Emotional awareness and expression therapy, cognitive behavioral therapy, and education for fibromyalgia: a cluster-randomized controlled trial

Fibromyalgia (FM) is a chronic pain condition affecting 2-4% of adults, predominantly women, characterized by widespread pain, fatigue, and cognitive dysfunction. While cognitive behavioral therapy (CBT) is the gold standard psychological treatment for FM, its average benefits are modest. The authors developed Emotional Awareness and Expression Therapy (EAET) based on the observation that patients with FM often have elevated lifetime rates of trauma and emotional conflict, which may drive or maintain symptoms through altered central nervous system processing. This trial tested whether directly addressing avoided emotions related to psychosocial adversity could improve outcomes beyond current standard treatments.

The study was a cluster-randomized controlled trial involving 230 adults with FM recruited from two Michigan sites and assigned to one of three 8-session treatments: EAET (stress and emotions treatment), CBT (thoughts and behaviors treatment), or FM education (brain and body treatment). Participants completed assessments at baseline, post-treatment, and 6-month follow-up. The primary outcome was pain severity using the Brief Pain Inventory, with secondary outcomes measuring FM symptoms, physical functioning, cognitive dysfunction, mood, sleep, and life satisfaction. The study achieved excellent retention (90.4% at 6-month follow-up) and high treatment fidelity.

EAET did not differ significantly from FM education on the primary outcome of pain severity at 6-month follow-up, but EAET outperformed FM education on most secondary outcomes including overall FM symptoms, widespread pain, cognitive difficulties, depression, anxiety, physical functioning, positive affect, and life satisfaction (effect sizes d = 0.29-0.45). Notably, 34.8% of EAET patients reported being "very much/much improved" compared to 15.4% in the FM education group. When compared to CBT, EAET showed comparable outcomes on most measures but superior results on pain-related outcomes including FM symptoms, widespread pain, and achievement of 50% pain reduction (22.5% vs 8.3%). Adverse events were minimal and occurred at lower rates in EAET than in control conditions.

These findings suggest that EAET represents a viable and feasible alternative psychological treatment for FM that may be particularly valuable for patients with histories of trauma or psychosocial adversity. The results support the therapeutic value of providing patients with an emotionally-focused conceptual framework for understanding FM and directly engaging avoided emotional experiences. Clinicians should consider EAET as an option when standard CBT approaches have been ineffective, though future research should identify which patient subgroups benefit most from this approach and whether combining EAET and CBT elements might produce even stronger outcomes.