• Mean Pain Severity [ Time Frame: Change from baseline to 8 weeks ]
  Average of 4 self report items: current pain, worst pain over the last 7 days, least pain over the last 7 days, and average pain over the last 7 days. Each item is scored 0-10 (0 = no pain; 10 = pain as bad as can be), yielding a total score between 0 and 10.
• Mean Pain Severity [ Time Frame: Change from baseline to 20 weeks ]
  Average of 4 self report items: current pain, worst pain over the last 7 days, least pain over the last 7 days, and average pain over the last 7 days. Each item is scored 0-10 (0 = no pain; 10 = pain as bad as can be), yielding a total score between 0 and 10.

• Percent of Group Therapy Sessions Attended [ Time Frame: 8 weeks ]
  Number of sessions each participant attends divided by 8 sessions (total number of sessions available to attend).
• Satisfaction with Therapy and Therapist Scale-Revised [ Time Frame: 8 weeks ]
  Satisfaction with therapy subscale is the summation of 6 items, each scored 1-5 (1 = maximum dissatisfaction; 5 = maximum satisfaction), yielding a total score between 6 and 30. Satisfaction with therapist subscale is the summation of 6 items, each scored 1-5 (1 = maximum dissatisfaction; 5 = maximum satisfaction), yielding a total score between 6 and 30. Overall satisfaction is an additional single item scored 1-5 (1 = maximum dissatisfaction; 5 = maximum satisfaction). The two subscales and the overall satisfaction item are each reported separately.
• PROMIS-Pain Behavior Short Form 7a v1.1 [ Time Frame: Change from baseline to 8 weeks ]
  Sum of seven self-report items assessing behaviors associated with pain over the past 7 days. Items range from 1-6 (1 = had no pain; 6 = always), yielding a total score between 7 and 42.
• PROMIS-Pain Behavior Short Form 7a v1.1 [ Time Frame: Change from baseline to 20 weeks ]
  Sum of seven self-report items assessing behaviors associated with pain over the past 7 days. Items range from 1-6 (1 = had no pain; 6 = always), yielding a total score between 7 and 42.
• PROMIS-Pain Interference Short Form 8a v1.0 [ Time Frame: Change from baseline to 8 weeks ]
  Sum of eight self-report items assessing interference of pain with daily activities over the past 7 days. Items range from 1-5 (1 = no interference; 5 = maximum interference), yielding a total score between 8 and 40.
• PROMIS-Pain Interference Short Form 8a v1.0 [ Time Frame: Change from baseline to 20 weeks ]
  Sum of eight self-report items assessing interference of pain with daily activities over the past 7 days. Items range from 1-5 (1 = no interference; 5 = maximum interference), yielding a total score between 8 and 40.
• PROMIS-Depression Short Form [ Time Frame: Change from baseline to 8 weeks ]
  Sum of eight self-report items assessing depression and emotional distress over the past 7 days. Items range from 1-5 (1 = never feeling a type of distressing emotion; 5 = always feeling that emotion), yielding a total score between 8 and 40.
• PROMIS-Depression Short Form [ Time Frame: Change from baseline to 20 weeks ]
  Sum of eight self-report items assessing depression and emotional distress over the past 7 days. Items range from 1-5 (1 = never feeling a type of distressing emotion; 5 = always feeling that emotion), yielding a total score between 8 and 40.
• PROMIS-Anxiety Short Form [ Time Frame: Change from baseline to 8 weeks ]
  Sum of seven self-report items assessing anxiety over the past 7 days. Items range from 1-5 (1 = never experiencing a type of distressing emotion; 5 = always feeling that emotion), yielding a total score between 7 and 35.
• PROMIS-Anxiety Short Form [ Time Frame: Change from baseline to 20 weeks ]
  Sum of seven self-report items assessing anxiety over the past 7 days. Items range from 1-5 (1 = never experiencing a type of distressing emotion; 5 = always feeling that emotion), yielding a total score between 7 and 35.
• PTSD Symptom Scale [ Time Frame: Change from baseline to 8 weeks ]
  Sum of seventeen self-report items assessing PTSD according to the frequency in which symptoms are experienced over the last two weeks. Items range from 0-3 (0 = not experiencing a symptom; 1 = once per week or less / a little bit / once in a while; 2 = 2 to 4 times per week / somewhat / half the time; 3 = 3 to 5 or more times per week / very much / almost always), yielding a total score between 0 and 51.
• PTSD Symptom Scale [ Time Frame: Change from baseline to 20 weeks ]
  Sum of seventeen self-report items assessing PTSD according to the frequency in which symptoms are experienced over the last two weeks. Items range from 0-3 (0 = not experiencing a symptom; 1 = once per week or less / a little bit / once in a while; 2 = 2 to 4 times per week / somewhat / half the time; 3 = 3 to 5 or more times per week / very much / almost always), yielding a total score between 0 and 51.
• NIH Toolbox-Positive Affect Short Form [ Time Frame: Change from baseline to 8 weeks ]
  Sum of fifteen self-report items assessing positive affect over the past 7 days. Items range from 1-5 (1 = not at all experiencing a type of positive emotion; 5 = very much feeling that emotion), yielding a total score between 15 and 75.
• NIH Toolbox-Positive Affect Short Form [ Time Frame: Change from baseline to 20 weeks ]
  Sum of fifteen self-report items assessing positive affect over the past 7 days. Items range from 1-5 (1 = not at all experiencing a type of positive emotion; 5 = very much feeling that emotion), yielding a total score between 15 and 75.
• NIH Toolbox-Purpose and Meaning Short Form [ Time Frame: Change from baseline to 8 weeks ]
  Sum of seven self-report items assessing general feelings of meaning and purpose. Items range from 1-5 (1 = no purpose and meaning; 5 = maximum purpose and meaning), yielding a total score between 7 and 35.
• NIH Toolbox-Purpose and Meaning Short Form [ Time Frame: Change from baseline to 20 weeks ]
  Sum of seven self-report items assessing general feelings of meaning and purpose. Items range from 1-5 (1 = no purpose and meaning; 5 = maximum purpose and meaning), yielding a total score between 7 and 35.
• NIH Toolbox-Life Satisfaction Short Form [ Time Frame: Change from baseline to 8 weeks ]
  Sum of five self-report items assessing general life satisfaction. Items range from 1-5 (1 = no satisfaction; 5 = maximum satisfaction), yielding a total score between 5 and 25.
• NIH Toolbox-Life Satisfaction Short Form [ Time Frame: Change from baseline to 20 weeks ]
  Sum of five self-report items assessing general life satisfaction. Items range from 1-5 (1 = no satisfaction; 5 = maximum satisfaction), yielding a total score between 5 and 25.
• PROMIS-Sleep Disturbance Short Form [ Time Frame: Change from baseline to 8 weeks ]
  Sum of eight self-report items assessing sleep disturbance over the past 7 days. Items range from 1-5 (1 = no sleep disturbance; 5 = maximum sleep disturbance), yielding a total score between 8 and 40.
• PROMIS-Sleep Disturbance Short Form [ Time Frame: Change from baseline to 20 weeks ]
  Sum of eight self-report items assessing sleep disturbance over the past 7 days. Items range from 1-5 (1 = no sleep disturbance; 5 = maximum sleep disturbance), yielding a total score between 8 and 40.
• PROMIS-Fatigue Short Form [ Time Frame: Change from baseline to 8 weeks ]
  Sum of seven self-report items assessing fatigue over the past 7 days. Items range from 1-5 (1 = no fatigue; 5 = maximum fatigue), yielding a total score between 7 and 35.
• PROMIS-Fatigue Short Form [ Time Frame: Change from baseline to 20 weeks ]
  Sum of seven self-report items assessing fatigue over the past 7 days. Items range from 1-5 (1 = no fatigue; 5 = maximum fatigue), yielding a total score between 7 and 35.
• Ambivalence over Emotional Expression Questionnaire [ Time Frame: Change from baseline to 8 weeks ]
  Sum of fourteen self-report items assessing ambivalence of emotional expression. Items range from 1-5 (1 = no ambivalence; 5 = maximum ambivalence), yielding a total score between 14 and 70.
• Ambivalence over Emotional Expression Questionnaire [ Time Frame: Change from baseline to 20 weeks ]
  Sum of fourteen self-report items assessing ambivalence of emotional expression. Items range from 1-5 (1 = no ambivalence; 5 = maximum ambivalence), yielding a total score between 14 and 70.
• Emotional Approach Coping Scales [ Time Frame: Change from baseline to 8 weeks ]
  Sum of eight self-report items assessing whether the subject uses an emotional approach to coping when experiencing stress or difficulties. Items range from 1-4 (1 = I don't use this emotional coping strategy; 4 = I use this emotional coping strategy a lot), yielding a total score between 8 and 32.
• Emotional Approach Coping Scales [ Time Frame: Change from baseline to 20 weeks ]
  Sum of eight self-report items assessing whether the subject uses an emotional approach to coping when experiencing stress or difficulties. Items range from 1-4 (1 = I don't use this emotional coping strategy; 4 = I use this emotional coping strategy a lot), yielding a total score between 8 and 32.
• Pain Catastrophizing Scale [ Time Frame: Change from baseline to 8 weeks ]
  Sum of thirteen self-report items assessing the types of thoughts and feelings experienced with pain. Items range from 0-4 (0 = not experiencing a type of thought / feeling; 5 = experiencing that thought / feeling all the time), yielding a total score between 0 and 52. Higher scores indicate the subject experiences thoughts and emotions that typically catastrophizes their pain.
• Pain Catastrophizing Scale [ Time Frame: Change from baseline to 20 weeks ]
  Sum of thirteen self-report items assessing the types of thoughts and feelings experienced with pain. Items range from 0-4 (0 = not experiencing a type of thought / feeling; 5 = experiencing that thought / feeling all the time), yielding a total score between 0 and 52. Higher scores indicate the subject experiences thoughts and emotions that typically catastrophizes their pain.
• Survey of Pain Attitudes [ Time Frame: Change from baseline to 8 weeks ]
  Sum of fourteen self-report items assessing the subject's attitude towards their pain. Items range from 0-4 (0 = this attitude is very untrue for me; 4 = this attitude is very true for me), yielding a total score between 0 and 56.
• Survey of Pain Attitudes Supplement [ Time Frame: Change from baseline to 8 weeks ]
  Three self-report items assessing the subject's attitude towards their pain. Items range from 0-4 (0 = strongly disagree; 4 = strongly agree). Each item is scored individually.
• Survey of Pain Attitudes [ Time Frame: Change from baseline to 20 weeks ]
  Sum of fourteen self-report items assessing the subject's attitude towards their pain. Items range from 0-4 (0 = this attitude is very untrue for me; 4 = this attitude is very true for me), yielding a total score between 0 and 56.
• Survey of Pain Attitudes Supplement [ Time Frame: Change from baseline to 20 weeks ]
  Three self-report items assessing the subject's attitude towards their pain. Items range from 0-4 (0 = strongly disagree; 4 = strongly agree). Each item is scored individually.
• Beliefs in Pain Control Questionnaire [ Time Frame: Change from baseline to 8 weeks ]
  A list of thirteen statements relating to the subject's general beliefs about pain management. Each statement is rated 0-4 (0= strongly disagree; 4=strongly agree), yielding a total score between 0 and 52.
• Beliefs in Pain Control Questionnaire [ Time Frame: Change from baseline to 20 weeks ]
  A list of thirteen statements relating to the subject's general beliefs about pain management. Each statement is rated 0-4 (0= strongly disagree; 4=strongly agree), yielding a total score between 0 and 52.
• Pain Beliefs and Perceptions Inventory [ Time Frame: Change from baseline to 8 weeks ]
  Eight self-report items assessing the subject's beliefs and perceptions about their pain. Items range -2 to 2 (-2 = strongly disagree; 2 = strongly agree). Scored with four two-item scales, each yielding a total score between -4 and 4.
• Pain Beliefs and Perceptions Inventory [ Time Frame: Change from baseline to 20 weeks ]
  Eight self-report items assessing the subject's beliefs and perceptions about their pain. Items range -2 to 2 (-2 = strongly disagree; 2 = strongly agree). Scored with four two-item scales, each yielding a total score between -4 and 4.
• Fourteen-item Coping Strategies Questionnaire [ Time Frame: Change from baseline to 8 weeks ]
  Sum of fourteen self-report items assessing the subject's use of coping strategies. Items range 0-6 (0 = never use this strategy; 6 = always use this strategy), yielding a total score between 0 and 84.
• Fourteen-item Coping Strategies Questionnaire [ Time Frame: Change from baseline to 20 weeks ]
  Sum of fourteen self-report items assessing the subject's use of coping strategies. Items range 0-6 (0 = never use this strategy; 6 = always use this strategy), yielding a total score between 0 and 84.
• Patient's Gobal Impression of Change Scale [ Time Frame: Change from baseline to 8 weeks ]
  Patient rates on a single item with a scale of 1-7 the change (if any) they've experienced since beginning treatment in the study (1 = no change or condition has worsened; 7 = a great deal better and a considerable improvement that has made all the difference).
• Patient's Gobal Impression of Change Scale [ Time Frame: Change from baseline to 20 weeks ]
  Patient rates on a single item with a scale of 1-7 the change (if any) they've experienced since beginning treatment in the study (1 = no change or condition has worsened; 7 = a great deal better and a considerable improvement that has made all the difference).
• Working Alliance Inventory Short Form C [ Time Frame: 8 weeks ]
  Sum of twelve self-report items assessing the subject's thoughts and feelings on their therapist. Items range 1-7 (1 = never; 4 = sometimes; 7 = always), yielding a total score between 12 and 84.
• At Least 30% Improvement in Mean Pain Severity [ Time Frame: Change from baseline to 8 weeks ]
  Mean pain severity is calculated from an average of 4 self report items: current pain, worst pain over the last 7 days, least pain over the last 7 days, and average pain over the last 7 days. Each item is scored 0-10 (0 = no pain; 10 = pain as bad as can be), yielding a total score between 0 and 10. Mean pain severity is calculated at baseline and 8 weeks, and the two scores are compared to see if mean pain severity at 8 weeks is 30% lower than at baseline.
• At Least 30% Improvement in Mean Pain Severity [ Time Frame: Change from baseline to 20 weeks ]
  Mean pain severity is calculated from an average of 4 self report items: current pain, worst pain over the last 7 days, least pain over the last 7 days, and average pain over the last 7 days. Each item is scored 0-10 (0 = no pain; 10 = pain as bad as can be), yielding a total score between 0 and 10. Mean pain severity is calculated at baseline and 20 weeks, and the two scores are compared to see if mean pain severity at 20 weeks is at least 30% lower than at baseline.
• At Least 50% Improvement in Mean Pain Severity [ Time Frame: Change from baseline to 8 weeks ]
  Mean pain severity is calculated from an average of 4 self report items: current pain, worst pain over the last 7 days, least pain over the last 7 days, and average pain over the last 7 days. Each item is scored 0-10 (0 = no pain; 10 = pain as bad as can be), yielding a total score between 0 and 10. Mean pain severity is calculated at baseline and 8 weeks, and the two scores are compared to see if mean pain severity at 8 weeks is at least 50% lower than at baseline.
• At Least 50% Improvement in Mean Pain Severity [ Time Frame: Change from baseline to 20 weeks ]
  Mean pain severity is calculated from an average of 4 self report items: current pain, worst pain over the last 7 days, least pain over the last 7 days, and average pain over the last 7 days. Each item is scored 0-10 (0 = no pain; 10 = pain as bad as can be), yielding a total score between 0 and 10. Mean pain severity is calculated at baseline and 20 weeks, and the two scores are compared to see if mean pain severity at 20 weeks is at least 50% lower than at baseline.
• At Least 70% Improvement in Mean Pain Severity [ Time Frame: Change from baseline to 8 weeks ]
  Mean pain severity is calculated from an average of 4 self report items: current pain, worst pain over the last 7 days, least pain over the last 7 days, and average pain over the last 7 days. Each item is scored 0-10 (0 = no pain; 10 = pain as bad as can be), yielding a total score between 0 and 10. Mean pain severity is calculated at baseline and 8 weeks, and the two scores are compared to see if mean pain severity at 8 weeks is at least 70% lower than at baseline.
• At Least 70% Improvement in Mean Pain Severity [ Time Frame: Change from baseline to 20 weeks ]
  Mean pain severity is calculated from an average of 4 self report items: current pain, worst pain over the last 7 days, least pain over the last 7 days, and average pain over the last 7 days. Each item is scored 0-10 (0 = no pain; 10 = pain as bad as can be), yielding a total score between 0 and 10. Mean pain severity is calculated at baseline and 20 weeks, and the two scores are compared to see if mean pain severity at 20 weeks is at least 70% lower than at baseline.

This study is being performed to compare the effects of two alternate types of psychotherapy, Cognitive Behavior Therapy (CBT) and Emotional Awareness and Expression Therapy (EAET), for chronic musculoskeletal pain in older adults. In addition, the investigators will evaluate which patients respond better to each treatment and further investigate how each treatment works. CBT, which focuses on improving coping skills for pain, is the standard form of psychotherapy offered at VA. EAET instead focuses on understanding how life stress, relationships, and emotions may cause and perpetuate pain.

The investigators are performing the study because pain is a large problem among Veterans. Studies show that chronic pain affects as many as 50% of male Veterans and 75% of female Veterans. The investigators are focusing on older adult Veterans because they have the highest rates of chronic pain at VA, perhaps as high as 80%. The investigators are looking at psychotherapy in this study because VA, the Department of Defense, and the CDC recently recommended psychosocial treatments, such as psychotherapy, as first treatments for chronic pain, along with medications other than opioids (e.g., oxycodone). However, only one form of psychotherapy, CBT, is currently available in clinical practice at VA, and this study may provide evidence for making EAET available to Veterans as well.

The overarching goal of the proposed research is to learn how to optimize psychotherapy for those Veterans most in need and most likely to benefit from psychotherapy, older Veterans with chronic musculoskeletal pain. Chronic pain is a critical healthcare challenge, as the condition affects 50% of all Veterans and affects older Veterans most commonly, severely, and persistently. For years, chronic pain treatment has been notoriously difficult at VA and elsewhere, especially in light of the recent "opioid crisis," in which opioid analgesics, previously a mainstay of chronic pain treatment, have come under increased scrutiny. In response, CDC, VA/DoD, and some experts have called for enhancing and expanding psychosocial treatment options for chronic pain, such as psychotherapy, which are low risk for older Veterans who frequently have multiple medical comorbidities and are taking multiple medications.

Yet standard VA psychotherapy approaches, such as Cognitive Behavior Therapy (CBT), have shown modest benefits for Veterans on pain and other related outcomes, such as mood, anxiety, and sleep. In contrast, a novel psychotherapy approach, Emotional Awareness and Expression Therapy (EAET), has shown medium to large benefits for some chronic pain patients. Whereas CBT improves pain and negative emotion by teaching patients cognitive and behavioral coping skills, affecting brain regions that enhance "cognitive control" of pain, EAET operates primarily through emotion regulation, which is thought to influence brain regions and circuits that modulate both physical pain and emotion-a mechanism absent from existing approaches. The literature and the investigators' pilot data indicate that patients who express emotional distress at baseline, such as high anxiety and depressive symptoms, may be particularly likely to benefit from EAET's emotion regulation approach, whereas patients who express less emotional distress may derive more benefit from an approach like CBT, which does not require ready access to emotions.

The proposed randomized clinical trial tests the hypothesis that EAET is superior to CBT on reduction in mean pain severity and other outcomes derived from IMMPACT. To examine which patients are most likely to benefit, this research also tests whether greater baseline emotional distress (using measures of anxiety and depression) predicts stronger benefits from EAET and whether lower baseline emotional distress predicts stronger benefits from CBT. Finally, this research explores whether the benefits of EAET are mediated by improved emotion regulation, whether the benefits of CBT are mediated by improved cognitive and behavioral coping, and whether the benefits of both are mediated by a stronger working alliance. The investigators plan to enroll 160 multi-ethnic/multi-racial older Veterans (age 60-95 years) with chronic musculoskeletal pain at the West Los Angeles VA Medical Center.

This research can introduce an additional, potentially more effective format of psychotherapy at VA so that more Veterans with chronic pain can respond. In addition, this research can lead to better treatment targeting and enhance the understanding of how psychotherapy treatments work. Finally, this research can facilitate the development of critical skills for the PI in psychotherapy research and pain management and enhance his ability to effect positive change for older Veterans.

Recruitment was resumed after the Covid-19 Administrative Hold was lifted in October 2020.

• Behavioral: Emotional Awareness and Expression Therapy
  Focus on emotions, writing about stress, assertiveness training, role playing new ways to handle relationships, and sharing feelings and experiences with others.
  Other Name: EAET
• Behavioral: Cognitive Behavior Therapy
  Focus on cognitive and behavioral skills, such as relaxation, increasing pleasant activities, pacing, and changing ways of thinking.
  Other Name: CBT

• Experimental: Emotional Awareness and Expression Therapy
  Seeks to reduce physical (e.g., pain) and emotional (e.g., depression, anxiety) symptoms by helping individuals become aware of their emotions, express them, and resolve emotional conflicts. It will use techniques such as writing about stress, role playing how to handle difficult relationships, recognizing and expressing anger and other feelings, and being more open with others.
  Intervention: Behavioral: Emotional Awareness and Expression Therapy
• Active Comparator: Cognitive Behavior Therapy
  Seeks to help individuals function better and improve symptoms by teaching various cognitive and behavioral skills to manage symptoms. It will use techniques such as relaxation training, engaging in pleasant activities, pacing yourself, and changing unhelpful ways of thinking.
  Intervention: Behavioral: Cognitive Behavior Therapy

Inclusion Criteria:

Eligible Veterans are age 60 to 95 years old and have had at least 3 months of musculoskeletal pain, including the following conditions most likely to benefit from psychosocial intervention based on previous research:

• regional pain syndromes (e.g., low back, neck, leg, or pelvic pain, or temporomandibular joint disorders);
• widespread pain syndromes (e.g., fibromyalgia);
• whiplash;
• tension headaches; or
• any combination of these disorders.

Exclusion Criteria:

• Confirmed hip or knee osteoarthritis without other musculoskeletal pain complaints;
• Leg pain greater than back pain only without other musculoskeletal pain complaints (to exclude radiculopathy in isolation);
• EMG-confirmed "tunnel" syndromes (e.g., carpal or tarsal tunnel syndrome) only without other musculoskeletal pain complaints;
• Autoimmune disease that typically generates pain (e.g., systemic lupus erythematosus, rheumatoid arthritis, inflammatory bowel disease, ankylosing spondylitis);
• Cancer pain, sickle cell disease, neuralgias (e.g., trigeminal neuralgia), burn pain, infection associated with pain (e.g., vertebral infection), cauda equina syndrome, gout, migraine or cluster headaches without additional musculoskeletal pain complaints;
• Uncontrolled severe psychiatric disorder including current psychotic disorder or severe mood disorder not controlled with medications (e.g., schizophrenia or bipolar I disorder), dissociative identity disorder, or active suicide/violence risk in the past 6 months;
• Substantial cognitive impairment or dementia (Mini-Mental State Exam (78) score 24);
• Active severe alcohol or substance use disorder that inhibits the participant's ability to attend session or participate in homework;
• Currently with pain-related litigation or applying for pain-related compensation or compensation increase, or undergoing compensation re-evaluation (e.g., applying for VA service connection or service connection increase for pain);
• Patients who have undergone CBT for pain within the last 3 months of enrollment or who are currently receiving CBT or EAET psychotherapy treatment for pain;
• Unable to fluently read/converse in English;
• Planning to move from the area in the next 6 months.