Jennifer N. Carty

Emotional disclosure interventions for chronic pain: from the laboratory to the clinic

ABSTRACTLife stress and the avoidance of negative emotions may contribute to chronic pain. The technique of written or spoken emotional disclosure can reverse emotional avoidance and improve health, and 18 randomized studies have tested it among people with chronic pain. We review these studies to provide guidance for the clinical use of this technique. The benefits of emotional disclosure for chronic pain are quite modest overall. Studies in rheumatoid arthritis show very limited effects, but two studies in fibromyalgia suggest that disclosure may be beneficial. Effects in other populations (headaches, cancer pain, pelvic pain, abdominal pain) are mixed. Moderator findings suggest that some patients are more likely to benefit than others. Emotional disclosure has been tested in well-controlled efficacy trials, leaving many unanswered questions related to translating this technique to practice. Issues needing further study include determining disclosure’s effects outside of randomized controlled trials, identifying the optimal pain populations and specific individuals to target for disclosure, presenting a valid rationale for disclosure, selecting the location and method of disclosure, and choosing between cognitive–behavioral or emotional disclosure techniques.

The effects of a novel psychological attribution and emotional awareness and expression therapy for chronic musculoskeletal pain: A preliminary, uncontrolled trial

OBJECTIVE Current psychological and behavioral therapies for chronic musculoskeletal pain only modestly reduce pain, disability, and distress. These limited effects may be due to the failure of current therapies: a) to help patients learn that their pain is influenced primarily by central nervous system psychological processes; and b) to enhance awareness and expression of emotions related to psychological trauma or conflict. METHODS We developed and conducted a preliminary, uncontrolled test of a novel psychological attribution and emotional awareness and expression therapy that involves an initial individual consultation followed by 4 group sessions. A series of 72 patients with chronic musculoskeletal pain had the intervention and were assessed at baseline, post-treatment, and 6-month follow-up. RESULTS Participation and satisfaction were high and attrition was low. Intent-to-treat analyses found significant improvements in hypothesized change processes: psychological attributions for pain, emotional awareness, emotional approach coping, and alexithymia. Pain, interference, depression, and distress showed large effect size improvements at post-treatment, which were maintained or even enhanced at 6 months. Approximately two-thirds of the patients improved at least 30% in pain and other outcomes, and one-third of the patients improved 70%. Changes in attribution and emotional processes predicted outcomes. Higher baseline depressive symptoms predicted greater improvements, and outcomes were comparable for patients with widespread vs. localized pain. CONCLUSION This novel intervention may lead to greater benefits than available psychological interventions for patients with chronic musculoskeletal pain, but needs controlled testing.

The effects of written emotional disclosure and coping skills training in rheumatoid arthritis: A randomized clinical trial

OBJECTIVE Two psychological interventions for rheumatoid arthritis (RA) are cognitive-behavioral coping skills training (CST) and written emotional disclosure (WED). These approaches have developed independently, and their combination may be more effective than either one alone. Furthermore, most studies of each intervention have methodological limitations, and each needs further testing. METHOD We randomized 264 adults with RA in a 2 × 2 factorial design to 1 of 2 writing conditions (WED vs. control writing) followed by 1 of 2 training conditions (CST vs. arthritis education control training). Patient-reported pain and functioning, blinded evaluations of disease activity and walking speed, and an inflammatory marker (C-reactive protein) were assessed at baseline and 1-, 4-, and 12-month follow-ups. RESULTS Completion of each intervention was high (>90% of patients), and attrition was low (10.2% at 12-month follow-up). Hierarchical linear modeling of treatment effects over the follow-up period, and analyses of covariance at each assessment point, revealed no interactions between writing and training; however, both interventions had main effects on outcomes, with small effect sizes. Compared with control training, CST decreased pain and psychological symptoms through 12 months. The effects of WED were mixed: Compared with control writing, WED reduced disease activity and physical disability at 1 month only, but WED had more pain than control writing on 1 of 2 measures at 4 and 12 months. CONCLUSIONS The combination of WED and CST does not improve outcomes, perhaps because each intervention has unique effects at different time points. CST improves health status in RA and is recommended for patients, whereas WED has limited benefits and needs strengthening or better targeting to appropriate patients.

Emotional awareness and expression training improves irritable bowel syndrome: A randomized controlled trial

Current clinical guidelines identify several psychological treatments for irritable bowel syndrome (IBS). IBS patients, however, have elevated trauma, life stress, relationship conflicts, and emotional avoidance, which few therapies directly target. We tested the effects of emotional awareness and expression training (EAET) compared to an evidence‐based comparison condition—relaxation training—and a waitlist control condition.

Beyond traumatic events and chronic low back pain: assessment and treatment implications of avoided emotional experiences.

A burgeoning literature demonstrates that emotionally difficult experiences, including trauma, interpersonal conflicts, work stress, and social rejection contribute to chronic pain [2,5], particularly in patients with central sensitization or augmentation disorders [12]. In their study, Tesarz and colleagues [10] demonstrated the contribution of traumatic events to pain amplification in people with chronic low back pain (CLBP). Using comprehensive and sophisticated quantitative sensory testing, the authors showed that self-reported trauma exposure was associated with hyperalgesia at both the lower back and a distal site, compared to patients with CLBP not reporting trauma exposure and controls without pain. Although trauma-related hyperalgesia was limited to pressure pain threshold, and the difference in threshold between CLBP trauma groups was modest in size, the studys use of sensory testing is persuasive because it attenuates the bias that often accompanies clinical pain reports in trauma-exposed patients. However, the studys conceptualization, assessment, and treatment implications of trauma exposure deserve comment, because a greater understanding of trauma and emotional processes can lead to a more nuanced appreciation of their impact on pain. It is likely that both groups of patients with CLBP—those classified as either with or without trauma—were heterogeneous, leading to smaller study differences in pain augmentation than might otherwise have been found. Although the group with trauma excluded patients with full PTSD, presumably some patients in this group had trauma that remained unresolved or problematic to them, continuing to augment their pain. In contrast, other individuals in this group probably experienced traumatic events that no longer affected them—that had resolved with time, with or without professional help. We would expect such people to have little or no trauma-induced pain augmentation [8], so their inclusion in the trauma group probably reduced observed study differences in hyperalgesia. Ideally, one should assess when in life the trauma occurred and, more importantly, whether or not the person remains emotionally conflicted or troubled by it. We also think that the group of patients with CLBP but no trauma merit much closer inspection and critical thought. Although this group likely included some individuals who were free from psychological problems, it probably also included two types of people with emotional difficulties that contributed to their hyperalgesia. First, some patients in this group likely had experienced trauma, but they simply did not report it. The disclosure of stigmatizing or emotionally painful experiences requires not only self-awareness but also the willingness to acknowledge it openly to both oneself and an interviewer. In possible support of this view, we note that only 37.6% of the 149 pain patients in this study reported lifetime trauma. This prevalence, and that of several specific traumas, seem well below population base rates, especially for patients who lack structural pathology for their pain, most of whom have chronic widespread pain (68%) and are female (69%)—three factors associated with increased trauma exposure [2,3]. For example, sexual assault was reported by only one person (0.7%), and sexual contact as a child was reported by only nine (6%). Although these low rates might stem from the exclusion of people with PTSD and the requirement that the event generated “intense fear, helplessness, or horror,” some patients likely just avoided disclosure of such experiences and, hence, were misclassified. Second, some patients without trauma likely experienced important psychological conflicts that contributed to hyperalgesia. Tesarz et al. followed standard diagnostic practice, which views trauma exposure as an external experience—something exceptional that happens to a person. However, many people report no traumatic events but are, nonetheless, quite emotionally and relationally conflicted [1]. For example, unresolved struggles with parents or siblings, conflicts over perfectionism, shame or guilt related to stigmatized desires or actions, ambivalence toward ones children, and a host of other issues can drive stress reactions and pain. We view the key pathological process in both unresolved trauma and internal conflict to be the avoidance or suppression of ones primary or adaptive emotions, which then activates neural pathways that trigger, augment, or maintain pain and other symptoms. Classifying emotionally conflicted patients as “without trauma” likely weakened the studys effects. Regarding clinical implications, Tesarz et al. rightly suggest that practitioners approach patients with CLBP and trauma from a “central point of view.” They recommend assessing further signs of pain augmentation but make no treatment suggestions. It is unfortunate that many pain practitioners seem not to be influenced by the evidence that trauma and emotional conflict drive pain, and they offer such patients only cognitive-behavioral pain management. The effect of this approach on pain reduction, however, is rather small [11], perhaps because it fails to deal directly with patients’ trauma or emotional conflicts. Our team has been developing and testing approaches that target unresolved trauma, conflict, and relational disturbances in patients with musculoskeletal pain, fibromyalgia, headaches, irritable bowel syndrome, and pelvic pain [4,6,7,9]. We first conduct a life-course interview, which commonly identifies associations between patients’ stressful experiences and emotions and the onset and exacerbation of their pain. Interviews also test the expression of avoided emotions, and immediate changes in pain demonstrate to patients the connection between their emotions and symptoms. In therapy, we present patients with a mind-body model that explains chronic pain as due to neural pathways that were formed by prior learning and maintained by emotional avoidance, but which can be “unlearned” with powerful corrective emotional experiences. We help patients identify, experience, and express three types of primary emotions or needs: power or anger toward sources of hurt; vulnerability and intimacy (grief, love) toward sources of attachment; and compassion and forgiveness toward the self. We then help patients learn to adaptively express genuine feelings directly to others. Our clinical and research experiences thus far indicate that many patients are open to this model, willing to engage in the difficult therapeutic work, and often show remarkable pain reduction as well as improvement in various life domains. We encourage researchers and clinicians to follow the growing evidence, bolstered by the findings of Tesarz et al., and assess and treat trauma and emotional conflict in their patients.

Computer-based written emotional disclosure: the effects of advance or real-time guidance and moderation by Big 5 personality traits

Standard written emotional disclosure (WED) about stress, which is private and unguided, yields small health benefits. The effect of providing individualized guidance to writers may enhance WED, but has not been tested. This trial of computer-based WED compared two novel therapist-guided forms of WED – advance guidance (before sessions) and real-time guidance (during sessions, through instant messaging) – to both standard WED and control writing; it also tested Big 5 personality traits as moderators of guided WED. Young adult participants (n = 163) with unresolved stressful experiences were randomized to conditions, had three, 30-min computer-based writing sessions, and were reassessed six weeks later. Contrary to hypotheses, real-time guidance WED had poorer outcomes than the other conditions on several measures, and advance guidance WED also showed some poorer outcomes. Moderator analyses revealed that participants with low baseline agreeableness, low extraversion, or high conscientiousness had relatively poor responses to guidance. We conclude that providing guidance for WED, especially in real-time, may interfere with emotional processing of unresolved stress, particularly for people whose personalities have poor fit with this interactive form of WED.

Resident Ratings of Communication Skills Using the Kalamazoo Adapted Checklist

BACKGROUND The Kalamazoo Essential Elements Communication Checklist-Adapted (KEECC-A) is a well-regarded instrument for evaluating communication and interpersonal skills. To date, little research has been conducted that assesses the accuracy of resident self-ratings of their communication skills. OBJECTIVE To assess whether residents can accurately self-rate communication skills, using the KEECC-A, during an objective structured clinical examination (OSCE). METHODS A group of 104 residents from 8 specialties completed a multistation OSCE as part of an institutional communication skills curriculum conducted at a single institution. Standardized patients (SPs) and observers were trained in rating communication skills using the KEECC-A. Standardized patient ratings and resident self-ratings were completed immediately following each OSCE encounter, and trained observers rated archived videotapes of the encounters. RESULTS Resident self-ratings and SP ratings using the KEECC-A were significantly correlated (r104  = 0.238, P = .02), as were resident self-ratings and observer ratings (r104  = 0.284, P = .004). The correlation between the SP ratings and observer (r104  = 0.378, P = .001) ratings were larger in magnitude, but not significantly different (P > .05) from resident/SP or resident/observer correlations. CONCLUSIONS The results suggest that residents, with a modicum of training using the KEECC-A, can accurately rate their own communication and interpersonal skills during an OSCE. Using trained observers to rate resident communication skills provides a unique opportunity for evaluating SP and resident self-ratings. Our findings also lend further support for the reliability and validity of the KEECC-A.

A Life-Stress, Emotional Awareness, and Expression Interview for Primary Care Patients With Medically Unexplained Symptoms: A Randomized Controlled Trial.

Objective: Lifetime trauma, relationship adversities, and emotional conflicts are elevated in primary care patients with medically unexplained symptoms (MUS), and these risk factors likely trigger or exacerbate symptoms. Helping patients disclose stressors, increase awareness and expression of inhibited emotions, and link emotions to physical symptoms may improve health. We developed an emotional awareness and expression interview that targets stressful life experiences and conflicts and then tested its effects on primary care patients with MUS. Method: Patients (N = 75) with MUS were recruited at a family medicine clinic and randomized to an interview condition or treatment-as-usual (TAU) control condition. In a single 90-min interview in the clinic, the interviewer elicited disclosure of the patient’s stressors, linked them to the patient’s symptom history, and encouraged emotional awareness and expression about unresolved relationship trauma or conflict. At baseline and 6-week follow-up, patients completed self-report measures of their physical and psychological health. Results: Analyses of covariance, controlling for baseline symptoms, compared patients in the interview condition with TAU at 6-week follow-up. Compared with TAU, the interview led to significantly lower pain severity, pain interference, sleep problems, and global psychological symptoms. Conclusions: This study provides preliminary evidence for the value of integrating a disclosure and emotional awareness and expression interview into the primary care setting for patients with MUS.

The role of social constraints and catastrophizing in pelvic and urogenital pain

Introduction and hypothesisPelvic and urogenital pain is complex and highly prevalent in women, and increased attention to psychosocial influences can guide more effective treatments. This study tested the hypothesis that social constraints (the perception that close others inhibit, discourage, or dissuade a person from disclosing one’s feelings or talking about one’s problems) would be associated with distress, pain, and problems with functioning, beyond the influence of the widely recognized risk factor of pain catastrophizing.MethodsA total of 122 women completed psychosocial and pain questionnaires during an initial evaluation at a multidisciplinary urology center. Correlational and multiple regression analyses examined pain catastrophizing and social constraints in association with general distress, general pain severity, urogenital pain, and pain interference with functioning.ResultsIn zero-order correlations, pain catastrophizing and social constraints were significantly associated with all pain measures (p < 0.05) and distress. In regressions, both pain catastrophizing and social constraints were simultaneously independent predictors of general distress (β = 0.48 and 0.33, p < 0.001 respectively), general pain severity (β = 0.55 and 0.21, p < 0.001 and 0.01 respectively), and pain interference with functioning (β = 0.65, p < 0.001, and β = 0.16, p < 0.05 respectively), and together explained a moderate portion of the variance in outcome variables. Pain catastrophizing (but not social constraints) also significantly predicted urogenital pain (β = 0.43, p < 0.001).ConclusionsBoth pain catastrophizing and social constraints are important to the experience of pelvic and urogenital pain, and effective pain treatment should include attention to these psychological and social factors.