Work 30 (2008) 149155 149IOS Press

Internal locus of control and vocationalrehabilitationJohn Selandera,, Sven-Uno Marnetofta, Malin sellb and Ulrika SelandercaCentre for Studies on National Social Insurance, Mid-Sweden University, Ostersund, SwedenbDepartment of Odontology, Clinical Oral Physiology, Ume, SwedencCommodia, Ostersund, Sweden

Received 5 May 2006Accepted 14 August 2006

Abstract. In previous studies, internal locus of control (ILC) has been pointed out as a key factor for return to work after vocationalrehabilitation. The aim of the current study was to gain a deeper understanding of the concept of ILC in a Swedish vocationalrehabilitation context. The study was based on data from 347 long-term sick-listed clients collected at the onset of vocationalrehabilitation. A first bi-variate analysis showed that ILC was positively associated with physical functioning and general health,and negatively associated with bodily pain. The analysis also showed that women, more than men, reported high internal locusof control. After a second multivariate analysis, only bodily pain remained associated. It is concluded that there exist a strongand negative association between bodily pain and internal locus of control. Clients with severe pain often also suffer from lowinternal locus of control. This should be kept in mind when providing vocational rehabilitation.

1. Background

During latter years in Sweden, a dramatic increase ofpeople not working due to sick-listing has been noted.In 2004, roughly 17% of a working age population(1665 years) was absent long term from work due toill health [22]. Similar developments are experiencedin other western countries [7]. In order to reintroducepeople who are sick or injured to a job, increasingemphasis has been focused on vocational rehabilitation.

In a previous study [25], based on the same materialas the current study, internal locus of control (ILC) waspointed out as a key factor for return to work after vo-cational rehabilitation. The study showed that chancesfor people with high ILC were roughly 70% better of re-ceiving a positive rehabilitation outcome than for thosewith low ILC. The results also showed that the vari-

Address for correspondence: John Selander, Centre for Studieson National Social Insurance, Mid-Sweden University, S-831 25Ostersund, Sweden. Tel.: +46 63 16 57 56; Fax: +46 63 16 56 26;E-mail: john.selander@miun.se.

ables: Age, general health and vitality, were associatedwith rehabilitation outcome, but not to the same extentas ILC. Other research studies also indicate ILC as arelevant variable to consider in a vocational rehabilita-tion context (e.g. [5,19]) Against this background, it isof interest to gain a deeper understanding of ILC in avocational rehabilitation context. Questions of interestin this study are: Which relevant rehabilitation vari-ables are associated with ILC? What are the nature ofthese associations? What affects ILC? and What canbe done to strengthen ILC in a vocational rehabilitationcontext?

1.1. Locus of control

Psychologists have long been interested in differ-ent psychological determinants of human behaviour.One concept, which has attracted significant interest,is locus of control (LOC). LOC has its origins in Rot-ters [24] Social Learning Theory, which states that anindividuals expectancy of an outcome will predict be-haviour in a given circumstance. Individuals with aninternal LOC expect their own behaviour to effect the

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150 J. Selander et al. / Internal locus of control and vocational rehabilitation

outcome, while individuals with external LOC expectthat the outcome will be determined instead by externalfactors, such as other people or forces beyond them-selves.

Questioning the conceptualisation of LOC as a uni-dimensional construct, Levenson [12] argued that notonly are internal beliefs orthogonal to external beliefs,but understanding could be further improved by study-ing external control by powerful others separately fromexternal control by fate, chance or luck. Consequently,Levenson expanded the concept of LOC into a multi-dimensional concept, by proposing three independentdimensions; a) internal influences, b) influence of pow-erful others, and c) effects of occurrences of chance,fate or luck, where each dimension can vary in strength,i.e. be high or low. Subsequently, this has led over theyears to the development of a great number of differ-ent domain-specific LOC measures, e.g. health locusof control and work locus of control, and the amountof research focusing on LOC has been enormous.

Locus of control is only one of a number of psycho-logical constructs related to perceived control. Selig-mans learned helplessness [26], Langers percep-tion of control [10] and Banduras self-efficacy [1]are other examples. These constructs are in many waysrelated. Lefcourt [11] however, posits that a main dif-ference between these constructs is that some are basedon motivational terminology while others, such as locusof control, are based on expectancy terminology. An-other aspect that separates locus of control from othercontrol theories is that its use is mainly as an attribute ofpersonality, which, it is assumed, encompasses strongelements of stability and generalisation. However, allof these concepts have in common interest in seekingto explain the degree to which people believe they canbring about positive events and avoid negative ones.

Over the years, LOC as a construct has occasionallybeen criticized. In a study from 1992 health locus ofcontrol (HLC) was exhaustively questioned by one ofthe authorities in this field, i.e., K. Wallston [32]. In thisparticular paper he argued that his own original modi-fication of Rotters social learning theory highlightingthe construct of HLC was no longer adequate. In lat-er studies [27], however, it is argued and shown thatHLC is relevant and that associations between HLCand health behaviour exist and are of considerable sig-nificance.

1.2. Locus of control and vocational rehabilitation

A number of international studies show that LOC,and especially ILC, is relevant in a vocational rehabil-

itation context. Tseng [29] found that under the vo-cational rehabilitation process, differences occur be-tween clients of internal and clients of external ori-entation in the areas of self-reliance, reliability, worktolerance, knowledge and need for achievement, all ofwhich are important for the outcome of vocational reha-bilitation programs. Partridge and Johnston [20] foundthat clients with a higher level of internal control hadshorter recovery periods than others. Norman and Nor-man [19], studying the relationship between progressin rehabilitation and LOC, found that clients designat-ed as of internal orientation made faster progress thenthose designated as of external orientation. Duvde-vany and Rimmerman [5] found that clients with dis-abilities who had an internal locus of control had morefavourable attitudes to work and participation in voca-tional rehabilitation than counterparts with an externallocus of control. Krause et al. [9] found that locus ofcontrol was correlated with a number of aspects of lifeadjustment after spinal cord injury, with internality be-ing positively correlated with subjective well-being andgeneral recovery. Millet [16] reported that clients withan external locus of control had a less favourable pointof departure at the start of vocational rehabilitation andalso that internal locus of control had an impact on vo-cational rehabilitation outcome. Rotter [23] argues thatlocus of control is influential in the important area ofproblem solving techniques, and thus is related to plan-ning, coping, persistence, practice, and analysis, mak-ing the concept a central part of human functioning ineveryday situations that are new or ambiguous, similarto what many unemployed persons with disabilities ex-perience daily. The conclusion here is that locus of con-trol is a doubly interesting factor for vocational reha-bilitation, influencing the clients motivation, resourcemobilisation, learning, and work adjustment.

2. Aim of study

The aim of the current study was to gain a deeperunderstanding of the concept of internal locus of controlin a Swedish vocational rehabilitation context.

3. Subjects and methods

The study was based on data from 347 clients at theonset of their vocational rehabilitation. At the start ofrehabilitation, all clients were on long term sick leave(> 60 days) due to back pain problems. Back pain

J. Selander et al. / Internal locus of control and vocational rehabilitation 151

problems are defined as major long-term (> 3 months)complaints of pain and discomfort from the back region,i.e., cervical region, thoracic region, lumbar region orcombinations of these regions. The study is based onall clients who participated in and completed a 4 weekrehabilitation programme between June 2003 and June2004 at the Rygginstitutet (in English roughly In-stitute for Back Problems) in Sweden. The Ryggin-stitutet is a privately owned rehabilitation provider,which is located in four cities in Sweden. 150 clientsparticipated in the programme at the Rygginstitutetin the city of Sundsvall and 197 in the city of Vaxjo.The rehabilitation programmes in Sundsvall and Vaxjoare identical. Clients at the Rygginstitut are most oftensent there (and paid for) by the social insurance officeor by the clients employer and always referred by aphysician. Rehabilitation costs are often shared, e.g.between the social insurance office and the employer.In Sweden, the employer is responsible for analysingthe employees need of rehabilitation, and when nec-essary, initiating rehabilitation activities. The socialinsurance office is responsible for coordinating and su-pervising the rehabilitation process.

At an introductory meeting with the occupationaltherapist, the clients were informed about the study andasked if they were willing to participate. Participationwas voluntarily; and all the subjects approached,agreedto participate. The only clients excluded from the studyare those who did not complete the entire programme(n = 3). Reasons for not finishing the program isunknown. The programme is briefly described undera separate heading (see The Vocational RehabilitationProgramme).

The studys results are based on base line data (e.g,.age, employment, perceived pain, previous sicknessabsence, quality of life etc.) routinely collected at theRygginstitut, and on data received from a question-naire on locus of control specific for this study, i.e., amodified version of Wallstons Health Locus of Con-trol scale. The questionnaire contained questions onall three concepts of LOC, i.e. ILC, ELC (powerfulothers) and ELC (chance/luck/fate), but since only ILCshowed significance to rehabilitation outcome (in orig-inal study), only ILC is considered in the current study.To investigate ILC, the clients were asked to respondto three statements (see Appendix, statement 3, 6 and9). To each statement the client could agree totally orpartly, neither agree nor disagree, or disagree partly ortotally.

Quality of life, which routinely is measured at theRygginstitut, was measured by using Short Formula 36

(SF-36), which is a tool designed to survey health statusand quality of life. The SF-36 includes one multi-itemscale that assesses eight health concepts: 1) limitationsin physical activities due to health problems; 2) limi-tations in social activities due to physical or emotionalproblems; 3) limitations in usual role activities due tophysical health problems; 4) physical pain; 5) generalmental health (psychological distress and well-being);6) limitations in usual role activities due to emotionalproblems; 7) vitality (energy and fatigue); and 8) gen-eral health perceptions. Each of the eight concepts in-cludes a number of questions to which the respondentcan agree totally or partly, neither agree nor disagree,disagree partly or totally. Both questionnaires, i.e. themodified version of Wallstons Health Locus of Con-trol scale and the SF-36 questionnaire, are question-naires internationally well used and accepted [8,18].Both questionnaires were handed out at the introducto-ry meeting with the occupational therapist.

3.1. The vocational rehabilitation programme

In short, the 4 week rehabilitation programme inthe current study consisted of individual and group ac-tivities, carried out eight hours a day, with the aimof preparing the client for the demands in their dailylife and work-situation. In the programme the clientswere instructed in the anatomy and function of thespine, ergonomics, biomechanics, eating habits, stressbehaviour, mental training, and why and how theyshould exercise. The programme also contained prac-tical parts, with a mixture of exercises and training,focusing on improving the participants physical func-tion and activity level. One of the major goals withthe vocational rehabilitation programme is to providethe clients with a toolbox so that they can help them-selves and take responsibility for their own well-beingand health.

3.2. Statistics

The bi-variate analyses were made with Pearson cor-relation test and paired and unpaired two-sided t-tests.The multivariate analysis was performed by backwardstepwise logistic regression. Variables were initiallyincluded in the regression model if the bi-variate sig-nificance was < 0.05 or if the variables was deemedto be of major potential clinical significance (e.g. age,gender). P-values lower than 0.05 were consideredsignificant.

152 J. Selander et al. / Internal locus of control and vocational rehabilitation

Table 1Type of back pain and experienced pain intensity (VAS) among the 347 clients includedin the study

Total sample (n = 347) Men (n = 187) Women (n = 160)% VAS % VAS % VAS

Cervical region 52 48 47 46 59 49Thoracic region 41 45 40 45 42 44Lumbar region 77 53 94 52 78 54

3.3. Ethics

The study was approved by the Ethics Committee ofthe University of Ume, Sweden.

4. Results

4.1. Sample data

The sample (n = 347) consisted of 54% (n = 187)men and 46% (n = 160) women. The mean age was42 years for men and 41 for women. At rehabilitationstart, 88% of the clients (n = 307) were employedand had a job to return to after rehabilitation and 12%(n = 40) were unemployed. All 347 clients undergoingrehabilitation suffered from long term back pain (seeTable 1).

At the start of rehabilitation, 68% (n = 128) of themen and 53% (n = 85) of the women received fullsickness allowance. The remaining men and womenreceived part time allowances. Average total time onsickness allowance (i.e. days on partial benefits con-verted to days on full benefit), during a two-year peri-od before the start of rehabilitation, was 13 months forboth men and women.

4.2. Bi-variate analysis

In a first bi-variate analysis, the following variablesshowed significant associations to ILC: sex (p = 0.003)(women reported higher ILC), physical functioning[from SF-36] (p = 0.011) (positive association), bodilypain [from SF-36] (p = 0.001) (negative association)and general health [from SF-36] (p = 0.000) (positiveassociation).

In the same bi-variate analysis, the following vari-ables showed no significant associations to ILC: age,working status [employed vs. not employed], previ-ous sickness absence, general fitness, body mass index,analgesics (yes vs. no),physical role function [from SF-36], vitality [from SF-36], social functioning [from SF-36], emotional role function [from SF-36], and mentalhealth [from SF-36].

4.3. Multivariate analysis

In a second step, the variables were analysed in amultivariate model. The result from the backward lo-gistic regression analysis showed that only bodily painremained significantly and negatively associated to ILC(p = 0.000). The other included variables, i.e., sex,age, physical functioning and general health, were alldeleted by the model.

4.4. Other findings

The results also showed that ILC was higher aftertermination of rehabilitation than at start of rehabilita-tion (p = 0.000). The increase was similar for bothmen and women and similar regardless of age. Theresults also showed a negative association between ILCand ELC (p = 0.000 [r = 0.21]).

5. Discussion

The results show a negative association between ILCand perceived bodily pain. Clients with low ILC ex-perienced pain more often than others. This finding,although perhaps not so surprising, is still interesting.Both pain and low ILC are unfavourable factors in rela-tion to vocational rehabilitation and the return to workprocess, and when experienced together could very wellconstitute a significant problem.

The association between different psychological fac-tors and perceived pain has been extensively examinedin literature, and locus of control has been found to beone of the key factors involved. In general, a moreinternal LOC is associated with higher pain toleranceand less negative pain response [4,34]. Clients with in-ternal LOC have also been shown to use lower and lessfrequent doses of analgesic in the control of pain [21].

The nature of the association is complex [13], butstudies indicate a cause and effect relation, where ILChas a direct effect on pain [3]. Crisson and Keefe [4]found that people with pain and high ILC believe that

J. Selander et al. / Internal locus of control and vocational rehabilitation 153

their own actions can affect the future course of thepain and that these people develop effective strategiesto deal with the pain and therefore report lower painintensity. Harkapaa et al. [6] found strong beliefs inthe ILC of back pain to be associated with a decreasein disability and of a higher frequency of exercising.Moreover, Turner and Clancy [30] and Harkapaa etal. [6] showed that people with external LOC rely moreon ineffective coping strategies. They do not believe inrecovery, they avoid increasing their activity level andreport poor ability to decrease and control their pain.Psychological variables, such as perceived control overpain, have also been associated with changes withinthe endogenous opioid system. Specifically, Banduraet al. [2] reported that perceived control over pain isassociated with increased endogenous opiates, whichmay then serve to reduce pain perception.

On the contrary, however, the direction of the relationbetween pain and ILC may well be vice versa. It isnot surprising if a client with severe bodily pain comesto a point where he/she experiences his/her situation ashaving become too difficult or impossible to influencepersonally, and consequently entrusts his/her problemto others, e.g. a doctor or physiotherapist.

In a vocational rehabilitation context, the finding re-garding the association between bodily pain and ILCis perhaps most relevant in the interaction between therehabilitation provider and the client. Since locus ofcontrol is considered as not being static, but ratheras changeable, the rehabilitation provider should usestrategies which encourage the client in such a way thatincreases ILC. Instead of helping the client by tak-ing over his/her problem and promising to fix him orher, the provider should help the client instead to helphim/herself. This strategy can be used by all rehabil-itation professionals (physicians, physiotherapists, re-habilitation counsellors) being aware of and adaptingattitudes. In a rather old, but still relevant study byMacDonald et al. [15] different counselling techniquesthat favour ILC are discussed. Three different tech-niques are presented: 1) Counselling for Changes inResponse Style, 2) Action Programmes, and 3) Be-havioural Reinterpretation. These three techniques arebriefly described here.

5.1. Counselling for changes in response style

The aim of counselling for changes in reponse styleis to make the client aware of the fact that he/she hasthe power to effect change. This is done by: a) con-fronting external statements (e.g., they want me to

be . . . ) with internal questions (e.g., what do youwant to be . . . ). Here the counsellor is trying to getthe client to examine his/her reasons for choosing fromamong certain options. b) Rewarding internal state-ment (e.g., I will try to . . . ). With positive reinforce-ment from the counsellor, the client moves towardsself-sufficiency. c) Getting the client to recognize andfocus on the results of his behaviour (e.g., if the clientdoes a particular thing, then certain results will occur.).With changed response styles, clients can move towarda more internal orientation.

5.2. Action programmes

In the action programmes, the client is asked to listsome significant others with whom he/she has dif-ficulty. The counsellor then helps the client to defineinterpersonal problems in behavioural terms. Next, thecounsellor helps the client to establish new action pro-grammes incorporating specific behaviours aimed atimproving relationships with the significant others. Inthis method, it is obviously assumed that behaviourallyorientated action programmes are more effective thanre-education programmes, which only use verbal dis-cussions for including attitudinal changes.

5.3. Behavioural reinterpretation

In behavioural reinterpretation, the counsellor at-tempts to get the client to alter his perceptions or at-titudes about a particular behaviour, without changingthe behaviour per se. For example, a client may beforced to work with something he/she does not partic-ularly like, or for a supervisor perceived by the clientas one who makes oppressive demands. If the coun-sellor can assist the client to change his attitude aboutthe job, or to perform on the job in such a way that per-ceived oppression is reduced, e.g. cleaning up beforebeing asked, then work is performed intentionally bythe client, rather than as a result of being ordered. Thisis also an example of client control.

The three previously described strategies are main-ly different techniques for rehabilitation counselling.Comprehensive cognitive-behavioural therapy orient-ed rehabilitation programmes is another possible strat-egy to apply when working towards stronger internalorientation among clients [14,28].

Some additional findings from the study are inter-esting. Age, for example, is previously shown as be-ing negatively associated to ILC [9,25]. In the currentstudy, age showed no association to ILC. Regarding

154 J. Selander et al. / Internal locus of control and vocational rehabilitation

gender, previous studies show inconsistent results [17].In the current study, the bi-variate analysis showedthat women were more internally orientated than men.The detected differences between the results achievedhere and results from other studies may have severalmethodological explanations. It is probable that thecurrent sample (individuals selected to participate ina vocational rehabilitation programme in Sweden) dif-fers in many ways from a general population or otherinvestigated samples.

The finding that ILC was higher after terminationof rehabilitation than at start of rehabilitation (p =0.000) is encouraging and indicates that the rehabilita-tion provider involved in this study is successful regard-ing one of the major goals; to provide the participantswith a toolbox so that they can help themselves andtake responsibility for their own well-being and health.Also a strong negative association between ILC and ex-ternal locus of control (ELC) (p = 0.000 [r = 0.21])was found. This is not surprising, but still worth somenotice.

One of the current studys strengths is that it is basedon a large and substantial material. 347 subjects withsimilar problems and who have all been selected to par-ticipate in the same rehabilitation programme. Datawas collected, by only a few involved persons (6 occu-pational therapists), at the start of rehabilitation. Thequestionnaires used (SF-36 and Wallstons Health Lo-cus of Control [modified version]) are standardised andhave previously been tested for validity and reliabili-ty [31,33].

One of the studys potential weaknesses is that thevariables investigated are relatively few and limited. Ifother relevant variables had been available, e.g. clientseducation and self-confidence, the results would per-haps be more comprehensive. One may be of the opin-ion that the data should be further analysed, e.g. an in-vestigation of potential variable interaction should becarried out. Due to problems with mass significances,we choose to do no further analyses.

6. Conclusion

The aim of the current study was to achieve betterknowledge of the concept of internal locus of controlin a Swedish vocational rehabilitation context. Amongother things, this study showed a significant associationbetween internal locus of control and perceived bod-ily pain. Clients with low ILC more often than oth-ers suffered from pain. In a rehabilitation context this

finding is relevant. In contact with a rehabilitee suffer-ing from bodily pain, the rehabilitation provider shouldbare in mind that the client probably experience his/herinternal locus of control as low. Instead of helpingthe client by taking over his/her problem, the providershould instead help the client to help himself.

Appendix 1

Modified version of Wallstons Health Locus of Con-trol scale

1. It mostly depends on my co-workers whether ornot I will get back to work full time.

2. If it is meant to be, I will get back to work fulltime.

3. It is mainly what I do myself that affects whetherI get back to work or not.

4. Rehabilitation professionals control my rehabili-tation and full return to work.

5. Luck plays a big part in how soon I will be ableto return to work.

6. My own behaviour determines when or if I willget back to work.

7. No matter what I do Im not likely to get back towork full-time.

8. Whenever I return to work it will be because otherpeople have been taking good care of me.

9. Im in control of my rehabilitation and return towork.

Internal LOC = nr 3, 6 and 9External LOC (powerful others) = 1, 4 and 8External LOC (chance/fate/luck) = 2, 5 and 7

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