Necessary components of psychological treatment for chronic pain: More packages for groups or process‐based therapy for individuals?

Abstract

This journal recently published a paper by Sharpe et al., entitled “Necessary components of psychological treatments in chronic pain management programs: A Delphi study” (Sharpe, Jones, Ashton-James, Nicholas, & Refshauge, 2020). These researchers sought the views of authors of relevant RCTs published up to September 2016 and supplemented these with input from psychologists working in pain management programs in Australia. In the end, this expert panel agreed that (a) psychoeducation, (b) cognitive approaches and (c) strategies to increase activity, ought to be included within “gold standard” psychological pain management approaches. Reducing the message of a study down to one sentence is unfair, so interested readers should seek further details in the full report. The point of this commentary is to emphasize a wider message around a view on necessary components. Over the decades, particularly with the advent of evidenced-based therapy (EBT), clinicians have asked whether it is best to deliver Behavior Therapy, Cognitive Behavior Therapy, Mindfulness-Based Stress Reduction, Acceptance and Commitment Therapy or whatever. I believe we now know, or ought to know, that this is not the best question. Dropping the question of which therapy type, and instead asking about necessary components is probably a better question. At the same time, higher quality treatments are not likely to come from the answers to this question alone, at least not substantially. If we want better treatments, today and for the future, the knowledge we need is a little more complicated. Most probably, what we mainly need is to identify evidence-based processes of change known to impact on outcomes of interest, evidence-based methods known to impact on these processes, for whom should these be applied, and under what circumstances? The answers to these questions form the basis for a different kind of EBT, one that cuts across therapy types. Recently this is called “process-based therapy” (PBT; Hayes et al., 2019). Sharpe et al. naturally are correct in pointing out that Delphi expert consensus methods produce a low, or very low, level of evidence. This is a clear reason to take the findings as one perspective on necessary components, and certainly not the only one. Recent higher quality evidence show alternative views. For example, treatments that include just one small component of psychoeducation and one predominant component of exposure therapy are able to produce large effect sizes in chronic pain. This includes for people with chronic back pain treated face to face (Glombiewski et al., 2018) and for people with fibromyalgia treated via the internet (Hedman-Lagerlöf et al., 2018), as examples. Further, in analyses of processes of change in treatments like this, little change happens during the psychoeducation component, and nearly all during the exposure component (Schemer et al., 2018). Worth noting, these treatments focus on a relatively narrow set of processes of change, in fear and avoidance, and include individual treatment delivery, not the predominant mode of delivery in most pain management programs. These points are not to contradict the findings of Sharpe and colleagues, as they derive from different types of settings. They do show an alternative view, however, and the knowledge gained may apply to pain management more broadly. For many it will appear helpful to have a list of three general approaches, seven separate strategies deemed necessary, and 24 deemed desirable, in psychological treatments for chronic pain management programs, as produced by Sharpe et al. A risk however is that such lists might create treatment programs jammed full of too many methods, including some that simply will not be necessary or even desirable for every single person treated. After all, I believe we all agree that one size does not fit all. The necessary components here, if indeed taken as the “gold standard,” may populate treatment protocols and manuals. If nothing else, they may populate our routines where no formal manuals are used. In this process, they may find themselves packaged for delivery as a whole. After all, this is how it goes in the mainly group-based approaches we apply in pain management programs. An alternative model of delivery for the future could be individualized, modularized treatment, including only the components needed and none of the components not needed, based on demonstration that selected components impact on uniquely targeted psychological processes, and on evidence for when and for whom to apply them (Hayes et al., 2019; Villatte et al., 2016). It is good to know which components of psychological treatments best produce outcomes desired in pain management programs. Asking experts what they think, and organizing a consensus, is one way to approach this. However, consensus is not necessarily correct or cutting edge. The point being that this type of approach may only take us so far. To go farther, we will most probably need to know other things, such as outlined here. Treatments for chronic pain need to address high complexity, and just knowing components alone cannot tackle that. With an aim to raise our aspirations, one might suggest an alternate “gold standard” psychological treatment in chronic pain management. It could include the following: (a) evidence-based processes of change known to impact on outcomes of interest, (b) methods with empirically demonstrated links to processes of change (c) delivered in a way that is sensitive to individual need and the current context of treatment. We are not there yet, but it seems to be where we are going or ought to go.

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