You are in physical pain. You go to your doctor, and after identifying where you feel pain and how long it has been going on, a medical profession proceeds to ask you a number of questions. You may be given a pain scale chart, a numeric scale (NRS – Numeric Rating Scale) sometimes replaced or accompanied by emojis (FPS-R – Facial Pain Scale-Revised) intended to prod you to provide your own assessment of the intensity of your pain experience that is reflective of agreed upon measures clinicians know how to interpret. Scales, such as the Stanford Pain Scale, may be offered with suggestive categorical descriptors (VRS – Verbal Rating Scale), such as burning, tingling, aching, and stabbing, furnish you with language, so that you can also qualify your pain. Clinicians recognize that “because pain is subjective, patients’ self-reports provide the most valid measure of the experience” (Katz and Mezack, 231). Often, following a physical exam, lab tests and imagining are done to arrive at a diagnosis. Based on the diagnosis and level of pain, the clinician makes an assessment, and, as part of the treatment, prescribes medication to diminish the pain. Just as there is a ladder of pain intensity, so there is a ladder of interventions -- treatments for pain dependent on its severity. A doctor will usually prescribe the mildest mode likely to produce relief, starting with topical treatments and over-the-counter analgesics for mild, acute complaints up to benzodiazepines and opioids for severe, debilitating conditions. But what if the pain is psychological?
How is psychological pain assessed? Self-described physical complaints are replaced by reports of observed uncharacteristic or aberrant behaviors, sometimes self-reported, sometimes by concerned family, friends, and professionals. An individual may be asked about how well they are functioning—if they are having difficulty doing normal activities. Function may also be assessed when diagnosing physical complaints, though the inquiry is often confined to an afflicted body part, and, when appropriate, a referral is made for occupational therapy to improve functionality. In psychological diagnoses, the focus is more often on the activities one can no longer perform or on others’ perceptions of an individual’s inability to conduct routine daily activities. While impaired function in also considered in the case of physical illness, in addition, intensity and description of pain are also considered, which also have the effect of validating the suffering experienced. Lab tests and imaging to validate a psychiatric diagnosis do not exist, and in fact, a psychiatric diagnosis is often the default offered when no underlying physical cause can be identified. This can contribute to an individual feeling dismissed for not having a legitimate medical condition and to self-stigmatization which can result in not seeking further help.
Often in a crisis or an initial consultation, the only assessment of the quality of psychological pain a person is experiencing is whether they are at imminent risk (IR), in danger of ending their life or hurting someone else. Short of being at imminent risk, which is considered severe and requiring immediate intervention, there is little consensus about evaluating the intensity of pain, and an individual may wait weeks or months to receive assessment or treatment. An individual is too often left to feel that their pain is insignificant, not severe enough to warrant attention, or to question whether it is real or just personal weakness. While mental health is talked about more openly than ever before, and we try to destigmatize mental illness, care is often difficult to acquire, and discouraging and discriminatory messages are still commonly conveyed.
Counselors and therapists often find individuals describe themselves as being in pain but ill-equipped to further elucidate. Our responses are often, “I hear you are pain; I can tell you are suffering. Tell me about it.” That often produces a narrative or list of experienced states: "I feel empty, exhausted depressed’; “I feel anxious or overwhelmed”; “my thoughts race or circle.” Counselors uses their best judgment to intuit the quality and intensity of the pain. Arguable many individuals speak using stereotypical, learned descriptors and will even characterize themselves as feeling “crazy” or “nuts,” as the language available to them to describe what they are experiencing is often limited. We assess symptoms: “how are you sleeping”; “Have you been eating”? But again, there is little language to qualify or quantify the pain that the individual is experiencing. Sometimes a highly articulate or imaginative individual can open a window into their pain through metaphoric insights:
that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there is no escape from this smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion. (William Styron, 12)
Such talented wordsmiths can give us a greater insight into mental illness, but when asked to describe what they are experienced and feeling, many people are at a loss and will sit silently or report they lack the words, while others resort to the clichés like “the walls are closing in” or a phrase they have heard from a movie or song. For far too many individuals, the capacity to describe their experience is limited, and, moreover, providers often listen for key conventional descriptors to make a diagnosis and do not probe further but quickly, and sometimes prematurely, settle on a diagnosis as well as a form of pharmaceutical intervention. A lack the language and measures for assessing the intensity and quality of psychological pain may do a disservice to both the individual seeking treatment and the provider.
Consider how this may affect diagnosis and treatment. Is the paucity of information on the intensity, level, and nature of what is currently best described as amorphous pain inhibiting our capacity to treat individuals and to form therapeutic alliances? Treatment options often depend on understanding what patients are experiencing through the narratives and descriptors they provide. A better understanding of pain levels and intensity may be particularly helpful in understanding self-medicating, self-harming, and other addictive behaviors and be useful in gauging progress, tracking successful interventions, and the personal management of chronic conditions. Spoon theory which can be used to describe the amount of energy depletion during the day due to psychological distress and guided imagery, especially interactive (IGI), may suggest potential avenues for exploring the developing descriptive language and assessment tools.
Our ability to speak about mental illness in a way that invites empathy often feels limited. Working to improve the discourse on the nature of psychological pain may not only facilitate assessment and treatment but may also accelerate the social acceptance and the understanding of mental illness. Helping individuals to articulate what they are experiencing may further the sense that what they are experiencing is tangible and legitimate and change their self-perception as well as help to diminish social stigma that if often an obstacle to seeking treatment.
Cite This Article
Donnelly, C. (2020, April). Amorphous pain. [Web article]. Retrieved from https://societyforpsychotherapy.org/amorphous-pain/
Katz, M., & Metzack R. (2019). Measurement of pain. Surg Clin North Am. 79(2), 231-52.
Peterson, Ashley. (2019, Jan 28). Applying spoon theory to mental health. http://www.mentalhealthathome.org/2019/01/28/spoon-theory-mental-illness
Selva, Joaquin. (2020, Nov. 2). Interactive guided imagery therapy: therapeutic value of imagination. http://www.positivepsychology.com/interactive-guided-imagery-threrapy
Styron, William. (1989). Darkness visible: a memoir of madness. New York, NY: Random House.