Pain dynamics: an integrative roadmap for navigating through the experiential process

ABSTRACT

The authors present a theoretical integrative model of pain-dynamics for the categorization and transformation of emotional pain in person-centered and experiential psychotherapies. Integrating data from research literature and clinical work, the model distinguishes between three types of emotional pain: basic emotional pain, relational pain, and self-pain. The authors show how each type of emotional pain has not only distinct developmental etiology and evolutionary function, but also how each type requires a fundamentally different transformational process to be healed. Though clients experience all three types of pain in their life, usually one particular pain is dominant in the session. The model provides markers for identifying the active pain in the session, directing the therapist to one of three transformational paths. It thus provides a focus for the work, but also leaves plenty of room for intuitive moment-to-moment tracking of emerging experience. Although this new conceptual model emerged from the integration of the authors’ AEDP practice with EFT principles, pain dynamics can help to systematically select interventions and techniques from a variety of experiential models. Conceptualizing the active pain in the session combines the advantages of case conceptualization and moment to moment work of process formulation.

KEYWORDS:

• emotional pain
• self-pain
• experiential psychotherapy
• trauma
• shame

View correction statement:

Correction

Disclosure statement

No potential conflict of interest was reported by the author(s).

Notes

1. In this article we will use the terminology of psychodynamic defenses (Freud, 1936/66) to refer to the regulatory processes and coping mechanisms as we find they provide the most elaborate and precise descriptive framework.

2. This category we previously called “core emotional pain”, but we chose to refer to it in this article as “basic emotional pain” to avoid confusion with existing uses of “core pain” in the PCE literature (e.g. Timulak, 2015; Greenberg & Goldman, 2019).

3. The fact that grieving loss and separation of an attachment figure is a process of basic emotional pain rather than a relational pain may be confusing at first, especially as separation and loss are the titles of the seminal books on attachment by Bowlby (1980). The loss (e.g. death) of the attachment figure is not a failure or conflict that results from within the attachment relationship (only feeling anger at the parent for dying might come up as relational pain in the context of such an event). (Emotional) abandonment or rejection happen within the attachment relationship and therefore lead to relational pain.

4. Compare annihilation anxiety (Freud, 1926).

5. Napier (2019) refers to this as unmetabolized emotion that got stuck in the body.

6. Janina Fisher (1999) refers to this as feeling flashbacks or intrusive affects that represent feeling memories.

7. SE: Somatic Experiencing (Levine &Frederick, 1997), IFS: Internal Family Systems (Anderson et al., 2017), EFT: Emotion focused Therapy (Greenberg et al., 1993), AEDP: Accelerated Experiential Dynamic Psychotherapy (Fosha, 2000), EMDR: Eye Movement Desensitization of Reprocessing (Shapiro, 2001).

8. Portrayal is a typical AEDP therapeutic task in which the client interacts with significant others or parts of oneself, imagining reparative, avoided or wished for experiences. (Fosha, 2000). It is in many ways equivalent to the different chair-work enactments of EFT. The authors who have training in both AEDP and EFT use these techniques interchangeably.

9. Sometimes this learning is not from first-hand experience with the parent, but from observing the outcomes of interactions between siblings and parents, or from the interaction of parents with each other.

10. Mikulincer et al. (2003) refers to these strategies as hyperactivation versus deactivation, which form the basis of ambivalent and avoidant attachment styles.

11. Davanloo (1990) noted that not only the expression of certain needs can be dangerous and will be repressed, but that also the disappointment and anger over the pain of the unmet needs, rejection, abandonment or abuse by the parent is repressed.

12. Davanloo (1990) considers the repression of prolonged anxiety over feelings and impulses that may threaten the attachment relationship as the main cause of psychosomatic symptoms like migraines, bowel problems, etc.

13. Such therapeutic presence reflects the three core conditions for therapeutic change (empathy, unconditional positive regard and congruence) as proposed by Rogers (1957). As such they are facilitating in working with all three kinds of pain, but are at the heart of the change process in relational pain.

14. ISTDP: Intensive Short-Term Dynamic Psychotherapy (Davanloo, 1990). ST: Schema Therapy (Young et al., 2003).

15. We prefer self-pain over the term social-pain (MacDonald & Jensen-Campbell, 2011) as the notion of self has more clinical relevance and self-pain can be caused in other contexts than the social one (See next paragraphs).

16. Paivio and Pascual-Leone, (2010) have an excellent chapter on shame and self-blame resulting from such trauma and abuse.

17. This concept of our true nature, identity, or the one we were born or meant to be can be found in many therapeutic approaches such as the self which one truly is in PCEP (Rogers, 1961), Self (Energy) in IFS (Anderson et al., 2017), or birthright self in IRT (Benjamin, 2018).

18. We want to acknowledge that many of these ideas about the conceptualization and treatment of shame, were developed in collaboration with Einat Shaked Gross.

19. These categories detaching, countering, and displacing defenses, are inspired but not completely equivalent to ISTDP’s categories of isolation of affect, repression and projection (Davanloo, 1990). For instance, we distinguish mild self-criticism as a defense to counter unacceptable feelings from a more severe self-attack resulting from a self-concept of defectiveness.

20. Undoing aloneness (Fosha, 2000) is crucial for transformation in all three types of emotional pain, though the aloneness has a different quality in each type: aloneness from feeling vulnerable and being unprotected in basic emotional pain (e.g. alone in the forest (example from Les Greenberg, 2019)); aloneness from feeling disconnected and being uncared for in relational pain (e.g. alone in bed with dirty diaper (example from Les Greenberg, 2019)); aloneness from feeling defective and being excluded in self-pain (e.g. alone in the playground/party).

21. This reminds of Wittgenstein’s (1953) argument that concepts may be easy to understand or use, but elusive to define in terms of their formal attributes.

22. In the autobiography “the choice” (Eger, 2018) there is a beautiful account of how a first therapy that focused on relational issues, was ineffective to help her with her (basic emotional) pain from overwhelming concentration camp experiences and (self) pain around worthlessness and feeling undeserving.

23. Sharbanee et al. (2019, pp. 247) while discussing task analysis in EFT have made a similar point: “In addition, there is an intriguing idea in the insecurity model of a possible sequence in which people need implicitly or explicitly to solve negative self-treatment before they can feel entitled to having had their unmet need met in primary relationships.

24. This is a process that can be promoted by, for example, by metaprocessing (Fosha, 2000, Iwakabe & Conceição, 2016).