Emotional Awareness and Expression Therapy

Original Editor - Kapil Narale

Top Contributors - Kim Jackson and Kapil Narale  

Introduction

The Emotional Awareness and Expression Therapy (EAET) was developed by Mark A. Lumley and Howard Schubiner. It is a treatment method which was developed for psychological trauma or conflict in patients with primary chronic pain. Another reason for its development was to help manage the risk factors for fibromyalgia, which include heightened levels of psychosocial difficulties, trauma, and emotional challenges. This can include unresolved stressful, traumatic, or problematic emotional experiences. This therapy incorporates other psychological techniques and therapies, which will be discussed further.

EAET was developed to aid patients with assigning their pain and symptoms to emotionally-driven CNS mechanisms and gain awareness, insight, and communicate their emotions, which are elicited from difficulties, trauma, or challenges.

It is known to be the preferred treatment method for patients with primary pain conditions. Primary pain, unlike secondary pain, can be referred to as 'central sensitisation' or 'nociplastic pain', which is generated from the brain or spinal cord. Primary chronic pain includes fibromyalgia, irritable bowel syndrome, chronic pelvic pain, temporomandibular pain, head pain, back pain, and other types of musculoskeletal pain.

The most common psychological treatments for chronic pain Cognitive Behavioral Therapy (CBT), acceptance and mindfulness-based therapies. CBT instructs patients to manage symptoms through training of various skills, while mindfulness-based therapies elicits patients to engage in significant life events, while accepting rather than controlling their pain, thoughts, and feelings. However, the respective interventions does not specifically focus on the trauma, life adversity, or conflicts which are controlling the primary pain. In addition, other general psychotherapies can be used which are directed towards trauma and psychological conflict, and lead to significant improvements in symptoms management. These psychotherapies assist patients to interact with and process various stimuli, such as memories, experiences, relationships, or emotions. These stimuli are generally neglected through suppression, distraction, intellectualization, and other strategies. This helps to explain that psychotherapy process studies note that the emotional expression of patients during a therapy session helps strongly correlate to positive treatment outcomes.

There may be cases where patients are resistant to having EAET administered. Encouraging patients or providing them with skills to help regulate their emotions before conducting EAET may help with the efficacy of the therapy. Many patients began to see a noticeable improvement with the use of EAET, and claimed that more sessions would help to uncover long standing emotional pain.

Primary vs Secondary Pain

Careful physical examination, medical history, and psychosocial assessment can help distinguish primary from secondary pain. It is critical to search for peripheral nociceptive drivers of pain and address them when found. The authors suggest that when no clear peripheral etiology is found, the pain should be assumed to be central, rather than attributed to various non-specific findings such as degenerative disc disease. There are also clinical clues that help to “rule in” a central cause: pain that persists after tissue healing is complete, is intermittent, shifts locations, occurs in a distribution that is not neurophysiologic, is triggered by mild stimuli (sound, light, foods, weather changes, light touch), or varies with time of day or stressful life events.

Psychological factors such as attention, appraisal, mood, as well as environmental factors can influence both secondary and primary pain. However, primary pain can have more influence from psychosocial stress or trauma, and interpersonal and intrapsychic difficulties.

History of EAET

Schubiner developed an "affective self-awareness" program based on the theory that musculoskeletal pain arises from the mind blocking negative involuntary emotions, rather than stemming from the peripheral tissue damage itself.

The program consisted of an:

• An initial patient evaluation with a review of the medical records and psychosocial history - this helped ruling out any structural/disease contributors to pain.
• This is followed by patient education directed towards mind-body connections, and the role of various emotions eliciting neural pathway pain.

Patients participated in classes of 3-4 sessions per week, which were based on the manual 'Unlearn Your Pain'.

These sessions consisted of:

• Education about a psychophysiological model of chronic pain
• Expressive writing
• Techniques to reduce fear, which can include mindfulness exercises, affirmations regarding self-acceptance and recovery
• Progressive re-introduction to their triggering activities, regardless of any pain experienced - this would help with the application of regulated cognitive and emotional skills

2007-2008

Schubiner’s program was examined in a Randomized Controlled Trial (RCT):

• There were 45 women with fibromyalgia, with an average age of 51
• The intervention consisted of the 'affective self-awareness program', which was compared to the control waitlist patients.
• Upon the 6-month follow-up, there was a noticeable improvement in patients who received the intervention. These improvements were in pain severity, pain interference, widespread pain, and tender point threshold. Areas such as mental health, sleep, or fatigue were however not improved.

2008-2010

During this time, Schubiner’s clinical practice was assessed using an uncontrolled cohort study. There were 72 patients (79.2% were female and the mean age was 49.3 years) with musculoskeletal pain throughout treatment, who were monitored over a 6-month follow-up. Large effect size improvements were present in pain severity, pain interference, and depressive symptoms.

Development of EAET

An early version of EAET, which was called Emotional Exposure Therapy, was developed by Lumley. The aim of this therapy was on emotional processing of trauma-related avoidance behavior. This therapy was tested, from 2006 to 2008, in an uncontrolled case study of 10 middle-aged women who had fibromyalgia and prior psychological trauma. With the completion of 8 to 15 therapy sessions, and a follow-up of 3-months, there were large impacts on the improvements with fibromyalgia, trauma symptoms, life satisfaction, and distress. However, there were small to medium benefits on pain and disability.

Another version of EAET was then developed by Lumley, which was directed towards anger and healthy assertion. Anger Awareness and Expression Training (AAET) was tested between 2009 to 2011, in 147 young adults with chronic head pain (87.8% female, with a mean age of 22.1 years). The patients received three sessions of group-based AAET, group-based relaxation training, or waitlist control, via random allocation. With a 4-week follow-up, it was seen that both interventions were effective in relation to controls on headache-related outcomes, which had small to medium effects of similar types. However, relaxation training, greatly improved psychological distress.

Upon creation of the EAET, it's benefits were tested against an active control condition, fibromyalgia education, and the gold-standard intervention CBT for symptom management. EAET was seen to have much better outcomes than fibromyalgia education in general symptom management, widespread pain, physical functioning, cognitive dysfunction, anxiety, depression, positive affect, and satisfaction with life. The use of EAET, compared to CBT, also led to fewer fibromyalgia symptoms and widespread pain.

EAET and other Psychological Therapies

As mentioned, this therapy incorporates other psychological techniques and therapies. These include:

• a) Pain neuroscience education or the model of “explaining pain” - this helps explain that the brain is an output of the brain, and pain can subside with changes in thoughts and beliefs
• b) Pain exposure therapy - this motivates patients to elicit their pain triggering behaviors, in order to help them forget their pain related fear
• c) Exposure-based cognitive-behavioral therapies - this will help patients understand emotions which stem from PTSD and/or other anxiety related conditions
• d) Intensive short-term psychodynamic therapy - this provokes the patients’ preventive mechanisms to help them facilitate and covey involuntary emotions
• e) Experiential therapies - these utilise techniques such as focusing, empty chair, and 2-chair dialogue to empathically elicit the awareness and expression of patients' emotions
• f) Written emotional disclosure or expressive writing - this helps with benefitting centralised pain
• g) Assertiveness training - this is known to help patients control their fears of expressing their power and strength, and being assertive, in relationships, and
• h) Rescripting therapy - this helps patients imagine and express new, more powerful, and less frightening conclusions to repeated nightmares or disturbing memories

Core Principles and Techniques of EAET

The core principles and techniques of EAET are as follows:

1. Patients need to understand that their brain is what generates and amplifies the primary pain that is experienced, rather than being generated at the site of pain. The brain is what will signal pain, although areas such as muscle tension or inflammation may contribute to the pain experienced. The neural pathways that regulate the pain are affected by the person's thoughts and thus can be heightened or reduced. When this is discussed with patients, personal demonstrations which elicit the emotions can be provided for the patient to understand and identify their 'emotion-brain-pain links'. These discussions with the patient need to be empathetic, so the patient sees that the practitioner understands that their pain is real, they are not weak, mentally unfit, and that they are not being blamed for experiencing the pain.
2. The brain has been wired through neuroplasticity from experiences and events that occurred throughout one’s life. These can include injuries or painful procedures, abuse, neglect, or victimization, as well as interpersonal or personal psychological conflicts. Stressful experiences can also elicit or amplify the pain. This can become quite difficult when attempting to avoid the distressing experience results with the patient feeling helpless, hopeless, and worrisome. These beliefs and experiences wouldn't help with psychological growth, and minimising and alleviating the triggers causing the pain. This is why it is important to help the patients recognise, discuss, and understand prior traumatic events and experiences.
3. Receiving Therapy can help the patient with confronting and managing their emotionally disturbing memories and past experiences, become mindful of their emotions and experiences, and carefully express them. It is seen that the most common emotions are the need for connection, power, protection, and independence. These are elicited by patient's anger and pride, and also the need for relatedness, communion, attachment, or dependence. These needs are brought on by feelings of association such as sadness, love, and healthy guilt.
4. In a therapy session, the patient is requested to remember a person and situation which caused aggravation. They are asked to express their underlying emotions that are directed to this person and situation, by using suitable words, tones, expressions, and movements. Expressing their conflicts in this manner will help heighten their emotional experience, understand the reasoning of the pain and experience, and will allow less frightful communication of their experience. The patient needs to 'express the right emotion with the right target'. The patient benefits by being able to express their story, and fostering newer emotions which were not initially expressed.
5. Patients are asked to recognise the needs and feelings that might be encountered in a real relationship, which is done in order to help minimise stress and pain. Balanced communication would involve assertion as well as feelings of connectedness, and may involve setting new boundaries or being distant form others. This is practiced in the therapy session by planning for and role playing such scenarios, and then being ready to encounter them in real life.

Within an EAET session patients were encouraged to mention any psychologically aggravating factors, and were aided with noting and expressing avoided emotions by enacting situations, using 'empty chair techniques', while verbally and physically expressing unsurfaced emotions. The sessions also included expressing avoided forgiveness, gratitude, and sexuality, and elicited the development of a new identity. Home exercises for these patients included expressive writing, identifying emotional and communication patterns, and conducting emotionally eliciting activities.

EAET and Fibromyalgia

EAET vs. Fibromyalgia Education

The intervention of EAET is shown to produce a lower pain intensity compared to fibromyalgia education, however this was seen only subsequent to treatment and not at a 6-month follow up. There were also fewer sleep problems reported only directly after the EAET intervention, and not with follow-up

However, EAET was seen to be advantageous compared to fibromyalgia education on various secondary outcomes at the 6-month follow up. EAET helped produce:

Lower:

• Fibromyalgia symptoms,
• Widespread pain,
• Cognitive difficulties,
• Depression, and
• Anxiety

Greatly increased:

• physical functioning,
• positive affect, and
• life satisfaction.

In general, EAET had much more beneficial outcomes than fibromyalgia education.

Between these two methods, its noted that fatigue, negative affect, and use of healthcare did not have a significant difference between EAET and fibromyalgia education. Also, there wasn't a substantial pain reduction with either method, as only a moderate pain reduction was noted.

EAET vs. CBT

EAET and CBT had less of a discrepancy with average pain severity ratings, and most secondary outcomes such as moderate pain reductions.

EAET was more effective compared to CBT on three secondary measures at follow up. There were lower fibromyalgia symptoms, less widespread pain, and a much greater chance of meaningful pain reduction.

As compared to CBT, which manages the symptoms of a chronic disease like fibromyalgia, EAET helps to categorise the symptoms of fibromyalgia to the respective pathways in the brain. These pathways can be reconditioned by creating new experiences by leading patients to elicit the experience rather than avoid negative emotions and interactions.

In fact, it is seen that EAET and CBT compliment each other, and would benefit a patient more if they are both administered.

Efficacy

It is seen that a pharmacological or psychological intervention can have a very small improvement on fibromyalgia. In the study to determine the efficacy of EAET, it was shown to have a very small effect overall. However, it did greatly help some individuals especially with reduction of pain. The effect of EAET, compared to medicine, did last for at least 6 months after treatment.

It is seen that there is efficacy of treatment in centralised and primary pain conditions, such as, fibromyalgia, irritable bowel syndrome, pelvic pain, head pain, non-specific musculoskeletal pain, and conditions with unexplained symptoms.

Throughout the testing and comparison to the gold standard of CBT, it is seen that EAET does have specificity. It was seen to be more effective than the alternate therapy of CBT. However, further comparisons to other therapies are needed to confirm the efficacy of EAET.

Here is a brief video helping to explain the efficacy of EAET:

Limitations

EAET is an effective intervention to reduce pain, bodily symptoms and, and improve functioning, in individuals or groups, which can span 1-8 sessions.

The testing during the development of EAET was greatly based on female participants. Although there was a very positive response, it is unclear how the intervention would be suited with male patients, and in conditions that may be more prevalent in men, such as chronic back pain.

As well, since EAET was tested on primary or centralised pain conditions, it is unknown how the therapy would have an effect on more general conditions. It is also unclear if EAET is most suitable for patients with clear trauma histories, or can be used with patients who display differing interpersonal and intrapsychic challenges which are not classified as trauma.

Experimenter bias could also be a confounding factor since it was tested by the researchers who created the therapy.

Conclusion

It is seen that a treatment targeting emotional awareness and expression directed towards psychosocial difficulties and challenges is quite effective, more so than providing education about managing the condition the condition, and is beneficial compared to CBT when considering pain.

Resources

Here is some information on Emotional Awareness and Expression Therapy from the Pain Guide, presented by the University of Michigan.