Case Study 4: Evidencing the effectiveness of psychological treatment for chronic pain
Submitting InstitutionUniversity of Leeds
Unit of AssessmentPsychology, Psychiatry and Neuroscience
Summary Impact TypeHealth
Research Subject Area(s)
Medical and Health Sciences: Clinical Sciences, Public Health and Health Services
Psychology and Cognitive Sciences: Psychology
Summary of the impact
Chronic pain, defined as pain lasting for more than 6 months, affects
more than 25% of adults in developed nations. Drugs are costly, carry
risks of side effects and dependence, and are of limited effectiveness in
many cases. Morley, at the University of Leeds (UoL), collaborated
on a series of definitive reviews and meta-analyses proving that active
psychological treatments based on cognitive behavioural therapy (CBT) are
effective in treating chronic pain. This led to changes in UK government
and world health organization (WHO) guidelines and the adoption of CBT at
specialist pain clinics, reducing patient suffering, increasing social
role functioning and ensuring more cost-effective treatment.
Morley (Professor, Clinical Psychology) has been working on
psychological treatments for pain at the UoL since 1984. Between 1996 and
2010, in collaboration with Dr. Williams at University College London
(UCL) and Professor Eccleston at the University of Bath, Morley
produced a body of work that proved the effectiveness of CBT as a
treatment for chronic pain and provided the foundation for its widespread
adoption in clinical settings.
CBT is a systematic psychotherapeutic approach that focuses on changing
people's behaviour and emotional state. It was originally developed for
the treatment of depression and anxiety and its application in pain
therapy focuses on changing a wide range of behaviours, expectations and
psychological problems that tend to exacerbate suffering.
In 1996, Morley started a collaboration with Williams and
Eccleston looking at the effectiveness of psychological interventions in
the treatment of chronic pain. In 1999, the three researchers, with Morley
acting as lead author and performing the meta-analysis, published the
first large scale synthesis of randomised controlled trials that evaluated
CBT for pain relief, integrating the findings of 33 papers, including 25
clinical trials, on psychological treatments for chronic pain in adults.
This provided the first comprehensive evidence of the effectiveness of CBT
as a treatment for chronic pain  (729 cites) and provided
supporting evidence for the widespread adoption of CBT in clinical
In 2001, Morley et al. carried out a similar analysis of 123
papers, including 28 potential therapeutic trials, of CBT treatments of
chronic pain in children, proving CBT's effectiveness in this younger age
group  (132 cites). In 2005, they developed and reported a
scale for assessing the quality of reports of randomised controlled trials
(RCTs) for psychological treatments, providing a sound basis for future
meta-analyses . In 2008, Morley and Williams developed
a practise-based study, which provided evidence for the effectiveness of
CBT in routine clinical settings. This adopted a simple psychometric
technology for evaluating reliable and clinically important changes at an
individual level .
Finally, Morley, Eccleston and Williams, as leaders in their
field, published a Cochrane review to disseminate their findings 
(108 cites) and an update of their meta-analyses in children and
adolescents, confirming and extending their earlier conclusions 
(68 cites). In the papers cited above, Morley, Eccleston and
Williams led the research (with Palermo, a senior academic in the US in
reference ), with contributions from junior researchers (Yorke
& Mastroy) and research students from the US (Lewandowski) and the UoL
(Hussain & Yates).
References to the research
 Morley*, S., Eccleston, C., & Williams, A. (1999).
Systematic review and meta-analysis of randomized controlled trials of
cognitive behaviour therapy and behaviour therapy for chronic pain in
adults, excluding headache. Pain, 80, 1-13. doi:
This paper was the first major meta-analysis of the available RCT data
i.e. it did not include other studies, for psychological treatments for
chronic pain and established their effectiveness.
 Eccleston, C., Morley*, S., Williams, A., Yorke, L.,
& Mastroyannopoulou, K. (2002). Systematic review of randomised
controlled trials of psychological therapy for chronic pain in children
and adolescents, with a subset meta-analysis of pain relief. Pain, 99,
157-165. doi: 10.1016/S0304-3959(02)00072-6
This paper extended the range of  with respect to
the evidence for treatments of pain in young people.
 Yates*, S.L., Morley*, S., Eccleston, C., &
Williams, A.C.D. (2005). A scale for rating the quality of psychological
trials for pain. Pain, 117, 314-325. doi:
This paper reported the development of a scale for assessing quality
and bias in randomised control trials of psychological therapies for
pain. It explicitly recognised that standard double blind methodology is
not feasible in such trials.
 Morley*, S., Williams, A., & Hussain*, S. (2008).
Estimating the clinical effectiveness of cognitive behavioural therapy in
the clinic: Evaluation of a CBT informed pain management programme. Pain,
137, 670-680. doi: 10.1016/j.pain.2008.02.025
This paper used a simple methodology to illustrate the principles of
evaluating real-world clinical data going beyond the simple statistical
test of pre-treatment post-treatment mean differences previously
reported in the literature.
 Eccleston, C., Williams, A.C.deC., & Morley*, S.
(2009). Psychological therapies for the management of chronic pain
(excluding headache) in adults. Cochrane Database Of Systematic
Reviews, 2009(2), 1-102. doi: 10.1002/14651858.CD007407.pub2
This paper provided an update of  using more
stringent criteria including the application of the quality scale .
Williams, A.C.deC., Eccleston, C., & Morley*, S. (2012).
Psychological therapies for the management of chronic pain (excluding
headache) in adults. Cochrane Database Of Systematic Reviews, 2012(11),
1-78. doi: 10.1002/14651858.CD007407.pub3
 Palermo, T.M., Eccleston, C., Lewandowski. A.S,, Williams,
A.C.deC,, & Morley*, S. (2010). Randomized controlled trials
of psychological therapies for management of chronic pain in children and
adolescents: An updated meta-analytic review. Pain, 148, 387-397.
This paper replicated and extended the findings of  also
incorporating data on trial quality.
Note: All UoA4 researchers in bold; *research conducted by
academics at the UoL.
Details of the impact
Chronic pain is common, affecting up to 40% of the population in
community samples (Croft, P. R., Blyth, F. M., & van de Windt, D.
(Eds.) (2010). Chronic Pain Epidemiology: From Aetiology to Public
Health. Oxford: Oxford University Press), and is caused by a wide
range of medical conditions including back pain, fibromyalgia and chronic
musculoskeletal pain. For 25% of the population chronic pain interferes
with life and for 10% it is disabling (Croft et al. 2010). In the UK back
pain is estimated to cost the NHS £1 billion per annum, with primary care
management of patients with chronic pain accounting for 4.6 million
appointments per year, equivalent to 793 whole time general practitioners
(GPs), at a total cost of around £69 million (Phillips, C. J. (2009). The
cost and burden of chronic pain. Reviews in Pain, 3(1), 2-4).
Morley et al.'s findings were disseminated to healthcare
professionals and policymakers through a series of high-profile
presentations, including plenary lectures at the The World Congress on
Pain (IASP) 2010 Montreal, The British Pain Society (2009) and The Dutch
Rehabilitation Society (2011), as well as numerous talks to national
meetings. Morley conducted a refresher course at the IASP World
Congress on Pain in 2008 and the Cochrane review  gave an
authoritative overview of the efficacy of CBT to a wide clinical audience.
Morley also engaged directly with patients and the general public,
as a member of the steering group for the production of the chronic pain
section of the Database of Individual Patient Experiences database (DIPex:
contributing to a PainConcern.co.uk podcast on the topic, and delivering a
series of public outreach talks.
Impact on policy and practice
The underpinning research and this dissemination effort has played a key
part in changing practice in the UK and internationally. Morley's
research [1, 2, 5] has been specifically referenced in, and made a
significant contribution to, health guidelines within the UK. Conclusions
from these publications, which indicate that CBT is a beneficial form of
treatment for chronic pain, have contributed to NICE (National Institute
of Clinical Excellence; CG88, Low back pain [A]), SIGN (Scottish
Intercollegiate Guidelines Network; SIGN106, Cancer Pain [B]),
GAIN (NI Guidelines and Audit Implementation Network, palliative care)
guidelines and Health Commission Wales directives as well as Royal College
of Physicians' and Anaesthetists' guidelines. This work has also
demonstrated substantial reach, influencing American National Institutes
of Health (NIH) [C] guidelines on the non-pharmacological
treatment of persisting pain and is the only work referenced in relation
to CBT for a pain treatment guide published by the WHO [D].
The British Pain Society is the largest multidisciplinary professional
organisation in the field of pain within the UK, bringing together
doctors, nurses, physiotherapists and other healthcare professionals. Morley
and Eccleston were on the working party that produced its Recommended
Guidelines for Pain Management Programmes for Adults [E].
The executive summary states:
"Pain management programmes (PMPs), based on cognitive behavioural
principles, are the treatment of choice for people with persistent pain
which adversely affects their quality of life."
The second item referenced Morley et al.'s review in 1999 
in support of this central statement. Publications  and 
were referenced throughout the 22-page document (8 times) in support of
specific claims of effectiveness and recommendations about delivery [E].
Impact on outcomes for patients
Pete Moore is the author of the Pain Toolkit, a book and website (www.paintoolkit.org)
aimed at helping people self-manage their pain using CBT principles. He
suffers from chronic pain and describes the profound significance of
chronic pain for the individual patient and the fact that programmes based
on cognitive-behaviour therapy (CBT) have helped change his life [F].
He has played an important role in promoting this approach in the UK and
internationally and from 2002 - 2011 worked for the UK Expert Patient
Programme as a Senior Trainer. Since 2009 more than 200,000 copies of the
Pain Toolkit have been printed and are in circulation in the UK, and it
has been translated into German, French and Italian for use
internationally. Moore describes Morley et al.'s work as critical
to convincing professionals and patients to adopt the CBT approach:
"The scientific paper by Stephen Morley, Christopher
Eccleston and Amanda Williams (1999) played an invaluable part in
documenting the evidence for CBT" [F].
The widespread introduction of CBT (according to the 2009 National Pain
Audit at least 108 pain clinics throughout the UK employ a psychologist)
has improved pain management outcomes for patients. There is evidence that
drug treatments have limited effectiveness. Success rates were above 50%
for only four drugs in postoperative pain and one in migraine. Many
conditions have painkiller failure rates of more than 70% [G]. The
use of CBT alongside, or to replace, drug regimens as recommended by
National guidelines described above [A, B, C, D, E] that draw on Morley's
research [1, 2, 5, 6] has significantly improved clinical pain
management and has the potential to significantly reduce opiate use and
dependence (Naylor, M. R., Naud, S., Keefe, F. J., & Helzer, J. E.
(2010). Therapeutic Interactive Voice Response (TIVR) to reduce analgesic
medication use for chronic pain management. The Journal of Pain, 11(12),
Morley's recent research [H] has created a tool with
evidence-based benchmarks against which local services can evaluate their
delivery of CBT for pain relief. Using data from routine clinical
services, they then demonstrate that these benchmarks can indeed be used
for local evaluation in order to improve services offered to patients.
Impact on the cost of health provision
Cognitive behavioural treatment of pain is cost effective. A 2010 trial
of group CBT treatment of low-back pain in primary care in the UK showed a
sustained effect of CBT on subacute and chronic low-back pain at a low
cost to the health-care provider; the cost per quality-adjusted life year
for a CBT intervention is half that of alternatives [I]. A
subsequent systematic review found evidence supporting the
cost-effectiveness of guideline-endorsed treatments of interdisciplinary
rehabilitation, exercise, acupuncture, spinal manipulation and CBT
for sub-acute or chronic LBP [J]. Morley's own work has
shown that use of CBT improves social role performance, reduces distress ,
and that the adoption of CBT in routine clinical care has a positive
Sources to corroborate the impact
[A] National Institute for Health and Clinical Excellence (NICE).
(2009). Low back pain: Early management of persistent non-specific low
back pain: CG 88 (p. 170). Retrieved from
[B] Scottish Intercollegiate Guidelines Network (SIGN). (2008). Control
of pain in adults with cancer. A national clinical guideline (p. 8).
Retrieved from http://www.sign.ac.uk/pdf/SIGN106.pdf
[C] Medline Plus (US National Library of Medicine and the National
Institutes for Health Service). (2011). Cognitive behavioral therapy
for back pain and Pain and your emotions. Retrieved from
[D] World Health Organisation. (2012). WHO guidelines on the
pharmacological treatment of persisting pain in children with medical
illnesses (p. 122). Retrieved from
[E] British Pain Society. (2007- Current). Recommended guidelines
for Pain Management Programmes for adults: A consensus statement prepared
on behalf of the British Pain Society (pp. 1, 3, 5, 9, 10, 24). Retrieved
[F] Testimonial from the founder of the Pain Toolkit website (www.paintoolkit.org);
a site that offers self-help support, advice and information for those
with chronic pain (11.06.13).
[G] Moore, A., Derry, S., Eccleston, C., & Kalso, E. (2013).
Expect analgesic failure; pursue analgesic success. British Medical
Journal, 346, f2690. doi: 10.1136/bmj.f2690
[H] Fenton, G., & Morley, S. (2013). A tale of two
RCTs: using randomized controlled trials to benchmark routine clinical
(psychological) treatments for chronic pain. Pain 154(10),
2108-19. doi: 10.1016/j.pain.2013.06.033
[I] Lamb, S. E., Hansen, Z., Lall, R., Castelnuovo, E., Withers,
E. J., Nichols, V., Potter, R., & Underwood, M. R. (2010). Group
cognitive behavioural treatment for low-back pain in primary care: a
randomised controlled trial and cost-effectiveness analysis. The
Lancet, 375(9718), 916-923. doi: 10.1016/S0140-6736(09)62164-4
[J] Lin, C.W., Haas, M., Maher, C., Machado, L. C., & Tulder,
M. (2011). Cost-effectiveness of guideline-endorsed treatments for low
back pain: a systematic review. European Spine Journal, 20(7),
1024-1038. doi: 10.1007/s00586-010-1676-3