School of Psychology, The University of Queensland, Brisbane, QLD, Australia; Department of Rehabilitation Medicine, The University of Washington, Seattle, Washington.
Department of Rehabilitation Medicine, The University of Washington, Seattle, Washington.
J Pain. 2024 Apr;25(4):843-856. doi: 10.1016/j.jpain.2023.10.007. Epub 2023 Oct 11.
A variety of evidence-based psychosocial treatments now exist for chronic pain. However, on average, effect sizes have tended to be modest and there is a high degree of heterogeneity in treatment response. In this focus article, we explore the potential role that therapist quality in delivering treatment may have in accounting for a degree of this variability in outcome. Therapist quality refers to the skillful delivery of treatment, harnessing both specific and common therapeutic factors during sessions. While recognized as important to assess and report in clinical trials by some reporting guidelines, few randomized controlled trials evaluating psychosocial treatments for chronic pain have reported on therapist factors. We reviewed the clinical trials included in three systematic reviews and meta-analyses of trials of cognitive-behavioral therapy (mainly), mindfulness-based interventions, and acceptance and commitment therapy. We found that of the 134 trials included, only nine assessed and reported therapist quality indicators, with a variety of procedures used. This is concerning as without knowledge of the quality in which treatments are delivered, the estimates of effect sizes reported may be misrepresented. We contextualize this finding by drawing on the broader psychotherapy literature which has shown that more skillful, effective therapists demonstrated ten times better patient response rates. Examination of the characteristics associated with these more effective therapists tends to indicate that skillful engagement of common factors in therapy sessions represents a distinguishing feature. We conclude by providing recommendations for assessing and reporting on therapist quality within clinical trials evaluating psychosocial treatments for chronic pain. PERSPECTIVE: Therapist quality in the delivery of psychosocial treatments for chronic pain has rarely been assessed in clinical trials. We propose that therapist quality indicators are an under-studied mechanism that potentially contributes to the heterogeneity of treatment outcomes. We provide recommendations for assessing and reporting on therapist quality in future trials.
目前已有多种基于证据的心理社会治疗方法可用于治疗慢性疼痛。然而，平均而言，这些方法的效果往往较为有限，且治疗反应存在很大的异质性。在这篇重点文章中，我们探讨了治疗师在提供治疗方面的质量是否可能在一定程度上解释了治疗结果的这种变异性。治疗师质量是指在治疗过程中熟练地运用治疗方法，利用特定和一般的治疗因素。虽然一些报告指南认为在临床试验中评估和报告治疗师质量很重要，但很少有评估慢性疼痛心理社会治疗的随机对照试验报告治疗师因素。我们回顾了三篇系统评价和荟萃分析中包含的临床试验，这些系统评价和荟萃分析评估了认知行为疗法（主要）、正念干预和接纳与承诺疗法。我们发现，在纳入的 134 项试验中，只有 9 项评估和报告了治疗师质量指标，且使用了各种程序。这令人担忧，因为如果不知道治疗的质量，报告的效果大小估计可能会有偏差。我们通过借鉴更广泛的心理治疗文献来理解这一发现，该文献表明，更熟练、更有效的治疗师表现出的患者反应率高出十倍。对这些更有效的治疗师的特征进行研究，往往表明在治疗过程中熟练地运用一般因素是一个显著特征。最后，我们提出了在评估慢性疼痛心理社会治疗的临床试验中评估和报告治疗师质量的建议。观点：在评估慢性疼痛的心理社会治疗的临床试验中，治疗师的质量很少被评估。我们提出，治疗师质量指标是一个研究不足的机制，可能是治疗结果异质性的原因之一。我们为未来的试验提供了评估和报告治疗师质量的建议。
