A pragmatic trial of emotional awareness and expression therapy for veterans with chronic pain

The National Institute of Neurological Disorders and Stroke awarded a $823,860 Cooperative Agreement to the University of California, Los Angeles on August 15, 2025, to conduct a pragmatic trial evaluating Emotional Awareness and Expression Therapy (EAET) for veterans with chronic pain. The project addresses a significant clinical need, as chronic pain affects approximately one-third of the veteran population and frequently co-occurs with trauma and mental health conditions. Although eleven prior efficacy trials and two single-site studies demonstrated EAET's superiority to cognitive behavioral therapy for chronic pain (CBT-CP), the proposed research will evaluate EAET's real-world effectiveness when implemented across diverse clinical settings. The study is structured in two phases: a one-year UG3 phase involving clinician training at seven geographically diverse Veterans Affairs healthcare systems, feasibility confirmation through open pilot testing, and formative evaluation to identify implementation barriers and facilitators; and a four-year UH3 phase conducting a multisite pragmatic randomized controlled superiority trial comparing group-based EAET to group-based CBT-CP.

UCLA's research team is supported by specialized sub-awardees providing critical expertise. The University of Texas Health Science Center at San Antonio contributes qualitative research and implementation methodology guidance through Dr. Erin Finley, the University of Utah oversees data system algorithm development and economic evaluation including cost-effectiveness analysis and healthcare utilization assessment, and the Greater Los Angeles Veterans Research and Education Foundation manages veteran recruitment, assessment, and institutional review board coordination at the VA Greater Los Angeles Healthcare System under the leadership of site Principal Investigator Dr. Stephen R. Marder. This Cooperative Agreement, funded under the Drug Use and Addiction Research Programs (CFDA 93.279), will generate evidence on EAET's practical implementation and effectiveness for managing chronic pain in veteran populations while advancing understanding of how this evidence-based intervention performs in typical clinical care environments.

Abstract

Chronic pain is present in nearly one-third of veterans and is frequently accompanied by comorbid trauma and mental health symptoms. Emotional awareness and expression therapy (eaet) is an evidence-based psychological treatment for chronic pain that was developed to directly target comorbid trauma and mental health symptoms with the goal of reducing or eliminating chronic pain. Eleven controlled and uncontrolled efficacy trials of eaet in veterans and civilians have shown eaet can produce robust effects on improving outcomes that include pain severity, pain interference, depression, anxiety, and post-traumatic stress disorder (ptsd) symptoms. Consequently, eaet was recommended as a pain management best practice by the U.S. Department of health & human services in 2019. Moreover, in two single-site efficacy trials conducted at VA greater LOS angeles healthcare system, eaet was found to be superior on several outcomes to gold- standard cognitive behavioral therapy for chronic pain (CBT-CP) among older veterans with chronic pain. Yet these more tightly controlled trials may not reflect the true effectiveness of eaet when implemented by diverse clinicians. The overall goal of the proposed project is to conduct a rigorous and comprehensive evaluation of eaet delivered in usual care settings. The project will proceed in two phases. During a 1-year UG3 phase, clinicians at 7 geographically diverse VA healthcare systems will be trained in eaet via an eaet learning collaborative, and an open pilot of eaet will be performed at each site to confirm feasibility. In addition, a formative evaluation will be conducted to engage clinicians, administrators, and veterans and to identify barriers and facilitators to implementation. During a 4-year UH3 phase, a multisite pragmatic randomized controlled superiority trial of group-based eaet compared to group-based CBT-CP will be conducted among 672 veterans with chronic musculoskeletal pain. The aims are to determine whether veterans randomized to eaet versus CBT-CP experience improved pain severity (primary outcome), pain interference, functioning, quality of life, depression, anxiety, ptsd symptoms, and sleep; and decreased use of opioid pain medications and unhealthy substance use from baseline to 10 weeks (primary endpoint), 6 months, and 12 months after enrollment. Outcomes will also be compared for those who do or do not have comorbid mental health diagnoses (i.e., VA service-connection for depressive disorders, anxiety disorders, and ptsd) and for men compared to women veterans. In addition, a longitudinal process evaluation will support the development of an implementation toolkit for scaling, and the effects of eaet and CBT-CP will be compared on healthcare use and costs, including a cost-effectiveness evaluation from the VA healthcare system perspective. Findings may promote a paradigm shift in the treatment of chronic pain that could influence policy and guidelines.