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Does Change Occur for the Reasons We Think It Does? A Test of Specific Therapeutic Operations During Cognitive-Behavioral Treatment of Chronic Pain

Burns, John W. PhD*; Nielson, Warren R. PhD; Jensen, Mark P. PhD; Heapy, Alicia PhD§,∥; Czlapinski, Rebecca MA§; Kerns, Robert D. PhD§,∥

The Clinical Journal of Pain: July 2015 - Volume 31 - Issue 7 - p 603–611
doi: 10.1097/AJP.0000000000000141
Original Articles

Objective: To examine the relative validity of 2 conceptual models—Specific, General—by which therapeutic mechanisms in cognitive-behavioral therapy (CBT) for chronic pain achieve favorable outcomes.

Methods: As part of a clinical trial of enhanced versus standard CBT, people with chronic pain received treatment consisting of 3 pain coping skill modules. In secondary analyses of a subsample (n=56), we examined pretreatment to session 4 (of 10 sessions) changes in Chronic Pain Coping Inventory subscales that corresponded to receipt of one of 3 modules; namely Relaxation, Exercise, and Cognitive Coping modules.

Results: Findings indicated that: (1) participants receiving the Relaxation module improved more than other groups in relaxation skills, and improved substantially on other coping skills, as well; (2) participants receiving Exercise and Cognitive Coping modules showed mixed improvements and did not improve more than other groups on exercise use or cognitive coping, respectively; and (3) measures of patient-therapist working alliance and patient expectations of treatment benefit at session three correlated significantly with some coping skills changes.

Discussion: Change with CBT may occur both by theory-specified mechanisms and general mechanisms. However, the results provide the most support for a General Mechanism model in which changes on coping skills have spreading effects on the use of other coping skills. Significant relationships between some skill changes and indexes of patient-therapist working alliance and outcome expectations suggest that nonspecific factors also play a role in treatment-related changes in the use of pain coping strategies.

*Department of Behavioral Sciences, Rush University Medical Center, Chicago, IL

Beryl & Richard Ivey Rheumatology Day Programs, St. Joseph’s Health Care, London, ON, Canada

University of Washington Medical Center, Seattle, WA

§VA Connecticut Healthcare System, West Haven

Yale University School of Medicine, New Haven, CT

The project is registered with (clinical trials identifier: NCT00108381).

This material is based upon work supported by Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Clinical Science Research and Development Service Merit Grant, and by the Health Services Research and Development Center of Innovation (CIN-13-407), West Haven, CT. The authors declare no conflict of interest.

Reprints: John W. Burns, PhD, Department of Behavioral Sciences, Rush University Medical Center, 1645 W Jackson Blvd, Chicago, IL 60612 (e-mail:

Received February 7, 2014

Received in revised form July 12, 2014

Accepted July 12, 2014

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