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Chronic Pain
Efficacy, Innovations, and Directions for Research
Dawn M. Ehde, Tiara M. Dillworth, and Judith A. Turner
University of Washington
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Over the past three decades, cognitive-behavioral therapy stimuli and consequences. The repertoire of chronic pain
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(CBT) has become a first-line psychosocial treatment for treatments expanded to include behavioral treatments that
individuals with chronic pain. Evidence for efficacy in aimed to decrease patients’ pain behaviors (e.g., limping,
improving pain and pain-related problems across a wide guarding) and increase “well” behaviors (e.g., participation
spectrum of chronic pain syndromes has come from mul- in customary activities). Also in the 1970s, Aaron Beck
tiple randomized controlled trials. CBT has been tailored developed cognitive therapy for depression (Beck, Rush,
to, and found beneficial for, special populations with Shaw, & Emery, 1979). The increased attention to the role
chronic pain, including children and older adults. Innova- of cognitions in mood, anxiety, and other psychological
tions in CBT delivery formats (e.g., Web-based, telephone- disorders sparked interest in incorporating cognitive ther-
delivered) and treatments based on CBT principles that are apy techniques into behavioral therapies for chronic pain
delivered by health professionals other than psychologists (Turk, Meichenbaum, & Genest, 1983; Turner & Romano,
show promise for chronic pain problems. This article re- 2001).
views (a) the evidence base for CBT as applied to chronic Over the three decades since the initial applications of
pain, (b) recent innovations in target populations and CBT to chronic pain, a vast body of research has estab-
delivery methods that expand the application of CBT to lished the importance of cognitive and behavioral processes
underserved populations, (c) current limitations and in how individuals adapt to chronic pain. As postulated by
knowledge gaps, and (d) promising directions for improv- learning theory (Fordyce, 1976), social and environmental
ing CBT efficacy and access for people living with chronic variables (e.g., responses from family) have been shown to
pain. be associated with pain behaviors and disability levels (Flor
& Turk, 2011). Numerous studies have also documented
Keywords: chronic pain, cognitive-behavioral therapy the associations of pain-related beliefs and appraisals with
A
pain intensity and related problems, including depression,
n estimated 100 million U.S. adults suffer from physical disability, and activity and social role limitations
chronic pain (Institute of Medicine, 2011), a con- (Gatchel, Peng, Peters, Fuchs, & Turk, 2007). In particular,
dition influenced by biological, psychological, pain catastrophizing (magnification of the threat of, rumi-
and social factors and optimally managed by treatments nation about, and perceived inability to cope with pain) has
that address not only its biological causes but also its consistently been found to be associated with greater phys-
psychological and social influences and consequences. ical and psychosocial dysfunction, even after controlling
Over the past 60 years, parallel advances in the scientific for pain and depression levels (Edwards, Cahalan,
understanding of pain and the development of cognitive Mensing, Smith, & Haythornthwaite, 2011; Quartana,
and behavioral therapies have led to the widespread appli-
cation of cognitive-behavioral therapy (CBT) to chronic
pain problems. Indeed, CBT is now a mainstream treat- Editor’s note. This article is one of nine in the February–March 2014
ment, alone or in conjunction with medical or interdisci- American Psychologist “Chronic Pain and Psychology” special issue.
plinary rehabilitation treatments, for individuals with Mark P. Jensen was the scholarly lead for the special issue.
chronic pain problems of all types.
Arguably, the start of this modern era in chronic pain Authors’ note. Dawn M. Ehde, Department of Rehabilitation Medicine,
treatment began with the publication of the gate control University of Washington; Tiara M. Dillworth, Department of Psychiatry
theory of pain (Melzack & Wall, 1965), which emphasized and Behavioral Sciences, University of Washington; Judith A. Turner,
Department of Psychiatry and Behavioral Sciences and Department of
the importance of cognitive and affective, as well as sen- Rehabilitation Medicine, University of Washington.
sory, influences on pain. In the following decade, the This research was supported in part by a grant from the National
understanding and treatment of chronic pain made another Institute of Child Health and Human Development (National Center for
leap forward with psychologist Wilbert Fordyce’s applica- Medical Rehabilitation Research Grant 5R01HD057916).
Correspondence concerning this article should be addressed to Dawn
tion of learning theory and operant behavioral principles to M. Ehde, Department of Rehabilitation Medicine, University of Wash-
pain behaviors (Fordyce, 1976), which, like any behavior, ington, Box 359612, Harborview Medical Center, 325 Ninth Avenue,
can be elicited and shaped by social and environmental Seattle, WA 98104. E-mail: ehde@uw.edu
Low-literacy and rural samples. A notable evidence that psychological interventions for patients with
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gap is the lack of RCTs of CBT tailored to adults charac- acute and subacute back pain are effective in preventing
terized by low literacy, rural residence, or racial/ethnic chronic pain (Nicholas, Linton, Watson, Main, & “Decade
minority status (Campbell, 2011). One exception (Thorn et of the Flags” Working Group, 2011). Larger studies with
al., 2011) compared CBT with pain education in a sample adequate statistical power are needed. Because many pa-
of primarily African American women of low literacy in tients with acute and subacute pain will improve over time
the rural American South with various chronic pain prob- regardless of treatment, large samples may be needed to
lems (primarily low back and arthritis-related pain). The demonstrate benefits of CBT or to identify patient sub-
interventions and study methods were tailored to be cul- groups for which CBT is most effective. Patients at high
turally sensitive and suitable for those with low literacy. risk for chronic pain due to factors not targeted by CBT
The two groups did not differ significantly posttreatment on (e.g., medical issues) may be less responsive to CBT than
measures of pain intensity, activity interference, physical patients at high risk due to psychological factors such as
disability, or quality of life. Treatment completers in both depression, catastrophizing, and fear-avoidance. CBT ef-
groups showed small improvements, on average, in pain fectiveness may be increased by targeting specific psycho-
intensity and pain interference with activities that were social risk factors (Nicholas et al., 2011).
sustained through six months. Recently, there has been a surge of interest in using
Thorn et al. (2011) found that low literacy and related brief risk screening tools that include assessment of psy-
variables still posed potential barriers to participation de- chosocial factors to identify individuals at high risk for
spite the authors’ efforts to reduce these barriers. Among persistent clinically important pain and to stratify treatment
study participants, 26.5% did not complete treatment. In- based on risk (Beneciuk et al., 2013; Hill, Vohora, Dunn,
dividuals with lower education and reading levels were less Main, & Hay, 2010). In a large RCT (Hill et al., 2011) of
likely to begin treatment, and participants with lower edu- risk-stratified primary care for back pain (of any duration),
cation and income were less likely to complete treatment. intervention patients with low risk of an unfavorable out-
Written homework, common in CBT, may pose challenges come were reassured and encouraged to resume normal
for some individuals, even when adapted for lower literacy activities, whereas medium- and high-risk intervention pa-
(Campbell, 2011). Further research is needed to develop tients received standardized physiotherapy to improve
and test strategies for improving CBT participation and symptoms and function. For high-risk patients, physiother-
efficacy for individuals with low literacy or education. apy also addressed psychosocial obstacles to recovery.
Individuals with acute and subacute pain. Intervention patients had improved physical disability out-
Although no universally accepted definitions exist, chronic comes and lower costs of care relative to usual-care phys-
pain is often defined as pain that has persisted for three iotherapy control patients.
months or longer (International Association for the Study Although CBT aimed at preventing acute/subacute
of Pain Task Force on Taxonomy, 1994), whereas acute pain from becoming chronic could potentially apply to any
pain is often considered to be pain of less than 7 weeks’ type of pain, most studies have focused on back pain, likely
duration and subacute pain is considered to be pain that has because of its prevalence. One RCT evaluated the efficacy
lasted between approximately 7 and 12 weeks (Goertz of cognitive-behavioral skills training and biofeedback,
et al., 2012). Most studies of CBT have focused on chronic compared with a no-intervention group, for patients clas-
pain. However, given the refractoriness of pain once it is sified as at high risk for transitioning from acute to chronic
chronic, evidence that risk factors for progression of acute/ temporomandibular disorder (TMD) pain (Gatchel, Stow-
subacute pain to chronic pain include patient psychosocial ell, Wildenstein, Riggs, & Ellis, 2006). At a one-year
characteristics (Chou & Shekelle, 2010; Mallen, Peat, follow-up, participants who received the intervention, com-
Thomas, Dunn, & Croft, 2007; Ramond et al., 2011), and pared with those who did not receive any intervention, had
the secondary prevention potential for psychosocial inter- significantly lower levels of pain, depressive symptoms,
ventions, there has been increasing interest in the applica- health care utilization, and jaw-related health care expen-
tion of CBT to acute and subacute pain. Indeed, the Insti- ditures; higher rates of improved coping; and lower rates of
tute of Medicine (2011) report on pain called for providing DSM-IV (Diagnostic and Statistical Manual of Mental Dis-
primary, secondary, and tertiary care settings (Mularski et This area is ripe for further research to refine and
al., 2006), and psychosocial interventions in particular are evaluate technology-assisted CBT interventions for chronic
underutilized (Keefe, Abernethy, & Campbell, 2005). A pain. Questions remain regarding the importance of thera-
variety of factors likely account for underutilization of pist contact in Web-based treatments and regarding the
CBT for pain, including financial (e.g., lack of sufficient efficacy, effectiveness, and cost-effectiveness of Web-
insurance coverage), environmental (e.g., lack of afford- based and telephone- or video-call-delivered treatment rel-
able transportation, no providers in the geographic region), ative to in-person treatment. Potential advantages of tech-
patient attitude-related (e.g., stigma associated with psy- nology-assisted CBT include improved access and a
chological care, belief that pain can only be improved by reduction of stigma that might prevent some individuals
medical or surgical interventions), and health care system from seeking psychological care. Web-based programs and
barriers (e.g., providers unfamiliar with CBT for pain or smartphone or tablet applications also hold great potential
having insufficient time and skills to enhance patient mo- for enhancing CBT. For example, such technologies could
tivation for CBT, no existing referral system to psycholo- provide easy and instant access to a variety of educational
gists). Treatment disparities based on patient age or racial/ materials, guided relaxation exercises, tools for tracking
ethnic group, lack of culturally appropriate care, and activities and progress toward behavioral goals, and tai-
patient language differences, communication difficulties, lored feedback and suggestions. Also promising is the
and cognitive impairments may also pose barriers to ade- application of interactive voice response technology to
quate care. monitor pain and behaviors and to provide reminders and
The underutilization of CBT is likely also related to skills practice sessions during or following CBT (Lieber-
how it is commonly delivered: via individual or group man & Naylor, 2012). Medico-legal barriers to cross-state
psychotherapy by a psychologist trained in CBT for pain in telephone and video conference delivery of CBT will need
a private practice or pain clinic setting. The limited access to be addressed for such interventions to be feasible outside
to mental health treatment has been attributed not only to a of research settings.
lack of trained providers but also to the current delivery Use of professionals other than psycholo-
model of individual psychotherapy for the majority of gists to deliver treatments based on CBT prin-
psychological services (Kazdin & Blase, 2011). Kazdin and ciples and strategies. A number of studies have
Blase recommended development of a “portfolio” of ser- evaluated the efficacy of treatments for pain, based on CBT
vice delivery models (e.g., Web, video call, and telephone principles and including some CBT strategies, which are
technologies; service provision in community settings; use delivered by individuals who are not doctoral-level psy-
of nonprofessionals) to meet the demand for mental health chologists. For example, brief CBT-based self-manage-
care. In the following section, we review several innova- ment interventions for TMD pain delivered by dental hy-
tions in methods of delivery of CBT for pain, including gienists who were trained and supervised by clinical
technology methodologies, use of other professionals to psychologists were found efficacious compared with usual
deliver care, and collaborative care models. TMD care (S. F. Dworkin et al., 2002) and compared with
Technology. Advances in technology have been continuous oral contraceptive therapy (used to reduce hor-
paralleled by efforts to use technology to expand the reach monal fluctuations associated with TMD pain in women) in
of chronic pain interventions (Keogh, Rosser, & Eccleston, a sample of women (Turner et al., 2011). CBT-based
2010). A range of pain interventions, including CBT-based interventions delivered by trained nurses have produced
ones, have been delivered with technological assistance, improvements in important pain outcomes (Dalton, Keefe,
including telephone-delivered treatment (McBeth et al., Carlson, & Youngblood, 2004; Dysvik, Kvaloy, & Natvig,
2012), use of interactive voice response technology 2012; Wells-Federman, Arnstein, & Caudill, 2002), al-
(Lieberman & Naylor, 2012), video conferencing (Gard- though some of these studies had no comparison or control
ner-Nix, Backman, Barbati, & Grummitt, 2008), and Web- groups and only one (Dalton et al., 2004) was an RCT.
based programs (Ruehlman, Karoly, & Enders, 2012). A Many physical therapists are interested in working
meta-analysis of RCTs of Web-based CBT for chronic pain with patients with chronic musculoskeletal pain in accor-
value of assessing and addressing fear-avoidance and other psychologist care manager, who had limited formal train-
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psychosocial risk factors (K. R. Archer et al., 2013; ing in treating chronic pain before the study began but
George, Fritz, Bialosky, & Donald, 2003; Hill et al., 2011; received training in and ongoing supervision of care man-
Sullivan & Adams, 2010; Sullivan et al., 2006; Von Korff, agement and chronic pain treatment. Study participants
et al., 2005). received assessment, monitoring, and care management,
The degree to which the training, experience, exper- including components of CBT for pain. For patients whose
tise, and interpersonal qualities of the CBT interventionist pain and/or depression did not respond to treatment, care
affect CBT outcomes is unclear. In mental health treatment, was stepped up (e.g., more contacts with the care manager,
there is no evidence that therapists with a doctoral degree referral to a specialty pain clinic, mental health care, or
in psychology are more effective than therapists with less substance use treatment). Care was delivered in a variety of
training (Kazdin & Blase, 2011). This issue has received formats, including in person, by telephone, and by video
minimal investigation in the pain literature. In their review conferencing; patients were also encouraged to attend a
of secondary prevention interventions for people with re- four-session behavioral skills training workshop. Com-
cent onset of low back pain, Nicholas et al. (2011) hypoth- pared with usual care, patients assigned to collaborative
esized that the expertise of the interventionist may be care demonstrated greater improvements in pain and dis-
relevant because among the studies in which the psycho- ability, and for those who were depressed at baseline,
logical treatments were not superior to usual care, none greater improvements in depression. This study demon-
used a psychologist to deliver the treatment. Conversely, strates the potential for collaborative care approaches to
the majority of studies in which the psychological treat- improve pain outcomes and to use physician and psychol-
ment was delivered by a psychologist demonstrated a ben- ogist resources efficiently in primary care.
efit above usual care. Nonetheless, it remains an empirical
question as to whether a certain type of professional de- Future Directions for Improving the
gree, level of training, or expertise is required to deliver Efficacy and Dissemination of CBT for
efficacious CBT to patients with chronic pain. Consider- Chronic Pain
ation must be given to what CBT techniques can be applied
naturally as part of that provider’s usual care (e.g., physical A considerable volume of research supports the efficacy of
therapists using graded activity techniques for back pain, CBT in improving chronic pain and related outcomes
nurses offering instruction in relaxation techniques) and across a wide variety of pain syndromes. However, its
what CBT techniques, such as cognitive restructuring, may benefits are often modest on average. What can be done to
require the education and experience of a psychologist and improve outcomes of CBT for patients with chronic pain?
may be less appropriate for delivery by others. How can progress be made in overcoming the underutili-
Collaborative care models. There is increas- zation of CBT for the many people living with chronic
ing interest in applying collaborative care models, demon- pain? Progress in answering these questions may come
strated as effective in improving depression and anxiety from addressing several gaps in the CBT literature.
outcomes in primary care settings (J. Archer et al., 2012),
to chronic pain, which is also largely treated in primary Gaps in Knowledge of Optimal Treatment
care. Collaborative care for depression involves systematic Content, Format, and Dose
care management by a nurse, social worker, or other trained CBT interventions evaluated in RCTs vary widely in their
clinical staff person to facilitate case identification, coor- content, format (e.g., group vs. individual, in-person vs.
dinate a guideline-based treatment plan (with consultation Web), and dose. CBT for pain is typically a multicompo-
from a mental health expert and regular communication nent treatment with no single standard treatment manual for
with the patient’s primary care provider), provide proactive either group or individual therapy. Among studies that use
follow-up, monitor treatment adherence and response, and treatment manuals, many are developed by the investiga-
modify treatment as needed (Unützer, Schoenbaum, Druss, tors for the trial and are not published, making comparisons
& Katon, 2006). Other key elements include measurement- of specific CBT interventions across studies impossible.
based care, incremental increases in treatment for those Research comparing differing treatment doses, formats,
Mechanisms and Moderators and under what circumstances does it work?” Increased
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