HEALTH PSYCHOLOGY, 1992,11(4), 208-209 Copyright © 1992, Lawrence Erlbaum Associates, Inc.
I Know Distraction Works Even Though It Doesn't! Howard Leventhal
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Institute for Health Rutgers University Resistance is high to findings negating commonsense beliefs. If McCaul, Monson, and Maki's (1992) four studies are taken seriously, we will address new questions about the components of analgesic interventions—specifically, whether distraction works only when combined with a competing affect, an analgesic cognition, or both. Addressing these questions should increase our understanding of the mechanisms involved in pain processing and may increase our ability to intervene and modify chronic as well as acute pain. Laboratory studies offer an efficient route to such understanding, although the question of generalization will always lurk in the background.
McCaul, Monson, and Maki's (1992) four experiments present a rather convincing argument that distraction by itself lacks analgesic properties. These findings pose an interesting challenge to the theory, research, and practice of health psychologists involved in the study and treatment of pain. I am concerned, however, that neither these studies, nor others like them, will change the beliefs or practices of individuals (psychologists included) who are convinced that distraction is an effective analgesic. No matter how many null results are published, statistical findings will lose out to the commonsense belief that distraction works even if it doesn't. Exactly how strong this belief can be became clear to us in two ways. First, subjects in a laboratory study gave very high ratings to distractive procedures for effective pain control and very low ratings to sensation monitoring, even though monitoring proved to be the more effective analgesic (Ahles, Blanchard, & H. Leventhal, 1983). Second, in pilot trials for our field study on the effects of monitoring the somatic sensations of contractions during childbirth (E. A. Leventhal, H. Leventhal, Shachman, & Easterling, 1989), repeated revision and weeks of testing were necessary in order for us to develop instructions that were effective in getting women to monitor the somatic sensations of their contractions. These mothers wanted to distract, not to monitor; we had no trouble encouraging another group of mothers to distract. After giving birth, several of those who monitored expressed surprise that monitoring actually reduced distress! In sum, it is counterintuitive to monitor sensations in order to reduce pain and distress and intuitively consistent to distract. I have emphasized the commonsense bias that favors distraction to persuade you, as well-trained critical readers, (a) to refrain for just a moment from the methodological nit-picking that allows all of us to ignore findings counter to our common sense and (b) to give careful thought to the implications of McCaul et al.'s conclusions. Yes, there are "things wrong" with these studies. The subjects were undergraduates, not adults in clinical settings. The noxious stimulation was from a laboratory, cold-pressor task, not from a dental procedure (Anderson & Baron, 1991) or a chemotherapy treatment for cancer. Distraction may work for some types of pain (abrupt onset, short duration) and not others! Pain and distress might be
Requests for reprints should be sent to Howard Leventhal, Institute for Health, Rutgers University, P.O. Box 5070, New Brunswick, NJ 089035070.
reduced while subjects are performing the distraction task but not while attending to their hand to make a pain report—this criticism failing, of course, to account for successful distress reduction in other studies that used distraction in combination with other types of information. What makes McCaul et al.'s studies important is their effort to isolate one component of what is typically a complex experimental and/or clinical manipulation. By doing so, they point to a new set of questions to guide research and practice. For example, studies of distraction might ask whether distraction reduces pain only when it is accompanied by a strong, positive affect. Or, studies may try to see if distraction reduces pain when accompanied by a believable, analgesic suggestion, as is the case with hypnotic analgesia (Hilgard, 1971). These questions seek to identify additional components necessary for distraction-induced analgesia and to ask whether these additional components are classifiable as moods and/or emotions or as cognitions (i.e., the analgesic meaning of the distractive activity). If the additional component is a mood or an emotion, we might ask if the emotion need be positive or if it can be negative. For example, can fear be the analgesic addition in humans, as it is with lower animals (Fanselow & Helmstetter, 1988)? Whatever the outcome, the data would be consistent with McCaul et al.'s conclusion that distraction, or a simple "clogging" of the higher level serial processor, is insufficient to reduce pain and distress; a substantive factor (a particular feeling or meaning) must be added to the content-free variable of attention. Answers to these questions may also help us understand individual differences in response to noxious stimulation. Thus, particular ways of thinking about noxious stimuli might characterize and differentiate individuals with high pain thresholds and much tolerance for pain from individuals with low thresholds and little tolerance for pain. The practitioner might wonder whether any of these distinctions are critical for practice and, if adopted in practice, whether they would produce effects as important as those brought about by the pharmacological approaches to pain reduction for combat wounds reported five decades ago by Beecher (1946). Beecher's initial approach to pharmacological analgesia (using morphine to block the sensory conduction of pain signals) was based on a cognitive analogue. When morphine proved fatal in a few cases, therapy shifted to the control of emotion, and phenobarbital was used for its anxioly tic, analgesic action. The study of individual differences could
209
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
DISTRACTION WORKS
therefore move from efforts to characterize people as "possessing" differential amounts of an abstract trait to the identification of the cognitions they generate in specific problem situations and the understanding of how these situational representations affect the adoption of specific coping procedures. Individual differences in reactivity in specific physiological channels—that is, differences in temperament—could play a role in this process, as could differences in knowledge based on differences in past history. In short, the study of individual differences would be transformed from the study of Trait x Situation interactions to the study of Person x Situation interactions (Contrada, H. Leventhal, & O'Leary, 1990). Lastly, will the identification of the combinations effective for pain reduction have implications for practice as well as for psychological theory? Although I doubt that the identification of the critical additions to distraction will produce as dramatic effects in practice as did the changes in the pharmacological treatment of pain, I do believe that their identification will prove to be more than a theoretical nicety. Critical reviews of investigations of procedures for stress and pain management during noxious medical procedures point to the multicomponent nature of clinical interventions, the partial overlap of presumably "different" interventions, and the lack of information on the contribution of specific components and combinations of components to positive outcomes (Ludwick-Rosenthal & Neufeld, 1988). Laboratory experiments such as McCaul et al.'s are an inexpensive route to such knowledge. They provide controlled settings in which one can examine the effects of specific factors alone and in combination. Identifying key components and understanding how they work alone and in combination will allow us to generate brief interventions, the components of which are tuned to the analgesic demands of specific types of pain in particular contexts. The result will be the efficient and effective use of distraction-based combinations in cases in which these combinations are likely to be of greatest value (e.g., for regulating distress over the short term; Suls & Wan, 1989). In addition to efficiency, however, identification of these combinations should increase our understanding of the mechanism underlying the pain experience and prove valuable to enhancing the treatment of chronic pain disorders. Among those who live with cancer, heart disease, arthritis, and injury, there are dramatic differences between those who do not feel, attend to, or allow somatic sensations to disrupt their daily activities and those who are absorbed with their moment-by-moment somatic experience and become walking prototypes of a specific illness (Nerenz & H. Leventhal, 1983). Although an attentional factor is involved in this difference in illness behavior (Mechanic, 1985; Pilowsky, 1985), attention cannot fully explain the difference. An increase in our understanding of the combinations and mechanisms underlying short-term, distrac-
tion-based analgesia may take us a step toward identifying the components and processes that lead to or allow us to avoid the experience of chronic pain. Although McCaul et al.'s experiments do not address these issues, they raise questions that may stimulate movement in this direction.
ACKNOWLEDGMENTS I thank Elaine Leventhal, Michael Diefenbach, and Linda PatrickMiller for their helpful comments. REFERENCES Ahles, T. A., Blanchard, E. B., & Leventhal, H. (1983). Cognitive control of pain: Attention to the sensory aspects of the cold pressor stimulus. Cognitive Therapy and Research, 7, 159-177. Anderson, R. A., & Baron, R. S. (1991). Distraction, control, and dental stress. Journal of Applied Social Psychology, 21, 156-171. Beecher, H. K. (1946). Pain of men wounded in battle. Annals of Surgery, 123, 96-105. Contrada, R., Leventhal, H., & O'Leary, A. (1990). Personality and health. In L. Pervin (Ed.), Handbook of personality: Theory and research (pp. 638-669). New York: Guilford. Fanselow, M. S., & Helmstetter, F. J. (1988). Conditional analgesia, defensive freezing, and benzodiazepines. Behavioral Neuroscience, 102, 233243. Hilgard, E. R. (1971). Hypnotic phenomena: The struggle for scientific acceptance. American Scientist, 59, 567-577. Leventhal, E. A., Leventhal, H., Shachman, S., & Easterling, D. V. (1989). Active coping reduces reports of pain from childbirth. Journal of Consulting and Clinical Psychology, 57, 365-371. Ludwick-Rosenthal, R., & Neufeld, R. W. J. (1988). Stress management during noxious medical procedures: An evaluative review of outcome studies. Psychological Bulletin, 104, 326-342. McCaul, K. D., Monson, N., & Maki, R. H. (1992). Does distraction reduce pain-produced distress among college students? Health Psychology, 11, 210-217. Mechanic, D. (1985). Illness behavior: An overview. In S. McHugh & T. M. Vallis (Eds.), Illness behavior: A multidisciplinary model (pp. 101-110). New York: Plenum. Nerenz, D. R., & Leventhal, H. (1983). Self-regulation theory in chronic illness. In T. G. Burish & L. A. Bradley (Eds.), Coping with chronic disease: Research and applications (pp. 13-17). New York: Academic. Pilowsky, I. (1985). Abnormal illness behavior: A review of the concept and its implications. In S. McHugh & T. M. Vallis (Eds.), Illness behavior: A multidisciplinary model (pp. 391-396). New York: Plenum. Suls, J., & Wan, C. K. (1989). Effects of sensory and procedural information on coping with medical procedures and pain: A meta-analysis. Journal of Consulting and Clinical Psychology, 57, 372-379.
I Know Distraction Works Even Though It Doesn't! Howard Leventhal
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Institute for Health Rutgers University Resistance is high to findings negating commonsense beliefs. If McCaul, Monson, and Maki's (1992) four studies are taken seriously, we will address new questions about the components of analgesic interventions—specifically, whether distraction works only when combined with a competing affect, an analgesic cognition, or both. Addressing these questions should increase our understanding of the mechanisms involved in pain processing and may increase our ability to intervene and modify chronic as well as acute pain. Laboratory studies offer an efficient route to such understanding, although the question of generalization will always lurk in the background.
McCaul, Monson, and Maki's (1992) four experiments present a rather convincing argument that distraction by itself lacks analgesic properties. These findings pose an interesting challenge to the theory, research, and practice of health psychologists involved in the study and treatment of pain. I am concerned, however, that neither these studies, nor others like them, will change the beliefs or practices of individuals (psychologists included) who are convinced that distraction is an effective analgesic. No matter how many null results are published, statistical findings will lose out to the commonsense belief that distraction works even if it doesn't. Exactly how strong this belief can be became clear to us in two ways. First, subjects in a laboratory study gave very high ratings to distractive procedures for effective pain control and very low ratings to sensation monitoring, even though monitoring proved to be the more effective analgesic (Ahles, Blanchard, & H. Leventhal, 1983). Second, in pilot trials for our field study on the effects of monitoring the somatic sensations of contractions during childbirth (E. A. Leventhal, H. Leventhal, Shachman, & Easterling, 1989), repeated revision and weeks of testing were necessary in order for us to develop instructions that were effective in getting women to monitor the somatic sensations of their contractions. These mothers wanted to distract, not to monitor; we had no trouble encouraging another group of mothers to distract. After giving birth, several of those who monitored expressed surprise that monitoring actually reduced distress! In sum, it is counterintuitive to monitor sensations in order to reduce pain and distress and intuitively consistent to distract. I have emphasized the commonsense bias that favors distraction to persuade you, as well-trained critical readers, (a) to refrain for just a moment from the methodological nit-picking that allows all of us to ignore findings counter to our common sense and (b) to give careful thought to the implications of McCaul et al.'s conclusions. Yes, there are "things wrong" with these studies. The subjects were undergraduates, not adults in clinical settings. The noxious stimulation was from a laboratory, cold-pressor task, not from a dental procedure (Anderson & Baron, 1991) or a chemotherapy treatment for cancer. Distraction may work for some types of pain (abrupt onset, short duration) and not others! Pain and distress might be
Requests for reprints should be sent to Howard Leventhal, Institute for Health, Rutgers University, P.O. Box 5070, New Brunswick, NJ 089035070.
reduced while subjects are performing the distraction task but not while attending to their hand to make a pain report—this criticism failing, of course, to account for successful distress reduction in other studies that used distraction in combination with other types of information. What makes McCaul et al.'s studies important is their effort to isolate one component of what is typically a complex experimental and/or clinical manipulation. By doing so, they point to a new set of questions to guide research and practice. For example, studies of distraction might ask whether distraction reduces pain only when it is accompanied by a strong, positive affect. Or, studies may try to see if distraction reduces pain when accompanied by a believable, analgesic suggestion, as is the case with hypnotic analgesia (Hilgard, 1971). These questions seek to identify additional components necessary for distraction-induced analgesia and to ask whether these additional components are classifiable as moods and/or emotions or as cognitions (i.e., the analgesic meaning of the distractive activity). If the additional component is a mood or an emotion, we might ask if the emotion need be positive or if it can be negative. For example, can fear be the analgesic addition in humans, as it is with lower animals (Fanselow & Helmstetter, 1988)? Whatever the outcome, the data would be consistent with McCaul et al.'s conclusion that distraction, or a simple "clogging" of the higher level serial processor, is insufficient to reduce pain and distress; a substantive factor (a particular feeling or meaning) must be added to the content-free variable of attention. Answers to these questions may also help us understand individual differences in response to noxious stimulation. Thus, particular ways of thinking about noxious stimuli might characterize and differentiate individuals with high pain thresholds and much tolerance for pain from individuals with low thresholds and little tolerance for pain. The practitioner might wonder whether any of these distinctions are critical for practice and, if adopted in practice, whether they would produce effects as important as those brought about by the pharmacological approaches to pain reduction for combat wounds reported five decades ago by Beecher (1946). Beecher's initial approach to pharmacological analgesia (using morphine to block the sensory conduction of pain signals) was based on a cognitive analogue. When morphine proved fatal in a few cases, therapy shifted to the control of emotion, and phenobarbital was used for its anxioly tic, analgesic action. The study of individual differences could
209
This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
DISTRACTION WORKS
therefore move from efforts to characterize people as "possessing" differential amounts of an abstract trait to the identification of the cognitions they generate in specific problem situations and the understanding of how these situational representations affect the adoption of specific coping procedures. Individual differences in reactivity in specific physiological channels—that is, differences in temperament—could play a role in this process, as could differences in knowledge based on differences in past history. In short, the study of individual differences would be transformed from the study of Trait x Situation interactions to the study of Person x Situation interactions (Contrada, H. Leventhal, & O'Leary, 1990). Lastly, will the identification of the combinations effective for pain reduction have implications for practice as well as for psychological theory? Although I doubt that the identification of the critical additions to distraction will produce as dramatic effects in practice as did the changes in the pharmacological treatment of pain, I do believe that their identification will prove to be more than a theoretical nicety. Critical reviews of investigations of procedures for stress and pain management during noxious medical procedures point to the multicomponent nature of clinical interventions, the partial overlap of presumably "different" interventions, and the lack of information on the contribution of specific components and combinations of components to positive outcomes (Ludwick-Rosenthal & Neufeld, 1988). Laboratory experiments such as McCaul et al.'s are an inexpensive route to such knowledge. They provide controlled settings in which one can examine the effects of specific factors alone and in combination. Identifying key components and understanding how they work alone and in combination will allow us to generate brief interventions, the components of which are tuned to the analgesic demands of specific types of pain in particular contexts. The result will be the efficient and effective use of distraction-based combinations in cases in which these combinations are likely to be of greatest value (e.g., for regulating distress over the short term; Suls & Wan, 1989). In addition to efficiency, however, identification of these combinations should increase our understanding of the mechanism underlying the pain experience and prove valuable to enhancing the treatment of chronic pain disorders. Among those who live with cancer, heart disease, arthritis, and injury, there are dramatic differences between those who do not feel, attend to, or allow somatic sensations to disrupt their daily activities and those who are absorbed with their moment-by-moment somatic experience and become walking prototypes of a specific illness (Nerenz & H. Leventhal, 1983). Although an attentional factor is involved in this difference in illness behavior (Mechanic, 1985; Pilowsky, 1985), attention cannot fully explain the difference. An increase in our understanding of the combinations and mechanisms underlying short-term, distrac-
tion-based analgesia may take us a step toward identifying the components and processes that lead to or allow us to avoid the experience of chronic pain. Although McCaul et al.'s experiments do not address these issues, they raise questions that may stimulate movement in this direction.
ACKNOWLEDGMENTS I thank Elaine Leventhal, Michael Diefenbach, and Linda PatrickMiller for their helpful comments. REFERENCES Ahles, T. A., Blanchard, E. B., & Leventhal, H. (1983). Cognitive control of pain: Attention to the sensory aspects of the cold pressor stimulus. Cognitive Therapy and Research, 7, 159-177. Anderson, R. A., & Baron, R. S. (1991). Distraction, control, and dental stress. Journal of Applied Social Psychology, 21, 156-171. Beecher, H. K. (1946). Pain of men wounded in battle. Annals of Surgery, 123, 96-105. Contrada, R., Leventhal, H., & O'Leary, A. (1990). Personality and health. In L. Pervin (Ed.), Handbook of personality: Theory and research (pp. 638-669). New York: Guilford. Fanselow, M. S., & Helmstetter, F. J. (1988). Conditional analgesia, defensive freezing, and benzodiazepines. Behavioral Neuroscience, 102, 233243. Hilgard, E. R. (1971). Hypnotic phenomena: The struggle for scientific acceptance. American Scientist, 59, 567-577. Leventhal, E. A., Leventhal, H., Shachman, S., & Easterling, D. V. (1989). Active coping reduces reports of pain from childbirth. Journal of Consulting and Clinical Psychology, 57, 365-371. Ludwick-Rosenthal, R., & Neufeld, R. W. J. (1988). Stress management during noxious medical procedures: An evaluative review of outcome studies. Psychological Bulletin, 104, 326-342. McCaul, K. D., Monson, N., & Maki, R. H. (1992). Does distraction reduce pain-produced distress among college students? Health Psychology, 11, 210-217. Mechanic, D. (1985). Illness behavior: An overview. In S. McHugh & T. M. Vallis (Eds.), Illness behavior: A multidisciplinary model (pp. 101-110). New York: Plenum. Nerenz, D. R., & Leventhal, H. (1983). Self-regulation theory in chronic illness. In T. G. Burish & L. A. Bradley (Eds.), Coping with chronic disease: Research and applications (pp. 13-17). New York: Academic. Pilowsky, I. (1985). Abnormal illness behavior: A review of the concept and its implications. In S. McHugh & T. M. Vallis (Eds.), Illness behavior: A multidisciplinary model (pp. 391-396). New York: Plenum. Suls, J., & Wan, C. K. (1989). Effects of sensory and procedural information on coping with medical procedures and pain: A meta-analysis. Journal of Consulting and Clinical Psychology, 57, 372-379.
