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Work 30 (2008) 149–155
IOS Press

Internal locus of control and vocational
rehabilitation
John Selander a,∗, Sven-Uno Marnetofta , Malin Åsellb and Ulrika Selanderc
a

¨
Centre for Studies on National Social Insurance, Mid-Sweden University, Ostersund,
Sweden
Department of Odontology, Clinical Oral Physiology, Umeå, Sweden
c
¨
Commodia, Ostersund,
Sweden
b

Received 5 May 2006
Accepted 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 vocational
rehabilitation. The aim of the current study was to gain a deeper understanding of the concept of ILC in a Swedish vocational
rehabilitation context. The study was based on data from 347 long-term sick-listed clients collected at the onset of vocational
rehabilitation. 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 locus
of control. After a second multivariate analysis, only bodily pain remained associated. It is concluded that there exist a strong
and negative association between bodily pain and internal locus of control. Clients with severe pain often also suffer from low
internal locus of control. This should be kept in mind when providing vocational rehabilitation.

1. Background
During latter years in Sweden, a dramatic increase of
people not working due to sick-listing has been noted.
In 2004, roughly 17% of a working age population
(16–65 years) was absent long term from work due to
ill health [22]. Similar developments are experienced
in other western countries [7]. In order to reintroduce
people who are sick or injured to a job, increasing
emphasis has been focused on vocational rehabilitation.
In a previous study [25], based on the same material
as the current study, internal locus of control (ILC) was
pointed out as a key factor for return to work after vocational rehabilitation. The study showed that chances
for people with high ILC were roughly 70% better of receiving a positive rehabilitation outcome than for those
with low ILC. The results also showed that the vari∗ Address

for correspondence: John Selander, Centre for Studies
on National Social Insurance, Mid-Sweden University, S-831 25
¨
Ostersund,
Sweden. Tel.: +46 63 16 57 56; Fax: +46 63 16 56 26;
E-mail: [email protected]

ables: Age, general health and vitality, were associated
with rehabilitation outcome, but not to the same extent
as ILC. Other research studies also indicate ILC as a
relevant variable to consider in a vocational rehabilitation context (e.g. [5,19]) Against this background, it is
of interest to gain a deeper understanding of ILC in a
vocational rehabilitation context. Questions of interest
in this study are: Which relevant rehabilitation variables are associated with ILC? What are the nature of
these associations? What affects ILC? and What can
be done to strengthen ILC in a vocational rehabilitation
context?
1.1. Locus of control
Psychologists have long been interested in different psychological determinants of human behaviour.
One concept, which has attracted significant interest,
is locus of control (LOC). LOC has its origins in Rotter’s [24] Social Learning Theory, which states that an
individual’s expectancy of an outcome will predict behaviour in a given circumstance. Individuals with an
internal LOC expect their own behaviour to effect the

1051-9815/08/$17.00  2008 – IOS Press and the authors. All rights reserved

150

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

outcome, while individuals with external LOC expect
that the outcome will be determined instead by external
factors, such as other people or forces beyond themselves.
Questioning the conceptualisation of LOC as a unidimensional construct, Levenson [12] argued that not
only are internal beliefs orthogonal to external beliefs,
but understanding could be further improved by studying external control by powerful others separately from
external control by fate, chance or luck. Consequently,
Levenson expanded the concept of LOC into a multidimensional concept, by proposing three independent
dimensions; a) internal influences, b) influence of powerful 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 the
years to the development of a great number of different domain-specific LOC measures, e.g. health locus
of control and work locus of control, and the amount
of research focusing on LOC has been enormous.
Locus of control is only one of a number of psychological constructs related to perceived control. Seligman’s “learned helplessness” [26], Langer’s “perception of control” [10] and Bandura’s “self-efficacy” [1]
are other examples. These constructs are in many ways
related. Lefcourt [11] however, posits that a main difference between these constructs is that some are based
on motivational terminology while others, such as locus
of control, are based on expectancy terminology. Another aspect that separates locus of control from other
control theories is that its use is mainly as an attribute of
personality, which, it is assumed, encompasses strong
elements of stability and generalisation. However, all
of these concepts have in common interest in seeking
to explain the degree to which people believe they can
bring about positive events and avoid negative ones.
Over the years, LOC as a construct has occasionally
been criticized. In a study from 1992 health locus of
control (HLC) was exhaustively questioned by one of
the authorities in this field, i.e., K. Wallston [32]. In this
particular paper he argued that his own original modification of Rotter’s social learning theory highlighting
the construct of HLC was no longer adequate. In later studies [27], however, it is argued and shown that
HLC is relevant and that associations between HLC
and health behaviour exist and are of considerable significance.

itation context. Tseng [29] found that under the vocational rehabilitation process, differences occur between clients of internal and clients of external orientation in the areas of self-reliance, reliability, work
tolerance, knowledge and need for achievement, all of
which are important for the outcome of vocational rehabilitation programs. Partridge and Johnston [20] found
that clients with a higher level of internal control had
shorter recovery periods than others. Norman and Norman [19], studying the relationship between progress
in rehabilitation and LOC, found that clients designated as of internal orientation made faster progress then
those designated as of external orientation. Duvdevany and Rimmerman [5] found that clients with disabilities who had an internal locus of control had more
favourable attitudes to work and participation in vocational rehabilitation than counterparts with an external
locus of control. Krause et al. [9] found that locus of
control was correlated with a number of aspects of life
adjustment after spinal cord injury, with internality being positively correlated with subjective well-being and
general recovery. Millet [16] reported that clients with
an external locus of control had a less favourable point
of departure at the start of vocational rehabilitation and
also that internal locus of control had an impact on vocational rehabilitation outcome. Rotter [23] argues that
locus of control is influential in the important area of
problem solving techniques, and thus is related to planning, coping, persistence, practice, and analysis, making the concept a central part of human functioning in
everyday situations that are new or ambiguous, similar
to what many unemployed persons with disabilities experience daily. The conclusion here is that locus of control is a doubly interesting factor for vocational rehabilitation, influencing the client’s motivation, resource
mobilisation, learning, and work adjustment.

1.2. Locus of control and vocational rehabilitation

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

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

2. Aim of study
The aim of the current study was to gain a deeper
understanding of the concept of internal locus of control
in a Swedish vocational rehabilitation context.

3. Subjects and methods

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

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 or
combinations of these regions. The study is based on
all clients who participated in and completed a 4 week
rehabilitation programme between June 2003 and June
2004 at the “Rygginstitutet” (in English roughly “Institute for Back Problems”) in Sweden. The “Rygginstitutet” is a privately owned rehabilitation provider,
which is located in four cities in Sweden. 150 clients
participated in the programme at the “Rygginstitutet”
in the city of Sundsvall and 197 in the city of V a¨ xj¨o.
The rehabilitation programmes in Sundsvall and V a¨ xj¨o
are identical. Clients at the Rygginstitut are most often
sent there (and paid for) by the social insurance office
or by the client’s employer and always referred by a
physician. Rehabilitation costs are often shared, e.g.
between the social insurance office and the employer.
In Sweden, the employer is responsible for analysing
the employees’ need of rehabilitation, and when necessary, initiating rehabilitation activities. The social
insurance office is responsible for coordinating and supervising the rehabilitation process.
At an introductory meeting with the occupational
therapist, the clients were informed about the study and
asked if they were willing to participate. Participation
was voluntarily; and all the subjects approached, agreed
to participate. The only clients excluded from the study
are those who did not complete the entire programme
(n = 3). Reasons for not finishing the program is
unknown. The programme is briefly described under
a separate heading (see The Vocational Rehabilitation
Programme).
The study’s results are based on base line data (e.g,.
age, employment, perceived pain, previous sickness
absence, quality of life etc.) routinely collected at the
Rygginstitut, and on data received from a questionnaire on locus of control specific for this study, i.e., a
modified version of Wallston’s Health Locus of Control scale. The questionnaire contained questions on
all three concepts of LOC, i.e. ILC, ELC (powerful
others) and ELC (chance/luck/fate), but since only ILC
showed significance to rehabilitation outcome (in original study), only ILC is considered in the current study.
To investigate ILC, the clients were asked to respond
to three statements (see Appendix, statement 3, 6 and
9). To each statement the client could agree totally or
partly, neither agree nor disagree, or disagree partly or
totally.
Quality of life, which routinely is measured at the
Rygginstitut, was measured by using Short Formula 36

151

(SF-36), which is a tool designed to survey health status
and quality of life. The SF-36 includes one multi-item
scale that assesses eight health concepts: 1) limitations
in physical activities due to health problems; 2) limitations in social activities due to physical or emotional
problems; 3) limitations in usual role activities due to
physical health problems; 4) physical pain; 5) general
mental health (psychological distress and well-being);
6) limitations in usual role activities due to emotional
problems; 7) vitality (energy and fatigue); and 8) general health perceptions. Each of the eight concepts includes a number of questions to which the respondent
can agree totally or partly, neither agree nor disagree,
disagree partly or totally. Both questionnaires, i.e. the
modified version of Wallston’s Health Locus of Control scale and the SF-36 questionnaire, are questionnaires internationally well used and accepted [8,18].
Both questionnaires were handed out at the introductory meeting with the occupational therapist.
3.1. The vocational rehabilitation programme
In short, the 4 week rehabilitation programme in
the current study consisted of individual and group activities, carried out eight hours a day, with the aim
of preparing the client for the demands in their daily
life and work-situation. In the programme the clients
were instructed in the anatomy and function of the
spine, ergonomics, biomechanics, eating habits, stress
behaviour, mental training, and why and how they
should exercise. The programme also contained practical parts, with a mixture of exercises and training,
focusing on improving the participants’ physical function and activity level. One of the major goals with
the vocational rehabilitation programme is to provide
the clients with a “toolbox” so that they can help themselves and take responsibility for their own well-being
and health.
3.2. Statistics
The bi-variate analyses were made with Pearson correlation test and paired and unpaired two-sided t-tests.
The multivariate analysis was performed by backward
stepwise logistic regression. Variables were initially
included in the regression model if the bi-variate significance was < 0.05 or if the variables was deemed
to be of major potential clinical significance (e.g. age,
gender). P-values lower than 0.05 were considered
significant.

152

J. Selander et al. / Internal locus of control and vocational rehabilitation
Table 1
Type of back pain and experienced pain intensity (VAS) among the 347 clients included
in the study

Cervical region
Thoracic region
Lumbar region

Total sample (n = 347)
%
VAS
52
48
41
45
77
53

Men (n
%
47
40
94

= 187)
VAS
46
45
52

Women (n = 160)
%
VAS
59
49
42
44
78
54

3.3. Ethics

4.3. Multivariate analysis

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

In a second step, the variables were analysed in a
multivariate model. The result from the backward logistic regression analysis showed that only bodily pain
remained significantly and negatively associated to ILC
(p = 0.000). The other included variables, i.e., sex,
age, physical functioning and general health, were all
deleted by the model.

4. Results
4.1. Sample data
The sample (n = 347) consisted of 54% (n = 187)
men and 46% (n = 160) women. The mean age was
42 years for men and 41 for women. At rehabilitation
start, 88% of the clients (n = 307) were employed
and had a job to return to after rehabilitation and 12%
(n = 40) were unemployed. All 347 clients undergoing
rehabilitation suffered from long term back pain (see
Table 1).
At the start of rehabilitation, 68% (n = 128) of the
men and 53% (n = 85) of the women received full
sickness allowance. The remaining men and women
received part time allowances. Average total time on
sickness allowance (i.e. days on partial benefits converted to days on full benefit), during a two-year period before the start of rehabilitation, was 13 months for
both men and women.
4.2. Bi-variate analysis
In a first bi-variate analysis, the following variables
showed significant associations to ILC: sex (p = 0.003)
(women reported higher ILC), physical functioning
[from SF-36] (p = 0.011) (positive association), bodily
pain [from SF-36] (p = 0.001) (negative association)
and general health [from SF-36] (p = 0.000) (positive
association).
In the same bi-variate analysis, the following variables showed no significant associations to ILC: age,
working status [employed vs. not employed], previous sickness absence, general fitness, body mass index,
analgesics (yes vs. no), physical role function [from SF36], vitality [from SF-36], social functioning [from SF36], emotional role function [from SF-36], and mental
health [from SF-36].

4.4. Other findings
The results also showed that ILC was higher after
termination of rehabilitation than at start of rehabilitation (p = 0.000). The increase was similar for both
men and women and similar regardless of age. The
results also showed a negative association between ILC
and ELC (p = 0.000 [r = −0.21]).

5. Discussion
The results show a negative association between ILC
and perceived bodily pain. Clients with low ILC experienced pain more often than others. This finding,
although perhaps not so surprising, is still interesting.
Both pain and low ILC are unfavourable factors in relation to vocational rehabilitation and the return to work
process, and when experienced together could very well
constitute a significant problem.
The association between different psychological factors and perceived pain has been extensively examined
in literature, and locus of control has been found to be
one of the key factors involved. In general, a more
internal LOC is associated with higher pain tolerance
and less negative pain response [4,34]. Clients with internal LOC have also been shown to use lower and less
frequent doses of analgesic in the control of pain [21].
The nature of the association is complex [13], but
studies indicate a cause and effect relation, where ILC
has 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

their own actions can affect the future course of the
pain and that these people develop effective strategies
to deal with the pain and therefore report lower pain
intensity. H¨ark¨ap¨aa¨ et al. [6] found strong beliefs in
the ILC of back pain to be associated with a decrease
in disability and of a higher frequency of exercising.
Moreover, Turner and Clancy [30] and H a¨ rk¨ap¨aa¨ et
al. [6] showed that people with external LOC rely more
on ineffective coping strategies. They do not believe in
recovery, they avoid increasing their activity level and
report poor ability to decrease and control their pain.
Psychological variables, such as perceived control over
pain, have also been associated with changes within
the endogenous opioid system. Specifically, Bandura
et al. [2] reported that perceived control over pain is
associated with increased endogenous opiates, which
may then serve to reduce pain perception.
On the contrary, however, the direction of the relation
between pain and ILC may well be vice versa. It is
not surprising if a client with severe bodily pain comes
to a point where he/she experiences his/her situation as
having become too difficult or impossible to influence
personally, and consequently entrusts his/her problem
to others, e.g. a doctor or physiotherapist.
In a vocational rehabilitation context, the finding regarding the association between bodily pain and ILC
is perhaps most relevant in the interaction between the
rehabilitation provider and the client. Since locus of
control is considered as not being static, but rather
as changeable, the rehabilitation provider should use
strategies which encourage the client in such a way that
increases ILC. Instead of “helping” the client by taking over his/her problem and promising to “fix” him or
her, the provider should help the client instead to help
him/herself. This strategy can be used by all rehabilitation professionals (physicians, physiotherapists, rehabilitation counsellors) being aware of and adapting
attitudes. In a rather old, but still relevant study by
MacDonald et al. [15] different counselling techniques
that favour ILC are discussed. Three different techniques are presented: 1) Counselling for Changes in
Response Style, 2) Action Programmes, and 3) Behavioural Reinterpretation. These three techniques are
briefly described here.
5.1. Counselling for changes in response style
The aim of counselling for changes in reponse style
is to make the client aware of the fact that he/she has
the power to effect change. This is done by: a) confronting “external statements” (e.g., they want me to

153

be . . . ) with “internal questions” (e.g., what do you
want to be . . . ). Here the counsellor is trying to get
the client to examine his/her reasons for choosing from
among certain options. b) Rewarding “internal statement” (e.g., I will try to . . . ). With positive reinforcement from the counsellor, the client moves towards
self-sufficiency. c) Getting the client to recognize and
focus on the results of his behaviour (e.g., if the client
does a particular thing, then certain results will occur.).
With changed response styles, clients can move toward
a more internal orientation.
5.2. Action programmes
In the action programmes, the client is asked to list
some “significant others” with whom he/she has difficulty. The counsellor then helps the client to define
interpersonal problems in behavioural terms. Next, the
counsellor helps the client to establish new “action programmes” incorporating specific behaviours aimed at
improving relationships with the significant others. In
this method, it is obviously assumed that behaviourally
orientated action programmes are more effective than
re-education programmes, which only use verbal discussions for including attitudinal changes.
5.3. Behavioural reinterpretation
In behavioural reinterpretation, the counsellor attempts to get the client to alter his perceptions or attitudes about a particular behaviour, without changing
the behaviour per se. For example, a client may be
forced to work with something he/she does not particularly like, or for a supervisor perceived by the client
as one who makes “oppressive” demands. If the counsellor can assist the client to change his attitude about
the job, or to perform on the job in such a way that perceived oppression is reduced, e.g. cleaning up before
being asked, then work is performed intentionally by
the client, rather than as a result of being ordered. This
is also an example of client control.
The three previously described strategies are mainly different techniques for rehabilitation counselling.
Comprehensive cognitive-behavioural therapy oriented rehabilitation programmes is another possible strategy to apply when working towards stronger internal
orientation among clients [14,28].
Some additional findings from the study are interesting. Age, for example, is previously shown as being negatively associated to ILC [9,25]. In the current
study, age showed no association to ILC. Regarding

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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 showed
that women were more internally orientated than men.
The detected differences between the results achieved
here and results from other studies may have several
methodological explanations. It is probable that the
current sample (individuals selected to participate in
a vocational rehabilitation programme in Sweden) differs in many ways from a general population or other
investigated samples.
The finding that ILC was higher after termination
of rehabilitation than at start of rehabilitation (p =
0.000) is encouraging and indicates that the rehabilitation provider involved in this study is successful regarding one of the major goals; to provide the participants
with a “toolbox” so that they can help themselves and
take responsibility for their own well-being and health.
Also a strong negative association between ILC and external locus of control (ELC) (p = 0.000 [r = −0.21])
was found. This is not surprising, but still worth some
notice.
One of the current study’s strengths is that it is based
on a large and substantial material. 347 subjects with
similar problems and who have all been selected to participate in the same rehabilitation programme. Data
was collected, by only a few involved persons (6 occupational therapists), at the start of rehabilitation. The
questionnaires used (SF-36 and Wallston’s Health Locus of Control [modified version]) are standardised and
have previously been tested for validity and reliability [31,33].
One of the study’s potential weaknesses is that the
variables investigated are relatively few and limited. If
other relevant variables had been available, e.g. client’s
education and self-confidence, the results would perhaps be more comprehensive. One may be of the opinion that the data should be further analysed, e.g. an investigation of potential variable interaction should be
carried 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 better
knowledge of the concept of internal locus of control
in a Swedish vocational rehabilitation context. Among
other things, this study showed a significant association
between internal locus of control and perceived bodily pain. Clients with low ILC more often than others suffered from pain. In a rehabilitation context this

finding is relevant. In contact with a rehabilitee suffering from bodily pain, the rehabilitation provider should
bare in mind that the client probably experience his/her
internal locus of control as low. Instead of “helping”
the client by taking over his/her problem, the provider
should instead help the client to help himself.

Appendix 1
Modified version of Wallston’s Health Locus of Control scale
1. It mostly depends on my co-workers whether or
not I will get back to work full time.
2. If it is meant to be, I will get back to work full
time.
3. It is mainly what I do myself that affects whether
I get back to work or not.
4. Rehabilitation professionals control my rehabilitation and full return to work.
5. Luck plays a big part in how soon I will be able
to return to work.
6. My own behaviour determines when or if I will
get back to work.
7. No matter what I do I’m not likely to get back to
work full-time.
8. Whenever I return to work it will be because other
people have been taking good care of me.
9. I’m in control of my rehabilitation and return to
work.
Internal LOC = nr 3, 6 and 9
External LOC (powerful others) = 1, 4 and 8
External LOC (chance/fate/luck) = 2, 5 and 7
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