In the abuse survivor peer group I belong to, we often discuss emotional suffering – “how much you hurt as a human being” (Shniedman 1996).
We experience it as deep and contemporaneous, even when the trauma is not recent.
At times we characterise it as despairing, dissociative, represented by Van Gogh’s image, Sorrowing old man ‘At eternity’s gate’.
Or we might describe it as agonising, unbearable, reflected in Brazilian artist Guido Rocha’s sculpture, The Tortured Christ.
We see it accompanying the wounds of trauma, from life events (such as abuse, bereavement) or social exclusion (such as racism, poverty). Perhaps the symptoms used in mental health diagnoses (e.g. Borderline Personality Disorder (BPD)) – such as hearing voices, suicidal ideation – are actually reactions to extreme pain.
What is emotional pain?
In my continuing journey of reporting non-recent rape and sexual abuse, I have been surprised by the depth and intensity of emotional pain I am experiencing. It all happened so long ago, it is my third time of initiating reporting procedures and I have spent many years uncovering my story, working through my trauma and using my experience to help others, surely I was over the pain by now?
Wham! Like a malicious elf, the pain sneaked up behind me and invaded my daily life as though the trauma wound was as fresh as a new candle. It wasn’t quite the same as before but it was equally deep, complex and at times almost unbearable. Perhaps I should have expected this but I was unprepared and it left me wondering, what exactly is emotional pain? And how to deal with it, to ‘recover’? As well as reflecting on my experience, I looked at research for some answers and was surprised by what I found.
(It also provided useful material for an assignment for the MSC in Mental Health Recovery and Social Inclusion I am studying. So this post includes more research references than usual, for those who are interested in such articles.)
Fuzzy wool
We each have an individual experience of pain and recovery, and make our own meaning from our personal perspective, as well as our cultural context. We often use body language to describe our emotions – we are heart-broken, it was gut-wrenching – because we feel emotional pain in our whole self, it’s an embodied experience, not just an intellectual concept. We interpret pain according to cultural norms about endurance, suffering, and our understanding of what is okay or not okay in navigating our world. Is it cool to be brave or weak to be vulnerable? Should we suffer in silence or let it all hang out? Is it natural to feel so hurt if we are bullied, or should we just toughen up and take it?
Surprisingly, I found very few research articles exploring the meaning, causes and treatment of emotional pain in relation to trauma. There were lots about trauma and physical pain from somatic conditions such as fibromyalgia, or about abuse but not emotional pain. Those that looked at pain were mainly in relation to suicide, which left me wondering do researchers only notice pain when it is unbearable? It seems that emotional pain is one of those fuzzy concepts that are hard to pin down, and very much subjective. There were even new words for pain that is not just physical – like ‘psychache’ (Tossani 2013)- and many descriptions that used comparison and metaphors to try to capture its essence – it’s a “personal shattering” (Holm & Severinsson 2008), like ‘balancing on a slack wire over a volcano’ (Holm et al 2009).
Most researchers similarly described emotional pain as “subjectively unbearable, unending, and inescapable psychological pain that develops as a result of unmet psychological needs” (Dangel et al 2018). It causes severe mental suffering (Dermikol et al. 2019), with heightened emotional experiences (Holm et al 2009). So it’s a complex weave of emotion, sensation, need and endurance, experienced not just as a single event but over time. How to unravel this tangled ball of fuzzy wool?
Pain Narratives
The experience of emotional pain is individual so the best way to understand it is through the personal narrative (Loeser (2000) quoted in Tossani, 2013). I reflected that I find emotional pain a somatic experience, which I would describe as an at times unbearable psychological ache felt in my body. The two artworks I use to illustrate the trauma-wound echo the strong metaphors the papers describe.
Leknes & Tracey (2008) suggest “even suffering can be rewarding if it has meaning to the sufferer” and I felt this meaning-making was missing from the definitions, so I created the “Cloak of Shame” to depict something of the significance my psychache has for me.
The cloak illustrates the connection between the experience, causes and effects of emotional pain, that it is both nuanced and interconnected. Many survivors internalise shame; I used a cloak to indicate that we ‘inhabit’ it, but it is also something that is put on us by our abusers, the result of the dynamic of abuse. This reflects the trauma-informed view (‘what happened to you?’ rather than ‘what is wrong with you?’) that is significant in Holm & Sverinnson’s research. I wrote more about shame and its roots in abuse, and how we can help ourselves and others to unshame, in my #churchtoo blog #3.
Talking with other survivors, many of us have found that child sexual abuse carries stigma and victim-blaming, which we often internalise as the pain of shame (‘dirty’ on the Cloak of Shame). It wasn’t our fault but the abuser says it was, and we are trapped in that false belief, and think that we are bad, contaminated, vile and even evil.
According to Dermikol et al (2019), Shneidman suggested the unmet psyhological needs behind psychache include the need to be loved, to have autonomy, a coherent sense of self, to feel safe. This chimes with the themes of loneliness, rejection, and fear reported in the study with abused women (‘abandoned’ and ‘hiding’ on the Cloak). At the extreme, Shneidman said, “Suicide occurs when the psychache is deemed by that person to be unbearable.” I first reached that point as a teenager, and like many survivors, have been there a number of times. Thankfully, there has always been someone to bring me back.
Pain as our warning system
Okay, so emotional pain can be more unbearable than the worst physical pain, and is closely associated with our needs, experiences and the impact of life. But what actually is psychache as we experience it in our body? I looked to recent neuroscience for answers. The neurobiology reveals that psychological and physical pain (Eisenburger et al. 2003), and pain and pleasure (Leknes & Tracey 2008) are experienced by the body and brain in similar ways. For example, they found that the same nociceptors (nerve-endings) are triggered by both psychological and physical pain. This means that our bodies are recognising a potential threat, and may go on to trigger our instinctive flight/fight/freeze response.
I found this very validating. Often we can be made to feel that finding emotional pain unbearable, or seeking help to deal with it, or reacting strongly to the psychache, is because somehow we are weak or needy or wimpish or unstable. But actually our bodies are just doing what they are programmed to do, and we are no more weak than someone who takes a painkiller because they have broken their leg, or seeks help with chronic backache. The difference with trauma can be that perhaps the immediate threat has passed (I do not live with my abuser anymore), so the pain reflects the ‘threat’ from the unhealed impact of the abuse (my mother abandoned me, I am unloveable).
How to heal emotional pain?
On the worst days you don’t believe it, but both the research and my experience show that we can heal from even unbearable emotional pain. In our Survivors Charter (Perôt et al. 2018) we suggested that work with survivors should be the opposite of abuse. Similarly Holm et al (2009) suggest that solutions should be reflections of the unmet psychological need. So the pain of silencing is met by encouraging people to describe their emotions and develop a personal narrative of their life. The pain of not being cared for is met by being involved in their own care. The pain of being victimised is answered with courageous listening, by both peers and professional helpers.
Abuse survivors often feel pressured to forgive an abuser, even if they show no remorse. But Dangel et al. found that forgiving yourself, and the uncontrollable circumstances you find yourself in, were the most important factors, reducing psychache and the risk of suicide. The poet Amy Carmichael (1867-1951) wrote “In acceptance lieth peace” and this seems to be the key to this mediating form of forgiveness, echoing Shneidman’s view that if all the psychological needs can’t be met, tolerance and acceptance of pain are the key to recovery.
Serenity?
Acceptance of course does not mean that the abuse that happened to us was okay. Many of us will be familiar with the Serenity Prayer:
“God grant me the serenity to accept the things I cannot change,
courage to change the things I can,
and wisdom to know the difference.” (Reinhold Niebuhr).
It is this kind of acceptance, of ourselves (with all our imperfections) and of those things we cannot change, that brings healing. A strong sense of the injustice of the wrongs done to us is just as important. Righteous anger is also a mediator for transforming pain into the courage and energy for transformative change, and the ‘survivor mission’ that Judith Herman talks about.
I don’t think acceptance is the key, though, when we are dealing with pain from the trauma of violence or relational abuse. A broken relationship needs relational healing. Polyvagal theory explains that the impact of trauma is we ‘never stopped needing, and longing for, connection. When opportunities for connection are missing, we carry the distress in our nervous system’ (Dana 2018). Healing comes when we find ‘co-regulation’ through connection with others (Kok & Fredrickson 2010). Co-regulation is how we learn to manage our feelings, through experiencing warm and comforting responses from others. Have you noticed what you do when you pick up a crying baby? Instinctively you meet the distress with acknowledgement ‘oh dear!’, a friendly face, soothing noises and reassurance ‘it’s okay’. That’s how normally we learn to soothe ourselves, even when we are distressed. If poor parenting or abuse means we haven’t fully developed that ability, we need connection (and affection) with someone who can co-regulate with us.
I shared some of my learning from this research with Big Heart (my therapist), as we worked on how to deal with my pain. The images enabled me to describe it and create alternative narratives that put the cloak of shame back where it belongs, on my abusers. Ultimately though I think it is the warmth and connection of our relationship that helps me to travel through the pain, and learn how to sooth myself when I want to hid inside that cloak again. One day soon, I hope to have thrown off that cloak for good, and to be writing here about the shawl of joy and whole-heartedness.
References
Dana, D. (2018) The Polyvagal theory in therapy: engaging the rhythm of regulation. New York: W.W. Norton & Company.
Dangel, T. J., Webb, J. R., & Hirsch, J. K. (2018). Forgiveness and suicidal behavior: Cynicism and psychache as serial mediators. United States: Routledge. Doi:10.1080/00223980.2017.1408555
Demirkol, M. E., Namlı, Z., & Tamam, L. (2019) Psychological pain Psikiyatride Güncel Yaklaşımlar-Current Approaches in Psychiatry; 11(2):205-213 doi:10.18863/pgy.444006
Eisenberger, N., Lieberman, M., & Williams, K. (2003). Does Rejection Hurt? An fMRI Study of Social Exclusion. Science (New York, N.Y.). 302. 290-2. doi:10.1126/science.1089134.
Herman, J.L. (1992). Trauma and recovery. New York: Basic Books
Holm, A. L., & Severinsson, E. (2008). The emotional pain and distress of borderline personality disorder: A review of the literature. International Journal of Mental Health Nursing 7, 27–35 doi:10.1111/j.1447-0349.2007.00508.x
Holm, A. L., Bégat, I. & Severinsson, E. (2009) Emotional pain: surviving mental health problems related to childhood experiences. Journal of Psychiatric and Mental Health Nursing, 9, 16, 636–645 doi: 10.1111/j.1365-2850.2009.01426.x
Kok, B.E., & Fredrickson, B.L. (2010). Upward spirals of the heart: autonomic flexibility, as indexed by vagal tone, reciprocally and prospectively predicts positive emotions and social connectedness. Biological. Psychology. 85(3) 432-436. doi:10.10016/j.biopsycho.2010.09.005
Leknes, S., & Tracey, I. (2008). A common neurobiology for pain and pleasure. Nature Reviews Neuroscience 9(4):314-20. doi: 10.1038/nrn2333
Loeser, J.D. (2000). Pain and suffering. Clinical Journal Pain, 16(Suppl 2):S2-S6. Quoted in Tossani, E. (2013) The concept of emotional pain, Psychotherapy and Psychosomatics, 82:67–73. doi:10.1159/000343003.
Perôt, C., Chevous, J. & Survivors’ Voices Research Group (2018). Turning pain into power: a charter for organisations engaging abuse survivors in projects, research & service development, Survivors Voices/Reshapers CIC.
Shneidman ES. (1996)The Suicidal Mind. Oxford University Press; Appendix A Psychological Pain Survey. p. 173.
Tossani, E. (2013). The Concept of Mental Pain. Psychother Psychosom 82:67-73. doi: 10.1159/000343003