Emotional Awareness and Expression Therapy vs Cognitive Behavioral Therapy for Chronic Pain in Older Veterans: A Randomized Clinical Trial

Chronic pain is a significant and disabling condition in older adults, particularly among veterans who experience higher rates of severe pain and psychiatric comorbidities such as depression, anxiety, and PTSD. While cognitive-behavioral therapy (CBT) is the standard psychological intervention for chronic pain, it produces only modest benefits. Emotional awareness and expression therapy (EAET) is a newer approach that targets trauma and emotional processing as key drivers of chronic pain, but had not been rigorously tested in diverse older populations.

This randomized clinical trial enrolled 126 racially and ethnically diverse veterans aged 60-95 years with chronic musculoskeletal pain at the VA Greater Los Angeles Healthcare System from May 2019 to September 2023. Participants were randomly assigned to either EAET (n=66) or CBT (n=60), each consisting of one 90-minute individual session followed by eight 90-minute group sessions. The primary outcome was pain severity reduction from baseline to 10 weeks (posttreatment) and 6-month follow-up, measured using the Brief Pain Inventory. Secondary outcomes included anxiety, depression, PTSD symptoms, life satisfaction, and patient satisfaction.

EAET demonstrated significantly greater pain severity reduction than CBT at posttreatment (−1.59 points vs −0.60 points; P<.001) and at 6-month follow-up (−1.26 vs −0.25; P=.01). Notably, 63% of EAET participants achieved clinically significant pain reduction of at least 30% compared to only 17% in the CBT group. EAET also showed superior improvements in anxiety, depression, PTSD symptoms, life satisfaction, and overall satisfaction with treatment. Critically, moderation analyses revealed that patients with higher baseline depression, anxiety, or PTSD symptoms experienced particularly robust pain reductions with EAET but not with CBT.

These findings suggest that EAET may be a preferred intervention for medically and psychiatrically complex patients, particularly older veterans with overlapping pain and mental health conditions. The results support further incorporation of EAET principles into mainstream clinical pain medicine and suggest that targeting emotional processing alongside pain coping skills may be more effective than traditional cognitive-behavioral approaches, especially for patients with significant psychiatric comorbidities. The sustained benefits at 6-month follow-up indicate lasting therapeutic effects beyond the active treatment period.