Guided versus unguided internet-administered emotional awareness and expression therapy (I-EAET) for patients with persistent physical symptoms: A randomized trial

Persistent physical symptoms (PPS) are common, disabling, and associated with high health care use, yet effective and scalable psychological treatments remain limited. Internet-administrated self-help programs may improve access to care. Asynchronous Internet-administered Emotional Awareness and Expression Therapy (I-EAET) with therapist guidance has been shown to reduce somatic symptoms in PPS, but the added value of the of therapist is unclear. Therefore, adults with PPS (N = 154) were randomized to guided (n = 76) or unguided (n = 78) I-EAET. Both formats comprised 10 self-help modules over 10 weeks, focusing on increasing emotional awareness, addressing unresolved conflicts, and fostering adaptive expression of avoided feelings. Guided participants received weekly written therapist feedback, whereas unguided participants had only technical support. Somatic symptom severity (PHQ-15) was assessed weekly and analyzed using linear mixed-effects models. Results showed that both groups improved significantly over time, but the group × time interaction was not significant, indicating no clear advantage of therapist guidance. However, at post-treatment, guided I-EAET was associated with a small effect size benefit in PHQ-15 scores (d = −0.21) and a higher proportion of responders (47.2% vs. 29.6%) than unguided I-EAET. Secondary outcomes (PHQ-9, GAD-7, PCL-5, DERS-16) also showed small, mostly non-significant differences favoring guidance. These small group differences were attenuated at 10-week follow-up. Taken together these findings indicate that guided and unguided I-EAET yield largely comparable outcomes for persistent physical symptoms. As the study was not powered to detect small between-group effects, these findings should be interpreted cautiously and require confirmation in adequately powered trials. • The added value of therapist guidance in asynchronous internet-administered psychodynamic interventions remains unclear. • RCT comparing guided vs unguided internet-administered I-EAET for PPS. • No significant between-group differences on continuous somatic symptom scores although effect sizes favored guided (d = −0.21). • A significantly higher proportion of participants achieved a clinically meaningful response in guided treatment (47% vs 30%). • Findings inform the role of therapist guidance in internet-administered psychodynamic interventions.