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Secondary analysis identifies possible mediators for chronic pain treatments in VeteransStudy in Veterans with chronic pain explores how three mind-body treatments may work

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Key Takeaway
Consider possible mediators like pain willingness and catastrophizing in chronic pain treatments, but recognize these findings require validation.

This secondary analysis examined data from a randomized clinical trial comparing three non-pharmacological treatments for chronic pain in 328 US Veterans. Participants received either clinical hypnosis, mindfulness meditation training, or pain education through 8 in-person group sessions. The analysis explored potential mediators of treatment effects rather than direct treatment comparisons.

Across all three treatment conditions, three candidate variables were significantly associated with reductions in both pain intensity and pain interference: greater willingness to tolerate pain, greater engagement in valued activities despite pain, and reduced catastrophizing. Working alliance was significantly associated with reductions in pain intensity specifically for those receiving clinical hypnosis. The analysis suggested catastrophizing might play a larger role for mindfulness effects on pain intensity and interference, while pain willingness might play a larger role in hypnosis effects on pain interference. No effect sizes, absolute numbers, or statistical confidence intervals were reported.

Safety and tolerability data were not reported in this secondary analysis. The authors explicitly note that further research is needed to validate the reliability of these identified mediators, emphasizing that these are possible mediators requiring replication and definitive testing. The findings, if replicated, would support focusing treatment on thoughts about pain, pain avoidance, engagement in valued activities, and working alliance. However, as a secondary analysis of a single trial in a Veteran population, generalization is limited.

Researchers wanted to understand how different mind-body treatments might help people with chronic pain. They re-analyzed data from a previous study of 328 US Veterans with chronic pain. The Veterans had received one of three treatments: clinical hypnosis, mindfulness meditation training, or pain education classes. The study did not report on the safety of these treatments.

The analysis looked for factors that might explain why these treatments could work. They found that across all three treatments, Veterans who reported being more willing to tolerate their pain, who engaged more in activities they valued despite pain, and who worried less about their pain (a process called catastrophizing) tended to have less pain intensity and less interference from pain in their lives. For those who received clinical hypnosis, having a good connection with their therapist (called a working alliance) was also linked to better pain reduction.

It's important to be careful with these results. This was a secondary look at data from one study, not a new experiment designed to test these specific ideas. The researchers themselves say more studies are needed to confirm if these factors truly help explain how the treatments work. The findings are specific to Veterans and may not apply to everyone with chronic pain. For now, this research suggests that focusing on thoughts about pain, staying active in meaningful ways, and building a good relationship with a therapist might be helpful areas to explore in chronic pain treatment, but these are not yet proven strategies.

What this means for you:
Early study suggests how you think about and react to pain may be linked to treatment success, but more research is needed.

Study Details

Study typeRct
EvidenceLevel 2
PublishedApr 2026
View Original Abstract ↓
Psychological interventions have reliable but modest effects on chronic pain outcomes, but our understanding of the mechanisms that underlie these effects remains limited. This paper presents the findings from a series of secondary analyses using data from a randomized clinical trial (clinicalTrials.gov, NCT02653664). Three hundred and twenty-eight Veterans of the US Armed Forces with chronic pain were randomized to receive clinical hypnosis, mindfulness meditation training, or pain education via 8 in-person group sessions. Of 17 candidate mediator variables assessed before and after treatment, 10 changed with treatment. Three of these were associated significantly with reductions in pain intensity and interference across all three treatment conditions: greater willingness to tolerate pain, greater engagement in valued activities despite pain, and reduced catastrophizing. A fourth candidate mediator assessed during treatment (working alliance) was significantly associated with reductions in pain intensity for those receiving clinical hypnosis. When comparing effects between treatments, catastrophizing appeared to play a larger role for the effects of mindfulness training on pain intensity and interference, and pain willingness appeared to play a larger role in the effect of therapeutic hypnosis on pain interference. Further research is needed to validate the reliability of the mediators identified in this study. If the findings from the current study replicate in other samples, they would support the importance of focusing treatment on thoughts about pain, pain avoidance, engagement in valued activities, and working alliance. PERSPECTIVE: Three psychological variables were identified as being possible mediators of the beneficial effects of mindfulness, clinical hypnosis, and pain education on pain. Additional research is needed to definitively test these variables as potential mediators of psychological pain treatments.
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