Common and specific treatment mechanisms in psychosocial pain interventions: the need for a new research agenda.

Jensen’s article [3] in this issue of PAIN synthesizes various conceptualizations of psychosocial treatments for pain into an overarching framework, providing a springboard for future research. The author tackles an important and timely topic. Many psychosocial treatments provide some evidence of efficacy, and Jensen encourages us to take stock of what we have in our armamentarium, document how treatments work, and, as Paul suggested [6], develop principles by which we can find the best treatment for a particular problem given a patient’s unique circumstances. Our commentary intends to amplify some of Jensen’s points and suggest 2 additional areas in need of research. We believe, with Jensen, that commonalities across treatment approaches must be examined. It is tempting to attend to distinctions among the therapies Jensen discusses, debate their relative merits based on apparent differences, and focus on ‘‘building better mousetraps.’’ Doing so has spawned many ‘‘new and improved’’ treatment techniques presumed to offer unique advantages over the ‘‘old.’’ When a certain approach shows efficacy – usually compared to wait-list or attention-placebo control – the inference is that it works because of its ostensible unique qualities. This may not necessarily be the case. Efficacious psychosocial pain treatments all seem to reduce pain and distress and increase physical function. If seemingly different therapies get to the same place, then wemay hypothesize that they do so partly because of common features. It may thus prove fruitful to divert some attention away from the study of differences and toward identifying common mechanisms across treatments. Jensen does this to some extent, pointing to possible common brain states achieved with hypnosis, relaxation, and mindfulness. To further this endeavor, we can borrow from a well-established body of theoretical and empirical work. Psychotherapy research has long wrestled with issues regarding common and unique factors of efficacy. Goldfried [2] and others [1] argue that common principles underlie most psychotherapy approaches, and warrant examination and understanding. Two common principles of therapeutic change involve stimulating patient expectations that treatment will help, and establishing a sound therapeutic relationship between patient and therapist. Although Jensen acknowledges that certain psychosocial pain treatments (eg, hypnosis, relaxation) work partly via fostering positive patient expectations, the importance of the therapeutic relationship was not featured in his review. In behavioral medicine, we may have lost appreciation for the centrality of this factor, relegating it to part of ‘‘placebo’’ responses. Results from many studies of psychotherapy process and outcome confirm that the therapeutic