Group Therapy for Chronic Pain

Melissa A. Day

Beverly E. Thorn

Group therapy continues to be an appealing and common method of chronic pain treatment delivery both in clinical and research settings.¹ First appearing over three decades ago in the pain management literature, case reports² and open clinical trials³^,⁴ began reporting on adapted individual treatments applied in small-group settings that explored the patient acceptability of a group format. Since that time, controlled trials have demonstrated the utility, efficacy, and cost-effectiveness of this mode of delivery, and the group format is commonly used in interdisciplinary pain management clinics for helping patients manage heterogeneous chronic painful conditions.

Although there are multiple levels of evidence, and each has advantages and disadvantages, in an evidence-based practice, randomized controlled trials (RCTs) provide stronger support.⁵ Therefore, the primary findings presented in this chapter are based on evidence emerging from searches of the scientific literature that were performed as recommended within the practice of evidence-based medicine.⁶ Specifically, the search implemented in the prior edition of this chapter that searched the literature dating back to 1980 until 2007 was extended to identify literature published between 2007 and August 2017. As per the prior edition, combinations of controlled vocabulary terms, keywords, and methodologic filters were used in an effort to identify the highest level of evidence currently available on group treatment of chronic pain. Details of these searches may be found in Appendix 87.1.

These literature searches revealed that RCTs have primarily evaluated five different types of groups: (1) cognitive-behavioral therapy (CBT) groups that focus on teaching pain selfmanagement skills; (2) mindfulness-based interventions (MBIs) including mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT); (3) acceptancebased approaches, primarily acceptance and commitment therapy (ACT); (4) education groups; and (5) supportive/expressive groups. Although the evidence has rapidly evolved to add further support to mindfulness and acceptance-based approaches since the last edition of this chapter, the vast majority of wellcontrolled trials of group-delivered treatments for chronic pain continue to be dominated by CBT, which has been shown to be an efficacious treatment of chronic pain; as a result, the focus of this chapter is on group CBT for the management of chronic pain conditions.

Rationale and Basic Considerations of Group Treatment for Pain

EVIDENCE FOR EFFICACY OF GROUP TREATMENT FOR CHRONIC PAIN MANAGEMENT

The highest level of evidence from an evidence-based practice viewpoint is meta-analyses and systematic reviews that quantitatively synthesize the evidence. To our knowledge, no meta-analyses or systematic reviews specifically of group CBT for chronic pain management have been published to date, although reviews of both individual- and group-delivered CBT (combined) have been published.⁷^,⁸ Our literature search revealed numerous controlled studies (both RCTs and non-RCTs) of cognitive and behavioral approaches that have compared (1) group treatment to individual treatment; (2) group treatment to wait-list controls, to treatment as usual, and to other kinds of group treatment (e.g., relaxation or education/support groups); and (3) behavioral group treatments to group exercise and physical therapy treatments. These are reviewed in the following text, followed by a description of the current evidence for group mindfulness- and acceptance-based approaches.

GROUP VERSUS INDIVIDUAL TREATMENT

Table 87.1 summarizes the controlled studies that have directly compared the efficacy of group-administered treatment to individually administered treatment for chronic pain.⁹^,¹⁰^,¹¹^,¹²^,¹³^,¹⁴^,¹⁵^,¹⁶ Relatively few studies have compared group to individual treatment, and we found only one further RCT specifically addressing this question since the prior edition,¹⁰ and one further RCT that compared group in-person delivered CBT to individually delivered CBT via the Internet.⁹ These studies have consistently demonstrated few meaningful differences in outcome between the two treatment modalities, and no differences were observed in the one study comparing in-person group therapy and online individual therapy.

One of the earliest RCTs comparing group to individual treatment¹⁴ found no differences in outcome between the two modes of treatment for headache patients with the exception that at the 6-month follow-up, participants in the group condition showed less of a tendency to drift back toward baseline levels of pain ratings. Because participants knew prior to treatment that they would be randomly assigned to group or individual treatment formats, posttreatment interviews queried their perceptions regarding the treatment modality to which they were ultimately assigned. Patients in group treatment highlighted the benefit of being able to share openly with other headache sufferers and to discuss their progress with others in the group. Patients in individual treatment valued the personalized attention given via the dyadic therapeutic relationship and expressed concern that group treatment would not have offered sufficient therapist time for each individual. Thus, patients who participated in each treatment modality seemed to highlight the positive aspects of the treatment modality to which they were assigned as the reasons why this would be the preferred mode of treatment.

Another early RCT focusing on patients with pain in the upper extremities also demonstrated minimal overall differences between individual and group treatment.¹⁵ At 6-month and 2-year follow-up, those who received the group treatment reported less pain-related interference than those who were treated individually, and treatment outcome was otherwise equally efficacious.¹⁵^,¹⁶ It is interesting to note that posttreatment satisfaction ratings were higher for individually treated patients, and individual treatment was more effective than group treatment on the outcome measure of self-reported coping strategies. One limitation of these early RCTs, however, was the relatively low number of participants in each condition, which limited the statistical power. A benefit of the studies was the collection of patient satisfaction data.

Several later trials confirmed these general findings. In patients with chronic low back pain, Rose et al.¹³ reported few differences in an RCT comparing patients treated individually and those treated in groups. Another RCT by Kääpä et al.¹⁰ examined group-delivered multidisciplinary treatment compared to individual physiotherapy for chronic low back pain and found few differences in outcome immediately following treatment

and at 6-, 12-, and 24-month follow-up; however, this study was limited by design features with the two conditions receiving different treatment doses and intervals. In a sample of patients with mixed chronic pain, Frettlöh and Kröner-Herwig¹² also found few statistically significant differences in treatment outcome between individual and group modalities, although the effect sizes in improvement at follow-up suggested that group treatment may have been superior to individual treatment.¹²

TABLE 87.1 Individual Versus Group Therapy

Authors	N	Study	Treatment Type	Treatment Components	Duration	Outcome Measures	Results	Limitations	Follow up (f/u)
de Boer et al.⁹	72 with nonspecific chronic pain	RCT	Group in-person CBT vs. individual Internetdelivered CBT	Same treatment components across conditions, included psychoeducation on CBT model and pain, graded activity, painstress connection, relaxation, pain cognitions, cognitive restructuring, disengaging attention from pain Online treatment group received personal feedback from psychologist via e-mail with the option for additional e-mail/phone contact in the case of technical problems, aggravated symptoms or additional questions.	Group CBT: seven 2-h weekly sessions and a booster session at 2 mo	Pain Catastrophizing Scale, VAS pain intensity, fatigue and interference, Pain Coping and Cognition List (PCCL), RAND-36	In ITT analyses, group = Internet on PCS pain catastrophizing, pain intensity, PCCL catastrophizing, pain coping, internal and external pain management, and aspects of global health-related QOL, with both significance improved at posttreatment and 2-mo f/u; in completer analyses, Internet > group on PCS, pain intensity, pain coping, and select QOL dimensions. No significant change in interference or fatigue. Internet course was considered costeffective relative to group delivery.	Brief f/u; time spent with psychologist in the online condition was not recorded.	2 mo
Kääpä et al.¹⁰	120 women with chronic low back pain	RCT	Group multidisciplinary rehabilitation (n = 59) vs. individual physiotherapy (n = 61)	Group treatment included physical training, workplace interventions, back school, relaxation training, and cognitive-behavioral stress management; individual treatment included physical exercise, massage, spine traction, manual spine mobilization, ultrasound	Group program was 70 h over 8 wk; individual program was ten 1-h sessions over 6-8 wk.	NRS for pain intensity, sciatic pain intensity, subjective working capacity; Oswestry disability; sick leave due to pain; health care consumption due to back pain; depression symptoms, belief in future working ability, and well-being	Group = individual at posttreatment and f/u, except for general wellbeing, which was better in the group condition at posttreatment. Both groups showed significant improvements in disability and health care consumption. Within group, the individual condition showed significantly improved pain intensity, whereas group-delivered showed improved subjective working ability, belief in future working ability.	Treatment dose and intervals differed according to group or individual assignment; some measures lacked adequate psychometric properties.	6, 12, and 24 mo
Turner-Stokes et al.¹¹	113 with mixed chronic pain	RCT	Group CBT (N = 66) vs. individual CBT (N = 47)	Group and individual: relaxation, cognitive coping strategies, activity pacing, encouraged to exercise by building up with achievable goals	Group: 1 full afternoon per week for 8 wk Individual: 1-h sessions every other week for 8 wk	West-Haven Yale Multidimensional Pain Inventory (WHYMPI), State-Trait Anxiety Inventory (STAI), Beck Depression Inventory (BDI), general activities, analgesic medication consumption, and pain severity	Both groups: significant improvements in pain interference, control over pain, and depression. Group = individual at f/u. Rapid improvements in group, slower improvements in individual. Differences leveled off at f/u. Group = individual overall	Treatment intervals differ according to group or individual assignment.	6-12 mo
Frettlöh and Kröner-Herwig¹²	102 with mixed chronic pain	Non-RCT^a	Group CBT (N = 34) vs. individual CBT (N = 34) vs. control (TAU) (N = 34)	Education, relaxation, imagery, cognitive restructuring	12 wk	Subjective disability, catastrophizing, depression, coping, pain diary	Group and individual > control for majority of outcomes. Group = individual for depression and most other measures. Larger effect sizes for group compared to individual at f/u.	Session duration not specified	6 mo
Rose et al.¹³	84 with chronic low back pain	RCT	Part 1: group CBT (N = 26) vs. individual CBT (N = 24) Part 2: compared 15-h (N = 22), 30-h (N = 22), or 60-h duration treatments	Education, cognitive therapy, graded aerobic exercise, relaxation	15, 30, or 60 h duration	VAS pain severity scale (0 to 100), Roland-Morris Disability Questionnaire, Modified Somatic Perception Questionnaire (MSPQ), Modified Zung Depression Inventory, Pain Locus of Control Scale, Pain Self-Efficacy Questionnaire	Individual = group treatments on outcome measures. Individual treatment more strongly associated with changes in disability and on MSPQ. No differences in program duration on outcome.	No control for baseline differences on some variables	6 mo
Johnson and Thorn¹⁴	22 with headache	RCT	Group CBT (GCBT) (N = 7) vs. individual CBT (ICBT) (N = 7) vs. wait-list control (WLC) (N = 8)	Psychoeducation, cognitive coping strategies, relaxation	5 weekly 90-min sessions	McGill Pain Questionnaire (MPQ), Brief Symptom Inventory (BSI), self-monitoring cards (for pain intensity, number of prescribed medications, number of OTC medications, number of prescribed pills consumed, number of OTC pills consumed)	Improvement in pain ratings and decrease in anxiety across groups from Times 1 to 2. Decreases in number of times individuals took medication and in number of different medications taken. GCBT = ICBT overall	Small sample size, limited power	1, 3, and 6 mo
Spence¹⁵,¹⁶ (2-y f/u)	45 chronic work-related pain of the upper extremity (19 followed at 2 y)	RCT	GCBT (N = 13) vs. ICBT (N = 14) vs. WLC (N = 15)	Goal setting, cognitive restructuring, relaxation, cognitive skills training, dealing with sleep problems, assertiveness training	9 weekly sessions at 1.5 h	BDI, STAI, Coping Strategies Questionnaire (CSQ), McGill Pain Rating Index (PRI), Sickness Impact Profile (self-report and other-report) Daily Self-Monitoring	GCBT and ICBT > WLC for reductions on all outcome measures. Improvements maintained at f/u. GCBT = ICBT 2-y f/u: less relapse for GCBT for pain ratings and interference, GCBT = ICBT for other outcomes	Small sample size, limited power	6 mo, 2 y
^aInformation obtained from English abstract only.
CBT, cognitive-behavioral therapy; ITT, intention-to-treat; NRS, Numerical Rating Scale; OTC, over-the-counter; PCS, Pain Catastrophizing Scale; QOL, quality of life; RCT, randomized controlled trial; TAU, treatment as usual; VAS, visual analog scale.

In another RCT of individuals with mixed chronic pain, Turner-Stokes et al.¹¹ compared outpatient group and individual therapies and found that both treatments resulted in improvements on measures of depression, anxiety, medication consumption, general activity, and pain severity. Those treated in a group showed greater initial gains than those treated individually, but these treatment differences were not sustained over time. Patients treated individually showed slower initial gains but evidenced the same benefits as those who had been treated in a group at the end of treatment. These authors also reported less of a tendency for the treatment gains made by individually treated patients to drift back toward baseline over time. In this study, however, group treatment was delivered for more hours at a time and over a shorter duration (8 weeks) than individual treatment (spread over 16 weeks), and this difference could explain the slower treatment gains witnessed with the individually treated patients.

Finally, one recent RCT compared group-delivered, inperson CBT to individual, Internet-delivered CBT.⁹ The results showed that both formats resulted in significant improvements across a number of important pain-related outcomes, with the Internet-delivered condition outperforming group therapy on some domains in the completer analyses, although the longevity of these effects was not fully examined. Other research now in progress is examining the utility and efficacy of groupdelivered telepain management programs that implement videoconferencing interfaces; these innovative delivery platforms have the potential to improve access to CBT in the future.¹⁷ Overall, the research comparing group to individually delivered treatment has generally concluded that there are very few meaningful differences between outcomes resulting from group and individually administered treatments for chronic pain.

GROUP COGNITIVE-BEHAVIORAL THERAPY VERSUS WAIT-LIST, TREATMENT AS USUAL, OR OTHER GROUP TREATMENTS

Table 87.2 summarizes the controlled studies that have compared the effects of group-administered CBT to wait-list control conditions, treatment as usual conditions, or other group treatments such as relaxation, education, or supportive/expressive group therapy.¹⁸^,¹⁹^,²⁰^,²¹^,²²^,²³^,²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹^,³⁰^,³¹^,³²^,³³^,³⁴^,³⁵^,³⁶^,³⁷^,³⁸^,³⁹^,⁴⁰^,⁴¹^,⁴²^,⁴³^,⁴⁴^,⁴⁵^,⁴⁶^,⁴⁷^,⁴⁸^,⁴⁹^,⁵⁰^,⁵¹^,⁵²^,⁵³^,⁵⁴^,⁵⁵^,⁵⁶^,⁵⁷^,⁵⁸^,⁵⁹^,⁶⁰^,⁶¹^,⁶²^,⁶³^,⁶⁴ Trials comparing CBT to MBIs and ACT are reported in Tables 87.3 and 87.4, respectively. There are an impressive number of controlled trials that have been carried out by different research groups focusing on different populations of individuals with pain that together establish the efficacy of CBT for chronic pain. Systematic reviews of these trials have been conducted that include both individual and group-delivered CBT formats across pain types and in children and adult populations; due to space limitations, not all of the studies reported in these reviews are included here.⁷^,⁸^,⁶⁵^,⁶⁶ In most cases, RCTs that compared group CBT to other types of group treatments also included a wait-list condition to control for the natural progression of the chronic pain disorder. In the following text, we highlight findings from select studies reported in Table 87.2 comparing group CBT to other types of group treatment because they have played an important role in identifying the effects of CBT; later in this chapter, we also describe a selection of studies that have examined the mechanisms underlying CBT treatment efficacy.

CBT is a generic term used to describe a complex and multifaceted treatment, and the included treatment components within group CBT protocols vary across studies and research groups. However, the general principles associated with CBT are typically consistent across studies (i.e., that one’s thoughts and feelings influence one’s ability to cope with pain and teaching pain self-management strategies). An overarching component of CBT includes strategies to educate patients about how the brain processes pain and psychological factors affecting pain perception. Furthermore, training in specific pain management skills almost always includes one or more modules on recognizing and modifying maladaptive or distorted pain-related automatic cognitions and beliefs, enhancing cognitive coping, learning relaxation strategies (including one or more types of relaxation techniques such as biofeedback, autogenic relaxation, progressive or passive muscle relaxation, meditation, and/or self-hypnosis), and completing regular homework assignments such as thought records or guided relaxation for skills acquisition. Frequently, but less consistently, CBT includes modules focusing on stress management (sometimes referred to as stress inoculation), paced physical activity, assertive communication, pleasant activity scheduling, and coping self-statements.

Because of the varied approaches that have all been subsumed under the label of CBT in the literature, it has historically been difficult to identify the specific treatment components that account for treatment efficacy, and this continues to be the case. There are a limited number of dismantling studies that have evaluated specific CBT components for pain management. However, controlling for nonspecific treatment effects (e.g., attention from therapist, expectations of health care provider and patient) is an important step toward determining the specific components of treatment efficacy as well as for elucidating specific and shared treatment mechanisms. Comparing patients receiving group treatment for chronic pain to those on a waitlist does not allow for this type of analysis, although wait-lists do control for the natural progression of the disorder over time and potential reactivity associated with self-monitoring or keeping pain diaries (if included as part of the study). The social context in which the treatment is administered is of particular relevance for the study of the active components of group treatment approaches. Therefore, studies comparing one type of group treatment to another type of group “attention control” treatment (e.g., support group) provide better evidence for disentangling the specific versus nonspecific treatment effects of CBT. Furthermore, comparing CBT to other active treatments demonstrates the relative effects and also allows for examination of whether the treatments exert benefit for the reasons proposed by the respective theory.

Although there is strong evidence for CBT delivered in nongroup formats in nonadult populations, most of the group CBT research to date has been conducted within adult populations with chronic back pain, headache, orofacial pain, or arthritis-related pain and to a lesser degree across an array of other pain conditions.⁶⁷ Systematic reviews of the CBT literature typically collapse across most pain types (indicative that the treatment approach and effects are sufficiently similar across these conditions to do so); however, headache and migraine are usually reviewed separately due to differences in the overall approach as well as history.⁸ More recently, the treatment of neuropathic pain was isolated within a systematic review and results showed that compared to nociceptive pain, neuropathic pain is particularly recalcitrant to treatment.⁷ The primary focus here is on adult populations; the specific type of pain investigated in each study is reported in the corresponding Table 87.2.

There continues to be a limited number of studies in which one group treatment for pain has been compared to another. One study in patients with fibromyalgia, for example, compared group education plus CBT versus group education plus group discussion (which controlled for the effects of attention).⁴⁴

These authors found that both groups showed equal improvements in pain coping and knowledge, and both were superior to a wait-list control condition. An economic evaluation of the treatments resulted in the authors’ suggestion that the extra health care costs associated with the addition of the CBT modules were not warranted based on the outcomes.⁴⁴^,⁶⁸ It is important to note that the education modules that were offered to all participants included structured physical fitness training after each of 12 sessions, and this behavioral component may have served to increase the overall outcome efficacy of both groups. Furthermore, the discussion modules (attention control) included weekly homework assignments, which is typical of CBT groups but atypical of control conditions. The authors suggest that the homework assignments may have served as a form of graded exposure for the fearful participants, thereby resulting in treatment gains in the control group. It is also important to mention that both treatment groups in the mentioned study used limited therapist time in an effort to reduce treatment costs. It may be that the principles associated with cognitive-behavioral change require some threshold amount of therapeutic intervention in order to be successfully implemented. These findings and others led Vlaeyen and colleagues⁴⁴ raise the important point that the active components of group treatment need further careful study.

TABLE 87.2 Group Cognitive and Behavioral Therapy Studies

Authors	N	Study	Treatment Type	Treatment Components	Duration	Outcome Measures	Results	Limitations	Follow up (f/u)
Thorn et al.¹⁸	290 with mixed chronic pain	RCT	Literacy-adapted CBT (n = 95) vs EDU (education) (n = 97) vs. treatment as usual (TAU) (n = 98)	CBT: psychoeducation, cognitive restructuring, activity pacing, relaxation, motivational reinforcement EDU: pain-related information provided, no specific skills-building exercises	Ten 1.5-h weekly sessions	Brief Pain Inventory intensity and interference, Patient Health Questionnaire-9	CBT = EDU at posttreatment, both > TAU on pain intensity and physical function; gains in intensity maintained at f/u for EDU but not CBT, gains in physical function maintained for both CBT and EDU. No significant changes in depression.	Participants were recruited from a single health care system, so a self-selection bias was possible.	6 mo
Helminen et al.¹⁹	111 with knee osteoarthritis, aged 35-75 y	RCT	CBT (n = 55) vs. medical TAU (n = 56)	CBT: psychoeducation on pain, problemsolving skills, relaxation, scheduling activities, cognitive appraisals and beliefs, assertiveness training	Six 2-h weekly sessions	Western Ontario and McMaster Universities Osteoarthritis Index Pain Scale, Pain Self-Efficacy Questionnaire, RAND-36 emotional well-being, Pain Catastrophizing Scale, Tampa Scale for Kinesiophobia (TSK), Beck Depression Inventory (BDI)	CBT = TAU on pain and function; CBT > TAU on well-being, TAU > CBT on self-efficacy. No significant differences at f/u.	Lack of fidelity monitoring, low recruitment to enrollment rate; baseline self-efficacy was high at baseline for both groups.	3 mo 12 mo
Linden et al.²⁰	103 with chronic low back pain	RCT	CBT (n = 53) vs. unspecified occupational therapy (OT; n = 50)	All participants treated for 21 d in an inpatient interdisciplinary rehabilitation unit. In addition: CBT group: gate control theory, stress reduction, problem solving, self-monitoring, cognitive restructuring, reducing avoidance, increasing activities, relaxation OT: additional OT sessions, playing games, motivated to engage in activities	Six 90-min sessions (3/wk)	Symptom Checklist-90, Rating of Health Locus of Control Attributions, Fear Avoidance Belief Questionnaire, VAS pain	All outcomes significantly improved in both groups; CBT > OT on pain and fear avoidance beliefs.	Lack of fidelity monitoring; effect of CBT in isolation from other interdisciplinary treatments not established; no f/u	—
Seminowicz et al.²¹	13 with mixed chronic pain vs. 13 healthy and age-matched controls (baseline only)	Nonrandomized trial	CBT (n = 13)	Self-regulatory skills such as relaxation, cognitive coping strategies such as cognitive restructuring, attention diversion methods, activity pacing, scheduling pleasant events, exercise, methods for enhancing social support	Eleven 1.5-h weekly sessions	Structural neuroplasticity (i.e., gray matter, GM), McGill Pain Questionnaire-Short-Form, Treatment Outcomes in Pain Survey, Short-Form Health Survey (SF-36), BDI, Coping Strategies Questionnaire	Increased GM post-CBT in the bilateral dorsolateral prefrontal, posterior parietal, subgenual anterior cingulate/orbitofrontal, and sensorimotor cortices as well as hippocampus; reduced GM in supplementary motor area. Most increases in GM became significantly greater than GM in controls. CBT-related reductions in pain catastrophizing and increases in pain control were correlated with several of these regional GM changes.	Small sample size; no comparison or randomization; lack of f/u	—
Slavin-Spenny et al.²²	147 with mixed headaches	RCT	Anger awareness and expression training (AAET; n = 50) vs. relaxation (n = 48) vs. WL (n = 49)	AAET: psychoeducation on stress-headache connection, experiential exercises for emotional awareness, assertive communication Relaxation: psychoeducation on stress-headache connection, progressive muscle relaxation, deep breathing, brief relaxation	Three 1-h weekly sessions	Self-Assessment Manikin, Headache Management Self-Efficacy Scale, Toronto Alexithymia Scale, Rathus Assertiveness Schedule, Emotional Approach Coping Scales, Migraine Disability Assessment Scale, headache frequency, severity and duration, Brief Symptom Inventory	AAET = relaxation on self-efficacy and headache outcomes, both > control. AAET significantly improved alexithymia, emotional processing, and assertiveness, compared to the other two conditions.	Lack of f/u; lack of fidelity monitoring; use of a college sample limits generalizability; no headache diagnostic information obtained; no daily diaries of headache outcomes	—
Heutink et al.²³	61 with neuropathic pain after SCI	RCT	CBT (n = 31) vs. WL (n = 30)	CBT: psychoeducation, ABC model, stress, movement and pain, assertiveness, relaxation, goals, social aspects; significant other attended first 2 sessions	Ten 3-h sessions over 10 wk and booster session 3 wk posttreatment	Chronic Pain Grade Questionnaire, Hospital Anxiety and Depression Scale, Utrecht Activities List, Life Satisfaction Questionnaire	CBT = WL on intensity and disability; CBT > WL on anxiety and participation in activities	Small sample size	3 and 6 mo
Thorn et al.²⁴	83 with mixed chronic pain	RCT	Literacy-adapted CBT (n = 49) vs. EDU (n = 34)	CBT: stress-pain connection, automatic thoughts, challenging automatic thoughts and beliefs, relaxation, coping statements, expressive writing, assertive communication EDU: psychoeducation on chronic pain treatment, gate control theory, costs of pain, acute vs. chronic pain, sleep, mood changes, pain behaviors, communication, working with health providers	Ten 1.5-h sessions over 10 wk	Brief Pain Inventory, Roland-Morris Disability Questionnaire (RMDQ), Pain Catastrophizing Scale, Center for Epidemiologic Studies Depression Scale, Quality of Life Scale	CBT = EDU; completer analysis showed CBT > EDU on catastrophizing and depression. Gains maintained at 6-mo f/u	Higher dropout rate in CBT; underpowered to detect effects of CBT compared to active treatment	6 mo
Lamb et al.²⁵	701 with subacute or chronic low back pain	RCT + costeffectiveness	Active management consultation + CBT (n = 468) vs. active management consultation only	Active management: active advice on remaining active, avoiding bed rest, medication/symptom management, also provided with The Back Book CBT: challenging negative thoughts and beliefs, pacing, graded activity, relaxation, activity, and avoidance	Active management: 15 min CBT: an individual 1.5-h assessment, six 1.5-h CBT sessions	Change in RMDQ and modified Von Korff scores at 12 mo	Consultation + CBT > consultation only on both primary outcomes; inclusion of CBT > cost-effectiveness	CBT delivered by a range of professionals with a 2-d training (physiotherapists, nurses, occupational therapists, psychologists)	12 mo
Van Koulil et al.²⁶	158 with fibromyalgia (FM)	RCT	Tailored CBT + exercise training vs. wait-list control	Pain avoidance or pain persistence treatment based on baseline cognitivebehavioral pattern Patient’s significant other attended 3rd, 9th, and 15th sessions	16 sessions of CBT (2 h) + exercise training (2 h) over 10 wk and 1 booster session at 3 mo	Pain, fatigue, functional disability, negative mood, and anxiety scales of the Impact of Rheumatic Diseases on General Health and Lifestyle (IRGL), Pain Coping Inventory	CBT + exercise > WL on all primary outcomes, with large effect sizes	Did not compare “tailored” to nontailored treatment; inert comparison	6 mo
Falcão et al.²⁷	60 females aged 18-65 y with FM	RCT	CBT (n = 30) vs. TAU (n = 30)	CBT: relaxation training, cognitive restructuring, stress management	CBT: 10 weekly 3-h sessions	VAS for pain, SF-36, State-Trait Anxiety Inventory, BDI, Fibromyalgia Impact Questionnaire, paracetamol	CBT > TAU on improved depression, mental health, and paracetamol. Both groups showed significant improvements on all indicators over time.	Dropouts were excluded from the analyses; limited f/u; participants had not received any prior treatment.	3 mo
Ersek et al.²⁸	256 with noncancer pain, ≥65 y	RCT	Pain selfmanagement (n = 133) vs. EDU (n = 123)	Self-management: education about persistent pain, problem solving, exercise for pain, relaxation training, pacing and activity scheduling, challenging negative thoughts, medication management, hot/cold packs EDU: read an assigned book, The Chronic Pain Workbook or Managing Your Pain Before It Manages You	Self-management, 7 weekly 90-min group sessions	Primary: RMDQ. Secondary: Geriatric Depression Scale, Brief Pain Inventory (intensity and interference)	Pain self-management = EDU at posttreatment and 6- and 12-mo f/u. Use of relaxation and exercise/stretching significantly increased in self-management	The number of strategies covered in selfmanagement may have limited effectiveness.	6, 12 mo
Thorn et al.²⁹	34 with headache	RCT compared order of treatment modules	CBT (N = 22) vs. WLC (N = 11)	Cognitive restructuring, cognitive coping, relaxation, assertiveness, behavioral pacing, homework	Ten 90-min group sessions	Pain Catastrophizing Scale (PCS), Pain Anxiety Symptoms Scale (PASS), Beck Depression Inventory-II (BDI-II), Headache Management Self-Efficacy Scale (HMSE), pain and medication via pain diaries; no difference in outcome based on order of treatment	CBT > WLC for improvements in catastrophizing, anxiety, headache management self-efficacy. 50% treated patients showed clinically significant reductions in headache frequency, medication use.	Small sample size rendered limited power to detect potential differences in order of treatment modules.	6, 12 mo
Li et al.³⁰	64 with work-related injuries	RCT	Training on work readiness (T) (N = 34) vs. control (C) (N = 30)	T: individual vocational counseling (3 sessions), CBT, pain and stress management, relaxation, stages of change assessment, job acquisition, preemployment training	T: 3 weekly group sessions at 2-3 h, three 1-h individual sessions	Spinal Function Sort (SFS), Loma Linda University Medical Centre Activity Sort (LLUMC), Chinese Lam Assessment of Stages of Employment Readiness (C-LASER), Chinese State Trait and Anxiety Inventory (C-STAI), SF-36	T > C for improvements in anxiety, work readiness, readiness to change, and perceived health status T: within-group improvements from baseline for most SF-36 subscales and physical capacity	Lack of f/u, stages of change may require longer time period for assessment	None specified
Linton et al.³¹	185 workers with back/neck pain	RCT	CBT (N = 69) vs. CBT and physical therapy (CBT 1 PT) (N = 69) vs. minimal treatment (N = 47)	CBT: problem solving, homework, skills training, stress management, relaxation CBT + PT: CBT plus personalized exercise program Minimal: medical visit and advice, educational booklet	6 weekly 2-h sessions	Sick absenteeism, health care visits, Outcome Evaluation Questionnaire, VAS pain ratings, HAD, PCS, TSK, activities of daily living (ADLs), RMDQ	CBT + PT = CBT for most measures. CBT + PT > Minimal for reductions in health care visits. At f/u: CBT + PT fewest sick days, followed by CBT and Minimal. Both treatment groups 5 times less likely to be on long-term sick leave than Minimal.	Different intervention lengths	1 y
Gold et al.³²	185 with vertebral fracture	RCT	Part 1: Intervention (I) (N = 94) vs. education control (EC) (N = 91) Part 2: Crossover: EC becomes I group after 6 mo. Initial I group selfmaintenance	I: exercise, coping skills (relaxation, stress reduction) EC: education of health issues for women	Part 1: I: 5 weekly exercise and coping sessions (225 min) EC: 1 weekly session at 45 min Part 2: I: self-maintain EC = I group	Trunk extension strength, Functional Status Index (FSI), Global Severity Index of Hopkins Symptom Checklist-Revised	Part 1: I > EC for improvement in trunk extension and psychological symptoms EC: worse for all three outcomes Part 2: EC showed withingroup improvements in trunk extension and psychological symptoms after intervention I: decrease in back strength from posttreatment, improvement in psychological state maintained	Different session lengths for I and EC, no control group at f/u. I group did not receive education in cross-over design.	6 mo
van Lankveld et al.³³	59 with rheumatoid arthritis (RA)	RCT compared couples to patient-only group	Couples (C) (N = 31) vs. patient-only (P) (N = 28)	Education, cognitive restructuring, encouragement to use active coping skills	C: 2 weekly 1.5-h sessions for 4 wk	Disease Activity Score (DAS): swollen joint count IRGL, Coping with Rheumatoid Stressors Questionnaire (CORS), Maudsley Marital Questionnaire (MMQ)	Sample improvements in disease activity, cognitions, coping, physical and psychological function (C = P). At f/u: C > P for improvements in diseaserelated communication with spouse.	Possible selection bias of highly invested couples because of study design	6 mo
Ersek et al.³⁴	45 elderly with chronic pain	RCT	Self-management (SM) (N = 17) vs. educational booklet (control) (EB) (N = 23)	SM: education, self-monitoring, communication, relaxation, individualized goals, homework EB: booklet with information about pain, medications, instructions for self-management, and pain resources	SM: 7 group sessions at 90 min	SF-36, Graded Chronic Pain Scale, Geriatric Depression Scale, Survey of Pain Attitudes (SOPA), survey assessing use of pain management strategies, treatment usefulness scales	SM > EB for improvements in pain intensity and physical role function (pre- to postchange); clinically significant improvement in 43% SM and 13% EB; SM = EB at f/u.	Brief f/u	3 mo
Tkachuk et al.³⁵	28 with irritable bowel syndrome (IBS)	RCT	CBT (n = 14) vs. home-based symptom monitoring with weekly telephone contact (SMTC) (n = 14)	CBT: education, relaxation, cognitive restructuring, assertiveness training SMTC: daily symptom monitoring, discussion of symptom patterns	Ten 90-min sessions for 9 wk	Daily monitoring IBS scores, BDI-II, cognitive emotional distress (CSFBD), trait anxiety (STAI-T), discomfort with assertion (AQ), quality of life (SF-36)	CBT > SMTC for pain relief ratings, improvement in GI symptoms, quality of life. Maintained at f/u. One-third treated patients experienced clinically significant improvement.	Brief f/u	3 mo
Mishra et al.³⁶	94 with chronic TMD	Urn method of assignment	CBT (n = 22), biofeedback (n = 23), CBT + biofeedback (n = 24), no treatment (n = 25)	CBT: self-change plain; relaxation training; distraction; pleasant activity scheduling; cognitive restructuring; social skills and assertive communication. Biofeedback: 15 min of temperature feedback and 15 min of electromyography (EMG) biofeedback Combined: include components of both of the above	12 sessions of 1.5 h, except for combined treatment which was 2 h; 2/wk for first 4 wk, 1/wk for other 4-wk	Characteristic Pain Intensity (CPI), Graded Chronic Pain Score (GCPS), Profile of Mood States (POMS)	CBT = biofeedback = combined and all 3 greater than no treatment on CPI and POMS. No significant pre- to posttreatment change was observed for GCPS across any group. Biofeedback improved the most compared to the no treatment control on CPI.	Combined treatment was a higher dose. Lack of f/u	—
Leibing et al.³⁷	55 with RA	RCT	CBT (N = 19) vs. TAU (N = 36), change in medication-matched control group (CN) (N = 20)	CBT: education, relaxation, cognitive restructuring, pain management, pleasant activity scheduling	CBT: 12 weekly sessions at 90 min	C-reactive protein (CRP), blood sedimentation rate (Westergren), swollen joint count, Hannover Functional Ability Questionnaire (HFAQ), medication types, VAS pain intensity, affective pain score, pain diary, STAI, Depression Scale (DS), Arthritis Helplessness Scale (AHI), Bernese Coping Modes	Overall increase in disease activity across sample CBT less progressive inflammation than TAU. CBT > CN for pain reduction, improvements in depression, anxiety, helplessness; CBT: improved depression, helplessness, positive coping from baseline	Potential type I error from multiple significance tests; lack of f/u	None specified
Potts et al.³⁸	60 with noncardiac chest pain	RCT	CBT (N = 34) vs. WLC (N = 26)	CBT: education, relaxation, biofeedback, graded exercise, challenging automatic thoughts, homework WLC: delayed treatment	6 sessions at 2 h	HADS, Nijmegen hyperventilation scale, Sickness Impact Profile (SIP), Nottingham Health Profile (NHP), chest pain diaries, hyperventilation: portable carbon dioxide monitor, exercise electrocardiography (ECG)	CBT > C for improvements in chest pain frequency, pain-free days, anxiety, and depression, disability, and exercise tolerance. Similar results for delayed treatment group once treated. Overall, 76% had improvements in chest pain. Maintained at f/u.	Lack of control group at f/u	6 mo
Cole³⁹	113 with mixed chronic pain	Non-RCT	CBT (N = 88) vs. TAU (N = 25)	Coping skills, pain self-management, adjustment, stress management, relaxation, self-esteem, positive thinking	75 min, 1 per week for 16 wk	Multidimensional Pain Inventory (MPI), Minnesota Multiphasic Personality Inventory-2 (MMPI-2), BDI Reported narcotic medication usage, health care visits, work status	CBT: decreases in BDI and MPI scores, and health care visits from baseline, increase in return to work f/u: medication decreased from 75% at baseline to 44%, health care visits decreased from 5/mo to 1/mo. Work status increased from 10% to 31%.	Patients not randomly assigned. No direct comparison between CBT and control groups.	1 y
Keel et al.⁴⁰	27 with FM	RCT	CBT (N = 14) vs. autogenic (N = 13)	CBT: stress inoculation, cognitive restructuring, activities for pain diversion, information, relaxation, group discussion, stretching, aerobic exercise Autogenic: practice relaxation	15 weekly sessions lasting 1-2 h	Freiburg Personality Inventory, Locus of Control Scale, Rosenzweig Picture-Frustration Diary (of active hours, resting hours, sleep index, pain intensity, and medication consumption), General Symptom Checklist	2 CBT clients vs. 1 autogenic had clinically significant improvement in medication consumption, physical therapies, sleep, pain scores, general symptoms At f/u, CBT > autogenic for improvement in pain ratings. 4 CBT vs. 0 autogenic had clinically significant improvements at f/u.	Small sample size; statistical analyses not described	3 mo
Keel et al.⁴¹	411 with low back pain	Non-RCT	Experimental (E) (N = 243) vs. standard physiotherapy (S) (N = 168)	E: coping strategies, stress management, relaxation, simulated work situations fitness training, education and group activity, individual physiotherapy or psychotherapy for acute pain S: mostly individual physiotherapy	E: 4-wk (27 d) inpatient program S: 3-wk (20 d) inpatient program	Work situation, physical activities, pain history, VAS pain rating, pain drawing, RMDQ, Psychological General Well-Being Index (PGWB), health costs, quality of life, impairment	E = S for improvements in functional ability, limitations in daily life, health care visits E: higher proportion of individuals in work rehabilitation (23% work incapacity decrease), E > S daily hours worked, decrease in professional handicaps; at f/u, larger proportion of S worsened	Preexisting differences between groups on demographic variables; different predominant treatment modalities in each condition (E = group, S = individual)	3 mo, 1 y
Basler et al.⁴²	94 with low back pain	RCT	CBT (N = 36) vs. TAU (N = 40)	Education, relaxation, modifying thoughts and feelings, pleasant activity scheduling, postural training	12 weekly sessions at 150 min	Pain diary (pain intensity, control over pain, medication consumption), Heidelberg Coping Scale (HCS), Dusseldorf Disability Scale (DDS)	CBT: decreases in pain intensity, improvements in coping with pain, mental performance, and disability Gains maintained at 6-mo f/u TAU: little or no change	High attrition rate at f/u	6 mo
van Dulmen et al.⁴³	45 with IBS	Non-RCT	CBT (N = 25) vs. WLC (N = 20)	Patient education (e.g., roles of cognitions, behaviors, in IBS), homework, discussion, progressive muscle relaxation	8 weekly sessions lasting for 2 h	Diary (duration of pain, daily avoidance behavior, GI complaints), Abdominal Complaint Inventory, Symptom Checklist 90 (SCL-90)	CBT > WLC for improvement in Daily Abdominal Complaint Score (DAC), duration, avoidance, and number of successful coping strategies delayed treatment group: decreases in DAC; improvements maintained at f/u	No WLC at f/u, wide range of f/u assessment times (6 mo-4 y)	Mean = 2.25 y
Vlaeyen et al.⁴⁴	131 with FM	RCT	Cognitive educational intervention (ECO; N = 47) vs. attention control condition of education and discussion (EDI; N = 39) vs. WLC (N = 40)	ECO: imaginative transformation of pain, relaxation and biofeedback, homework EDI: education, sharing thoughts with group members, listening to music, homework	ECO and EDI = 12 90-min sessions conducted in 6 wk	Pain cognition list, Coping Strategies Questionnaire (CSQ), Behavioral Approach Test, Pain Behavior Scale, McGill Pain Questionnaire (MPQ), Multidimensional Pain Locus of Control Scale, Checklist for Interpersonal Pain Behavior, Fear Survey Schedule, BDI	ECO = EDI for improvements in pain coping and knowledge EDI > WLC on knowledge and pain control. At 12-mo f/u, ECO = EDI, although ECO had an increase in pain intensity.	Potential confounding of treatment (EDI group shared thoughts, completed homework). Low education level of participants may have made ECO difficult.	12 mo
Newton-John et al.⁴⁵	44 with chronic back pain	RCT	CBT (N = 16) vs. electromyographic biofeedback (EMGBF; N = 16) vs. WLC (N = 12)	CBT: education, goal setting, relaxation, cognitive restructuring, homework EMGBF: education, diaphragmatic breathing, adaptation, homework	8 sessions at 1 h (2 sessions per week)	BDI, STAI, CSQ, Pain Disability Index, Pain Beliefs Questionnaire (PBQ)	CBT and EMGBF > WLC for improvements in intensity, disability, adaptive beliefs, and depression. Improvements maintained at f/u, along with improvements in anxiety and active coping	Small sample size per group	6 mo
James et al.⁴⁶	33 with headache	RCT	CBT with goals (goal group) (N = 13) vs. CBT with no goals (open group) (N = 13) vs. WLC (N = 7)	Both CBT groups: education, coping, developing appropriate self-talk, generalization of skills, relaxation Goal: specific time goals for coping with pain/stress Open: instructions to cope as long as possible	6 weekly sessions at 90 min	Goal specificity: coping with daily stressors and pain, daily self-monitoring, pain index, medication intake, downtime, Pain Behavior Questionnaire, SCL-90, SIP, BDI, STAI, Cognitive Coping Index	Goal and open groups > WLC for improvements in pain coping skills, goal group > open and WLC group for reduction of headache and nonnarcotic medication use	Lack of f/u period	None specified
Turner and Jensen⁴⁷	102 with low back pain	RCT	Relaxation (R) (N = 17) vs. cognitive therapy (C) (N = 21) vs. cognitive therapy and relaxation (CR) (N = 16) vs. WLC (N = 18)	R: imagery, progressive muscle relaxation (PMR) C: identify negative thoughts, counter negative automatic thoughts CR: combined treatment	6 weekly sessions at 2 h	VAS pain ratings, SIP, BDI, Observed Pain Behaviors, Cognitive Errors Questionnaire, BDI	R, C, and CR > WLC for improvements in pain ratings and disability. At f/u: all three patient groups improved. At both f/u, patients in all groups improved R = C = CR.	No comparison to control group at f/u, attrition rates for control condition	6, 12 mo
Kneebone and Martin⁴⁸	35 with headache	Non-RCT Compared couples to standard noncouple and control groups	Partners involved (PI) (N = 12) vs. no partners (NPI) (N = 10) vs. no treatment control (NTC) (N = 13)	PI and NPI: selfmonitoring, relaxation, cognitive restructuring, assertiveness, group process (e.g., support), homework PI: partners educated in reinforcement principles	10 weekly sessions at 1.5-2 h	Headache activity, intensity, medication usage, relaxation practice, Partner Involvement Questionnaire, Dyadic Adjustment Scale (DAS), self-monitoring forms	PI = NPI for relaxation time, PI > NPI for partner involvement: spouse assisted with relaxation PI: decrease headache activity from baseline NPI: decreased medication usage from baseline. NTC increased medication usage. At f/u: NPI > NTC for reductions in medication. Other measures: PI = NPI at f/u.	Potential for type 1 inflation; low motivation across treatment groups to practice relaxation	2, 12 mo
Nicholas et al.⁴⁹	58 with low back pain	RCT	Cognitive therapy (CT) + relaxation (N = 8) or CT (N = 10) vs. behavior therapy + relaxation (N = 9) or BT (N = 10) vs. attention (ATC; N = 10) and no attention control (N = 11)	All groups: physiotherapy, education, exercise CT: cognitive restructuring, distraction, imagery, self-monitoring BT: activity pacing, medication reduction, reinforcement Relaxation: PMR ATC: group discussion about back pain	Five 1.5- to 2-h sessions twice per week	Pain Rating Chart STAI, PBQ, CSQ, SIP, SIP-Others (SIP-O), medication intake, report of alternative treatments, visits to health care facilities	Sample improved on affective distress, functional impairment, medication use, and active coping. Both CBT groups and both BT groups > ATC and control for improvements in pain intensity, self-reported disability, pain beliefs, and active coping. BT > CBT for improvements in impairment. Improvements somewhat maintained at f/u.	Physiotherapy included as part of all treatments Small sample size	6, 12 mo
Subramanian⁵⁰,⁵¹	39 with mixed chronic pain Long-term f/u = 22	RCT	Structured group therapy (N = 19) vs. WLC (N = 20)	Therapy: stress management, relaxation cognitive restructuring (coping thoughts, self-defeating, selfenhancing thoughts), assertiveness training	8 weekly 2-h sessions	SIP, Pain level (0-10 scale) used a control variable Profile of Mood States (POMS), Social Support Questionnaire	Therapy > WLC for improvements in physical and psychosocial dysfunction, negative mood states. Within-group improvements also apparent. Long-term f/u: improvements maintained, improvement in pain severity observed, 77% improved from posttreatment to f/u, 36% reduction in prescription medication usage	No comparison group at longterm f/u	6 mo Long-term: 18-22 mo
Peters and Large⁵²	68 with chronic pain	RCT	Group inpatient program (IPMP) (N = 29) vs. Group outpatient program (OPMP) (N = 23) vs. control (C) (N = 16)	IPMP: education, pain management, relaxation, cognitive restructuring, exercise, vocational counseling, reinforcement OPMP: education, activity goal setting, exercise, medication and stress management, relaxation	Inpatient: 4 wk Outpatient: 9 weekly sessions at 2 h	BDI, MPQ, General Health Questionnaire (GHQ), SIP, Pain Behaviour Checklist, pain drawings, VAS ratings, VAS stair climbing test, physiologic measures, physical endurance	Sample improvements in disability, GHQ scores, BDI, and MPQ scores IPMP and OPMP > control for improvements in disability, VAS pain ratings, and pain behavior	Results may have been influenced by timing of the assessments; lack of f/u	None specified
Turner et al.⁵³	96 chronic low back pain patients	RCT	Group behavioral and aerobic exercise (BE) (N = 18) vs. behavioral therapy only (B) (N = 18) Aerobic exercise only (E) (N = 21) vs. WLC (N = 23)	BE: behavioral intervention followed by exercise in each session B: reinforcement role-playing, discussion, homework, communication E: Exercises 5 times per week	BE and B: 8 weekly 2-h sessions E: 5 weekly sessions	MPQ, SIP, Pain Behavior Checklist (PBC), PBCspouse ratings, Physical Work Capacity (PWC), Center for Epidemiologic Studies—Depression Scale (CES-D), recorded pain behaviors	All three groups improved more than the WLC from pre- to posttreatment, BE > WLC from preto posttreatment on self-report and observer rated pain behavior measures, BE > E on PBC Spouse ratings F/u: all treatment groups improved over time	Interaction with therapists varied by condition	6, 12 mo
Linton et al.⁵⁴	66 nurses with back pain	RCT	Physical and behavioral preventive intervention (PBI) (N = 36) vs. WLC (N = 30)	PBI: physical therapy, “low back school,” relaxation, pain control instruction, goal setting, problem solving, coping, identifying high-risk situations	PBI: 8 h/d for 5 wk	Daily pain diaries, VAS intensity, fatigue, anxiety, sleep, pain behavior, ADLs, BDI, AHI, marital satisfaction, absenteeism, medication intake	PBI > WLC for improvements in pain intensity, fatigue, pain behavior, sleep, ADLs, helplessness Most differences maintained at f/u	Use of nonstandardized measures of sleep quality, ADLs, marital satisfaction	6 mo
Puder⁵⁵	69 with mixed chronic pain	RCT	Stress inoculation training (SIT) (N = 31) vs. WLC (N = 38)	SIT: explaining treatment, reviewing progress, problem solving	10 weekly 2-h group sessions	Daily pain diary, nontreatment technique usage: psychological support, exercise, heat/cold, massage, TENS, injections	SIT > WLC for improvements in pain interference, coping, decreased analgesic intake, discontinuation of heat/cold, and home traction technique. No difference according to age. Improvements maintained at f/u.	Use of nonstandardized measures	1, 6 mo
Bradley et al.⁵⁶	53 with RA	RCT	Biofeedbackassisted CBT (N = 17) vs. structured group social support therapy (SGT) (N = 18), no adjunct treatment (NAT) (N = 18)	CBT: thermal biofeedback, education, relaxation, behavioral goal setting, self-rewards SGT: education, discussion of coping strategies, encouragement to develop improved strategies	CBT: 5 thermal sessions, 10 family/friend meetings SGT: 15 sessions family/friends	STAI, Depression Adjective Checklist (DACL), Health Locus of Control Scale (HLCS), AHI, pain behaviors, rheumatologist ratings of disease activity level, rheumatoid factor titers, sedimentation rate (Westergren)	CBT > SGT and NAT for decreases in pain behavior, pain ratings, rheumatoid activity (RAI), NAT: lower RAI scores than SGT SGT and NAT increased in depression and rheumatoid factor titer across assessments CBT and SGT > NAT for improvement in anxiety CBT maintained improvement at f/u	Session duration not specified	6 mo
Larsson et al.⁵⁷	36 high school students with tension/migraine headaches	RCT	Self Help Relaxation (SHR) (N = 12) vs. Problem Discussion Condition (PDC) (N = 10) vs. Untreated Self-Monitoring Condition (SM) (N = 12)	SHR: relaxation programs, rapid cue-controlled strategy, homework, help solving problems during relaxation PDC: discussion of conflicts in everyday life, role-play, identifying stressors, assertiveness	5 weekly sessions SHR = 3 h PDC = 7 h	Headache diary: frequency, duration headache free days, peak intensity, modified Depression Scale for Female adolescents, Children’s Manifest Anxiety Scale, Social Relationship-Competence Questionnaire (SRCQ)	Headache activity: Greatest reductions for SHR group, SHR > SM and PDC Headache sum and peak intensity: SHR > PDC during pre-f/u interval Headache duration and headache-free days: SHR > SM and PDC	Small sample size, different therapist interaction for two interventions	5 mo
Bradley et al.⁵⁸	33 with RA	RCT	Thermal biofeedback and group cognitive behavioral (CB = 11) vs. social support (SS = 10) vs. NAT (N = 12)	CB: thermal biofeedback, education, skills acquisition, self-instructional training, application SS: education, support, encouragement to develop own coping strategies NAT = control	CB: 5 individual thermal sessions, 10 family meetings SS: 15 family meetings	STAI, DACL, VAS ratings of pain intensity, unpleasantness, severity of morning stiffness, pain behaviors, HLCS, rheumatoid factor titers, Westergren, rheumatologist ratings of disease activity	CB > NAT group for significant decreases in pain intensity, pre- to posttreatment: CB less pain behavior from preto posttreatment, less rheumatoid activity, and rheumatoid factor titer. CB and SS less anxiety and depression. SS increase in sedimentation rate NAT: significant reduction in morning stiffness.	Small sample size, lack of f/u	None specified
Linton et al.⁵⁹ and Melin and Linton⁶⁰	28 with heterogeneous chronic pain 26 with heterogeneous chronic pain	RCT Long-term f/u	Regular treatment (RT) vs. applied relaxation and operant activities (RT + BT) vs. WLC	RT: prescribed treatment plan RT + BT: plan and relaxation training, operant training, reinforcement of well behaviors, decrease in medication	12 sessions	BDI, Activities of Daily Living questionnaire, self-monitoring of pain, medication consumption, sleep f/u measures also included pain, health, activity, level, sleep, occupation	RT + BT > RT and WLC for improvements in pain level and leisure activity Improvements maintained at f/u	Small sample size Long-term f/u: WLC group received individual treatment prior to assessment	14-16 mo
Moore and Chaney⁶¹	43 with mixed chronic pain	RCT	Couples group therapy (CBT) (N = 17) vs. patient-only group therapy (N = 14) vs. WLC (N = 12)	Couples and patient only: education, goal setting, problem solving, relaxation and controlled breathing, direct pain reduction method, coping strategies, homework	16-h program, couples: 8 biweekly 2-h sessions	VAS pain severity (patient and spouse) MMPI Hs, D, and Hy scales only, SIP, PARS IV Community Adjustment Scale (spouses), Locke-Wallace Marital Adjustment Test (LMAT), utilization of medical resources medication usage	Couples and patient-only groups > WLC for improvements in VAS ratings, pain severity and pain behavior ratings, somatization, and PARS (spouse rating) Patient-only groups > controls on LMAT and SIP scores Treatment gains maintained at f/u Couples = patient-only therapy	Small sample sizes for each condition	3, 7 mo
Cohen et al.⁶²	25 with chronic low back pain	RCT	Behavioral intervention (BT) (N = 13) vs. physical therapy (PT) (N = 12)	PT: pain control strategies, relaxation, exercise, pool therapy, use of body mechanics BT: goal setting, activity pacing, problem solving, assertiveness	10 weekly 2-h sessions	Physical Abilities and Walking Abilities testing, Knowledge and Functional Measure of Body Mechanics, CES-D, Psychological Adjustment to Role Scale (PARS-V)	PT: greater low back control and decreases in CES-D score. BT and PT: lower anxiety and depression per patients and significant others on PARS-V, others. Decreases in physical and activity limitations for both groups	Small sample size, validity data for some instruments not provided	None specified
Figueroa⁶³	15 tension headache patients	RCT	Behavior therapy (BT) (N = 5) vs. psychotherapy (P) (N = 5) vs. self-monitoring (SM; N = 5)	BT: problem solving, relaxation, anxiety management training, stress inoculation P: discussion, conflict resolution, discussion of stressful events	BT: seven 90-min sessions P: seven 90-min sessions (twice weekly)	Headache questionnaire, headache checklist (e.g., level of relaxation, number of headaches, duration, severity, medication usage, disability), self-monitoring forms	Pre to f/u: B > P and SM for improvements in perceived disability BT > SM for reductions in headache frequency and duration, medication usage, level of relaxation, and pain severity	Small sample size, use of nonstandardized measures	Time not specified
Turner⁶⁴	36 chronic low back pain patients	RCT	CBT (N = 13), vs. relaxation (N = 14) training, WLC/attention conditions (N = 9)	CBT: stress inoculation, behavioral goals, cognitive and affective responses to pain, coping self-statements, relaxation Wait-list/attention: gave daily pain ratings to therapist in weekly phone calls	5 weekly 90-min sessions	SIP, SIP Significant Other (SIP-O), VAS ratings, self-ratings of improvement, BDI, work hours, health care usage	CBT and relaxation groups > WLC for improvements in pain, depression, disability, and spousal ratings of physical and psychosocial function At f/u: CBT improved on SIP, SIP-O, pain severity, relaxation: worse pain severity 1.5- to 2-y f/u: both groups retain improvements, CBT > in hours worked per week	Small sample size	1 mo, 1.5-2 y
AQ, Assertiveness Questionnaire; CBT, cognitive-behavioral therapy; CSFBD, Cognitive Scale for Functional Bowel Disorders; GI, gastrointestinal; HADS, Hospital Anxiety and Depression Scale; IPMP, inpatient pain management program; OPMP, outpatient pain management program; RAI, Rheumatoid Activity Index; RCT, randomized controlled trial; SCI, spinal cord injury; STAI-T, State-Trait Anxiety Inventory-Trait Scale; TMD, temporomandibular disorder; VAS, Visual Analog Scale; WL, wait-list; WLC, wait-list control.