Emotional Awareness and Expression Therapy Achieves Greater Pain Reduction than Cognitive Behavioral Therapy in Older Adults with Chronic Musculoskeletal Pain: A Preliminary Randomized Comparison Trial

Chronic pain is highly prevalent in older adults and increasingly recognized as a central nervous system disorder rather than purely a peripheral tissue problem. While cognitive behavioral therapy (CBT) is considered the gold standard psychological treatment for chronic pain, it produces only modest pain reduction for most patients. This study investigated whether emotional awareness and expression therapy (EAET)—an emotion-focused approach based on pain neuroscience principles—might achieve superior pain reduction compared to CBT in older adults with chronic musculoskeletal pain.

This was a preliminary randomized comparison trial conducted at the VA Greater Los Angeles Healthcare System with 53 veterans (mean age 73.5 years, 92.4% male, 54.7% non-white). Participants were randomized to receive either EAET or CBT, each consisting of one 90-minute individual session followed by eight 90-minute group sessions. EAET emphasizes emotional processing and disclosure of avoided emotions to reduce pain through changes in brain function, while CBT focuses on coping skills and behavioral management. Pain severity (primary outcome), pain interference, anxiety, depression, sleep disturbance, fatigue, and life satisfaction were assessed at baseline, post-treatment, and three-month follow-up.

EAET produced significantly lower pain severity than CBT at both post-treatment and three-month follow-up, with large effect sizes (partial η² = 0.129 and 0.157, respectively). At post-treatment, 41.7% of EAET patients achieved clinically significant (≥30%) pain reduction, one-third achieved ≥50% reduction, and 12.5% achieved ≥70% reduction. In contrast, only one CBT patient (5.4%) achieved at least 30% pain reduction. EAET also showed significant advantages over CBT on anxiety reduction at post-treatment and marginally on pain interference at follow-up. Secondary outcomes demonstrated small to medium effect size advantages favoring EAET, though the limited sample size reduced statistical power.

These findings support the hypothesis that emotion-focused psychotherapy targeting pain neuroscience principles and emotional processing may be more effective than standard CBT for chronic musculoskeletal pain, particularly in older adults. The results challenge conventional assumptions that older adults are less receptive to emotion-focused therapy and that men are less responsive to such approaches. The study suggests a paradigm shift toward brain and emotion-centered models of chronic pain treatment and supports EAET as a potentially preferred first-line psychological intervention for many patients with chronic centralized pain who have not achieved adequate pain reduction with other treatments.