Future Of Cbt For Chronic Pain

Clinical researchers are constantly striving to improve the effectiveness of treatments. A traditional strategy has been to try to identify characteristics that define patient responsiveness to treatment and to use these criteria in several ways: (1) to select patients; (2) to attempt to understand what it is about these characteristics that influence responsiveness to treatments; or (3) to develop customized treatments for specific subgroups of patients. On balance, this approach has yet to be successful. The major issues in developing customized treatments are discussed in a special section of the Clinical Journal of Pain.53[V] Rather than pursue these arguments in detail, we suggest that future development in this field may occur in the following ways.

• Refining the theoretical understanding of chronic pain and the development of more specific treatments. The fear-avoidance model9 is an example of a model-driven approach for which there is some evidence from replicated single case series45, 47[III] and two small RCTs.54,55[II] A second example is the development of a new formulation of chronic pain. Whereas traditional CBT has focused directly on teaching coping strategies and restoring behavioral function, "third-wave CBT'' based around the concept of acceptance approaches the problem from a different stance.56 It is not possible to convey the details of this approach here, but the key issue is that it invites pain sufferers to consider how they can develop valued lives in the presence of persistent pain (see Chapter 13, Psychological effects of chronic pain: an overview). Initial studies, including uncontrolled case series and a small RCT,57[II], 58,59 [IV] indicate the feasibility and promise of the approach.

• Identifying key cognitive and behavioral changes that mediate outcomes and the therapeutic actions that facilitate these changes. Despite a significant number of randomized controlled trials, there are relatively few studies that have examined processes of change. RCTs provide an opportunity to identify moderators and mediators of treatment and the statistical techniques to model these data are available. Burns and colleagues have tested these methods in single cohort studies60,61[IV] and Turner et al. have recently applied the method to data from a high quality RCT.62[II]

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