Further Validation of the Chronic Pain Coping Inventory

Gabriel Tan,*,‡ Quang Nguyen,† Karen O. Anderson,储 Mark Jensen,¶ and

John Thornby§

Abstract: Multidisciplinary treatment programs for chronic pain typically emphasize the importance
of decreasing maladaptive and encouraging adaptive coping responses. The Chronic Pain Coping
Inventory (CPCI), developed to assess coping strategies targeted for change in multidisciplinary pain
treatment, is a 64-item instrument that contains 8 subscales: Guarding, Resting, Asking for Assistance,
Relaxation, Task Persistence, Exercising/Stretching, Coping Self-Statements, and Seeking Social Sup-
port. A previous validation study with 210 patients in a Canadian academic hospital setting supported
an 8-factor structure for the CPCI. The current study was undertaken to validate the CPCI among 564
veterans with a more extended history of chronic pain. Patients completed the study questionnaires
before multidisciplinary treatment. A confirmatory factor analysis was used to examine the factor
structure of the 64-item CPCI. A series of hierarchical multiple regression analyses were performed
with depression, pain interference, general activity level, disability, and pain severity as the criterion
variables and the 8 CPCI factors as the predictor variables, controlling for pain severity and demo-
graphic variables. The confirmatory factor analysis results strongly supported an 8-factor model, and
the regression analyses supported the predictive validity of the CPCI scales, as indicated by their
association with measures of patient adjustment to chronic pain.
Perspective: This article validated the 8-factor structure of the CPCI by using a confirmatory factor
analysis and a series of linear regressions. The results support the applicability and utility of the CPCI
in a heterogeneous population of veterans with severe chronic pain treated in a tertiary teaching
hospital. The CPCI provides an important clinical and research tool for the assessment of behavioral
pain coping strategies that might have an impact on patient outcomes.
Key words: Coping with chronic pain, behavioral assessment instrument, validation of CPCI.

A
cognitive-behavioral model of chronic pain em-
phasizes the importance of an individual’s at-
tempts to cope with pain and pain-related issues
or problems. Coping has been defined as “ѧconstantly
changing cognitive and behavioral efforts to manage
specific external and/or internal demands that are ap-
praised as taxing, or exceeding the resources of the per-
son.”34 Coping is an ongoing process that includes ap-
praisals of a demand or stressor; cognitive, behavioral,
and emotional coping responses; and subsequent reap-
praisals of the demand. Most individuals view pain and
its impact as stressful and cope according to their unique
history, personality, beliefs, biologic characteristics, and
social environment.8 Coping responses can be classified
as problem-focused responses directed at changing or
managing the problem causing the stress or as emotion-
Received February 24, 2004; Revised September 17, 2004; Accepted Sep-
tember 25, 2004.
From the *Pain Section, Anesthesiology and Mental Health Care Line and
†Psychosocial Rehabilitation Program, VA Medical Center; ‡Department
of Anesthesiology and §Department of Family Medicine, Baylor College
of Medicine; and 储Department of Symptom Research, The University of
Texas M.D. Anderson Cancer Center, Houston, Texas; and ¶Department of
Rehabilitation Medicine, University of Washington, Seattle, Washington.
Address reprint requests to Gabriel Tan, PhD, ABPP, Veterans Affairs
Medical Center, Department of Anesthesiology, 2002 Holcombe Blvd
(116 MH), Houston, TX 77030. E-mail: tan.gabriel@med.va.gov
1526-5900/$30.00
doi:10.1016/j.jpain.2004.09.006
focused responses directed at regulating emotional re-
actions to the problem.34 Coping responses also can be
considered adaptive or maladaptive, depending on the
usual outcome of the coping behavior, cognition, or
emotion.
Multidisciplinary treatment programs for chronic pain
typically emphasize the importance of stopping the use
of maladaptive and teaching and encouraging the use of
adaptive coping responses.37,48 Certain coping re-
sponses, such as task persistence, have been associated
with better physical and psychological functioning
among individuals with chronic pain, whereas other cop-
ing responses, such as pain-contingent resting and
guarding, have been correlated with impaired func-
tion.12,15,25,31,51
Cross-sectional and longitudinal studies have demon-
strated that coping responses are associated with
both short- and long-term adjustment to chronic
pain.1,5,8,28,36,47,59 Pain coping responses have been
shown to be related to measures of pain intensity, emo-
tional distress, physical function, disability status, and
other psychosocial variables. For example, the use of
multiple pain coping strategies has been correlated neg-
atively and significantly with disability14,38 and with psy-
chosocial dysfunction.23 A composite measure represent-
ing cognitive coping responses (labeled “perceived
control over pain and rational thinking”) has been sig-

The Journal of Pain, Vol 6, No 1 (January), 2005: pp 29-40 29

30
3,27,46,53
nificantly associated with less intense pain and
lower levels of distress and disability.3,10,27,52 In contrast,
catastrophizing responses have been significantly corre-
lated with greater pain intensity,11,12,19,50,51,58 affective
distress,12,20,23,55,57 and disability.13,34,35,38,42 Studies of
coping responses such as diverting attention,1,49 coping
self-statements,18,23,33 reinterpreting pain sensa-
tions,1,27 ignoring pain,22 praying or hoping,2,23,41 and
social support16,29,44 have produced mixed or inconclu-
sive results. One reason for the inconsistent findings
across studies might be the variety of measures used to
assess coping responses.
Accurate assessment of pain coping responses is impor-
tant in research and clinical settings. For example, in mul-
tidisciplinary pain treatment programs, measurement of
coping responses helps to determine a patient’s coping
strengths and weaknesses, to identify possible targets
for treatment, and to evaluate treatment outcomes. In a
study to specifically identify the coping responses most
closely linked to treatment outcome, Jensen et al24
found that decreases in the coping strategies of guard-
ing, resting, and catastrophizing were associated with
decreased disability during the course of multidisci-
plinary pain treatment. In this same study, decreases in
catastrophizing cognitions were also associated with de-
creases in pain intensity and depression.
A variety of pain coping measures have been devel-
oped to address the need for reliable and valid assess-
ment of pain coping responses. The Vanderbilt Pain
Management Inventory (VPMI),7 Coping Strategies
Questionnaire (CSQ),45 and Chronic Pain Coping Inven-
tory (CPCI)25 are 3 of the most widely used measures. The
VPMI assesses active and passive coping strategies re-
lated to chronic pain. Active strategies are defined as
adaptive coping responses (eg, staying busy or active),
and passive strategies are defined as maladaptive ones
(eg, restricting social activities). Passive coping has been
associated with high levels of pain, disability, and dis-
tress. In contrast, active coping has been correlated with
positive affect and higher activity levels.48,56,61 More-
over, longitudinal studies have found that passive coping
responses were predictive of subsequent pain levels and
disability.40,56
The CSQ has been the most frequently used tool for the
assessment of pain coping strategies in previous re-
search. The 50-item CSQ assesses 6 cognitive and 2 be-
havioral coping strategies. Scores on the CSQ subscales
have been significantly associated with measures of
pain, distress, and function across a variety of samples of
patients with chronic pain.5,8
The VPMI and CSQ focus largely on cognitive coping
strategies. In contrast, the CPCI was developed to assess
many of the behavioral coping strategies that are em-
phasized in multidisciplinary pain treatment programs.25
These coping strategies include ones that are taught and
encouraged during treatment (eg, relaxation, exercising,
task persistence), ones that are discouraged (eg, guard-
ing, resting, asking for assistance), and one neutral strat-
egy (seeking social support). The CPCI contains 8
multiple-item subscales: Guarding, Resting, Asking for
Validation of the Chronic Pain Coping Inventory
Assistance, Relaxation, Task Persistence, Exercising/
Stretching, Coping Self-Statements, and Seeking Social
Support. In the initial validation study, 176 patients re-
ferred to a multidisciplinary pain treatment program
completed the CPCI and measures of function. The re-
sults indicated that scores on the Guarding, Resting, and
Asking for Assistance subscales were associated with
poor adjustment to pain. Task Persistence was associated
with more favorable adjustment.25 Surprisingly, in the
initial validation study, the strategy of Coping Self-
Statements was associated with a higher level of pain-
related emotional distress.
In a recent study of 564 veterans referred to a chronic
pain program, subjects were administered the CPCI and
CSQ, as well as measures of pain, distress, and disabili-
ty.51 Both the CPCI and CSQ subscale scores were signif-
icantly associated with concurrent disability, although
the CPCI Guarding subscale was the single most powerful
predictor of disability. The CPCI Seeking Social Support,
the CSQ Catastrophizing, and the CSQ Increasing Behav-
ioral Activities subscale scores were also significantly as-
sociated with disability. Although the CSQ Catastrophiz-
ing subscale score and education level were the
strongest predictors of pain severity, the CPCI Guarding
and Resting subscale scores were also associated with
pain severity in this Veterans Affairs sample.
In a factor analytic study of the CPCI, 210 patients in a
multidisciplinary pain treatment program were adminis-
tered multiple measures of pain, coping, and adjust-
ment.17 An exploratory factor analysis of the CPCI items
supported an 8-factor solution that corresponded to the
original 8 CPCI subscales.17 Although the item content of
the subscales was generally supported, some modifica-
tions to subscale scoring were suggested for the patient
sample in this study. For example, the Guarding subscale
was supported by the factor analysis results, but a few of
the Guarding items had higher factor loadings on other
scales. Regression analyses found that scores on the sub-
scales of Asking for Assistance, Guarding, and Social Sup-
port were significantly associated with less favorable ad-
justment to chronic pain. Surprisingly, Relaxation was
associated with increased emotional distress and de-
creased perceptions of control. Task Persistence was as-
sociated with more favorable adjustment to pain. The
authors concluded that the CPCI is a valuable measure
for identifying coping strategies and evaluating adjust-
ment and treatment outcomes. They recommended ad-
ditional studies to confirm the factor structure of the
CPCI in other patient populations.
The purpose of the current study is to confirm the fac-
tor structure of the CPCI in a population of patients with
chronic pain in a Veterans Administration Medical Cen-
ter. In the previous factor analytic study of the CPCI cited
above, an exploratory factor analysis was used, and the
patient sample was composed of women and men who
were evaluated in a pain treatment program in an aca-
demic medical center.17 This program focused on work-
ers compensation rehabilitation in which the majority of
patients presented with pain in one site, and the average
duration of pain was 14 months. In contrast, the sample
ORIGINAL REPORT/Tan et al
in the current study was composed primarily of male
veterans with a more severe and extended history of
chronic pain (more than half of this population had been
on disability for more than 5 years, and a majority, 72%,
reported pain at multiple sites). We sought to determine
whether the 8-factor structure originally proposed by
Jensen et al25 and subsequently supported by Had-
jistavropoulos et al17 would be confirmed by performing
a confirmatory factor analysis in a new sample of pa-
tients with chronic pain and also determine how the fac-
tor scores relate to patient adjustment.
A secondary but equally important reason for under-
taking this study was to underscore the importance of
assessing the behavioral domain of coping in addition to
cognitive coping strategies. Coping with pain depends
on what people do as well as what they think. Pain man-
agement programs teach and encourage changes in
both thoughts and behavior. A well-validated behavioral
coping measure is, therefore, of immense importance,
given that measures of both cognitive and behavioral
responses to pain are needed to guide interventions.
Limiting coping assessment to just one potentially limits
information needed to guide treatment and therefore
might ultimately limit treatment efficacy.
Methods
Participants
The sample was obtained from the population of pa-
tients with chronic noncancer pain referred to the Inte-
grated Pain Management Program (IPMP) of the Hous-
ton VA Medical Center, a tertiary teaching hospital. This
is the same sample used in a previous study comparing
CPCI and CSQ responses.51 The IPMP is a multidisciplinary
outpatient pain assessment, consulting, and treatment
program that receives referrals from surgical, medical,
and psychiatric departments within the medical center.
Patients referred to the IPMP typically have an extended
history of chronic pain and have received prior treat-
ments for pain. Patients were required to complete a
packet of self-report questionnaires before initial IPMP
assessment. The questionnaire packet was mailed to pa-
tients with a cover letter explaining that the question-
naires were to be used primarily for clinical purposes, but
the data might also be used for program evaluation and
research. Before data were analyzed for the current
study, approval from the Institutional Review Board was
obtained. Of the 1265 packets mailed from 1995 through
1998, 564 packets were returned, with a return rate of
44.6%. Thus, slightly less than half of all patients referred
to the IPMP followed through on their referral and com-
pleted the necessary paperwork to receive services.
The demographic characteristics of the subject sample
were reported in our previous study comparing CPCI and
CSQ responses.51 The mean age of patients completing
the questionnaires was 50.8 years (SD, 11.4; range, 22 to
82 years). Most (84.5%) had at least a high school educa-
tion; 12% were college graduates. The majority of the
subjects were male (90.3%). Although most were white
(62.4%), 22.6% were black, 4.6% were Hispanic, 0.5%
31
were “Other,” and 9.9% did not respond to this item.
Approximately half (50.2%) were married. Almost half
of the participants (48.0%) were already receiving dis-
ability compensation for a pain-related condition, and
58.0% indicated disability as a result of pain for more
than 5 years. Information about specific pain diagnosis
was not collected, but breakdowns by primary pain sites
were as follows: back (39.0%), limbs (32.0%), neck/shoul-
ders (19.0%), head (6.0%), and “all over” (4.0%). Fur-
thermore, 72% of the patients reported that they had
pain at multiple sites.
To evaluate possible nonresponse bias, we collected
demographic and disability information on all patients
referred between January 1996 and December 1996. In-
formation was obtained on 94% of the patients and re-
sulted in a sample of 126 responders and 168 nonre-
sponders. The responders and nonresponders did not
differ with regard to age (mean, 54.5 and 53.9 years,
respectively). There was also no significant difference in
gender (␹2 ⫽ 1.92, not significant), marital status (␹2 ⫽
0.03, not significant), or disability status (ie, receiving no
disability, service-connected disability, or non-service-
connected disability) (␹2 ⫽ 0.68, not significant).
Measures
CPCI
The CPCI has 65 items that measure 11 coping strategies
that patients might use to cope with or manage chronic
pain.25 The CPCI was specifically developed to assess many
of the coping strategies targeted for change (either to be
encouraged or discouraged) in multidisciplinary treatment
of chronic pain.25 The strategies assessed include illness-
focused strategies (Guarding, Resting, Asking for Assis-
tance, Opioid Medication Use, Nonsteroidal Medication
Use, Sedative-Hypnotic Medication Use), wellness-focused
strategies (Relaxation, Task Persistence, Exercise/Stretch,
Coping Self-Statements), and the strategy of Seeking Social
Support.
In the initial validation and cross-validation studies,25
each of the CPCI scales demonstrated adequate to excel-
lent test-retest stability (ranging from .65 to .90). In ad-
dition, the internal consistency of the multiple-item (ie,
not medication) scales ranged from .74 to .91. Validity
was demonstrated by the scales’ ability to predict
spouse-rated patient functioning. In particular, patient-
reported use of Guarding, Resting, Asking for Assistance,
and Sedative-Hypnotic Medication Use demonstrated
moderate to strong associations (rs ⬎ .30 or ⬍ ⫺.30) with
spouse-rated patient disability, spouse-rated patient ac-
tivity level, or both. Less strong, but still substantial (rs
between .20 and .30 or ⫺.20 and ⫺.30), associations were
found between Coping Self-Statements and Seeking So-
cial Support and spouse-reported disability. For the cur-
rent study, subscales relating to medication consumption
were excluded because of difficulty getting accurate and
reliable self-reports on this measure from the subjects;
therefore, only 8 of the 11 CPCI scales were used.
32
Measures of Function and Adjustment
Measures of pain and functioning available for analysis
included the Center for Epidemiological Studies Depres-
sion Scale (CES-D) to assess depression, the Roland-Morris
Disability Questionnaire (RMDQ) to assess disability, the
Interference scale of the West Haven–Yale Multidimen-
sional Pain Inventory (WHYMPI) to assess the extent to
which pain interferes with the patient’s life, the General
Activity scale of the WHYMPI to assess the patient’s gen-
eral activity level, and the Pain Severity scale of the
WHYMPI.
CES-D. The CES-D was used as a measure of psycho-
logical functioning in this study. The CES-D was devel-
oped to assess the presence and severity of depressive
symptoms in a general population. The CES-D includes 20
items that are answered on a 4-point scale (0, rarely; 3,
most of the time), resulting in scores ranging from 0 to 60
(higher scores indicating greater depressive symptoms).
The CES-D has been widely used in pain research6,22,39
and has adequate reliability and convergent validity.41
Criterion validity has also been established because the
CES-D scores of depressed and nondepressed subjects
have been found to be significantly different.41
RMDQ. The RMDQ is used to assess disability associ-
ated with chronic pain. The RMDQ, derived from the
Sickness Impact Profile, was originally developed to as-
sess disability associated with back pain.43 Items focus
almost exclusively on the physical dimensions of disabil-
ity.9 Subjects indicate which, if any, of 24 statements
describe them today and are related to their pain (for
example, “I stay at home most of the time because of my
pain”). Scores range from 0 to 24, with higher scores
indicating greater disability.
Chronic pain treatment centers have found that the
RMDQ is simple to use and provides a great deal of useful
clinical information about patients’ disability.60 Research
has supported the validity and reliability of the scale for
assessing disability among persons with mixed chronic
pain problems23 as well as low back pain.9,32
WHYMPI. The WHYMPI30 is a 56-item measure that
assesses the impact of pain on the patient’s life, the pa-
tient’s view of how significant others respond to their
communication of pain, and the patient’s general activ-
ity level. The validity and reliability of the WHYMPI have
been well established.30 The validity of the WHYMPI has
been further supported by the results of exploratory and
confirmatory factor-analytic procedures.54 Two of the
scales, Interference and General Activity Level, were
used as measures of function and adjustment for this
study.
The Interference scale of the WHYMPI consists of 11
items that assess how pain has interfered with day-to-
day activities and functioning, including the ability to
work, to enjoy family, to participate in social and recre-
ational activities, and to perform household chores.30
Scale scores range from 0 to 66, with higher scores indi-
cating greater perceived interference over one’s daily
functioning. The Interference scale has been reported to
have an excellent internal consistency of 0.90 and a test-
Validation of the Chronic Pain Coping Inventory
retest stability of 0.86.30 The General Activity Level scale
consists of 18 items representing household chores, out-
door work, activities away from home, and social activi-
ties. The scale score is computed by averaging the scores
of these 4 activities. Scale scores range from 0 to 108,
with higher scores indicating higher levels of activities
engaged by the patients from self-report. In the original
article,30 the Cronbach ␣ of the 4 individual activity scales
ranged from .70 to .86; however, the ␣ for the total scale
was not reported. A subsequent study reported an ␣ of
.76 for the total general activity scale.4
Pain Severity
Because pain severity could influence the predictors
(CPCI scales) as well as the criterion measures of psycho-
logical and physical functioning (depression, interfer-
ence, general activity level, and disability) in the study,
the Pain Severity subscale of the WHYMPI was used to
assess pain severity and was entered in the analyses to
control for this potential confound. The Pain Severity
subscale consists of 3 items that assess both pain intensity
and suffering. Subscale scores range from 0 to 18, with
higher scores indicating greater intensity and suffering.
The pain severity subscale has an internal consistency of
0.72 and a test-retest stability of 0.82.30
Data Analysis
The confirmatory factor analysis was performed by us-
ing version 8.30 of LISREL.26 The initial model was based
on the 8-factor model obtained from a previous explor-
atory factor analysis.17 Each of the 64 observed variables
was assumed initially to be associated with the factor
variable having its largest factor loading from the Vari-
max rotation result of exploratory factor analysis. Thus
each observed variable was assumed initially to be asso-
ciated with 1 and only 1 of the 8 factor variables,
whereas each factor variable was assumed to be associ-
ated with the observed variables having their largest fac-
tor loadings. The correlation matrix between all 64 ob-
served variables served as input data to the analysis. The
factor variables were specified as standardized so that
the covariance matrix among factor variables was esti-
mated with the restriction of having 1’s on the diagonal
and correlation coefficients on the off-diagonal ele-
ments. In succeeding iterations of the model, changes
were made on the basis of the sizes and t values of factor
loadings (␭) on the observed variables currently included
in the model and on diagnostic indicators (modification
indices) of improvements as indicated by decreases in
unexplained ␹2 values that could be realized by adding
additional loadings not included in the current model.
Output from each model included the matrix of factor
loadings, the correlation matrix between factors,
the correlation matrix between measurement errors,
squared multiple correlations between observed vari-
ables, various measures of goodness of fit and modifica-
tion indices. In addition, the output from each model
contained the regression coefficients for calculating fac-
tor scores from values of the observed variables.
ORIGINAL REPORT/Tan et al
Factor scores were obtained by applying the factor score
regression coefficients to the rescaled input variables. Al-
though there were regression coefficients for each factor
on all 64 variables, only those coefficients associated with
variables in the model for each factor were actually used, as
is customary in exploratory factor analysis. The difference is
that factor scores from exploratory factor analysis used unit
weights, whereas factor scores from confirmatory factor
analysis used weights that were approximately propor-
tional to the factor loadings.
Results
Factor Analysis of the CPCI
The initial confirmatory factor analysis model provided
strong support for the exploratory factor analysis model
conducted by the Canadian researchers.17 Loadings of
the 8 factors on the 64 variables were essentially compa-
rable in magnitude to those obtained previously for
those associations assumed to exist. However, the modi-
fication indices, along with magnitudes of the estimated
loadings, indicated that improvements could be made in
the initial and succeeding confirmatory factor analysis
models, either by adding loadings not part of the current
model or by eliminating loadings considered to be too
weak for inclusion in the model. The results of the final
model of the confirmatory facto analysis are shown in
Table 1.
As a measure of similarity between the initial explor-
atory factors and those derived from confirmatory factor
analysis, we computed the correlation between the 2
sets of factors when applied to our input data, with the
following results:
Factor: Exercise/Stretch, Coping Self-Statements, Guard-
ing, Seeking Social Support, Task Persistence, Relaxation,
Asking for Assistance, Resting
Correlation: 0.993, 0.990, 0.979, 0.994, 0.996, 0.937,
0.999, 0.995
This analysis, showing very high correlations be-
tween factor scores calculated from either the explor-
atory or confirmatory factor analysis, provided ratio-
nale for using either the unit weights (exploratory) or
factor regression coefficients (confirmatory) when es-
timating factor scores and also showed that it is not
necessary to use all variables when calculating values
for each factor because the factor regression coeffi-
cients not used in the calculations were all negligible
in size and would have had minimal effect on the ac-
tual scores. Because of this finding, the tables to follow
were based on unit weights rather than factor regres-
sion coefficients for ease of comparisons to the origi-
nal CPCI validation studies.
Descriptive Statistics for Primary
Variables
Means, SDs, and ranges were computed for the empir-
ically derived CPCI factors and the depression (CES-D),
pain interference (Multidimensional Pain Inventory–Pain
Interference [MPIIF]), general activity level (Multidimen-
33
sional Pain Inventory–General Activity Level [MPIGL]),
disability (RMDQ), and pain severity (Multidimensional
Pain Inventory–Pain Severity [MPIPS]) scales (Table 2). It is
important to note that the mean CES-D score of 28.29 is
substantially above the cutoff score of 23 for probable
depression as suggested by Husaini et al21 and larger
than that of a sample of persons with chronic pain before
multidisciplinary pain treatment (mean, 25.11; SD,
12.86).24 Disability scores in this sample (mean, 16.32; SD,
4.91) are similar to those of a chronic pain sample before
multidisciplinary pain treatment (mean, 15.10; SD, 4.94)
but significantly higher than the postmultidisciplinary
pain treatment scores from this same sample (mean,
9.12; SD, 5.70; P ⬍ .01).24 Finally, pain severity in this
sample (mean, 5.10; SD, .86) is significantly higher than
the original published data from a heterogeneous
chronic pain population at the University of Pittsburgh
(mean, 4.53; SD, 1.04; t ⫽ 8.76; P ⬍. 001) but lower than
a sample of patients with chronic pain about to enter
multidisciplinary pain treatment (mean, 6.15; SD, 1.51; P
⬍ .001).24 Taken as a whole, our sample appears to re-
port pain severity, depressive symptoms, and disability at
least as great as, and perhaps greater than, other sam-
ples of patients with chronic pain that were available for
comparison.
Intercorrelations of Empirically Derived
CPCI Factors
A correlation matrix was computed to examine the
relationships among the empirically derived CPCI factors
(based on outcome from the confirmatory factor analy-
sis). As can be seen in Table 3, there are a number of
statistically significant correlations among the CPCI fac-
tors, and the Pearson product-moment correlation coef-
ficients tended to be in the low to moderate range.
Correlations between Empirically
Derived CPCI Scales and Criterion
Variables
The relation between the empirically derived CPCI
scales and the criterion variables of depression (CES-D),
pain interference (MPIIF), general activity level (MPIGL),
disability (RMDQ), and pain severity (MPIPS) were initially
examined via zero-order correlations, yielding Pearson
product-moment correlation coefficients (Table 4). Be-
cause of the large number of correlation coefficients
computed and examined for these analyses, the ␣ level
was set at P less than .01 to help control for the possibility
of Type I error when interpreting these findings.24 As can
be seen in Table 4, depression had significant, positive
correlations with the Guarding, Asking for Assistance,
and Resting factors and a significant, negative correla-
tion with the Coping Self-Statements and Task Persis-
tence factors. Pain interference was positively correlated
with Guarding, Asking for Assistance, and Resting and
negatively correlated with Task Persistence.
Six of the factors were significantly correlated with
general level of activity: Exercise/Stretch, Task Persis-
tence, and Seeking Social Support had positive associa-
34 Validation of the Chronic Pain Coping Inventory

Table 1. Eight-Factor Model of the CPCI: Factor Loadings by Item

FACTORS

I II III IV V VI VII VIII

ITEM (ORIGINAL CPCI SCALE) (EXE) (COP) (GUA) (SEE) (TAS) (REL) (ASK) (RES)

60. (Exercise/Stretch) .79

29. (Exercise/Stretch) .78
61. (Exercise/Stretch) .76
43. (Exercise/Stretch) .74
17. (Exercise/Stretch) .73
55. (Exercise/Stretch) .71
38. (Exercise/Stretch) .70
26. (Exercise/Stretch) .69
52. (Exercise/Stretch) .67
3. (Exercise/Stretch) .67
13. (Exercise/Stretch) .59
32. (Exercise/Stretch) .31
45. (Coping Self-Statements) .77
54. (Coping Self-Statements) .72
19. (Coping Self-Statements) .71
27. (Coping Self-Statements) .67
23. (Coping Self-Statements) .64
21. (Coping Self-Statements) .63
10. (Coping Self-Statements) .62
37. (Coping Self-Statements) .62
14. (Coping Self-Statements) .61
49. (Coping Self-Statements) .60
30. (Coping Self-Statements) .59
46. (Guarding) .71
33. (Guarding) .67
48. (Guarding) .65
15. (Guarding) .57
41. (Guarding) .56
56. (Guarding) .54
35. (Guarding) .50
11. (Guarding) .46
40. (Resting) .39
39. (Guarding) .32 .38
64. (Resting) .32
44. (Seeking Social Support) .72
20. (Seeking Social Support) .70
57. (Seeking Social Support) .64
8. (Seeking Social Support) .63
16. (Seeking Social Support) .62
53. (Seeking Social Support) .48
22. (Seeking Social Support) .48
6. (Seeking Social Support) .42
63. (Task Persistence) .71
34. (Task Persistence) .64
28. (Task Persistence) .64
4. (Task Persistence) .64
2. (Task Persistence) .59
51. (Task Persistence) .54
1. (Relaxation) .63
59. (Relaxation) .62
12. (Relaxation) .61
36. (Relaxation) .53
24. (Relaxation) .51
31. (Relaxation) .49
50. (Relaxation) .49
9. (Asking for Assistance) .77
ORIGINAL REPORT/Tan et al
Table 1. Continued
I II
ITEM (ORIGINAL CPCI SCALE) (EXE) (COP)
25. (Asking for Assistance)
62. (Asking for Assistance)
42. (Asking for Assistance)
47. (Resting)
18. (Resting)
5. (Resting)
7. (Resting)
58. (Resting)
Abbreviations: EXE, Exercise/Stretch; COP, Coping Self-Statements; GUA, Guarding; SEE, Seeking Social Support; TAS, Task Persistence; REL, Relaxation; ASK,
Asking for Assistance; RES, Resting.
tions, whereas Guarding, Asking for Assistance, and Rest-
ing had negative associations. Disability was positively
correlated with Guarding, Seeking Social Support, Ask-
ing for Assistance, and Resting and negatively correlated
with Task Persistence. Finally, pain severity had signifi-
cant, positive correlations with Guarding, Asking for As-
sistance, and Resting and a negative correlation with
Task Persistence.
In general, the correlations between the CPCI factors
and the dependent measures were in the expected direc-
tions, assuming that the CPCI Task Persistence, Exercise/
Stretch, and Coping Self-Statements scales assess “adap-
tive” coping responses, and the CPCI Guarding, Resting,
and Asking for Assistance assess “maladaptive” coping
responses.
Multiple Regression Analyses
To explore the ability of the empirically derived CPCI fac-
tors to predict important pain-related outcomes, a series of
hierarchical multiple regression analyses were conducted
with depression (CES-D), pain interference (MPIIF), general
activity level (MPIGL), disability (RMDQ), and pain severity
(MPIPS) as the criterion variables and the 8 CPCI factors
(Guarding, Resting, Asking for Assistance, Relaxation, Task
Persistence, Exercise/Stretch, Seeking Social Support, Cop-
ing Self-Statements) as the primary predictor variables (Ta-
ble 5). Pain severity (when not used as a criterion variable)
was entered in the first step. Age, sex, and education were
entered in the second step. We controlled for these vari-
ables because they often correlate with adjustment, as well
as coping strategy use. The CPCI factors were entered last
into the equations to determine whether they accounted
for unique variance in the criterion variables, above and
beyond what is already accounted for by pain severity and
the demographic variables. Again, because of the large
number of analyses, we set the ␣ level at P less than .01 to
control for ␣ inflation associated with multiple analyses.24
As can been seen in Table 5, in each regression model,
the control variables and the CPCI factors as a group
accounted for a statistically significant amount of vari-
ance in the criterion variable, as indicated by the ad-
justed coefficient of multiple determination (adjusted
35
FACTORS
III IV V VI VII VIII
(GUA) (SEE) (TAS) (REL) (ASK) (RES)
.75
.74
.71
.70
.68
.66
.61
.59
R2), which ranged from 10.50% for pain severity to
40.70% for disability (P ⬍ .001 in all models). Further-
more, the addition of the CPCI factors in the last step in
each of the equations yielded a statistically significant
increase in R2, ranging from 9.80% for depression to
23.20% for disability (P ⬍ .001 in all models). In each
regression model, the CPCI factors accounted for unique
variance in the criterion variable, above and beyond
what is already accounted for by the control variables.
Table 6 presents the standardized, partial regression
coefficients (␤) for all predictor variables in the final re-
gression equations. The ␤ indicates the nature of the
relationship between the predictor and criterion vari-
ables, specifically the association between each predictor
variable and the criterion when all other predictor vari-
ables are controlled.
With regard to depression (CES-D), the Resting factor
was found to be a significant, positive predictor, whereas
Task Persistence was found to be a negative predictor.
Among the control variables, pain severity was a positive
predictor, and age was a negative predictor, when other
variables are taken into account. For pain interference,
the Guarding and Resting factors were significant, posi-
tive predictors, and Task Persistence was a negative pre-
dictor. Among the control variables, pain severity was
found to be a significant, positive predictor of pain in-
terference. Furthermore, the size of the ␤ (.37) and the
significance level (P ⬍ .001) suggest that pain severity
was the most powerful predictor of pain interference.
With respect to general activity level, Task Persistence
and Seeking Social Support were significant, positive
predictors, whereas Guarding was a negative predictor.
Pain severity was the only control variable to signifi-
cantly predict general activity level. Regarding disability,
Guarding and Asking for Assistance were significant,
positive predictors, whereas Task Persistence was found
to be a negative predictor. Among the control variables,
pain severity was a positive predictor. Finally, when pain
severity served as the dependent variable, Resting was
found to be a positive predictor. No demographic vari-
ables were significant predictors of pain severity.
In summary, the results of the regression analyses indi-
36 Validation of the Chronic Pain Coping Inventory

Means, SDs, and Ranges for Empirically Derived CPCI Factors, CES-D, MPIIF, MPIGL,
Table 2.
RMDQ, and MPIPS
SCALE MEAN SD RANGE N

CPCI factors
Exercise/Stretch 2.20 1.96 0-7 508
Coping Self-Statements 3.33 1.96 0-7 508
Guarding 4.43 1.63 0-7 510
Seeking Social Support 2.35 1.68 0-7 509
Task Persistence 3.13 1.92 0-7 509
Relaxation 2.20 1.68 0-7 508
Asking for Assistance 2.82 2.24 0-7 508
Resting 4.92 1.84 0-7 510
CES-D 28.29 12.14 0-60 526
MPIIF 5.04 .89 1.33-6.00 564
MPIGL 1.64 .98 0-5.19 561
RMDQ 16.32 4.91 1-24 561
MPIPS 5.10 .86 1-6 564

Table 3. Intercorrelations of the Empirically Derived CPCI Factors

FACTOR EXE COP GUA SEE TAS REL ASK RES

Exercise/Stretch — .41* .21* .28* .28* .54* .11 .21*

Coping Self-Statements — .24* .47* .34* .58* .22* .31*
Guarding — .22* ⫺.02 .28* .38* .55*
Seeking Social Support — .10 .39* .51* .28*
Task Persistence — .26* ⫺.12† .01
Relaxation — .17* .32*
Asking for Assistance — .32*
Resting —

Abbreviations: EXE, Exercise/Stretch; COP, Coping Self-Statements; GUA, Guarding; SEE, Seeking Social Support; TAS, Task Persistence; REL, Relaxation; ASK,
Asking for Assistance; RES, Resting.
*P ⬍ .001.
†P ⬍ .01.

cate that as a group, the empirically derived CPCI factors
accounted for unique variance in depression, pain inter-
ference, general activity level, disability, and pain sever-
ity above and beyond what is accounted for by the de-
mographic variables (age, sex, education) and pain
severity (when inserted as a predictor variable). Several
CPCI factors were found to be significant predictors of
each of the criterion variables. The Coping Self-
Statements, Relaxation, and Exercise/Stretch factors,
however, were not significant predictors in any of the
models. Task Persistence was the most consistent predic-
tor among the CPCI factors. Pain severity was a signifi-
cant predictor in all models, which lends support to its
inclusion as a control variable when assessing the predic-
tive ability of the coping scales. Finally, with the excep-
tion of age predicting depression, the demographic vari-
ables were not significant predictors in any of the
models.
Discussion
The purpose of the present study was to confirm the
factor structure and validity of the CPCI in a population
of patients with chronic pain in a Veterans Administra-
tion Medical Center. The factor structure of the original 8
CPCI subscales was generally confirmed. A confirmatory
factor analysis strongly supported the 8-factor model. Of
the original 64 items in the 8 subscales, only 2 items (#40
and #64) did not fit in the original Guarding subscale and
needed to be moved to the Resting subscale. The factor
model contained only 4 loadings between 0.30 and 0.40,
with the remaining loadings above 0.40.
The findings also support the predictive validity of the
CPCI scales and were consistent with a cognitive-
behavioral model of chronic pain that hypothesizes sig-
nificant associations between coping and functioning in
persons with chronic pain. As predicted, the CPCI factor
scores were significantly related to a number of mea-
sures of patient adjustment to chronic pain; with the
exception of the Relaxation factor, all of the factors were
significantly correlated with at least one of the depen-
dent variables. Although the significant correlations
were generally modest and also variable across the cop-
ing factors, not all coping factors are necessarily equally
important to the management of chronic pain. In fact,
one of the goals of the CPCI is to identify those coping
strategies that are most important to patient function-
ORIGINAL REPORT/Tan et al 37

Table 4. Correlations of the Empirically Derived CPCI Factors with CES-D, MPIIF, MPIGL, RMDQ,
MPIPS
FACTOR CES-D MPIIF MPIGL RMDQ MPIPS

Exercise/Stretch ⫺.06 ⫺.02 .15* .00 ⫺.05

Coping Self-Statements ⫺.13* .03 .10 .08 ⫺.01
Guarding .20† .38† ⫺.23† .50† .22†
Seeking Social Support ⫺.04 .11 .12* .21† .10
Task Persistence ⫺.24† ⫺.19† .36† ⫺.21† ⫺.15*
Relaxation .01 .09 .04 .10 .04
Asking for Assistance .12* .20† ⫺.16† .37† .17†
Resting .22† .37† ⫺.21† .33† .26†

*P ⬍.01.
†P ⬍ .001.

Hierarchical Multiple Regression Analyses Predicting Depression, Pain Interference,

Table 5.
General Activity Level, Disability, and Pain Severity with CPCI Empirically Derived Factors
STEP R2/ADJUSTED R2 F R2 CHANGE F CHANGE

Criterion variable: Depression (CES-D)

1. Pain severity (MPIPS) .064/.062 33.09* .064 33.09*
2. Age, sex, education .084/.076 10.96* .020 3.42
3. CPCI subscales .182/.161 8.77* .098 7.12*
Criterion variable: Pain interference (MPIIF)
1. Pain severity (MPIPS) .238/.237 151.36* .238 151.36*
2. Age, sex, education .243/.237 38.60* .005 1.02
3. CPCI subscales .357/.341 21.92* .114 10.52*
Criterion variable: General activity level (MPIGL)
1. Pain severity (MPIPS) .063/.062 32.82* .063 32.82*
2. Age, sex, education .096/.088 12.74* .032 5.73†
3. CPCI subscales .280/.262 15.35* .184 15.15*
Criterion variable: Disability (RMDQ)
1. Pain severity (MPIPS) .183/.181 108.47* .183 108.47*
2. Age, sex, education .190/.183 28.19* .007 1.35
3. CPCI subscales .422/.407 28.77* .232 23.73*
Criterion variable: Pain severity (MPIPS)
1. Age, sex, education .018/.012 3.02 .018 3.02
2. CPCI subscales .125/.105 6.16* .107 7.22

*P ⬍ .001.
†P ⬍ .01.

ing. The current validity data demonstrate that the CPCI
is useful for this purpose, given the variability found in
the correlates of the CPCI factor scores. The zero-order
correlations between the CPCI factors and self-reported
adjustment to chronic pain suggest that Task Persistence,
Exercise/Stretch, and Coping Self-Statements are adap-
tive coping responses, and that Guarding, Resting, and
Asking for Assistance are maladaptive in this sample. The
2 remaining factors, Seeking Social Support and Relax-
ation, are less clear as to whether they are adaptive or
maladaptive. Our results are generally consistent with
those from previous studies of the CPCI. For example,
Jensen et al25 found that Guarding and Resting were
positively associated with depression and pain-related
affective distress and negatively correlated with general
activity. Task Persistence demonstrated significant nega-
tive associations with depression and affective distress.
The empirically derived CPCI factors also demonstrated
impressive predictive ability. After controlling for demo-
graphic variables and pain intensity, the CPCI factors ac-
counted for a significant amount of variance in patients’
self-reported depression, disability, pain interference,
and general activity level. The CPCI factors also made an
independent contribution to the prediction of pain se-
verity. The factors that were most highly associated with
Disability, Pain Interference, and General Activity Level
explained 41.0%, 35.0%, and 28.0% of the variance, re-
spectively, in these variables. In a previous study of the
CPCI, the empirically derived factors also made signifi-
cant contributions to the prediction of pain severity and
pain-related interference.17 However, unlike the find-
ings of the previous research, this study did not find Re-
laxation to be associated with emotional distress. In-
stead, our finding suggests that Relaxation appears to be
38 Validation of the Chronic Pain Coping Inventory

Table 6. Standardized Regression Coefficients (␤) for All Predictor Variables in the Final
Regression Equation
PREDICTOR VARIABLES CES-D MPIIF MPIGL RMDQ MPIPS

Pain severity (MPIPS) .15* .37† ⫺.13* .28† –

Age ⫺.13* ⫺.04 ⫺.07 .06 ⫺.02
Sex ⫺.01 .03 .08 .00 .05
Education ⫺.07 ⫺.05 .08 ⫺.07 ⫺.12
CPCI subscales
Exercise/Stretch ⫺.03 ⫺.05 .11 ⫺.05 ⫺.08
Coping Self-Statement ⫺.14 ⫺.02 ⫺.01 ⫺.02 ⫺.08
Guarding .07 .22† ⫺.15* .41† .12
Seeking Social Support ⫺.10 .01 .23† .07 .05
Task Persistence ⫺.16* ⫺.12* .28† ⫺.13* ⫺.11
Relaxation .09 .03 ⫺.09 .02 .03
Asking for Assistance .07 ⫺.00 ⫺.11 .13* .05
Resting .18* .17† ⫺.11 ⫺.02 .19*
*P ⬍ .01.
†P ⬍ .001.

more adaptive, a finding more consistent with current
conception of the role of relaxation. We also found that
Asking for Assistance and Seeking Social Support were
not associated with less favorable adjustment to chronic
pain.
With regard to the individual CPCI factors in the
present study, Task Persistence was a significant predic-
tor of depression, interference, activity, and disability.
Guarding predicted all of the criterion variables except
depression and pain severity, and Resting predicted all of
the variables except disability and general activity level.
Asking for Assistance, Seeking Social Support, and Cop-
ing Self-Statements each predicted one criterion vari-
able. Overall, these results confirm the clinical impor-
tance of teaching and reinforcing the coping strategy of
Task Persistence and discouraging the regular use of
Guarding and Resting. The results suggest that Coping
Self-Statements is a positive strategy, but this coping
strategy was significantly associated with only one out-
come variable. Relaxation and Exercise/Stretch did not
predict any outcome variable.
The Seeking Social Support factor was a significant
positive predictor of general activity level. These results
suggest that Seeking Social Support is an adaptive cop-
ing strategy. In the zero-order correlations, however,
Seeking Social Support was positively associated with dis-
ability. Our findings demonstrate the complicated na-
ture of the association between Seeking Social Support
and functioning. The social support coping strategy is
undoubtedly multidimensional and might include both
adaptive (eg, obtaining emotional support that en-
hances functioning) and maladaptive (eg, obtaining help
with tasks that the patient can perform) components. It
is also possible that this strategy is adaptive, but that
patients use it more when they experience greater dis-
ability or distress (eg, effective medications would be
used more often by people who are ill, thereby produc-
ing a positive association between medication use and
illness, even though the medications are effective).
The Asking for Assistance coping strategy was signifi-
cantly associated with Seeking Social Support and might
represent a negative component of social support seek-
ing. In the regression models, the Asking for Assistance
strategy might have controlled for the negative aspect of
social support and left the positive aspects of support
that are associated with adaptation to chronic pain. Our
results emphasize the clinical importance of helping pa-
tients distinguish between the adaptive and maladap-
tive aspects of seeking social support.
Given that our study design was cross-sectional and
correlational, it is not possible to draw causal conclusions
from the findings. For example, we cannot determine
whether the coping strategy of Task Persistence helps to
promote activity and prevent depression, disability, and
pain-related interference. It is possible that patients who
are active, not depressed, and functioning relatively well
are more apt to develop and use Task Persistence as a
coping strategy. In addition, it should be noted that, as a
group, the 8 CPCI factors accounted for only 10% to 18%
of the variance in each of the criterion variables, after
controlling for pain severity and demographic variables.
Given the difficulties associated with treating chronic
pain, however, identifying coping strategies associated
with positive outcomes is clinically meaningful, even if
the associations found are modest. Additional research is
needed to identify other factors that help to predict pa-
tient outcomes. In particular, prospective longitudinal
and experimental studies are needed to assess patient
coping strategies and other potential predictors over
time and to determine their causal relation to multiple
outcome variables.
Additional limitations of the current study include the
unique characteristics of the patient sample and the reli-
ance on self-report measures. Because our sample consisted
of primarily male veterans, we were not able to evaluate
any possible gender differences. The results of recent stud-
ies suggest that men and women might differ somewhat in
their preferred strategies for coping with chronic pain.8,58
In addition, the patients in our sample reported more se-
vere pain, pain duration, depression, and disability than did
ORIGINAL REPORT/Tan et al
samples of patients with chronic pain from other pain
treatment settings. Also, only 45% of the eligible patients
chose to participate in the study by returning the com-
pleted questionnaires. Although the responders did not
differ significantly from nonresponders on demographic
variables, they might have differed on other pain-related
variables that were not assessed. Thus, the generalizability
of the current findings is limited.
Despite the limitations of the current study, the find-
ings provide additional support for the cognitive-
behavioral model of chronic pain, for the potential im-
portance of coping in adjustment to chronic pain, and
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