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measures enumerated above, all patients completed treatment expectation ratings before the first sessions and satisfaction ratings at the end of the first and last sessions based on Borcovec and Nau [32]. Satisfaction was rated on a 6-point scale ranging from 0 ('completely unsatisfied') to 6 ('completely satisfied'). This measure was included as a means of determining whether the groups differed in their beliefs about the quality of the treatment received. Assessment of pain behaviors Pain behaviours were elicited by the standardised performance of a window washing task. Patients were videotaped performing this task. Pain behaviours were assessed using the Tübingen Pain Behaviour Scale (TBS) [33]. The frequency of occurrence of each pain behaviour was coded by two independent raters in 10-second epochs for a period of 8 minutes [10]. The TBS rates the presence of behaviours on a 0–2 scale (0 = none, 1 = sometimes, 2 = always). The total value of pain behaviours was calculated by summing the absolute frequencies of the individual pain behaviours observed during the task. The inter-rater reliability was good (kappa = 0.82; P < 0.001). Scores for pain behaviours in the absence and in the presence of the spouse were computed. Health care utilization Medication consumption and number of physician visits 12 months prior to and 12 months after treatment were obtained from the medical records maintained at the various Rheumatology Outpatient Clinics. Patients were routinely observed at the clinic at 6-week scheduled intervals. Treatments Each treatment consisted of 15 weekly 2-hour sessions co-led by a psychologist and rheumatologist and conducted in groups of five patients. Spouses attended the first, fifth, ninth, and 13th sessions. Both CBT and OBT were based on structured manuals [34], whereas the AP treatment consisted of unstructured discussions of problems associated with having FMS and support provided by the therapists and group members. The CBT focused on the patients' thinking and involved problem-solving, stress and pain coping strategies, and relaxation [34, 35]. Patients were taught the meaning of the stress-tension-pain circle as a cognitive pain model and learned coping strategies and the reduction of catastrophising thoughts. Patients and spouses received weekly homework tasks, were encouraged to engage in physical activities, and were asked to reduce analgesic medication use at a gradual rate over the course of the treatment. The patients participated in relaxation exercises during and between the sessions. The therapists identified instances of maladaptive thinking and encouraged the group to challenge these instances and to provide more appropriate interpretations and alternatives. Although the importance of behaviour change was noted, the focus of this treatment was on the change of maladaptive thoughts and attitudes. The treatment was administered in the fashion of a Socratic dialogue. Operant behavior therapy The OBT was primarily based on changing observable pain behaviours and included video feedback of expressions of pain as well as contingent positive reinforcement of pain-incompatible behaviours and punishment of pain behaviours in a group setting. Structured time-contingent exercises were provided according to operant principles [20] in the sessions and as homework exercises. The treatment also included time-contingent intake and reduction of medication, increase of bodily activity, reduction of interference of pain with activities, reduction of pain behaviours, and training in assertive pain-incompatible behaviours [34]. Patients engaged in role-playing to reduce pain behaviours and increase healthy behaviours. Patients, their spouses, as well as group members used a reinforcer plan that consisted of the presentation of a 'red card' when pain behaviours were displayed and a 'green card' when healthy behaviours were displayed. Patients were encouraged to increase their activity levels and were assigned homework that included specific instructions to increase activities and reduce pain behaviours. A reduction of medication was instituted immediately after the assessment phase, based on a physician-

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