.

Huskisson, E. C. (1974). Measurement of pain. Lancet, 1, 1127-1131.Kanfer, F. H., & Schefft, B. K. (1988) Guiding the process of therapeutic change. Champaign:

Research Press.Lazarus, R. S. (1991). Emotion and adaptation. New York: Oxford University Press.Maier, S. R, & Seligman, M. E. P. (1976). Learned helplessness: Theory and evidence. Journal

of Experimental Psychology, 105, 3-46.Manning, M. M., & Wright, T. L. (1983). Self-efficacy expectancies, outcome expectancies,

and the persistence of pain control in childbirth. Journal of Personality and SocialPsychology, 45, 421-431.

Meyer, W. U. (1970). Selbtverantworklichkeit und Leistungsmotivation. Unpublished doctoraldissertation, Ruhr Universitat, Bochum, Germany.

Mikulincer, M. (1986). Attributional process in the learned helplessness paradigm: Behavioraleffects of global attributions. Journal of Personality and Social Psychology, 51, 1248-1256.

Mikulincer, M. (1989). Learned helplessness and egotism: Effects of internal/externalattribution on performance following unsolvable problems. British Journal of SocialPsychology, 28, 17-29.

Miller, S. M. (1979). Controllability and human stress: Method, evidence and theory. BehaviourResearch and Therapy, 17, 287-304.

Rosenthal, R., & Rosnow, R (1985). Contrast analysis. New York: Cambridge University Press.Peterson, C., Maier, S. F., & Seligman, M. E. (1993). Learned helplessness: A theory for the

age of personal control. New York: Oxford University Press.Shaw, E. R., & Blanchard, E. B. (1983). The effects of instructional set on the outcome of

a stress management program. Biofeedback and Self-Regulation, 8, 555-565.Sherif, M. (1966). In common predicament: Social psychology of conflict and cooperation.

Boston: Houghton-Mifflinn.Staub, E., Tursky, B., & Schwartz, G. E. (1971). Self-control and predictability: Their effects

on reactions to aversive stimulation. Journal of Personality and Social Psychology, 18,157-162.

Thompson, S. C. (1981). Will it hurt less if I can control it? A complex answer to a simplequestion. Psychological Bulletin, 90, 89-101.

Turk, D. C., Meichenbaum, D., & Genest, M. (1983). Pain and behavioral medicine: A cognitivebehavioral perspective. New York: Guilford Press.

Weiner, B., Friez, I. H. Kukla, A., Reed, L., Rest, S., & Rosenbaum, R. H. (1971). Perceivingthe causes of success and failure, New York: General Learning Press.

Weiner, B., & Sierad, J. (1975). Misattribution for failure and enhancement of achievementstrivings. Journal of Personality and Social Psychology, 31, 415-421.

Weisenberg, M. (1987). Psychological intervention for the control of pain. Behaviour Researchand Therapy, 25, 301-312.

Weisenberg, M. (1989). Cognitive aspects of pain. In P. D. Wall & R. Melzack (Eds.), Textbookof pain (2nd ed., pp. 231-241). Edinburgh, Scotland: Churchill Livingstone.

Weisenberg, M. (1994). Cognitive aspects of pain. In P. D. Wall & R. Melzack (Eds.), Textbookof pain (3rd ed., pp. 275-289). Edinburgh, Scotland: Churchill Livingstone.

Weisenberg, M., Wolf, Y., Mittwoch, T., Mikulincer, M., & Aviram, O. (1985). Subject vs.experimental control in the reaction to pain. Pain 23, 187-200.

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