Self-Directed vs Clinician-Delivered Cognitive Behavioral Therapy for Chronic Pain: A Randomized Clinical Trial.

Cognitive behavioral therapy for chronic pain is a recommended first-line treatment, but getting an appointment with a clinician trained to deliver it is often difficult, which limits how many people actually receive it. This trial asked whether a self-directed version, where patients worked through the program largely on their own but received weekly personalized audio feedback from a coach based on daily reports of their pain coping and activity, could work as well as the usual clinician-delivered sessions. Researchers randomly assigned over 760 veterans with chronic musculoskeletal pain in the Veterans Health Administration system to one or the other approach and followed them for up to a year.

At four months, people in the self-directed group reported somewhat less pain interference than those in the clinician-delivered group, and this advantage persisted through six and twelve months. Other measures, including pain intensity and mood, also favored the self-directed approach. About a quarter of participants did not complete the four-month assessment, which is a limitation to keep in mind when interpreting how durable and generalizable these gains are.

If you live with chronic pain, you may know that cognitive behavioral therapy, a talk-based approach that helps people manage pain through coping skills and pacing activity, is often recommended, but it can be hard to access because of appointment availability and travel. This study looked at whether doing the therapy mostly on your own, with weekly personalized audio feedback from a coach based on how you were practicing pain-coping skills and staying active, could work as well as meeting with a clinician for regular sessions. In a large trial of veterans with chronic musculoskeletal pain, people who did the self-directed version reported somewhat less interference from their pain in daily life after four months compared to those who saw a clinician, and this difference lasted through a year of follow-up.

They also reported improvements in pain intensity, sleep, and mood, and tended to complete more of the planned sessions. It is worth remembering that about a quarter of participants did not complete the four-month follow-up survey, so we do not know how those people fared. The results suggest self-directed therapy with coaching feedback may be a workable alternative to in-person therapy, but this was one trial in a specific health system.

This is a summary of research, not medical advice. Talk to your own healthcare provider about anything affecting your care.

This pragmatic, open-label randomized trial compared self-directed cognitive behavioral therapy for chronic pain (CBT-CP), supported by weekly personalized asynchronous coach feedback based on interactive voice response data, against clinician-delivered CBT-CP under usual VHA practice conditions in 764 patients with chronic musculoskeletal pain across nine health systems. The primary outcome, Brief Pain Inventory-Interference at four months, favored self-directed CBT-CP over clinician-delivered CBT-CP (mean 5.26 vs 6.23; mean difference -0.98, 95% CI -1.31 to -0.65, P<.001), a difference near the stated minimum clinically important difference of 1 point, with superiority maintained at six and twelve months. Secondary outcomes, including pain intensity, catastrophizing, self-efficacy, sleep, global impression of change, and depressive symptoms, all favored self-directed CBT-CP at four months (P≤.001), and session-completion rates were higher in that arm.

Because this was an open-label design without a no-treatment or attention control, and clinician-delivered care reflected variable usual-practice dosing (four to eleven sessions), the comparison speaks to relative effectiveness between two active delivery models rather than efficacy against no treatment. Attrition was notable, with 76% completing the four-month assessment and 68% the twelve-month assessment, which may affect the precision and generalizability of the sustained effects reported.