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. Author manuscript; available in PMC: 2023 Sep 28.
Published in final edited form as: J Clin Psychol Med Settings. 2022 Oct 3;30(3):520–530. doi: 10.1007/s10880-022-09913-5

Emotional Awareness and Expression Interview: Examining Interview Content and Patient Experiences in Two Medical Samples

Shoshana Krohner 1, Jolin B Yamin 1, Maisa S Ziadni 1, Jennifer N Carty McIntosh 1, Howard Schubiner 2, Mark A Lumley 1
PMCID: PMC10122833  NIHMSID: NIHMS1890030  PMID: 36190608

Abstract

A single session of Emotional Awareness and Expression Therapy (EAET)—the EAET Interview—was previously shown to lead to clinical benefits for patients with centralized somatic conditions in primary care (Ziadni et al., 2018) and tertiary care (Carty et al., 2019) settings. There has yet to be an examination of patients’ experiences of and reactions to the EAET Interview, which is crucial in evaluating possible clinical implementation of the interview. We conducted secondary analyses on 88 patients (M age = 41.32, 90.9% women) from the two prior trials (primary care N = 51; tertiary care N = 37). Analyses examined interview processes (stress disclosure themes, working alliance, and emotional processing) and patients’ reactions to the interview (interview credibility and perceived value of the interview), comparing the two samples and examining correlations among these variables. All patients disclosed at least one stressful life experience, commonly interpersonal problems (89.2%) and childhood adversity (51.5%). Patients had moderately high levels of working alliance and emotional processing during the interview and reported high interview credibility and perceived value of the interview. More extensive emotional processing of stressors was associated with more positive patient reactions to the interview, including higher interview credibility (r = .23) and perceived value (r = .32). We conclude that the single-session EAET Interview was valued by most patients, and patients’ emotional processing is of particular value. Addressing the trauma and emotional conflicts of patients with centralized somatic conditions is both feasible and valuable in front-line medical settings.

Keywords: EAET, interview, centralized somatic conditions, emotions, medical settings

Patients with somatoform disorders, functional somatic syndromes, central sensitization syndromes, or nociplastic pain conditions—which we call “centralized somatic conditions,” comprise one-quarter to one-half of outpatient medical visits (Haller et al., 2015; Landa et al., 2012; Petersen et al., 2020). Such conditions include most cases of chronic widespread pain, irritable bowel syndrome, fibromyalgia, pelvic pain, headaches, and many others. These conditions are characterized by somatic symptoms (e.g., fatigue, dizziness, palpitations) including pain (e.g., urogenital pain, joint pain, abdominal pain, headaches), are associated with high levels of disability and healthcare utilization (Andersen et al., 2013; Barsky et al., 2005; Park et al., 2016), and are considered difficult to treat (Cramer et al., 2015; Fink, 2017; Henningsen et al., 2007). Although encompassing a range of presentations, these centralized somatic conditions likely share underlying mechanisms, as suggested by the high comorbidity and symptom overlap among the various syndromes (Petersen et al., 2020) and their shared links with psychiatric conditions (e.g., anxiety and depression) and premorbid psychological risk factors, especially lifetime trauma (Afari et al., 2014; Wessely & White, 2004).

Centralized somatic conditions are inadequately explained by peripheral structural, organic, or disease processes, but instead are strongly influenced by central nervous system processes that contribute to symptoms through the processes of sensitization, augmentation, or inferential construction (Bourke et al., 2015; den Boer et al., 2019). The association of psychosocial factors and trauma with centralized somatic conditions is well established. Many studies have reported that early life adversity is a risk factor for later development of somatic symptoms and pain in adulthood (Afari et al., 2014; Chui et al., 2017; Garnefski, et al., 2017; Karatzias et al., 2017). Emotional dysregulation, emotional avoidance, interpersonal dysfunction, and adulthood trauma/abuse also are associated with the development, onset, and maintenance of these conditions (Afari et al., 2014; Hauser et al., 2011; Jones et al., 2009). The prospective nature of many of these studies suggests that trauma and emotional processes cause or strongly contribute to these somatic conditions, rather than just result from them.

Assessment and Treatment of Psychosocial Factors in Medical Settings

There are various psychological interventions for centralized somatic conditions. Cognitive-behavioral therapies that target symptom management lead to some benefit, although effect sizes are relatively small, and most patients continue to have symptoms and disability (Menon et al., 2017; Williams et al., 2020; van Dessel et al., 2014). Mindfulness and acceptance-based interventions are also commonly used, but their effects for these populations also tend to be quite modest (Hilton et al., 2017).

Therapies that target underlying traumas and relational conflicts are promising alternatives to cognitive-behavioral, mindfulness, and acceptance-based approaches. Short-term psychodynamic therapies have been tested, and meta-analyses of both controlled (Abbass et al., 2020) and uncontrolled (Abbass et al., 2021) trials reveal large reductions in somatic symptoms from these therapies. Emotional Awareness and Expression Therapy (EAET) integrates psychodynamic, emotion-focused, and exposure-based models and was developed specifically for centralized somatic conditions (Lumley & Schubiner, 2019). This therapy conceptualizes such conditions as driven by inadequate processing of emotional trauma, interpersonal problems, and/or internal conflicts, as well as incorrect appraisals that disturbed bodily functions—rather than changeable central nervous system processes—drive somatic symptoms. EAET uses various techniques to address these processes, including educating about the brain’s role in somatic symptom generation or augmentation, linking somatic symptoms to emotional conflicts, clarifying interpersonal patterns, facilitating the experience and expression of suppressed but adaptive feelings, and encouraging genuine interpersonal communication. EAET has been tested on patients with centralized somatic conditions in several uncontrolled (Burger et al., 2016; Maroti et al., 2021) and controlled trials (Lumley et al., 2017; Slavin-Spenny et al., 2013; Thakur et al., 2017; Yarns et al., 2020), which collectively demonstrate EAET’s ability to reduce somatic symptoms and improve functioning, even surpassing cognitive-behavioral therapy on some pain-related outcomes (Lumley et al., 2017; Yarns et al., 2020).

The single-session EAET interview

Two deterrents to the use of EAET is that it requires patients to attend multiple sessions and to do so in settings other than their usual medical clinics. Thus, Lumley and colleagues (Carty et al., 2019; Ziadni et al., 2018) developed a brief version of EAET—the EAET interview—which is a single, 90-minute session offered in a medical clinic. The EAET Interview was compared to waitlist control conditions in two randomized trials, which were run simultaneously and used the same procedures, interview, and timing of assessments (baseline and 5-week follow-up); one trial was conducted in primary care (a family medicine clinic), and the other was in tertiary care (as women’s urology clinic). The main outcomes of these two trials have been published. Compared to controls, Ziadni et al. (2018) found that the EAET interview led to significant reductions in pain and somatic symptoms, interpersonal sensitivity, depression, and anxiety among patients with medically unexplained symptoms in family medicine. Carty et al. (2019) found that the EAET interview reduced pain and physical dysfunction (but not psychological distress or interpersonal dysfunction) among women with chronic urogenital pain (e.g., vulvodynia, interstitial cystitis) in a specialty clinic.

These two trials demonstrated the overall benefit of the EAET interview for centralized somatic conditions in medical settings, but nothing has yet been reported about how patients engage with its model of symptom generation and treatment, respond to an invitation to disclose and process traumas and stressors during the interview, and feel about the experience. These issues are particularly salient given that psychologists and other behavioral providers, when consulted by physicians to work with patients, typically do not target these emotional, often sensitive issues. Some clinicians are concerned that doing so may be poorly received by patients, stigmatize them, lead to symptom exacerbation, or “open a Pandora’s Box” of problems that will be difficult to close with a single session, necessitating longer therapy. Thus, in addition to the “average benefit” of the EAET interview that we have already published (Carty et al., 2019; Ziadni et al., 2018), we sought to understand patients’ experiences in more detail. In particular, we investigated how patients’ behavior during the interview predicts their later ratings of it. The EAET Interview encourages patients to disclose and process traumas, conflicts, and avoided emotions, and we examined how the degree to which patients engage in these processes predicts how patients react to the interview experience.

Furthermore, the two prior trials of the EAET interview were conducted in settings that differed regarding the integration of mental health treatment. Study 1 (Ziadni et al., 2018) was conducted in a family medicine clinic, where psychosocial influences on health are not typically considered, whereas Study 2 (Carty et al., 2019) was conducted in a specialty women’s urology clinic, where psychosocial issues such as sexual history were typically assessed. Thus, patients in the latter setting may be more aware of psychosocial influences on their health than those in the former setting. Thus, we also compared the two samples with respect to engagement and reactions to the interview.

In this paper, we present secondary analyses of these two clinical trials of the EAET interview. We include a priori hypotheses based on the EAET model of treatment as well as several exploratory questions. A priori hypotheses were that most patients will: a) disclose interpersonal stressors during the interview, in the form of either childhood adversity or adulthood relationship problems; b) demonstrate positive working alliance during the interview; and c) engage in emotional processing during the interview. To better understand the interview process and patients’ reactions to it, we included the following exploratory questions: a) How much do patients feel that the EAET model is credible and of value to them? b) How well does therapist-rated emotional processing and observer-ratings of working alliance predict patient reactions to the interview? To address these questions, we compare data from each sample separately as well as across studies to determine if patient behavior or reactions to the interview differ by clinical setting.

Methods

Patients

We recruited patients from two medical settings for RCTs comparing the EAET interview to a no-interview (waitlist) control condition (Carty et al., 2019; Ziadni et al., 2018). The current report and analyses are on only those 88 patients from both trials who received the EAET interview: Study 1 reports on 51 patients in primary care (family medicine) who had medically unexplained symptoms—primarily pain-related conditions, and Study 2 reports on 37 patients from a specialty urology center who had chronic urogenital pain. Table 1 presents descriptive data for patients in each study. Study 1 (primary care) patients were primarily White and young to middle-aged (range: 17 to 64) and identified as women. Study 2 (women’s urology clinic) patients were almost all White, middle-aged (range: 18 to 73), and all identified as women. The average patient in both studies had received some college education, and most patients in both studies had had prior psychological therapy.

Table 1.

Demographic and Background Descriptive Information: Study 1 (Primary Care), Study 2 (Women’s Urology Center), and Combined Total

Variable Study 1 (N = 51) Study 2 (N = 37) Combined (N = 88)
Age in years, M (SD) 38.73 (13.44) 44.89 (15.34) 41.32 (14.51)
Gender
 Woman, n (%) 43 (84.3%) 37 (100%) 80 (90.9%)
 Man, n (%) 8 (15.7%) 0 8 (9.1%)
Years of education, M (SD) 14.08 (1.99) 15.38 (2.36) 14.63 (2.24)
Race
 Black, n (%) 10 (19.6%) 2 (5.4%) 12 (13.6%)
 White, n (%) 39 (76.5%) 34 (91.9%) 73 (83%)
 Other, n (%) 2 (4%) 1 (2.7%) 3 (3.4%)
Household income
 < $10,000 12 (23.5%) 6 (16.2%) 18 (20.5%)
 $10,000 – $34,999 23 (45%) 1 (2.7%) 24 (27.3%)
 $35,000 – $74,900 11 (21.6%) 11 (29.7%) 22 (25%)
 75,000 – $149,999 3 (5.9%) 14 (37.8%) 17 (19.3%)
 $150,000 + 1 (2%) 4 (10.8%) 5 (5.7%)
Prior psychological therapy, n (%) 38 (74.5%) 27 (73%) 65 (73.9%)
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Note: Missing income data for 1 patient in Study 1 and 1 patient from Study 2

Procedure

Both studies were approved by our university’s institutional review board and registered on clinicaltrials.gov (NCT02151500 and NCT02286115). Although the samples and locations differed, the studies used very similar methods and the same EAET interview. The medical staff at each site identified potential patients and referred them to the research team for further screening, and those enrolled in the study provided written, informed consent and demographic information. Patients were randomized, and those assigned to the EAET interview received it in the medical setting in which they were recruited. The interview was conducted in a private room and audio-recorded. Each study had a set of two therapist interviewers—a total of four female doctoral students in clinical psychology—who were trained and supervised by a licensed clinical psychologist. Immediately after the interview, patients provided ratings of their emotional processing, interview credibility, and perceived value of the interview; and therapists independently provided ratings of emotional processing. These ratings were completed online.

EAET Interview

The single, 90-minute interview consists of two phases. The first phase involves eliciting stressor disclosures from patients, including a detailed examination of their health and symptoms, stressful life experiences, and core emotional conflicts. Patients are encouraged to provide a narrative of their stressful or traumatic life experiences, including recurrent or core conflicts with important people in their lives. The therapist points out the links between stressful experiences and the onset or worsening of somatic symptoms throughout this segment of the interview. The second component is experiential and involves helping patients express key relational needs or emotions (anger/rage, sadness, tenderness/connection, self-compassion). Patients are encouraged to demonstrate how they express these key emotions in their tone of voice, posture, and language towards key people in their lives with whom they have had conflictual relationships or by whom they were victimized. The therapist coaches the patients to achieve their most genuine and complete emotional expression. At the end, the therapist summarizes observations, provides feedback to patients about their emotional capacities, and discusses how they might engage in relationships in a healthier, more open and honest manner.

Constructs/Measures

In our secondary analyses of both study samples, we assessed two overarching domains, each of which was comprised of several constructs: 1) the interview process was captured by three constructs—stress disclosure themes, working alliance, and emotional processing; 2) patient reactions to the interview were captured by two constructs—interview credibility and perceived value of the interview. Note that different persons (patient, therapist, independent observer) provided ratings on one or more of these five constructs.

Stress disclosure themes.

Two independent psychology students listened to the recorded interviews and identified the stressors that were disclosed by each patient. Stressors were then placed into one of these six categories: 1) childhood adversity (e.g., family mental illness, neglect), and a subcategory of childhood sexual abuse; 2) adulthood relationship problems (e.g., marital discord, family conflict); 3) adulthood trauma/abuse (e.g., domestic violence), and a subcategory of adulthood sexual abuse/assault; 4) health-related stress (e.g., impaired physical function, disability status); 5) financial stress (e.g., job loss, debt); and 6) death or loss/grief.

Working Alliance.

The two students also provided observer ratings of working alliance from the recorded interview, using the 12-item segmented Working Alliance Inventory- Observer version (S-WAI-O; Berk, Safran, & Muran, 2010). This measure assesses agreement on tasks (e.g., “there is agreement about what client’s role or responsibilities are in this segment”) and therapist-client bond (e.g., “there is good understanding between the client and therapist. All items were rated from 1 (very strong evidence against) to 7 (very strong evidence for) and averaged for an overall measure of working alliance. Each student rated one study as well as 25% of the other study (to assess interrater reliability). The S-WAI-O demonstrated excellent internal consistency reliability (Cronbach’s α = .97), and interrater reliability (ICC = .98, 95% CI = .94–.99) in this sample.

Emotional processing.

This construct was assessed in two ways. First, patients rated, “During the interview I was very emotionally involved,” on a scale from 1 (strongly disagree) to 7 (strongly agree). Second, therapists rated overall patient emotional processing with this item (Patient “experienced or expressed emotions not previously experienced or expressed”), using a 0 (not at all) to 4 (a lot) scale.

Interview credibility.

Patients rated three items from the Credibility/Expectancy Questionnaire (CEQ; Devilly & Borkovec, 2000), assessing beliefs about the interview (“How logical does the information offered to you seem?”; “How helpful do you think the interview was for better understanding your symptoms?”; “How confident would you be in recommending this interview to a friend who experiences a similar condition or symptoms?”); items were rated from 1 (not at all) to 10 (very much) and averaged (3-item scale α = .90 for the combined sample).

Perceived value of the interview.

This construct was assessed with two variables, and all items were rated by patients. The General Value of the interview was assessed with three items (“Overall, how valuable did you find the interview activities?”; “Overall, how useful or helpful was the interview to you?” “Did you learn any new skills or information during the interview?”), rated on a scale from 1 (not at all) to 10 (very much) and averaged (α = .94). Insight Gained was comprised of three items that assessed patients’ sense of gaining new awareness into the nature of difficulties (“I feel that I understand myself and my problems better”; “I’m more aware of what I want now.”; We got closer to the core of my problems during the interview.”), rated from 1 (strongly disagree) to 7 (strongly agree) and averaged (α = .91).

Statistical Analyses

Analyses were conducted for each study separately and then for the combined samples. First, descriptive analyses examined the frequency or mean of each construct/measure. Second, chi-square tests compared the two studies on stress disclosure themes, and independent samples t-tests compared the two studies on all other variables. Biserial correlations examined the relationship of observer-coded stress disclosure themes with therapist- and observer-rated process variables and patient-rated response variables in each study separately. Bivariate correlations examined the relationship of observer- and therapist-rated process variables with patient-rated response variables in each study separately. Significance was set at 2-tailed alpha of 0.05 for all analyses. Therapist ratings were available for all 88 patients, but observer-rated stress disclosure themes and working alliance were not available for some patients due to missing or faulty audio-recordings (n = 9 in Study 1 and n = 5 in Study 2), and post-interview patient ratings were missing from some patients (n = 12 in Study 1 and n = 1 in Study 2).

Results

Interview Process: Stressor Disclosure Themes

All patients reported at least one stressor, and patients typically reported multiple stressors. On average, patients in Study 1 reported fewer types of stressors (M = 3.38, SD = 1.41) than patients in Study 2 (M = 5.07, SD = 2.16), t(72) = −3.87, p < .001. Table 2 presents the observer-coded stressor disclosure themes for each study sample separately. The two samples did not differ significantly on the frequency of most disclosure themes. Childhood adversity was reported by about half of each sample, whereas child sexual abuse was reported much less frequently by both samples. Adult relationship problems were disclosed by nearly all patients in both samples, and financial problems by about one-quarter of each sample. Notably, adult trauma/abuse was disclosed significantly more often in Study 1 than Study 2, and adult sexual assault/abuse was somewhat more common in Study 1 than Study 2, as was death/grief-related stressors. Finally, health-related stress was occasionally reported, and somewhat more common in Study 2 than Study 1 patients.

Table 2.

Frequency (and %) of Stressors Disclosed by Patients in Study 1 (Primary Care) and Study 2 (Women’s Urology Center), and Comparison between Study Samples

Theme Study 1
(n= 42)		 Study 2
(n = 32)		 Combined
(n = 74)		 χ2 p
Childhood adversity 24 (57.1%) 14 (43.8%) 38 (51.4%) 1.30 .25
 Childhood sexual abuse 5 (11.9%) 2 (6.3%) 7 (9.5%) 0.73 .39
Adulthood relationship problems 37 (88.1%) 29 (90.6%) 66 (89.2%) 0.12 .73
Adulthood trauma/abuse 22 (57.1%) 8 (25%) 30 (40.5%) 5.65 .02
 Sexual assault/abuse 14 (33.3%) 6 (18.8%) 20 (27%) 2.14 .14
Health-related stress 7 (16.7%) 10 (31.3%) 17 (23%) 2.18 .14
Financial problems 12 (28.6%) 8 (25%) 20 (27%) 1.12 .73
Death/grief 19 (45.2%) 9 (28.1%) 28 (37.8%) 2.26 .13
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Interview Process: Working Alliance and Emotional Processing

Table 3 presents data for the observer-rated working alliance and both therapist- and patient-rated emotional processing. For working alliance, both samples obtained mean scores greater than 5 (1 to 7 scale), suggesting an overall moderately strong level of bond between interviewer and patient and agreement on interview tasks. There were no differences between the two studies on level of working alliance. In both studies, patient ratings of emotional processing had mean scores greater than 5 on the 1 to 7 scale, with a rating of ‘agree’ or ‘strongly agree’ (ratings of 6 or a 7 on the scale) reported by 64.1% of the Study 1 patients and 79.3% of the Study 2 patients. Therapist ratings of overall emotional processing had mean scores of approximately 2 on the 0 to 4 scale, with ratings of ‘moderate’ (a 2 on the scale) or higher on overall emotional processing for 64.7% of Study 1 patients and 62.2% of Study 2 patients.

Table 3.

Means and Standard Deviations of Working Alliance, Emotional Processing, Interview Credibility, and Perceived Value: Study 1 (Primary Care), Study 2 (Women’s Urology Center), and Combined Total; Independent Samples t-tests Comparing Study 1 and Study 2 on Study Variables

Construct/Variable Study 1
M (SD)		 Study 2
M (SD)		 Combined
M (SD)		 t p
Observer-rated working alliance 5.61 (1.55) 5.83 (1.06) 5.71 (1.35) 0.66 .24
Emotional processing
 Patient-rated 5.36 (1.98) 5.86 (1.03) 5.57 (1.65) 1.25 .22
 Therapist-rated 1.78 (0.86) 1.81 (0.94) 1.8 (0.89) 0.14 .89
Interview credibility 6.82 (2.29) 7.79 (1.71) 7.29 (2.07) 2.04 .05
Patient-rated interview value
 General value 6.47 (2.33) 7.31 (2.04) 6.88 (2.22) 1.64 .11
 Insight gained 5.08 (1.54) 5.13 (1.22) 5.10 (1.40) 1.43 .89
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Note: Variables reported in this table had different sample sizes. Sample sizes for observer-ratings were as follows: Study 1 (N = 42), Study 2 (N = 32), Combined (N = 74). Sample sizes for therapist ratings were as follows: Study 1 (N = 51), Study 2 (N = 37), Combined (N = 88). Sample sizes for patient ratings were as follows: emotional processing: Study 1 (n = 39), Study 2 (n = 29), Combined (n = 68); interview credibility: Study 1 (n = 38), Study 2 (n = 36), Combined (N = 74); general value: Study 1 (N = 37), Study 2 (N = 35), Combined (N = 72); insight gained: Study 1 (n = 39), Study 2 (n = 29), Combined (n = 68).

Patient Reactions to the Interview: Interview Credibility and Perceived Value

Table 3 also shows the data on patient reactions to the interview. Patients in both studies reported relatively high interview credibility. Mean patient ratings of interview credibility were higher than 6 on the 1 to 10 scale in both studies; however, Study 2 had significantly higher levels of patient-rated interview credibility. Patients in both samples indicated that the interview was generally valuable to them, with ratings slightly higher than 6 (agree) on the 1 to 10 scale in both studies. On average, patients reported gaining insight during the interview, with mean ratings of approximately 5 (slightly agree) on the 1 to 7 scale. There were no significant differences between the two samples on general value or insight gained, although Study 2 had somewhat higher rates of general value than Study 1.

Associations of Working Alliance and Emotional Processing with Patient Reactions to the Interview

We next investigated whether working alliance and emotional processing during the interview predicted post-interview patient reactions to the interview. Table 4 shows correlations of these two variables—observer-rated working alliance average and therapist-rated emotional processing—with the four patient-rated reactions to interview. Results from the combined sample showed that higher levels of emotional processing were associated with higher acceptance of the EAET model (r = .23, p = .05), higher perceived value of the interview (r = .32, p = .01), and more insight gained (r = .28, p = .02). Working alliance was not associated with any patient-rated reactions in the combined sample.

Table 4.

Bivariate Correlations of Observer- and Therapist-rated Interview Process Variables with Patient-rated Reactions to Interview: Study 1 (Primary Care), Study 2 (Women’s Urology Center), and Combined Total

Interview process Patient Reactions to Interview
Interview credibility General value Insight gained
S1 S2 Combined S1 S2 Combined S1 S2 Combined
Working alliance .28 −.01 .20 .28 −.05 .17 .24 .07 .19
Emotional processing .33* .11 .23* .34* .30 .32** .37* .20 .28*
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Note: S1 refers to Study 1 (primary care) and S2 refers to Study 2 (women’s urology clinic)

*

p < .05,

**

p < .01

In Study 1, higher therapist-reported emotional processing was associated with higher patient-rated acceptance of the EAET model (r = .33, p = .04), higher perceived value of the interview (r = .34, p = .04), and more insight gained (r = .37, p = .02) during the interview. There were no significant associations between interview process variables and patient reactions in Study 2. Working alliance during the interview was unrelated to post-interview patient reactions in either study.

Discussion

The EAET interview is a single-session interview, which targets emotional conflicts and attributions that are thought to underlie centralized somatic conditions such as pain. EAET’s effectiveness for treating centralized somatic conditions is well-established (Lumley et al., 2017; Lumley & Schubiner, 2019; Thakur, et al., 2017; Yarns et al., 2020), and the EAET interview has shown clinical benefits in several randomized controlled trials (Carty et al., 2018; Ziadni et al., 2018). This study extends these trials by providing insight into patient behavior during, perceptions of, and responses to the EAET interview, which are critical to dissemination and implementation. Our primary aims included examining the types of disclosures patients made during the EAET interview along with aspects of interview process during the interview. We also sought to clarify how patients react to the model of symptoms and treatment offered by EAET and their thoughts about their EAET interview experience. We included exploratory analyses to understand whether patient behavior (i.e., working alliance, emotional processing) during the interview predicted post-interview reactions. As there were two parallel clinical trials of the EAET interview implemented in two different medical settings—a primary care clinic and tertiary care clinic—we also were able to examine similarities and differences across settings.

Summary of Key Findings

We found that all patients in both the family medicine and women’s urology clinic disclosed therapeutically-relevant stressful life experiences, showed moderately high levels of working alliance, and engaged in at least a moderate degree of emotional processing during the interview. A substantial majority of patients disclosed interpersonal problems and histories of lifetime trauma, abuse, or other substantial adversities. These findings supported our a priori hypotheses. Our exploratory analyses determined that the overwhelming majority of patients reported that they accepted the model linking stress and their emotions to their pain or somatic symptoms. This insight was apparently novel for many patients, who reported that the interview offered them a new understanding of themselves, their symptoms, and their interpersonal and emotional functioning. Overall, patients had favorable views of the EAET interview experience, and there was evidence that greater emotional processing during the interview predicted positive patient reactions to the interview.

Expanded Findings and Implications for Treatment of Centralized Somatic Conditions in Medical Settings

We examined patients’ stress disclosure themes, working alliance, and emotional processing during the interview. In both study samples, patients disclosed therapeutically-relevant personal stories and stressors. Six themes were identified from the collective personal stories and stressors that were shared by patients during the interview: adulthood relationship problems, adulthood trauma/abuse, childhood adversity, financial problems, grief/loss, and health-related stress. The relative prevalence of these themes revealed much about the types of psychosocial challenges experienced by patients with centralized somatic conditions as well as patients’ willingness to disclose these issues. Nearly all patients reported relationship problems during the interview, and interpersonal traumas were common in both samples (reported by over half of primary care patients and a quarter of tertiary care patients), including sexual assault, verbal/emotional abuse, and domestic violence. Childhood adversity was common in both samples, consistent with the prevalence reported in recent surveys of the general U.S. population (Kessler et al., 2018; McLaughlin et al., 2018).

The frequency that these reports of interpersonal challenges and traumas aligns with literature that links interpersonal problems (Ehnvall et al., 2009, Lumley 2004; Porter et al., 2007) and childhood adversity (Afari et al., 2014; Davis et al., 2005; Jones et al., 2009) with the onset and maintenance of centralized somatic conditions. The other three stressor categories—health-related problems, financial problems, and loss/death of a loved one—were less frequently disclosed in both studies, relative to the interpersonal themes. These results suggest that many patients with centralized somatic conditions will capitalize on an opportunity to discuss personal, often sensitive issues with an empathetic provider when those patients are invited to do so. High levels of working alliance in both samples suggests that many patients with centralized somatic conditions are interested in and motivated to discuss their psychosocial stress history.

The EAET interview was viewed as emotionally activating by patients and therapists alike; in their post-interview surveys, therapists rated most patients as emotionally expressive, and most patients reported feeling emotionally engaged during their interview. We also found that patients who demonstrated more extensive emotional processing (as rated by the therapist) more readily accepted the emotion-focused model of symptoms, felt that they had gained insight during the interview, and had more positive perceptions of the interview experience. These findings align with a recent meta-analysis showing that patient emotional expression is the most powerful predictor of positive therapy outcomes (Peluso & Freund, 2018).

Perceived Value and Interview Credibility

Most patients in both medical settings accepted the EAET model, which frames psychosocial traumas or conflicts and subsequent emotional avoidance as a key driver of somatic symptoms. Most patients reported that the interview was a valuable experience, providing opportunities to develop insight into their core conflicts or problems and their emotions and needs. In fact, the more that patients experienced and processed their emotions during the interview, the most positive their reactions were to the interview. These findings suggest the value of integrating a psychosocial model of symptoms into front-line medical patient education and treatment. For those providers who may be concerned about damaging their rapport with patients or stigmatizing patients, these results provide reassurance that inquiring about patients’ traumas and their reactions and providing an emotion-focused model of somatic symptoms is generally better received than providers might fear.

Comparing Primary Care and Tertiary Care Samples

We also noted some differences between the primary care (family medicine) and tertiary care (women’s urology center) samples. First, the proportion of family medicine patients who disclosed adulthood trauma or abuse experiences was more than double that of the women’s urology sample. Indeed, the prevalence of disclosed lifetime abuse was somewhat lower in our women’s urology sample than would be expected from prior research (Peters et al., 2008). Of note, the patients at the women’s urology clinic were routinely screened by staff for sexual assault and abuse experiences, which may have reduced their motivation to disclose and process these issues during the EAET interview. Alternatively, some patients may have avoided disclosing unwanted sexual experiences with a psychologist due to feared stigmatization related to the association of sexual assault/abuse with urogenital pain (Yosef et al., 2016).

The family medicine sample reported somewhat lower interview credibility than the women’s urology sample. In contrast to the multidisciplinary nature of the care provided at the women’s urology center, patients from the family medicine clinic likely had less exposure to a psychosocial model of their somatic symptoms, and thus may have been somewhat less open to the EAET model. Nonetheless, primary care patients were, in general, open to this model and had similarly high levels of working alliance as the women’s urology sample. Note also that the original RCTs showed that the 1-month clinical benefits of the interview were somewhat more robust in family medicine (Ziadni et al., 2018) than in women’s urology (Carty et al., 2019).

Limitations

There were some limitations to this study. The patients were mostly white women, and participation was voluntary; these characteristics limit generalizability to other demographic groups as well as the larger pool of all patients with centralized somatic symptoms identified in medical settings. Analyses were correlational, thereby limiting conclusions regarding causal relationships, such as between interview emotional processing and reactions to the interview. We also did not control for therapist characteristics that may have impacted the findings, including the fact that two different pairs of therapists conducted each study’s interviews. The use of several non-validated measures, including measures of emotional processing and perceived value of the interview, suggests the need to interpret these findings with caution. It is also possible that patients seen in medical settings that emphasize a biomedical model of pain to their patients may have fewer positive reactions to this interview and treatment model than we found. Finally, the sample sizes were relatively small, and some data, especially participant post-session ratings, was missing, which may introduce unknown bias.

Conclusions

There is value in implementing EAET in medical settings, which can yield a positive experience, even in a brief, single-session format. Despite growing evidence of the contributions of psychosocial stress and trauma to centralized somatic conditions (Generaal et al., 2015), it is relatively uncommon for providers to screen for or address these issues, due to time constraints, lack of trauma-informed training, concerns about stigma, and fears of patient reactions (Joanna van den Berk-Clerk & Renirie, 2021). These analyses and the two prior studies of the EAET interview directly address these concerns and unanswered questions. As the main effects (Carty et al., 2019; Ziadni et al., 2018) and these present findings indicate, this brief interview is clinically beneficial, valued by patients, and a time-efficient approach for medical settings that are often negotiating time constraints and limited resources. In contrast to some providers’ concerns, the majority of patients accepted the idea that emotional conflicts contribute to their health and symptoms and felt that discussing these issues furthered their understanding of their health problems. We acknowledge that a single EAET session may pose a challenge for some patients, perhaps constraining disclosure of abuse (Bacchus et al., 2003) or leading to the desire for additional psychological care. For ambivalent patients or those who are reticent to disclose, the interview may simply serve as an introduction to a psychosocial view of their symptoms and could be presented to patients accordingly. That is, the purpose of the EAET interview could be presented as an exploratory exercise that may or may not reveal a need for intervention. In these and all cases, the EAET interview may pave the way for individuals to seek additional psychotherapy services, which could further enhance clinical benefits.

Based on these and other studies demonstrating the benefits of EAET, we believe that inquiring about and addressing psychosocial trauma and stress is vital to the provision of appropriate care for these populations. We encourage providers in medical settings to explore the benefits of inquiring about their patients’ psychosocial adversities, doing so with compassion and cultural sensitivity, and using trauma-informed practices such as EAET.

Acknowledgements:

The authors acknowledge the contributions of Heather K. Doherty, Hannah J. Holmes, Kenneth Peters, John H. Porcerelli, Lisa J. Rapport, and Janice Tomakowsky to the design or conduct of the original studies.

Funding:

The original studies reported in this paper were supported by grants from the Blue Cross Blue Shield of Michigan Foundation, the American Psychological Association, and the National Institute of Arthritis and Musculoskeletal Diseases (AR057808 and AR057047).

Footnotes

Conflicts of interest: Mark A. Lumley is a paid research consultant to Cognifisense, Inc. on virtual reality therapy for chronic pain. Howard Schubiner obtains royalties from several books he has authored that are related to the topic of this paper. The other authors have no relevant financial or non-financial interests to disclose.

Ethics approval: Both studies were approved for human subjects research by the Institutional Review Board of Wayne State University.

Consent to participate: Written informed consent was obtained from all individual participants included in the study, consistent with IRB approval.

Availability of data and material:

Data and code may be made available upon appropriate request to the corresponding author.

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Data Availability Statement

Data and code may be made available upon appropriate request to the corresponding author.

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