title: 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.
  
  
  METHODS
  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.
authors: Department of Behavioral Sciences, Rush University Medical Center.
authors: John W
authors: JW
authors: Burns
authors: Beryl and Richard Ivey Rheumatology Day Programs, St. Joseph's Health Care London.
authors: Warren R
authors: WR
authors: Nielson
authors: Department of Rehabilitation Medicine, University of Washington Medical Center.
authors: Mark P
authors: MP
authors: Jensen
authors: Pain Research, Informatics, Multimorbidities and Education (PRIME) Center/Research Service, Veterans Affairs Connecticut Healthcare System.
authors: Alicia
authors: A
authors: Heapy
authors: Pain Research, Informatics, Multimorbidities and Education (PRIME) Center/Research Service, Veterans Affairs Connecticut Healthcare System.
authors: Rebecca
authors: R
authors: Czlapinski
authors: Pain Research, Informatics, Multimorbidities and Education (PRIME) Center/Research Service, Veterans Affairs Connecticut Healthcare System.
authors: Robert D
authors: RD
authors: Kerns
mesh_terms: D000328:Adult; D000368:Aged; D059350:Chronic Pain / Q000628:therapy*; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care