Coping styles, paradox, and the cold pressor task

Journal o f Behavioral Medicine~ Voi. 12, No. 1, 1989

Coping Styles, Paradox, and the Cold Pressor Task

Jay S. Efran, l Robert L. Chorney , 1 L. Michael Ascher , 1 and Michael D . Lukens l

Accepted for publication: July 30, 1988

The study investigated how coping style differences affected performance on the cold pressor task. Reactions of "'monitors" (individuals who prefer having information about stressors) and "blunters" (individuals who avoid cues connected with stressors) were compared, using different instructional sets. The study also assessed the effectiveness of paradoxical intention compared to more traditional cognitive strategies. Monitors and blunters were identified using Miller's recently developed Behavioral Style Scale. All instructional sets improved performance in comparison to a control condition, and individuals generally did better when an instructional set supported their preferred coping style. Paradoxical intention did not show any decided advantage over other strategies. The desirability o f designing stress management programs to f i t individual coping style patterns is discussed.

KEY WORDS: coping; cold pressor; stress; paradox; behavioral style.

I N T R O D U C T I O N

Research using the cold pressor t a sk - a s well as other laboratory and field measures of response to stress-suggests that cognitive techniques can indeed modify reactions to aversive stimuli. Many cognitive tasks have been found to have some effectiveness: listening to music, watching slides, counting backward, solving problems, engaging in "self-talk," and working at imaginal tasks of all descriptions. However, none of these tasks seems to be uniformly effective with all subjects, and the wide variability observed has caused a number of investigators to call for more attention to personali-

~Temple University, Philadelphia, Pennsylvania 19122.

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0160-7715/89/0200-0091506.00/0 �9 1989 Plenum Publishing Corporation

92 Efran, Chorney, Ascher, and Lukens

ty variables (e.g., McCaul and Matott, 1984; Rosenbaum, 1980; Spanos et al., 1979).

Recently, a promising new personality dimension has been proposed which classifies individuals in terms of their tendencies to "monitor" or "blunt" when faced with potentially stressful events (Miller, 1979, 1980, 1987; Miller et aL, 1988, 1989; Miller and Managan, 1983). Monitors prefer to observe their environment closely in order to detect stimuli that may predict aversive experiences. Blunters, on the other hand, prefer to distract themselves, avoid- ing a focus on details associated with impending threat. The monitor/blunter trait is reminiscent of the earlier repression/sensitization distinction (Byrne, 1961)-one of the few dimensions to show promise in predicting individual stress reactions (Epstein and Fenz, 1967; Horwitz et al., 1977). How- ever, Miller's approach is more straightforward. Unlike the repression/sensitization dichotomy, the monitor/blunter construct makes no assumptions about defensive structures or unconscious mechanisms. Instead, the dimension and scale are anchored directly to behavioral descriptions of how individuals choose to process information in stressful circumstances. Initial work with the Miller Behavioral Style Scale (MBSS; Miller, 1980, 1987) suggests that this less inferential measurement approach is relatively free from the response biases that contaminated repression/sensitization scores and made unambiguous interpretations difficult (Byrne, 1964). Moreover, the MBSS has already proved useful in predicting responses in a variety of situations, including aversive gynecological procedures (Miller and Mangan, 1983; Steptoe and O'Sullivan, 1986), chemotherapy (Gard et al., 1988), cardiac catheterization (Taylor et al., 1983; Watkins et al., 1986), amniocentesis (Phipps and Zinn, 1986), and the threat of electric shock (Miller, 1987). In these studies, blunters tend to exhibit generally lower stress levels than monitors. Furthermore, those who do least well in coping with stress are monitors who are deprived of the kind of detailed information on which they have come to depend.

The present study has two separate purposes. It examines how monitors and blunters respond to a laboratory stressor in the context of two different instructional sets-a rational statement condition and a self-observation condition. The rational statement strategy was designed to be consistent with the desire of blunters to avoid focusing on the details of their situation. The self-observation strategy is more consistent with how monitors are presumed to operate.

At the same time, the study attempts to assess the effectiveness of paradoxical intention. Paradoxical intention instructs the person to do the oppo- site of what common sense dictates. The individual is asked to amplify or exaggerate unpleasant sensations rather than to fight or avoid them. This counterintuitive strategy has proven useful in dealing with certain clinical problems (e.g., Ascher and DiTomasso, 1985; Ascher and Efran, 1978) and

Coping Style and Paradox 93

often leads individuals to experience a greater sense of mastery in situations that they initially experienced as difficult. We wondered if it might prove more helpful to individuals faced with a laboratory stressor than the traditional cognitive distraction approaches do.

Monitor /blunter theory (Miller, 1980, 1987), and our reading of past research with the cold pressor task, leads us to propose the following hypotheses: (a) any cognitive strategy or structure will prove advantageous in coping, compared to the absence of a suggested strategy; (b) monitors and blunters will perform best when operating under an instructional set that sup- ports their preferred style; (c) consistent with their general superiority in han- dling unavoidable stress, blunters will be able to tolerate cold pressor sensation more easily than monitors will; and (d) a novel "paradoxical" strategy will be more effective than a simple observational or distraction strategy in han- dling cold pressor stress.

METHOD

Subjects

Ninety-two male undergraduate psychology students volunteered for the study and were randomly assigned to the four treatment conditions. They received course credit for participating. Two were disqualified for medical reasons, another withdrew, and data from four were discarded because of recording errors. As in similar cold pressor studies, a proport ion of subjects reached the 5-min time limit during their baseline trial, and their data were unusable for certain comparisons. Twelve of our subjects reached this ce i l ing-roughly the same proport ion as in previous studies (Avia and Kan- fer, 1980; Hayes and Wolf, 1984).

Subjects were randomly assigned to the four conditions, and five male experimenters were used. No significant differences on any variable were attributable to differences among experimenters.

Apparatus and Procedure

Subjects were first told the nature of the experiment and were then asked to sign a consent form indicating their willingness to participate. Those who consented underwent a brief medical screening, including a short medical history (with questions about cardiovascular problems) and a check for nor- mal blood pressure using a standard sphygmomanometer and stethoscope.

The cold pressor task itself was then administered in a second room, which contained a chair flanked by two tanks of water. The first tank was


a warm water bath (32~ used to ensure that all subjects began a trial at approximately the same temperature. The cold water tank contained water and enough crushed ice to maintain the temperature near 0~ As in other studies, a pump kept the water circulating, while a mesh screen prevented the ice f rom coming into direct contact with the person's hand.

Each subject was instructed to immerse his nondominant hand up to the wrist, first in the warm w a t e r - for 1 r a i n - and then immediately in the ice water. He was told to say "Now" when he first experienced a painful sensation (the measure of threshold) and was instructed to leave his hand in the water as long as possible, up to a 5-min maximum (the measure of tolerance).2 The experimenter measured threshold and tolerance times with a stop- watch. After each trial, subjects rated their discomfort on an 8-point scale (from "mildly unpleasant" to "absolutely intolerable").

Following the baseline trial, subjects were given a 15-rain rest period. During this interval, subjects in the three experimental groups listened to tape- recorded training instructions appropriate to their groups. Those in the control group were provided with magazines to look at and then listened to a brief tape of instructions about the second trial. All subjects had a brief "re- hearsal" period prior to the start of the second trial, during which they could practice their strategy aloud; this enabled the experimenter to determine whether they had correctly understood the instructions. Subjects then proceed- ed with trial 2, again using the warmup bath for 1 min before proceeding with the cold water immersion. At the conclusion of the second trial, they again rated discomfort and then returned to the first room to complete a postsession questionnaire and several personality measures. As part of the questionnaire, subjects rated the subjective effectiveness of the strategy they had been taught and gave an estimate of the percentage of time they felt they were able to use the strategy. The personality measures were the Miller Be- havioral Style Scale (MBSS), the Marlowe-Crowne Social Desirability Scale (1964), and the Absorption scale of Tellegen's Differential Personality Ques- tionnaire (1974).

C o n d i t i o n s

The training instructions which defined the conditions were as follows. (1) Self-Observation. Subjects were asked to concentrate in detail on

the sensations they were experiencing. They were to note changes in sensation, including how their fingers felt, where they experienced cold, numb- ness, tingling, etc.

2Previous investigators have traditionally set 5 min as an immersion time limit, both to fore- stall the possibility of health hazards and because most variations in sensation appear to run their course within this period.


(2)Exaggeration. Subjects receiving these counterintuitive or "paradoxical" instructions were told not only to observe, but also to exaggerate the sensations they experienced, trying to make each one more intense. For example, if their fingers felt cold, they were to try to make them feel colder.

(3) Rational statements. Subjects were trained to use rational statements instead of focusing on the details of their experience. Sample statements, such as the following, were provided: "One of the good things about this experience is that it might help psychologists learn more about people" (Beers and Karoly, 1979).

(4) Control. Subjects in the control group were invited to approach the second trial in a way which they had decided would be most comfortable, using their own past experience as a guide.

In order to establish a uniform positive expectancy across conditions, all subjects were told that the second trial would be somewhat easier than the first. It was suggested that now that they were "experienced" in the task and knew what to expect, they would probably be more successful.

Measures

Monitoring~Blunting. The Miller Behavioral Style Scale consists of 16 monitor and 16 blunter items, organized around four brief vignettes. An example of a vignette is, "Vividly imagine that you are on an airplane. Thirty minutes from your destination, the plane unexpectedly goes into a nose dive and then suddenly levels off. The pilot announces that everything is okay, although the rest of the ride may be rough. You are not, however, convinced that all is well." One monitoring response is "I would listen carefully to the engines for unusual noises, and would watch the crew to see if their behavior was out of the ordinary." In contrast, a blunting response for this vignette is "I would watch the end of the movie even if I had seen it before." Subjects can endorse as many responses as they like and are classified by tallying the number of monitor items endorsed minus the number of blunter items endorsed. For this study, a mean split (M = 5.62, SD = 4.76) was used to divide subjects of the four groups into monitors (n = 44) and blunters (n = 29). (A median split has also been used in the past to divide monitors and blunters, but in our sample that method would have resulted in an ex- cessively large number of ties.) Other college samples have yielded almost identical means: 5.333 for 100 University of Pennsylvania students and 5.625 for 100 Temple University undergraduates. Test-retest reliability for the scale, assessed over a 2-month period, is reported to be .74 (N = 40) (Miller, 1987).

Other Measures. The Marlowe-Crowne Social Desirability Scale (1964) and the Tellegen Absorption scale (1974) were administered, partly to mask our special interest in monitoring/blunting but also because these scales were


considered to be of some interest in their own right. For example, it might be presumed that subjects with higher social desirability scores would keep their hands in the ice water longer in order to win approval. Also, correlations between MBSS scores and social desirability scores might point to an undesirable response bias factor in the MBSS.

The Absorpt ion scale has been said to measure the ability to become involved in imaginal activities. It was developed in connection with work on hypnosis, and correlations of about .40 with hypnotic performance have been reported. Absorpt ion scale scores might be relevant to predicting which subjects would be adept at using distraction techniques.

RESULTS

The two major dependent measures were tolerance and threshold (both measured as seconds). A third measure, subjective ratings of discomfort, was collected but proved relatively insensitive. Analyses of threshold and tolerance data for the baseline trial showed no significant differences across the four conditions, indicating that random assignment of subjects to groups had not inadvertently produced initial group differences in sensitivity to cold pressor stress (see Table I).

Table II presents the test trial means and standard deviations for the threshold and tolerance scores of each treatment group. 3 Threshold and tolerance scores were first subjected to analysis of variance; then, following the procedures recommended by Kirk (1968) for testing a priori hypotheses, the error terms f rom the analyses of variance were used to calculate t ratios for the specific predicted mean differences. The ANOVA for threshold scores yielded no significant main effects for condition or moni tor-blunter status but did yield a significant interaction between these two factors [F(3, 65) = 2.95, p < .05]. The ANOVA for tolerance scores yielded neither significant main effects nor a significant interaction.

Preplanned orthogonal contrasts demonstrate that subjects in the three treatment groups are better able than control subjects to delay the onset of discomfort [t(69) -- 2.81, p < .01]. The same cannot be said with regard to the amount of time (tolerance) subjects were willing to leave their hands in the ice water, which was not significantly different across groups. Thus, the first hypothes i s -concern ing the utility of being instructed in a specific s t r a t e g y - w a s supported for threshold but not tolerance scores.

3Because of marked heterogeneity of variance in threshold scores, all reported analyses of threshold data were actually performed with log transformations. The formula used to trans- form raw scores was X / = log (X + 1). This transformation successfully eliminated heter- oscedasticity (Bartlett-Box F = .139, p = .94) (Kirk, 1968).


Table I. Baseline Trial Means and Standard Deviations for Monitors and Blunters

Control Observation Exaggeration Rational

Threshold scores (sec)

Monitors n 10 10 13 11 M 21.5 38.2 47.5 20.4 SD 19.6 64.0 40.0 9.4

Blunters n 7 9 6 7 M 2!.4 34.0 24.0 32.1 SD 8.7 43.6 11.2 23.1

Tolerance scores (sec)

Monitors M 84.8 117,0 93.7 71.4 SD 71.1 89,4 46.3 69.4

Blunters M 106.7 86,4 58.0 95.4 SD 65.6 69.8 29.2 73.9

T h e h y p o t h e s i s t h a t m o n i t o r s a n d b l u n t e r s w o u l d p e r f o r m bes t w i t h

a n i n s t r u c t i o n a l set t h a t e n c o u r a g e d t h e u s e o f t h e i r p r e f e r r e d c o p i n g s ty les

was t e s t e d v ia p r e p l a n n e d c o m p a r i s o n s . B l u n t e r s d id , in f a c t , h a v e h i g h e r

t h r e s h o l d s t h a n m o n i t o r s w h e n i n v i t e d t o use t h e r a t i o n a l s t a t e m e n t s t r a t e -

gy, w h i c h a l l o w s t h e de t a i l s o f a s i t u a t i o n to r e m a i n b l u r r e d [ t (65) = 1,74,

Table 11, Test Trial Means and Standard Deviations for Monitors and Blunters

Control Observation Exaggeration Rational

Threshold scores (sec)

Monitors n 10 10 13 11 M 25.6 82.9 67.9 44.2 SD 21.0 95.1 72.0 32.5

Blunters n 7 9 6 7 M 31.0 36.9 36.7 96.3 SD 21.5 15.5 11.7 59.1

Tolerance scores (sec)

Monitors M 96.5 144.7 137.2 125.7 SD 93.7 108.1 92.8 I01.2

Blunters M 151.0 175.4 134.7 199.3 SD 97.6 110.8 86.0 100.4


p < .05]. However, the predicted superiority of monitors over blunters with the self-observation strategy (which allows a detailed focus on sensations) was nonsignificant [t(65) = .79].

Blunters in the rational statement group showed higher pain thresholds than blunters in either the observation condition [t(65) = 1.72, p < .05] or the exaggeration condition [t(65) = 1.49, p < .10]. Both of the latter conditions make it difficult to ignore one's sensations. Monitors in the observation condition did not have significantly higher thresholds than monitors in the other two treatment groups, although the means were arrayed in the predicted pattern (see Table II).

Tolerance scores proved relatively insensitive to differences in either instructional set or coping style.

There was no evidence at all for the superiority of the exaggeration s t r a t egy- our attempt at inducing paradoxical i n t en t ion - for either threshold or tolerance scores. The only difference in tolerance scores which approached significance was a general superiority of blunters (M = 167) over monitors (M = 127) [t(71) = 1.63, p = .054]. This finding is, of course, consistent with the previously mentioned possibility that blunters are overrepresented in the group that reached the 5-rain ceiling during the initial trial.

A small but significant relationship was found between monitor/blunter scores and subjects' ratings of how effective they found the cognitive strategies to be (r = - . 2 6 , p < .03, n = 85). 4 This finding, the only difference to emerge f rom the postsession questionnaire, coincides with reports that monitors do not have as much confidence as blunters do in their ability to handle themselves in stressful circumstances. Subjects in all three treatment groups reported that they were able to make use of the suggested techniques, and there were no other indications that any of the subgroups had markedly different expectations about the utility of the technique they had been taught.

Neither the Marlowe-Crowne Social Desirability measures nor the Ab- sorption scale related significantly to any of the other variables of the study. Thus, "absorpt ion" does not seem to predict performance on the cold pressure task, either with or without tutoring in special strategies, nor is there any evidence of a contaminat ion of MBSS scores with the kind of response style that social desirability scores represent.

Finally, it might be noted that the threshold and tolerance levels we obtained were well within the range of values reported in other studies that use the cold pressor task (e.g., Beers and Karoly, 1979; Stevenson et al., 1984).

4Higher monitor/blunter scores indicate a preference for monitoring over blunting.


DISCUSSION

The results of this experiment support the conclusion that cognitive strategies for enhancing pain threshold are differentially effective, depend- ing on the coping style of the individual. In our study the interaction between coping style and treatment strategy was visible only with regard to the threshold measure, not tolerancefl and was significant only for blunters. There is inconsistency in the literature concerning which of these s c o r e s - threshold or t o l e r ance - i s apt to be more sensitive to cognitive manipulations. Some investigators found that threshold scores were more sensitive, as we did, while others found that tolerance measures were more readi- ly influenced (see McCaul and Malott , 1984). In this regard, McCaul and Haugtvedt (1982) note that psychological manipulations can have more effect when the pain is mild and brief, but this has not always proven to be the case. In our study, tolerance scores were characteriz- ed by a high degree of variability. The experimenters who worked with our subjects had the impression that some of this variability was related to differences in the overall stance subjects took with regard to the task. Some subjects, for example, appeared quite serious about it, wanting to see if they could "meet the challenge." Others seemed more interested in getting through this potentially discomforting assignment as quickly and easily as possible. Such differences in motivation and task definition might have masked differences in tolerance associated with the particulars of the strategy taught or preferences in styles of coping with unavoidable stress. For some subjects, this was not unavoidable s t r e s s - i t was an interesting challenge.

Subjective ratings of discomfort had been collected but did not prove helpful in teasing out differences in reaction. Some investigators, noting the insensitivity of this measure in similar contexts, have argued that this insensitivity results f rom the fact that these ratings are generally administered after rather than during a given trial (Avia and Kanfer, 1980; McCaul and Malott, 1984). We recognized that assessing discomfort retrospectively potentially weakened the utility of the measure. However, on balance, we decided it was better to run that risk than to introduce any additional cognitive dis- tractions during the trials themselves. Even the simple requirement of having to say "now" upon experiencing distress artificially introduces a certain degree of cognitive strain for subjects, particular btunters, who are presuma-

~However, 6 of the 12 subjects who tolerated the ice water for the full 5 rain on the initial trial were hlunters. Since the overall ratio of blunters to monitors in the study was 1 to 1.428, blunters seem to be overrepresented in this self-selected group. Given the small numbers involved, the difference in ratios was not significant, but the pattern hints at a superiority of blunters in tolerance as well as threshold. The 5-min ceiling may have prevented that superiority from showing up in the formal analyses.


bly employing various strategies to remain psychologically inattentive to the proceedings.

In the present study, our predictions for monitors were not significantly confirmed, although the pattern of means was as predicted. The lack of statistical significance here is clearly attributable to the fact that monitors were much more variable than blunters in their response to instructions, producing standard deviations which "swamped" mean differences between conditions. This is consistent with another impression that developed as we worked more intimately with the cold pressor s i tua t ion-namely , that it is easier to design effective standardized instructions for blunters than for monitors. This is because blunters need only to avoid the details of the situation, and the exact nature of the distractor does not seem very crucial. Monitors, on the other hand, are actively processing information moment to moment, and their questions and needs change as the task unfolds. Thus, it is harder to design an initial instruction that will provide them with the informational resources they desire. Perhaps this is also why, in our study, those with high scores on the MBSS reported less confidence in the effectiveness of the techniques they were shown. To produce optimal effects with monitors, it may be necessary to provide more individualized and ongoing assistance. This would apply in field settings as well, where monitors might profit from more detailed and continuing "orientation" sessions, with op- portunities to ask questions and report experiences.

Research on the pain experience has often emphasized the importance of a sense of control (e.g., Melzack, 1973). Pain is, of course, not simply a set of physiological sensations, but a psychological experience colored by interpretations of danger and uncontrollability. Thus, it is not surprising that a "training" procedure, which provides structure, can produce effects on discomfort, almost regardless of its specific content. When the content of the structure is consistent with, rather than opposed to, the individual's own in- clinations, the effect can be expected to be enhanced.

McCaul and Malott (1984) report that, in the past, only repression/sensitization has shown a consistent relation to cold pressor performance under different instructional conditions. Now the MBSS appears to provide a measure of coping styles that is also useful in stressful contexts. The content of the MBSS is more directly relevant to coping performance, and thus the scale entails fewer interpretative assumptions than Byrne's MMPI-based measure. Moreover, scores on the MBSS appear freer of response bias con- taminants. As we have already indicated, the MBSS is doing well at predicting coping responses in naturalistic field settings as well as in laboratory tasks such as the cold pressor.

Blunters are reputed to handle stress situations "better" than monitors do, that is, with fewer outward signs of distress. While monitors want to be "in the know" and say that they prefer having information to not having


information, they are not necessarily relaxed in the face of aversive consequences. Blunters, with their willingness and /o r ability to "tune out ," seem to have an easier time with the experience itself. In this study, the data sug- gest that blunters both react less strongly and are able to leave their hands in the cold water for longer periods of time. With or without special instructions, they "sit through" these situations with more equanimity. A potentially important but open question in the field of stress management is whether monitors c a n - a n d s h o u l d - b e trained to adopt blunting strategies.

Finally, a word about our unsuccessful at tempt to demonstrate a special benefit of paradoxical intention instructions with the cold pressor task. As far as we know, there has been only one other at tempt to apply paradoxical intention in a cold pressor environment, and there, too, it showed no special merit over other cognitive strategies (Gilligan et al., 1984). In many clinical settings, however, paradoxical intention seems to decrease a client's experience of helplessness, breaking the "fear of fear" cycle (see Ascher, 1980). There are, of course, many differences between those clinical circumstances and our laboratory situation. A laboratory task is of a short duration and terminates soon even if one has not developed mastery over it. This is not true of clinical problems, which persist and even intensify over time if they are not successfully solved. Paradoxical intention has been most useful when a person has already exhausted his or her supply of "common-sense" approaches to the problem and comes to the clinic looking for something new to try. For most of our subjects, the cold pressor task was a novelty, rather than a source of persistent frustration. Under these conditions, paradoxical intention had no special advantage.

A C K N O W L E D G M E N T S

The authors wish to acknowledge G. Craig Caputo, Margot L. Green, and Alan Sockloff for their assistance in analyzing the data. Lawrence Bren- nan, Seth Glicksman, Bradley D. Langendorf , and Dennis Sandrock aided in running the study. Elsa R. Efran and Robert J. Lukens helped prepare the manuscript for publication.

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Coping styles, paradox, and the cold pressor task

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