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

Chronic pain, particularly primary or centralized pain conditions like fibromyalgia and irritable bowel syndrome, affects millions of people and is often inadequately treated with conventional approaches. Patients with these conditions frequently have elevated rates of psychological trauma and unresolved emotional conflicts. While cognitive-behavioral therapy and mindfulness-based interventions are standard treatments, they do not directly address the underlying trauma and emotional processing difficulties that appear to drive primary pain. This review presents Emotional Awareness and Expression Therapy (EAET), a treatment developed by the authors specifically designed to target these emotional factors and potentially reduce pain through emotional processing.

EAET is grounded in the principle that the brain, rather than peripheral tissue damage, generates or amplifies primary pain. The therapy incorporates techniques from multiple evidence-based approaches including pain neuroscience education, exposure therapy, experiential therapy, and assertiveness training. Core techniques involve helping patients recognize the connection between emotions and pain, encouraging recall of emotionally difficult experiences, facilitating emotional expression toward conflict targets, and improving interpersonal communication. The authors developed and tested multiple versions of EAET ranging from single-session interviews to eight-week group programs across various patient populations.

Four recent randomized controlled trials demonstrated EAET's efficacy across fibromyalgia, irritable bowel syndrome, pelvic pain, and medically unexplained symptoms. Notably, in the largest trial (PAST-FM), EAET was superior to both an active control condition (fibromyalgia education) and cognitive-behavioral therapy on pain outcomes, with 22.5% of EAET patients achieving 50% pain reduction compared to 8.3% in cognitive-behavioral therapy. Patient retention rates were high (77.2% in the largest trial), and adverse events were rare. However, effects on anxiety and depression were less consistent across trials, though longer follow-up periods (6 months) showed better psychological improvements than shorter ones.

EAET merits inclusion as an evidence-based treatment option for primary pain conditions and may be preferred for some patients, particularly those with clear trauma histories or emotional conflicts. The authors recommend focusing on core principles of emotional processing rather than rigid protocol adherence, and they identify important research gaps including the need for larger samples of men, trials with less motivated community samples, investigation of treatment mechanisms, and studies by independent research teams. Future work should explore how to better prepare and motivate patients for emotional processing and whether adding emotional regulation skills could improve treatment engagement and outcomes.