Copyright by Yiwei Wang 2020
The Dissertation Committee for Yiwei Wang Certifies that this is the approved version of the following dissertation:
Talking about Torment: Agency Assignment and Grammatical Metaphor in Pain Communication
Committee:
Matthew McGlone, Supervisor
Anita Vangelisti
Erin Donovan
Elena Bessarabova
Talking about Torment: Agency Assignment and Grammatical Metaphor in Pain Communication
by
Yiwei Wang
Dissertation
Presented to the Faculty of the Graduate School of The University of Texas at Austin in Partial Fulfillment of the Requirements for the Degree of
Doctor of Philosophy
The University of Texas at Austin May 2020 Dedication
This dissertation is dedicated to my father, Longming Wang; mother, Xiazhen Li; grandmother, Shumei Pan; and to my grandfather, Wengen Li, who passed away last year —I love you all so deeply. 谨以此文献给我的父亲，王龙明；母亲，李霞珍；外婆，潘书妹；以及我去年离世
的外公，李文根——我深深地爱你们。
Acknowledgements
I would like to express my deepest gratitude to my advisor, Dr. Matthew McGlone, for his guidance, support, and encouragement which helped me tremendously during the dissertation process. Dr. McGlone has been my advisor since the beginning of my doctoral studies. His passion for research and his kindness as a mentor have inspired me to become a better scholar. My gratitude extends to the members of my dissertation committee, Dr. Anita Vangelisti, Dr. Erin Donovan, and Dr. Elena Bessarabova. Their immense knowledge and insightful feedback has helped to improve the quality of my work. I would also like to pay my special regards to Dr. Michael Beatty who encouraged me to pursue a Ph.D. in Communication Studies. I am deeply indebted to my participants, without whom this project would have not been possible. Finally, many thanks to my family, friends, and partner who have always believed in me and my work.
v Abstract
Talking about Torment: Agency Assignment and Grammatical Metaphor in Pain Communication
Yiwei Wang, PhD The University of Texas at Austin, 2020
Supervisor: Matthew McGlone
People suffering from pain often express their experience in metaphor. Empirical research suggests that the metaphors they use may shed light on their adjustment to pain conditions. While linguistic agency and pain metaphors often co-occur, no study has examined how people assign agency when describing pain and the impact of agency assignment on message receivers’ perceptions and responses. This research investigated 1) patterns of linguistic agency assignment in individuals’ descriptions of pain differing in intensity and duration, and 2) the impact of linguistic cues (i.e., agency assignment and grammatical category) used in fictitious pain narratives on audience’s pain perception. Two studies are reported. Study 1 investigated the language people spontaneously use to articulate their experience of mild vs. severe and acute vs. chronic pain. The author hypothesized that participants would be more likely to assign agency to pain or body parts where pain is localized (e.g., back) when describing chronic and/or severe pain than when describing acute and/or mild pain. As predicted, pain/body agency assignment rate was
vi higher in the chronic vs. acute pain condition. However, there was no significant difference in the pain/body agency assignment rate between the severe and mild pain conditions.
Study 2 featured a 3 (pain location: back, head, or joint) × 2 (agency assignment: person or pain/body) × 2 (pain process encoding: verb or nominalization) factorial experimental design. Participants read a pain narrative differing in linguistic cues and then rated their perception of the speaker and their pain. Findings from univariate analyses of covariance indicated that pain/body agency predicted higher ratings of perceived pain intensity and duration and lower ratings of internal locus of control and pain responsibility than human agency. However, no significant effect of agency assignment and nominalization were found on perceived pain affect, pain-related disability, sympathy, and support for higher dose. Pain perception was also subjected to individual differences in medical expertise, personal pain history, and experience of caretaking. This research offers insight to researchers and healthcare professionals about the influence of various linguistic choices in pain description on others’ interpretation of sufferers’ experience and their subsequent reactions.
vii Table of Contents
List of Tables ...... xi
Chapter 1: Introduction ...... 1
Chapter 2: Theoretical Background ...... 7
Chronic Illness and Lexical Metaphor ...... 7
Agency Assignment in Language ...... 12
Ideational Metaphor and Nominalization ...... 17
Chapter 3: Hypotheses ...... 20
Chapter 4: Method ...... 32
Participants ...... 32
Study 1 ...... 35
Design and procedure ...... 35
Agency coding and reliability ...... 37
Study 2 ...... 39
Experimental design and procedure ...... 39
Dependent measures ...... 41
Perceived pain intensity ...... 41
Perceived pain duration ...... 41
Perceived pain affect ...... 41
Perceived pain-related disability ...... 42
Perceived pain locus of control ...... 43
Perceived pain responsibility ...... 43
Sympathy ...... 44
viii Perceived need for higher dose ...... 44
Individual differences ...... 44
Chapter 5: Results ...... 46
Study 1 ...... 46
Study 2 ...... 47
Agency assignment ...... 48
Nominalization ...... 55
Individual differences ...... 59
Medical training ...... 59
Personal pain history ...... 61
Experience of being a primary caretaker ...... 62
Regular interactions with chronic pain patients ...... 63
Chapter 6: Discussion ...... 65
Theoretical implications ...... 66
Practical implications ...... 72
Limitations ...... 74
Conclusion ...... 75
Tables ...... 77
Appendices ...... 83
Appendix A: Questionnaire for Study 1 ...... 83
Appendix B: Questionnaire for Study 2 ...... 85
Appendix C: Demographic questions for Study 2 ...... 87
Appendix D: Pain narratives for Study 2 ...... 89
ix Works Cited ...... 93
x
List of Tables
Table 1: Means and standard deviations for rate of each agency type by condition (i.e., chronic and acute pain; severe and mild pain) of each coder in Study 1 ...... 77
Table 2: Summary of intercorrelations, means, and standard deviations for the dependent variables in Senario 1 (n=209) ...... 78
Table 3: Summary of intercorrelations, means, and standard deviations for the
dependent variables in Senario 2 (n=120) ...... 79
Table 4: Summary of intercorrelations, means, and standard deviations for the
dependent variables in Senario 3 (n=149) ...... 80
Table 5: Effects of agency assignment on the dependent variabls across the
scenarios when controlling for covariates ...... 81
xi Chapter 1: Introduction Putting one’s pain into words is difficult, for the experience is not only intangible but also unique to the individual. In her essay On Being Ill (1930), Virginia Woolf poetically depicted the problem: “the merest schoolgirl, when she falls in love, has
Shakespeare or Keats to speak her mind for her; but let a sufferer try to describe a pain in his head to a doctor and language at once runs dry.” Woolf offers us a glimpse of the struggle patients face when trying to express their pain to others.
The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with the actual or potential tissue damage, or described in terms of such damage” (1979, p. 250). A widely acknowledged distinction between chronic and acute pain is that chronic pain persists beyond the normal time of healing (i.e., more than 3 to 6 months) and no longer serves the function of alerting sufferers to physiological nociception (Treede et al., 2015). A recent survey suggested that
30.7% of Americans aged 18 years and older have suffered chronic pain, primarily lower back pain and osteoarthritis pain (Johannes et al., 2010). Half of respondents with chronic pain experienced daily pain and about one third reported their pain intensity being severe
(i.e., ≥ 7 on a scale ranging from 0 to 10).
People suffering from chronic pain are susceptible to a set of psychosocial and physical consequences, such as sleep disturbance (Smith & Haythornthwaite, 2004) and decreased ability to participate in various daily activities ranging from walking to attending social activities and maintaining independent lifestyle (Breivik et al., 2006). One fourth of
1 respondents in a European survey of chronic pain said that it had adversely affected their employment status and those who were employed reported losing an average of 7.8 days of work time to pain in the last six months (Breivik et al., 2006).
Chronic pain has also been found to have detrimental psychological effects on patients as well as caregivers and family members (Hooten, 2016; Williams et al., 2012).
About one fifth of respondents in Breivik et al.’s (2006) survey reported they had been diagnosed with depression because of chronic pain. Similarly, McWilliams, Cox, and Enns
(2003) found that chronic pain was positively associated with mood and anxiety disorders, which in turn aggravated the disability causing the pain. Spouses of chronic pain patients also reported having significantly more pain symptoms (e.g., headaches, chest pains, etc.) themselves than spouses of diabetics’, symptoms that derive from depression (Flor et al.,
1987). In addition, chronic pain has a strong impact on the family environment of patients, causing sadness and sleep disturbance of relatives and reduction in their leisure activity
(Ojeda et al., 2014).
Given the prevalence of chronic pain and its substantial impact on patients and caregivers, it is important to understand the communicative construction of pain experience and how pain description may affect receivers’ interpretation and subsequent reactions.
Because pain experience is largely subjective, healthcare providers often rely on self-report information to evaluate the sufferer’s condition for treatment. One of the most commonly used pain measurement, the McGill Pain Questionnaire (Melzack, 1975), assesses pain by asking respondents to rate the applicability of English pain descriptors (throbbing, pulsing, etc) to their experience. Clinicians have also sought to understand the role language plays 2 in pain communication and its relationship with patients’ inner status (Shahar & Lerman,
2013; Schattner et al., 2008). In particular, patients with chronic pain and other long-term medical problems often resort to metaphor, especially personification, to make sense of their experience and communicate it to others (Gwyn, 1999; Lascaratou, 2007; Locock et al., 2012). Scholars have addressed the issue of metaphor in two senses: metaphor as a figure of speech and as a symbol or conceptual representation (Glucksberg & McGlone,
2001). As a figure of speech, metaphor figuratively compares one kind of object or idea to another to suggest some degree of likeness or similarities (e.g., all the world’s a stage); as a symbol, metaphor is used to represent one thing with another (e.g., time is money).
Empirical research suggests that conceptual and linguistic metaphorizing of illness are associated with patients’ emotional well-beings and adjustment. For instance, a longitudinal study found that three years after the initial survey, women with breast cancer who originally identified their condition as an enemy, a form of punishment, or a loss exhibited significantly higher levels of depression, anxiety, and poorer quality of life than others who identified the cancer using more positive terms (Degner et al., 2003). Similarly,
Schattner and Shahar (2011) found that pain personification, rather than pain intensity, was a distinctive predictor of pain-related affective conditions. Patients who viewed their condition as a “bad” internal object by assigning more negative human attributes to it reported higher levels of depression, illness intrusiveness, and pain-related distress. These findings support Radley’s (1993) claim that metaphor is a communicative structure of adjustment to illness sufferers use to give expressive form to their condition. However, there is very limited research investigating how others interpret and share sufferers’ pain 3 experience when exposed to verbal descriptions of pain. Understanding this process in more detail can inform how health professionals may best support and care for chronic pain sufferers.
An important linguistic marker often associated with metaphor is inanimate agency assignment. In linguistics, agency assignment is the ascription of action or change to one or more entities in discourse (McGlone et al., 2013). Such choices are typically made without conscious awareness (McGlone & Pfiester, 2009) and realized with great flexibility in language (Dragojevic et al., 2014; Bell et al., 2014). When talking about their experience of chronic pain, patients may assign the agency to humans, such as themselves
(e.g., “I can’t bear this torture.”), or to inanimate agents, such as pain (e.g., “The pain ruined my life.”) or body parts (e.g., “My back is killing me.”), etc. Previous research suggests that different patterns of agency assignment in health education materials may affect an audience’s attitudes toward the health threat and recommended treatment (Bell et al., 2014; McGlone et al., 2013; McGlone et al., 2017). While inanimate agency assignment and metaphoric language, especially personification, are often intertwined, no study to date has investigated how people spontaneously assign agency when talking about various pain experiences. Furthermore, no existing research has examined the attributional consequences (Bradac & Mulac, 1984) of agency assignment in pain communication – i.e., how these linguistic devices influence the perceptions and impressions audiences form of the communicator’s pain experience.
Another language choice that co-occurs with inanimate agency assignment is grammatical metaphor, the most common of which is nominalization. Previous research 4 on the use of metaphoric language in pain communication primarily focused on “lexical metaphor,” in which a word or phrase is used to describe something it does not literally denote – e.g., this pain is vicious. Grammatical metaphor, as described by Halliday (1985), is a different form of “transcategorization,” in which a phenomenon of one sort is linguistically treated like another. In lexical metaphor, words describing one realm of experience (interpersonal aggressive behavior as literally denoted by “vicious”) are used to describe a different experience (the sensation of intense pain). In grammatical metaphor, words from one grammatical class (nouns, verbs, adjectives, etc.) are used to represent a different class. Halliday proposed two major categories of grammatical metaphor, ideational and interpersonal, which he characterized as “language as reflection” and
“language as action,” respectively. The proposed study focuses on ideational grammatical metaphor which pertains to expressing the speaker’s experience of the outside world as well as their internal world.
The most common form of ideational metaphor is nominalization, a grammatical device that transcategorizes a verb or adjective as a noun – irritate à irritation, sore à soreness, etc, and thus packing meanings in nominal groups which allows additional layers of meanings to be construed. Nominalization is also a form of agency assignment (i.e., assignment to process) as the speaker omits the noun subject but ascribes agency to the nominalized verb, which transforms the process itself into the agent of the sentence (e.g., the irritation in my knees made it hard to walk). Some linguists have suggested that nominalization removes or deletes human agency from the process and thereby makes messages more passive and impersonal (Billig, 2008; Zheng et al., 2014). 5 Drawing on Halliday’s theory of grammatical metaphor (GM) and research in psycholinguistics, my dissertation investigated patterns of spontaneous agency assignment in descriptions of pain that differ in intensity and duration. This study also examined the attributional consequences of linguistic agency assignment and nominalization in pain communication. Understanding how people make linguistic choices to describe various pain experience and how these linguistic devices influence audience’s perceptions and impressions of a communicator’s experience can benefit how healthcare professionals treat and comfort pain sufferers.
6 Chapter 2: Theoretical Background
CHRONIC ILLNESS AND LEXICAL METAPHORS A milestone in the study of metaphor in health communication is Susan Sontag’s
(1978) Illness as Metaphor, which was inspired by her difficult recovery from breast cancer. Focusing mainly on cancer and tuberculosis, Sontag explored how people assign meaning to diseases and criticizes how these meanings both depart from the actual physical causes of disease and can aggravate people’s experience of and recovery from them.
Specifically, Sontag took issue with three common illness metaphors: disease as personality (i.e., the idea that certain people have personalities that cause cancer or tuberculosis), as punishment (i.e., disease is a consequences of prior lapses in morality, brought about by divine intervention or chronic anxiety), and as warfare (i.e., treatment of the disease, including the sufferer’s self-care, is akin to a battle with a sentient adversary).
Sontag was critical of “metaphorizing” illness, claiming it leads to social stigma and patient shaming. She argued that illness metaphors promote harmful notions such as patients deserve certain diseases (e.g., syphilis) as a punishment for their moral failing or social transgressions and that people cause their own diseases unwittingly (e.g., TB was regarded as a disease of passion and cancer a disease of repression) and they can be cured if they choose to mobilize their will. She also suggested that illness metaphors provoke fear of diseases and pessimism about effective treatment. However, many researchers have pointed out that the use of metaphoric language is motivated by a need for sense making, especially when an experience is hard to describe (Halliday, 1998; Kövecses, 2000;
Lascaratou, 2007). 7 The conventional use of lexical metaphors by sufferers usually involves personification or ascription of meanings to illness, such as referring to illness as an
“enemy,” “path,” “punishment,” or “intruder” (Degner et al., 2003; Locock et al., 2012).
Schattner, Shahar, and Abu Shakra (2008) report an interview with a woman suffering from chronic pain who described it as “something evil, something demonic” that would sometimes “go away and hide in its corner” (p. 468) if she took care of herself. Another woman articulated her experience by saying she would “go to war” and not let the disease defeat her, implying the existence of an enemy. As Lascaratou (2007) noted, because pain is not only complex and abstract but also threatening, patients attempt to assimilate pain- related experience into other ordinary experience. Hence, metaphors help sufferers understand, structure, and transfer their experience.
Some scholars have argued that the way patients ascribe meanings to their chronic conditions may also reflect how they feel about themselves (Schattner et al., 2008).
Metaphorical framing of illness, in this sense, is a part of the process whereby patients cope with the changes they experience in their bodies and their lives (Locock et al., 2012). One specific form of metaphorical framing is illness personification, an individual’s tendency to assign human characteristics to the physical illness (Shahar & Lerman, 2013). For example, an illness can be labeled as an “intruder” by a patient to reflect a feeling that the disease is invading his or her physical and/or mental space. It may also be described as an unannounced “guest” while the self as the “host” to suggest that despite the intrusion, accommodation is necessary (Locock, et al., 2012). Shahar and Lerman (2013) posit that the persistent and continuous qualities of chronic stress make personification more likely 8 to occur since chronic stress is best coped with by changing one’s attitude. With time, sufferers become more familiar with their condition and how it may affect them physically and psychologically, as well as how they can better manage it. They propose that the role of pain personification can be understood from an object-relations perspective, which considers chronic pain as an internal “object.”
According to object-relations theorists, the impressions we form of significant others (e.g., primary caregivers, friends, etc.) and events (e.g., mother-child interactions, school experiences, etc.) become represented as “objects” in the unconscious, which in turn influence how we form and negotiate personal and social relationships (Fairbairn, 1952;
Greenberg & Mitchell, 1983). An individual’s perception of non-human entities (e.g., a mother’s breast, medications, etc.) can also become objects if they are deeply and symbolically connected powerful experiences internalized by the self (Flanagan, 2011).
Adopting this perspective, Schattner, Shahar, and Abu-Shakra (2008) suggested that patients living with chronic illness, such as lupus, may constitute a mental representation of the disease within their inner sphere which in turn impacts their affect and behaviors.
Although this line of work has opened up new avenues for exploring the inner world of sufferers’ pain experience, researchers have not given much attention to how metaphorical expressions of pain experience are interpreted by others and how others judge the sufferer’s status based on the pain description.
From a cognitive linguistic view, metaphor is a process in which one complex domain of experience is understood and construed in terms of another more discernible domain (Lakoff & Johnson, 2003; Lascaratou, 2007). For instance, a sufferer may describe 9 abstract pain experience using metaphoric vehicles that are more likely to be recognized by others (e.g., it feels like being stabbed in the back). Perceptual simulation theory (PST)
(Barsalou, 2008) claims that language units, such as words, phrases, and grammatical structures, are comprehended by partially activating neural pathways that are in association with referenced objects, states, and actions. When we hear the word “dog,” according to this theory, the brain activates conjunctive neurons that have previously encoded experiences of the referenced object (i.e., dog), which in turn activate lower order conjunctive neurons that partially simulate the modal states (e.g., activations in the visual system, auditory system, etc.) that are likely to occur when an actual encounter with the referenced object happens. Similarly, when we hear someone say “my neck hurts!”, the neural pathways associated with neck pain in the hearers’ ear exhibit a small amount of activity.
Experimental evidence in psycholinguistic and neuroscientific research has offered some evidence for a connection between metaphorical representations and embodied experiences (Gibbs & Matlock, 2008). Gibbs and Matlock (2008) reported experiments in which participants’ mental images for metaphorical (e.g., chew on the idea) and non- metaphorical (e.g., chew on the gum) phrases were compared based on their descriptions of the action. Participants’ interpretations of the abstract concepts were shaped by embodied simulations, even though the actions were physically impossible. For example, participants noted that ideas can be physically examined by stretching them out while concepts can be understood by a person if they extended the body to grasp them (e.g., grasp the concept). In addition, when participants watched, imitated, or imagined a bodily action 10 relevant to the main verb in a metaphorical phase, they were significantly more likely to refer to those actions and their consequences when describing their mental images. Gibbs and Matlock (2008) thus suggest that not only people are able to interpret metaphorical action statements using embodied metaphors (i.e., imagining metaphorical action statements) but physically moving their bodies in relevant ways enhanced the creation of the stimulations.
Taking this embodiment perspective, Kövecses (2000) pointed out the metaphorical language not only reflects experiences, but also constructs them as “we say what we feel and we feel what we say” (p. 192). Semino (2010) took one step further to suggest that metaphorical descriptions of pain (e.g., sharp pain, burning pain) may elicit more empathetic responses from message receivers by triggering some form of embodied simulations. She discussed several studies that have lent support to her claim which shown that when people experience a painful stimulus (e.g., watching photographs representing limbs in a pain-inducing situation), the relevant areas of their pain matrix become active
(Singer et al., 2004; Jackson et al., 2005). For example, when someone hears onomatopoeia words suggestive of subjective pain (e.g., ghan-ghan for splitting headaches), the anterior cingulate cortex in their brains are significantly activated (Osaka et al., 2004). Such activity, however, does not occur when people hear nonsense words involving similar repetitions of sounds. Based on these studies, Semino suggested that an internal simulation involving the neural system for pain may be elicited by both linguistic descriptions of pain and the perception of pain in others.
11 Semino further highlighted a potential relationship between the simulation at the neural level in response to others’ pain sensations and descriptions and the person’s empathy for the sufferer. In the study of Singer and colleagues (2004), researchers found that while observing their partners in a pain-inducing situation, not only participants’ pain matrix became active but there was a correlation between the degree of pain matrix activity and their empathic tendencies. Similarly, Jackson et al. (2005) reported a correlation between participants’ pain matrix activity during their exposure to others’ pain and their ratings of the sufferer’s pain intensity. Based on these psycholinguistic and neuroscientific research, Semino proposed that using metaphorical expressions to convey pain experiences may facilitate embodied simulation of pain experience on message receivers and therefore elicit more empathetic responses.
In sum, chronic pain is a complex form of experience that often compels sufferers to construe and express their experience in lexical and grammatical metaphor. The way sufferers use metaphorical language to describe pain may reflect their adjustment to the condition and how they view themselves. Furthermore, based on neuroscientific and psycholinguistic observations, it is also possible that metaphorical expressions of pain may affect how others interpret pain experience and their reactions.
AGENCY ASSIGNMENT IN LANGUAGE Agency assignment refers to the lexical and grammatical choices individuals make to describe action and change in events. When describing one’s pain experience, a person can assign the agency to different entities in a sentence, such as the self (e.g., I have fought
12 against back pain for three years), the pain (e.g., The pain is destroying me), body parts where pain is localized (e.g., My back hurts all day long), etc.
Research on spontaneous language production suggests that different patterns of agency assignment reflect communicators’ attitudes toward a target or event (Frazer &
Miller, 2009; McGlone & Pfeister, 2009). For instance, Frazer and Miller (2009) reported that when describing male-on-female crimes, writers preferred to ascribe a causal role to the victim by adopting a passive voice. In their first study, a content analysis of published news stories covering severe domestic violence suggests when men were perpetrators and women victims, writers were more likely to use a passive verb for voice in their writings
(e.g., The victim was beaten by her boyfriend.). To remedy the limitations of using mass media reports to study the relationship between gender, verb voice, and violence, researchers conducted an experiment in which participants were asked to write short stories using given information about the crime (i.e., the event, victim’s and perpetrator’s name, gender, and age, weapon, date, and place). Examination of the stories revealed that both female and male participants were more likely to adopt a passive-voice for the male-on- female violence condition (e.g., A woman had been killed by her husband at night.).
Researchers suggested that the deemphasizing of male perpetrator’s role may reflect writers’ gender-related attitudes of victim blaming.
McGlone and Pfeister (2009) observed that communicators were more likely to ascribe temporal agency to themselves (e.g., we are getting close to our anniversary) when describing a pleasant event but to events (e.g., the deadline is coming up) when they were considered unpleasant, indicating that agency assignment is influenced by speakers’ affect. 13 In a subsequent study, these researchers found that temporal agency assignments have
“attributional consequences” (Bradac & Mulac, 1984), in that they colored participants’ perceptions of a fictitious communicator’s affective orientation toward an event.
Participants read a series of fabricated diary entries in which the writer described temporal passage toward an event in the future, consistently assigning agency to humans (e.g., we are fast approaching the peer counseling conference) or to events (e.g., the peer counseling conference is fast approaching). Although there were no explicit cues in these entries to her affective orientation toward the future event, participants perceived her to be more positive about it than when she encoded it in human-agent rather than event-agent terms.
Consistent with perceptual simulation theory, these findings suggest a symbolic relationship between emotion and movement, in which human approach is equated with positivity and avoidance/stasis with negativity (Barsalou, 1999).
Patterns of agency ascription in spontaneous language may also be indicative of the communicator’s internal states, such as one’s self-efficacy. In a study of smoking initiation and cessation narratives, Wartel (2017) observed an increase in inanimate agency assignment (e.g., smoking is ruining my life.) when participants described experience during their use of nicotine and suggested that the increase symbolized a loss of control to cigarettes and addiction. The researcher also found that personal agency assignment (e.g.,
I’m done with smoking) significantly increased during the description of the cessation maintenance stage and reached its highest level at the post-cessation stage, suggesting that participants were regaining a sense of control. Given that pain of greater intensity and duration tends to have a stronger impact on sufferers, it is plausible that people may be 14 more likely to assign agency to themselves when talking about mild and/or acute pain but to the pain when the sensation is more severe and/or enduring.
Extensive experimental research has shown that manipulation of agency assignment in health messages can affect recipients’ perceptions of illness severity and prevention efficacy (Bell et al., 2014; Glowacki et al., 2016; McGlone et al., 2013). When threat agency is assigned to a virus (e.g., HPV infects millions of people every year), people tend to perceive it as more dangerous and themselves as more susceptible to it than when it is assigned to people (e.g., Millions of people contract HPV each year), and also reported stronger intentions to seek vaccination.
Effects of agency assignment on recipients’ perceptions may also vary depending on the nature of health threats (e.g., acute vs. chronic diseases). A recent study on linguistic agency assignment in diabetes prevention policy material found that although perceptions of severity were higher when the threat agency was assigned to diabetes (e.g., “Diabetes has attacked over 29 million Americans…”) instead of humans (e.g., “Over 29 million
Americans have developed diabetes…”), attitudes toward the recommended prevention program were more favorable when the prevention agency was assigned to humans (e.g.,
“children who eat a healthy diet and exercise regularly protect themselves from Type 2”) rather than the program (e.g., “a healthy diet and regular exercise protect children from
Type 2) (Glowacki et al., 2016). These researchers noted that because Type 2 diabetes is a chronic lifestyle disease that prompts a self-management mindset, assigning prevention agency to humans fostered more positive attitudes toward prevention behaviors than assigning it to the recommended behaviors. 15 However, in a study of patient education about colon cancer, Chen, McGlone, and
Bell (2015) found that susceptibility beliefs increased when participants read an article about colon cancer wherein the disease agency was assigned to human (e.g., I developed cancer) rather than colon cancer (e.g., Cancer developed inside me). This finding may be due to the locus of the threats as cancer are essentially mutating cells that originate within the person, while most health threats (e.g., H1N1 virus, Hepatitis C) studied to date in this research are perceived as exogenous. Thus, the effects of linguistic agency assignment on receivers’ perceptions cannot be assumed, but must be investigated in the specific context of the health threat.
Researchers have noted that patients living with chronic pain may assign features of animacy and agentivity to the pain (Lascaratou, 2007), demonstrating a link between pain metaphors and agency assignment. Schattner and colleagues (Schattner et al., 2008) suggested that sufferers often implicitly regarded their illness as a sentient entity unto itself.
One woman in their study described herself being “strangled” by the lupus as if “they’ve taken out my soul already.” Without explicitly stating “agency,” researchers labeled one of the major line of narratives emerging from the interview text as “protagonization,” which they defined as “assigning the illness the role of a principal character, or protagonist,” and pointed out that personification and protagonization often co-exist. Similarly, Fabrega and
Tyma (1976) noted that when pain is personified as a moving entity (e.g., a pain ran through my chest), it is “conceived of as an agent capable of ‘performing’ an action” which conveys the implication that it is “active, energized and dynamic” (p. 368). Employing this perspective, Lascaratou (2007) pointed out that when pain is grammaticalized as the subject 16 of transitive verbs that actively do something to someone (e.g., the pain is ripping me apart) instead of a subject of intransitive structures where there is only one participant (e.g., the pain continued for a while), it is not only an actor or initiator of the process but also the agent. She argued that the construal of pain as an initiator of action enables it to become a voluntary and self-willed agent and thus the conceptualizations of pain as “actor/subject” and “agent” are closely related and interdependent of one another. It is reasonable, therefore, to hypothesize that when a sufferer assigns agency to pain or pain-related body parts, an audience will perceive the sufferer as more passive and the pain as more active and in control.
IDEATIONAL METAPHOR AND NOMINALIZATION Halliday (1985) suggested that language serves three major metafunctions -- textual, interpersonal, and ideational. The textual metafunction organizes the flow of discourse and gives it cohesion. The interpersonal metafunction renders language a means for establishing and maintaining personal and social relationships with others. The ideational metafunction is fulfilled by using language to represent experience. The ideational metafunction can be differentiated into two categories of construing experience: experiential and logical. The former refers to the organization of one’s world experience and social relations, while the latter pertains to constructing logical relations. It is important, therefore, to understand the potential impact of ideational metaphors in pain description on receivers’ interpretation of the sufferer’s pain experience.
17 Ideational grammatical metaphor is realized primarily through the systems and networks of transitivity, which includes process types and nominalization. Halliday suggests that a transitivity process has three components, including the process itself (i.e., what event is described), participants involved in the process (i.e., actors), and the circumstance associated with the process, when applicable. A process is realized by the verbal group of the clause, participants by nominal groups, and circumstances by adverbial groups or prepositional phrases. For example, if a patient tells a doctor that “the pain attacks when I stand up,” then the pain and the patient are both participants in the process of
“attack,” which is specified by the condition of “when I stand up”.
In an analysis of pain language, Halliday (1988) observed that pain in English is linguistically represented as process, quality, or thing. When represented as a process, pain is encoded as a verb, such as ache or hurt (e.g., my tooth is aching, my foot hurts, etc.).
When represented as a quality, pain is encoded as an adjective, such as sore or tender (e.g., my leg is sore, my back feels tender). When represented as a thing, pain is articulated as a noun, which can assume roles as a sentence subject (e.g., the pain is killing me) or object, the latter of which can be conveyed directly in figure (e.g., I have a headache) or indirectly as a circumstance (e.g., I woke up in pain).
Halliday suggested that the linguistic encoding of concepts tends to evolve from process to entities, which can be realized through nominalization, which in turn is the most common form of grammatical metaphor (Halliday & Matthiessen, 2014). Nominalization
“transcategorizes” verbs and adjectives as nouns, thereby turning a process or attribute into a thing with causal force. For example, a patient could encode a pain experience as a 18 process by saying “My neck irritates me. It’s making it hard for me to concentrate.” In contrast, she could encode pain as a thing by saying “The irritation in my neck is making it hard for me to concentrate.” Similarly, she may describe her pain as a quality by saying
“My neck is so sore I’m finding it hard to concentrate.” Alternatively, she could articulate it as a nominalized inanimate agent, as in “The constant soreness makes it hard for me to concentrate.”
Linguists have delineated how nominalization serves to reify processes as agents with causal force and in turn deplete human agency in language (Billig, 2008). In this process, the nominalized verb becomes animate and actively doing things as the agent of the sentence while the human agent becomes passive and is distant from the presented information. For instance, nominalized affects (e.g., Recent events have raised fears in the local community.) in news agency report can function as a participant in processes while the original mental process of feeling is suppressed in the expression (e.g., Residents of the local community are afraid due to recent events.) (Stenvall, 2008). In such cases, it is unclear who is the person that has experienced the emotion which makes the language vague and ambiguous. It is reasonable to hypothesize that a self-description of pain using nominalized language (e.g., the throbbing lasted for a few minutes) may provide others more information about a sufferer’s experience, but it may also be perceived as more abstract and impersonal and less likely to elicit sympathetic feelings from receivers. The current study, therefore, will investigate whether description of nominalized pain experience affect receivers’ perception of the sufferer and his/her condition.
19 Chapter 3: Hypotheses This study investigates how people assign linguistic agency when talking about pain of different levels of intensity and duration as well as the attributional consequences of linguistic devices in pain communication. Specifically, the study examines how certain language features (i.e., linguistic agency assignment and nominalization) influence the perceptions and impressions audiences form of the communicator’s pain experience.
Prior research indicates that the use of metaphor to describe illness, such as pain personification, is related to patients’ internal status and adjustment to the condition.
Schattner and Shahar (2011) reported a positive correlation between sufferer’s negative personification of pain and other psychological variables, including depression, illness intrusiveness, and pain-related distress, when controlling the level of pain intensity.
Interestingly, pain intensity did not predict illness intrusiveness nor pain-related distress, suggesting that illness intrusiveness and distress are perhaps more related to the mental representation of the pain than to the actual levels of pain experienced. Comparable findings from a longitudinal study (Schattner et al., 2010) provide further support to this theory: illness intrusiveness (i.e., disruptions to the patient’s routines, activities, and interests caused by chronic illness and/or its treatment) but not physical illness markers preceded depression, indicating that the subjective illness experience may have a stronger impact on emotional well-being of the sufferer than physical sensations.
Researchers have also acknowledged that the tendency of assigning human characteristics to physical conditions may be a double-edged sword that plays both a protective and problematic role in physical functioning and emotional status of the sufferer
20 (Shahar & Lerman, 2013). For example, Schattner et al. (2008) observed that women who viewed their lupus as a persecutor and themselves as victims were more likely to acknowledge their suffering and seek help relative to others who considered lupus an enemy and themselves heroes. They pointed out that women who adopted “heroic” narratives may struggle more if they are self-critical and not given enough social support.
On the other hand, Shahar and Lerman (2013) argue that when pain is personified as a persecutor, it becomes “ominous, non-negotiable, and impenetrable”, and the sufferer
“crippled” and “submissive” (p. 50). Data support at least some of these claims. Degner and colleagues (2003) found in a longitudinal study that breast cancer patients who selected more positive terms (e.g., “challenge”) to describe their illness reported lower levels of depression, anxiety, and better quality of life than others who selected more negative meanings like “enemy” or “punishment.” Women who saw their cancer as an enemy struggled with making sense of why it happened to them and demonstrated a lack of confidence, as they were not sure whether they would be able to defend themselves against the illness. However, these studies have not examined how sufferers assign agency when talking about their pain and illness.
Previous research reveals that patterns of spontaneous agency assignment reflect communicators’ attitudes toward events and targets (Frazer & Miller, 2009; McGlone &
Pfeister, 2009) and their internal states (Kurlak et al., 2018; Wartel, 2017). A study by
Kurlak et al. (2018) reported that newlyweds tended to use more positive emotional terms
(e.g., nice, wonderful) and human temporal agency (e.g., We are nearing our first anniversary) to describe events they associated with an increase in relationship 21 commitment than those they associated with a decrease in commitment. Their findings indicate that linguistic cues, including agency assignment, may illuminate how relationships evolve over time and reflect spouses’ views of their commitment to each other.
Similarly, after analyzing narratives of individuals who attempted to quit smoking, Wartel
(2017) found that non-human agency (e.g., smoking) increased in descriptions of nicotine addiction while personal agency assignment increased following descriptions of cessation.
The researcher pointed out that the overall pattern of agency assignment in smoking initiation and cessation narrative and pattern of speakers’ self-efficacy at different stages of change are conceptually similar to each other. Following this logic, since a brief and minor sensation of pain is less likely to affect the sufferer’s physical performance, mental health, and social life than a persistent and intense pain, the author proposed the following hypotheses:
H1: People are more likely to assign agency to pain or body parts when describing
a) chronic than acute pain, and b) severe than mild pain.
A rich body of research initiated by Bradac, Mulac, and other communication scholars suggests that the variations in linguistic dimensions of messages may influence the attitudes of receivers (Bradac & Mulac, 1984; Gibbons et al., 1991; McGlone & Pfiester,
2008). For example, Bradac and Mulac (1984) reported that respondents were able to discriminate among levels of linguistic power demonstrated by various message types.
Hesitation (e.g., My father…uh…is in business.) and tag (e.g., That is the place to go, right?) message types are considered less powerful, effective, and less likely to fulfill the communicator’s intention than powerful (e.g., I don't want excessive travel, however.), 22 polite (e.g., Thank you for the advice), and intensifier (e.g., It was really a stimulating time) message types. Similarly, Gibbons, Busch, and Bradac (1991) found that messages containing powerful language features (i.e., characterized by the absence of hedges, tag questions, and hesitations) attributed greater intellectual competence and self-control to the source than messages with powerless language (i.e., characterized by the presence of hedges, tag questions, and hesitations).
Empirical research suggests that certain agency assignments hold attributional consequences. McGlone and Pfiester (2008) found that participants perceived the writer of a diary entry to be more excited and less worried about a future event when the entry consistently assigned agency to humans (e.g., we are fast approaching the peer counseling conference) rather than events (e.g., the peer counseling conference is fast approaching), indicating that temporal agency affected readers’ impression of the fictitious communicator’s attitude toward the event. Examining the attributional consequences of certain linguistic features in pain communication may help researchers understand how audiences form perceptions of the pain experience and its sufferer from a cognitive linguistic perspective.
Although previous studies have highlighted a link between pain metaphor and the sufferer’s physical and psychological wellbeing (Schattner et al., 2008; Shahar & Lerman,
2011), the attributional consequences of metaphor in pain communication have not been explored heretofore. In addition, when a lexical pain metaphor (e.g., enemy) appears in a sentence, it can be either an agent or object. For instance, when someone says “It (pain) is eating my life away,” pain is an agent that is doing something. In contrast, when the person 23 says “I’m controlling the pain,” the pain is metaphorically expressed as something animate and possibly adversarial, but it is an object being acted upon by the agentic sufferer. This study, therefore, focuses on how patterns of linguistic agency assignment and nominalization in pain description affect message receivers’ interpretation of the fictitious sufferer’s pain experience.
Although agency is commonly assigned to animate, living entities (e.g., people, dogs), it may also be assigned to inanimate and abstract entities, such as time (McGlone &
Pfiester, 2009), health threats (Dragjevic et al., 2014), emotional states (Cooren, 2010), and texts (Robichaud & Cooren, 2013). For instance, Cooren (2004) systematically explored various types of action that texts (e.g., contracts, reports, memos, etc.) can (e.g., certify, contradict, pardons, etc.) and cannot (e.g., renounce, admit, brag, etc.) perform in organizational contexts. Dowty (1991) suggests that four properties characterize a prototypical grammatical agent, including sentience (i.e., the ability to feel or be conscious), causation (i.e., causing an event or change of state in another participant), volition (i.e., volitional involvement in the event or state), and movement (i.e., relative to the position of another participant). Hence, when a speaker ascribes agency to the pain (i.e., the pain runs through my leg from time to time) instead of him/her self, pain could be perceived as carrying some of these characteristics and thus likely to be considered more severe and lasting. In addition, assigning agency to some entities involved in an event implies passivity of other entities in the same event (Dowty, 1991). For example, when a speaker says “the pain weakens me,” the speaker’s pain is acting upon him/her while the speaker is at the receiving end of the action. Therefore, when agency is assigned to humans in discourse, it 24 also implies passivity of objects in the discourse context. But when agency is assigned to an inanimate entity by describing it doing actions that are normally attributed to humans, this encoding conveys control and potency to the object. These considerations motivated the following hypotheses:
H2: A sufferer’s assignment of agency to pain or a body part where pain is localized
invites audiences to infer that the pain is a) more intense and b) more persistent than
assignment of agency to the self.
H3: A sufferer’s assignment of agency to pain or a body part where pain is localized
invites audiences to infer that the sufferer has lower pain control than assignment
of agency to the self.
In addition to pain intensity and chronicity, pain-related disability and affect are also considered important aspects that define pain and its effects in assessment (Haefeli &
Elfering, 2006). Pain-related disability is considered a major indicator of pain severity and can be defined as the degree to which the sufferer’s pain interferes with his/her physical performance. Pain affect refers to “the degree of emotional arousal or changes in action readiness caused by the sensory experience of pain” (Van Korff et al., 2000). One of the most commonly used scales for measuring pain affect is the McGill affective subscale
(Melzack, 1975) which includes five sets of words describing affective qualities of the pain, such as tiring, sickening, fearful, punishing, and wretched. When agency is assigned to pain or body parts where pain spreads or originates, pain and body parts are actively doing things to the sufferer and becomes the onset of related consequences while the sufferer is more passive and aroused by the non-human entities. Cooren (2010) used “Jealousy struck 25 again” from Othello as an example to point out that a strong passion may animate an individual by dictating the person’s mind and conduct. Jealousy provided Othello with a reason for his terrible conduct (murdering Desdemona) and thus makes his behavior understandable and describable. Furthermore, the vocabulary people employ to talk about a strong passion such as jealousy is similar to the ones used for mental illness or addiction: someone is possessed, consumed, devoured by the illness or addiction. He also emphasized that a person animated by his/her passion may seem very active and energetic, but it was because the person is acted upon or driven by the passion and therefore the person is always relatively passive in the situation. This rationale motivated the following hypotheses:
H4: A sufferer’s assignment of agency to pain or a body part where pain is localized
invites audiences to infer that the speaker has greater pain-related disability than
assignment of agency to the self.
H5: A sufferer’s assignment of agency to pain or a body part where pain is localized
invites audiences to infer that the speaker has more negative pain affect than
assignment of agency to the self.
Research also suggests that certain agency assignments imply displacement of responsibility (McGlone & Glowacki, 2018). For example, when a policy is invoked to turn down a request (i.e., the policy forbids us to…), it justifies the refusal, as it is the policy that is making the decision while the employee is only acting in its name and thereby shifting the responsibility (Cooren, 2010). An infectious disease can also be transformed into a malicious entity when people are informed that the disease can “target” or “prey on” them. As such, responsibility for transmission is attributed to the disease. Conversely, when 26 people are told they can “catch” or “contract” an illness, it is implied that they are responsible for potential infections. However, this impact may be applicable to other non- infectious illness as well. In the study of agency assignment in policy discourse about Type
II diabetes, Glowacki et al. (2016) found that respondents reported greater severity of Type
II diabetes after reading health education messages that assigned the threat agency to the disease instead of to people. When agency is ascribed to pain or body parts, it suggests that the illness is responsible for the health outcomes and thus the audience may feel more sympathetic toward the speaker. As a result, the audience will be more likely to believe that the speaker’s request for more pain medication is reasonable. Based on this consideration, I proposed the following hypotheses:
H6: A sufferer’s assignment of agency to the self invites audiences to perceive the
sufferer as more responsible for managing his/her own pain than assignment of
agency to pain or a body part where pain is localized.
H7: A sufferer’s assignment of agency to pain or a body part where pain is localized
invites audiences to feel more sympathetic toward the sufferer than assignment of
agency to the self.
H8: A sufferer’s assignment of agency to pain or a body part where pain is localized
invites audience to perceive the sufferer as more in need of intervention (e.g., higher
dose of pain relief medication) than assignment of agency to the self.
Nominalization is generally considered an informative, factual, and objective way of expression characteristic of scientific and technical writing (Halliday & Matthiessen,
2014). However, linguists have argued that a verb (e.g., explode) and its de-verbal noun 27 (e.g., explosion) used to describe the same event can be semantically different and even contrasting as they may use various images to structure the same conceptual content
(Langacker, 1987; Maynard, 1996). For instance, the verb “batter” depicts a process in which an agent initiates an action and causes the event while its de-verbal nominal “battery” creates a still picture of fact which is no longer active. Maynard (1996) pointed out that when employing nominalizations, the speaker positions the self as an observer who is distant from the event and the event becomes abstracted and objectified.
Empirical research has found that nominalization can be used to obscure responsibility by omitting the agency or adopting a passive voice (Bohner, 2001; Lamb,
1991; McGlone & Glowacki, 2018). Bohner (2001) conducted an experiment in which
German college students were asked to watch a silent video segment depicting an assault and then write down an open description of what they had seen and judge the responsibility of the victim and the perpetrator. The circumstances of the assault, depending on the experimental condition, could or could not be easily interpreted in terms of rape myths (i.e., stereotypic beliefs that justify the rape and blame the victim). He reported that the tendency of using distancing language, such as nominalization, to generate story headlines was associated with lower perceived crime severity and heightened responsibility attributed to the victim.
In addition to obscuring responsibility, nominalization can also be used to downplay the vividness of events and regulate emotions. In an analysis of introductory sections from articles about abuse of women by men, Lamb (1991) found that authors nominalized the act of violence so that no agency was named (e.g., the violence, the 28 battering, and the process of abuse) and avoided the graphic image a verb creates. Lamb pointed out that nominalization of men’s violence helps diffuse the responsibility of the assailants and allow writers to distance themselves from emotionally disturbing events.
Recent experiments of Idan and colleagues (Idan et al., 2018) found that strategically phrasing conflict-relevant policies using nouns (e.g., I am for the division of Jerusalem within a permanent status agreement) instead of verbs (e.g., I am for dividing Jerusalem within a permanent status agreement) may reduce audiences’ anger and increase their support for the policy. They pointed out that noun form is stative and abstract, while verb form is more agentive and vivid. Because noun labels focus less on the agency of the actor, audiences feel less compelled to actively challenge the policy and confront the agents responsible for the concession.
McGlone and Glowacki (2018) also argued that activities/process nouns entail abstraction and evasiveness. They found that people reported stronger agreement with fictitious op-ed essays that praised actors (e.g., Immigrants strengthen and diversify the nation’s workforce) than semantically equivalent versions praising activities (e.g.,
Immigration strengthens and diversifies the nation’s workforce). On the other hand, people agreed more with essays criticizing activities (e.g., Immigration drives down wages and depletes limited resources) than versions criticizing actors (e.g., Immigrants drive down wages and deplete limited resources). The authors interpret the contrasting findings as consistent with Sears’ (1983) person positivity bias, whereby people’s inclination to have positive attitudes toward a concept increases with the concept’s resemblance to a human.
29 By this reasoning, people are more receptive to praise for actors (e.g., immigrants) than their activities (immigration), but are more receptive to indictments of activities than actors.
Based upon these findings and previous linguistic scholarship on nominalization, it is reasonable, therefore, to hypothesize that when pain is nominalized in a description, it entails less vividness and thus become more abstract to the audiences who will in turn consider the pain to be less intense and lasting. Without the vividness of verbs, audiences may also underestimate the degree to which the speaker is physically and emotionally affected by the pain. Nominalized pain will also lead to a shift of responsibility from pain to the patient since noun labels focus less on the agency of the actor (i.e., pain). In addition, because the severity of the pain may be downplayed, it would be more difficult for the audiences to relate to the speaker and feel sympathetic. These considerations motivated the following hypotheses:
H9: A sufferer’s description of pain experience that features nominalized pain
invites audiences to infer that the pain is a) less intense and b) less persistent than
a description featuring pain experience in verb form.
H10: A sufferer’s description of pain experience that features nominalized pain
invites audiences to infer that the speaker has less negative pain affect than a
description featuring pain experience in verb form.
H11: A sufferer’s description of pain experience that features nominalized pain
invites audiences to infer that the speaker has less pain-related disability than a
description featuring pain experience in verb form.
30 H12: A sufferer’s description of pain experience that features nominalized pain invites audiences to perceive the sufferer as more responsible for managing his/her own pain than a description featuring pain experience in verb form.
H13: A sufferer’s description of pain experience that features nominalized pain invites audiences to feel less sympathetic toward the speaker than a description featuring pain experience in verb form.
H14: A sufferer’s description of pain experience that features nominalized pain invites audiences to be less likely to agree that the speaker’s need for higher dose of pain relief medication is valid than a description featuring pain experience in verb form.
31 Chapter 4: Method
PARTICIPANTS A power analyses using the mean effect size reported in social psychology (r=.21;
Richard, Bond, & Stokes-Zoota, 2003) at 80% power revealed that 45 participants were needed to find an effect in Study 1 and 172 participants were needed for each Scenario in
Study 2.
Participants for this study were recruited from two different online platforms.
Participants for Study 1 were 69 Fibromyalgia patients recruited from ChronicPain-Reddit
(www.reddit.com/r/ChronicPain/), a forum dedicated to patients living with chronic pain on the website Reddit. Fibromyalgia (FM) is a common chronic pain disorder characterized by “pain all over the body, sleep problems, fatigue, and often emotional and mental stress”
(Centers for Disease Control and Prevention [CDC], 2017). According to the CDC (2017), about 4 million US adults suffer from FM, which is 2% of the adult population. The onset of FM is unclear but it can be effectively treated and managed with medication and self- management strategies, such as pain relievers, exercise, and massage. FM patients were chosen as participants for Study 1 because not only FM is prevalent but also it involves a wide variety of pain experience (e.g., crushing, shooting, spasms). Patients tend to find it difficult to communicate FM symptoms and are likely to use metaphorical language to describe their experience (Paulson et al., 2003; Söderberg, et al., 1999).
681 participants for Study 2 were recruited through a task request on Amazon
Mechanical Turk (i.e., mTurk or http://www.mturk.com), a website that allows requesters to post small tasks (e.g., online surveys) for workers to complete in exchange for minimal 32 fees. This platform has been extensively used for participant recruitment and data collection by social scientists in recent years. It is considered a reliable source for high- quality data since mTurk participants are more demographically diverse than typical
American college samples and standard Internet samples while the data obtained meets acceptable psychometric standards (Buhrmeister et al., 2011; Sheehan, 2018). MTurk samples are not significantly different from community samples in terms of age, gender, and education but can be collected more rapidly (Goodman et al., 2013). It is noteworthy that the US mTurk population consists of 55% females, which is slightly biased (Difallah et al., 2018). However, since population-based research reveals that chronic pain conditions are more prevalent for women than men (Bartley & Fillingim, 2013), such bias is less problematic.
Two studies were conducted separately, each of which took approximately 15 minutes for participants to complete. For both studies, participants were required to be adult native English speakers. To be eligible, participants for Study 1 had to self-identify as someone who has been diagnosed with FM. Participants for Study 2 must have completed at least 100 tasks on mTurk with an approval rating at or above 95%, as workers who achieve this high reputation are likely to follow instructions (Peer et al., 2014). Each participant for Study 1 received a $5 Amazon eGift card as compensation. Each participant for Study 2 received $0.50 for compensation.
An examination of the written response of the participants in Study 1 revealed that
13 participants failed to follow the instruction properly (e.g., participated repeatedly, provided irrelevant responses and/or failed to write about pain experience that matched the 33 condition), which resulted in a final sample of 56 participants (36 Females, 20 Males). Of the final sample, 27 participants were in Group 1 (chronic and acute pain) and 29 participants were in Group 2 (severe and mild pain). The mean age was 34.52 years
(SD=9.5). A majority of the participants were Caucasian (75.0%), followed by African
Americans (8.9%), Hispanics (8.9%), American Indians or Alaska Natives (3.6%), Asians or Asian Indians (1.8%), and others (1.8%). Most participants had at least a college degree or received some college level education (82.1%). About half of the participants were employed full time (48.2%) or part-time (5.4%). Participants had been diagnosed with FM for an average of 76.32 months (SD=82.54). In addition to FM, 39.3% of the participants also stated that they had been diagnosed with other chronic pain conditions, such as arthritis.
To ensure that participants in Study 2 were sufficiently attentive, only those who spent over 180 seconds completing the task were included in the final sample. Among the
478 (N1=209, N2=120, N3=149) adult participants who met such criteria, most self- identified as Caucasian (55.5%, 55.5%, 50.3%), were employed full-time (78.0%, 80%,
68.5%), and received some college education or held a Bachelor’s degree (95.2%, 95%,
93.3%). The mean age was 34.04 years (M1=34.91, M2=33.35, M3=33.38). About 51.7%
(41.7% in Scenario 2, 51% in Scenario 3) are females and 46.9% (57.5% in Scenario 2, 49% in Scenario 3) are males. Participants in the three scenarios differed in some of the demographic characteristics but remained largely similar.
34 STUDY 1
Design and procedure After reading a recruitment post on ChronicPain-Reddit for a study on pain experience, participants were directed to an online study on Qualtrics and randomly assigned to one of two groups. In each group, they read instructions prompting them to write about two separate experiences of their pain conditions. In Group 1, participants were instructed to write about an experience of an acute pain and of a chronic pain (one each).
In Group 2, participants were asked to write about an experience of a mild pain and of a severe pain. The prompts were presented in random order to avoid an order effect. For example, the prompt in Group 1 for writing about an acute pain was as follows:
“Throughout our lives, most of us have had acute pain (such as a finger cut, wisdom
tooth pain, or a broken arm) from time to time. Such pain may result from a specific
traumatic incident such as an injury to a specific part of the body, or an illness. Pain
like this comes on quickly but often has a limited overall duration. Please recall an
acute pain that is most memorable to you and describe it the best you can by
answering the following questions in detail.
• When and how did it happen?
• How did you feel physically?
• How did you feel psychologically?
• How did you feel socially?”
The prompt for writing about a chronic pain was as follows:
35 “You have identified yourself as a fibromyalgia patient. One of the most common symptoms of fibromyalgia is widespread pain (i.e., pain all over the body). Please tell me about a pain experience of yours that is caused by FM (such as daily headaches and recurrent muscle tension). Pain like this may continue for months and years instead of days and weeks. Please recall a FM-related pain experience of yours that is most memorable to you, describe it the best you can by answering the following questions in detail.
• When and how did it happen?
• How did you feel physically?
• How did you feel psychologically?
• How did you feel socially?”
The prompt in Group 2 for writing about a mild pain was:
“Throughout our lives, most of us have had mild pain from time to time that is not caused by a chronic condition (such as paper cuts, light sprains, muscle twitching).
Such pain generally does not interfere with most of our day-to-day activities. Please recall a mild pain (not due to a chronic condition) that is most memorable to you, and describe it the best you can by answering the following questions.
• When and how did it happen?
• How did you feel physically?
• How did you feel psychologically?
• How did you feel socially?”
The prompt in Group 2 for writing about a severe pain in group 2 was: 36 “Throughout our lives, some of us have had severe pain from time to time which
may or may not be caused by a chronic condition (such as a broken rib, intense back
pain). Such pain could interfere with our day-to-day activities. Please recall
a severe pain (may or may not due to Fibromyalgia) that is most memorable to
you, and describe it the best you can by answering the following questions in detail.
• When and how did it happen?
• How did you feel physically?
• How did you feel psychologically?
• How did you feel socially?”
Upon completing the writing, participants were asked to fill out a short questionnaire to provide demographic information. They were also asked to identify how long they had been diagnosed with fibromyalgia, whether they had any other chronic pain condition, and if they had, what is the condition and how long they had been diagnosed with it. After finishing the questionnaire, they were instructed to leave an email address to receive a $5 Amazon e-Gift Card.
Agency coding and reliability Participants’ writings were coded by two coders searching for agent phrases, verb types, and agents. Prior to the coding process, all identifiable information about the participant author was removed by the researcher and each case was assigned a number.
Each agent phrase consists of a subject, verb, and an indirect or direct object if applicable.
Coding focused on the main verb of each agent phrase. An agent phrase could be a
37 complete sentence or a part of a sentence that contains multiple agent phrases. When a sentence comprised multiple agent phrases, each phrase was coded separately. To facilitate coding, the researcher parsed the text into codable agent phrase units, leaving each unit with grammatical components that are necessary for identifying agents.
To help locate agents, once an agent phrase was identified, coders determined its main verb (i.e., the verb that describes the action) and categorized it as transitive (e.g., Pain destroys me.), intransitive verbs (e.g., Pain destroys.), and linking/being verbs (e.g., I feel sore). Since linking/being verbs are generally not associated with actions and linguistic agencies but considered an indication of a state of being, this study did not include agent phrases using linking/being verbs as main verbs in the next step of coding. As action verbs, transitive and intransitive verbs both denote action performed by a subject while intransitive verbs may not take a direct object receiving the action. If an agent is connected with multiple verbs in a phrase (e.g., my back spasms and hurts badly.), it is counted once for each action ascribed. In addition, voice of the construction was coded as either active or passive depending on whether the subject is performing the action of the verb (e.g., pain is destroying my life) or being acted upon (e.g., my life is being destroyed by pain.). In the latter case, pain is the agent.
Since this study focuses on personal agency and pain/body agency only, all other types of agency that are not relevant to the hypothesis were coded as others. Agents were classified into three categories, including personal agency (i.e., I), pain/body agency (e.g., pain, arthritis, my legs), and others (e.g., my doctor, the medication). In cases where agents were omitted (e.g., Sprained my ankle.), coders were instructed to record the agent type of 38 the “implied” agent. Coders were provided with a coding book which detailed the operation definitions of coded variables and related coding rules.
For training purpose, a subset of six narratives were randomly selected from the sample for coding agent types. In cases of disagreement, coders met with the researcher and resolved the disagreement through discussion. Inter-coder reliability for agent type was assessed for the entire sample using Krippendorff's alpha with .80 as desired level
(Krippendorff, 2004) and testing yielded a high reliability of 0.973.
STUDY 2
Experimental design and procedure Participants were randomly assigned to one of 12 conditions dictated by a 3 (pain location: back, head, or joint) × 2 (agency assignment: person or pain/body) × 2 (pain process encoding: verb or nominalization) between-participants factorial design. In each condition, participants read a description from a fictitious sufferer about his/her pain experience and then completed a survey assessing their impressions of the person. They were told that to protect the person’s identity, the researcher had assigned an alias “Pat” to the person. The descriptions are presented in Appendix D. Conditions differed in pain location (i.e., back pain, headaches, and joint pain) and the wording of the descriptions’ narrative. The author was interested in whether response patterns of participants will be consistent across different locations of pain. These three pain types were selected because of their high prevalence among American adults (Freburger et al., 2009; Jensen & Stovner,
2008). For agency assignment manipulation, the language used to describe pain was either
39 assign agency to the human sufferer or to the pain and body part where pain is localized.
For pain process encoding manipulations, pain experience was phrased using either nominalized verbs (e.g., pounding) or verbs (e.g., pound). The narrative versions were identical in other respects and each post shared similar word counts. To ensure that participants’ perceptions of the sufferer’s pain was not affected by factors other than linguistic variations, descriptions were deliberately ambiguous about the objective duration and intensity of pain and provided no cues to “Pat’s gender and age. For example, a description in the Back pain × Human agency × Nominalized Verbs condition reads:
“I started having back pain a while ago. At the beginning, the irritation wasn’t too bad. But lately I have taken a turn for the worse. I feel a throbbing whenever I move rapidly.
I wake up in pain every morning. My job requires some long time sitting, but I ache so badly because of that. I basically tie myself to the bed when I am off the clock. I have also stopped going out. My boss and my family are understanding, but there isn’t much they can do. I am hurting. The invasion of pain is unpredictable. My doctor has prescribed me some Tylenol. But I still feel this tension in my back. I am slowly breaking down physically and mentally. I have reached a point where the current medication is not enough. I need greater dose.”
After reading the post, participants completed a survey questionnaire that included demographic questions and the measures described below. Upon finishing filling the questionnaire, participants received a randomized 4-digit confirmation code and were directed back to mTurk to collect compensation using the code.
40 Dependent measures Higher scores of measures reflect a greater amount or intensity of the variable.
Reliability of dependent measures were calculated using Cronbach’s alphas.
Perceived pain intensity Pain intensity numerical rating scale (NRS) was originally designed to measure perceived pain intensity of the patient by asking them to rate their average pain during the last week (Jensen & Karoly, 2011). For the purpose of this investigation, participants were asked to rate perceived pain intensity of the fictitious sufferer on a scale of 0 (i.e., no pain) to 10 (i.e., worst pain imaginable). Scores were later converted into a seven-point scale for consistency.
Perceived pain duration A single-item from the Pain Frequency-Severity-Duration Scale (PFSD) was used to assess the inferred pain duration of participants (Salamon et al., 2014). The item asked participants to rate the degree to which they believe that the person’s pain is recurrent or continuous (1=not at all, 7=very much so).
Perceived pain affect To assess inferred pain affect, this study adopted a numeric graphic rating version of the Visual Analogue Scale (VAS) with an adaptation that incorporates more descriptors.
The VAS-affect scale is a reliable and valid self-report measure of both pain intensity and pain affect (Jensen & Karoly, 2011). In this study, the scale asked respondents to indicate their level of agreement to adjectives describing the fictitious sufferer’s increasing
41 unpleasantness (i.e., 0= “not bad at all” and 10= “the most unpleasant feeling possible”) caused by pain affect. The number chosen by respondents should best reflect their perceptions. The original VAS affect scale cannot distinguish between pain intensity and pain affect due to its uni-dimensional nature (Duncan et al., 1989). Therefore, this study derived three other sets of adjective descriptors, including annoying (i.e., 0= “not annoying at all” and 10= “the most annoying feeling possible”), intolerable, and distressing (α1=.93,
α2=.86, α3=.87). Scores were converted into a seven-point scale for consistency.
Perceived pain-related disability Two measures, the Roland-Morris Disability Questionnaire (RDQ) (Roland &
Morris, 1983) and the Oswestry Disability Index (ODI) (Fairbank & Pynsent, 2000), are widely used for measuring physical disability caused by pain. However, these two measures are condition-specific while this study focused on inferred pain-related disability of others based on verbal description instead of self-observed conditions. Therefore, the researcher used a three-item, 7-point Likert-type scale (1=strongly disagree, 7=strongly agree) wherein participants were asked to rate the degree to which they believe that the statements reflect their perceptions regarding the person’s pain-related disability. The items were the speaker’s ability to perform daily activities is limited by pain, the speaker is likely to encounter physical difficulty while performing heavy duty, and pain impinges on the speaker’s life (α1=.75, α2=.75, α3=.85)
42 Perceived pain locus of control Pain control, or pain locus of control, refers to an individual’s beliefs about how well they can control their pain (Main & Waddell, 1991). Previous measurements of health and pain control are mainly rated on an internal-external dimension. For instance, the Form
C of Multidimensional Health Locus of Control questionnaire (Form C of the MHLC)
(Wallston et al., 1994), assesses a patient’s locus of control in three categories: internality
(i.e., the patient), powerful others (i.e., doctors and health professionals), and chance. This investigation, however, focused on participants’ perceptions of how much control the sufferer has over his/her pain. Therefore, participants were asked to rate the following statements on a scale of 1 (i.e., strongly disagree) to 7 (i.e., strongly agree) with the higher number representing greater control. The statements included: the sufferer is in control of his/her own pain, the sufferer has little control over his/her pain (reverse coded), and the sufferer is capable of managing his/her pain (α1=.60, α2=.55, α3=.54). After dropping the reverse item, the reliability significantly increased (α1=.87, α2=.85, α3=.89).
Perceived pain responsibility Pain responsibility refers to the degree to which people believe they are responsible for managing their own pain (Main & Waddell, 1991). To assess perceived pain responsibility of the sufferer, this study adopted a 7-point Likert type scale (i.e., 1=strongly disagree, 7= strongly agree) with three items. Participants were asked to rate the degree to which they agree with the statements they read by choosing a number that best reflects their beliefs. Statements included Pat is directly responsible for his/her pain getting better or worse, Pat is the one with the responsibility for what happens with his/her pain, and Pat 43 deserves the credit when his/her pain improves and the blame when it gets worse (α1=.91,
α2=.86, α3=.91)
Sympathy Sympathy refers to heightened awareness of another individual’s suffering or feelings of sorrow and concern for that person (Wispé, 1986; Eisenberg & Strayer, 1987).
This study adopted a three-item 7-point Likert-type scale (i.e., 1=strongly disagree,
7=strongly agree) wherein participants rate the degree to which the statements reflect their beliefs. Statements included I am understanding of what the person has said, I feel sympathetic toward this person, and I feel compassionate for this person (α1=.81, α1=.75,
α3=.77).
Perceived need for higher dose Participants were asked to rate the degree to which they believe the statements they read reflect their perceptions on a scale of 1 to 7 with 1 being strongly disagree and 7 being strongly disagree. The statements included the sufferer’s request for higher doses of medication is understandable, I believe the sufferer’s demand for higher doses is reasonable, I do not believe that the sufferer needs higher doses of medication (reverse coded) (α1=.66, α2=.56, α3=.61). Reliability increased (α1=.76, α2=.70, α3=.77) after the reverse item was dropped.
Individual differences Participants were asked to indicate whether they have medical training background, whether they have experienced chronic pain themselves, and if so, how long they have 44 experienced chronic pain. Participants were also asked to indicate whether they were caretakers of someone who is living with chronic pain or regularly interact with someone living with chronic pain. These dichotomous variables were entered as covariates in the analyses but only significant covariates are reported in the text.
45 Chapter 5: Results
STUDY 1 Hypothesis 1 proposed that pain/body agency assignment rate would be higher in narratives describing chronic pain than acute pain, and narratives describing severe pain than mild pain. The dependent variable for the hypothesis testing was body/pain agency frequency (i.e., number of body and pain agency assignment per 100 assignments), which were the sum of body agent and pain agent divided by the total number of agent phrases multiplied by 100. Coder One identified a total of 456 human agents, 167 pain/body agents, and 167 other agents, while Coder Two identified 466 human agents, 170 pain/body agents, and 174 other agents. See means and standard deviations for rate of each agency type by condition (i.e., chronic and acute pain; severe and mild pain) of each coder in Table 1.
A Paired-sample T test was conducted to test Hypothesis 1a by comparing the pain/body agency assignment rates in the acute pain condition and the chronic pain condition. There was a significant difference in the pain/body agency assignment rate for the acute pain condition (M=14.31, SD=20.82) and the chronic pain condition (M=27.38,
SD=25.08)；t(26)=2.36 , p=.026. The results suggest that participants were more likely to assign agency to pain or body parts when describing chronic pain than acute pain.
Hypothesis 1a was thus supported.
Following the sample procedure, a paired-sample T test was performed to test
Hypothesis 1b by comparing the pain/body agency assignment rates in the mild pain condition and the severe pain condition. There was not a significant difference in the pain/body agency assignment rate between the mild pain condition (M=21.05, SD=25.34) 46 and the severe pain condition (M=21.59, SD=24.72); t(28)=-.088, p=.930. Hypothesis 1b was therefore not supported.
STUDY 2 In the final sample of Study 2, 34.9% (38.3% in Scenario 2, 39.6% in Scenario 3) of the participants reported receiving at least some formal medical training, 45.9% (47.5% in Scenario 2, 46.3% in Scenario 3) having been diagnosed with some chronic pain conditions or experienced chronic pain, 40.2% (47.5% in Scenario 2, 47.7% in Scenario 3) reported being a caretaker of someone living with chronic pain, and 47.8% (53.3% in
Scenario 2, 57.7% in Scenario 3) said they regularly interact with someone living with chronic pain.
Correlations among the dependent variables were tested (See Table 2). For Scenario
1, results indicated that perceived pain intensity (M=4.99, SD=1.04) was positively associated with pain duration (r=.47, M=5.85, SD=1.08, p<.001), pain affect (r=.58,
M=5.60, SD=1.13, p<.001), perceived disability (r=.47, M=5.84, SD=.93, p<.001), sympathy (r=.39, M=5.85, SD=.96, p<.001), and support for dose change (r=.39, M=5.65,
SD=1.15, p<.001). There was a marginally significant relation between pain intensity and pain control (r=-.13, M=3.57, SD=1.89, p=.068). No significant relationship was found between pain intensity and pain responsibility (r=-.10, M=3.88, SD=1.80, p=.134).
Perceived control was negatively associated with all dependent variables except perceived pain responsibility, with which it was positively associated (r=.84, p<.001). It is noteworthy that sympathy and support for dose change were both negatively associated
47 with control (r=-.29, p<.001; r=-.18, p=.008) and pain responsibility (r=-.29, p<.001; r=-.18, p=.011), suggesting that participants who perceived the speaker as having greater control and more pain responsibility were less sympathetic toward the person and less likely to support an increased dose. Correlations among the dependent variables for
Scenario 2 and 3 are reported in Table 3 and 4.
Agency Assignment Hypothesis 2 predicted that a sufferer’s assignment of agency to pain or a body part where pain is localized would invite audiences to infer that the pain is a) more intense and b) more persistent than assignment of agency to the self. To test the hypothesis, analysis of covariance (ANCOVA) was performed for each scenario using a univariate general linear model (GLM) with pain intensity and duration as dependent variables and agency assignment and nominalization as fixed independent factors. The four individual difference variables (i.e., medical training, personal pain history, primary caretaker, and interaction with patients) were factored in as covariates separately. Post Hoc comparisons using a
Bonferroni correction for Scenario 1 found that participants in the pain agency condition rated perceived pain intensity (M=5.13, SD=.87) marginally significantly higher than those
2 in the human agency condition (M=4.85, SD=1.19, F(1, 204)=3.79, p=.053, ηp =.02), after controlling for the experience of being a primary caretaker for a patient living with chronic pain (p=.02). Medical training, personal pain history, and interaction with patients did not significantly adjust the association between agency assignment and pain intensity.
Participants in the pain agency condition also rated perceived pain duration (M=6.00,
48 SD=.96) higher than those in the human agency condition (M=5.67, SD=1.18, F(1,
2 204)=4.93, p=.028, ηp =.02), when experience of receiving medical training (p=.054) was controlled for. None of the other covariates significantly adjusted for the relation between agency assignment and perceived pain duration. Testing for H2 in Scenario 2 found that medical training, experience of being a primary caretaker, and interaction with patients did not significantly adjust the relationship between agency assignment and perceived pain intensity. When personal pain history was controlled for (p=.011), no significant main effect of agency assignment was found on pain intensity (p=.347). Similarly, there was no significant main effect of agency assignment on perceived duration (p=.904) with personal pain history (p=.009) as a covariate. These results, however, indicated that participants with chronic pain history were more likely to rate “Pat’s pain to be more severe and persistent. Testing for H2a in Scenario 3 found no significant covariate and there was no significant main effect of agency assignment on perceived pain intensity. When controlling for medical training (p=.051) and being a primary caretaker (p=.084) respectively, agency assignment did not have a significant main effect on perceived pain duration (p=.749; p=.963). Therefore, Hypothesis 2a and 2b were only partially supported.
Hypothesis 3 posited that a sufferer’s assignment of agency to pain or a body part where pain is localized would invite audiences to infer that the sufferer has lower pain control than assignment of agency to the self. Testing for H3 in Scenario 1 found no main effect of agency assignment, as there was no significant difference in perceived pain control in participants in the pain (M=3.42, SD=1.89) and human agency (M=3.72,
2 SD=1.89) conditions, F(1, 204)=1.44, p=.231, ηp =.007, after controlling for experience of 49 being a primary caretaker (p<.001). However, there was a marginally significant crossover
2 interaction between agency assignment and nominalization, F(1, 204)=3.18, p=.076, ηp
=.02. The effect of nominalization on pain responsibility was opposite, depending on the agency assignment; pain control was rated highest in the Human agency × Nouns condition
(M=3.89, SD=1.86) and lowest in the Pain agency × Verbs (M=3.14, SD=1.89) condition.
The other three covariates did not significantly adjust the relationship between the interaction term and perceived pain control. Testing for H3 in Scenario 2 found that when experience as a primary caretaker was controlled for (p<.001), there was no significant main effect of agency assignment (p=.460). However, there was a marginally significant
2 main effect of nominalization, F(1, 115)=3.42, p=.067, ηp =.03. Similarly, after controlling for interaction with patients (p=.044), there was also a main effect of nominalization, F(1,
2 115)=4.55, p=.035, ηp =.04. In both analyses, participants who read pain narratives written in noun form (M=4.30, SD=1.72；M=4.37, SD=1.72) believed that “Pat”, the patient, was in greater control of his/her pain, than those who read pain narratives in verb form (M=3.76,
SD=1.70; M=3.71, SD=1.70). Although no hypothesis was proposed regarding the effect of nominalization on perceived pain control, the data were consistent with the argument that verb form is more agentive than noun form and thus a narrative featuring verb form may compel participants to believe that “Pat” was passive and in less control. In Scenario
3, when controlling for medical training (p<.001), there was a significant main effect of
2 agency assignment on perceived control, F(1, 144)=5.17, p=.024, ηp =.04. Participants in the human agency condition (M=4.06, SD=1.90) perceived “Pat” as having greater control than those in the pain agency condition (M=3.49, SD=1.75). No significant main effect of 50 agency assignment was found when controlling for personal pain history (p=.339), experience of being a primary caretaker (p=.502), and regular interaction with patients
(p=.371) respectively. Since the results were inconsistent across the scenarios, Hypothesis
3 was only partially supported.
Hypothesis 4 stated that a sufferer’s assignment of agency to pain or a body part where pain is localized would invite audiences to infer that the speaker has greater pain- related disability than assignment of agency to the self. Testing for H4 in Scenario 1 found no significant main effect of agency assignment on perceived disability, F(1, 205)=2.30,
2 p=.131, ηp =.01. In addition, no covariate significantly adjusted for the relationship between agency assignment and perceived disability. Testing for H4 in Scenario 2 found that medical training, personal pain history, and being a primary caretaker significantly adjusted the relationship between agency assignment and perceived disability. However, no significant effect of agency assignment was found when any of these variables was controlled for. Similarly, testing in Scenario 3 found that medical training (p=.049), being a primary taker (p=.001), and interaction with patients (p=.009) were significant covariates.
However, when controlling for each of them respectively, no significant main effect of agency assignment was found on disability. Therefore, the null hypothesis could not be rejected.
Hypothesis 5 predicted that a sufferer’s assignment of agency to pain or a body part where pain is localized would invite audiences to infer that the speaker has more negative pain affect than assignment of agency to the self. Testing for H5 found no significant main
2 effect of agency assignment, F(1, 204)=.57, p=.45, ηp =.003, after controlling for personal 51 pain history (p=.024). There was also no main effect of nominalization (p>.564). However, there was a significant crossover effect between agency assignment and nominalization,
2 F(1, 204)=4.53, p=.035, ηp =.02. The effect of nominalization on pain affect was opposite, depending on the agency assignment; pain affect was rated highest in the Pain agency ×
Nouns condition (M=5.85, SD=1.08), followed by Human agency × Verbs condition
(M=5.65, SD=.81), and lowest in the Human agency × Nouns (M=5.46, SD=1.08), and Pain agency × Verbs (M=5.45, SD=1.38) condition. Similarly, when experience as a primary caretaker is controlled for (p=.069), there was no significant main effect of agency
2 assignment, F(1, 204)= .39, p=.536, ηp =.002, but a marginally significant crossover effect
2 between the two independent variables, F(1, 204)=3.49, p=.063, ηp =.02. Medical training and regular interaction with chronic pain patients did not significantly adjust the relationship between agency assignment and perceived pain affect. Testing for H5 in
Scenario 2 found that personal pain history adjusted the relationship between agency assignment and pain affect (p=.032) but there was no significant main effect of agency assignment (p=.949) nor interaction effect (p=.475). Testing in Scenario 3 found no significant covariate. In addition, there was no significant main effect of agency assignment
(p=.991) or interaction effect (p=.470). Hypothesis 5 was therefore not supported.
Hypothesis 6 posited that a sufferer’s assignment of agency to the self would invite audiences to perceive the sufferer as more responsible for managing his/her own pain than assignment of agency to pain or a body part where pain is localized. Testing for H6 in
Scenario 1 found that when controlling for medical training (p<.001), primary caretaker experience (p<.001), and regular interaction with patients (p=.004) respectively, there were 52 both a marginally significant main effect of agency assignment (F(1, 204)=2.89, p=.091,
2 2 2 ηp =.01; F(1, 204)=2.89, p=.091, ηp =.01; F(1, 204)=2.96, p=.087, ηp =.01) and a
2 significant (or marginally significant) interaction effect (F(1, 204)=3.09, p=.080, ηp =.02;
2 2 F(1, 204)=4.61, p=.033, ηp =.02; F(1, 204)=3.58, p=.060, ηp =.02) between agency assignment and nominalization. Results showed that participants in the human agency condition (M=4.07, SD=1.76) were more likely to infer that “Pat” had greater pain responsibility than those in the pain agency condition (M=3.70, SD=1.83). The effect of nominalization depends on the agency assignment; responsibility was rated highest in the
Human agency × Nouns condition (M=4.19, SD=1.84) and lowest in the Pain agency ×
Nouns condition (M=3.28, SD=1.89). When personal pain history was held constant
(p=.001), however, no significant main effect of agency assignment (p=.150) nor significant interaction term (p=.117) was found, suggesting that participants having personal pain history believed that “Pat” had greater pain responsibility in comparison with those with no personal pain history. Testing for H6 in Scenario 2 found that medical training (p<.001), personal pain history (p=.002), being a primary caretaker (p<.001), and interactions with chronic pain patients (p=.043) all respectively adjusted the relationship between agency assignment and pain responsibility. However, no significant main effect of agency assignment was found both with or without factoring the covariates. In Scenario
3, when controlling for medical training (p<.001), there was a main effect of agency
2 assignment on perceived responsibility, F(1, 114)=4.83, p=.030, ηp =.03. Participants who read a pain description featuring human agency (M=4.24, SD=1.74) believed that the speaker had greater responsibility than those who read a pain description featuring pain 53 agency (M=3.72, SD=1.63). When experience of being a primary caretaker (p<.001) and interaction with patients (p<.001) were controlled for respectively, no significant main effect of agency assignment (p=.475; p=.357) was found. Given that significant main effect of agency assignment on perceived pain responsibility was found in one of the three scenarios, Hypothesis 6 was only partially supported.
Hypothesis 7 stated that a sufferer’s assignment of agency to pain or a body part where pain is localized would invite audiences to feel more sympathetic toward the sufferer than assignment of agency to the self. Testing for H7 in Scenario 1 found a marginally
2 significant main effect of agency assignment, F(1, 205)=3.52, p=.062, ηp =.02.
Participants in the pain agency condition (M=5.97, SD=.92) reported being more sympathetic toward “Pat” than those in the human agency condition (M=5.72, SD=1.00).
None of the four covariates significantly adjusted the relationship between agency assignment and sympathy. Testing in Scenario 2 found that while medical training (p=.024) and personal pain history (p=.075) respectively adjusted the relationship between agency assignment and sympathy, there was no significant main effect of agency assignment
(p=.541; p=.577). In Scenario 3, when controlling for experience of being a primary caretaker (p=.034), there was a significant main effect of agency assignment on sympathy,
2 F(1, 144)=4.64, p=.033, ηp =.03. Participants in the human agency condition (M=6.08,
SD=.78) were more sympathetic toward “Pat” than those in the pain condition (M=5.78,
SD=.93). Since results across the three scenarios were inconsistent, the null hypothesis could not be rejected.
54 Hypothesis 8 predicted that a sufferer’s assignment of agency to pain or a body part where pain is localized would invite audience to perceive the sufferer as more in need of pain relief medication than assignment of agency to the self. Testing for H8 in Scenario 1 found that with personal pain history (p=.054) controlled for, there was no significant main
2 effect of agency assignment on support for higher dose, F(1, 204)=2.23, p=.137, ηp =.01.
No other covariate significantly adjusted the relationship between agency assignment and support for higher dose. Testing in Scenario 2 found no significant covariates. Furthermore, there was no main effect of agency assignment with and without covariates. In Scenario 3, when controlling for experience of being a primary caretaker (p=.072), there was a
2 marginally significant main effect of agency assignment, F(1, 144)=3.09, p=.081, ηp =.02.
Participants in the human agency condition (M=5.94, SD=.87) were more likely to support for dose change than those in the pain agency condition (M=5.65, SD=1.14). Given the inconsistent results, the null hypothesis could not be rejected.
See Table 5 for effects of agency assignment on the main dependent variables across the scenarios when controlling for covariates.
Nominalization Hypothesis 9 stated that a pain description featuring nominalized pain would invite audiences to infer that the pain is a) less intense and b) less persistent than a description featuring pain experience in verb form. Testing for H9 in Scenario 1 found no significant main effect of nominalization (p=.319) on perceived pain intensity after controlling for the experience of being a primary caretaker (p=.02). Similarly, no significant main effect of
55 nominalization was found (p=.274) on perceived pain duration when medical training was controlled for (p=.054). In Scenario 2, testing for H9a found that personal pain history
(p=.011) significantly adjusted the relationship between nominalization and perceived pain intensity, but there was no significant main effect of nominalization on pain intensity
(p=.656). Testing for H9b found a marginally significant main effect of nominalization on
2 perceived pain duration, F(1,116)=3.16, p=.078, ηp =.03, with no covariate controlled for.
Participants who read a pain description written in verb form (M=5.87, SD=.95) perceived pain duration to be longer than those who read a pain description in noun form (M=5.53,
SD=1.08). However, when personal pain history was controlled for (p=.009), no main effect of nominalization was found on perceived pain duration (p=.157). The results suggested that participants without personal pain history were more likely to perceive
“Pat’s pain to be more lasting. Testing for H9 in Scenario 3 found no significant covariate and there was no main effect of nominalization on perceived pain intensity (p=.201). When controlling for medical training (p=.051) and being a primary caretaker (p=.084) respectively, there was no significant main effect of nominalization on perceived pain duration (p=.521; p=.517). Given the results across the scenarios, the null hypothesis could not be rejected.
Hypothesis 10 predicted that a sufferer’s description of pain experience that features nominalized pain would invite audiences to infer that the speaker has less negative pain affect than a description featuring pain experience in verb form. Testing for H5 in
Scenario 1 found no significant main effect of nominalization (p=.453) after controlling for personal pain history (p=.024). Similarly, when experience as a primary caretaker is 56 controlled for (p=.069), there was no significant main effect of nominalization (p=.517).
In Scenario 2, though personal pain history (p=.032) adjusted the relationship between nominalization and negative pain affect, there was no significant main effect of nominalization (p=.699). Testing for H10 in Scenario 3 found no significant covariate. In addition, there was no significant main effect of nominalization on negative pain affect
(p=.828). Therefore, the null hypothesis could not be rejected.
Hypothesis 11 posited that a sufferer’s description of pain experience that features nominalized pain would invite audiences to infer that the speaker has less pain-related disability than a description featuring pain experience in verb form. Testing for H11 in
Scenario 1 found that no covariate significantly adjusted the relationship between nominalization and perceived disability. Furthermore, there was no significant main effect of normalization on perceived disability (p=.923). Testing for H11 in Scenario 2 found that although all covariates but interaction with patients were significant, there was no significant main effect of nominalization. In Scenario 3, no significant main effect of nominalization was found on perceived disability when medical training, being a primary taker, and interaction with patients were respectively controlled for. Therefore, Hypothesis
11 was not supported.
Hypothesis 12 posited that a sufferer’s description of pain experience that features nominalized pain would invite audiences to perceive the sufferer as more responsible for managing his/her own pain than a description featuring pain experience in verb form.
Testing for H12 in Scenario 1 found that although medical training, primary caretaker experience, and regular interaction with patients significantly adjusted the relationship 57 between nominalization and pain responsibility respectively, there was no significant main effect of nominalization. Testing in Scenario 2 found that when controlling for personal pain history, experience of being a primary caretaker, and interaction with patients respectively, there was a significant main effect of nominalization on perceived
2 2 responsibility, F(1, 115)= 4.09，p=.045, ηp =.03; F(1, 115)=4.69，p=.032, ηp =.04; F(1,
2 115)=5.95，p=.016, ηp =.05. Participants in the nouns condition (M=4.45, SD=1.60;
M=4.45, SD=1.60; M=4.52, SD=1.60) rated significantly higher on pain responsibility on those in the verbs condition (M=3.87, SD=1.57; M=3.86, SD=1.57; M=3.81, SD=1.57). In
Scenario 3, although all four covariates were significant, no significant main effect of nominalization was found on pain responsibility when controlling for these covariates respectively. Given the results were inconsistent cross the scenarios, Hypothesis 12 was only partially supported.
Hypothesis 13 stated that a sufferer’s description of pain experience that features nominalized pain would invite audiences to feel less sympathetic toward the speaker than a description featuring pain experience in verb form. Testing for H13 in Scenario 1 found no significant main effect of nominalization (p=.490). No covariate adjusted the relationship between the relationship between nominalization and sympathy. Results of
Scenario 2 found that although medical training and personal pain history both significantly adjusted the relationship between nominalization and sympathy, there was no significant main effect of nominalization. Similarly, in Scenario 3, with experience of being a primary caretaker (p=.034) as a covariate, there was no main effect of nominalization (p=.430).
Therefore, the null hypothesis could not be rejected. 58 Hypothesis 14 predicted that a sufferer’s description of pain experience that features nominalized pain would invite audiences to be less likely to agree that the speaker’s need for higher dose of pain relief medication is valid than a description featuring pain experience in verb form. Testing for H14 in Scenario 1 found that when personal pain history was controlled for (p=.054), no significant main effect of nominalization was found on support for higher dose (p=.326). In Scenario 2, no covariate was found significant and there was no significant main effect of nominalization (p=.425). Testing for H14 in
Scenario 3 found that when controlling for experience of being a primary caretaker, there was no significant main effect of nominalization on support for higher dose (p=.976).
Combining the results across the scenarios, the author concluded that Hypothesis 14 was not supported.
Individual differences
Medical training Independent T-tests were performed to examine the impacts of the individual difference variables on the dependent variables. In Scenario 1, testing found a significant effect of medical training on perceived control [t(207)=7.76, p<.001], pain responsibility
[t(207)=7.66, p<.001], pain duration [t(207)=-2.01, p=.045], and support for higher dose
[t(207)=-3.47, p=.001]. Participants with medical training (n=73) rated significantly higher on perceived control (M=4.14, SD=1.08), pain responsibility (M=5.04, SD=1.55) but lower on perceived pain duration (M=5.64, SD=1.17) and support for higher dose (M=4.79,
59 SD=.77) than those with no medical training (n=136) (Mcontrol=2.75, SD=1.08;
Mresponsibility=3.26, SD=1.62; Mduration=5.96, SD=1.01; Mdose change=5.37, SD=1.32).
Testing in Scenario 2 found a significant effect of medical training on perceived disability [t(118)=-3.54, p=.001], pain control [t(118)=5.69, p<.001], pain responsibility
[t(118)=5.42, p<.001], sympathy [t(118)=-2.29, p=.024]，and support for higher dose
[t(118)=-4.20, p<.001]. Those with medical training (n=46) rated higher on perceived pain control (M=4.25, SD=.93) and pain responsibility (M=5.03, SD=1.23) but lower on perceived disability (M=5.19, SD=.92), sympathy (M=5.50, SD=.90), and support for higher dose (M=4.53, SD=.82) than those without medical training (n=74) (Mcontrol=3.09,
SD=1.22；Mresponsibility=3.55, SD=1.57; Mdisability=5.80, SD=.92; Msympathy=5.88, SD=.97;
Mdose change=5.35, SD=1.16).
In Scenario 3, results of independent T-tests found a significant effect for medical training on pain duration [t(147)=-1.99, p=.049], perceived disability [t(147)=-2.13, p=.035], perceived control [t(147)=6.97, p<.001], pain responsibility [t(147)=7.42, p<.001], and support for higher dose [t(147)=-4.28, p<.001]. Participants who had medical training (n=59) rated significantly lower on pain duration (M=5.73, SD=1.13), perceived disability (M=5.74, SD=1.05), and support for higher dose (M=4.85, SD=1.01) than those who did not have medical training (n=90) (Mduration=6.07, SD=.93; Mdisability=6.09, SD=.93;
Mdose change=5.61, SD=1.08). On the other hand, participants with medical training rated significantly higher on perceived control (M=5.02, SD=1.63) and pain responsibility
(M=5.07, SD=1.37) than those without training (Mcontrol=2.97, SD=1.45; Mresponsibility=3.28,
SD=1.49). 60 Personal pain history In Scenario 1, there was a significant effect of personal pain history on pain affect
[t(207)=2.12, p=.035], perceived control [t(207)=3.36, p=.001], pain responsibility
[t(207)=3.41, p=.001], and support for higher dose [t(207)=1.80, p=.074]. Participants who have been diagnosed with chronic pain conditions or experienced chronic pain (n=96) have rated significantly higher on perceived pain affect (M=5.78, SD=1.04), perceived pain control (M=3.58, SD=1.44), pain responsibility (M=4.33, SD=1.94), and support for higher dose (M=5.80, SD=1.02) than those who have not (n=113) (Maffect=5.45, SD=1.17;
Mcontrol=2.95, SD=1.28; Mresponsibilty=3.50, SD=1.59; Mdose change=5.50, SD=1.24).
Testing in Scenario 2 found a (marginally) significant effect of personal pain history on perceived pain intensity [t(118)=-2.66, p=.009], duration [t(118)=-2.93, p=.004], pain affect [t(118)=-2.26, p=.026], perceived disability [t(118)=-2.71, p=.008], pain control
[t(118)=3.89, p<.001], responsibility [t(118)=3.56, p=.001], sympathy [t(118)=-1.21, p=.073], and support for higher dose [t(118)=-2.95, p=.004]. Participants with personal pain history (n=57) rated significantly higher on pain control (M=3.99, SD=1.07) and responsibility (M=4.64, SD=1.49) but lower on pain intensity (M=4.33, SD=1.25), duration
(M=5.44, SD=1.13), pain affect (M=5.03, SD=1.12), perceived disability (M=5.32,
SD=.90), sympathy (M=5.58, SD=.93), and support for higher dose (M=4.73, SD=.97) than participants with no personal pain history (n=63) (Mcontrol=3.14, SD=1.29; Mresponsibility=3.64,
SD=1.59; Mintensity=4.85, SD=.86; Mduration=5.97, SD=.84; Maffect=5.47, SD=1.04;
Mdisability=5.79, SD=.97; Msympathy=5.87, SD=.85; Mdose change=5.31，SD=1.17).
61 In Scenario 3, there was a significant effect for personal pain history on perceived control [t(147)=4.37, p<.001], pain responsibility [t(147)=4.46, p<.001], and support for higher dose [t(147)=-3.25, p=.001]. Participants with personal pain history (n=69) rated significantly higher on perceived control (M=4.44, SD=1.74) and responsibility (M=4.61,
SD=1.60) but lower on support for higher dose (M=5.00, SD=1.03) than those without personal pain history (n=80) (Mcontrol=3.21, SD=1.71; Mresponsibility=3.45, SD=1.58; Mdose change=5.58，SD=1.12).
Experience of being a primary caretaker Testing in Scenario 1 found a significant effect of being a primary caretaker on perceived pain intensity [t(207)=2.43, p=.016], pain affect [t(207)=2.02, p=.045], perceived control [t(207)=3.33, p=.001], and pain responsibility [t(207)=6.30, p<.001].
Participants with experience of being a primary caretaker for chronic pain patients (n=84) rated significantly higher on perceived pain intensity (M=5.20, SD=.83), pain affect
(M=5.79, SD=.85), perceive control (M=3.62, SD=1.47), and pain responsibility (M=4.51,
SD=1.91) than those without such experience (n=125) (Mintensity=4.85, SD=1.14;
Maffect=5.47, SD=1.26; Mcontrol=2.98, SD=1.28; Mresponsibility=3.46, SD=1.60).
Testing in Scenario 2 found a significant effect of experience of being a primary caretaker on disability [t(118)=-3.06, p=.003], control [t(118)=4.66, p<.001], responsibility
[t(118)=5.50, p<.001], support for higher dose [t(118)=-4.02, p<.001], and sympathy
[t(118)=-2.66, p=.097]. Participants who have been a primary caretaker for chronic pain patients (n=57) rated significantly higher on pain control (M=4.06, SD=.98) and pain
62 responsibility (M=4.83, SD=1.31) but lower on pain disability (M=4.29, SD=.91), support for higher dose (M=4.63, SD=.87), and sympathy (M=5.59, SD=.87) than those who have not (n=63) (Mcontrol=3.07, SD=1.30; Mresponsibility=3.47, SD=1.60; Mdisability=5.81, SD=.95;
Msympathy=5.86, SD=.91; Mdose change=5.40，SD=1.19).
Testing in Scenario 3 found a (marginally) significant effect of experience of being a primary caretaker on perceived pain duration [t(147)=-1.81, p=.072], disability [t(147)=-
3.40, p=.001], pain control [t(147)=8.89, p<.001], pain responsibility [t(147)=7.49, p<.001], sympathy [t(147)=-1.92, p=.057], and support for higher dose [t(147)=-5.03, p<.001]. Participants who have been a primary caretaker (n=71) rated significantly higher on pain control (M=4.14, SD=.93) and pain responsibility (M=4.92, SD=1.44) but lower on pain duration (M=5.77, SD=1.10), disability (M=5.67, SD=1.05), sympathy (M=5.78,
SD=.91), and support for higher dose (M=4.86, SD=.99) than those who have not been a primary caretaker (n=78) (Mcontrol=2.62, SD=1.13; Mresponsibility=3.15, SD=1.44;
Mduration=6.08, SD=.94; Mdisability=6.21, SD=.86; Msympathy=6.06, SD=.81; Mdose change=5.71，
SD=1.07).
Regular interactions with chronic pain patients Testing in Scenario 1 found a significant effect of interactions with patients on pain duration [t(207)=1.72, p=.087], perceived control [t(207)=2.13, p=.034], and pain responsibility [t(207)=2.68, p=.008]. Participants who interact with chronic pain patients regularly (n=100) rated significantly higher on pain duration (M=5.98, SD=1.00), perceived control (M=3.45, SD=1.47), and pain responsibility (M=4.23, SD=1.93) than
63 those do not (n=109) (Mduration=5.72, SD=1.14; Mcontrol=3.04, SD=1.29; Mresponsibility=3.57,
SD=1.61).
Testing in Scenario 2 found a significant effect of interactions with patients on perceived pain control [t(118)=2.03, p=.044], pain responsibility [t(118)=2.01, p=.047], and support for higher dose[t(118)=-1.99, p=.049]. Participants who interact with chronic pain patients regularly (n=64) rated significantly higher on perceived pain control (M=3.76,
SD=1.24) and pain responsibility (M=4.39, SD=1.57) but lower on support for higher dose
(M=4.85, SD=1.00) than those who do not (n=56) (Mcontrol=3.30, SD=1.25;
Mresponsibility=3.80, SD=1.63; Mdose change=5.25，SD=1.21).
Testing in Scenario 3 found a significant effect of interaction with chronic pain patients on perceived disability [t(147)=-2.69, p=.008], pain control [t(147)=5.44, p<.001], pain responsibility [t(147)=4.97, p<.001], and support for higher dose [t(147)=-2.41, p=.017]. Participants who regularly interact with chronic pain patients (n=86) rated higher on pain control (M=3.79, SD=1.23) and pain responsibility (M=4.53, SD=1.57) but lower on perceived disability (M=5.77, SD=1.11) and support for higher dose (M=5.12, SD=1.09) than those who do not (n=63) (Mcontrol=2.73, SD=1.12; Mresponsibility=3.24, SD=1.56;
Mdisability=6.20, SD=.74; Mdose change=5.56, SD=1.11).
64 Chapter 6: Discussion This research investigated how people spontaneously assign linguistic agency when talking about pain experience and the impacts of various grammatical choices on the audience’s perceptions of the patient. To do so, the author examined the pain/body agency assignment rate of participants in chronic vs. acute pain and severe vs. mild pain conditions in Study 1. Results indicated that when describing one’s pain experience, people were more likely to assign agency to the pain or body parts where pain is localized if the pain is chronic rather than acute. However, there was no evidence that pain/body agency assignment rate was affected by pain severity.
In Study 2, the author examined whether or not participants would make different attributions about a fictitious patient based on various linguistic markers, including agency assignment and nominalization. Results indicated that in Scenario 1 (i.e., headache scenario), when participants read a pain description that assigned agency to pain or body parts where pain is localized, they were more likely to rate the patient’s pain to be more intense and persistent, after controlling for experience of being a primary caretaker and medical training respectively. Participants in the pain/body agency condition also rated perceived responsibility to be greater than those in the human agency condition, when controlling for each covariate respectively except for personal pain history. These participants also reported more sympathy toward “Pat” than their fellow participants in the human agency condition. No main effect of agency assignment was found on any dependent variables in Scenario 2 (i.e., back pain scenario). Results did find significant main effects of nominalization on perceived pain control and pain-related responsibility.
65 When controlling for each covariate except for medical training, participants in the noun form condition rated pain responsibility higher than those in the verb form condition.
Similarly, with experience as a primary caretaker and interaction with patients controlled for respectively, such participants rated perceived control higher than their counterparts in the verb form condition. In Scenario 3 (i.e., joint pain scenario), with medical training controlled for, participants in the human agency condition perceived “Pat” as having greater control and pain responsibility than those in the pain/body agency condition. When controlling for experience as primary caretaker, participants in the human agency condition reported more sympathy toward “Pat” than those in the pain/body agency condition.
In general, participants in the human agency condition believed that “Pat” had greater pain control and pain responsibility than those in the pain agency condition. They also rated “Pat’s pain to be less intense and lasting. Participants who read a pain description featuring noun form also believed that “Pat” has greater locus of control and pain management responsibility than those who read a description featuring verb form.
However, the data were only partially consistent with expected effects of linguistic agency and nominalization on other dependent variables.
THEORETICAL IMPLICATIONS This research suggests that the spontaneous assignment of linguistic agency in pain description may vary based on the types of pain (i.e., acute vs. chronic pain). Previous research suggests that the language used by people when talking about stressful life events, such as chronic illness and traumatic incidents, are indicative of their psychological and
66 physical health. For example, a social linguistic analysis of narratives of cancer found that complexity in illness narratives is an index of the degree of life disruption experienced by patients (Jordens et al., 2001). In other words, patients whose life was more disrupted by illness were more likely to use a greater number of discrete story genres (i.e., “stories within the story”) in illness narratives than those whose life was less disrupted. The authors argued that complex narratives reflect the ongoing process of reinstating order while simple narratives reflect the outcomes of such process. A study by Campbell and Pennebaker
(2003) using latent semantic analysis found that flexibility in the use of personal pronouns when writing about one’s traumatic memories was associated with health improvement.
The researchers pointed out that pronoun choice is perspective based and altering individual and social perspectives can help people think about oneself in relation to others and thus come to terms with their traumatic experience.
This thinking is consistent with the rationale behind Hypothesis 1 as people suffering from chronic pain may experience more life disruption and thus are less able to shift their attention away from pain. In this study, participants were more likely to assign agency to pain or body parts affect by pain when writing about a chronic pain experience than writing about an acute pain experience. One explanation is that acute pain is oftentimes caused by injuries and accidents resulting from patients’ own activities and thus patients are more likely to assign agency to themselves or non-pain entities to describe how the related event unfolds. When writing about chronic pain experience, however, people may fixate on the pain as it is likely to have stronger and more lasting impacts on their daily life than acute pain. Thus, they may assign agency to their chronic pain more 67 frequently. Another explanation for this finding concerns people’ sense of agency when dealing with different types of pain. Oren, Friedmann, and Dar (2016) reported that individuals with high obsessive-compulsive tendencies were more likely to use non-agentic sentences (e.g., Things happen.) than those with low obsessive-compulsive tendencies.
They suggest that the use of non-agentic expressions by individuals with high OC tendencies demonstrate a generalized diminishment of sense of agency. It is possible that when recalling and writing about chronic pain, participants experienced a lower sense of agency, than recalling and writing about acute pain experience.
Although Study 1 found that pain/body agency assignment rate did not differ by pain intensity, it does lend further support to Schattner and Shahar (2011)’s theory that the subjective illness experience of patients may be a stronger predictor of their mental health outcomes than physical condition. Experiences of severe pain might have greater psychological impacts on participants temporarily than those of mild pain, but such impacts are likely not lasting and thus not reflected in retrospective narratives. Furthermore, a previous survey of 140 retirement community residents with chronic pain found no significant association between pain intensity and participants’ self-efficacy (Turner et al.,
2005). This echoes McCracken’s (1998) earlier observation that acceptance of pain, which predicts better adjustment to the pain experience, is not simply a function of having less severe pain. Turner and colleagues thus pointed out that severe pain does not necessarily lead to a lower sense of self-efficacy for pain management. Study 1 would seem to strengthen this case since it was found that pain/body agency assignment rate, which may
68 be indicative of self-efficacy based on previous research (Wartel, 2017), was not predicted by pain intensity, suggesting that pain intensity alone might not influence self-efficacy.
This research found significant main effects of pain agency on perceived pain intensity, duration, and internal locus of control, which extend the agency assignment research paradigm to a new context. Prior research has found that linguistic descriptors used in health communication materials may influence audience’ judgements of illness.
For example, when asked to assess perceived risk based on a statement (e.g., Jamie has a family history of heart disease. How likely is Jamie to get heart disease?), people tend to associate higher levels of health risk with the terminology “has a gene that causes” while lower risk with the terminology “has a family history of” (Condit & Parrott, 2004).
Reynaert and Gelman (2007) found that when asked to judge the permanence of a set of novel illnesses that differed in wording, participants perceived nouns (e.g., He is a baxtermic) to be most permanent and possessive nouns (e.g., He has baxtermia) to be least permanent. In addition, participants were more likely to describe mental illness with relatively permanent forms (“is” and “is a”) and physical illness with less permanent forms
(“has”). The current finding indicates that people could infer the quality of pain of others as well as their adaptation based on simple and subtle linguistic cues provided by the person. This finding can be interpreted from a cognitive linguistic perspective. As previously discussed, a prototypical grammatical agent can be characterized by four properties, including sentience, causation, volition, and movement (Dowty, 1991).
Therefore, when a speaker adopts pain/body agency (e.g., My heart was exploding out of my chest.) instead of human agency, pain is more likely to be perceived as a sentient being 69 actively causing changes and thus associated with greater intensity and duration. Agentive pain also implies the passivity of the patient (Dowty, 1991), leading to the perceived lack of control.
The findings of Study 2 also highlight a connection between linguistic agency assignment and attribution of responsibility; namely, the use of pain/body agency in pain description ascribes greater pain responsibility to the pain than the patient. Fausey and
Boroditsky (2010) found that when reading a report describing accidents, participants were more likely to attribute blame to the people involved and request higher financial penalties if the report featured agentic verb form (e.g., she toppled the candle) than non-agentive verb form (e.g., the candle toppled). Furthermore, the effect of linguistic framing held even when the accident was well known and when a video of the accident was shown to the participants. Wang and McGlone (2020) reported a series of experiments in which participants read a hypothetical scenario describing a transgression (e.g., being badmouthed, property damage) committed by a fictitious person against them. Following the scenario, participants read an apology from the fictitious person. The researchers found that apologies that adopted transgressor (I am sorry that I upset you) or transgression agency (I am sorry that it upset you) were more likely to induce favorable responses from participants than apologies that omitted agency (I am sorry that you are upset). They also found that apology recipients were able to infer the degree to which a transgressor assumes responsibility for a transgression based on the linguistic agency used in the apology. The current study provided a first report on the impact of agency assignment on perceived
70 responsibility pertaining to pain management, lending additional support to the argument that agency assignment bears attributional consequences.
Although this study found a similar connection between nominalization and responsibility, the data were only consistent with the prediction in one of the three scenarios. In both studies by Bohner (2001) and Lamb (1991), researchers suggested that distancing language, such as nominalization, can diffuse the responsibility of the actors.
Idan et al. (2018) also argued that noun form and verb form differ in their level of focus on the agent as noun form is stative while verb form emphasize the agent responsible for causing the outcome. Since nouns are divorced from agents, pain agency combined with verbs should predict lowest perceived responsibility among the groups. However, such speculation was not supported by the data. Two reasons may explain this discrepancy. One concerns the fact that only a low number of noun and verb labels were manipulated in the materials and therefore the manipulations may have limited effects. The researcher did not manipulate more cues, particularly noun form, because excessive usage of noun form may be perceived as too formal and unnatural by participants. The second reason is that in order to manipulate verb form in pain descriptions, pain/body agency inevitably appeared in some conditions that were characterized by human agency. For instance, a sentence in the
Headache × Human agency × Verb form reads “It is unpredictable when pain will invade.”
The narrative in this condition adopted predominantly human agency, but this sentence features pain agency and verb form. This could potentially reduce the effect of nominalization on dependent variables in these conditions. Future research is necessary to examine the impact of nominalization separately. 71 PRACTICAL IMPLICATIONS This study indicates that not only patients with different types of pain differ in their choice of agency assignment, but people can infer others’ pain experience based on their linguistic expressions. The author argues that these inferences might be of diagnostic value and clinical importance. Since the current psychological approach to chronic pain management focuses on improving self-management and enabling positive behavioral and cognitive changes rather than eliminating the locus of pain directly (Roditi & Robinson,
2011), pain evaluation needs to be informed by an appreciation of patients’ experience.
Previous research has identified a number of cues that can influence pain judgment, such as access to patients’ ratings, expectation for cheating, and behavioral cues (Kappesser et al., 2006; Kappesser & Williams, 2008). An experiment by Kappesser and Williams (2008) found that observers reported high pain estimates when reading about a fictitious patient giving high pain self-reports and stopping all liked and disliked tasks; observers reported lowest pain estimates when reading about the patient stopping disliked but continued with liked tasks. The current findings inform both psycholinguistic research and pain communication research by demonstrating that pain assessment may also be affected by the linguistic devices employed by the patient. Additional research needs to replicate the observed effects and further examine the possibility of using agency assignment rate as an index of pain assessment by comparing the pain estimations of observers to patients’ ratings.
This study also found that a number of individual differences may influence pain judgment. In all three scenarios, participants with medical training, personal pain history,
72 or experience of caring for or interacting with chronic pain patients tend to believe that
“Pat” was in greater control of the pain and had greater pain responsibility than those without such training and experience. In both Scenario 2 and 3, these participants perceived
“Pat’s pain to be less intense and persistent and that “Pat” was less affected and disabled.
They were also less sympathetic toward “Pat” and less supportive of prescribing “Pat” higher dose of pain relief medication. Previous studies have shown discrepancies in pain estimations between observers and sufferers as most studies reported underestimations of pain by observers while some reported overestimations (Goubert et al., 2009).
This study, however, found a pain perception discrepancy among observers which may bear major consequences in practice. As Goubert et al. (2005) pointed out, both overestimation and underestimation carry risks and may become barriers to effective pain treatment; namely, underestimation of pain could lead to insufficient care and feelings of being misunderstood on the part of patients while overestimation could result in unnecessary medication and overprotective behaviors of caretakers. This study does not necessarily suggest that healthcare providers and caretakers are more likely to misevaluate pain than lay observers. It does indicate, though, that people with medical training and experience of dealing with chronic pain are more likely to believe that the responsibility of pain management falls on patients than lay observers and they are more reserved about prescribing pain relief medication, which could lead to patients’ frustration. Furthermore, the discrepancy in sympathy between trained eyes and lay observers may reflect in patient- caregiver communication and become a barrier to effective consultation. Understanding how observers’ perceptions of others’ pain are affected by their own expertise and 73 experience of pain can inform better patient-caregiver communication and improve quality of care. For example, Tait et al. (2011) found that regardless of patients’ self-reported pain intensity, neurosurgeons rated pain severity and pain-related pain disability lower than internists, suggesting that physician specialty and clinical experience can influence pain assessment. They suggested that pain assessment should be understood within a social cognitive framework. Future research should compare the pain perception of healthcare professionals, primary caretakers, patients, and lay observers to further investigate the impacts of expertise and personal experience on pain assessment to achieve better pain calibration.
LIMITATIONS There are several limitations to this study. First, the analyses of Scenario 2 (n=120) and 3 (n=149) in Study 2 were underpowered to detect true effects due to modest sample sizes. This might explain some of the non-significant findings and the inconsistent results found across the scenarios. Second, the study examined the impact of linguistic devices in written narratives on audience’ pain perception in three pain scenarios. Therefore, the generalizability of the observed effects to other media (e.g., audios, videos) and other types of pain should be further investigated. Particularly, the current findings seem to suggest that agency assignment had stronger impact in the headache scenario than back and joint pain scenarios. Future research needs to further investigate the cause for this discrepancy.
Third, the language manipulation used was heterogeneous; namely, the manipulations were comprised of various types of word cues and expressions and thus it is unclear whether the
74 observed effects were caused by specific cues or their aggregations (Bell et al., 2004;
McGlone et al., 2013). A fourth limitation of this study lies in the strength of manipulations.
While this study shows simple and subtle linguistic cues can influence audience’s pain perception, these cues may have limited effects due to a number of factors, including length of the narratives and the lack of control in web experiment. Additional research should employ multiple messages and longer narratives to compare the impacts of language manipulations. A fifth, related concern pertains to the measures of manipulations.
Following Bell and colleagues (2014), four memory-based manipulation checks were initially included to examine participants’ recognition memory for the agency assignment and nominalization language manipulations in the narratives. In each manipulation check question, participants read a pair of sentences that convey the same information from the narrative featuring various agency assignment and grammatical categories. They were then asked to choose the sentence that matches what they have read previously. Recognition accuracy would reflect participants’ sensitivity to the linguistic manipulation. However, upon completing the experiment for Scenario 1, a significant portion of participants reported that they had trouble recalling the exact sentences they read despite of spending sufficient time reading the prompt. The memory-based manipulation checks were therefore replaced by an alternative attention check based on participation time.
CONCLUSION The two primary goals of this study were to investigate whether the spontaneous assignment of linguistic agency in pain description is affected by patients’ pain intensity
75 and/or duration, and assess the impact of agency assignment and nominalization on audience’s perception of patients upon reading a pain description. There was no evidence to suggest that pain/body agency assignment rate differed between the mild and severe pain conditions. However, the findings do suggest participants were more likely to assign agency to pain/body when writing about a chronic than acute pain experience. Furthermore, when reading a pain description that adopted pain/body agency instead of human agency, participants rated the fictitious sufferer’s pain to be more intense and lasting and they believed the person had greater locus of control and pain management responsibility.
However, there was no evidence to suggest that nominalization had any impact on audience’s pain perception other than locus of control and pain responsibility. These findings extend existing work on attributional consequences of agency assignment and have important implications for pain assessment and chronic pain management.
76 Tables
Table 1: Means and standard deviations for rate of each agency type by condition (i.e., chronic and acute pain; severe and mild pain) of each coder in Study 1
Human agency Pain/body Other agency Coder 1 Condition rate agency rate rate Group1 Acute pain 60.17(32.28) 15.11(23.12) 24.72(25.01) (n=27) Chronic pain 50.31(31.35) 27.64(25.16) 14.64(14.81) Group2 Mild pain 58.84(29.76) 21.10(25.34) 20.06(24.16) (n=29) Severe pain 55.46(24.06) 20.67(24.14) 23.88(24.07) Human agency Pain/body Other agency Coder 2 Condition rate agency rate rate Group1 Acute pain 60.29(32.29) 13.50(18.78) 26.21(24.66) (n=27) Chronic pain 48.99(29.76) 27.12(25.03) 16.49(15.53) Group2 Mild pain 58.95(29.85) 20.99(25.35) 20.06(24.16) (n=29) Severe pain 53.94(24.90) 22.52(25.67) 23.54(23.97)
77 Table 2: Summary of intercorrelations, means, and standard deviations for the dependent variables in Scenario 1 (n=209)
Variable 2 3 4 5 6 7 8 M SD 1. Pain intensity .47** .58** .47** -.13 -0.10 .39** .39** 4.99 1.04 2. Pain duration .45** .42** -.25** -.27** .37** .36** 5.85 1.08 3. Pain affect .54** -.20** -.14* .47** .46** 5.60 1.13 4. Disability -.33** -.35** .63** .60** 5.84 .93 5. Locus of control .84** -.29** -.18** 3.57 1.89 6. Pain responsibility -.29** -.18* 3.88 1.80 7. Sympathy .57** 5.85 .96 8. Support for 1 5.65 1.15 higher dose **p<.01 (2-tailed) * p<.05 (2-tailed)
78 Table 3: Summary of intercorrelations, means, and standard deviations for the dependent variables in Scenario 2 (n=120)
Variable 2 3 4 5 6 7 8 M SD 1. Pain intensity .43** .71** .46** -.12 .02 .46** .39** 4.60 1.09 2. Pain duration .58** .47** -.22* -.19* .50** .37** 5.72 1.02 3. Pain affect .63** -.10 .00 .59** .52** 5.26 1.10 4. Disability -.32** -.25** .71** .57** 5.57 0.97 5. Locus of control .76** -.16 -.09 3.99 1.74 6. Pain responsibility -.18 -.18* 4.12 1.62 7. Sympathy .72** 5.73 0.90 8. Support for higher 1 5.64 1.05 dose **p<.01 (2-tailed) * p<.05 (2-tailed)
79 Table 4: Summary of intercorrelations, means, and standard deviations for the dependent variables in Scenario 3 (n=149)
Variable 2 3 4 5 6 7 8 M SD 1. Pain intensity .35** .55** .32** -.12 -.02 .38** .27** 4.79 0.94 2. Pain duration .57** .56** -.20* -.19* .54** .47** 5.93 1.02 3. Pain affect .57** -.11 -.08 .58** .56** 5.60 0.92 4. Disability -.32** -.25** .77** .67** 5.95 0.99 5. Locus of control .76** -.23** -.16 3.78 1.82 6. Pain responsibility -.14 -.15 3.99 1.69 7. Sympathy .74** 5.93 0.87 8. Support for higher 1 5.80 1.02 dose
**p<.01 (2-tailed) * p<.05 (2-tailed)
80 Table 5: Effects of agency assignment on the dependent variables across the scenarios when controlling for covariates Pain/body Scenario Human agency Significant covariates agency 1 4.85 (1.19)a 5.13 (0.87)b Primary caretaker (p=.02) Pain intensity 2 4.70 (1.06) 4.52 (1.11) Personal history (p=.011) 3 4.90 (0.87) 4.67 (1.00) 1 5.68 (1.18)a 6. 00 0.96)b Medical training (p=.054) 2 5.71 (1.20) 5.69 (0.87) Personal history (p=.009) Pain duration 3 5.90 (1.02) 5.96 (1.03) Medical training (p=.051) 5.93 (1.02) 5.93 (1.03) Primary caretaker (p=.084) 1 5.54 (0.97) 5.66 (1.25) Personal history (p=.024) Pain affect 2 5.27 (1.24) 5.25 (0.98) Personal history (p=.032) 3 5.61 (0.94) 5.61 (0.91) 1 5.74 (0.94) 5.93 (0.92) 2 5.61 (0.99) 5.54 (0.95) Medical training (p=.001) 5.61 (0.99) 5.53 (0.95) Personal history (p=.010) Disability 5.62 (0.99) 5.52 (0.95) Primary caretaker (p=.003) 3 6.03 (0.83) 5.87 (1.13) Medical training (p=.049) 5.94 (0.83) 5.96 (1.13) Primary caretaker (p=.001) 6.05 (0.83) 5.84 (1.13) Patient interaction (p=.009) 1 3.72 (1.88) 3.42 (1.89) Primary caretaker (p<.001) Locus of 2 4.14 (1.75) 3.92 (1.74) Primary caretaker(p<.001) control 4.17 (1.75) 3.91 (1.74) Patient interaction (p=.044) 3 4.06 (1.90)a 3.49 (1.74)b Medical training (p<.001) 1 4.07 (1.76)a 3.70 (1.83)b Medical training (p<.001) 4.06 (1.76) 3.71 (1.83) Personal history (p=.001) 4.09 (1.76)a 3.69 (1.83)b Primary caretaker (p<.001) 4.10 (1.76)a 3.68 (1.83)b Patient interaction (p=.004) 2 4.25 (1.65) 4.05 (1.60) Medical training (p<.001) Pain 4.24 (1.65) 4.07 (1.60) Personal history (p=.002) responsibility 4.23 (1.65) 4.08 (1.60) Primary caretaker (p<.001) 4.26 (1.65) 4.07 (1.60) Patient interaction (p=.043) 3 4.24 (1.74)a 3.72 (1.63)b Medical training (p<.001) 4.07 (1.74) 3.90 (1.63) Primary caretaker (p<.001) 4.11 (1.74) 3.87 (1.63) Patient interaction (p<.001)
81 Table 5 Cont'd. Pain/body Scenario Human agency Significant covariates agency 1 5.72 (1.00)a 5.97 (0.92)b 2 5.79 (0.85) 5.70 (0.94) Medical training (p=.024) Sympathy 5.79 (0.85) 5.69 (0.94) Personal history (p=.075) 3 6.08 (0.78)a 5.78 (0.93)b Primary caretaker (p=.034) 1 5.52 (1.27) 5.76 (1.02) Personal history (p=.054) Support for 2 5.65 (1.08) 5.65 (1.04) higher dose 3 5.94 (0.87)a 5.65 (1.14)b Primary caretaker (p=.072)
Note: Values are means with standard deviations in parentheses. Within rows, means with different letter subscripts are (marginally) significantly different from one another (p<.05)
82 Appendices
APPENDIX A: QUESTIONNAIRE FOR STUDY 1 We are almost finished! To help us understand our results better, we need to know a few things about the people who have participated in this study.
What is your sex?
¨ Female ¨ Male ¨ Other ¨ Prefer not to identify
What is your age?
_____ years old
Are you a native English speaker? ¨ Yes ¨ No à(not eligible for the study)
What is your race? (Check all that apply.)
¨ African-American (Black) ¨ American Indian / Alaskan Native ¨ Asian ¨ Native Hawaiian or Other Pacific Islander ¨ White (Including Hispanic Whites) ¨ Other (Specify: ______)
What is the highest level of education you have completed?
¨ Less than high school ¨ High school/GED ¨ Some college ¨ 2-year College Degree ¨ 4-year College Degree ¨ Master’s Degree ¨ Doctoral Degree
83 ¨ Professional Degree (MD, DDS, JD, etc.)
Which of the following best describes your current employment status?
¨ Employed full-time ¨ Employed part-time ¨ Unemployed and looking for work ¨ Full-time student ¨ Homemaker ¨ Retired ¨ Other (Specify: ______)
How long have you been diagnosed with Fibromyalgia? _____year(s) and _____ month(s)
Have you been diagnosed with any other chronic pain conditions? ¨ Yes ¨ No à (end of the questionnaire)
If you have been diagnosed with any other chronic pain conditions, can you specify the condition(s)? ______.
If you have been diagnosed with any other chronic pain conditions, how long have you been diagnosed with it or them? ______.
Please leave an email address here if you’d like to be selected to win a $25 Amazon eGift card. ______.
84 APPENDIX B: QUESTIONNAIRE FOR STUDY 2
This questionnaire asks about your perception of Pat and Pat’s condition. Your responses are anonymous.
On a scale of 0 (i.e., no pain) to 10 (i.e., worst pain imaginable), how intense do you think Pat’s pain is? 0 1 2 3 4 5 6 7 8 9 10
Please indicate the degree to which you believe Pat’s pain is recurrent or continuous (1=not at all, 7=very much so). 1 2 3 4 5 6 7
Please indicate the level of your agreement to adjectives describing the increasing unpleasantness in Pat caused by pain by selecting the number that best reflect your perceptions. Pat’s pain is… unpleasant 0 1 2 3 4 5 6 7 8 9 10 not bad at all the most unpleasant feeling possible annoying 0 1 2 3 4 5 6 7 8 9 10 not annoying at all the most annoying feeling possible intolerable 0 1 2 3 4 5 6 7 8 9 10 not intolerable at all the most intolerable feeling possible distressing 0 1 2 3 4 5 6 7 8 9 10 not distressing at all the most distressing feeling possible
Please indicate the degree to which you agree or disagree with the following statements.
Strongly 1 2 3 4 5 6 7 Strongly Disagree Agree i. Pat’s ability to perform daily activities is limited by pain. ii. Pat is likely to encounter physical difficulty while performing heavy duty. iii. Pain impinges on Pat’s life.
85 Please indicate the degree to which you agree or disagree with the following statements.
Strongly 1 2 3 4 5 6 7 Strongly Disagree Agree i. Pat is in control of the pain. ii. Pat has little control of his/her pain (reverse coded). iii. Pat is capable of managing the pain.
Please indicate the degree to which you agree or disagree with the following statements.
Strongly 1 2 3 4 5 6 7 Strongly Disagree Agree
i. Pat is directly responsible for his/her pain getting better or worse. ii. Pat is the one with the responsibility for what happens with his/her pain. iii. Pat deserves the credit when his/her pain improves and the blame when it gets worse.
Please indicate the degree to which you agree or disagree with the following statements.
Strongly 1 2 3 4 5 6 7 Strongly Disagree Agree
i. I am understanding of what Pat has said. ii. I feel sympathetic toward Pat. iii. I feel compassionate for Pat.
Please indicate the degree to which you agree or disagree with the following statements.
Strongly 1 2 3 4 5 6 7 Strongly Disagree Agree
i. Pat’s request for greater doses of medication is understandable. ii. I believe Pat’s demand for greater doses of medication is reasonable. iii. I do not believe Pat needs greater doses of medication. (reverse coded)
86 APPENDIX C: DEMOGRAPHIC QUESTIONS FOR STUDY 2
We are almost finished! To help us understand our results better, we need to know a few things about the people who have participated in this study.
What is your sex?
¨ Female ¨ Male ¨ Other ¨ Prefer not to identify
What is your age?
_____ years old
Are you a native English speaker? ¨ Yes ¨ No à(not eligible for the study)
What is your race? (Check all that apply.)
¨ African-American (Black) ¨ American Indian / Alaskan Native ¨ Asian ¨ Native Hawaiian or Other Pacific Islander ¨ White (Including Hispanic Whites) ¨ Other (Specify: ______)
What is the highest level of education you have completed?
¨ Less than high school ¨ High school/GED ¨ Some college ¨ 2-year College Degree ¨ 4-year College Degree ¨ Master’s Degree ¨ Doctoral Degree ¨ Professional Degree (MD, DDS, JD, etc.)
87 Which of the following best describes your current employment status?
¨ Employed full-time ¨ Employed part-time ¨ Unemployed and looking for work ¨ Full-time student ¨ Homemaker ¨ Retired ¨ Other (Specify: ______)
Have you received any formal medical training? ¨ Yes ¨ No
Have you been diagnosed with any chronic pain conditions or experienced chronic pain? ¨ Yes ¨ No
If you have been diagnosed with any chronic pain conditions or experienced such condition(s), can you specify the condition(s)? ______.
If you have been diagnosed with any other chronic pain conditions or experienced such condition(s), how long have you been diagnosed with/experiencing it or them? ______.
Are you a caretaker of someone living with chronic pain? ¨ Yes ¨ No
Do you regularly interact with someone living with chronic pain? ¨ Yes ¨ No
88 APPENDIX D: PAIN NARRATIVES FOR STUDY 2 On the next page, you will read a description from someone who suffers from chronic pain. To protect the person's identity, we have assigned an alias “Pat" to the person. Please read Pat's description carefully and answer a few questions based on your impression of Pat.
Scenario 1 Headache × Human Agency × Noun Form: “I started having headaches a while ago. At the beginning, the irritation wasn’t too bad. However, lately I have taken a turn for the worse. I feel a throbbing whenever I move my head around rapidly. I wake up in pain every morning. My job requires concentration for long hours, but I hurt so badly because of that. I basically tie myself to the bed when I am off the clock. I have also stopped going out. My boss and my family are understanding, but there isn’t much they can do. I am hurting. The invasion of pain is unpredictable. My doctor has prescribed me some pain relievers. But I still feel this pulsation in my head. I am slowly breaking down physically and mentally. I have reached a point where the current medication is not enough. I need higher dose.”
Headache × Human Agency × Verb Form: “I started having headaches a while ago. At the beginning, it irritated me but not too badly. However, lately I have taken a turn for the worse. I throb whenever I move my head around rapidly. I wake up in pain every morning. My job requires concentration for long hours, but I hurt so badly because of that. I basically tie myself to the bed when I am off the clock. I have also stopped going out. My boss and my family are understanding, but there isn’t much they can do. I am hurting. It is unpredictable when pain will invade. My doctor has prescribed me some pain relievers. But I still pulsate. I am slowly breaking down physically and mentally. I have reached a point where the current medication is not enough. I need higher dose.”
Headache × Pain/Body Agency × Noun Form: “My headaches started a while ago. At the beginning, the irritation wasn’t too bad. However, lately my condition has taken a turn for the worse. A throbbing hits me whenever I move my head around rapidly. It wakes me up every morning. My job requires concentration for long hours, but my head hurts so badly because of that. The pain basically ties me to the bed when I am off work. It has also stopped me from going out. My boss and my family are understanding, but there isn’t much they can do. My head is hurting me. The invasion of pain is unpredictable. My doctor has prescribed me some pain relievers. But my head still feels this pulsation. It is slowly breaking me down physically and mentally. My pain has reached a point where the current medication is not enough. It needs higher dose.”
89 Headache × Pain/Body Agency × Verb Form: “My headaches started a while ago. At the beginning, it irritated me but not too badly. However, lately the condition has taken a turn for the worse. My head throbs whenever I move it around rapidly. It wakes me up every morning. My job requires concentration for long hours, but my head hurts so badly because of that. The pain basically ties me to the bed when I am off work. It has also stopped me from going out. My boss and my family are understanding, but there isn’t much they can do. My head is hurting me. It is unpredictable when pain will invade. My doctor has prescribed me some pain relievers. But my head still pulsates. It is slowly breaking me down physically and mentally. My pain has reached a point where the current medication is not enough. It needs higher dose.”
Scenario 2 Back Pain × Human Agency × Noun Form: “I started having back pain a while ago. At the beginning, the irritation wasn’t too bad. But lately I have taken a turn for the worse. I feel a throbbing whenever I move rapidly. I wake up in pain every morning. My job requires some long periods of sitting, but I ache so badly because of that. I basically tie myself to the bed when I am off the clock. I have also stopped going out. My boss and my family are understanding, but there isn’t much they can do. I am hurting. The invasion of pain is unpredictable. My doctor has prescribed me some Tylenol. But I still feel this tension in my back. I am slowly breaking down physically and mentally. I have reached a point where the current medication is not enough. I need higher dose.”
Back Pain × Human Agency × Verb Form: “I started having back pain a while ago. At the beginning, it irritated me but not too badly. But lately I have taken a turn for the worse. I throb whenever I move rapidly. I wake up in pain every morning. My job requires some long periods of sitting, but I ache so badly because of that. I basically tie myself to the bed when I am off the clock. I have also stopped going out. My boss and my family are understanding, but there isn’t much they can do. I am hurting. It is unpredictable when pain will invade. My doctor has prescribed me some Tylenol. But I still tense up. I am slowly breaking down physically and mentally. I have reached a point where the current medication is not enough. I need higher dose.”
Back Pain × Pain/Body Agency × Noun Form: “My back pain started a while ago. At the beginning, the irritation wasn’t too bad. But lately my condition has taken a turn for the worse. A throbbing hits me whenever I move rapidly. It wakes me up every morning. My job requires some long periods of sitting, but my back aches so badly because of that. The pain basically ties me to the bed when I am off work. It has also stopped me from going out. My boss and my family are understanding, but there isn’t much they can do. My back is hurting me. The invasion of pain is unpredictable. My doctor has prescribed me some Tylenol. But my back still feels this
90 tension. It is slowly breaking me down physically and mentally. My pain has reached a point where the current medication is not enough. It needs higher dose.”
Back Pain × Pain/Body Agency × Verb Form: “My back pain started a while ago. At the beginning, it irritated me but not too badly. But lately the condition has taken a turn for the worse. My back throbs whenever I move rapidly. It wakes me up every morning. My job requires some long periods of sitting, but my back aches so badly because of that. Pain basically ties me to the bed when I am off work. It has also stopped me from going out. My boss and my family are understanding, but there isn’t much they can do. My back is hurting me. It is unpredictable when pain will invade. My doctor has prescribed me some Tylenol. But my back still tenses up. It is slowly breaking me down physically and mentally. My pain has reached a point where the current medication is not enough. It needs higher dose.”
Scenario 3
Joint Pain × Human Agency × Noun Form: “I started having joint pain a while ago. At the beginning, the irritation wasn’t too bad. However, lately I have taken a turn for the worse. I feel a throbbing whenever I move rapidly. I wake up in pain every morning. My job requires some long periods of standing, but I ache so badly because of that. I basically tie myself to the bed when I am off the clock. I have also stopped going out. My boss and my family are understanding, but there isn’t much they can do I am hurting. The invasion of pain is unpredictable. My doctor has prescribed me some pain relievers. But I still feel this pulsation in my legs. I am slowly breaking down physically and mentally. I have reached a point where the current medication is not enough. I need higher dose.”
Joint Pain × Human Agency × Verb Form: “I started having joint pain a while ago. At the beginning, it irritated me but not too badly. However, lately I have taken a turn for the worse. I throb whenever I move rapidly. I wake up in pain every morning. My job requires some long periods of standing, but I ache so badly because of that. I basically tie myself to the bed when I am off the clock. I have also stopped going out. My boss and my family are understanding, but there isn’t much they can do. I am hurting. It is unpredictable when pain will invade. My doctor has prescribed me some pain relievers. But I still pulsate. I am slowly breaking down physically and mentally. I have reached a point where the current medication is not enough. I need higher dose.”
Joint Pain × Pain/Body Agency × Noun Form: “My joint pain started a while ago. At the beginning, the irritation wasn’t too bad. However, lately my condition has taken a turn for the worse. A throbbing hits me whenever I move 91 rapidly. It wakes me up every morning. My job requires some long periods of standing, but my legs ache so badly because of that. The pain basically ties me to the bed when I am off work. It has also stopped me from going out. My boss and my family are understanding, but there isn’t much they can do. My legs are hurting me. The invasion of pain is unpredictable. My doctor has prescribed me some pain relievers. But my legs still feel this pulsating. It is slowly breaking me down physically and mentally. My pain has reached a point where the current medication is not enough. It needs higher dose.”
Joint Pain × Pain/Body Agency × Verb Form: “My joint pain started a while ago. At the beginning, it irritated me but not too badly. However, lately the condition has taken a turn for the worse. My legs throb whenever I move rapidly. It wakes me up every morning. My job requires some long periods of standing, but my legs ache so badly because of that. The pain basically ties me to the bed when I am off work. It has also stopped me from going out. My boss and my family are understanding, but there isn’t much they can do. My legs are hurting me. It is unpredictable when pain will invade. My doctor has prescribed me some pain relievers. But my legs still pulsate. It is slowly breaking me down physically and mentally. My pain has reached a point where the current medication is not enough. It needs higher dose.”
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