Examining the evidence about psychological treatments for chronic pain: Time for a paradigm shift?

Psychological interventions are now well established as a core part of modern pain practice. Randomized controlled trials (RCT) of psychological treatment for chronic pain were first performed in the 1970s, and considerable effort, skill, and sophistication have been applied to establishing the evidence of effectiveness 26. Over the last 2 decades, we and others have conducted systematic reviews and meta-analyses of psychological interventions, predominantly cognitive behaviour therapy (CBT), for chronic pain 3,6,8,16,17,27,40. Meta-analysis facilitates the emergence of underlying patterns in data by controlling the bias and error inherent in individual studies. These meta-analyses suggest that, overall, CBT has a beneficial average effect for a range of outcomes, principally disability, depression, and pain experience. Evidence of harm is not available. Although the headline effect is positive, current analyses are limited to average results, and conclusions are typically confined to the general. The aim of this topical review is to consider the next steps in developing and evaluating psychological treatments for chronic pain. In this examination, we take as our unit of analysis the meta-analyses rather than individual RCTs. We briefly summarize the results of the meta-analyses, their benefits, and their limits, then offer directions for improving the next generation of studies. We argue that we have reached a critical point in the evolution of psychological interventions, and a paradigm shift is now needed in how we investigate treatment efficacy, effectiveness, and harm.