Chronic Illness

Chronic Illness http://chi.sagepub.com/ The non-specific effects of group-based cognitive−−behavioural treatment of chronic pain Toby R. Newton-John and Jenny Geddes Chronic Illness 2008 4: 199 DOI: 10.1177/1742395308091868 The online version of this article can be found at: http://chi.sagepub.com/content/4/3/199

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Chronic Illness (2008) 4, 199–208

RESEARCH PAPER The non-specific effects of group-based cognitive–behavioural treatment of chronic pain TOBY R. NEWTON-JOHN*,y and JENNY GEDDES* *

Innervate Pain Management, 91 Chatham Street, Broadmeadow, Newcastle, NSW 2292, Australia y Faculty of Medicine, University of Sydney, NSW 2006, Australia Received 7 September 2007, Accepted 17 March 2008

Group-based cognitive–behavioural therapy (CBT) for chronic, non-malignant pain is recognized as the treatment of choice for patients with intractable pain problems. The core components of CBT pain treatment have been standardized, and meta-analyses have shown that that this form of intervention is effective. However, the psychotherapy literature points to a range of influences on treatment outcome that arise out of the process of treatment, rather than directly from the active treatment components. These so-called non-specific treatment effects include the composition of the group, the leadership style of the group leader, and the ways in which group dynamics are dealt with. Although CBT pain management programmes are conducted in a group format, and are therefore subject to similar kinds of influences to other forms of group treatment, these issues have not been discussed in detail in any previous literature. The present paper proposes a number of non-specific treatment factors that are likely to be associated with positive outcomes from CBT pain management programmes, and discusses ways in which these factors may be deliberately manipulated in order to maximize treatment effectiveness. Keywords: CBT, Chronic pain, Non-specific effects, Placebo, Treatment

INTRODUCTION Persistent or chronic non-malignant pain is highly represented in surveys of chronic illness and associated morbidity.1 Any pain that has persisted on a more or less daily basis for more than 3 months, or for longer than the expected healing time for body tissues, is defined as a chronic pain.2 Prevalence studies indicate that approximately 20% of the adult population experience chronic pain at any time,3 with the incidence rising with age and women more likely to report chronic pain across a number of pain sites than men.4 Our understanding of the pathophysiology of chronic pain has advanced enormously Reprint requests to: T.R. Newton-John Email: [email protected]; fax: þ61 2 4940 0322 ß SAGE Publications 2008 Los Angeles, London, New Delhi and Singapore

over the 10–20 years. Multiple body systems are now known to contribute to the development and maintenance of persisting pain states, including neuroendocrine changes, immunological responses, cortical reorganization, dorsal horn ‘wind-up’ and central sensitization, and alterations to the hypothalamus–pituitary–adrenal axis.5 Unfortunately, these insights have not yet led to major gains in terms of medical treatments for chronic pain. Surgical interventions have notoriously poor outcomes for persistent pain.6 Pain specialists are therefore left with palliative treatment approaches, including spinal or nerve blocks, the implantation of neuromodulatory devices such as spinal cord stimulators, or pharmacological trials.7 Ultimately, despite efforts to cure or significantly relieve pain, many individuals go on to experience pain on a persistent basis for many months or years. The physical, DOI: 10.1177/1742395308091868


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emotional, social and occupational toll that chronic pain can have upon an individual has been well documented.8 Perhaps as a result of the limited efficacy of interventional medicine for chronic pain, there has been strong interest in psychological approaches to chronic pain management over the past 20 years. Group-based cognitive–behavioural therapy (CBT) programmes for pain have been developed, and their outcomes have been evaluated with more scrutiny than most medical interventions ever attract. The most widely cited meta-analysis in the literature, that of Morley et al.,9 analysed data from 25 randomly controlled trials of CBT for adults with persistent pain problems. This meta-analysis indicated that, in comparison to alternative treatments (typically conservative medical management), CBT produced significantly greater improvements in the domains of pain experience, cognitive coping and appraisal, and reduced behavioural expression of pain. Their conclusion was that active psychological treatments based on the principles of CBT are effective. A 2007 meta-analysis by Hoffman et al.10 was similarly supportive, with 205 effect sizes from 22 studies demonstrating significant positive benefits for CBT-based treatments for pain: ‘the robust nature of these findings should encourage confidence among clinicians and researchers alike’ (p. 8). While the authors of these papers point out that there is some variation between studies in their definition of what constitutes CBT for chronic pain, there is a set of core elements that organizations such as the British Pain Society consider to be intrinsic to a pain management programme.11 These include: physical reconditioning; posture and body mechanics training; applied relaxation techniques; information and education about pain and pain management; medication review and advice; psychological assessment and intervention; graded return to activities of daily living.

Of course, no treatment is perfect, and efforts to improve the efficacy of CBT pain management programmes have looked at identifying the key components of groupbased treatments12 or developing entirely new approaches to the self-management of persistent pain.13 While research efforts such as these are undoubtedly worthwhile, keys for improving the efficacy of CBT pain programmes might lie within the existing validated treatment models. Breuhl has recently called for an investigation of the wider treatment factors related to groupbased pain treatment.14 He stated: An often overlooked question about comprehensive pain program (CPP) efficacy is how much of the improved pain and function is attributable to the actual interventions used and how much is due to nonspecific factors (for example, the highly structured nature of these programs, the high level of treatment team contact, vicarious learning from more adaptive pain copers in the CPP, and so forth). These issues are not trivial . . . nonspecific treatment factors may contribute just as much to positive outcomes as do the specific techniques used . . . Research aimed at identifying and maximizing any non-specific effects of CPPs could enhance their efficacy even further’ (p. 795).14 The purpose of this discussion paper is to pick up on Breuhl’s point, and initiate a discourse on the non-specific effects of group-based CBT treatment for chronic pain. It is somewhat surprising that this topic has been dealt with so sparsely in the chronic pain literature to date, given the data that exist in other areas of psychology and psychological medicine. We will begin with a definition of non-specific treatment effects, draw on the psychotherapy literature to examine how it has explored this area, and outline a number of factors by which CBT pain programmes engender positive outcomes beyond application of the treatment components themselves. Finally, we will make some recommendations for maximizing treatment benefits, utilizing the factors that we have highlighted.


NON-SPECIFIC EFFECTS OF GROUP-BASED COGNITIVE–BEHAVIOURAL DEFINING NON-SPECIFIC TREATMENT EFFECTS Definitions of non-specific treatment effects typically invoke notions of the placebo effect. Take, for example, the definition offered by Turner et al.: ‘The term placebo effect is often used synonymously with non-specific effects . . . a placebo effect is a change in a patient’s illness attributable to the symbolic import of a treatment, rather than a specific pharmacologic or physiological property’ (p. 1610).15 While we would agree that there can be important symbolism occurring within pain management programmes to enhance treatment effects — e.g. the physician being in attendance to validate the treatment — we would argue that this definition does not go far enough. Non-specific factors are not equivalent to placebo factors, insofar as they go beyond mere symbolic representation. Indeed, we will argue that non-specific treatment effects can be wide-ranging, encompassing both the individual and the group, and involve more complex processes of social interaction than the rather narrow definition of Turner et al. suggests. However, defining a non-specific treatment effect as ‘non-specific’ is not without problems. First, to some extent the definition is based upon the theory of the mechanism of action involved in the treatment. If the theory evolves, or is found to be flawed, the non-specific can become the specific and vice versa. For example, it was commonly held that in order to be effective, acupuncture required needle administration into precise meridians or Hoku points. Research has since shown that it is the intense stimulation that produces pain relief in acupuncture (hyperstimulation anaesthesia), and that the site of administration is of far less importance.16 This theory problem is always present in clinical research. Second, the term non-specific treatment effect in this paper is used from the CBT perspective. It refers to those factors which the CBT chronic pain literature has not

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acknowledged as being important or relevant to treatment outcome; in other words, aspects of the treatment process that sit outside those core elements identified by the British Pain Society. However, there is an acknowledged inconsistency here, and the theory problem referred to above surfaces again. When we review the psychotherapy literature, we see that several of the ‘non-specific’ treatment effects as defined from a CBT pain management perspective are considered to be very much active, specific components of psychotherapy treatment. For example, a construct such as the therapeutic alliance has received scant attention from the chronic pain world,17 yet it is considered to be intrinsic aspect of psychotherapeutic interventions.18 In addressing this issue, Grunbaum19 has suggested using the term ‘incidental factors’ instead of non-specific factors, as the latter is said to imply a ‘waste-paper basket’ of variables that are not otherwise accounted for. However, the term non-specific factor was retained for this paper because of its familiarity to readers, notwithstanding the above caveats. Chronic pain research has not ignored these issues completely, but the investigations have been minimal considering the size of the group-based treatment literature in this area. Nicholas et al. developed an attention control group in their investigation of CBT for chronic low back pain.20 Subjects randomly assigned to the attention control condition attended in groups, and discussed relevant issues (e.g. effects of back pain on family life, ways in which they coped with pain, the treatments they had received for pain and so on) with a psychologist. The psychologist was friendly and empathic, and encouraged group members to share their experiences, but did not give any specific information or discuss coping strategies. Clearly, this attention control condition was intended to incorporate a number of the non-specific treatment factors that Bruehl was referring to in the quote above. However, we will argue that the effects operating in a group pain management


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programme are more varied and complex than just positive regard from the therapist and mutual sharing of experience by participants. A recent review of CBT pain programmes makes mention of ‘the group process’ as being an important aspect of this treatment format, but devotes less than a paragraph to discussing the issue.21 In possibly the only systematic evaluation of non-specific treatment effects in CBT pain programmes to date, Williams examined the effect of the therapeutic alliance on treatment outcome.17 She cites data from her own pain management programme in which there was an immediate reduction in catastrophizing among patients with a higher therapeutic alliance to staff, as compared to smaller short-term, and absent long-term, treatment benefits in those with a lower therapeutic alliance. These preliminary data suggest that these factors are of considerable importance, but we are unaware of any other published work on the therapeutic alliance in relation to CBT group programmes for chronic pain. It should be acknowledged at this point that non-specific treatment factors do not only apply to psychologically based interventions. For example, cardiac surgeons given brief training in doctor–patient communication skills generated significantly improved post-surgical outcomes following bypass procedures (reduced need for postoperative analgesia, briefer hospitalization, faster returns to normal activities) than surgeons not given this training.22 The way in which the surgeon interacts with the patient would not typically be viewed as an active component of cardiac surgery, and yet the evidence indicates that it is an important, albeit non-specific, factor.

NON-SPECIFIC FACTORS IN PSYCHOTHERAPY RESEARCH While the issue of non-specific factors in CBT for chronic pain has generally been overlooked, researchers in other areas of

psychological treatment have not been so short-sighted. The psychotherapy literature has examined a number of potential influences on treatment outcome that exist outside the framework of the active treatment components, and we will discuss those briefly before moving on to the topic of pain management programmes. The process by which change occurs in psychotherapy has been the subject of considerable discussion in the psychotherapy literature over the past five decades. There has been a consistent finding in this research that patient outcomes are correlated more strongly with so-called non-specific treatment factors than with specific components of treatment. For example, Lambert and Barley pooled the results of a number of outcome studies that provided analyses on predictor variables, and averaged the size of the contribution that each predictor made to treatment outcome.23 Their estimates of the percentages in improvement that could be attributed to the various predictors were: specific therapeutic techniques, 15%; treatment expectancy effects, 15%; extratherapeutic changes, 40%; and common factors, 30%. Within the framework of common factors are the notions of unconditional positive regard, empathy, congruence and acceptance as espoused by Carl Rogers. Yalom has stated that successful psychotherapy is mediated by a positive therapeutic alliance, and went on to state that it is the necessary ingredient by which more specific treatment strategies may have their effect.24 The term therapeutic alliance refers to the strength and quality of the collaborative relationship between the client and the therapist,25 and has been a robust predictor of positive outcomes across different patient samples and types of psychotherapeutic intervention18 (including pain management programmes, as was noted). But what of non-specific treatment effects in group-based psychotherapy? Yalom described ‘group cohesiveness’ as the primary curative factor in group therapy, such that a cohesive group enables group members to


NON-SPECIFIC EFFECTS OF GROUP-BASED COGNITIVE–BEHAVIOURAL engage in the necessary work that contributes to effective therapy.24 Group cohesiveness refers to a wide range of qualities that develop when a number of people attend a group for a common purpose, but includes shared experiences and goals, mutual respect, acceptance, supportive feedback and interaction, reality testing and vicarious learning. Participants in groups can benefit from sharing their common experiences, observing each other and expressing themselves in a safe and non-threatening environment. The author also pointed to the difficulties in evaluating this area in a systematic way, arguing that while group cohesiveness may be influential in therapeutic terms, it does not lend itself to rigorous research methodology.

NON-SPECIFIC FACTORS IN GROUP-BASED CBT PAIN MANAGEMENT PROGRAMMES The following discussion is based upon the authors’ combined experience over two decades in conducting group-based treatment programmes for chronic pain, as well as a review of the literature in this area such as it is. Starting with the observational, our aim is to stimulate discussion in this area in the hope that some of these issues might be tested empirically. We have divided our discussion into a number of broadly distinct areas: the group process, validation and life skills. However, we recognize that certain factors could fall into more than one category area. Furthermore, the assumption throughout this discussion is that non-specific treatment effects become more influential in better-delivered, well-organized group programmes. In other words, the better the active treatment components, the more influential the non-specific treatment effects. It is arguable whether non-specific effects would be realized in a poorly run group programme, and in fact there are potential ‘nocebo’ effects that occur when groups are

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inexpertly run. For example, as much as the group environment discussed below can be a powerful positive influence on outcome, it is also true that when a significant proportion of a group are dissatisfied with their treatment, the group can rebel in a cohesive way, and this can undermine the treatment effect. The Group Process Perhaps the strongest influence on treatment outcome reported by chronic pain programme participants themselves is the effect of being in a group. To start with, for many individuals the experience of living with chronic pain is a lonely and isolated one. Social interaction is reduced dramatically because of the loss of employment, leisure pursuits and hobbies are often curtailed, and there is restricted participation in family activities.26 There is often a sense that even when the individual is physically capable of participating in social activities, there are other barriers that come into play. There is often stigma about receiving income support or workers’ compensation benefit, and people may be reluctant to disclose their social welfare status. There is also the issue of how you respond to the inevitable questions, such as ‘What do you do for a living’ or ‘What have you been up to lately?’ — questions that are difficult to answer satisfactorily from a chronic pain patient perspective. Therefore, for many individuals with chronic pain, their only meaningful social contact outside their immediate family is with their healthcare providers — clearly a highly artificial sort of interaction. Placing a collection of such individuals together in one location for extended periods of time is often a major test of social skills and competencies. There are often high levels of anxiety observed (and subsequently expressed) regarding their ability to get on with other group members, whether they will be accepted by the group, and so on.21 It may have been many months or even years since group members were in a situation in which they had to interact socially with strangers for any sustained length of time.


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As we saw in the psychotherapy group literature, groups typically do move towards a cohesive state. Members find that not only are they accepted, but that their difficult, distressing and damaging experiences of living with chronic pain are validated by the group. It can be enormously reassuring to learn that one’s frustration with the medical profession, periods of hopelessness about the future and loss of status within the family26 are not the brandings of a flawed personality but are in fact common experiences for those experiencing chronic pain. In addition, a group of similarly afflicted individuals quickly learn that they can communicate with each other in a way that they cannot generally do outside the pain group. Participants in a pain group have no need to prove to others that their affliction is real. The acceptance that this engenders is significant, and participants often refer to the relief they feel through being in the group — as if all of the rest of the time, it is a strain trying to get the world to believe them. In the domain of non-specific effects of treatment, the validation of the pain experience by the group is of crucial importance. It is not coincidental that in the study of Coughlin et al. of drop-outs from groupbased CBT pain management programmes, one of the strongest predictors of drop-out was having an unusual pain site — abdominal.27 Presumably, these patients did not feel validated by the group, and felt different from or out of step with the others, which echoes the importance of group cohesiveness once again. There are a several other non-specific factors that we have placed in the group process category. Social comparison theory suggests that individuals placed in group situations tend to make upward and downward comparisons of themselves with other group members in order to enhance mood and confirm their own beliefs.28 Group-based CBT pain programmes offer a number of upward comparison possibilities (I want to be as fit/flexible/confident as her)

as well as downward comparison options (at least I am not as disabled/distressed as him), which are not intrinsic to individually based treatments. By observing other group members tackling similar activities (exercise programmes, relaxation techniques), there are also opportunities for behavioural modelling among group members. Therefore, not only can participants feel supported and validated by the group, but they can also learn from and be indirectly motivated by others going through the same treatment process. The group process may have additional, less direct influences upon positive treatment outcome. For example, an important CBT treatment principle is the use of patient selfmonitoring and the provision of feedback on the data collected by the patient.29 In many pain programmes, patients are encouraged to give feedback to the rest of the group as well as the staff team on their use of the pain management strategies. They may be required to report on their success in tackling a certain activity or give an account of their weekend while managing their pain using the techniques that they have been shown. Less formally, participants may be invited to give their opinions or comments on the topics being discussed to the group as a whole. Although giving verbal feedback in these ways can provoke public speaking anxieties in many individuals, gentle encouragement to participate like this can lead to significant boosts in self-confidence. Many initially reluctant participants find that overcoming their anxieties in this way can have significant therapeutic value. Standing up and speaking in front of a group of peers can be a turning point in the rehabilitation process — the point at which the individual really confronted his or her anxiety and succeeded. These indirect boosts to self-esteem can come from simply completing the programme itself, particularly when the individual’s initial appraisal was that the course would be too hard or demanding for them and they would not be able to manage.


NON-SPECIFIC EFFECTS OF GROUP-BASED COGNITIVE–BEHAVIOURAL Validation We have referred to the validation that a group participant may feel from other members of the group who report similar experiences to their own. This is the validation that one’s experience is not a reflection of some personal weakness but is common to those on the chronic pain merry-go-round. However, there is an additional important source of validation that group-based pain management programmes offer, and that is the validation of the pain itself. There is still a pervasive belief in the wider community and in some members of the medical community that pain has either a biomedical or psychogenic basis. Tests, scans and investigations are supposed to point to the organic substrates of pain; if they fail to reveal sufficient pathophysiology, then the patient who complains of ongoing pain is neurotic at best and a malingerer at worst. As noted by Eccleston et al., ‘Pain is most often constructed as a symptom in need of corroborating evidence . . . a common construction of pain in Western clinical practice is as a sign of physical damage or injury . . . for the medical practitioner, [absence of evidence] may mean viewing the patient as ‘‘imagining’’ the pain, suffering from a psychosomatic illness or ‘‘attention seeking’’’(pp. 700–701).30 For those who are injured and are seeking to make use of a workers’ compensation system, insurance companies will often seek to establish either neurosis or dissimulation by formal medicolegal means, occasionally using video-tape surveillance of the individual. Not surprisingly, this adversarial approach to proving one’s illness creates a great deal of anxiety, frustration and exaggerated pain behaviour in many individuals with chronic pain. You cannot show someone your pain level, but you can show them how much you are hurting, so displays of pain behaviour (cautious, slow gait, limping, grimacing, rubbing body parts, eye rolling and so on) are common. At the other extreme, many individuals report questioning themselves as to whether they are really experiencing the

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pain that they are. These patients report getting to a state of despair whereby they ask themselves whether perhaps the pain could be a figment of their imaginations, as their doctors, insurance company case managers, employers and wider society tells them that it is.30 By the time that these individuals come to attend a group pain management programme, they can be highly defensive and suspicious about how others perceive their complaint. Validation of the genuineness of their problem is critical to their engagement in treatment, and may be conveyed directly or indirectly. Professional validation can be given directly, such as in the information and advice sessions common to all CBT pain programmes referred to previously. It has been empirically shown that good information about chronic pain on its own can significantly improve coping with the condition.31 Anecdotally, many patients say that they found the doctor’s talk very reassuring and helpful, but when asked what the doctor actually spoke about, will struggle to give any specific detail. The reassurance was that the medical specialist seemed to have an understanding of what chronic pain is and is not, and confirmed that the pain programme was the right treatment for this condition. However, psycho-education is a component of the active treatment, so the non-specific treatment effects invoked here exist outside this framework. Second, group CBT pain programmes are staff-intensive and, according to the British Pain Society recommendations,11 should include a clinical psychologist, physiotherapist, occupational therapist, medical specialist, pain nurse and possibly also a pharmacist, dietician or social worker. For a number of participants, this level of staffing in and of itself speaks volumes for their validation. The problem must be being taken seriously for there to be this many people involved in my care; there would not be doctors, nurses and physiotherapists treating me if I only had a mental problem; my problem must be an important one for


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there to be so many highly qualified, high-status people helping me with it — these thoughts represent the logic brought to bear by many group participants. For individuals who have previously felt slighted, dismissed or disbelieved by health professionals involved in their care, these indirect treatment effects can be important in helping to rebuild self-esteem. Life Skills The final domain of non-specific treatment effect is that of teaching and demonstrating basic life skills. CBT pain management programmes require structure.29 They have timetabled sessions, with specific times where pre-determined things occur in a reliable and ongoing fashion. Timetables are necessary both to build the momentum of the programme in a systematic way, and for staff to know when they are required to facilitate the group. For many work-intolerant, depressed, physically de-conditioned chronic pain sufferers, daily life has lost much of its structure and routine. There are no specific demands during the day (families having given up expectations of contributing to housework beyond some light chores when pain allows), and their primary awareness of time passing is to judge when their next pain medication dose or appointment is due. However, on coming into the pain management course, participants are forced to adopt a structure. They must arrive by a certain time, which requires a morning routine and travel arrangement. Their day assumes some shape and form (often with a lunch break or morning tea break mirroring a working day), and they begin to carry out activities in a regular, reliable way (for example, each morning starts with exercise, or the afternoons involve lecture sessions). In order to attend and continue attending, they must plan ahead and problem-solve (meals, clean clothes, travel) to some degree. Thus, by the pragmatics required of a multidisciplinary timetable, CBT pain programmes can assist participants to regain

some order and structure within their day. The indirect effect of the structure for most participants is an increase in activity levels, and a decrease in rest time, which improves the quality of night-time sleep.32 A second non-specific treatment effect grouped under the life skills category that CBT pain programmes can engender is the generalization that results from a wellformulated course. From the operant behavioural treatment model,33 which specifically ignores displays of pain behaviour (but seeks to explicitly positively reinforce healthy behaviours such as completing exercise quotas), to the cognitive therapy strategies of restructuring negative or self-defeating thoughts, CBT pain programmes convey a therapeutic message in which ceasing to be self-pitying, taking responsibility for one’s situation and looking to improve wellbeing without necessarily being cured of the condition are key. A number of pain programme participants then generalize this message, and begin to address other areas of their lives which do not have a cure or a perfect solution, but over which they have suffered significantly in the past. These areas can include managing behaviourally difficult children, confronting parents over distressing issues from long ago, or tackling longheld marital dissatisfactions. Other group members can be as encouraging of these changes as they are of the changes in relation to managing pain, as these life stressors are more or less universal. It is the ‘subtext’ of the programme that generates these changes — all problems can be dealt with better if one applies strategies to their management. And, of course, as these other life areas begin to improve, the participant’s mood lifts and there is a positive feedback to the management of the pain.

CONCLUSION This has been an initial foray into discussing non-specific treatment effects in chronic pain management, and as such is an attempt


NON-SPECIFIC EFFECTS OF GROUP-BASED COGNITIVE–BEHAVIOURAL to raise awareness and to stimulate thought. The next step is to develop research designs by which some of these factors may be systematically evaluated, and the studies by Nicholas et al.20 using attention control groups show that these kinds of studies can be done. However, whether or not it is possible to truly disentangle the specific from the non-specific in clinical practice is an ongoing debate, as discussed above. As Nathan34 has noted, even surgical interventions can produce placebo or non-specific therapeutic effects; thus, the theory problem referred to above is even more relevant when considering group-based psychological interventions. Nevertheless, there are two thrusts suggested for future research in this area. First, an attempt to quantify the group process within CBT pain programmes would be essential. Validated measures for this purpose have been developed (e.g. Working Alliance Inventory35), and these have begun to be used within the CBT group treatment framework (e.g. for sleep disorders36). It is only an extension then to apply similar methodology to chronic pain groups, although such an application would suggest a paradigm shift in this literature to consider these group-based factors as more specific than incidental. Having moved to quantify these non-specific factors in a formal sense, the next logical area for research would be to explore the effect of the group process on the maintenance of treatment gains following participation in a CBT programme. In the otherwise very thorough review of Turk and Rudy of relapse issues following pain treatment,37 no mention is made of the group process. Research in this important area could and should investigate how disengaging from the group environment might impact upon the patient’s motivation to continue applying the pain management strategies. Such research would help to address the issue of how critical (or nonspecific) the group environment is to the maintenance of the treatment effect, and

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would be an important element of treatment progression in this clinical area. However, in the interim we suggest that practitioners involved in running groupbased CBT programmes for chronic pain consider whether the strategies discussed here may be incorporated into their programme structures. CBT has been accused of being mechanistic, a cookbook approach to treatment, and superficial at times. It is hoped that the preceding discussion has illustrated how subtle, sensitive and complex CBT-based treatment can be when one looks beyond linear causal relationships.

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