Department of Behavioral Sciences, Rush University Medical Center.
Beryl and Richard Ivey Rheumatology Day Programs, St. Joseph's Health Care London.
J Consult Clin Psychol. 2015 Feb;83(1):1-11. doi: 10.1037/a0037208. Epub 2014 Jun 30.
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.
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.
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.
Adopting an action attitude early in treatment may represent a specific CBT mechanism but with effects held largely in common with 2 general mechanisms.
许多研究都记录了认知行为疗法（CBT）对慢性疼痛的疗效，但很少有研究探讨潜在的治疗机制。在对一项对照试验数据的分析中，我们研究了治疗早期对采用疼痛自我管理方法（CBT 特定机制）的态度以及治疗早期对工作联盟质量和患者期望（一般机制）的改变是否与后期治疗结果的改变有关。
我们的样本由 94 名成年人组成（主要为白人；平均年龄：55.3 岁，标准差=11.7；23%为女性），他们参加了强化或标准 CBT，并在治疗前、4 周和 8 周评估以及治疗后完成了对自我管理（机制）、疼痛强度、疼痛干扰、抑郁症状和目标完成（结果）的态度、工作联盟（4 周和 8 周）和患者期望（3 周）的测量。
由于 CBT 条件产生了可比的改善，我们将它们合并。对疼痛自我管理的前沉思和行动态度在评估中呈现出显著的二次趋势，即 67%和 94.1%（分别）的总前后变化发生在最初的 4 周内。结果仅显示出显著的线性趋势。交叉滞后回归显示，治疗前到 4 周的行动态度变化和 4 周的工作联盟水平与 4 周到治疗后的疼痛强度和干扰变化显著相关，但反之则不相关，而 3 周的患者期望与 4 周到治疗后的干扰变化相关。在同时纳入机制因素的分析中，结果显示对结局没有显著的独特影响。
在治疗早期采取行动态度可能代表了一种特定的 CBT 机制，但与 2 种一般机制具有很大的共同效应。
