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Journal of Health Psychology
DOI: 10.1177/1359105304045378
2004; 9; 661 J Health Psychol
Gwnola Herbette and Bernard Rim
Adjustment
Verbalization of Emotion in Chronic Pain Patients and their Psychological
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661
Verbalization of
Emotion in Chronic
Pain Patients and Their
Psychological
Adjustment
GWNOLA HERBETTE & BERNARD
RIM
Universit catholique de Louvain at Louvain-la-Neuve,
Belgium
GWNOLA HERBETTE, PhD, works as a clinician
psychologist in health psychology and anxiety
disorders, and conducts research at the University of
Louvain, Louvain-la-Neuve, Belgium, on chronic pain,
emotional expression and pro-social behaviors.
BERNARD RI M, PhD, is Professor of Psychology at
the University of Louvain, Louvain-la-Neuve,
Belgium. His research relates to emotion, expression
and communication.
Journal of Health Psychology
Copyright 2004 SAGE Publications
London, Thousand Oaks and New Delhi,
www.sagepublications.com
Vol 9(5) 661676
DOI: 10.1177/1359105304045378
Abstract
Little attention has been paid to
the issue of emotional
verbalization in people
undergoing chronic situations.
We addressed this issue in the
present study focusing on
chronic pain patients. Our study
investigated the verbalization of
their health-related emotions,
as well as the role of
interpersonal variables on
patients disclosure, and their
relation to their psychological
adjustment. Results indicate
that chronic pain patients talk
more frequently about their
illness with their intimates. Yet,
the medical staff represents a
favored sharing target as it
elicits the highest satisfaction
degree. Results also reveal that
others social constraint
behavior and lack of credibility
of sufferers health status
negatively predict patients
psychological adjustment.
Therefore, the social
environment appears to play a
signicant part in patients
well-being.
Keywords
chronic pain, emotion,
psychological adjustment, social
sharing, verbalization
ACKNOWLEDGEMENTS. Research reported in this article was
supported by grants 2.4585.99 F and 8.450698 (Fonds National de la
Recherche Scientique) and 01/06-270 (Action de Recherche
Concerte). Gwnola Herbette was a Research Fellow at the Belgian
National Fund for Scientic Research at the time of this research.
COMPETI NG I NTERESTS: None declared.
ADDRESS. Correspondence should be directed to:
GWNOLA HERBETTE, Facult de Psychologie, Place du Cardinal
Mercier, 101348 Louvain-la-Neuve, Belgium.
[email: Gwenola.Herbette@psp.ucl.ac.be]
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Introduction
SOCI AL sharing of emotions has been studied
only in the context of discrete emotional
episodes. Findings indicated that people share
their emotions to a very large extent (up to 90
percent of the cases) and the targets of sharing
are mainly intimates (Rim, Finkenauer,
Luminet, Zech, & Philippot, 1998; Rim, Philip-
pot, Boca, & Mesquita, 1992). It is associated
with various cognitive benets for the sharer
(relief, being understood and, thus, included in
the social group, better personal understanding,
etc.), as well as physical and social ones (see
Pennebaker, 1985, 1989; Rim et al., 1998; Zech,
2000). It also induces emotional reactions in the
sharing partner: he/she feels empathy, interest
and attraction. The emotional sharing thus
increases peoples intimacy and liking
(Christophe & Rim, 1997).
Little attention has been paid to the issue of
emotional sharing in people going through
chronic situations, such as chronic illnesses.
Does it also bring benets for the sharer? What
are the consequences for the dynamic between
the sharer and the partner? In other words, how
does the sharer cope with sharing thoughts and
emotions associated with a chronic situation,
how does the recipient react to chronic sharing
and what are the consequences of his/her reac-
tions to the sharer? We addressed these ques-
tions in the present study focusing on chronic
pain patients.
Previous research has shown that people who
are victims of life events (such as, parents whose
infant died, cancer patients, victims of a natural
disaster) also report the need to share their
emotions associated with their condition and to
receive listening, attention and feedback from
their social environment (Helmrath & Steinitz,
1978; Mitchell & Glicksman, 1977; Pennebaker
& Harber, 1993; Silver & Wortman, 1980).
However, as time goes by, Pennebaker and
Harber (1993) reported that survivors of the
Loma Prieta Earthquake still wanted to talk
about the disaster, but they did not want to
listen to others sharing their thoughts and
emotions related to the disaster anymore; they
started to wear t-shirts with Thank you for not
sharing your earthquake experience written on
them. It seems that the duration of the situation
eliciting sharing plays a determining role in
peoples receptiveness to others emotional
sharing.
Indeed, when looking at the victimization
literature, it appears that life event victims
report complaints about their social environ-
ments receptiveness to their sharing. In particu-
lar, cancer patients claim that expression of
illness-related issues are among the most prob-
lematic and disturbing ones, and only half of
them seem to be satised with the social support
they receive (Peters-Golden, 1982; Wortman &
Dunkel-Schetter, 1979). Similarly, a large
majority of life event victims reported unhelpful
behaviors from their social environment. This
included behaviors such as advice, minimiza-
tion, rude remarks, and so on, which were all
perceived to discourage or to limit victims
emotional expression (Lehman, Ellard, &
Wortman, 1986). It should be pointed out that
during the interviews conducted by Herbette
and Rim (2003) with chronic pain patients, lack
of understanding and lack of listening from their
intimates were among the most common issues
cited as being very difcult to live with.
If we examine the perception from victims
social environment, the perspective of the
suffering people seems to be conrmed. Indeed,
nurses as well as patients families try to avoid
or to limit geriatric patients discussions about
death (Kastenbaum & Aisenberg, 1972; Quint,
1965). Similarly, when healthy people are ques-
tioned, 66 percent of them say that they would
do their best if confronted with a cancer patient
to cheer him/her up (Peters-Golden, 1982).
People consider emotional expression to be
non-adaptive for these suffering persons, and
believe that it is not benecial to them because
it may shatter their will to ght (Peters-Golden,
1982; Wortman & Dunkel-Schetter, 1979).
Thus, it appears that life event victims, although
being willing to express their condition-related
emotions, seem to suffer from their social
environments constraint behavior, leading
them to limit their emotional expression.
While the benets of expression of emotions
have been clearly demonstrated on various
psychological and physical indicators (e.g. well-
being, health, etc.), a lack of social support (or
an inadequate social support) and social
constraint exercised on peoples emotional
expression have also been shown to have
induced deleterious consequences for people.
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Manne and Zautra (1989) conducted a study to
assess the relation between psychological
adjustment of women with rheumatoid arthritis
and their spouses support and criticism. Results
showed that patients with highly critical spouses
reported poorer psychological adjustment and
more maladaptive coping behaviors. Con-
versely, patients who perceived their spouse
to be supportive engaged in more adaptive
coping.
King and Emmons (1990) refer to ambiva-
lence over emotional expression to character-
ize: (1) people who are not emotionally
expressive when they want to be expressive; (2)
people who are emotionally expressive, but
later regret that they were expressive; and also
(3) people who are emotionally expressive when
they do not want to be expressive. Chronic pain
patients can fall into these three categories:
although they wish to express their emotions,
they feel they should not because of others
rejection, or sometimes, when others want
patients to express their emotions, the patients
avoid doing so, fearing being rejected or becom-
ing a burden. Regardless of its form, feeling
ambivalent about emotional expression is
associated with less psychological adjustment
(depression, anxiety, negative affect, lower life
satisfaction, lower self-esteem, etc.; King &
Emmons, 1990). Thus, social constraint may
have several deleterious effects on chronic pain
patients personal adjustment.
This may add to the already negative impact
of chronic pain on patients psychological
adjustment. Bourgignon (2001) has shown that
chronic pain patients report a signicantly
higher level of depression and anxiety and a
lower level of life satisfaction and self-esteem
than their healthy signicant others. Chronic
pain has been shown to have a widespread
deleterious impact on patients physical, social
and psychological well-being (energy, vitality,
emotions, health perceptions, physical function-
ing, social function, mental health, etc.; Penny,
Purves, Smith, Chambers, & Smith, 1999;
Romano & Turner, 1985). Becker, Thomsen,
Olsen, Sjgren, Bech and Eriksen (1997) claim
that the health-related quality of life of chronic
non-malignant pain patients is among the lowest
observed for any medical condition.
Herbette and Rim (2003) showed that in
addition to the importance of expressing
themselves during interviews conducted with
chronic pain patients, ill people expressed the
importance of being understood and recognized
for their physical and psychological suffering.
Many of them explained that they had been
discredited because pain is invisible. And
because people around them disbelieved their
pain or minimized it, the patients were led to
question the integrity of their experience and
even to discredit their own identity (see Radley,
1994). Thus, recognition of their pain is a crucial
issue for patients: if their credibility is not ques-
tioned, then their signicant others might be
better able to listen to them and provide them
with efcient support.
Several authors have looked into this issue.
Ware (1992), writing about chronic fatigue
syndrome, notes that Self-doubt . . . the threat
of stigma [and] . . . the shame of being wrong
about really being sick all contribute to the
psychic suffering of the chronic fatigue victim
(1992, p. 355). Skelton (1991) claims that
illnesses that are attributed to legitimate
causes (from the standpoint of the perceivers
implicit model of illness) are likely to elicit
different perceptions of the patient and reac-
tions toward him/her than problems attributed
to illegitimate or suspicious causes. Skelton
reports a study conducted by Burgess (1980) in
which 100 hospital nurses were presented a
short vignette describing a hypothetical patient
who reported suffering from severe pain. Half
of the vignettes described a stereotypical
chronic pain patient (he had suffered from pain
for a relatively long time, the diagnostic results
were inconclusive and he exhibited symptoms of
psychological depression), and the other half
described a typical acute pain patient (short-
duration suffering, resulting from documented
pathology, and no depression symptoms).
Results are astonishing: Nurses rated the
chronic patient to be suffering much less than
the acute patient. What differentiated nurses
assessments were the inconclusive diagnostic
signs, which were interpreted as demonstrating
the absence of pathology. Additionally, the
mere presence of long-duration pain (indepen-
dent of diagnostic results) led nurses to estimate
the suffering as less intense (Taylor, Skelton, &
Butcher, 1984). Rhodes, McPhillips-Tangum,
Markham and Klenck (1999) reported that diag-
nostic testing for chronic low back pain patients
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caused the patients to return again and again for
medical care. They conducted a study on 70 low
back pain patients and showed that 33 percent
of them claimed that the invisibility of their pain
was problematic and it led people (family
members, coworkers and employers) to ques-
tion the legitimacy of their complaints. This
problem is also raised in a study conducted by
Osborn and Smith (1998) on nine women with
low back pain. The authors analyzed the
patients answers in semi-structured interviews
designed to explore the psychological processes
that determine and maintain the dynamic
relationship between the participants chronic
pain, distress and disability. The concern of not
being believed appeared in the four recurrent
themes that respondents mentioned. Appearing
healthy was considered to be problematic to
patients social networks and to be incompatible
with suffering or disability. It led them to either
exaggerate their complaints to have their illness
considered as credible (and conform to others
expectations) or to withdraw socially to avoid
the costs linked to feeling stigmatized and
rejected. Radley (1994) points out that the
threat of being disbelieved is that ill peoples
identities may be contaminated by others value
judgments about their illness and thereby
reduce their healthy self to a sick self.
Feeling discredited leads patients to experi-
ence a series of negative consequences, from not
being seen, to not being heard, to feeling
ashamed and decient (Osborn & Smith, 1998).
Pain is the most private of human experiences;
the person in severe pain suffers an unmaking
and disintegration of the normal relationship
between self and world, along with difculty in
conveying this experience to others (Rhodes et
al., 1999, p. 1193). Some ndings also show that
misperception of patients condition can precip-
itate disease by undermining the immune
system (Laudenslager & Reite, 1984). Thus, the
perception of credibility of peoples condition
seems to play a determining role in their psycho-
logical adjustment.
The present study was designed to investigate
chronic pain patients verbalization of their
health-related thoughts and emotions. More
specically, we examined its characteristics, the
role of interpersonal variables on their
disclosure, and their relation to psychological
adjustment.
The rst part of the study was dedicated to the
description of chronic pain patients verbaliza-
tion characteristics and to the investigation of
the role of the duration of their pain on these
verbalization characteristics. We hypothesized
that, through others reactions, chronic pain
patients verbalization characteristics evolve as
pain becomes chronic. We predicted that the
range of people with whom patients share
health-related issues becomes narrower, they
talk less about any matter associated with their
conditions (facts and emotions) and they report
lowered satisfaction with their sharing.
In the second part, the study investigated,
beyond the perspective that considers the dele-
terious impact of pain on chronic pain patients
psychological adjustment, the contribution of
interpersonal variables to adjustment. More
specically, we hypothesized that signicant
others social constraint and their perceived
disbelief with respect to chronic pain patients
health condition takes part in patients psycho-
logical adjustment.
Method
Participants
The recruitment of patients relied upon the
collaboration of two Belgian pain clinics. With
the agreement of physicians, the pain clinics
psychologist and secretary provided us with a
list of 283 patients (75 patients from one clinic
and 208 patients from the other). They scanned
their patients database and excluded those they
judged to have limited cognitive capacities (due
to age or education) that might interfere with
the ability to answer the questionnaire.
Out of the 283 patients, we were able to
contact 255 patients (for the remaining 28
patients, either we could not reach them by tele-
phone or we did not have their correct addresses
to send them the questionnaire). Among those,
a large majority (95%) volunteered to partici-
pate in the study and 79 percent of the mailed
questionnaires were sent back. Two patients
were eliminated from the sample because they
only completed the demographic questions.
Thus, the sample comprised 190 patients.
The mean age of patients was 48.75 (SD =
10.73; Minimum = 17, Maximum = 85). They
were mainly female (73.2%). A majority of
them were married (68.4%) and had French as
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their rst language (90.5%). Most of them were
employed (39.5%). The remaining were either
unemployed (35.3%) or retired (17.9%). The
majority of the sample had a rather high level of
education. The distribution was as follows: 2.6
percent of patients had less than 6 years of
education, 10.5 percent had 6 years of
education, 32.6 percent had 9 years, 21.1 percent
had 12 years and 32.6 percent had more than 12
years.
1
A large majority of participants suffered from
bromyalgia (44.7%); 11.1 percent of the
chronic pain patients suffered from a slipped
disc, 9.5 percent had a lumbago, 2.6 percent
suffered from algodystrophia and 1.6 percent
from phantom limb. The remaining (30.5%)
reported various diagnoses such as neuropathic
pain, breast cancer, osteoarthritis, paraplegia,
etc. The diagnoses were self-reported.
Procedure
The recruitment procedure involved three
steps. First, once the selection of the 283
patients was completed, they were sent a letter
signed by the pain clinic team (the physicians
and the psychologist) and ourselves. They were
informed about the study being conducted with
pain patients that investigated the character-
istics of their discussions about their health
status with their social environment. They were
notied that we would soon call them in order
to nd out whether they would be interested in
participating in the study. Then, a week later,
each potential participant was personally
contacted. We explained the procedure and
asked for their consent. Finally, when partici-
pants agreed to get involved in the study, they
were sent the questionnaire and asked to return
it within two weeks. If we did not receive the
questionnaire within three weeks, we re-
contacted each patient once in order to nd out
if he/she intended to send it back.
Dependent measures
Demographic and health measures After
answering demographic questions, participants
completed further questions regarding their
health status: pathology (self-reported diag-
nosis), date of first symptoms and date of
diagnosis. They also rated their pain and their
fatigue intensities during the past days on two
10-point scales (1 = no pain or no fatigue;
10 = the most intense pain or fatigue conceiv-
able).
Verbalization The questions were designed to
identify a prole of chronic pain patients
verbalization characteristics. Patients had to list
their health-related verbalization partners
during the past month and for each of them, to
write down his/her initials and the nature of the
relationship with this person (spouse, friend,
doctor, etc.). For each partner, patients specied
the content of their discussions by rating 2 items
on 5-point scales (1 = never; 5 = very often): (1)
discussions are focused on practical issues (such
as medical ones, examinations, medical treat-
ment); (2) discussions are focused on emotional
issues (such as hopes, fears, worries associated
with the illness). They also had to assess their
degree of satisfaction with discussions for each
partner (1 = very unsatised; 5 = very satised).
They could list up to 10 partners. From these
lists, we computed for each patient: (1) a
summed number of the partners to whom he/she
talked about his/her health problem, and, inde-
pendently of the type of partner, the averaged
scores of (2) factual verbalization, (3) emotional
verbalization and (4) satisfaction with verbal-
ization. We also computed the averaged scores
of factual verbalization, emotional verbalization
and satisfaction for each partner type.
Then, respondents also had to select among
the various listed partners the one with whom
talking was the most benecial, and to assess to
what extent the last discussion with this partner
had been benecial (1 = not at all; 5 = to a great
extent).
Social constraint Participants were asked to
complete the Lepore, Silver, Wortman and
Wayment (1996) social constraint question-
naire, which included ve items. It has been
adapted to the context of chronic pain: (1) Do
you keep your feelings about your illness to
yourself because they make other people
uncomfortable? (2) Can you discuss your feel-
ings about your illness with other people when
you want to? (3) When you talk about your
illness, do other people want to hear about it?
(4) Do you feel other people let you down by
not showing you as much love and concern as
you would have liked? (5) Do other people
really get on your nerves? Item 2 was reverse
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coded. Participants answered on 5-point scales
(1 = almost never; 5 = almost always; Cron-
bachs alpha = .70).
Perception of credibility of health condition
Respondents answered a 5-item questionnaire
designed to assess to what extent their health-
condition appeared credible. They rated on
5-point scales (1) to what extent their health
problem had been clearly identied by a doctor,
and to what extent their illness and the origin of
their pain were understood by themselves (23)
and by their social environment (45) (1 = not
at all; 5 = to a great extent). These ve items
were averaged into 1 score (Cronbachs alpha =
.77).
Psychological adjustment Participants rst
completed the 40-item Pain Anxiety Symptoms
Scale (PASS; McCracken, Zayfert, & Gross,
1992). It includes items such as: I feel that if the
pain becomes too strong, it will never decrease;
Since the pain appeared, I fear dying from it;
When the pain becomes very invasive, I have
difculties thinking about anything else; If I
have the opportunity to do something that I like,
I do not hesitate, even if it causes pain (reverse
coded); During the most intense pain periods, I
want to be reassured that it is nothing serious.
Participants answered on a 5-point scale (1 =
never; 5 = always). Scores can be computed on
a total averaged score, or on 4 subscales: (1)
cognitive anxiety; (2) escape/avoidance; (3)
fearful appraisal; (4) physiological anxiety. In
the present study, we used the total averaged
score (Cronbachs alpha = .85).
Respondents also completed the Hospital
Anxiety and Depression scale (HAD; Zigmond
& Snaith, 1983), which includes 7 items assess-
ing anxiety (Cronbachs alpha = .80) and 7 items
assessing depression (Cronbachs alpha = .84).
Finally, participants answered Rosenbergs self-
esteem questionnaire (1965; Vallieres &
Vallerand, 1990) including 10 items (1 =
completely disagree; 5 = completely agree) such
as: (1) I feel that Im a person of worth, at least
on an equal plane with others; (5) I feel I do not
have much to be proud of; (7) On the whole, I
am satised with myself; (9) I certainly feel
useless at times. We computed an averaged total
score (Cronbachs alpha = .85).
Results on verbalization
Descriptive results
Duration of pain The rst symptoms appeared
on average 12.22 years ago (SD = 9.32) and the
diagnosis had been stated on average 8.05 years
ago (SD = 7.91). As Table 1 shows, participants
usually had quite a long history of illness (the
highest frequencies appear in the range of 3 to
20 years), but the diagnosis was most frequently
stated less than a year after the appearance of
the rst symptoms (30 percent of the cases).
Verbalization Participants completed the
verbalization questionnaire assessing their
sharing partners during the past month, and for
each of them, the content of their discussions
(factual-focused and emotional-focused) and
the extent to which they were satised with
these discussions. Descriptive analyses of data
JOURNAL OF HEALTH PSYCHOLOGY 9(5)
666
Table 1. Distribution of the illness duration in terms of symptoms and diagnosis
Difference between rst
Appearance of rst symptoms appearance
symptoms Diagnosis and diagnosis
no difference 16.84%
less than 1 year 1.05% 4.74% 30.00%
12 years 1.58% 7.37% 7.89%
35 years 19.47% 30.00% 13.16%
6 10 years 27.37% 25.26% 13.16%
1115 years 21.05% 14.21% 5.79%
1620 years 11.05% 4.21% 1.58%
2125 years 7.37% 3.68% 2.63%
2630 years 2.63% .53%
3140 years 4.21% 1.58% 1.05%
> 40 years 2.11% 1.05%
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showed that 95.8 percent of participants did talk
about their health problem. They mentioned on
average 4.99 sharing partners (SD = 2.82). The
most frequently mentioned sharing partners
were, in descending order
2
: spouse (16.88%),
family doctor (12.40%), pain clinic doctor
(10.10%), close friend (9.85%), children
(8.82%), parents (8.57%), siblings (7.80%),
other family members (4.86%), physical
therapist (4.86%), psychologist (3.96%),
colleague (3.45%), friends (1.92%) and other ill
persons (1.66%). Other sharing partners (other
medical specialists, neighbors, acquaintances,
alternative medicines, occupational therapists
and social workers) were only rarely mentioned
(less than 10 times) and, thus, data referring to
these partners will not be reported.
In sum, data showed that the most frequently
mentioned sharing partner of chronic pain
patients was the person generally considered to
be the most intimate, the spouse. It is also the
person with whom people may generally spend
most of their time if they do not work. Then,
before the other family members (children,
parents, siblings and other family members)
were cited, medical personnel (family doctor
and pain clinic doctor) and close friends were
noted. Frequencies with which medical
specialists were mentioned (physical therapist
and psychologist) should be treated as tentative,
considering that not all patients consulted with
them. Colleagues, friends and other ill persons
did not appear to be preferred sharing partners.
For each type of partner, we averaged scores
on the factual social sharing scale, the
emotional sharing scale and the satisfaction
with social sharing scale. Data in Table 2 show
that partners associated with the highest satis-
faction scores are the following: other ill person
(M= 4.31, SD = .75), psychologist (M= 4.26, SD
= 1.00), pain clinic doctor (M= 3.99, SD = 1.19),
physical therapist (M = 3.91, SD = 1.03), close
friend (M = 3.83, SD = 1.07) and family doctor
(M = 3.67, SD = 1.22). Only after these comes
the spouse (M = 3.52, SD = 1.32).
It should be noted that: (1) these sharing
recipients were also those who elicited the
highest scores of factual and emotional sharing,
(2) and above all, they were all pain specialists,
namely health care professionals or other
patients, except for the close friends, whose
relationship is most likely wholehearted, even in
the face of the pain. Additionally, psychologists
were the sharing partners with the highest levels
of factual and emotional sharing, and psycholo-
gists reached a satisfaction score close to the one
attributed to other ill persons (which were only
rarely mentioned). These data suggest that satis-
faction with discussions could be linked to a
high level of factual and emotional sharing,
which is conrmed by the signicant positive
correlations between factual sharing and satis-
faction, r = .43, p < .001, and emotional sharing
and satisfaction, r = .43, p < .001. It should also
be pointed out that psychologists and other ill
persons, the two partners associated with the
highest satisfaction, were also the only ones
eliciting discussions that were slightly more
emotions-centered than facts-centered. This
suggests that although sharing facts and
emotions is associated with satisfaction, disclos-
ing emotions in particular might elicit more
satisfaction with discussions. Finally, it should
be noticed that, although the spouse was the
sharing partner the most frequently mentioned,
on average he/she came well behind several
other partners in terms of satisfaction with
sharing.
After completing the sharing grid (see the
earlier descriptive results), participants were
asked in an additional question to cite the
sharing partner with whom talking was the most
benecial, and to assess their degree of satis-
faction with the last discussion with this sharing
target. Interestingly, the most frequently cited
partner with whom sharing was the most
benecial was the spouse (35.40%). This target
was followed by the close friend (17.39%), the
family doctor (8.70%), the pain clinic doctor
(8.70%) and the psychologist (6.21%).
However, when asked to assess their degree of
satisfaction with the last discussion with this
sharing target, the spouse was not the one
associated with the highest satisfaction score (M
= 3.61). The highest degree of satisfaction was
attributed to the psychologist (M= 4.00).
3
Thus,
if chronic pain patients believe their spouse to
be the sharing partner with whom talking is the
most benecial, data showed that this is not the
case. The sharing targets who elicited the most
satisfaction were indeed the health care
professionals who are in close contact with
patients (apart from other ill persons, who were
only rarely mentioned).
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Correlational analyses
We aimed at examining the extent to which
social sharing by chronic pain patients was
related to duration of pain symptoms. We rst
conducted Pearson correlations between the
time elapsed since the appearance of the rst
symptoms and the ve social sharing variables
(number of sharing partners, emotional sharing,
factual sharing, satisfaction with sharing and
social constraint). In contrast to our predictions,
the time elapsed since the appearance of the
rst symptoms was not related to the number of
sharing partners, nor to satisfaction with
sharing, nor to social constraint (see Table 3).
However, consistent with our predictions, the
time elapsed since the appearance of the rst
symptoms was negatively related to the sharing
content, whether emotional-focused, r = .24,
p = .001 or factual-focused, r = .23, p = .001.
Results from interpersonal
variables and psychological
adjustment
Descriptive results
Social constraint Lepore et al.s scale (1996)
designed to assess the social constraint exerted
on peoples emotional sharing showed a mean
score of 3.11 (SD = .89).
Perception of credibility of illness On
average, participants indicated that the mechan-
isms responsible for their problem had been
clearly identied (M= 4.05, SD = 1.27). Only 6.8
JOURNAL OF HEALTH PSYCHOLOGY 9(5)
668
Table 2. Sharing targets frequencies, means (and standard deviations) of content of discussions and
satisfaction with discussions
Frequency Facts-centered Emotions-centered Satisfaction
Spouse 16.88 3.66 3.47 3.52
(1.20) (1.24) (1.32)
Family doctor 12.40 3.89 3.46 3.67
(.99) (1.21) (1.22)
Pain clinic doctor 10.10 4.02 3.77 3.99
(.97) (1.10) (1.19)
Close friends 9.85 3.61 3.60 3.83
(1.08) (1.07) (1.07)
Children 8.82 3.00 2.92 3.26
(1.32) (1.35) (1.30)
Father 1.79 3.21 2.64 2.57
(1.31) (1.39) (1.55)
Mother 6.78 3.45 3.06 3.23
(1.19) (1.15) (1.28)
Brother 2.30 3.28 3.22 3.11
(1.18) (1.22) (1.45)
Sister 5.50 3.24 3.15 3.19
(1.16) (1.24) (1.45)
Other family member 4.86 3.21 2.96 3.21
(1.11) (1.29) (1.44)
Physical therapist 4.86 3.95 3.18 3.91
(1.13) (1.18) (1.03)
Psychologist 3.96 4.03 4.32 4.26
(1.05) (.87) (1.00)
Colleague 3.45 3.13 3.11 3.52
(1.25) (1.42) (1.45)
Friends 1.92 3.27 3.07 3.23
(1.05) (1.12) (1.12)
Other ill persons 1.66 3.77 3.85 4.31
(1.17) (1.14) (.75)
Notes: Values in the table correspond to the percentage of all sharing partners who fall into a particular type
and to the means and standard deviations of the discussions characteristics with each sharing target.
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percent of them answered not at all (i.e. 1 on
the 5-point scale running from 1 = not at all, to
5 = to a great extent). According to participants
assessments, their social environment under-
stood their illness (M= 3.22, SD = 1.27) and the
origin of their pain (M = 3.10, SD = 1.42) to a
signicantly lesser extent than did the partici-
pants themselves (M= 4.14, SD = 1.06 and M=
3.89, SD = 1.28, respectively), F(1, 374) = 59.40,
p < .0001, and F(1, 373) = 32.79, p < .0001,
respectively. In further analyses, the averaged
score of these 5 items was used to assess the
perception of credibility of chronic pain
patients health condition (Cronbachs alpha =
.77).
Physical well-being and psychological
adjustment The averaged level of pain reached
7.34 (SD = 1.86) and the averaged level of
fatigue reached 6.97 (SD = 1.85).
The Pain Anxiety Symptoms Scale (PASS),
the two scales of the HAD (anxiety and depres-
sion) and the Rosenbergs self-esteem question-
naire were all correlated along with the two
physical measures, pain and fatigue (see Table
4). A principal component analysis with
Varimax rotation on these 6 measures provided
a solution with 73.58 percent of variance on the
rst 2 components. The rotated solution is
presented in Table 5. The rst factor included
the following scales: PASS, anxiety, depression
and self-esteem, and was named psychological
adjustment. The eigenvalue was 3.30 and
explained 54.99 percent of the variance before
the rotation, and 45.25 percent after the rota-
tion. The second factor included the pain and
the fatigue scales, and was named physical well-
being. The eigenvalue was 1.12 and explained
18.59 percent of the variance before the
rotation, and 28.33 percent after the rotation.
We rst computed a global psychological
adjustment scale by averaging each of the 4
scales average scores, which we had previously
transformed into z-scores.
4
This psychological
adjustment score showed a satisfying internal
consistency (Cronbachs alpha = .86) with an
average of 9.77
16
(SD = .84). Second, we
computed a global physical well-being scale by
averaging scores of the pain and the fatigue
scales. It showed a satisfying internal consist-
ency (Cronbachs alpha = .72) with an average
of 3.85 (SD = 1.64).
5
Regressions analysis
Hierarchical regression analyses were
computed to examine to what extent chronic
pain patients psychological adjustment was
predicted by physical well-being (computed
from pain and fatigue reversed assessments),
social constraint and perceived credibility of
illness. The predictors were entered in different
blocks representing different classes of
processes. Physical well-being was considered as
one block. The interpersonal factors (social
constraint and perceived credibility) were
considered a separate block. At each step, the
increase of explained variance is reported. The
analyses are presented by entering rst physical
well-being, followed by social constraint and
perceived credibility. The rationale behind
these analyses was to test to what extent inter-
personal factors predicted psychological adjust-
ment in chronic pain patients, beyond a
predictor already found in previous studies
(pain and fatigue). If social constraint and
perceived credibility still predict psychological
adjustment after the variance explained by
physical well-being is taken out, this will mean
that social constraint and perceived credibility
make a unique contribution to the prediction of
psychological adjustment.
Pearson correlations were used to assess the
HERBETTE & RIM: CHRONIC PAIN AND ADJUSTMENT
669
Table 3. Intercorrelations (Pearsons r) between sharing scales
1 2 3 4 5 6
1. Number of sharing partners .13 .13 .03 .01 .01
2. Emotional sharing .69** .43** .11 .24**
3. Factual sharing .43** .13 .23**
4. Satisfaction with sharing .38** .04
5. Social constraint .049
6. Time elapsed since appearance of rst symptoms
**p < .001
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relations between physical well-being, social
constraint, perceived credibility and psycho-
logical adjustment (see Table 6). As can be seen,
all variables correlate with the outcome, psycho-
logical adjustment.
Consistent with our predictions, physical
well-being was positively related to
psychological adjustment (R
2
= .19, p < .0001;
Adjusted R
2
= .19; = .44, p < .0001; see Table
7).
Social constraint and perceived credibility
contributed to a signicant increase in the
explained variance of 12 percent, p < .0001 (R
2
= .32, p < .0001; Adjusted R
2
= .30; R
2
change =
.12; F change = 16.81, p < .0001). Consistent with
our hypothesis, this was explained by a negative
relation with social constraint ( = .28, p <
.0001) and a positive relation with perceived
credibility ( = .16, p < .05).
Uncertainty
Beyond the role of the objective perceived
credibility of the illness, we investigated the
effects of the time elapsed between the appear-
ance of the rst symptoms and the diagnosis (a
variable that will be called uncertainty,
because it refers to the length of time during
which the person is kept in an uncertain state
regarding his/her health condition). Indeed,
such a variable may be related to the credibility
of the illness. According to the literature on
chronic illness (see Radley, 1994), the
JOURNAL OF HEALTH PSYCHOLOGY 9(5)
670
Table 4. Intercorrelations (Pearsons r) between psychological adjustment scales
1 2 3 4 5 6
1. PASS .67 .61 .54 .39 .46
p < .0001 p < .0001 p < .0001 p < .0001 p < .0001
2. Anxiety .58 .59 .25 .37
p < .0001 p < .0001 p = .001 p < .0001
3. Depression .63 .28 .37
p < .0001 p < .0001 p < .0001
4. Self-esteem .22 .26
p = .002 p < .0001
5. Pain .56
p < .0001
6. Fatigue
Table 5. Rotated component matrix on the six well-
being scales
Component

1 2
PASS .756 .385
Self-esteem .842
Anxiety .828
Depression .820
Pain .884
Fatigue .833
Note: Extraction method: principal component
analysis
Rotation method: Varimax with Kaiser normalization
Total explained variance = 73.58
Table 6. Cronbachs alpha coefcients (), means, standards deviations and intercorrelations (Pearsons r) of
scales
M 1 2 3 4
(SD)
1. Physical well-being 7.15 .24** .50** .44**
( = .72) (1.64)
2. Social constraint 3.11 .28** .42**
( = .70) (.89)
3. Perceived credibility 3.36 .25**
( = .77) (.91)
4. Psychological adjustment 3.37
( = .85) (.59)
** p < .001
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uncertainty of the diagnosis contributes to
patients anxiety and impedes their capacities to
adjust to their new health condition, as it limits
the predictability of the future course of the
illness and its consequences (e.g. impairment
and disability, reactions of others, redenition
of a self).
We created two groups from the uncertainty
variables, according to the distribution pre-
sented in Table 1. A rst group, Low Uncer-
tainty, included patients for whom the diagnosis
was stated less than one year after the appear-
ance of the rst symptoms, and the second
group, High Uncertainty, included patients for
whom the diagnosis was stated beyond one year
after the appearance of the rst symptoms. We
conducted univariate analyses of variance
(ANOVAs) on the perceived credibility of the
illness, on social constraint, on psychological
adjustment and on physical well-being.
Results indicated that, as compared to
chronic pain patients with Low Uncertainty,
those with High Uncertainty reported a lower
credibility level for their illness (Mhigh = 3.45,
SDhigh = .82 vs. Mlow= 3.96, SDlow= .82), F(1,
173) = 14.82, p < .0001, more social constraint
(Mhigh = 3.32, SDhigh = .77 vs. Mlow = 2.91,
SDlow = .93), F(1, 173) = 9.99, p < .005, a lower
psychological adjustment, (Mhigh = 0.81,
SDhigh = .73 vs. Mlow = 1.20, SDlow = .92),
F(1, 173) = 9.65, p < .005, and tended to report
less physical well-being, (Mhigh = 3.62, SDhigh
= 1.38 vs. Mlow = 4.07, SDlow = 1.85), F(1, 173)
= 3.19, p = .076.
Thus, ndings show that the time elapsed
before the diagnosis plays a key role in others
reactions toward the chronic pain patients
(social constraint and perceived credibility)
and in their own psychological and physical
state.
Discussion
Our research included two goals: rst, we
attempted to describe the characteristics of
chronic pain patients verbalization of their
health-related thoughts and emotions and to
test the hypothesis that, as pain becomes
chronic, the pattern of patients verbalization
characteristics would evolve: the range of
sharing partners would become narrower, they
would talk less about any matter associated with
their condition (whether facts or emotions) and
they would report lowered satisfaction with
their sharing.
Second, we tested the hypothesis that chronic
pain patients psychological adjustment would
be predicted by additional factors besides only
their physical condition (i.e. fatigue and pain)
namely, others social constraint on patients
emotional expression and patients perceptions
of others disbelief toward their health
condition.
As regards chronic pain patients verbaliza-
tion of their health-related thoughts and feel-
ings, it appeared that the recipients with whom
they shared the most frequently were split
between their intimates (family members:
46.93%; close friends and other friends:
11.77%) and health care professionals
(31.33%). First and foremost, the partner with
whom chronic pain patients talk is their spouse
(16.88%). This is not surprising considering that
he/she is the most often present partner and,
usually, the preferred partner for social sharing
(Rim et al., 1998). Then, participants
mentioned the two main health care
professionals involved in the monitoring of their
health condition, namely the family doctor and
the pain clinic doctor (22.5%). They were
followed by close friends, who take a privileged
HERBETTE & RIM: CHRONIC PAIN AND ADJUSTMENT
671
Table 7. Summary of hierarchical regression analysis for variables predicting psychological adjustment (N =
190)
R
2
Adjusted R
2
R
2
d.f. F F
Step 1 .19 .19 .19 1, 188 44.43***
Physical well-being .44***
Step 2 .32 .30 .12 2, 186 28.51*** 16.81***
Physical well-being .36***
Perceived credibility .16*
Social constraint .28***
*p < .05, ***p < .0001
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place, as they are mentioned in 9.85 percent of
the cases. Next comes family members
(children, siblings, parents and other family
members; 30.05%), followed by two pain-
related medical specialists (physical therapist
and psychologist; 8.82%). So, as it can be seen,
patients very often appeal to their physicians to
listen to their sharing.
These results contrast with those reported by
Morley, Doyle and Beese (2000). They
conducted a study of 45 chronic pain patients
who underwent structured interviews exploring
their interpersonal communication. They found
that 70 percent of the communication related to
their health condition was within the family
(compared to only 46.93 percent in our study),
13 percent of patients talked to friends and 11
percent talked only to their doctor about their
pain. The difference in the proportion related to
the doctor can be accounted for by the fact that
in Morley et al.s study, participants were asked
if they talked only to their doctor about their
pain, whereas in our study, the percentage
(31.33%) included several health care
professionals, namely the family doctor
(12.40%), the pain clinic doctor (10.10%), the
physical therapist (4.86%) and the psychologist
(3.96%). The difference in the proportion
related to the family may be accounted for by a
difference in computing proportions. In our
study, 46.93 percent reects the proportion of
particular sharing partners among all partners
mentioned (100%). Now, if we calculate the
proportion of patients who talked to their family
members (which might be what the 70 percent
in Morley et al.s study reect), we nd that 85
percent do so. Nevertheless, contrary to Rim et
al.s nding (1992, 1998) showing that people
socially share their emotions with their inti-
mates, our results indicate that chronic pain
patients have a more diverse social network:
although a very large proportion of chronic pain
patients generally talk to their family (with the
spouse as the rst partner), health care
professionals are also very often called upon as
sharing partners.
Interestingly, when explicitly asked who,
among the cited partners, was the one with
whom talking was the most benecial, partici-
pants named their spouse. However, on the
satisfaction scale, the spouse was not rated as the
most satisfying partner to talk with. How could
such a contradictory nding be accounted for?
It could be hypothesized that chronic pain
patients feel ambivalent toward their spouse.
On the one hand, they are aware of the difcult
position in which they put their spouse, against
their own will (see Herbette & Rim, 2003). The
spouse has to live with the others illness,
because chronic pain and all its consequences
lead to several consequences for the daily life of
the couple. On the other hand, chronic pain
patients are also not always satised with their
spouses reactions, which may be negative: the
spouse may question the credibility of the illness
and may lack understanding. These negative
feelings, mixed with a sort of duty to be grateful
toward their spouse for enduring their illness
and its consequences, may lead chronic pain
patients to have ambivalent feelings toward
their spouse (Pierce, Sarason, & Sarason, 1991).
This could account for the discrepancy between
our ndings when participants were asked to
name the partner with whom talking was the
most benecial, and the satisfaction scores.
Additionally, research suggests that supportive
and conict-related features of relationships are
nearly orthogonal (Hirsch, 1979; Pierce et al.,
1991). Thus, individuals who have high levels of
support available to them may experience either
high or low levels of ambivalence regarding the
support they receive from family members and
friends. Conversely, individuals who experience
low levels of social support may not necessarily
have high-conict relationships within their
network. Thus, social support may have both
costs and benets. Finally, the benets perceived
in the discussions with the spouses might be
linked to these partners availability. Even if
verbalizations with these partners do not appear
to be the most satisfactory, the simple presence
of the partner brings benets. Conversely, the
satisfaction with the discussions with the health
care professionals might refer to the content of
sharing. Indeed, these discussions were charac-
terized with the highest levels of emotional and
factual sharing. It can be hypothesized that the
health care professionals are more open to
discussions, which make such discussions
deeper. In our questionnaire, benecial and
satisfactory might thus be two terms referring
to two different qualities of sharing, with the
rst one related to the frequency of sharing, and
the second one relating to the content of
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sharing. Further research is needed to more
deeply investigate this issue in order to under-
stand what might differentiate the benets of
verbalizing with the spouse versus those of
verbalizing with the health care professionals.
Analysis of the predictive role of chronicity
(duration of illness) on verbalization character-
istics revealed only a negative relation with the
extent of sharing, whether emotional-focused or
facts-focused, but no relation with the number
of sharing partners, nor with the satisfaction
assessments. This lack of ndings does not mean
that there is no effect of chronicity. We may
have missed it because of too little variance in
the distribution of the length of time since the
appearance of the rst symptoms. Indeed, it
should be pointed out that our sample was
mainly composed of very chronic patients.
Only 1.05 percent of them reported being ill for
less than one year. The effect of chronicity on
peoples verbalization might appear within the
rst few months of illness. Therefore, a repli-
cation of this study on a younger sample is
required to denitively rule out any effect of
chronicity on peoples verbalization.
Although chronicity was negatively related to
the extent of sharing, it was independent of
social constraint, r = .05, NS. It suggests that, as
the illness persists, the social network does not
limit the patients verbalization, but limited
verbalization might instead be a choice of the
ill persons. As shown in the study conducted by
Osborn and Smith (1998) and by Herbette and
Rim (2003), analysis of respondents tran-
scripts revealed that chronic pain patients
suffered from not being believed and conse-
quently, preferred to withdraw from others. To
account for our results, it could be argued that
within one year, chronic pain patients social
networks exert social constraint over ill peoples
health-related verbalization. A signicant
relation between chronicity and social
constraint, and chronicity and verbalization
characteristics would thus be expected. After
several months, the personal costs associated
with verbalizing with others would be too high,
thereby leading people to prefer to withdraw
from their social world and no longer express
their health-related emotions. Then, relations
between chronicity and other variables should
disappear. It is crucial to better understand the
dynamics between chronically ill persons and
their social network. Further studies are needed
to explore the evolution of ill peoples
emotional expression as a function of others
behaviors within the rst year of the illness.
More than the chronicity by itself, the time
before a diagnosis is given seems to determine
social networks behavior and chronic pain
patients well-being. As the ndings showed,
being undiagnosed for over a year is associated
with greater social constraint and lower credi-
bility of the illness. Patients also report less
psychological adjustment and physical well-
being. The lack of a diagnosis leaves patients
and their social network in a state of uncertainty
(Maes, Leventhal, & de Ridder, 1996; Radley,
1994; Rhodes et al., 1999), increasing their
anxiety and increasing questioning of the health
condition. The study conducted by Osborn and
Smith (1998) as well as Herbette and Rim
(2003) indicated that not being believed
remained among the greatest concerns of
chronic pain patients, as it calls into question the
legitimacy of their complaints, and more gener-
ally, their own identity (Radley, 1994). If the
legitimacy of the chronic pain patients
condition is questionable, the social network
might want to limit the patients emotional
expression about his/her health status. It
decreases peoples adjustment to their social
world and to their social support, as others
perceptions of them being healthy sometimes
contradicts with their intermittent distress and
disability (Radley, 1994; Rhodes et al., 1999). To
avoid such tension and the exposure to others
incredulity, chronic pain patients prefer to with-
draw socially (Osborn & Smith, 1998).
The analyses designed to test our second
hypothesison the contribution of inter-
personal factors in the prediction of psycho-
logical adjustmentshowed that, as predicted,
physical well-being (assessed by reversed scores
of pain and fatigue) was positively related to
chronic pain patients psychological adjustment.
Additionally, social constraint negatively
predicted psychological adjustment, whereas
perceived credibility predicted it positively.
These ndings, consistent with chronic pain
patients transcripts analyzed in Herbette and
Rim (2003), emphasize the importance of
taking an interpersonal approach in the study of
chronic pain patients psychological adjustment
and in clinical interventions when patients seek
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medical care in pain clinics. A longitudinal study
could provide us with a more detailed picture of
the specic processes involved in chronic pain
patients psychological adjustment. Addition-
ally, addressing both patients and providers
perceptions of support offered and received
could offer more valid information.
In the past few years, a new investigation
method enabling collection of data in naturally
occurring social life has appeared. The Elec-
tronically Activated Recorder (EAR) is a
micro-tape recorder that tracks daily lives of
participants by recording 30-second snippets of
ambient sounds in participants environments
approximately every 12 minutes over a period of
up to four days (Mehl, Pennebaker, Crow,
Dabbs, & Price, 2001). It provides information
about participants social environment and
language they use in their natural conversations.
Then, the recordings are transcribed and
submitted to a linguistic analysis using the word-
based language analysis program Linguistic
Inquiry and Word Count (LIWC; Pennebaker,
Francis, & Booth, 2001). This program
compares all words of a text to an internal
dictionary containing more than 2300 words and
word stems sorted into over 70 categories (e.g.
article, rst person singular pronoun, positive
emotion, preposition, present tense). Each word
is assigned to the LIWC categories that apply.
In addition, the EAR data can be analyzed by
judges coding the recordings using the Social
Environment Coding of Sound (SECSI). This
system codes information on the persons
location (e.g. in apartment, outdoors), activity
(e.g. listening to music, on the computer), and
interaction (e.g. alone, talking to others; Mehl &
Pennebaker, in press). Such a method can
provide information on the type of language
that people use according to their location (e.g.
apartment, public places, restaurant), their
activity (e.g. working, amusement) and their
mode of interaction (e.g. talking to a person
directly vs. on the phone). More generally, it
provides information about participants social
processes (e.g. their social integration, their
relationships with others), personality and
cognitive and clinical processes (e.g. peoples
mood, the evolution of people in terms of their
concerns; Pennebaker, 2002; Pennebaker &
Mehl, 2002).
Such a method could be applied to chronic
pain patients to investigate the characteristics of
their social environment and language, as pain
becomes chronic. It may reveal valuable infor-
mation on patients cognitive and emotional
evolution. Understanding the processes that
account for the limitation of the sufferers
disclosing even when they do want to talk about
their pain, and the consequences on their
psychological adjustment, could provide crucial
information to develop interventions in order to
promote chronic pain patients psychological
adjustment and their relationships with their
social network.
To conclude, it should be pointed out that this
study collected very much data, which some-
times makes interpretation difcult, as the inter-
relations between the variables are complex to
analyze. Yet, in our view, it provided very inter-
esting data that need further investigation. We
suggest the questions raised by the present study
be addressed by several future studies, in line
with the different aims of the present study.
Notes
1. The cumulated proportions do not reach 100
percent because a few patients did not provide us
with this information.
2. These values correspond to the frequency with
which each sharing partner was mentioned by each
participant. It should be noted that some partners,
such as siblings or friends, could be mentioned
several times in the sharing grid, but this is not
indicated in these values.
3. It should be pointed out that these satisfaction
degrees have been computed by dividing the sum
of the satisfaction assessments for each partner by
the frequency with which each partner was
mentioned. Thus, a potential bias might have crept
into these conclusions, considering that the nal
satisfaction score depends on the frequency with
which the partner was mentioned. For instance,
while the spouse was mentioned in 35.40 percent
of the cases, the psychologist was mentioned in
only 6.21 percent of the cases. For this reason, we
do not report the averaged scores for the other
partners.
4. This transformation was necessary because the
HAD averaged scores varied from 1 to 4 and the
PASS and self-esteem averaged scores varied from
1 to 5.
5. The pain and fatigue scales were reversed to
obtain a physical well-being score.
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