Emotional Awareness and Expression Therapy for Chronic Pain

Why EAET was developed

Recent estimates of chronic pain prevalence in the United States indicate that more than 50 million adults (20.5 percent) report experiencing pain on most days or every day (Yong, Mullins, and Bhattacharyya, 2022), and chronic pain can significantly disrupt a person’s quality of life and overall well-being. Fortunately, psychological treatments are available for chronic pain. Cognitive Behavioral Therapy (CBT) is considered the “gold standard,” and for good reason. There is substantial evidence from several decades of research to support the effectiveness of CBT. A 2020 Cochrane review (Williams et al.) concluded that compared to active control groups, CBT had statistically significant effects on pain, disability, and distress, and without the potential side effects of medications and surgeries to boot.

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Why would we need an additional intervention? The systematic review described above noted that the effects of CBT at treatment end on pain, disability, and distress were "small" compared to treatment as usual and "very small" compared to active control groups. Statistically significant but small effects indicate that although we can say confidently that CBT is beneficial, the change or improvement is, at least for some patients, relatively modest. As is the case with many psychological treatments, it is possible that although some people with chronic pain benefit substantially from CBT— and I have personally observed how powerful a tool CBT can be—there are also some people struggling with chronic pain for whom CBT provides less benefit.

Additionally, there is evidence that patients with chronic pain have elevated rates of trauma (Lumley and Schubiner, 2019) and there is comorbidity between post-traumatic stress disorder (PTSD) and chronic pain. In fact, some researchers conceptualize PTSD and chronic pain as “mutually maintaining conditions,” in part due to the role that avoidance (of pain, emotions, or other triggers) seems to play in both conditions (Sharp and Harvey, 2001). However, the role that unresolved trauma and emotional conflicts may play in causing and or maintaining chronic pain is often overlooked by mental health providers treating pain patients.

What is EAET and how is it different from CBT?

EAET was developed to treat psychological trauma or conflict in patients with certain pain conditions —specifically, primary pain conditions such as fibromyalgia, irritable bowel syndrome, and head pain, as opposed to pain resulting from pathological somatic processes such as neuropathy, inflammation, or tumors. EAET is a relatively new intervention—with trials of the earliest versions of EAET occurring from 2006 to 2011—but it draws from many established psychological approaches including exposure therapy, intensive short-term psychodynamic therapy, experiential therapies, and written emotional disclosure, among others. Several randomized controlled trials have demonstrated its effectiveness for patients suffering from a variety of pain conditions including fibromyalgia (Lumley et al., 2017), chronic pelvic pain (Carty et al., 2019), irritable bowel syndrome (Thakur et al., 2017), chronic musculoskeletal pain (Yarns et al., 2020), and general medically unexplained symptoms (Ziadni et al., 2018).

Like CBT, in EAET patients are taught that their brain and stressful experiences play a substantial role in pain. What distinguishes EAET from CBT is the strong emphasis in EAET on emotional processes. In CBT, patients learn skills to manage their pain by changing the way they think (for example, challenging all-or-nothing thinking or catastrophic thoughts about pain) and by changing their behaviors (for example, relaxation techniques or engaging in activities that have been avoided due to pain).

In EAET, patients are challenged to become aware of and express avoided emotions, such as anger or sadness. Specifically, patients are encouraged not only to talk about and analyze their feelings, but also to recall a person and situation involved with any unexpressed emotions and to experience vividly what it is like to feel and express those emotions toward that person using words, tone of voice, facial expressions, and posture. This experiential technique is used in session and, if possible and appropriate, strategies for expressing these emotions in real-life relationships are explored.

Who should try EAET and how to find it

In my own clinical work treating chronic pain patients, I integrate principles from a variety of modalities, including EAET, based on the needs and preferences of the patient. I highly recommend EAET for individuals with primary pain disorders such as fibromyalgia, IBS, chronic migraines, or chronic pelvic pain who:

1. Have already tried CBT and would like to learn additional techniques for addressing their pain symptoms
2. Have histories of trauma or unresolved emotional conflicts that may be contributing to their pain symptoms

Because EAET is a relatively new intervention, it can be difficult to find a mental health practitioner in your area who has been trained in EAET. A good place to start is the Psychology Today therapist directory, which allows you to filter by specialization and treatment orientation. Whether or not you’re able to find someone who can specifically administer EAET, you can speak with potential therapists about their willingness to explore the role that unresolved emotional conflicts or past trauma play in your pain. Therapists with training in exposure, psychodynamic, and or experiential therapy may be able to use the techniques they already practice to help you access and approach important emotional experiences.