Advertisement

Emotional Awareness and Expression Therapy for Chronic Pain: Rationale, Principles and Techniques, Evidence, and Critical Review

  • Mark A. LumleyEmail author
  • Howard Schubiner
Chronic Pain (R Staud, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Chronic Pain

Abstract

Purpose of Review

Patients with chronic pain, especially primary or centralized pain, have elevated rates of psychosocial trauma and intrapersonal or intrapsychic conflict. To address these risk factors and potentially reduce pain, the authors developed emotional awareness and expression therapy (EAET). This article presents the rationale for EAET, describes its principles and techniques, reviews its development and early testing as well as recent clinical trials, and critically analyzes the evidence base.

Recent Findings

Four initial trials (between 2006 and 2011) demonstrated the efficacy of earlier versions of EAET. Four recent randomized, controlled trials of different EAET durations (1 to 8 sessions) and formats (individual or group) in patients with fibromyalgia, irritable bowel syndrome, pelvic pain, or medically unexplained symptoms support the earlier findings. EAET reliably reduces pain and interference, although improvements in anxiety and depression are less reliably achieved and may be delayed. The largest and best conducted trial found superiority of EAET over cognitive-behavioral therapy for fibromyalgia. Patient retention in EAET is high, and adverse events are rare.

Summary

EAET merits inclusion as a treatment option for primary pain conditions, and it may be the preferred treatment for some patients. Research is needed on EAET with other pain conditions and samples, using better controls and comparison conditions, and on additional ways to motivate and help patients engage in successful emotional processing.

Keywords

Chronic pain Primary pain Emotional awareness and expression Emotional processing Randomized trial 

Notes

Acknowledgments

We are grateful for the numerous colleagues and students who have contributed to the development and testing of EAET.

Funding Information

Preparation of this manuscript was supported by the National Institutes of Arthritis, Musculoskeletal, and Skin Diseases under award numbers AR057808 and AR074020.

Compliance with Ethical Standards

Conflict of Interest

Dr. Schubiner reports grants from National Institute of Arthritis, Musculoskeletal, and Skin Diseases, supporting some of the studies reported in this article other from self-publishing company, outside the submitted work.

Dr. Lumley reports grants from National Institute of Arthritis, Musculoskeletal, and Skin Diseases supporting some of the studies reported in this article.

Mark Lumley has no conflicts of interest. Howard Schubiner is the author of a manual mentioned in this article, but otherwise has no conflicts of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

All reported studies/experiments with human subjects performed by the authors have been previously published and complied with all applicable ethical standards (including the Helsinki Declaration and its amendments, institutional/national research committee standards, and international/national/institutional guidelines).

Disclaimer

The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Gatchel RJ, Peng YB, Peters ML, Fuchs PN, Turk DC. The biopsychosocial approach to chronic pain: scientific advances and future directions. Psychol Bull. 2007;133:581–624.  https://doi.org/10.1037/0033-2909.133.4.581.CrossRefPubMedGoogle Scholar
  2. 2.
    •• Lumley MA, Schubiner H. Psychological therapy for centralized pain: an integrative assessment and treatment model. Psychosom Med. 2019;81:114–24.  https://doi.org/10.1097/psy.0000000000000654 This article describes limitations of current pain approaches, reviews and alternative therapies and presents a novel model of assessment and intervention. CrossRefPubMedGoogle Scholar
  3. 3.
    Williams DA. Phenotypic features of central sensitization. J Appl Biobehav Res. 2018;23(2):e12135.  https://doi.org/10.1111/jabr.12135.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Nijs J, Torres-Cueco R, van Wilgen P, Lluch Girbés E, Struyf F, Roussel N, et al. Applying modern pain neuroscience in clinical practice: criteria for the classification of central sensitization pain. Pain Physician. 2014;17:447–57.PubMedGoogle Scholar
  5. 5.
    Yunus MB. Fibromyalgia and overlapping disorders: the unifying concept of central sensitivity syndromes. Semin Arthritis Rheum. 2007;36:339–56.  https://doi.org/10.1016/j.semarthrit.2006.12.009.CrossRefPubMedGoogle Scholar
  6. 6.
    Varinen A, Kosunen E, Mattila K, Koskela T, Sumanen M. The relationship between childhood adversities and fibromyalgia in the general population. J Psychosom Res. 2017;99:137–42.  https://doi.org/10.1016/j.jpsychores.2017.06.011.CrossRefPubMedGoogle Scholar
  7. 7.
    Generaal E, Vogelzangs N, Macfarlane GJ, Geenen R, Smit JH, de Geus EJCN, et al. Biological stress systems, adverse life events and the onset of chronic multisite musculoskeletal pain: a 6-year cohort study. Ann Rheum Dis. 2016;75:847–54.  https://doi.org/10.1136/annrheumdis-2014-206741.CrossRefPubMedGoogle Scholar
  8. 8.
    Nicol AL, Sieberg CB, Clauw DJ, Hassett AL, Moser SE, Brummett CM. The association between a history of lifetime traumatic events and pain severity, physical function, and affective distress in patients with chronic pain. J Pain. 2016;17:1334–48.  https://doi.org/10.1016/j.jpain.2016.09.003. CrossRefPubMedGoogle Scholar
  9. 9.
    Van Houdenhove B, Luyten P, Tiber Egle U. Stress as a key concept in chronic widespread pain and fatigue disorders. J Musculoskel Pain. 2009;17:390–9.CrossRefGoogle Scholar
  10. 10.
    Landa A, Peterson BS, Fallon BA. Somatoform pain: a developmental theory and translational research review. Psychosom Med. 2012;74:717–27.  https://doi.org/10.1097/PSY.0b013e3182688e8b.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Sachs-Ericsson NJ, Sheffler JL, Stanley IH, Piazza JR, Preacher KJ. When emotional pain becomes physical: adverse childhood experiences, pain, and the role of mood and anxiety disorders. J Clin Psychol. 2017;73:1403–28.  https://doi.org/10.1002/jclp.22444.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Luyten P, Van Houdenhove B, Lemma A, Target M, Fonagy P. Vulnerability for functional somatic disorders: a contemporary psychodynamic approach. J Psychother Integr. 2013;23:250–62.  https://doi.org/10.1037/a0032360.CrossRefGoogle Scholar
  13. 13.
    Kross E, Berman MG, Mischel W, Smith EE, Wager TD. Social rejection shares somatosensory representations with physical pain. Proceed Nat Acad Sci. 2011;108:6270–5.  https://doi.org/10.1073/pnas.1102693108.CrossRefGoogle Scholar
  14. 14.
    Lane RD, Waldstein SR, Chesney MA, Jennings JR, Lovallo WR, Kozel PJ, et al. The rebirth of neuroscience in psychosomatic medicine, part I: historical context, methods, and relevant basic science. Psychosom Med. 2009;71:117–34.  https://doi.org/10.1097/PSY.0b013e31819783be.CrossRefPubMedGoogle Scholar
  15. 15.
    You DS, Meagher MW. Childhood adversity and pain facilitation. Psychosom Med. 2018;80:869–79.  https://doi.org/10.1097/psy.0000000000000638.CrossRefPubMedGoogle Scholar
  16. 16.
    You DS, Meagher MW. Childhood adversity and pain sensitization. Psychosom Med. 2016;78:1084–93.  https://doi.org/10.1097/psy.0000000000000399.CrossRefPubMedGoogle Scholar
  17. 17.
    Alvarez P, Green PG, Levine JD. Stress in the adult rat exacerbates muscle pain induced by early-life stress. Biol Psychiatry. 2013;74:688–95.  https://doi.org/10.1016/j.biopsych.2013.04.006.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Green PG, Chen X, Alvarez P, Ferrari LF, Levine JD. Early-life stress produces muscle hyperalgesia and nociceptor sensitization in the adult rat. Pain. 2011;152:2549–56.  https://doi.org/10.1016/j.pain.2011.07.021.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Williams ACDC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev. 2012;11:CD007407.  https://doi.org/10.1002/14651858.CD007407.pub3.
  20. 20.
    Ehde DM, Dillworth TM, Turner JA. Cognitive-behavioral therapy for individuals with chronic pain: efficacy, innovations, and directions for research. Am Psychol. 2014;69:153–66.  https://doi.org/10.1037/a0035747.CrossRefPubMedGoogle Scholar
  21. 21.
    McCracken LM, Vowles KE. Acceptance and commitment therapy and mindfulness for chronic pain: model, process, and progress. Am Psychol. 2014;69:178–87.CrossRefGoogle Scholar
  22. 22.
    Hilton L, Hempel S, Ewing BA, Apaydin E, Xenakis L, Newberry S, et al. Mindfulness meditation for chronic pain: systematic review and meta-analysis. Ann Behav Med. 2017;51:199–213.  https://doi.org/10.1007/s12160-016-9844-2.CrossRefPubMedGoogle Scholar
  23. 23.
    Lane RD, Ryan L, Nadel L, Greenberg L. Memory reconsolidation, emotional arousal, and the process of change in psychotherapy: new insights from brain science. Behav Brain Sci. 2015;38:e1.  https://doi.org/10.1017/S0140525X14000041.CrossRefPubMedGoogle Scholar
  24. 24.
    Abbass A, Town J, Driessen E. Intensive short-term dynamic psychotherapy: a systematic review and meta-analysis of outcome research. Harvard Rev Psych. 2012;20:97–108.  https://doi.org/10.3109/10673229.2012.677347.CrossRefGoogle Scholar
  25. 25.
    Pascual-Leone A, Greenberg LS. Emotional processing in experiential therapy: why “the only way out is through.”. J Consult Clin Psychol. 2007;75:875–87.CrossRefGoogle Scholar
  26. 26.
    Barlow DH, Allen LB, Choate ML. Toward a unified treatment for emotional disorders. Behav Ther. 2004;35:205–30.CrossRefGoogle Scholar
  27. 27.
    Brewin CR, Holmes EA. Psychological theories of posttraumatic stress disorder. Clin Psychol Rev. 2003;23:339–76.CrossRefGoogle Scholar
  28. 28.
    • Peluso PR, Freund RR. Therapist and client emotional expression and psychotherapy outcomes: A meta-analysis. Psychother. 2018;55:461–72.  https://doi.org/10.1037/pst0000165 This high-quality meta-analysis shows that patient emotional expression is one of the strongest predictors of positive psychotherapy outcomes. CrossRefGoogle Scholar
  29. 29.
    Leserman J. Sexual abuse history: prevalence, health effects, mediators, and psychological treatment. Psychosom Med. 2005;67:906–15.CrossRefGoogle Scholar
  30. 30.
    • Moseley GL, Butler DS. Fifteen years of explaining pain: the past, present, and future. J Pain. 2015;16:807–13.  https://doi.org/10.1016/j.jpain.2015.05.005 This excellent review describes key aspects of effect pain neuroscience education. CrossRefPubMedGoogle Scholar
  31. 31.
    Louw A, Diener I, Butler DS, Puentedura EJ. The effect of neuroscience education on pain, disability, anxiety, and stress in chronic musculoskeletal pain. Arch Physical Med Rehab. 2011;92:2041–56.  https://doi.org/10.1016/j.apmr.2011.07.198.CrossRefGoogle Scholar
  32. 32.
    Vlaeyen J, Morley S, Linton SJ, Boersma K, de Jong J. Pain-related fear: exposure based treatment for chronic pain. 1st ed. Seattle (WA): IASP Press; 2012.Google Scholar
  33. 33.
    Lumley MA, Sklar ER, Carty JN. Emotional disclosure interventions for chronic pain: from the laboratory to the clinic. Transl Behav Med. 2012;2:73–81.CrossRefGoogle Scholar
  34. 34.
    Speed BC, Goldstein BL, Goldfried MR. Assertiveness training: a forgotten evidence-based treatment. Clin Psychol Sci Pract. 2018;25:e12216.  https://doi.org/10.1111/cpsp.12216.CrossRefGoogle Scholar
  35. 35.
    Morina N, Lancee J, Arntz A. Imagery rescripting as a clinical intervention for aversive memories: a meta-analysis. J Behav Ther Exper Psych. 2017;55:6–15.  https://doi.org/10.1016/j.jbtep.2016.11.003.CrossRefGoogle Scholar
  36. 36.
    Sarno JE. The mind-body prescription: healing the body, healing the pain. New York: Hachette Book Group USA; 1998.Google Scholar
  37. 37.
    Sarno JE. Mind over back pain: the mind-body connection. New York: Warner Books; 1991.Google Scholar
  38. 38.
    Schubiner H, Betzold M. Unlearn your pain: a 28-day process to reprogram your brain. 3rd ed. Pleasant Ridge: Mind-Body Pubishing; 2016.Google Scholar
  39. 39.
    Hsu MC, Schubiner H, Lumley MA, Stracks JS, Clauw DJ, Williams DA. Sustained pain reduction through affective self-awareness in fibromyalgia: a randomized controlled trial. J Gen Intern Med. 2010;25:1064–70.  https://doi.org/10.1007/s11606-010-1418-6.CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Burger AJ, Lumley MA, Carty JN, Latsch DV, Thakur ER, Hyde-Nolan ME, et al. The effects of a novel psychological attribution and emotional awareness and expression therapy for chronic musculoskeletal pain: a preliminary, uncontrolled trial. J Psychosom Res. 2016;81:1–8.  https://doi.org/10.1016/j.jpsychores.2015.12.003.CrossRefPubMedGoogle Scholar
  41. 41.
    Lumley MA, Cohen JL, Stout RL, Neely LC, Sander LM, Burger AJ. An emotional exposure-based treatment of traumatic stress for people with chronic pain: preliminary results for fibromyalgia syndrome. Psychother Theory Res Practice Train. 2008;45:165–72.CrossRefGoogle Scholar
  42. 42.
    Slavin-Spenny O, Lumley M, Thakur E, Nevedal D, Hijazi A. Effects of anger awareness and expression training versus relaxation training on headaches: a randomized trial. Ann Behav Med. 2013;46:181–92.  https://doi.org/10.1007/s12160-013-9500-z.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    • Ziadni MS, Carty JN, Doherty HK, Porcerelli JH, Rapport LJ, Schubiner H, et al. A life-stress, emotional awareness and expression interview for primary care patients with medically unexplained symptoms: a randomized controlled trial. Health Psychol. 2018;37:282–90.  https://doi.org/10.1037/hea0000566 This clinical trial demonsrates the efficacy of EAET conducted in a single session. CrossRefPubMedGoogle Scholar
  44. 44.
    Carty JN, Ziadni MS, Holmes HJ, Tomakowsky J, Peters K, Schubiner H, et al. The effects of a life stress emotional awareness and expression interview for women with chronic urogenital pain: a randomized controlled trial. Pain Med in press. 2018.  https://doi.org/10.1093/pm/pny182.
  45. 45.
    Thakur ER, Holmes HJ, Lockhart NA, Carty JN, Ziadni MS, Doherty HK, et al. Emotional awareness and expression training improves irritable bowel syndrome: a randomized controlled trial. Neurogastroenterol Motil. 2017;29:e13143.  https://doi.org/10.1111/nmo.13143.CrossRefGoogle Scholar
  46. 46.
    •• Lumley MA, Schubiner H, Lockhart NA, Kidwell KM, Harte S, Clauw DJ, et al. Emotional awareness and expression therapy, cognitive-behavioral therapy, and education for fibromyalgia: a cluster-randomized controlled trial. Pain. 2017;158:2354–63 This very large, well-conducted clinical trial demonstrates the efficacy of EAET not only against an active control condition, but also against the gold standard, cognitive-behavioral therapy. CrossRefGoogle Scholar
  47. 47.
    Boersma K, Sodermarck M, Hesser H, Flink IK, Gerdle B, Linton SJ. The efficacy of a transdiagnostic emotion-focused exposure treatment for chronic pain patients with comorbid anxiety and depression: a randomized controlled trial. Pain. in press. 2019.  https://doi.org/10.1097/j.pain.0000000000001575.

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of PsychologyWayne State UniversityDetroitUSA
  2. 2.Department of Internal Medicine, Ascension Providence-Providence HospitalMichigan State University College of Human MedicineSouthfieldUSA

Personalised recommendations