Systematic review and meta-analysis of randomized controlled trials of cognitive behaviour therapy and behaviour therapy for chronic pain in adults, excluding headache
Abstract
A computer and a hand search of the literature recovered 33 papers from which 25 trials suitable for meta-analysis were identified. We compared the effectiveness of cognitive-behavioural treatments with the waiting list control and alternative treatment control conditions. There was a great diversity of measurements which we grouped into domains representing major facets of pain. Effect sizes, corrected for measurement unreliability, were estimated for each domain. When compared with the waiting list control conditions cognitive-behavioural treatments were associated with significant effect sizes on all domains of measurement (median effect size across domains = 0.5). Comparison with alternative active treatments revealed that cognitive-behavioural treatments produced significantly greater changes for the domains of pain experience, cognitive coping and appraisal (positive coping measures), and reduced behavioural expression of pain. Differences on the following domains were not significant; mood/affect (depression and other, non-depression, measures), cognitive coping and appraisal (negative, e.g. catastrophization), and social role functioning. We conclude that active psychological treatments based on the principle of cognitive behavioural therapy are effective. We discuss the results with reference to the complexity and quality of the trials.
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Over the past 30 years, empirical evidence has established that psychosocial treatment of chronic pain is efficacious beyond standard medical care.
“Over the past 30 years, a substantial body of empirical evidence has accrued establishing the efficacy of psychosocial treatment of chronic pain beyond the effects of standard medical care”
From Mindfulness and cognitive-behavioral interventions for chronic pain: Differential effects on daily pain reactivity and stress reactivity (2015) · cites this paper as Morley, Eccleston, & Williams, 1999
Cognitive Behavioral Therapy (on which PMPs are based) is an effective intervention in the management of chronic pain.
“An early systematic review in 1999 [28], which was subsequently updated in 2012 as a Cochrane review [29], concluded that Cognitive Behavioral Therapy (CBT) (on which PMPs are based) is an effective intervention in the armoury of the management of chronic pain.”
Cognitive-behavioural therapy (CBT) is the standard psychological treatment for people with chronic pain.
“Cognitive–behavioural therapy (CBT) is the standard psychological treatment for people with chronic pain6–11”
CBT has a significant record of success in the treatment of chronic pain.
“Cognitive Behavioral Therapy (CBT) has a significant record of success in the treatment of chronic pain (e.g., Hoffman, Papas, Chatkoff, & Kerns, 2007; Morley, Eccleston, & Williams, 1999).”
From Acceptance and values-based action in chronic pain: A three-year follow-up analysis of treatment effectiveness and process (2011) · cites this paper as Morley, Eccleston, & Williams, 1999
Cognitive Behavioural Therapies (CBT) are often effectively used to change the client's focus from the pain itself to the impact the pain is having on their functioning.
“In such cases, Cognitive Behavioural Therapies (CBT) are often effectively used to change the client's focus from the pain itself, to the impact the pain is having on their functioning 5, 6 .”
From The Effectiveness of an Acceptance and Commitment Therapy Self-help Intervention for Chronic Pain. (2010) · cites this paper as [6]
Usually, the effects of CBT for CLBP are moderate, around d = .6.
“Usually, the effects of CBT for CLBP are moderate, around d = .6 (Chou et al., 2017; Morley et al., 1999).”
From Exposure and CBT for chronic back pain: An RCT on differential efficacy and optimal length of treatment (2018) · cites this paper as Morley et al., 1999
During the past 20 years, numerous studies have demonstrated that behavioral and psychosocial protocols can benefit patients with persistent pain.
“During the past 20 years, numerous studies have demonstrated that behavioral and psychosocial protocols can benefit patients with persistent pain.”
From Psychological aspects of persistent pain: Current state of the science (2004) · cites this paper as [82]
Morley et al. (1999) found an effect size of 0.50 for cognitive coping and appraisal in chronic pain compared with wait list.
“| 16 | Cognitive coping and appraisal | Wait list | 0.50 | 69 |”
From The empirical status of cognitive-behavioral therapy: A review of meta-analyses (2006) · cites this paper as Morley et al. (1999)
Morley et al. (1999) found an effect size of 0.61 for social role functioning in chronic pain compared with wait list.
“| 15 | Social role functioning | Wait list | 0.61 | 73 |”
From The empirical status of cognitive-behavioral therapy: A review of meta-analyses (2006) · cites this paper as Morley et al. (1999)
Morley et al. (1999) found an effect size of 0.06 for mood in chronic pain compared with a heterogeneous collection of treatments.
“| 24 | Mood | | 0.06 | 53 |”
From The empirical status of cognitive-behavioral therapy: A review of meta-analyses (2006) · cites this paper as Morley et al. (1999)
Morley et al. (1999) found an effect size of 0.33 for cognitive coping and appraisal in chronic pain compared with a heterogeneous collection of treatments.
“| 23 | Cognitive coping and appraisal | | 0.33 | 63 |”
From The empirical status of cognitive-behavioral therapy: A review of meta-analyses (2006) · cites this paper as Morley et al. (1999)
Morley et al. (1999) found an effect size of 0.49 for pain expression behavior in chronic pain compared with wait list.
“| 5 | Pain expression behavior | Wait list | 0.49 | 69 |”
From The empirical status of cognitive-behavioral therapy: A review of meta-analyses (2006) · cites this paper as Morley et al. (1999)
Morley et al. (1999) found an effect size of 0.33 for pain experience in chronic pain (not headache) compared with wait list.
“Morley et al. (1999) | 16 | Pain experience | Wait list | 0.33 | 63 |”
From The empirical status of cognitive-behavioral therapy: A review of meta-analyses (2006) · cites this paper as Morley et al. (1999)
Morley et al. (1999) found an effect size of 0.26 for pain experience in chronic pain compared with a heterogeneous collection of treatments (not including behavior therapy or biofeedback).
“| 17 | Pain experience | Heterogeneous collection of treatments (not including behavior therapy or biofeedback) | 0.26 | 60 |”
From The empirical status of cognitive-behavioral therapy: A review of meta-analyses (2006) · cites this paper as Morley et al. (1999)
Morley et al. (1999) found an effect size of 0.48 for activity level in chronic pain compared with wait list.
“| 7 | Activity level | Wait list | 0.48 | 69 |”
From The empirical status of cognitive-behavioral therapy: A review of meta-analyses (2006) · cites this paper as Morley et al. (1999)
Morley et al. (1999) found an effect size of 0.40 for mood in chronic pain compared with wait list.
“| 22 | Mood | Wait list | 0.40 | 66 |”
From The empirical status of cognitive-behavioral therapy: A review of meta-analyses (2006) · cites this paper as Morley et al. (1999)
Morley et al. (1999) found an effect size of 0.31 for pain expression behavior in chronic pain compared with a heterogeneous collection of treatments.
“| 8 | Pain expression behavior | | 0.31 | 62 |”
From The empirical status of cognitive-behavioral therapy: A review of meta-analyses (2006) · cites this paper as Morley et al. (1999)
Morley et al. (1999) found an effect size of 0.10 for social role functioning in chronic pain compared with a heterogeneous collection of treatments.
“| 10 | Social role functioning | | 0.10 | 54 |”
From The empirical status of cognitive-behavioral therapy: A review of meta-analyses (2006) · cites this paper as Morley et al. (1999)
Cognitive treatments were significantly superior to waiting list on all domains except the expression of pain behavior, with a weighted grand mean ES of 0.46.
“Cognitive treatments were significantly superior to waiting list on all domains except the expression of pain behavior, with a weighted grand mean ES of 0.46.”
From The empirical status of cognitive-behavioral therapy: A review of meta-analyses (2006) · cites this paper as Morley, Eccleston, and Williams (1999)
Across domains, effect sizes for cognitive treatments were generally larger than those for behavior therapy, although there were fewer trials with behavior therapy.
“Across domains, the effect sizes for cognitive treatments were generally larger than those for behavior therapy, although there were fewer trials with behavior therapy.”
From The empirical status of cognitive-behavioral therapy: A review of meta-analyses (2006) · cites this paper as Morley, Eccleston, and Williams (1999)
When CBT was compared to a heterogeneous collection of alternative treatments (not including behavior therapy or biofeedback), it was superior in reducing pain experience, increasing positive cognitive coping and appraisal, and reducing behavioral expression of pain.
“When CBT was compared to a heterogeneous collection of alternative treatments (not including behavior therapy or biofeedback), it was found to be superior in reducing pain experience, increasing positive cognitive coping and appraisal, and reducing behavioral expression of pain.”
From The empirical status of cognitive-behavioral therapy: A review of meta-analyses (2006) · cites this paper as Morley, Eccleston, and Williams (1999)
These findings are consistent with previous studies demonstrating benefits of cognitive and behaviorally oriented approaches to managing fibromyalgia delivered in traditional face-to-face formats.
“These findings are consistent with previous studies demonstrating the benefits of cognitive and behaviorally oriented approaches to managing FM delivered in traditional face-to-face formats [40; 68; 67; 61].”
From Internet-enhanced management of fibromyalgia: A randomized controlled trial (2010) · cites this paper as [40]
Both CBT and ACT interventions can improve a person's quality of life, pain acceptance, functioning, and self-efficacy while also having the potential to reduce pain, depressive symptoms, and distress.
“Both types of interventions can improve a person’s quality of life, pain acceptance, functioning, and self-efficacy while also having the potential to reduce pain, depressive symptoms, and distress [10-18].”
From A User-Centered Approach to an Evidence-Based Electronic Health Pain Management Intervention for People With Chronic Pain: Design and Development of EPIO (2020) · cites this paper as [16]
CBT- and ACT-based psychological interventions have been shown to be effective, improving quality of life, depressive symptoms, and pain acceptance for people living with chronic pain.
“CBT- and ACT-based psychological interventions have been shown to be effective, improving quality of life, depressive symptoms, and pain acceptance for people living with chronic pain [10,11,13,14,16,66,67].”
From A User-Centered Approach to an Evidence-Based Electronic Health Pain Management Intervention for People With Chronic Pain: Design and Development of EPIO (2020) · cites this paper as [16]
One of the important challenges to be met within current CBT approaches to chronic pain is the challenge of treatment processes or mechanisms.
“One of the important challenges to be met within current CBT approaches to chronic pain is the challenge of treatment processes or mechanisms. 62,64,74,94”
From The Psychological Flexibility Model: A Basis for Integration and Progress in Psychological Approaches to Chronic Pain Management (2014) · cites this paper as [64]
The evidence for CBT for chronic pain is supportive.
“Generally the evidence for CBT for chronic pain is supportive.4, 22”
From A Trial of a Brief Group-Based Form of Acceptance and Commitment Therapy (ACT) for Chronic Pain in General Practice: Pilot Outcome and Process Results (2013) · cites this paper as [22]
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- Authors
- Morley, S., Eccleston, C., & Williams, A.
- Affiliations
- University of Leeds (GB)
- University of Bath (GB)
- University of London (GB)
- Corresponding author
- Morley, Stephen
- Venue
- Pain
- Published
- 1999-03-01
- Volume
- 80
- Issue
- 1
- Pages
- 1-13
- ISSN
- 0304-3959 (ISSN-L)
- OpenAlex
- W2079711079
- Cited by
- 1,597
- References
- 72
- Citations by year
- 2026: 11 · 2025: 16 · 2024: 24 · 2023: 18 · 2022: 32 · 2021: 50 · 2020: 35 · 2019: 43 · 2018: 49 · 2017: 56 · 2016: 63 · 2015: 63 · 2014: 72 · 2013: 90 · 2012: 96
- FWCI
- 5.69
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Pain (publishedVersion)
- PubMed (publishedVersion)
- UCL Discovery (University College London) (submittedVersion)
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- cognitive behavioral therapy, behavior therapy, chronic pain, psychological intervention, pain coping, pain catastrophizing, pain expression, depression, social role functioning, treatment effectiveness
- MeSH terms
- Adult, Behavior Therapy, Chronic Disease, Female, Humans, Male, Middle Aged, Pain, Research Design, Cognitive Behavioral Therapy, Randomized Controlled Trials as Topic, Sample Size, Pain Management
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
What counts as a claim ›How we measure confidence ›How we check this ›
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