4 - (OP6) Mapping CBT for Chronic Pain: An Iterative Component and Technique Taxonomy Based on Randomized Controlled Trials

World Health Organization (WHO) guidelines, the International Association for the Study of Pain (IASP), and the National Institute of Health (NIH) consistently recommend cognitive behavioral therapy (CBT)–based psychological interventions as first-line treatments for the management of chronic pain, supported by a substantial body of randomized controlled trial (RCT) evidence. As with other evidence-based health interventions, interpretation of treatment effects depends on a clear understanding of what interventions are composed of. In pharmacological research, this requirement is met through explicit specification of active ingredients and their mechanisms of action. In contrast, CBT trials are typically synthesized and interpreted at the level of a global treatment label, despite substantial variability in intervention content. This limited level of specification reduces interpretability of treatment effects, hinders mechanistic inference, and constrains the cumulative development of CBT as a precision intervention.

The present study aimed to enhance the precision of CBT-based interventions for chronic pain by developing a systematic taxonomy of intervention components and techniques. Intervention descriptions were examined from the RCTs included in the most recent Cochrane review encompassing psychological interventions based on behavioral change theories (Williams et al., 2022). A taxonomy was developed iteratively by examining intervention descriptions in trial publications, supplementary materials, protocols, and treatment manuals, and by integrating established CBT models of chronic pain. Interventions were coded at two levels, distinguishing higher-order CBT components, such as cognitive restructuring, behavioral activation, exposure to pain-related fear, skills training, and acceptance-oriented strategies, from specific CBT techniques, including activity pacing, goal setting, relaxation training, cognitive and behavioral distraction, behavioral experiments, and thought monitoring. Coding was conducted independently by two reviewers, with discrepancies resolved by consensus.

The resulting taxonomy comprised 24 distinct components and revealed substantial heterogeneity in the composition and therapeutic emphasis of CBT-based interventions across trials. Interventions labeled as CBT varied markedly in their component profiles, and no single configuration characterized CBT for chronic pain as a uniform intervention. By explicitly specifying the active ingredients of CBT interventions, this taxonomy provides a foundation for advancing CBT research toward greater precision. A structured representation of intervention content allows treatment effects to be examined in relation to specific components rather than global labels, supports component-level secondary analyses and more informative meta-analytic models, and facilitates the design of dismantling and mechanism-focused studies. At the same time, clearer specification of intervention ingredients improves transparency and fidelity in intervention reporting and creates opportunities to develop more modular and personalized CBT approaches to chronic pain management.