EMOTIONAL AWARENESS AND EXPRESSION THERAPY (EAET)
What is EAET?
Emotional Awareness and Expression Therapy (EAET) is a form of psychological therapy that targets the trauma, stress, and relationship problems that are found in many people with chronic pain, especially "centralized" (central sensitization, central augmentation) pain. Although all chronic pain is influenced by psychosocial factors, centralized pain conditions appear to be strongly influenced by the functions of the central nervous system, especially the brain's thoughts, feelings, and relationships. Such pain conditions include most cases of fibromyalgia, irritable bowel syndrome, pelvic pain, temporomandibular pain, head pain, and many cases of back or other localized pain. Research shows that stress throughout people's lives and how they handle the emotions from that stress, can trigger, worsen, or maintain their pain. Most psychological treatments for these pain conditions, including traditional Cognitive Behavioral Therapy (CBT) and Acceptance and Commitment Therapy (ACT), do not focus on helping people resolve these earlier life stressors, but this is the focus of EAET. This form of therapy is rather new, and so only a handful of clinical trials have been published testing it. Many case reports suggest that EAET can be quite powerful, even leading to the remission of pain in some people.
How does EAET work?
EAET can be conducted in individual or group sessions, and studies thus far have tested EAET protocols that range from a single, 90-minute session to 8 group sessions. It is likely, however, that more sessions are needed for many patients, because this therapy tries to address problems that are often long-standing in people's lives. Unlike CBT, which seeks to help people manage their pain and improve their adjustment to a chronic condition, EAET views centralized pain as potentially reversible if the person makes powerful changes in their emotions and relationships. EAET involves four components. First, patients are educated about the role of stress and emotions in their pain by using examples from their lives and demonstrations during intensive interviews. Second, patients are helped to disclose and talk or write about the traumas and psychological conflicts in their lives that appear to drive their pain. Third, patients are helped to express the emotions that they have been avoiding or blocking related to trauma or stressors, especially their anger but sometimes also their sadness, guilt, love, and self-compassion. Finally, given the newfound awareness of their feelings, patients learn how to communicate more effectively in real relationships by balancing assertiveness and healthy boundaries with openness and closeness. When patients are able to make these changes, they commonly have substantial pain reduction and their mood, physical functioning, and relationships will also improve.
What other names might this go by?
EAET borrows from other therapies that help people resolve trauma and psychological conflicts, including Prolong Exposure Therapy, Intensive Short-term Dynamic Therapy (ISTDP), Emotion-focused Therapy, Written Emotional Disclosure, and Rescripting Therapy. A common process of all of these therapies is that they offer support in helping patients face their traumas and conflicts, become aware of their feelings, experience their emotions, and express them in adaptive ways. These therapies, as well as others designed for trauma (e.g., Eye Movement Desensitization and Reprocessing and Cognitive Processing Therapy), are supported by research as being helpful to people who have post-traumatic stress disorder, and recent research supports many of these treatments for people who have chronic pain and trauma symptoms.
Who can be an EAET provider?
Because EAET is rather new, there are few providers who have been trained specifically to deliver it. However, many psychologists and other mental health providers have training in trauma-focused therapies and "exposure-based" therapies that help patients overcome their fears. Such therapists may be able to provide EAET-like interventions for patients, especially when patients openly discuss with these therapists that working on their avoided emotions and troubled relationships is what is needed.
There are also a number of self-help books that focus on dealing with stress and emotions underlying chronic pain and that help patients make important changes in their lives to reduce their pain. Authors of such books include John Sarno, Howard Schubiner, David Clarke, David Schechter, David Hanscom, and Nancy Selfridge. As noted under 'Resources' below, there are also apps designed to help patients address their emotions and reduce their pain, as well as a free internet-based Pain Recovery Program. The Psychophysiologic Disorders Association is the main professional organization of practitioners and scholars who use EAET and related approaches for chronic pain, and the Tension Myositis Syndrome (TMS) Wiki also provides numerous resources for patients and practitioners.
What to expect
The first several sessions usually involve learning about patients' health and psychosocial history, including stresses or traumas that have been experienced. The therapist will help patients see links between their pain and their emotional life experiences. Therapy has patients revisit important conflicts or traumatic experiences that involve other people and helps patients "express the unexpressed" feelings to those people. This can be done with writing exercises but also involves "talking to" an empty chair where the imagined other person sits. Patients are encouraged to activate and express their emotions fully, using their words, voice tone, and bodily expression (arms, face). Patients are helped to express the full range of avoided emotions, including anger, sadness, love, guilt, and self-compassion. Relief and some reduction in pain is usually felt after doing such exercises, but patients often need to do this "experience and expression" work several times. Finally, patients are encouraged to plan and role play how they would like to be in real life with people who have been a source of stress or conflict. Such communication depends on the type of relationship and may involve healthy assertiveness and setting boundaries, and often includes being open, vulnerable, and expressing intimacy. Throughout therapy, patients are encouraged to work on emotional awareness, writing exercises, emotional expression, and healthy communication as homework. Successful EAET is typically associated with substantial reductions or even elimination of pain as well as improvements in functioning, mood, and relationships.
Potential Risks
EAET and related approaches are associated with greater risk than CBT and ACT and other psychological treatments for chronic pain. EAET encourages patients to disclose and emotionally express experiences and feelings that may have been avoided for many years and that often are quite upsetting. It is not uncommon, therefore, for patients to become temporarily more upset (e.g., anxious, depressed, angry) as they start to deal with memories and feelings that have long been avoided. Pain and other physical symptoms sometimes increase temporarily. Because patients are encouraged to communicate and interact differently in their relationships, these relationships might change in ways that are unexpected. Practitioners of EAET believe, however, that such emotional and relationship changes are important to make, and even though they may be difficult in the short run, such changes can be healthy and lead to pain reductions in the longer-term. EAET, however, may not be appropriate for certain patients, especially those who have difficulties regulating their emotions, who dissociate or have trouble thinking when they are emotional, or who tend to hurt themselves or others when memories or feelings are activated or intense.
Resources
Psychophysiologic Disorders Association
Website: https://ppdassociation.org
Tension Myositis Syndrome Wiki (TMS Wiki), including its link to Alan Gordon's Pain Recovery Program
Website: www.tmswiki.org
Unlearn Your Pain (3rd Edition) by Howard Schubiner
Patient and Provider materials provided for free by EAET co-developer, Mark A. Lumley, Ph.D. (mlumley@wayne.edu)
