Extending the evidence base

So, overall, the evidence base appears to be very strong and in general supportive of CBT for chronic pain. This has been an active field of clinical research. The tools and techniques of CBT, both in isolation and in a programmatic multidisciplinary form, have been subject to evaluation with randomized controlled trials for the last 30 years. If we stand back to admire this picture it will all appear relatively well constructed and attractive. Closer examination, however, reveals some problems.

We should consider these trials perhaps as firstgeneration trials, which have a number of problems. First, many were designed to answer specific questions in specific settings, and were designed prior to the development of guidelines and standards of trials design and reporting such as CONSORT (see www. consort-statement.org/) who have recently introduced a revised statement to extend to trials concerned with nondrug interventions [26], and prior to the guidance offered by the Cochrane Collaboration (www. cochrane.org/). As a consequence, most of the individual trials entering the various meta-analyses reported above are small, bringing all the biases associated with small trials, most concerningly a lack of control over both type I and type II errors. Second, many of the trials are overcomplicated, comparing too many variations or types of therapy, and examining their effects on too many outcomes. In part, this arises from the complexity of the patient group, presenting with many disabilities that cannot meaningfully be captured in a primary outcome. Third, many of the trials have inadequate bias control mechanisms built into the design. In particular, infrequently reported are any attempts to control for the treatment quality: the training of the therapist, the allegiance of the therapist, the content of the therapy, whether it was delivered adequately, and its credibility with the patients. Fourth, the reliance on waiting list and no treatment controls rather than placebo controls causes problems of interpretation. Fifth, and related to this, the small numbers of patients and use of waiting list controls mean that it is difficult to maintain patients into trial beyond immediate post-treatment assessment. Therefore, the longer term effects of CBT remain largely a mystery. Although this is not a specific problem of trials of psychological therapy, it will become important to have some consideration of long-term effects for therapies that are aimed at self-management of lifelong health conditions. Finally, a serious problem for the discipline of psychology and first-generation trials has been the wholesale ignorance and avoidance of any concern with adverse effects of therapy. Rarely are adverse effects reported or discussed. It is not plausible that they do not exist, and the absence of their consideration undermines the credibility of psychotherapy as a clinical discipline.

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Natural Pain Management

Natural Pain Management

Do You Suffer From Chronic Pain? Do You Feel Like You Might Be Addicted to Pain Killers For Life? Are You Trapped on a Merry-Go-Round of Escalating Pain Tolerance That Might Eventually Mean That No Pain Killer Treats Your Condition Anymore? Have you been prescribed pain killers with dangerous side effects?

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