Cognitive exposure versus avoidance in patients with chronic pain: Adherence matters

<jats:title>Abstract</jats:title><jats:sec><jats:title>Background</jats:title><jats:p>Behavioural exposure methods can reduce pain‐avoidance behaviours, but outcomes vary. One possible explanation is that patients employ cognitive (experiential) avoidance during behavioural exposure. If so, reducing cognitive avoidance during behavioural exposure should help. One option is interoceptive exposure (<jats:styled-content style="fixed-case">IE</jats:styled-content>), which involves sustained exposure (via attention) to pain sensations. In order to test if <jats:styled-content style="fixed-case">IE</jats:styled-content> could improve outcomes from behavioural exposure, this study with mixed chronic pain patients compared outcomes from a cognitive behavioural therapy (<jats:styled-content style="fixed-case">CBT</jats:styled-content>) pain management programme incorporating either <jats:styled-content style="fixed-case">IE</jats:styled-content> or distraction from pain.</jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p>One hundred forty chronic pain patients were randomly assigned to <jats:styled-content style="fixed-case">CBT</jats:styled-content> + <jats:styled-content style="fixed-case">IE</jats:styled-content> or <jats:styled-content style="fixed-case">CBT</jats:styled-content> + distraction. Outcome measures included pain, disability, depression and medication. Measures reflecting degree of threat of pain were also employed (catastrophizing, fear‐avoidance, pain self‐efficacy and pain acceptance). An intention‐to‐treat approach, using mixed‐effects model repeated measures, as well as conventional inferential statistical tests, effect sizes and reliable change indices were employed to evaluate the outcomes up to 1‐year post‐treatment.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>Significant improvements were achieved by both treatment conditions on all outcome measures and on measures reflecting the threatening nature of pain, with no differences between treatment conditions.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>The addition of <jats:styled-content style="fixed-case">IE</jats:styled-content> to behavioural exposure did not improve outcomes. However, higher adherence to either attentional strategy was associated with larger effect sizes on all measures, suggesting factors shared by the two treatments could have contributed to the outcomes. Taken as a whole, the results suggest that increasing adherence to treatment strategies, possibly by motivational measures, would improve the overall outcomes of these interventions.</jats:p></jats:sec>