Chronic pain and emotions are closely tied. Not only is chronic pain linked to changes in depression, anxiety, and anger, but emotions also impact pain [1]. Some types of pain appear to be particularly influenced by emotional processes. Fibromyalgia, irritable bowel syndrome, pelvic pain, temporomandibular joint pain, headaches, and many cases of a non-specific musculoskeletal pain (e.g., low back, neck, arm) may be “centralized” conditions. They are thought to be driven largely by central nervous system processes, which may be influenced by a variety of factors such as adverse childhood and adulthood experiences, core beliefs, emotions, interpersonal relationships, and how all of these are regulated.
People with centralized pain conditions experience relatively high rates of adverse life experiences—both in childhood and adulthood—which appear to contribute to their pain—triggering, worsening, or maintaining it. We commonly find post-traumatic stress disorder, perceived victimization or injustice, relationship difficulties, and internal psychological conflicts in patients with centralized pain conditions. These experiences and conflicts maintain their power because the person has not addressed or resolved them. When people avoid or suppress emotional thoughts, memories, and encounters, they are unable to experience, express, and learn from important emotions, such as anger, sadness, guilt, and love [2-4]. Such avoidance of adaptive emotional experience and expression can increase pain sensitivity or even generate pain and other symptoms [5, 6].
What can we do about this problem? The most popular psychological interventions for centralized pain problems do not directly address these adverse life experiences, and they have a limited view of role of emotions. For example, most approaches to cognitive-behavioral therapy (CBT) for chronic pain teach patients various skills to manage their pain and improve functioning, including techniques to directly reduce negative emotions, such as relaxation, cognitive reappraisal, and engaging in positive experiences. Numerous clinical trials show that CBT is more effective than usual care for centralized pain conditions, but the size and scope of CBT’s benefits for these problems are quite limited [7, 8]. Interestingly, emotion-focused approaches, such as experiential and short-term psychodynamic psychotherapy, as well as exposure-based CBT—in which patients confront and emotionally process fear-inducing stimuli—have shown substantial success with post-traumatic and other anxiety or emotional disorders. Yet these therapies are not typically considered for chronic pain conditions.
We have developed and tested an emotion-focused approach for centralized pain conditions. When treating such patients, we stress that the brain is the key pain organ, and the brain can be changed most powerfully by engaging in new emotional experiences—especially those that are uncomfortable or anxiety-provoking. In our therapy, we help people approach, confront, and change the emotionally-laden experiences that they have been avoiding, and the result is that they are freer, braver, and healthier.
We call this approach “emotional awareness and expression therapy” (EAET), although in truth, it draws from many other existing therapies. EAET has three key components. First, we educate patients about the primary source of their pain—their brain—which has been influenced by a lifetime of experiences—especially emotionally difficult ones, and which is changeable. Second, we encourage patients to disclose traumatic, problematic, or conflicted experiences they have had, and help them identify and express their suppressed or avoided emotions. In therapy sessions, patients describe their difficult experiences and emotions, and “rescript” or tell their stories with new endings. We help patients access feelings of anger but also sadness, love, guilt, self-compassion, and forgiveness; and then express these feelings, with words, voice, and body, to an image or memory of the other person, as if that other person were present. This process can be scary but often brings relief and pain reduction. Third, we help patients change the way they engage in important but difficult relationships in real life, such as expressing assertion, setting boundaries, or becoming more intimate or connected.
We have conducted several clinical trials of EAET. In our most important study [9], 230 adults with fibromyalgia received one of three treatments, each presented to small groups of patients for eight, weekly, 1.5-hour sessions. We compared EAET to the field’s gold standard intervention, CBT for FM symptom management, and to a basic FM Education intervention, which provided patients in-depth scientific information about FM. We evaluated patients 6 months after treatments ended. Patients who received EAET did not differ significantly from FM Education on our primary outcome—mean pain severity—but EAET had better outcomes than Education on most secondary measures—less widespread pain, physical impairment, attention and concentration problems, anxiety, and depression; and more positive emotions and life satisfaction. More than twice as many patients in EAET (34.8%) reported being “much better” or “very much better” than before treatment, compared to 15.4% of Education patients. On most measures, EAET did not significantly surpass CBT; however,EAET was significantly more successful than CBT in reducing widespread pain (effect size d of 0.35 standard deviation) and in the percentage of patients achieving at least 50% pain reduction (22.5% vs. 8.3%). It is very rare for a trial to demonstrate the superiority of one treatment over another legitimate treatment, which suggests that EAET is both unique and comparatively effective.
In several additional, smaller trials, we have tested EAET in different formats (e.g., individual therapy), durations (e.g., one or three sessions), and populations. We found that EAET is as or more effective than intensive relaxation training for irritable bowel syndrome [10] and headaches [11]. We also found that one session of EAET, conducted in the medical clinic, reduces pain in primary care patients with medically unexplained symptoms [12], and in women with chronic pelvic pain [13]. Our evaluation of Dr. Schubiner’s clinical practice that used an earlier version of EAET (which did not include the intense emotional expression of our later version), documented excellent outcomes: 6 months after treatment, musculoskeletal pain decreased at least 30% in two-thirds of patients, and at least 70% in one-third—improvements that are almost never found in traditional pain management practice [14].
We acknowledge that some or even many patients do not benefit from this approach—some patients probably need a longer course of EAET than the brief versions that we have tested, and other patients likely need alternative treatments, such as CBT, exercise, other lifestyle changes, or medication. Of course, additional research is needed, including tests of EAET by independent researchers, as well as studies of which patients benefit from this therapy and the mechanisms that underlie its effects. Yet we hope that our research encourages patients and providers to recognize that difficult emotional experiences and how emotions are dealt with play a key role in chronic pain—especially centralized pain—and that encouraging corrective emotional experiences, such as with EAET, appears to be helpful to many patients, and life-changing for some.
About Mark A. Lumley, Ph.D.
Mark A. Lumley is Distinguished Professor and Director of the Ph.D. Program in Clinical Psychology in the Department of Psychology at Wayne State University, in Detroit, Michigan, USA. He conducts research on the role of stress and emotions on somatic health, particularly developing and testing emotional awareness and expression interventions for people with chronic pain conditions such as fibromyalgia, irritable bowel syndrome, headaches, and pelvic pain. He has published over 140 peer-reviewed articles, has had multiple grants from the National Institutes of Health, and is on the editorial boards of many journals. He has mentored 38 students to the Ph.D.
About Howard Schubiner, M.D.
Howard Schubiner, MD, is an internist and the director of the Mind Body Medicine Center at Providence-Providence Park Hospital in Southfield, Michigan. He is a Clinical Professor at the Michigan State University College of Human Medicine and is a fellow in the American College of Physicians, and the American Academy of Pediatrics. He has authored more than 100 publications in scientific journals and books, and lectures regionally, nationally, and internationally. Dr. Schubiner is the author of three books: Unlearn Your Pain, Unlearn Your Anxiety and Depression, and Hidden From View, written with Dr. Allan Abbass.
References
[1] Lumley, M.A., Cohen, J.L., Borszcz, G.S., Cano, A., Radcliffe, A., Porter, L., Schubiner, H., & Keefe, F.J. (2011). Pain and emotion: A biopsychosocial review of recent research. Journal of Clinical Psychology, 67, 942 – 968.
[2] Abbass, A., Kisely, S., & Kroenke, K. (2009). Short-term psychodynamic psychotherapy for somatic disorders. Psychotherapy and Psychosomatics, 78, 265-274.
[3] Larson, D. G., Chastain, R. L., Hoyt, W. T., & Ayzenberg, R. (2015). Self-concealment: Integrative review and working model. Journal of Social and Clinical Psychology, 34, 705-e774.
[4] Wenzlaff, R. M., & Wegner, D. M. (2000). Thought suppression. Annual Review of Psychology, 51, 59-91.
[5] Burns, J. W., Quartana, P., Gilliam, W., Gray, E., Matsuura, J., Nappi, C., . . . Lofland, K. (2008). Effects of anger suppression on pain severity and pain behaviors among chronic pain patients: evaluation of an ironic process model. Health Psychology, 27, 645-652.
[6] van Middendorp, H., Lumley, M. A., Jacobs, J. W., van Doornen, L. J., Bijlsma, J. W., Geenen, R., . . . Geenen, R. (2008). Emotions and emotional approach and avoidance strategies in fibromyalgia. Journal of Psychosomatic Research, 64, 159-167.
[7] Bernardy, K., Klose, P., Busch, A. J., Choy, E. H. S., & Hauser, W. (2013). Cognitive behavioural therapies for fibromyalgia. Cochrane Database of Systematic Reviews(9). doi:10.1002/14651858.CD009796.pub2
[8] Glombiewski, J. A., Sawyer, A. T., Gutermann, J., Koenig, K., Rief, W., & Hofmann, S. G. (2010). Psychological treatments for fibromyalgia: A meta-analysis. Pain, 151(2), 280-295.
[9] Lumley, M.A., Schubiner, H., Lockhart, N.A., Kidwell, K.M., Harte, S., Clauw, D.J., & Williams, D.A. (2017). Emotional awareness and expression therapy, cognitive-behavioral therapy, and education for fibromyalgia: A cluster-randomized controlled trial. PAIN, 158, 2354-2363.
[10] Thakur, E.R., Holmes, H.J., Lockhart, N.A., Carty, J.N., Ziadni, M.S., Doherty, H.K., Lackner, J.M., Schubiner, H., & Lumley, M.A. (2017). Emotional awareness and expression training improves irritable bowel syndrome: A randomized controlled trial. Neurogastroenterology and Motility, 29:e13143
[11] Slavin-Spenny, O., Lumley, M.A., Thakur, E.R., Nevedal, D.C., & Hijazi, A.M. (2013). Effects of anger awareness and expression training and relaxation training on chronic headaches: a randomized trial. Annals of Behavioral Medicine, 46, 181-192.
[12] Ziadni, M.S., Carty, J.N., Doherty, H.K., Porcerelli, J.H., Rapport, L.J., Schubiner, H., & Lumley, M.A. (in press). A life-stress, emotional awareness and expression interview for primary care patients with medically unexplained symptoms: A randomized controlled trial. Health Psychology.
[13] Carty, J., Ziadni, M., Holmes, H., Lumley, M., Tomakowsky, J., Schubiner, H., Dove-Medows, E., & Peters, K. (2016). The effects of a stress and emotion interview for women with urogenital pain: A randomized trial (Abstract). The Journal of Pain, 17, S103.
[14] Burger, A.J., Lumley, M.A., Carty, J.N., Latsch, D.V., Thakur, E.R., Hyde-Nolan, M.E., Hijazi, A.M., & Schubiner, H. (2016). The effects of a novel psychological attribution and emotional awareness and expression therapy for chronic musculoskeletal pain: A preliminary, uncontrolled trial. Journal of Psychosomatic Research, 81, 1-8.