Specific and general therapeutic mechanisms in cognitive behavioral treatment of chronic pain
Abstract
OBJECTIVE: Many studies document efficacy of cognitive behavioral therapy (CBT) for chronic pain, but few studies have examined potential treatment mechanisms. In analyses of data from a controlled trial, we examined whether changes in attitudes toward adopting a pain self-management approach-CBT-specific mechanisms-and quality of working alliance and patient expectations-general mechanisms-early in treatment were related to later-treatment changes in outcomes. METHOD: Our sample was composed of 94 adults (primarily White; mean age: 55.3 years, SD = 11.7; 23% female) who participated in enhanced or standard CBT, and completed measures of attitudes toward self-management (mechanisms), pain intensity, pain interference, depressive symptoms and goal accomplishment (outcomes) at pretreatment, 4- and 8-week assessments, and posttreatment. Working alliance was measured at 4 and 8 weeks, and patient expectations at 3 weeks. RESULTS: Because the CBT conditions produced comparable improvements, we combined them. Precontemplation and action attitudes toward pain self-management showed significant quadratic trends over assessments such that 67% and 94.1% (respectively) of total pre-post changes occurred in the first 4 weeks. Outcomes showed only significant linear trends. Cross-lagged regressions revealed that pretreatment-to-4-week changes in action attitudes and 4-week levels of working alliance were related significantly with 4-week-to-posttreatment changes in pain intensity and interference but not vice versa and that 3-week patient expectations were related to 4-week-to-posttreatment changes in interference. Analyses in which mechanism factors were entered simultaneously revealed nonsignificant unique effects on outcomes. CONCLUSIONS: Adopting an action attitude early in treatment may represent a specific CBT mechanism but with effects held largely in common with 2 general mechanisms.
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In a lumbar fusion study, high pre-operative depression was the only significant predictor of failure to return to work after surgery, even when pre- and post-operative pain intensity were included.
“In multivariate analyses, high pre-operative symptoms of depression remained the only significant predictor of failure to return to work after surgery, even in multivariate models with pre- and post-operative pain intensity included.”
From Evaluating psychosocial contributions to chronic pain outcomes (2018) · cites this paper as [56]
Patients with pre-operative depression scores in the upper half were about one-third less likely to return to work, and those who returned took nearly twice as long after surgery to start working again.
“patients in the upper half of the distribution of pre-operative depression scores were approximately ⅓ less likely to return to work and, among those who did return, took nearly twice as long post-operatively to begin working again 56.”
From Evaluating psychosocial contributions to chronic pain outcomes (2018) · cites this paper as [56]
In that lumbar fusion study, depression fully mediated the prospective association between pain intensity and occupational disability.
“In this study, depression fully mediated the prospective association between pain intensity and occupational disability.”
From Evaluating psychosocial contributions to chronic pain outcomes (2018) · cites this paper as [56]
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“It was found to improve the QOL for patients with chronic pain conditions [20-23], especially by encouraging a problem-solving attitude in the patients receiving the treatment [24].”
Group Process as a Mechanism of Change in the Group Treatment of Anger and Aggression
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“At present, the treatment outcome literature is composed primarily of pre-to-post treatment comparisons and randomized control trials that have not been designed to evaluate mechanisms of change (Burns et al., 2015; Kazdin, 2007).”
BackgroundMun, C. J., Speed, T. J., Finan, P. H., Wideman, T. H., Quartana, P. J., & Smith, M. T. (2023) · International Journal of Behavioral Medicine · doi:10.1007/s12529-023-10184-z · Cited by 7 · see citing works
“Previous studies on CBT suggest that changes in both specific and general therapeutic mechanisms occur early in treatment [30–35].”
The Historical Evolution and Modern Research of the Alliance in Psychotherapy and Counseling
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Meta-analysis of pain and stress in emergency department patients
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“For each patient, taken to an emergency department, in accordance with current guidelines, it is decided whether the patient requires emergency diagnostics, hospitalization and surgery on an ad hoc basis or supply within the emergency department of further diagnosis and therapy [2-4].”
MethodFurther Examination of the Pain Stages of Change Questionnaires Among Chronic Low Back Pain Patients
Mun, C. J., Otis, J. D., Concato, J., Reid, M., Burg, M. M., Czlapinski, R. A., & Kerns, R. D. (2019) · Clinical Journal of Pain · doi:10.1097/ajp.0000000000000733 · Cited by 7 · see citing works
Self-citationCosio, D., & Swaroop, S. (2016) · Journal of Pain Management & Medicine · doi:10.35248/2684-1320.16.2.114 · Cited by 7 · see citing works
“Although establishing efficacy is vital, the bias toward efficacy in extant research has led to the neglect of important questions regarding whether mind-body medical interventions work because of the mechanisms specified by theory [61].”
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“, analyzing thoughts; [14]), whereas in an MBI, the patient is taught not to reframe negative thoughts but to notice and accept thoughts (e.”
BackgroundMechanisms in psychosocial treatments of chronic pain: What does the evidence tell us?
Burns, J. W. (2025) · Current Opinion in Psychology · doi:10.1016/j.copsyc.2025.102050 · Cited by 5 · see citing works
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Écija, C., Catalá, P., Furlong, L. V., Pastor-Mira, M. D. L. Á., & Peñacoba, C. (2022) · Pain Management Nursing · doi:10.1016/j.pmn.2022.05.007 · Cited by 5 · see citing works
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Japanese cross-cultural validation study of the Pain Stage of Change Questionnaire
Adachi, T., Sunohara, M., Enomoto, K., Sasaki, K., Sakaue, G., Fujita, Y., Mizuno, Y., Okamoto, Y., Miki, K., Yukioka, M., et al. (2019) · PAIN Reports · doi:10.1097/pr9.0000000000000711 · Cited by 4 · see citing works
“Moreover, decrease in the precontemplation and increases in the Contemplation, Action, and Maintenance have been shown to be associated with increases in use of adaptive coping strategies and improved outcomes.(5,10,12,21) To evaluate the utility of the PRC model, as well as to evaluate the role that readiness to self…”
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Education programs for people living with chronic pain: a scoping review
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Cognitive behavioral therapy for chronic pain and opioid use disorder
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The role of the patient–clinician relationship in Chronic Pain Interventions: A systematic review
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“Participants were classified as average (WHYMPI-I score ≤ 4.4) or above average (WHYMPI-I score > 4.4; Burns et al., 2015; Kerns et al., 1985) interference.”
InfluentialSelf-citationLin, D., Koenig, C., Kaplan, S., Bittner, M., Paraiso, M., Buhn, N., Stokes, E., Ho, I., Lotz, J. C., Davidson, J. M., et al. (2025) · International Conference on Information and Computer Technologies (ICICT) · doi:10.1109/icict64582.2025.00067 · Cited by 2 · see citing works
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Chronic pain – definitions, models and cognitive-behavioural therapy
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Further Examination of the Pain Stages of Change Questionnaires Among Chronic Low Back Pain Patients
Mun, C. J., Otis, J. D., Concato, J., Reid, M., Burg, M. M., Czlapinski, R. A., & Kerns, R. D. (2019) · Clinical Journal of Pain · doi:10.1097/ajp.0000000000000796 · Cited by 2 · see citing works
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“64,65 Taken together, broader literature shows that social relationships and connection play a critical role in either impairing or facilitating the individual ’ s adjustment to and management of their CP.”
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“In a sample of adult patients with chronic pain, Burns et al. (2015) found that the therapeutic alliance during treat-ment is related to pain intensity post‐treatment, where a stronger perceived alliance was associated with less pain.”
Aliança terapêutica nos contextos de saúde e nos processos de adoecimento
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A Clinician’s Perspective on Treating Patients Suffering from Insomnia and Pain
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“Part-time employment 20 (12) Others 20 (12) Retirement 16 (9) Not working unrelated to pain 16 (9) Pain-related compensation Yes 14 (8) Prior surgery for pain treatment Yes 40 (23) Current pain treatments Medication 136 (79) Nerve block 52 (30) Exercise 44 (25) Other types of rehabilitation (eg, massage, hot-cold pack…”
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Intervenciones psicológicas para el tratamiento de la fibromialgia: una revisión narrativa
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Non-procedural Interventions for Chronic Pain
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Japanese cross-cultural validation study of the Pain Stage of Change Questionnaire.
安達, 友., 榎本, 聖., 新田, 一., 岩下成人, 北川, 裕., 柴田, 政., 福井, 弥., Adachi, T., Sunohara, M., Enomoto, K., et al. (2019) · Institutional Repositories DataBase (IRDB)
Self-citation
- Authors
- Burns, J. W., Nielson, W. R., Jensen, M. P., Heapy, A., Czlapinski, R., & Kerns, R. D.
- Affiliations
- Rush University Medical Center (US)
- St Joseph's Health Care (CA)
- University of Washington Medical Center (US)
- VA Connecticut Healthcare System (US)
- Venue
- Journal of Consulting and Clinical Psychology
- Published
- 2015
- Volume
- 83
- Issue
- 1
- Pages
- 1-11
- ISSN
- 0022-006X (ISSN-L)
- 1939-2117
- OpenAlex
- W2036053437
- Cited by
- 77
- References
- 50
- Citations by year
- 2026: 4 · 2025: 10 · 2024: 1 · 2023: 8 · 2022: 7 · 2021: 6 · 2020: 8 · 2019: 8 · 2018: 8 · 2017: 6 · 2016: 8 · 2015: 3
- FWCI
- 4.12
- Type
- journal article
- Language
- en
- Open access
- closed
- Locations
- Journal of Consulting and Clinical Psychology (publishedVersion)
- PubMed (publishedVersion)
- Funders
- Department of Veterans Affairs
- Health Services Research and Development Research Enhancement Award Program (REA 08-266)
- Topics
- Health Sciences › Medicine › Pharmacology › Musculoskeletal pain and rehabilitation
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
- Keywords
- cognitive behavioral therapy, chronic pain, therapeutic mechanisms, pain self-management, therapeutic relationship, patient expectations, pain intensity, pain interference, depressive symptoms, goal achievement, precontemplation
- MeSH terms
- Adult, Aged, Female, Humans, Male, Middle Aged, Outcome and Process Assessment, Health Care, Cognitive Behavioral Therapy, Chronic Pain
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