“It Hurts So Much”

What is Emotional Pain?

ireland stepsI spent 7 years researching the communication of emotional pain from suicidal patients to mental health professionals. I became interested in emotional pain many years ago when analysing an incident of self-harm behaviour with a client. He described his feelings during an argument as ‘painful’, and at first I accepted this as a colloquial term, as in, ‘relationships can be painful’. But I was intrigued; This pain in my client’s body was a key factor in his urge to harm himself. So was he actually experiencing pain? Or was he speaking metaphorically? Was he describing a component of a bigger experience such as grief? Was he somehow scrunching his internal organs to produce actual tissue damage? What exactly was going on?

I searched the literature and found a range of related phenomena but with slightly different names; social pain, psychological pain, emotional pain, mental pain, psyche-ache and psychic pain.  Furthermore it seems that high levels of this experience are thought to play a role in completed suicide. Back in the 1970s eminent suicidologist Edwin Shneidman analysed suicide notes for recurring themes and identified that the most common one was a desire to escape from emotional pain.

More recently neuroscientist Naomi Eisenberger and her colleagues at UCLA studied the brain scans of subjects during a computer-game which was deliberately manipulated to have some players experience being left out by the others. The brain areas that became active in the rejected players were those also activated during physical pain. One such area is the anterior cingulate cortex. Decades ago brain surgeons did experimental surgery on this brain-site while attempting to treat intractable physical pain, because ablation of the anterior cingulate cortex removed the unpleasantness of the pain experience. Sadly these poor patients ended up with such horrendous physical injuries from NOT feeling pain (such as when touching a hot surface) that this surgery was discontinued.

This sharing of the same neural networks in physical and social pain has been called ‘Pain overlap theory’. So if the same neural architecture is involved in physical and emotional pain, how do they differ? Research suggest that physical pain has an additional component; information from the somatosensory cortices, i.e. a location marker from your skin or vital organs, pointing to a specific place in your body where injury or illness has occurred. But why would the same neural alarm sound in a social situation where no wounding to the body has been sustained? Eisenberger suggests that pain acts not so much as a damage indicator, but as a discrepancy monitor, signalling where something is deviant from its desired (or usual) state. Pain focusses your attention on what is wrong, enabling you to attempt to heal your body, repair your relationships or mitigate your losses.

This theory makes sense on so many levels. Firstly it accounts for the shared language across physical and emotional pain, for example we talk about bereavement or unrequited love as aching or agony. Secondly it provides a good rationale for self-harming behaviour. If you have intense but free-floating pain you are relieved once you can identify one area of the body for that pain, not only does it give ‘reality’ to the experience, but also allows you to predict its ending. As your flesh heals you might reasonably assume that so will this inner torture. It also explains how any emotion can hurt if it is discrepant from what is desired or anticipated – we can even experience painful joy if its intensity takes us by surprise.

Some patients say it hurts when they self-harm, others that they don’t feel it. Could this depend on the difference in intensity between the physical injury and emotional pain in that moment? Like hearing a shout in a noisy factory – if the background noise is louder, it won’t be heard. If the emotional pain is more intense, pain from the injury site will go unnoticed. In these circumstances it is only seeing the injury that will have that reassuring ‘realising’ effect, and we know that some clients report it is the visual appearance of their wound that brings relief.

Because emotional and physical pain are so closely related analgesics work for both – alcohol, drugs and over the counter painkillers will numb emotional pain as they do physical pain. When people become suicidal they are often trying to destroy the seat of their pain where it resides – in the body. Intuitively we all know this already. The wonderful Paul Gilbert notes that when gangsters go to war they threaten to harm the children of their enemies rather than the enemies themselves. This is because the thought of emotional pain is the worst.

However, culturally we do not yet treat emotional pain as equivalent to physical pain. A colleague who read my research remembered a relative who had killed himself without warning. “Although there were no suicide threats before his death, there was a lot of emotional pain communication”.  Physical injury motivates us to move with urgency towards the injured party, to see what we can do to help. We  In contrast subjects in my research reported that even being able to articulate their emotional pain somehow communicated the message, “if you can talk, it can’t be that bad.”

I believe the current campaign for parity between mental health and physical health is an opportunity to call attention to these similarities. Let’s begin to ask our clients and patients routinely about their emotional pain. Just as when assessing physical damage a doctor usually asks, “How much pain is this causing you?” We can ask clients to monitor their emotional pain levels. We can assure them that this pain isn’t random, it’s not a sign of weakness, there is a proper physiological reason for it, and that we can help them problem-solve the issue that set it off. Emotional pain is the smoke to the fire of suicide and self-harm. We need to respond as if it is an actual fire, and as soon as we smell burning. Let’s not leave it until the flames have taken hold.