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COGNITIVE
PSYCHOTHER APY
JOURNAL OF
www.springerpub.com/jcp
SPECIAL ISSUE
Chronic Pain
GUEST EDITOR
Thomas Hadjistavropoulos, PhD
With the Compliments of Springer Publishing Company, LLC
114
© 2012 Springer Publishing Company
http://dx.doi.org/10.1891/0889-8391.26.2.114
Journal of Cognitive Psychotherapy: An International Quarterly
Volume 26, Number 2 • 2012
The Continuing Evolution of
Biopsychosocial Interventions
for Chronic Pain
Melissa A. Day, MA
Beverly E. Thorn, PhD, ABPP
The Department of Psychology, The University of Alabama, Tuscaloosa, Alabama
John W. Burns, PhD
Department of Behavioral Sciences, Rush University Medical Center, Chicago, Illinois
In the last several decades, great strides have been made in the treatment of persistent painful
conditions. The scope of treatment has shifted from purely biomedical, including approaches
built upon cognitive, behavioral, and social psychological principles. This article reports and
discusses several key paradigm shifts that fueled this revolutionary change in the management
of chronic pain. The progressive development of theoretical metamodels and treatment con-
ceptualizations is presented. Cognitive behavioral therapy (CBT) is the most widely accepted
biopsychosocial treatment for chronic pain and is founded upon a rich theoretical tradition.
The CBT rationale, and empirical evidence to support its efficacy, is presented. The emergence
and promise of mindfulness-based and acceptance-based interventions is also discussed. The
article concludes with the assertion that future treatment outcome research should focus on
understanding the treatment-specific and common factors associated with efficacy.
Keywords: chronic pain; intervention; biopsychosocial; mechanism
Chronic pain is a pervasive and costly healthcare concern. Recent estimates suggest that
approximately 116 million Americans are affected by chronic pain (Tsang et al., 2008),
and this translates into a staggering annual cost of over $61 billion in lost workdays,
medical expenses, and other benefit costs (American Academy of Pain Medicine, 2012). Chronic
pain is among the most common presenting complaints seen in medical settings; headache pain
alone accounts for 18 million physician visits per year (Schwartz, Stewart, Simon, & Lipton,
1998). While the frontline treatment approach for chronic pain has been biomedical in na-
ture, biopsychosocial treatments have evolved that are at least as efficacious as medically based
treatments and are cost effective relative to surgery and medication management (Eccleston,
Palermo, et al., 2009).
Biopsychosocial treatments for chronic pain emerged in the mid 1960s and continued to
develop and take hold in the 1970s and 1980s. During this time, several paradigm shifts occurred
and ultimately led to an understanding of pain as multidimensional in nature. This new under-
standing of pain expanded the points of intervention beyond an exclusive focus on biomedical
Copyright © Springer Publishing Company, LLC
115Evolution of Interventions for Chronic Pain
pathophysiology. This article highlights the historical roots from which grew an expansive body
of psychological research, which shaped today’s biopsychosocial treatment conceptualization for
chronic pain. The development of biopsychosocial treatments has been, and will continue to
be, a dynamic progression. The article concludes by suggesting some possible future directions
for the continued development of biopsychosocial interventions for chronic pain. This article is
conceptual in nature and not intended to cover all extant biopsychosocial treatments, nor provide
an exhaustive documentation of the huge volume of research dedicated to this topic.
His tor i c a l ro o t s o f Bi o p s y c H o s o c i a l in t e r v e n t i o n s
f o r cH r o n i c pa i n
Over the past 50 years, groundbreaking metatheoretical models emerged and converged to create
today’s conceptualization of biopsychosocial treatments for chronic pain. Some of these models
were pain-specific, whereas others were broader in nature. It could be argued that the initial
impetus for these developments stemmed from a growing awareness of the shortcomings inherent
in the biomedical approach to health care.
Mounting dissatisfaction with the biomedical model eventually led to Engel’s (1977)
biopsychosocial conceptualization of illness. Engel proposed that the illness itself was not an entity
independent of social, psychological, and behavioral influences. Rather, he suggested that each of
these dimensions form a complex interaction, which under certain conditions may culminate in
active disease or manifest illness. Thus, to provide both a basis for understanding the determi-
nants of disease and a framework for guiding medical treatment and health care, Engel proposed
the biopsychosocial model of disease conceptualization. Engel drew heavily on psychodynamic
concepts to address the psychology of disease conceptualization, which is quite different from
the current conceptual framework of the biopsychosocial model. Nevertheless, Engel’s emphasis
on looking beyond the biological was a key factor in shifting the way disease is conceptualized.
Subsequent application of the biopsychosocial model to pain conditions redefined the perception
of pain away from purely mechanistic terms. According to the biopsychosocial approach, pain is
the result of a convergence of a multitude of internal and external biological, psychological, and
social processes. Therefore, in theory and in practice, the biopsychosocial model broadened the
scope of pain treatment beyond the biomedical sphere.
In the realm of pain, a revolutionary theory also emerged that challenged a mechanistic and
reductionistic perspective. In their gate control theory of pain, Melzack and Wall (1965, 1982)
proposed that the experience of pain could best be understood within the context of the brain
playing a dynamic role in the interpretive processes of the sensory stimulus. They originally sug-
gested that descending signals from the brain opened or closed a gating mechanism in the spinal
column, which ultimately controlled the amount of pain signals that could reach the brain. It is
important to note that functional magnetic resonance imaging (fMRI) studies (e.g., Koyama,
McHaffie, Laurienti, & Coghill, 2005; Kupers, Faymonville, & Laureys, 2005; Ploghaus et al., 1999)
have since shown that critical pain pathways travel through areas of the brain associated with cog-
nitive and emotional activity (e.g., the thalamus, anterior cingulated cortex, and limbic system),
and Melzack and Wall emphasized that these areas had the capacity to inhibit or enhance the
sensory flow of painful stimuli. The gate control theory (and the subsequent neuromatrix model
of pain; Melzack, 2001, 2005) reconceptualized the experience of pain and proposed that psycho-
logical processes can actually shape the way painful stimuli are interpreted by the brain. In a sense,
this theory paved the way for a movement toward the integration of biopsychosocial interven-
tions into the standard treatment of chronic pain.
Although not specific to pain, a powerfully influential model in the evolution of biopsy-
chosocial treatments for chronic pain was Lazarus and Folkman’s (1984) transactional model
Copyright © Springer Publishing Company, LLC
116 Day et al.
of stress. This model is multidimensional in nature, incorporating personality, social consider-
ations, thoughts, behaviors, and biological factors. Importantly, the model qualitatively differenti-
ates among certain types of cognitions, considering them at varying levels, including immediate
judgments in reaction to changes in the environment (primary appraisals), thought processes de-
veloped to guide choice of coping strategies (secondary appraisals), and more deeply held beliefs
acquired over time. At its core, Lazarus and Folkman’s model is a model of stress, and without
question the stress response is an exacerbating factor in all chronic pain conditions. Thus, it is no
surprise that clinical researchers adopted the transactional model for refining the understanding
of the chronic pain experience (Thorn, 2004).
Overview of Biopsychosocial Treatments
Three “generations” of biopsychosocial treatment approaches have evolved from the convergence
of the aforementioned models: (a) behavioral therapy, which is founded on principles of rein-
forcement; (b) cognitive behavioral therapy (CBT), which targets thoughts as well as behavior;
and (c) mindfulness-based and acceptance-based interventions, which primarily emphasize
awareness and acceptance of the present moment.
Behavior Therapy. In the early 1960s, literature began to emerge that described application
of Skinner’s (1953) operant conditioning principles to various kinds of human problems (e.g.,
Ayllon & Michael, 1959; Ullman & Krasner, 1965). This work marked the advent of a behavioral
therapeutic tool initially applied within the context of mental disorders. With the emergence
of the gate control theory of pain and the biopsychosocial model of illness, chronic pain came
to be viewed as a problem that was amenable to a treatment approach based on behavioral
principles. The first application of behavioral technology in the assessment and treatment of
chronic pain was proposed by Fordyce in 1976. Fordyce’s approach was founded upon an op-
erant model and was based on the premise that certain interpersonal and social consequences
of chronic pain create powerful environmental contingencies that condition pain behaviors.
Specifically, the presence of maladaptive behaviors (e.g., guarding, pain-contingent resting)
and the absence of adaptive behaviors (e.g., physical activity, family interaction) represent key
elements of the pain experience that are learned. While Fordyce recognized that cognitive fac-
tors play a role in the experience of pain, he suggested that they do so via the reinforcing envi-
ronmental consequences, which occur subsequent to cognitive processes. For example, if one’s
attention and thoughts are focused on pain, he or she is likely to display pain behaviors. Others
in the patient’s surrounding environment are likely to attend to these behaviors, thus unwit-
tingly rewarding, reinforcing, and sustaining the pain behaviors. Hence, there is a reciprocal,
dynamic relationship between the behaviors of a person with chronic pain and the behaviors of
others within the environment such that both function to shape the other. Ultimately, the over-
arching goal of Fordyce’s model programs was to carefully analyze pain behavior patterns and
subsequently apply reinforcement principles to increase adaptive well behaviors and decrease
maladaptive pain behaviors. Thus, the operant models emerging from Fordyce’s approach used
structured behavioral programs that implemented contingency management to improve ad-
justment to chronic pain conditions. Athough popularity of the strictly behavioral approach
has faded, operant behavioral principles continue to influence the understanding and treat-
ment of pain, and research supports their efficacy (Keefe & Lefebvre, 1999; Ostelo, 2006). In
essence, Fordyce, Fowler, and DeLateur (1968) and Fordyce and colleagues (1973) provided
the first evidence that inclusion of psychological principles into interventions for chronic pain
management could be successful.
A promising extension of Fordyce’s behavioral approach emphasizes the importance of the
social components of the biopsychosocial model and incorporates this aspect into behavioral
Copyright © Springer Publishing Company, LLC
117Evolution of Interventions for Chronic Pain
treatment. Research has confirmed that partner responses to pain behaviors are associated with
the rate of pain behaviors exhibited by the patient (Cano, Weisberg, & Gallagher, 2000; Romano,
Jensen, Turner, Good & Hops, 2000). Further, there is evidence that incorporating the patient’s
partner and/or family members into treatment results in higher levels of pain coping attempts on
the part of the patient and a tendency toward reduced pain levels as well as improved marital sat-
isfaction (Keefe et al., 1996; Keefe et al., 2004). Thus, attending to and incorporating the patient’s
social support system into behavioral skills training is a promising avenue to pursue and to po-
tentially enhance the efficacy of behavioral treatments.
Another extension of the original Fordyce model has been one that focuses on the impor-
tance of respondent (rather than operant) conditioning. This behaviorally oriented pain manage-
ment approach explicitly focuses upon application of the fear-avoidance model of understanding
pain behaviors via use of exposure techniques (Vlaeyen & Linton, 2000). The approach stems
from the conceptualization that fear is an acquired, classically conditioned response to ongoing
pain and leads to behavioral avoidance that negatively influences pain-related outcomes. Hence,
one of the primary treatment goals is to reduce fear and associated avoidance through graded ex-
posure techniques (Leeuw et al., 2007; Vlaeyen, de Jong, Leeuw, & Crombez, 2004). Two random-
ized controlled trials (RCTs) that compared exposure in vivo to wait-list controls found that this
treatment approach was promising in terms of improving function, pain, and fear of pain (Linton
et al., 2008; Woods & Asmundson, 2008). Other studies report treatment-related reductions in
catastrophizing, fear, and self-reported disability, and improved return-to-work outcomes (Staal
et al., 2006; Sullivan, Adams, Rhodenizer, & Stanish, 2006; Sullivan & Stanish, 2003; Sullivan et
al., 2005; Vlaeyen, de Jong, Geilen, Heuts, & van Breukelen, 2002; Woods & Asmundson, 2008). It
is important to note that Linton and colleagues (2008) recommend that exposure interventions
not be used as a “stand alone” therapy adjunct to usual care. In their research, Linton et al. (2008)
found that apart from pain-related fear, patients reported other significant issues, such as cogni-
tive beliefs, family issues, and workplace changes that needed to be acknowledged and addressed.
In summary, although behavioral approaches appear to be effective in targeting specific fears and
maladaptive behaviors, a more comprehensive approach that concurrently targets maladaptive
cognitions and broader interpersonal factors is typically considered necessary.
Cognitive Behavioral Therapy. Whereas much of psychology focused on the study of
observable human behavior during the first half of the 20th century, a “cognitive revolution”
took place in the 1970s. During this time, clinical research across multiple disorders began to
emphasize the importance of including interventional strategies targeting maladaptive thoughts,
beliefs, and perceptions within behavioral interventions (e.g., Beck, Rush, Shaw & Emery, 1979;
Foreyt & Rathjen, 1978; Mahoney, 1974; Meichenbaum 1977). Furthermore, the behavioral
components of treatment were expanded to include behavioral activation; the goal of which is
to increase environmental reinforcement through engaging in rewarding activities. Within the
realm of pain, this realization fueled yet another paradigm shift in biopsychosocial treatment,
and the focus broadened beyond extinguishing maladaptive behaviors to include a focus on cog-
nitions as well as enhancing health-promoting activities. In 1983, Turk and colleagues presented
a comprehensive CBT perspective for the management of chronic pain. This “second wave” of
biopsychosocial approaches held the underlying assumption that emotions and behavior are
largely determined by cognitive perceptions of the world (Turk, Meichenbaum, & Genest, 1983).
According to this rationale, treatment can intervene at the point of cognitive belief structures,
cognitive processes (such as automatic thoughts and coping skills), behaviors, and/or environ-
mental/social consequences (Turk, Meichenbaum, & Genest, 1983). Early research by Turk,
Turner, Kerns and others demonstrated that this approach held tremendous potential in the
management of chronic pain (Kerns, Turk, Holzman, & Rudy, 1986; Turner, 1982; Turner &
Clancy 1988).
Copyright © Springer Publishing Company, LLC
118 Day et al.
CBT techniques for chronic pain primarily emphasize adaptive antecedent-focused cog-
nitive and behavioral pain coping strategies, usually aimed at stress management (Hofmann &
Asmundson, 2008). In essence, antecedent-focused strategies target cognitive and behavioral pro-
cesses that might cause or exacerbate the pain condition, such as catastrophic thought processes
about the way pain has “ruined” one’s life. A critical component of CBT for chronic pain inter-
ventions is promotion of a more positive and realistic reappraisal of situations initially judged as
stressful, such that negative automatic thoughts are addressed before they cascade and potentially
instigate poor pain-related outcomes.
Behavioral stress managements skills are also taught, such as relaxation, assertiveness,
and expressive writing (or other forms of emotional expression), and principles of behav-
ioral activation are also often employed. Although the social and interpersonal contexts within
which patients with chronic pain live rarely receive explicit attention in treatment manuals
(Hadjistavropoulos et al., 2011), we would argue that these elements are a critical compo-
nent inherent in the therapeutic process of CBT as it unfolds. To help patients learn to cope
with stressors and better manage their stress response, the sources of stress must be examined.
In many cases, the sources of stress have to do with a loss of previously established recrea-
tional, work, and family roles. Further, maladaptive beliefs and cognitions (that are restruc-
tured throughout the course of treatment) frequently stem from the drastic changes within the
patient’s life that occur because of chronic pain. For example, beliefs such as “I am worthless”
or “I am a weak person” often arise when loss of employment occurs or when one has to rely on
significant others for assistance. The CBT approach directly addresses the negative, exaggerated
quality of catastrophic cognitions to make them more realistic and positive such that they are
less disabling.
A proliferation of research has demonstrated the efficacy of CBT for various chronic pain
conditions across an array of pain-related outcomes (e.g., Astin, Beckner, Soeken, Hochberg,
& Berman, 2002; Chen, Cole, & Kato, 2004; Eccleston, Palermo et al., 2009; Keefe, Abernethy,
& Campbell, 2005; Lackner, Mesmer, Morley, Dowzer, & Hamilton, 2004; Morley, Eccleston,
Williams, 1999; Turner, Mancl, & Aaron, 2005; Weydert, Ball, & Davis, 2003). Specifically, CBT
has been shown to restore function and mood and reduce pain intensity, interference due to
pain, work absenteeism, medication use, and disability-related behavior. Treatment gains from
CBT have been shown to be maintained at short- and long-term follow-up assessments (e.g.,
Johansson, Dahl, Jannert, Melin, & Andersson; 1998; Linton & Ryberg, 2001; Thorn et al., in press;
Turner et al., 2005). Furthermore, this approach has been shown to be at least as efficacious as
medically-based treatments (Eccleston, Palermo et al., 2009). In essence, CBT is considered the
“gold standard” of biopsychosocial interventions for chronic pain.
Mindfulness-Based and Acceptance-Based Treatments. Present biopsychosocial inter-
ventions for chronic pain are grounded within a cognitively focused CBT model, and it seems
unlikely that emerging interventions will completely supersede this treatment approach. Recently,
however, the question has been raised as to whether explicitly changing the content of cognitions
per se is necessary to reduce distress and increase function. Future research may show that the
key cognitive process of change in CBT is not changing thought content, but rather engendering
more emotional distance from one’s maladaptive thoughts. Perhaps the CBT process of repeat-
edly identifying and examining the validity of negative thoughts and beliefs allows patients to
change their relationship to thoughts, such that thoughts are not necessarily regarded as the truth.
This fresh understanding has led to a particularly promising trend in recent years in which mind-
fulness and acceptance-based approaches have been integrated into traditional treatment modal-
ities for pain and other chronic conditions. Some clinical researchers have labeled these newer
treatment approaches the “third wave” of biopsychosocial treatments (Hayes, Luoma, Bond,
Masuda, & Lillis, et al., 2006).
Copyright © Springer Publishing Company, LLC
119Evolution of Interventions for Chronic Pain
Mindfulness-Based Approaches. Mindfulness meditation is a specific form of meditation
originally developed in Far Eastern cultures and more recently integrated into Western psy-
chology and health care. Mindfulness-based stress reduction (MBSR) and other similar therapies
emphasize the practice of mindfulness meditation as a means to cultivate awareness and accep-
tance of the full range of inner experiences, including thoughts, emotions, and bodily sensa-
tions. Mindfulness approaches primarily use response-focused pain coping strategies (Hofmann
& Asmundson, 2008). In response-focused strategies, the emphasis is on the patients’ cognitive,
emotional, and physiological responses to pain, such as a fear reaction to a pain flare-up. In par-
ticular, mindfulness techniques promote nonjudgmental awareness and acceptance of the present
moment, just as it is. Thus, via the experiential practice of meditation, MBSR takes the posited
underlying shift in relationship to thoughts (that is engendered implicitly in CBT) and makes it
the direct explicit focus of the treatment itself.
Although mindfulness-based treatments for chronic pain are still in their infancy, there is
a small but rapidly growing literature of controlled trials on mindfulness-based pain and stress
reduction or other meditative therapies for chronic illnesses (Carson et al., 2005; Grossman,
Niemann, Schmidt, & Walach, 2004; Grossman, Tiefenthaler-Gilmer, Raysz, & Kesper, 2007;
Kabat-Zinn, 1982; Morone, Greco, & Weiner, 2008; Plews-Ogan, Owens, Goodman, Wolfe, &
Schorling, 2005; Sagula & Rice, 2004). Most of these studies compared group meditation to stan-
dard biomedical care and found meditation to be more beneficial with respect to pain perception,
pain coping, and measures of affect immediately posttreatment and also at follow-up. Clearly,
well-controlled trials with adequately powered samples are needed, but the literature to date
suggests that group mindfulness-based treatments may prove to be efficacious for chronic pain
management.
Mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002) builds
upon both the CBT and MBSR frameworks to directly incorporate both antecedent-focused and
response-focused interventional strategies to form a comprehensive treatment approach. The orig-
inal 8-week MBCT protocol was developed for targeting relapse prevention in depression (Segal
eta al., 2002); recently, Day and Thorn (2010) adapted this existing protocol to tailor it toward
the treatment of chronic pain. The adapted MBCT for chronic pain treatment protocol integrates
key CBT and MBSR therapeutic techniques (Kabat-Zinn, 1990; Thorn, 2004). MBCT places an
explicit emphasis upon cognitions but also directly addresses emotions and bodily sensations,
such that the full spectrum of the multidimensional nature of chronic pain is targeted. Hence,
MBCT has the potential to extend and improve upon the positive treatment outcomes previously
reported with CBT or MBSR alone for chronic pain management.
Recent research supports the efficacy of MBCT in addressing cognitive aspects of depres-
sion, such as ruminative and catastrophic thinking while concurrently maintaining the general
effects seen in MBSR, such as reduced perceived stress and depressive symptoms, and increased
acceptance and psychological well-being (Carmody & Baer, 2008; Coelho, Canter, & Ernst, 2007;
Kenny & Williams, 2007; Ma & Teasdale, 2004; Sephton et al., 2007; Teasdale et al., 2002; Williams,
Duggan, Crane, & Fennell, 2006). However, a gap in the literature exists in that while the efficacy
of MBCT for other populations (e.g., anxiety and insomnia) has begun to be investigated (Craigie,
Rees, Marsh, & Nathan, 2008; Evans et al., 2008; Heidenreich, Tuin, Pflug, Michal, & Michalak,
2006; Yook et al., 2008), there has been no published work to date looking at MBCT for chronic
pain. In a recent pilot study using a single subject pre-post design, Day and Thorn (2011) imple-
mented their MBCT for chronic pain treatment manual with four patients with chronic pain.
Although pre-post outcome data were collected to pilot the measures, small N precluded quanti-
tative analysis. However, the qualitative feedback was uniformly positive indicating the treatment
approach was feasible and acceptable to patients. Day and Thorn are currently conducting a RCT
implementing the developed protocol with patients suffering from chronic headache pain; results
Copyright © Springer Publishing Company, LLC
120 Day et al.
of this study will begin to lay the foundation for continued research examining the potential of
MBCT for chronic pain.
Acceptance-Based Approaches. An emerging body of empirical research has investigated
the potential of acceptance-based interventions for chronic pain management, and preliminary
support is promising (e.g., Dahl, Wilson, & Nilsson, 2004; McCracken, MacKichan, & Eccleston,
2007; Vowles, Loebach-Wetherell, & Sorrell, 2009; Vowles & McCracken, 2008). Significant pos-
itive outcomes reported for acceptance-based interventions include improved physical perfor-
mance, fewer sick days, and reduced pain intensity, medical utilization, daytime rest, distress,
depression, and pain-related anxiety. Acceptance-based approaches for chronic pain take an al-
most antithetical view to CBT and emphasize that the changing of thoughts should not be a
focus of treatment. Rather, the critical issue is changing the way one interacts with and relates to
thoughts such that the unhelpful function of maladaptive cognitions is minimized (Hayes et al.,
2006). Acceptance-based interventions implement a more behaviorally oriented approach and
focus on modification of the functions rather than the symptoms of chronic pain. Specifically,
the focus is not on reducing the frequency or intensity of pain or on changing the specific content
of inner experiences. Instead, acceptance-based approaches emphasize changing the relation of
these aforementioned factors to behavior.
Acceptance-based interventions include therapeutic techniques based on both accep-
tance strategies (see Hayes et al., 2006 for a detailed description) and some mindfulness-based
components (such as an emphasis on being present and a nonjudgmental attitude). As such,
acceptance-based interventions such as acceptance and commitment therapy (ACT; Hayes et al.,
2006), contextual CBT (McCracken et al., 2007), and others are sometimes included under the um-
brella term of mindfulness-based interventions. However, although acceptance-based approaches
encourage the cultivation of mindful awareness, they typically have not included mindful medi-
tation practice within the treatment protocol (Fjorback, Arendt, Ornbøl, Fink, & Walach, 2011),
and we therefore consider them to be distinct from mindfulness-based approaches.
More recently, it has been proposed that mindfulness-based interventions actually fall under
the umbrella of acceptance-based interventions. Indeed, in a recent systematic review and meta-
analysis of “acceptance-based” interventions for chronic pain, 15 of the 22 articles included in
the review were actually manuscripts reporting the effects of MBSR (Veehof, Oskam, Schreurs,
& Bohlmeijer, 2011). In our opinion, this approach confounds the two theoretically and pro-
cedurally different treatment approaches and may cause confusion in the field. Mindfulness-
based and acceptance-based interventions share some similarities in terms of targeted outcomes
(i.e., acceptance). However, there are differences in the theoretical underpinnings of the two such
that semantic separation of the descriptive labels for the treatments seems warranted. Within
this context, a divergence within this “third wave” is marked by those interventions that are
mindfulness-based (i.e., treatments that cultivate mindfulness as both a process and a practice),
and those that are acceptance-based.
Overall, mindfulness-based and acceptance-based interventions hold potential for extend-
ing and improving previous conceptualizations of chronic pain management. These approaches
(as with past behavioral and cognitive-behavioral approaches) have distinct theoretical rationales
and propose unique mechanisms thought to be responsible for positive outcome. However, debate
within the field of psychology surrounds the notion of whether these interventions are “new wave
or old hat” (Hofmann & Asmundson, 2008). Proponents of CBT suggest that such interventions
are purely an extension of cognitive-behavioral approaches (e.g., Hofmann & Asmundsen, 2008),
whereas champions of ACT, for example, assert that acceptance-based interventions represent a
new, revolutionary generation of treatment approach (Hayes et al., 2006). Although valid arguments
can be made on both sides, it is probably premature to claim a new generation of biopsychoso-
cial treatments is upon us given the relative lack of quality RCTs conducted with these burgeoning
Copyright © Springer Publishing Company, LLC
121Evolution of Interventions for Chronic Pain
interventions. Within the context of the current debates regarding the major biopsychosocial treat-
ments, we suggest that the field may benefit from future research directed toward elucidating the
treatment-specific as well as common treatment mechanisms in each of the interventions.
Looking Toward the Future: To Avoid Extinction, We Must Continue to Evolve
Methodological Considerations. New treatments for chronic pain continue to be developed,
as documented earlier, and the emphasis within the field thus far in this process has primarily
focused on theoretical distinctions and procedural differences. This conventional course of treat-
ment development has spawned many “new” treatment techniques presumed to offer unique
advantages over the “old.” There is a temptation to focus on distinctions among different inter-
ventional approaches, weigh their relative merits based on apparent differences, and focus on
“building new and improved” techniques. There are, however, at least two important shortcom-
ings with our current methods of evaluating treatments.
The first limitation stems from the typical process of testing the efficacy of a new treatment
by comparing it to wait-list or attention control. Demonstration of superiority over control con-
ditions may reveal that the treatment works but does not reveal whether the new treatment works
“better” than existing (old) approaches. To determine relative efficacy of the two treatments, the
new treatment needs to be directly compared to old treatments. Few studies have employed such
an approach. When studies have compared different psychosocial treatments for chronic pain
or have examined the effects of individual components of multifactor interventions—variously
known as dismantling or additive studies—results show more similarity in outcomes than differ-
ences (e.g., Glombiewski, Hartwich-Tersek, & Rief, 2010; Redondo et al., 2004; Turner & Jensen,
1993). On the basis of comparisons between target treatments and relatively inert control con-
ditions, it is difficult to uphold mindfulness-based or acceptance-based therapies as offering
advances over CBT or CBT over behavior contingency management. Supplanting one kind of
treatment with another appears not to provide a valid metric by which to document progress.
The second shortcoming is our near exclusive focus on efficacy and outcomes. Although a
converging body of evidence suggests that a wide variety of biopsychosocial interventions are
effective in reducing pain and suffering and increasing quality of life for people with chronic
pain, it is also clear that we do not know how our treatments work (Jensen, 2011; Thorn & Burns,
2011). As argued by Thorn and Burns (2011), understanding whether an intervention works is in-
extricably intertwined with understanding the mechanisms by which an intervention works, and
knowing the latter is just as important as knowing the former. When a certain approach shows
efficacy—again, usually compared to wait-list or attention control—the typical inference made
by investigators and clinicians alike is that it works because of the mechanisms hypothesized to
be specific to that treatment. Investigators conducting treatment outcome research tend to make
inferences, such as cognitive restructuring of maladaptive pain beliefs in a CBT regimen is chiefly
responsible for patient improvements, for example. However, in most cases, these assumptions
about mechanisms have simply not been adequately tested.
To identify therapeutic mechanisms in chronic pain treatments and to disentangle effects
of putative unique mechanisms from common effects, research on treatment evaluation must
evolve. To avoid repeatedly reinventing the wheel by focusing exclusively on the efficacy of new
treatments, we must embrace a new research agenda. At minimum, we need to integrate current
RCT methods with state-of-the-art methods and analyses for exploring mechanisms being devel-
oped in the psychotherapy literature. Examining both time course of changes and lagged associa-
tions among changes moves much further toward supporting causal links between mechanisms
and outcomes. Careful, well-constructed investigations that measure and analyze candidate
mechanisms are needed before we can make judgments about how our treatments work.
Copyright © Springer Publishing Company, LLC
122 Day et al.
The Need for New Conceptual Frameworks. The apparent similarity in efficacy across
many chronic pain treatments suggests that they do not produce change solely through unique
mechanisms. Thus, starting from this observation that apparently different treatments exert sim-
ilar effects, we need a conceptual framework for considering common factors. We can begin by
borrowing from a well-established body of theoretical and empirical work in the psychotherapy
literature. Goldfried and Davila (2005) and other investigators argue that common principles
underlie most psychotherapy approaches and warrant examination and understanding. Results
from many studies of psychotherapy process and outcome confirm that stimulating patient expec-
tations that treatment will help and establishing a sound therapeutic relationship between patient
and therapist are crucial pieces of the foundation upon which successful interventions are built
(Castonguay, Constantino, & Holtforth, 2006). How common factors may augment psychosocial
pain treatment and when, in the course of treatment, these effects may be exerted remain largely
unexplored territories. We are not suggesting that effects of psychosocial chronic pain treatments
can be entirely reduced to those produced by common mechanisms. It is quite possible that
common factors function to build a therapeutic foundation from which patient integration of
specific therapeutic techniques occurs (Day, Thorn, & Kapoor, 2011). We argue that for the field
to continue to evolve, we need to acknowledge, identify, and measure the variance accounted for
by common factors, and we need to consider how to augment patient expectations and sound
relationships because they influence the impact of our interventions.
We also need a conceptual framework to examine the contribution of treatment-specific
mechanisms associated with various techniques. Conceptualizations must focus on defining what
are and are not unique mechanisms, and then we must set up designs and measurement strate-
gies to test these propositions. Specific mechanisms are not routinely examined in our research,
and we will need to assess those associated with the conceptual model of a particular treatment.
Additionally, keeping in mind that most viable treatments produce similar results, we also believe
it is vital to broaden our assessments to include changes in factors not necessarily expected to be
associated with the particular treatment (e.g., acceptance and CBT).
The scope of the problem in not testing specific mechanisms is truly monumental and may
be illustrated by so-called placebo effects. CBT for chronic pain shows much smaller effects com-
pared to attention control groups (also known as attention placebo) than to wait-list control
(Eccleston, Williams, & Morley, 2009), suggesting that therapist attention exerts some degree of
effect on outcomes. Indeed, we found that a pain education control group produced pre- to post-
treatment changes on pain severity and interference virtually equivalent to those produced by
CBT (Thorn et al., 2011). Regarding another kind of pain treatment, verum and sham acupunc-
ture have been reported to produce nearly identical effects on chronic pain intensity (Madsen,
Gøtzsche, & Hróbjartsson, 2009). Finally, even biomedical approaches have trouble exceeding
placebo effects. Improvements in pain and pain-related disability associated with osteoporotic
compression fractures in patients treated with vertebroplasty were similar to the improvements
in a placebo group (Kallmes et al., 2009), and in an RCT involving patients with osteoarthritis
of the knee, the outcomes after arthroscopic lavage or arthroscopic debridement were no bet-
ter than those after a placebo procedure (Moseley et al., 2002). Therapist attention, sham ma-
nipulation of needles, and inert surgical procedures all produced symptom reduction without
the benefit of the hypothesized specific mechanisms of the treatment approaches. It is certainly
premature and lacking in empirical justification to accept that the primary active mechanism is
cognitive restructuring in CBT, activation of nerve systems in acupuncture, and the removal of
fronds of joint material or degenerative tissue in arthroscopic lavage and debridement. Careful,
well-constructed investigations that measure and analyze candidate mechanisms, including those
variously described as placebo effects, are needed before we can make judgments about how our
treatments work.
Copyright © Springer Publishing Company, LLC
123Evolution of Interventions for Chronic Pain
The Current State of the Evidence Regarding Mechanisms. It is promising that some efforts
toward uncovering specific mechanisms in psychosocial pain treatments have begun. Most research
investigating treatment mechanism has thus far focused upon processes associated with CBT.
Thus, we will primarily target our discussion within this section to the CBT treatment approach.
As noted earlier, one specific hypothesized mechanism for CBT is to alter negative cognitions
that lead patients to engage in maladaptive coping behaviors. Correlational evidence led to pre-
liminary support for this hypothesis; studies have shown that treatment-related improvements
in cognitive variables such as pain catastrophizing (Jensen, Turner, & Romano, 2001; Spinhoven
et al., 2004; Thorn et al., 2007; Turner, Holtzman & Mancl, 2007), self-efficacy (Holroyd, Labus
& Carlson, 2009; Thorn et al., 2007; Turner et al., 2007), perceived pain control (Jensen et al.,
2001; Spinhoven et al., 2004; Turner et al., 2007), pain helplessness (Burns, Johnson, Mahoney,
Devine, & Pawl, 1998) and other pain-related beliefs (Jensen et al., 2001) are associated with
improvement across multiple pain-related outcomes. While relatively little is known about the
processes associated with possible loss of treatment gains subsequent to treatment, Jensen, Turner
and Romano (2007) found that reversal of treatment-related improvement in cognitive-related
variables (i.e., beliefs, catastrophizing, coping) was associated with worsening of outcomes.
Although the aforementioned noted evidence is a step in the right direction, the methods and
analyses used in this research only affords correlational support (which by its very nature entails
problems with directionality) and does not provide conclusive evidence that cognitive change
is a specific and unique mechanism to CBT. Although reduced catastrophizing, for example, is
a frequently reported correlate of improvement, it is conceivable that the converse is also true
that positive pain-related improvement caused reduced maladaptive cognitions. To address
such dilemmas and ascertain that cognitive change causes positive outcomes, lagged and cross-
lagged panel research designs showing that cognitive change occurs before changes in outcome
are necessary. To the best of our knowledge, only two published articles have implemented this
approach. Using a longitudinal, cross-lagged panel analysis, Burns, Glenn, Bruehl, Harden, and
Lofland (2003) and Burns, Kubilus, Bruehl, Harden, and Lofland (2003b) found that changes in
pain catastrophizing, perceived pain helplessness, and pain anxiety during CBT interventions are
significant mediators of treatment-related gains in pain-related variables.
It is less clear whether other biopsychosocial treatments, albeit through different techniques
and not necessarily as a focus of treatment, engender the same cognitive changes. Associations
between changes in cognitive flexibility and outcomes have also been demonstrated in accep-
tance-based therapy for chronic pain (Vowles & McCracken, 2008, 2010). Further, if direct efforts
to change appraisals and beliefs about pain are unique mechanisms by which CBT produces good
outcomes, then changes in constructs such as catastrophizing should be largest in CBT compared
to control conditions. We report that pain catastrophizing decreased significantly in a CBT condi-
tion but not in a pain education condition (Thorn et al., 2011). However, Smeets, Vlaeyen, Kester
and Knottnerus (2006) reported that treatment-related reductions in catastrophizing mediated
outcomes of both CBT and an active physical treatment for low back pain. More research is needed
to clearly determine whether cognitive change is a specific mechanism distinct to CBT. The extant
data are certainly moving in the direction of testing questions of specific mechanisms, but study
designs and analyses have been far from adequate to allow firm conclusions to be drawn.
co n c l u s i o n s
The evolution of biopsychosocial treatments is taking place in a healthcare context in which
resources are scarce. Thus, to demonstrate the public health value of psychosocial pain treatments
and to foster acceptance and dissemination of these approaches, we must be able to verify that the
treatments produce desirable outcomes and that they do so because of the therapeutic procedures
Copyright © Springer Publishing Company, LLC
124 Day et al.
that the interventions entail. We need to show that the patient and therapist resources devoted
to a complex approach not only produce larger outcomes than a less involved approach but that
the more complex approach works via the hypothesized specific mechanism. If we cannot show
that the benefits of time-intensive biopsychosocial approaches are rooted in tangible therapeutic
mechanisms, then there is no reason why patients should not be routinely prescribed a low-cost,
low-impact intervention, such as group pain education, which may produce sufficient benefit.
With the ongoing proliferation of psychosocial pain treatments, it is easy to move from one to
another, concerned only that they “work”—again, compared to a wait-list control—and priding
ourselves that our interventions often “work” as well as biomedical approaches. What may prove
more beneficial is a different research approach that acknowledges and takes to heart the similar-
ities in outcomes across treatments.
By uncovering mechanisms, we may be able to discriminate “active” from “inactive” ingredi-
ents in expensive, time- and energy-consuming regimens. Distinguishing essential from nonessen-
tial elements will bring about order and parsimony and will allow us to develop more streamlined
treatment packages that distill down the true active principles of change. This process will also
allow us to preserve the core constituents of treatments developed in well-controlled efficacy tri-
als as they move into real-world settings where certain components may be diluted due to lack of
time or resources. Finally, uncovering mechanisms may allow us to better identify specific patient
groups for whom the treatment may work well or poorly. We hope that the next phase of evolu-
tion for psychosocial chronic pain treatment is not to go on to the next new “fourth wave,” but to
take stock of what we already have and determine how it all works.
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Correspondence regarding this article should be directed to Melissa A. Day, MA, University of Alabama,
Department of Psychology, Box 870356, Tuscaloosa, AL 35487-0348. E-mail: day014@crimson.ua.edu
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