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.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
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.
•• 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.
Williams DA. Phenotypic features of central sensitization. J Appl Biobehav Res. 2018;23(2):e12135. https://doi.org/10.1111/jabr.12135.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
You DS, Meagher MW. Childhood adversity and pain facilitation. Psychosom Med. 2018;80:869–79. https://doi.org/10.1097/psy.0000000000000638.
You DS, Meagher MW. Childhood adversity and pain sensitization. Psychosom Med. 2016;78:1084–93. https://doi.org/10.1097/psy.0000000000000399.
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.
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.
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.
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.
McCracken LM, Vowles KE. Acceptance and commitment therapy and mindfulness for chronic pain: model, process, and progress. Am Psychol. 2014;69:178–87.
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.
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.
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.
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.
Barlow DH, Allen LB, Choate ML. Toward a unified treatment for emotional disorders. Behav Ther. 2004;35:205–30.
Brewin CR, Holmes EA. Psychological theories of posttraumatic stress disorder. Clin Psychol Rev. 2003;23:339–76.
• 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.
Leserman J. Sexual abuse history: prevalence, health effects, mediators, and psychological treatment. Psychosom Med. 2005;67:906–15.
• 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.
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.
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.
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.
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.
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.
Sarno JE. The mind-body prescription: healing the body, healing the pain. New York: Hachette Book Group USA; 1998.
Sarno JE. Mind over back pain: the mind-body connection. New York: Warner Books; 1991.
Schubiner H, Betzold M. Unlearn your pain: a 28-day process to reprogram your brain. 3rd ed. Pleasant Ridge: Mind-Body Pubishing; 2016.
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.
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.
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.
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.
• 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.
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.
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.
•• 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.
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.
Acknowledgments
We are grateful for the numerous colleagues and students who have contributed to the development and testing of EAET.
Funding
Preparation of this manuscript was supported by the National Institutes of Arthritis, Musculoskeletal, and Skin Diseases under award numbers AR057808 and AR074020.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
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.
Additional information
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Chronic Pain
Rights and permissions
About this article
Cite this article
Lumley, M.A., Schubiner, H. Emotional Awareness and Expression Therapy for Chronic Pain: Rationale, Principles and Techniques, Evidence, and Critical Review. Curr Rheumatol Rep 21, 30 (2019). https://doi.org/10.1007/s11926-019-0829-6
Published:
DOI: https://doi.org/10.1007/s11926-019-0829-6