Effects of suppression, acceptance and spontaneous coping on pain tolerance, pain intensity and distress

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Abstract

Wegner's Theory of Ironic Processes has been applied to study the effects of cognitive strategies to control pain. Research suggests that suppression contributes to a more distressing pain experience. Recently, the acceptance-based approach has been proposed as an alternative to cognitive control. This study assessed the tolerance time, the distress and the perceived pain intensity in three groups (suppression, acceptance and spontaneous coping groups) when the participants were exposed to a cold pressor procedure. Two hundred and nineteen undergraduates volunteered to participate. The suppression group showed the shortest tolerance time and the acceptance group showed the longest tolerance time. The acceptance group showed pain and distress immersion ratings that were significantly lower than in the other two groups, between which the differences were not significant. In the first recovery period, the suppression group showed pain and distress ratings that were higher than in the other two groups. In the second recovery period, although the acceptance group showed pain and distress ratings that were significantly lower than in the other two groups, the suppression and the spontaneous coping groups did not differ. The presence of a ‘rebound’ of physical discomfort and the effects of suppression on behavioural avoidance are discussed. These results support the acceptance approach in the management of pain.

Introduction

In western culture, distraction is a commonsense strategy to control pain, and ‘attention diversion training’ is an important element in most types of cognitive behavioural therapy. Nevertheless, the effectiveness of distraction in the control of pain is still a controversial matter (Goubert, Crombez, Eccleston, & Devulder, 2004; Roelofs, Peters, Van der Zijden, & Vlaeyen, 2004) and the results from clinical and experimental research are inconclusive (Ahles, Blanchard, & Leventhal, 1983; Cioffi, 1991; Elliot & Eccleston, 2003; Hodes, Howland, Lightfoot, & Cleeland, 1990; Leventhal, 1992; McCaul & Malott, 1984; Morley, Shapiro, & Biggs, 2003; Turk, Meichenbaum, & Genest, 1983).

Wegner (1994) contemplated thought suppression research to shed light on the contradictory results relating to the relative effectiveness of two cognitive strategies to control pain: attention to or distraction from the pain. Wegner, Schneider, Carter, and White (1987) demonstrated that when participants had been instructed to suppress neutral thoughts, they had more frequent thought occurrences compared with when they had been asked to express the thought (‘immediate enhancement effect’). Also, a ‘rebound effect’ was found, in which those who were initially asked to suppress a thought experienced that thought more frequently during a subsequent expression period compared with those who first expressed and then suppressed the thought. The Theory of Ironic Processes (Wegner (1992), Wegner (1994)) suggests that this increase of thoughts could be explained by the action of two opposing processes: an intentional operating process that searches for the mental contents that will yield the desired state; and an ironic monitoring process that searches for mental contents that signal the failure to achieve the desired state. Under mental load, the operating process will be limited and the monitoring process that searches for thoughts or sensations that are indicative of failed control will take them into consciousness. Nevertheless, based on an extensive review of more than a decade of research, Purdon (1999) concluded that the results of the studies investigating the paradoxical effects of suppression on frequency of neutral and clinically relevant thoughts have been highly inconsistent. The effects of suppression have also been studied in relation to discomfort and mood state (Koster, Rassin, Crombez, & Näring, 2003; Purdon & Clark, 2001; Purdon, Rowa, & Antony, 2005; Trinder & Salkovskis, 1994). Some found that suppression of obsessional thoughts was associated with greater discomfort and more negative mood state than suppression of positive or neutral thoughts, although they did not find paradoxical effects of suppression on the frequency of any type of thought (Purdon & Clark, 2001; Purdon, Rowa, & Antony, 2005). Purdon and Clark (2001) have argued that the discomfort that is associated with thought suppression should be the target of inquiry rather than the frequency of thoughts.

Cioffi and Holloway (1993) were the first to apply the Theory of Ironic Processes (Wegner (1992), Wegner (1994)) to the study of pain and found supportive evidence that subjects who are experiencing laboratory pain indicated greater pain perception with suppression than with distraction and/or monitoring. The target in their study was not a particular thought, but the experience of discomfort itself, and their results showed that the ‘rebound’ effect of thought suppression had an analogue in the subjective experience of somatic discomfort.

Sullivan, Rouse, Bishop, and Johnston (1997) found that participants who were asked to suppress their thoughts about an upcoming pain procedure experienced more thought intrusions during the suppression period, and experienced more pain during the ice-water immersion than participants who were not given suppression instructions.

Harvey and McGuire (2000) studied the effects of suppression of pain-related thoughts in a clinical sample. They found that the suppression instructions did not increase pain-related thoughts and that the subjects in the attention to pain condition showed more pain-related thoughts than the subjects in the suppression group. The authors explained that these unexpected results occurred as pain is primarily a physical sensation, and therefore could be less easily conceptualized as a discrete cognitive event. Harvey and McGuire (2000) proposed that future research should assess the effects of suppression of pain-related sensations rather than pain-related thoughts. Following this suggestion and in line with previous research (Cioffi & Holloway, 1993), the present study assessed the experience of discomfort itself as the target of suppression; pain was taken as a whole—that is, a complete experience comprising thoughts, emotions and sensations.

The best example of a therapeutic technique involving the suppression of unwanted thoughts is ‘thought-stopping’ (Wolpe & Lazarus, 1966), which is widely used and recommended in professional therapy (Druckman & Bjork, 1994). In order to favour the generalization to clinical practice, it is appropriate to test the effects of suppression instructions based on a specific therapeutic technique; therefore, the present study examined the effects of ‘thought-stopping’ on the tolerance time and on the distress when the participants were exposed to a painful procedure. As mentioned previously, the suppression instructions were directed not only to pain-related thoughts but also to pain-related sensations and emotions.

It is also interesting to compare the effects of suppression with the effects of alternative strategies. Goubert et al. (2004) suggested that acceptance-based protocols may be a promising alternative for attentional management of pain. A recent experimental study compared three groups—thought suppression, acceptance and monitoring-only—in relation to the frequency and distress associated with experiencing personally relevant intrusive thoughts (Marcks & Woods, 2005). Acceptance approaches seek to undermine the linkage between private events and overt behaviour, rather than attempting to control the form or frequency of private events (Hayes, Strosahl, & Wilson, 1999). Acceptance-based interventions attempt to teach clients to feel emotions and bodily sensations more fully and without avoidance, and to notice fully the presence of thoughts without following, resisting, believing or disbelieving them. Marcks and Woods (2005) found that those instructed to suppress their personal intrusive thoughts were unable to do so and experienced an increased level of distress after suppression, whereas those instructed to use an acceptance-based strategy experienced a decrease in discomfort level (but not thought frequency) after having used such a strategy. In the field of pain, Hayes et al. (1999), Hayes, Strosahl, & Wilson (1999) and Korn (1997) examined the behavioural and subjective impact of a control-based versus an acceptance rationale, using a cold pressor task. Subjects in the acceptance group demonstrated greater tolerance of pain compared with the control-based and placebo groups. The three groups did not differ in the measures related to the subjective experience of pain.

Gutiérrez, Luciano, Rodríguez, and Fink (2004) using electric shocks, found that the acceptance group showed significantly higher tolerance to pain compared to the control-based intervention group. Further, the control intervention produced a greater reduction in self-reported measures of pain.

The present study compared the effects of suppression—‘thought-stopping’—with the effects of an acceptance-based intervention on tolerance time and on the distress and the perceived pain intensity when the participants were exposed to a cold pressor procedure. The suppression and the acceptance instructions were directed not only to pain-related thoughts but also to pain-related sensations and emotions. Furthermore, it is important to compare the effects of these alternative interventions with the effects of the coping strategies that the participants spontaneously use. It is a well-known fact that, in experimental studies, participants report spontaneously using a wide range of coping strategies to help them endure the noxious sensations that they experience (Turk, Meichenbaum, & Genest, 1983). It has been argued that this condition is not of sufficient interest to warrant carrying out studies (Cioffi & Holloway, 1993); nevertheless, it must be demonstrated that, on average, the psychologically structured techniques are superior to the strategies that the individuals apply by themselves.

It was predicted that subjects in the suppression group, in comparison with subjects in the acceptance and the spontaneous coping groups, would show a shorter tolerance time and higher pain and distress ratings. Furthermore, subjects in the acceptance group are expected to show a longer tolerance time and lower pain and distress ratings than subjects in the spontaneous coping group.

Section snippets

Participants

Two hundred and nineteen psychology undergraduates volunteered to participate in exchange for course credits. The research project—of which this study is a part—was approved by the Carlos Haya Hospital Ethics Committee. Informed consent was obtained prior to data collection. The subjects were aware of the experimental procedure and of their right to withdraw from the study at any time without penalty.

Participants were excluded if the following medical problems were present: an existing pain

Results

Prior to analysis, the variables were examined for accuracy of data entry. According to the Kolmogorov–Smirnov test, the variables were normally distributed.

To assess the effect of the experimental manipulation, a one-way ANCOVA was conducted to determine whether the three groups differed in the dependent variables after the intervention procedure, which controlled for their baseline scores that were used as covariates.

Discussion

The aim of this study was to compare the effects of three alternative approaches directed at the management of pain: suppression by a specific therapeutic technique, the ‘thought stopping’ approach; an acceptance-based intervention; and the coping strategies that the participants spontaneously use. Participants were trained in one of these conditions and applied the learned strategies when they were exposed to a painful procedure.

According to our hypotheses, the acceptance group showed a

Acknowledgements

This research was supported by grants from the University of Málaga, Dirección General de Enseñanza Superior (BSO2002-02939) and Junta de Andalucía (HUM-566).

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