Single-session emotion-focused psychodynamic interview for chronic pain

1. Introduction

Version followed: the Lumley group's single-session (~90 min) life-stress, emotional awareness and expression interview. Its four-phase structure follows Carty et al. 2019 (also used in Ziadni et al. 2018). Its emotion-focused psychodynamic variant follows Krohner et al. 2024 (EAET + ISTDP, by video, adults with chronic musculoskeletal pain and 3 or more adverse childhood experiences, five components per trial registration NCT04498663). In-session emotional-processing steps come from the EAET manual (Lumley & Schubiner, 2012, updated 2017) and Schubiner's step-by-step procedure (EAET Principles and Procedures, 2022). Anxiety-tracking and graded-format elements come from Abbass's ISTDP. Thinness warning: there is no public stand-alone manual for the single-session interview. Published descriptions give components and approximate timings but not scripts. The full texts of Ziadni 2018 and Krohner 2024 are not drawn on, only abstracts, the dissertation abstracts and the trial registration. Anything finer-grained below is drawn from the 8-session EAET materials and marked as such. [uncertain]

What it is: one structured, intensive interview for people with chronic pain or other persistent somatic symptoms in which no structural disease explains the severity (often called centralized, primary or nociplastic pain). In it, the interviewer: (a) takes a life-course health history; (b) elicits disclosure of life stressors, trauma, childhood adversity and relationship conflicts; (c) explicitly links those to the patient's symptom history; (d) coaches in-session experience and expression of avoided, adaptive emotions (anger/assertion, sadness/grief, love, healthy guilt) toward key people, usually by empty-chair work; and (e) integrates the session and sends the patient home with a handout and ideas for continued private and relational expression. [source: Carty et al. 2019; Ziadni 2016 dissertation / Ziadni et al. 2018 abstract; Krohner 2022 dissertation, 2024 abstract; NCT04498663]

Core idea of change: pain is generated or amplified by the brain. Life adversity sensitizes the brain's danger and alarm systems. Avoided emotions from unresolved conflict (especially held-back anger and unprocessed grief or guilt) keep that alarm active. Change is expected through three routes. The patient reattributes pain as partly brain- and emotion-driven rather than tissue damage, which lowers fear. They disclose what has been kept secret. They have a corrective emotional experience: feeling and expressing the avoided emotion and discovering that the feared outcome does not happen. The authors state that these mechanisms are proposed and were not directly tested. [source: Lumley & Schubiner, EAET Principles and Procedures 2022; Carty et al. 2019; Krohner 2024 abstract, which reports mediator changes in pain attributions and pain-related anxiety]

2. Framework

Format. One session of about 90 minutes, delivered in person (clinic exam room in primary care, or a specialty pain or urology clinic) or by secure videoconference (Krohner). In the trials, interviewers were clinical-psychology doctoral students. Sessions were audio- or video-recorded and supervised by a licensed psychologist. Outcomes were reassessed about 6 weeks later. The protocols describe no booster session. [source: Carty et al. 2019; Ziadni 2016; NCT04498663]

Before the session (not described procedurally in the sources: [synthesis]). Confirm a medical evaluation has excluded red-flag and structural or inflammatory causes that need their own treatment. Screen for exclusions (see Phase 0). Agree with the referring clinician how findings will be communicated.

Phases (Carty 2019 timings; Krohner/NCT04498663 components mapped in):

Phase	Goal	Approx. time	Move on when…
0. Referral, screening, consent [synthesis for detail]	Right patient, medical work-up done, informed consent, safety	Before session	Medical clearance and no exclusion. Patient agrees to discuss stress and emotions.
1. Life-course health / pain history	Map illnesses, surgeries, symptom onsets and flares on a visual timeline the interviewer draws	10–15 min	A rough timeline of symptoms exists. Don't let this become a full medical history.
2. Stressors, trauma and relationships, plus linking	Add stressful and traumatic events, childhood, parents, siblings and partners, and inner struggles to the timeline. Ask directly about neglect and physical or sexual abuse. Point out temporal links to symptoms. Krohner/NCT add an explicit emotion model and identify the feelings hardest to express.	~30 min	At least one key conflictual relationship and the avoided emotion are identified. The patient can at least entertain a stress–symptom link.
3. Experiential emotional expression	Patient expresses two relational emotions or needs to key people, usually to an empty chair: (a) empowerment/autonomy, including anger, and (b) connection/caring (sadness, love, healthy guilt). Coach full expression through voice, posture and words, and track symptom changes throughout.	~30 min	Some genuine felt emotion has been reached, or it is clear what blocks it (that block becomes the take-home focus). Leave at least 10 minutes for Phase 4.
4. Integration	Patient reflects on what they learned and how their beliefs about stress, emotion and pain changed. The interviewer summarizes strengths and areas to work on. Give a handout on emotions, suppression and health, with ways to express emotions privately and in relationships.	10–15 min	End of session
5. After the session [uncertain / synthesis]	A follow-up call or post-session writing is described. The sources mention only the handout and suggested private practice, such as unsent letters and writing from the EAET program.	Optional	—

[source: Carty et al. 2019 for phases and timings; NCT04498663 for the five-component variant; Ziadni 2016 dissertation]

Decision rule for the experiential phase. Start with the relationship that carries the most charge but that the patient can tolerate. The EAET manual advises beginning with lower-difficulty relationships and never forcing disclosure. In ISTDP terms, choose the graded (supportive) format when anxiety shows in smooth muscle (gut, bladder, migraine-type vascular) or as cognitive-perceptual disruption (blurring, dizziness, dissociation, losing track). Choose fuller pressure toward feeling only when anxiety shows as striated-muscle tension (fist-clenching, sighing, neck and shoulder tension). [source: EAET manual 2012/2017; Abbass 2021, Tidsskrift for Norsk Psykologforening; Abbass et al. 2009, CJEM]

Single session vs. referral on. In Abbass's ED service, the first interview was both an assessment and a trial of therapy. Some patients needed only that session; others went on to more, a mean of 3.8 (range 1–25). Treat the single interview as complete in itself, but decide at the end whether to recommend further EAET or ISTDP. [source: Abbass et al. 2009 CJEM; synthesis for applying it to the Lumley interview]

3. Guiding principles

Brain as generator or amplifier of pain: say plainly that the pain is real and largely produced or amplified by the nervous system, which is changeable. Never imply "it's in your head" or that the pain is imagined. [source: EAET Principles and Procedures 2022]
Compassion, no blame: the patient is not weak, mentally ill or at fault. Say this before probing. [source: same]
Stress shapes emotional learning: ask about the whole lifespan, not only recent stress. Childhood adversity is a main target in the Krohner version. [source: same; Krohner 2024]
Avoidance is the problem; approach is the treatment: every topic that brings anxiety, embarrassment, guilt, shame, numbness or a pain spike is a target to approach, not to back away from. [source: EAET Principles and Procedures 2022]
Be an "avoidance detective" (Lumley's phrase): keep asking yourself what the patient is avoiding right now, in their story, in relationships and in the room. [source: same]
Agency and communion: look for two families of avoided emotion. Agency covers anger, assertion and pride; communion covers sadness, love, longing and healthy guilt. Aim to reach both in one session where possible. [source: same; Carty 2019]
The "right emotion at the right target" (Lumley's phrase): steer away from secondary emotions such as irritability or self-attack aimed at substitute targets, and toward the primary feeling aimed at the person it belongs to. [source: EAET Principles and Procedures 2022]
Experience over insight: move from talking about events to re-experiencing them in the present tense, directly addressed to the person. Insight alone is not the goal. [source: same]
Two hands: one hand pushes toward feeling; the other supports and respects the patient's pace. The patient decides; the therapist encourages. [source: EAET manual 2012/2017]
Voluntary, conscious alliance: get explicit agreement on the task. Passive compliance defeats the work. [source: Abbass 2021]
Calibrate to anxiety tolerance: watch where anxiety is discharged. Regulate it, using the graded format, before pressing toward feeling if smooth-muscle or cognitive-perceptual signs appear. [source: Abbass 2021; Abbass et al. 2009]
Timing of challenge: clarify a defense before challenging it. A challenge that comes too early feels like an attack. [source: Abbass 2021]
Test the two core fears experientially, not by debate: "it will turn out badly" and "I can't handle it" are disproved by doing, not arguing. [source: EAET manual; Principles and Procedures 2022]
Symptoms are live feedback: have the patient notice pain and body changes as emotions are engaged or avoided during the session. [source: Carty 2019; EAET manual]
Full anger belongs in fantasy or therapy; real-life expression is assertive and balanced with caring: never coach confrontation in the session that the patient would then act out in real life. [source: Principles and Procedures 2022]
The four Cs of therapist character: Commitment (to the model), Curiosity (about avoidance), Creativity (in designing approach experiences) and Courage (to push through discomfort). [source: Principles and Procedures 2022]
Accept negative feelings toward the therapist without defensiveness: invite them to be expressed directly. [source: same; EAET manual]
Medical humility [synthesis]: hold the brain-based frame alongside appropriate medical care. Do not tell a patient their body is "not diseased" without medical evaluation. The EAET manual contains such language but gives no medical-screening guidance, so you must supply it.

4. Intervention inventory

Interventions are listed in session order. Sources: Carty et al. 2019 and NCT04498663 for the interview components; the EAET manual (2012/2017) and EAET Principles and Procedures (2022) for the processing techniques; Abbass 2021 and Abbass et al. 2009 for ISTDP elements. Where a step-level detail comes from the 8-session EAET program rather than the single interview, it says so.

4.1 Medical coordination and referral pathway

Purpose / when: before any interview, and again after it. The sources require pain to be primary or medically unexplained. Ziadni recruited from family medicine, Carty from a women's urology centre, and Abbass's ED service took referrals only after urgent causes were ruled out. [source: Ziadni 2016; Carty 2019; Abbass et al. 2009] The procedural detail below is [synthesis].
Steps: (1) Get the referring clinician's confirmation that a work-up appropriate to the symptom is complete and red flags were considered: neurological deficit, fever, weight loss, cancer history, inflammatory signs and so on. (2) Ask what current treatments and any planned procedures exist. Krohner excluded surgery scheduled within 2 months. (3) Agree on a frame the physician will reinforce: pain is real, and nervous-system and stress factors are part of it, not instead of it. Abbass's ED model trained physicians with brief workshops and a patient pamphlet. (4) With consent, send a short post-interview letter: key stress–symptom links, the patient's main avoided emotion, and a recommendation (no further therapy / EAET / ISTDP / other). (5) Tell the patient that any new or changed symptom still goes to their doctor.
Example language (illustrative, to the physician): "After the interview I'll send you a one-paragraph summary and what I'd recommend next. Anything new or different medically still comes back to you."
Watch for: patients who feel "dumped" on psychology. Physician endorsement of the referral reduces this. Also watch for conditions Abbass flags as possibly worsened by emotional activation, such as active inflammatory bowel disease and some autoimmune conditions. For those, coordinate closely and favour the graded format. [source: Abbass 2021]

4.2 Screening, selection and informed consent

Purpose / when: before or at the start. Trial exclusions were current psychotic disorder, dementia, clinician-judged psychiatric instability and inability to communicate in English. Krohner required 3 or more on the ACE questionnaire. Abbass lists active intoxication and active psychosis or mania as requiring stabilization first. [source: Carty 2019; NCT04498663; Abbass 2021]
Steps: (1) Screen for the exclusions above, active suicidality (use your standard risk assessment; an interview that stirs strong affect is not the place to manage acute risk), current abuse or danger at home, and active substance intoxication. (2) Explain the purpose: to look at how life stress and feelings may be linked to the symptoms, and to practise feeling and expressing some of those feelings in the session. (3) Make the voluntary nature explicit: the patient can stop or skip anything. Schubiner stresses consent, patient control and the right to stop. (4) For videoconference, confirm the patient is in a private space, check where they are physically for emergencies, and have a backup phone number [synthesis].
Example language (illustrative): "Today is one long conversation. We'll map your health and life on a timeline, look for links, and then I'll invite you to try feeling and saying some things that may never have been said. You're in charge of the pace, and you can say no to anything."
Watch for: passive compliance ("whatever you think"). Abbass treats this as defeating the work, so get an active yes.

4.3 Opening frame: validation and the brain-based explanation of pain

Purpose / when: in the opening minutes, and again briefly during linking (Phase 2). It reduces fear and blame and opens a psychological or brain attribution. In Krohner, a shift in attributions was a measured mediator. [source: EAET Principles and Procedures 2022; Krohner 2024; Carty 2019]
Steps: (1) Validate that the pain is real. (2) Explain that the brain produces or amplifies pain and controls muscle tension and autonomic and inflammatory responses. (3) Explain that danger learning from injuries, abuse, neglect and conflict can sensitize this alarm. (4) Explain that held-in emotions, especially resentment, guilt and grief, keep the alarm turned on. (5) Say the brain can change and that new emotional experiences can turn the alarm down. (6) Check the patient's reaction and invite skepticism.
Example language (illustrative): "Your pain is real, and it's being produced by real nerve signals. The brain runs a danger alarm. Hard experiences, especially early ones, can make that alarm oversensitive. Feelings we've had to swallow can keep it ringing. The good news is that alarms can be re-set."
Watch for: defensiveness ("so you think I'm making it up"). Re-validate, and offer the idea as an experiment to test rather than a belief to adopt (EAET manual frames the program as an "experiment"). It is working when the patient starts wondering aloud about a link.

4.4 Life-course health and pain history on a visual timeline

Purpose / when: Phase 1, 10–15 min. It builds the scaffold for later linking. [source: Carty 2019; Ziadni 2016]
Steps: (1) Draw a horizontal line from birth to now, by hand or on a shared screen for video. (2) Ask for significant illnesses, surgeries, injuries, chronic conditions and the onset of each current symptom, plus major flares and remissions. (3) Mark each event at its age or year. (4) Keep it brisk: medical detail serves the timeline, not diagnosis.
Example language (illustrative): "Let's start with your body's story. When did you first have health problems? When did this pain start? When was it worst, and when did it ease?"
Watch for: the patient filling the whole session with medical detail, which is a common avoidance. Summarize and move on. Note any symptom onset with no obvious physical trigger; it is a candidate for linking.

4.5 Life-stress, trauma and relationship history added to the timeline

Purpose / when: Phase 2, the bulk of about 30 min. It elicits disclosure, including secrets. Ziadni noted widespread unresolved victimization, conflict and secrets that had rarely been raised in primary care. [source: Carty 2019; Ziadni 2016; Krohner 2024]
Steps: (1) Ask about childhood: home atmosphere, each parent, siblings, school. (2) Ask directly, matter-of-factly and without surprise, about neglect and physical, emotional and sexual abuse; Carty asked about these explicitly. (3) Ask about adult relationships (partners, children, work), losses, betrayals, inner struggles and secrets. (4) Ask about current stressors. (5) Mark each event on the timeline in a different colour or row from the medical events. (6) For each key relationship, ask briefly what was felt then and what was done with that feeling.
Example language (illustrative): "Some people had a lot of hurt growing up: being hit, neglected, touched in ways that weren't okay. Did anything like that happen to you?" / "What did you do with your anger at him back then?"
Watch for: vague or global answers ("it was fine"), flat affect while describing major events (isolation of affect), and laughing or smiling at painful content. Note body signs: sighing, hand-clenching, gut cramps, going foggy. Rising anxiety means you are near the important material (EAET).

4.6 Linking stressors to symptoms

Purpose / when: throughout Phase 2 and summarized at its end. The interviewer points out temporal links between stressors and symptom onsets or flares. [source: Carty 2019; Ziadni 2016]
Steps: (1) Point to coincidences on the timeline: "The back pain began the year your marriage fell apart." (2) Ask the patient what they notice rather than telling them. (3) Name possible mechanisms (alarm sensitization, held-back feelings). (4) Note situations, people or emotions that trigger flares now. (5) Link symptom patterns to the emotions being avoided, for example pain rising when anger at a family member is swallowed.
Example language (illustrative): "Look at this: the stomach problems started the year you left home to care for your mother. What do you make of that?"
Watch for: forced or premature interpretation that the patient rejects. Offer links tentatively. It is working when the patient adds a link you hadn't seen.

4.7 Emotion model and identifying the hardest-to-express feelings (Krohner/NCT variant)

Purpose / when: at the end of Phase 2. It introduces a model in which suppressing healthy feelings in relationships produces anxiety, stress or pain, and has the patient name the feelings they find hardest to express. [source: NCT04498663] The EAET manual's version is the triangle of conflict: feelings and needs, the anxiety and defenses that block them, and the resulting symptoms. [source: EAET manual session 2; Abbass 2021]
Steps: (1) Sketch a triangle with adaptive feelings at the bottom (anger/assertion, sadness/grief, love/closeness, healthy guilt, pride), anxiety at one top corner and defenses/symptoms at the other. (2) Explain that when a feeling was unsafe in childhood, the body learned to block it with anxiety, and blocking strategies follow (pleasing, numbing, busyness, self-criticism, pain). (3) Ask which feeling they find hardest to feel or say, and with whom. (4) Name the two families: agency (anger, assertion) and communion (sadness, love, guilt).
Example language (illustrative): "Of these feelings, which is the hardest for you to let yourself feel or say out loud? With whom?"
Watch for: the patient choosing the "safe" feeling, typically sadness when anger is the avoided one, or the reverse. Your observations from Phase 2 should guide the choice.

4.8 Choosing the target relationship and conflict

Purpose / when: the transition into Phase 3. It picks one or two key conflictual relationships to work with. [source: Carty 2019; NCT04498663; EAET manual]
Steps: (1) Select the person most linked to symptom history and most charged. (2) Weigh that against tolerability. In a single session, prefer one person worked thoroughly over several touched lightly [synthesis]. (3) Choose a specific scene or incident rather than a general relationship. (4) Ask permission to try an exercise.
Example language (illustrative): "Your father seems to sit at the centre of a lot of this. Would you be willing to try something a bit unusual: speaking to him as if he were here?"
Watch for: choosing a current partner the patient lives with when the core injury is historical. Clarify that the work targets the past person and time (Schubiner).

4.9 Avoidance detection and blocking defenses in real time

Purpose / when: throughout, and especially in Phase 3. It keeps the patient in contact with feeling. [source: EAET Principles and Procedures 2022; EAET manual; Abbass 2021]
Steps: (1) Notice a defense: vagueness, intellectualizing, "why" questions, minimizing, changing the subject, defending the other person, self-attack, laughing, helplessness, or describing how broken one is instead of what the other did. (2) Clarify it by naming it gently and asking whether the patient notices it. (3) Point out its cost: "when you do that, the feeling goes away and so does the chance to deal with it." (4) Invite them to set it aside and return to the feeling. (5) Use Lumley's redirections: from a "why" question to telling the person the feeling; from storytelling to what should be said directly; from self-ruin to what the other person did wrong; from a question to a statement. Challenge only defenses already clarified (Abbass).
Example language (illustrative): "You just asked him why. Instead of asking, could you tell him what you feel?" / "I notice you smile when you talk about this. What's under the smile?"
Watch for: a challenge that makes the patient feel attacked (a rupture, see 5.6). It is working when affect rises in the body rather than anxiety in the smooth-muscle or cognitive channels.

4.10 Tracking unconscious anxiety and regulating it (graded format)

Purpose / when: continuously. It keeps the patient inside their tolerance window and identifies who can take more pressure. [source: Abbass 2021; Abbass et al. 2009]
Steps: (1) Watch three channels Abbass describes. Voluntary/striated muscle: hand clenching, sighing, neck or shoulder tension, muscle pain. Smooth muscle: gut cramps, urge to urinate, headache or migraine, chest symptoms. Cognitive-perceptual disruption: blurred vision, ringing ears, losing track, foggy, dissociated. (2) If anxiety is in striated muscle, it is generally safe to continue toward feeling. (3) If it moves to smooth muscle or cognitive-perceptual disruption, stop pressing toward feeling. Shift to cognitive recap: ask the patient to notice and describe the bodily anxiety, name what feeling preceded it, and link feeling to anxiety to symptom. Continue until the anxiety returns to striated muscle, then resume more gently. (4) Use these moments as live evidence for the emotion–symptom link.
Example language (illustrative): "Let's pause. What do you notice in your body right now?" "So when we got near your anger at your mother, your stomach cramped and your thinking went foggy. That's anxiety. Let's slow down until your head is clear again."
Watch for: dissociation, faintness, vomiting urge or a sharp pain flare. These signal over-activation: switch to regulation and do not push. Note for your summary which channel the patient uses; it informs whether you recommend graded ISTDP or EAET afterwards. [synthesis for the treatment recommendation]

4.11 From talking about to re-experiencing (going to the scene)

Purpose / when: the opening of Phase 3. It activates the emotion rather than describing it. [source: EAET Principles and Procedures 2022; Schubiner phase 2]
Steps: (1) Get consent to go into the memory. (2) Have the patient elaborate one specific incident in concrete detail: where, who, what was said. (3) Invite them to close their eyes (optional on video) and tell it in the present tense. (4) Ask what emotions arise and where they are felt in the body. (5) If fear or helplessness comes first, gently reposition the patient as the older, wiser adult observing and helping the younger self, who can now choose other feelings such as anger or sadness (Schubiner). (6) If ambivalence appears, Schubiner borrows the Internal Family Systems idea of honouring conflicting "parts"; acknowledge both.
Example language (illustrative): "Close your eyes if that's okay. You're nine, in the kitchen, and he's shouting. What's happening? What do you feel, right now, in your body?"
Watch for: the patient reliving terror without adult perspective, which is a sign to re-anchor in the present (see 4.10, 5.3). It is working when affect becomes visible in voice, face or tears and the patient stays oriented.

4.12 Empty-chair expression of anger / assertion (agency)

Purpose / when: Phase 3, usually first. EAET sequences anger first, then connecting feelings, then soothing ones. It gives the corrective experience of protecting oneself. [source: Carty 2019; EAET manual sessions 2–3; Schubiner phase 4]
Steps: (1) Place the other person in an empty chair, or for video, in an imagined spot or an object on screen [synthesis for video]. (2) Ask the patient to speak directly to them in the second person ("you"). (3) Coach the body: sit up or stand, plant the feet, make fists if that fits, look at the chair, use a stronger and louder voice. (4) Move from "why" questions to statements of rights and refusal ("You had no right…", "I won't let you…"). (5) Model fuller wording if the patient is stuck, but let them say it in their own words. (6) Ask what the anger wants to do to protect them. Let it be expressed in imagination only, validating that it is fantasy. (7) Praise each step. (8) Continue until the patient feels finished, then check the body. (9) Use a closing gesture: breathe, picture releasing the anger, "wipe the hands", walk away with head held high (Schubiner).
Example language (illustrative): "Tell him. Not why. Tell him what you feel." / "Say it again, louder, as if you mean it." / "If your anger had its way in that kitchen, what would it do to protect that little girl?"
Watch for: feigned or performed anger with no bodily charge; anger turned inward ("I'm so stupid"), so redirect it to the target; guilt about the fantasy, so remind the patient it is imagined and aimed at the past person and time; and smooth-muscle or cognitive signs (4.10). It is working when the patient reports warmth, energy or a rising force in the body, then relief, lightness and often less pain. [source: Schubiner phase 7; EAET]

4.13 Guilt inquiry: healthy vs. unhealthy guilt

Purpose / when: after anger has been expressed toward someone the patient also loves, or whenever the patient shows self-blame. [source: Schubiner phase 5; EAET manual sessions 3–4; Carty 2019 lists healthy guilt among connection emotions]
Steps: (1) Ask whether guilt is present now; if none, affirm it. (2) For guilt about the anger toward a loved one: treat it as evidence of caring. Ask whether there is love under the anger, and what the patient would want the person to say from the heart. (3) For undeserved guilt (being abused, staying in a bad situation as a child): help the patient see they did nothing wrong or did their best, and direct assertion toward whoever placed the guilt on them. (4) For deserved guilt (real harm they caused): support self-forgiveness and possible amends. Ask whether they would forgive someone else who was truly sorry.
Example language (illustrative): "After saying all that to your mother, is there any guilt?" / "Whose voice is it that says this was your fault?"
Watch for: guilt used to cancel anger ("but she did her best") before the anger has been felt. That is a defense; name it and return to the anger first.

4.14 Sadness, grief, longing and love (communion)

Purpose / when: Phase 3, after anger or when it arises spontaneously. Expression of connecting emotions is one of the two targets in Carty. [source: Carty 2019; Schubiner phases 3 and 6; EAET manual]
Steps: (1) Ask what was lost or never received, and what the patient wanted from this person. (2) Allow tears; don't rush to comfort or fill the silence. (3) If love exists, invite the patient to tell the person in the chair, including what they wished for. (4) For non-intimate perpetrators (an assault by a stranger, for example), don't expect love or longing (EAET Principles and Procedures). (5) Note that some patients reach compassion for the other first, which can then make anger easier to access.
Example language (illustrative): "What did you need from him that you never got? Tell him." / "Let the tears come; they're for you."
Watch for: sadness used to avoid anger (weepy helplessness with no protest). Collapse into despair means stepping into 4.15.

4.15 Adult self comforts the younger self; self-compassion statements

Purpose / when: after grief is accessed, or when shame or self-blame dominates. [source: Schubiner phases 3 and 6; EAET manual session 3, step 5]
Steps: (1) Have the adult self visualize going to the younger self, sitting beside them and offering physical comfort. (2) Help them craft messages: you didn't deserve this, it wasn't your fault, you are good and worthy, you'll get through this, I'll protect you. (3) Ask whether the younger self can hear it. (4) Ask what the patient, with kindness, would say to themselves now.
Example language (illustrative): "Picture yourself now, sitting next to that nine-year-old. What does she need to hear from you?"
Watch for: the patient being unable to feel warmth toward the younger self, which reveals a self-contempt that is often a major target. If so, name it and link it to who taught it.

4.16 Letting go and closing the emotional sequence

Purpose / when: at the end of the experiential phase, to consolidate a new ending and a felt boundary. [source: EAET Principles and Procedures 2022; EAET manual sessions 3 and 5]
Steps: (1) Invite a release statement to the person in the chair, such as declaring they will no longer be allowed to cause harm. (2) Ask what the patient now wants with this person in the present: a boundary, distance or repair (EAET three-figure step: younger self, offender, present self). (3) Present forgiveness as optional. Letting go of resentment is an alternative.
Example language (illustrative): "Is there one last thing you want to say to him before we close the chair?"
Watch for: pressure to forgive. Don't push it; legitimate anger is acknowledged first.

4.17 Real-time symptom and body monitoring

Purpose / when: at the start, before and after each expressive exercise, and at the end. It produces the patient's own evidence that emotion affects pain. [source: Carty 2019 (patients examined symptom changes throughout); EAET manual session 2 (rate pain before and after exercises); Schubiner phase 7]
Steps: (1) Get a 0–10 pain rating at the start. (2) Ask about changes in pain and body sensations when a feeling is engaged versus avoided. (3) Re-rate after expression. (4) Reflect the pattern back.
Example language (illustrative): "Your pain was a 7 when we started. After telling your father off, where is it now?"
Watch for: pain rising during avoidance and dropping after expression, which supports the model. A rise after expression may mean an incomplete process or unaddressed guilt (see 5.2). Don't promise an immediate drop.

4.18 Planning adaptive communication in current relationships

Purpose / when: late Phase 3 or Phase 4. It turns in-session expression into balanced real-life assertion. It is part of the NCT04498663 goals (adaptive communication in current relationships). The EAET manual's full version is session 7 (connecting phrase plus assertive phrase). [source: NCT04498663; EAET manual; EAET Principles and Procedures 2022]
Steps: (1) Identify one current relationship where something needs saying. (2) Draft a statement that pairs connection ("I care about you / I value…") with assertion ("and I need / I won't…"). (3) Rehearse it briefly aloud in the session (a role-play). (4) Agree on whether, when and how to say it, with safety first. (5) Judge success by whether the patient said it, not by the other person's reaction.
Example language (illustrative): "Try: 'Mum, I love you, and I'm not going to listen to criticism of my marriage anymore.' How did that feel to say?"
Watch for: any plan to confront a dangerous person. Advise against it and use private expression instead (see 5.8).

4.19 Integration: patient reflection and interviewer summary

Purpose / when: Phase 4, 10–15 min. It consolidates learning and sets a direction. [source: Carty 2019; NCT04498663]
Steps: (1) Ask the patient what they learned and what changed in their view of stress, emotion and pain. (2) Check current feelings and body state. (3) Give the interviewer's summary: the key stress–symptom links found, the main avoided feeling and target, the patient's strengths (courage, capacity shown), and areas to work on. (4) Make a recommendation: self-practice only, further EAET, ISTDP, trauma-focused care or something else [synthesis].
Example language (illustrative): "What will you take away from today?" / "What I saw: real courage, and a big capacity for anger that's been pointed at yourself and at your body. The next step is pointing it outward, in words."
Watch for: leftover high arousal. Ask about lingering emotions or unfinished business with another person; Schubiner notes the process may need repeating over several sessions.

4.20 Handout and private home practice

Purpose / when: at the end. It continues the process privately. Carty gave a handout on how emotions, suppression and health are linked, with ways to express emotions privately and in relationships. Schubiner's procedure gives readings from his books and assigns weekly self-practice. [source: Carty 2019; Schubiner phase 7]
Steps: (1) Give your own short handout (the trial handouts are not public) [synthesis]. (2) Suggest private expression options drawn from EAET: an unsent letter to the target person, writing and speaking feelings aloud alone, imagery, and catching one avoided feeling or situation a day. These come from the 8-session program, not the single interview. [source: EAET manual; Principles and Procedures 2022] (3) Explain that private settings are the safest and allow full expression, fantasy included.
Example language (illustrative): "This week, write the letter you'd never send to your father. Write everything, then read it out loud to yourself."
Watch for: patients who sent the "unsent" letter. Clarify the instruction is not to send it.

4.21 Follow-up contact and hand-back to the medical team [uncertain / synthesis]

Purpose / when: after the session. A follow-up call or post-session writing is mentioned. The Carty and Ziadni trials, as published, describe only a 6-week assessment, no booster. Abbass's ED service offered further sessions where indicated.
Steps (synthesis): (1) Optionally make a brief phone check one to two weeks later: how they're doing, any flare or distress, whether they tried the home practice, and whether they want more therapy. (2) Send the physician the summary letter (4.1). (3) Book a reassessment at about 6 weeks, mirroring the trials, using pain severity and interference ratings.
Example language (illustrative): "I'm calling to check how you've been since our session, physically and emotionally."
Watch for: a post-session emotional or pain flare, or emerging trauma memories. Offer further sessions or a referral, and repeat the risk assessment if mood has worsened.

5. Handling problems

The single-interview papers give almost no troubleshooting guidance. The responses below draw on the EAET manual and Principles and Procedures (Lumley & Schubiner), on Abbass's ISTDP writing, and, where marked, on my own synthesis.

Patient can't identify any feeling ("I don't know," blankness, alexithymia). Offer possibilities rather than demanding an answer, for example suggesting that in that situation someone might feel angry, sad or afraid. Ask where in the body something is happening. Model a fuller statement for them to try on and see if it fits. [source: EAET Principles and Procedures 2022] If there is still nothing, track anxiety (4.10). The blank may be cognitive-perceptual anxiety, which calls for regulation, not more pressure. [source: Abbass 2021]
Balking or refusing the empty chair ("this feels silly," "I can't"). Ask what they fear will happen. Then say you believe it won't, that they can handle it and will come out stronger, and keep encouraging gently. [source: EAET Principles and Procedures 2022] Name the two core fears ("it will turn out badly" / "I can't handle it") and offer the exercise as a test of them. [source: EAET manual] Offer a smaller step: speaking to you about the person, eyes closed, or one sentence only [synthesis]. Respect a firm no; the patient sets the pace (two-hand stance).
Overwhelm, dissociation, panic or a sharp somatic surge. Stop pressing toward feeling. Switch to the graded format: have the patient name the bodily anxiety, connect it to the preceding feeling, and re-orient until anxiety returns to striated muscle (tension) and thinking is clear. [source: Abbass 2021; Abbass et al. 2009] The EAET manual gives no stabilization protocol. Add grounding as needed (feet on floor, eyes open, name the room, slow exhale) [synthesis]. Don't end the session in a dysregulated state. Use the integration time to settle and summarize, and plan follow-up contact.
Rejecting the brain or emotion explanation ("you think it's in my head"). Re-validate that the pain is real and physiologically produced. Accept the skepticism without defensiveness and invite them to treat the session as an experiment. [source: EAET manual; Principles and Procedures 2022] Use their own timeline links and in-session pain changes rather than argument (4.6, 4.17) [synthesis].
Guilt or fear about anger ("good people don't get angry," "I'll become like him"). Remind them the acts are only imagined; the anger is aimed at a past person and time, not necessarily the person in their life now; and challenge the belief that anger is bad or makes them like the abuser. [source: Schubiner, Principles and Procedures 2022]
Ruptures or anger at the therapist ("you're pushing me"). Accept it without defensiveness and invite them to say it directly; that is itself practice in assertion. [source: EAET manual; Principles and Procedures 2022] Reassess timing: did you challenge a defense before clarifying it? Repair by naming your part. [source: Abbass 2021]
Passive compliance (goes through the motions, flat "okay"). Name it, and ask whether the patient actually wants to do this and what they want for themselves. Without a conscious, voluntary agreement on the task, stop and say so. [source: Abbass 2021]
Endless medical detail or storytelling, so time runs out. Treat it as avoidance (4.4, 4.9). Name it and redirect: "what did you feel?" [source: EAET] Keep to the Carty timings and protect the last 10–15 min for integration even if the experiential work is incomplete. Name what remains as the next step [synthesis].
Sadness without anger, or anger without tenderness. Stuck in one emotional family means the other is the avoided one. Gently test it: "is there any protest in there?" / "is there any love under the anger?" [source: EAET agency and communion model; Schubiner phase 5]
Pain flare or emotional crash after the session. EAET's flare guidance is to ask which emotions are being blocked, try to feel and express them, and speak assertively to the symptom rather than focusing on it. [source: EAET manual sessions 3–4] Add [synthesis]: any new, different or red-flag symptom goes back to the physician, not to emotional work. Offer follow-up contact (4.21).
Patient plans to confront the person in real life. Real-world expression is the riskiest setting. Steer toward assertion balanced with caring, boundaries or distance, rather than the full anger allowed in session or in private. [source: EAET Principles and Procedures 2022] If there is any risk of violence, advise against confrontation and favour private expression and safety planning [synthesis].
Disclosure of current abuse, danger at home, or abuse of a child or dependent. Shift to safety assessment, safety planning and mandatory reporting as your jurisdiction requires. Defer expressive work about that person [synthesis].
Suicidal ideation emerges. Pause the experiential work and run your standard suicide risk assessment and safety planning. An intensive single interview is not a substitute for crisis care [synthesis].
Non-adherence to home practice. The trials assigned none beyond the handout, so there is no evidence-based response. Frame it as optional and small: one unsent letter, one avoided feeling noticed. Ask about it at the follow-up call and treat not doing it as information about avoidance, not failure [synthesis].
Medical condition that may worsen with emotional activation (active inflammatory bowel disease, some autoimmune conditions). Abbass flags these. Use the graded format, coordinate with the treating physician and lower the intensity. [source: Abbass 2021]
Structural or peripheral disease is clearly driving the pain. The interview was tested in primary or unexplained pain. Consider not doing it, or reframe it as coping with stress rather than a pain-reduction intervention [synthesis].
Videoconference-specific problems (privacy, a family member nearby, a dropped connection mid-expression). Before starting, confirm privacy and location and agree a reconnect plan. If someone else is home, choose a less charged target or postpone the anger work [synthesis; Krohner delivered by video, but the procedures are not drawn on].
Therapist anxiety, avoidance or countertransference (backing off when anger rises, over-pushing). Abbass names therapist anxiety and defenses as a main risk and recommends recorded self-review and supervision; the trials recorded and supervised every interview. [source: Abbass 2021; Carty 2019]

Sources

Sources:

Further reading (not drawn on in full) [uncertain]: Ziadni MS, Carty JN, Doherty HK, Porcerelli JH, Rapport LJ, Schubiner H, Lumley MA (2018), A life-stress, emotional awareness, and expression interview for primary care patients with medically unexplained symptoms: a randomized controlled trial, Health Psychology 37(3):282–290. Krohner S, Town J, Cannoy CN, Schubiner H, Rapport LJ, Grekin E, Lumley MA (2024), Journal of Pain 25(1):39–52. Lumley MA, Schubiner H (2019), Emotional awareness and expression therapy for chronic pain: rationale, principles and techniques, evidence, and critical review, Current Rheumatology Reports. Abbass A, Campbell S, Magee K, Tarzwell R (2009), CJEM 11(6). Schubiner H, Unlearn Your Pain (book; referenced in the Principles and Procedures document as patient reading).

← Previous · I-080Emotional awareness and expression therapy for chronic pain Next · I-082 →Intensive psychoanalytic psychotherapy of schizophrenia