Remaining Positive About Positive Psychological Interventions for Pain

More than 110 Americans die every day from an opioid overdose—that equates to over 40 000 deaths per year.¹ Changes in pharmacological management are a critical element of the effort to address this public health crisis, as is expanding our arsenal of safe, effective, and scalable nonpharmacological interventions for patients with pain. Behavioral therapies like cognitive behavioral therapy (CBT) for pain have been shown to be effective,² but also encouraging are interventions that specifically target enhancing resilience like acceptance and commitment therapy, mindfulness-based interventions, and positive psychological interventions. Positive psychological interventions can include activities that cultivate feelings of gratitude, purpose in life, kindness and altruism, and other positive emotions. These interventions are thought to be particularly promising strategies for patients with chronic pain.³

Hausmann and colleagues⁴ described a robust (N = 360), double-blind randomized clinical trial evaluating the effects of a 6-week, telephone-based positive psychological intervention program adapted for veterans (Veterans Affairs–based population) with osteoarthritis (OA) pain. The primary outcomes for this study were self-reported pain and functional difficulty based on subscale scores from the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). The authors also explored the notion that such a treatment could potentially reduce race disparities in pain management. Hausmann and colleagues⁴ found that compared with an attention control, those in the positive psychological intervention arm failed to demonstrate superior decreases in OA pain or improvements in functional status. Similarly, for the positive psychological intervention group, secondary outcomes either were not significantly improved over the control or were even somewhat worse. Lastly, there were no differences in regard to response to the intervention by race interaction. The authors concluded that positive psychological interventions do not appear to be an effective stand-alone treatment option for veterans with OA pain and related disabilities.

This article describes the largest study, to my knowledge, designed to evaluate a positive psychological intervention program in a clinical population. The study was well designed and the results important, but still, null studies are usually difficult to get published. This is the very type of study that needs to be read and considered as others design future trials in this area. Such well-being enhancing approaches are growing in interest and acceptance, yet their effectiveness as a stand-alone treatment for clinical populations is not clear. Meta-analyses conducted in a broad range of clinical and nonclinical populations have shown small to medium effects, but caution that many of the studies considered had methodological problems.^5,6 Weaknesses included too few participants, lack of or poor control groups, testing only a single activity, and/or testing the intervention over too little time. The current study addressed all of these issues and more; thus, detecting no signal is particularly unfortunate and possible reasons for these results require some thought.

One possible explanation could be that larger well-designed studies of psychotherapeutic interventions tend to show smaller effects than smaller, less rigorous studies.⁶ Hausmann and colleagues⁴ reported in their pilot study of veterans with OA (n = 42) that patients in the positive psychological interventions arm showed significantly greater improvement in OA symptom severity (P = .02; Cohen d = 0.86), negative affect (P = .03; Cohen d = 0.50), and life satisfaction (P = .02; Cohen d = 0.36) compared with the neutral activity control group.⁷ Yet, those impressive preliminary findings were not replicated in the current larger study although there were some modest improvements in pain and functioning in both groups. However, without a treatment-as-usual control group it is difficult to tell if those positive trends simply reflect regression to the mean.

Interestingly, the authors reported in their secondary analysis that life satisfaction slowly improved over time in the positive psychological intervention group and not in the control group. This has been observed in other studies of positive psychological interventions where the response to treatment is somewhat delayed. This lag in improvement is consistent with the broaden-and-build theory where the development of personal resources could be the key to increased resilience and these take time (eg, building relationships by drawing people in, improving coping skills, and benefitting from behavioral activation that gets patients moving).⁸

Another possible explanation for the null findings could be the study population—participants in the study by Hausmann and colleagues⁴ tended to be older (mean age, 64.2 years), male (76.4%), racially diverse, and veterans. Furthermore, these patient participants reported unusually high pain scores for an OA population (visual analog scale 0-10, mean [SD]: 7.2 [1.7] and WOMAC pain subscale >40). Thus, for many of the same reasons why Zumba classes might not be the best choice of exercise programs for these veterans, positive psychological interventions could be doomed to fail. In the study by Hausmann and colleagues,⁴ it was not clear whether expectations for and credibility of the positive psychological intervention program was formally assessed, although the authors noted that the intervention as delivered showed acceptability and feasibility in pilot testing. Here again, we contend with the notion that initial impressions and promising results observed in small pilot studies may not generalize to larger trials.

Null findings notwithstanding, it still might be premature to “throw the baby out with the bath water.” Positive psychological interventions may yet have a useful place in the treatment of chronic pain, but that place might be in patients other than veterans with OA pain. The real promise of positive psychological interventions could be as an adjunctive treatment for other more established behavioral interventions such as CBT for pain. Hausmann and colleagues⁴ rightly noted that positive psychological interventions do not inherently focus on directly challenging maladaptive pain-related cognitions, emotions, or behaviors as do more traditional approaches such as CBT for pain.

A better approach could be using these engaging activities to enhance the effectiveness of CBT and other behavioral therapies by more directly targeting positive thoughts and emotions, increasing behavioral activation, and improving adherence and persistence. That way maladaptive processes could be modified, while simultaneously fostering more adaptive behaviors. It is even possible that adding positive psychological interventions to traditional therapies could promote building character strengths, social connections, and purpose in life. The theoretical foundation of these positive interventions is to help individuals with chronic pain and other medical conditions not just to survive the adversity and stress of their illness, but rather to thrive despite it.

Published: September 21, 2018. doi:10.1001/jamanetworkopen.2018.2531

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Hassett AL. JAMA Network Open.

Corresponding Author: Afton L. Hassett, PsyD, Chronic Pain and Fatigue Research Center, Department of Anesthesiology, Michigan Medicine, University of Michigan, 24 Frank Lloyd Wright Dr, Domino’s Farms, Lobby M, PO Box 385, Ann Arbor, MI 48106 (afton@med.umich.edu).

Conflict of Interest Disclosures: None reported.