Cognitive Therapy, Mindfulness-based Stress Reduction, and Behavior Therapy for the Treatment of Chronic Pain

Randomized Controlled Trial

John W. Burns; Mark P. Jensen; Beverly Thorn; Teresa A. Lillis; James Carmody; Andrea K. Newman; Francis Keefe


Pain. 2022;163(2):376-389. 

In This Article

Abstract and Introduction


Trials of cognitive therapy (CT), mindfulness-based stress reduction (MBSR), and behavior therapy (BT) suggest that all 3 treatments produce reductions in pain and improvements in physical function, mood, and sleep disturbance in people with chronic pain conditions. Fewer studies have compared the relative efficacies of these treatments. In this randomized controlled study, we compared CT, MBSR, BT, and treatment as usual (TAU) in a sample of people with chronic low back pain (N = 521). Eight individual sessions were administered with weekly assessments of outcomes. Consistent with the prior work, we found that CT, MBSR, and BT produced similar pretreatment to posttreatment effects on all outcomes and revealed similar levels of maintenance of treatment gains at 6-month follow-up. All 3 active treatments produced greater improvements than TAU. Weekly assessments allowed us to assess rates of change; ie, how quickly a given treatment produced significant differences, compared with TAU, on a given outcome. The 3 treatments differed significantly from TAU on average by session 6, and this rate of treatment effect was consistent across all treatments. Results suggest the possibility that the specific techniques included in CT, MBSR, and BT may be less important for producing benefits than people participating in any techniques rooted in these evidence-based psychosocial treatments for chronic pain.


Treatments such as behavior therapy (BT), cognitive therapy (CT), and mindfulness-based stress reduction (MBSR) have been shown to produce reductions in pain and improvements in physical function, mood, and sleep quality in people with chronic pain.[9,17,40] Trials of these treatments have focused on testing efficacy by comparing treatments with largely inert control conditions (eg, treatment as usual [TAU]). Although this conventional practice is an important first step, this approach does not address the issue of whether existing or new treatments surpass one another on certain benchmarks. Comparative outcome studies between 2 or more active treatments conducted to address this issue are relatively few in number.

"Superiority" of beneficial effects may be defined in at least 3 ways, including whether a particular treatment (1) produces greater improvements in outcomes, (2) produces improvements at a faster rate than other treatments, or (3) demonstrates greater durability of benefits. However, results of comparative outcome studies for psychosocial chronic pain treatments generally suggest that different treatments have similar effects on primary outcomes. Many of these—especially early—studies used relatively small sample sizes and are underpowered to detect even medium between-group differences in outcomes.[18,23,27,32,34,38,39,43,45,47] It is possible, therefore, that some of the observed treatment group differences were nonsignificant because of inadequate power to detect significant differences.

Three recent comparative outcome studies used larger samples. Cherkin et al.[7] compared cognitive behavioral therapy (CBT) with MBSR with usual care (CBT: n = 113; MBSR: n = 116; and usual care: n = 113), Thorn et al.[37] compared CBT with pain education with usual care (CBT: n = 95: pain education: n = 97; and usual care: n = 98), and Lumley et al.[26] compared CBT with emotional awareness and expression therapy with pain education (CBT: n = 75; EAET: n = 79; and pain education: n = 76). Still, all 3 studies found that different psychosocial treatments produced largely similar effects on primary outcomes.

In the present study, we compared CT (n = 129), mindfulness-based stress reduction (MBSR, n = 143), BT (n = 120), and TAU (n = 129) in a sample of people with chronic low back pain. Treatment consisted of 8 weekly individual sessions. Although the study was adequately powered to reveal significant medium effect size differences between treatment conditions, based on the predominant finding emerging from comparative studies, we did not expect to find significant pretreatment to posttreatment differences between the 3 active treatments on the 5 outcome domains.

Instead, this study focused on 2 of the other metrics regarding differential outcomes, mentioned above. First, we examined the relative rates in which change occurred between the active treatments by assessing all outcomes weekly during the 8-week treatment. This strategy allowed us to examine rates of change during treatment across each treatment and relative to TAU. Second, we wanted to highlight how durability of improvements may be explicitly considered as another index of superiority. To this end, like most outcome studies, we assessed outcomes at a 6-month follow-up.