Confronting trauma alleviates chronic pain among older veterans

Published in JAMA Network Open on June 13, the study compared the newer therapy, known as emotional awareness and expression therapy, or EAET, to traditional cognitive behavioral therapy, or CBT, in treating chronic pain as well as mental health symptoms such as depression, anxiety and post-traumatic stress disorder symptoms among older veterans.

The study found that 63% of veterans who underwent EAET reported at least a 30% reduction in pain -- a clinically significant reduction -- after treatment compared to only 17% of veterans who underwent cognitive behavioral therapy. Pain reduction was sustained among 41% of EAET participants six months after treatment compared to 14% of CBT patients. Additionally, EAET patients reported greater benefits for addressing anxiety, depression, PTSD and life satisfaction.

"Most people with chronic pain don't consider psychotherapy at all. They're thinking along the lines of medications, injections, sometimes surgery or bodily treatments like physical therapy," said lead author Brandon Yarns, an assistant professor at UCLA Health's Department of Psychiatry and Biobehavioral Sciences and psychiatrist at the Veteran's Affairs Greater Los Angeles. "Psychotherapy is an evidence-based treatment for chronic pain. What this study adds is that the type of psychotherapy matters."

Cognitive behavioral therapy has long been the "gold standard" for psychotherapeutic treatment of chronic pain among veterans, Yarns said. However, studies so far have shown CBT produces modest benefits for relieving pain. For chronic pain, patients undergo a treatment package with some similar exercises to those used to treat depression or anxiety such as guided imagery, muscle relaxation, cognitive restructuring and activity pacing. The end goal is for patients to improve their ability to tolerate their pain, Yarns said.

"The goal in CBT is not necessarily to cure pain but to learn to cope and live well despite chronic pain," Yarns said.

By comparison, EAET has one primary intervention: experiencing, expressing and releasing emotions.

Developed in the 2010s, the therapy aims to show patients that the brain's perception of pain is strongly influenced by stress-related emotions. Patients are asked to focus on a stressful interaction, from anything as mundane as being cut off by a driver to severe traumas such as sexual assault. Yarns said the purpose is to have patients experience these emotions both in mind and in body. The patients then work to confront these emotions, express their reactions and ultimately to let go.

"If there is a hurt or stressor people have a series of normal, natural emotional reactions. There might be anger, guilt and sadness. Because these feelings are painful, people often avoid them, but EAET helps people face difficult feelings with honesty and self-compassion," Yarns said. "In therapy, they can release anger, pain and guilt that they've been carrying and are left with self-compassion in the end."

In the study, researchers recruited 126 veterans -- predominantly men -- ages 60 to 95 with at least three months of musculoskeletal pain. More than two-thirds of participants had a psychiatric diagnosis, with about one-third having post-traumatic stress disorder. The study was the first full-scale clinical trial of EAET among older adults, older men and veterans, with past studies being largely made up of younger, female participants, Yarns said.

Half of the participants underwent in-person cognitive behavioral therapy while the other half concurrently underwent in-person emotional awareness and expression therapy over nine sessions, which included one personal session and eight small group sessions.

Patients were asked to rate their pain levels using a 0 to 10 scale in the Brief Pain Inventory before starting treatment, at the end of the nine sessions and six months after the sessions ended. At posttreatment, 63% of EAET participants reported at least a 30% reduction in pain compared to 17% of CBT patients.

Yarns said he is now studying whether similar positive results could be replicated using virtual group sessions, which will compare EAET, CBT and also include a mindfulness therapy cohort. Additionally, Yarns said that neuroimaging studies will be pursued to understand the brain changes among participants in EAET versus CBT therapies.