Processing Emotion and Living With Chronic Pain: What Counselors Should Know
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In the chronic pain community, there’s a lot of talk about spoons and forks.
Spoons account for how much energy you have in a given day. If abled people have ten spoons of energy to accomplish ten tasks, a person with chronic pain, fatigue, or psychological duress may only have five spoons! Three of which will probably be used for daily activities like cooking and hygiene. This analogy was first presented in 2003 by Christine Miserandino to articulate her life with lupus in her blog “But You Don’t Look Sick.”
Forks are the number of agonies and obstacles that stack up in your body, from small annoyances like a headache or needing to pee to larger pains that impede your ability. This analogy for overwhelm came from Jenrose’s husband as they were discussing life with chronic mental and physical issues. It quickly went viral on Tumblr in 2018, as both the neurodiverse community, the differently abled community, and their overlap were able to communicate how a hundred small forks can make a “forkcupine,” or how one massive trident can pin you to the ground.
If this is a new concept for you, imagine literal forks stabbed into your shoulder, your hip, or your mind. The appropriate number of forks stabbed into any given person is zero, yet many people live in a state of constant injury or overstimulation.
So when we’re talking about spoons and forks, we’re talking about the finite energy a person has, and the literal pain and stress they contend with every waking moment. With so few spoons, it can be incredibly difficult to look for a therapist, let alone find one and schedule an appointment!
And when a person finally gets to session, it takes even more spoons to bring their therapist up to date on life, the universe, and everything. While telehealth cuts through some scheduling obstacles, the emotional strain remains. Since there is so much to cover regarding clients with chronic pain, today we’re going to zoom in on a very specific issue in therapy: processing emotion.
Therapy, and the introspection it requires, is no easy task. Yet for someone living in a state of constant or recurring physical pain, the prospect of mindfulness is both emotionally and physically daunting. Since counting the forks in one’s body demands a spoon of energy, it’s no wonder that the emotional process may be met with resistance. So how can counselors help?
Beyond identifying the type of disability a client lives with, mental health counselors must attune themselves to the unique needs of each client, as there are a myriad of psychosocial issues impeding emotional process work. Externally, these include how society perceives the client and the social defense mechanisms they use to shield themselves. Internally, these include how clients experience discomfort in their body, identify with their experience, and accept emotion itself.
External Obstacles To Processing Emotion
Clients with chronic pain may enter therapy with a certain level of cynicism, and for a valid reason. For a long time, psychology measured mental health by focusing on functionality, using the Western, individualistic definition of what it means to function. Does your distress impede your work life, or your family life, or your relationships?
Both disability rights advocates and community psychologists have challenged this “stand on your own two feet” concept of health, as many of the issues facing differently abled people are community-oriented. Lack of physical accessibility, social inclusion, and basic healthcare derail so much that it’s absurd to believe resilience, determination, or reframed cognitions will pick up a client by their bootstraps. Yet those with chronic pain have come to expect this framework from those trying to improve their mood.
The conundrum here is that mental health counselors are primarily trained to help clients explore their emotions and test their cognitions, and while that can certainly help, chronic pain remains regardless of one’s outlook. While the existential aspect is very internal, a counselor’s therapeutic approach is external.
Consider how the solution-focused counselor will gather resources like charity organizations, nonprofits, and government assistance programs. Yet this only reinforces the message of function over process. Differently abled people have to create all kinds of workarounds to accomplish their daily goals, and those with chronic pain are constantly calculating the cost-benefit analysis of every activity.
How many spoons will it cost? How many forks will be endured? On top of this, there’s the added stress of finances, as clients can lose their SSDI if they make too much money with a part-time job, even when they can barely afford rent, let alone medications and medical care. Take all this together, and it’s clear that people with chronic pain already spend an overwhelming amount of time figuring out how best to function.
To compare, a person-centered or Gestalt therapist may hold space for the client, even if they’re floundering, which is a bit like a lifeguard asking a drowning man how he feels. Sometimes, individuals with chronic pain may need an advocate, or a surrogate memory, or a body double, or an “accountabil-a-buddy” to help them keep track of life’s demands. They may need someone in the proverbial water with them, just to stay afloat. With this in mind, counselors should adapt how directive or nondirective they are to meet their client’s needs.
The counselor’s perception of their client can play a huge role, too, as some may hyper-focus on a client’s disability or turn a blind eye to it. Rhoda Olkin noted in their 2017 book Disability-Affirmative Therapy: A Case Formulation Template for Clients with Disabilities that therapists can overestimate and underestimate the role of a client’s disability in their mental health journey. When a counselor overestimates the impact of chronic pain, they may accidentally ignore a client’s strengths or misunderstand their fluctuating capacity. Just because a client may struggle with something today doesn’t mean they always struggle with it, or are unable to push through it, or find a workaround.
They may also falsely assume that a client’s anxiety, depression, or fatigue stems from their chronic pain, minimizing other issues in their life. When this happens, therapy becomes less explorative and more akin to pain management.
When a counselor underestimates the role of pain or disability, they can misread the whole case. As you can imagine, chronic pain adds to a client’s allostatic load, decreasing how much information they can hold onto or how much they can focus or multitask. This may lead to misdiagnosing a client with ADD or ADHD if they have a hard time focusing or have to keep moving to avoid physical pain, or with anxiety and depression if they’re constantly overwhelmed or contend with adrenal fatigue.
Arguably, they would meet the criteria for each diagnosis on paper, yet the treatment plan will fall short if the counselor doesn’t grasp the source issue. This will keep a client in a holding pattern, addressing surface-level symptoms without dropping into their feelings.
Adding more external obstacles to emotional process work, many stigmas face differently abled people. Some may have internalized the belief that emoting is overreacting, or that their physical symptoms are hypochondriacal. Consider how people with invisible disabilities may be accused of faking it or having a conversion disorder.
This matters a lot when talking about feelings, since emotions aren’t just cerebral; they’re physical sensations in the body. Many people with neurological, respiratory, muscular, skeletal, or pain-related issues exist in a sensitized and deeply embodied relationship with their feelings. Yet they’re forced to bite their tongue so people don’t think they complain too much, or think they’re playing a violin at their own pity party.
On the flip side, people with visible disabilities may not want to talk about their lived experience because able-bodied people look at them adoringly as “inspiration porn.” Society views differently abled people, especially those with chronic pain, as either fragile or motivational, or both. Yet this external view undermines the client’s trust that anyone will understand them.
Disappointment, frustration, grief, and anxiety are all valid, as the client is contending with other people’s reaction to their disability. If everyone believes they always need help, some may feel infantilized or made to feel old before their time. Full-grown adults may feel dropped in a limbo if everyone believes they’re nonsexual or lacking adult desires. Some clients may feel shunned if their chronic pain makes them irritable, and that irritability buffers people away, leading to a grumpy reputation like the thorn in the lion’s paw.
Navigating all this, clients with chronic pain may either hyperfocus on how people see them, which costs more spoons than they have, or armor themselves with stoicism, which may isolate them more. Both forms of shielding sidestep emotional processing. Focusing on what other people think decenters the self because the client does not feel safe speaking without repercussion. Emotional armor inadvertently numbs the self because the client does not feel safe connecting with others.
To explore feelings a client may resist, it can help to explore their meta-emotions. The feelings they have about their feelings. For example, those old phrases like “I can’t let the dam break,” or “I have to keep it all together,” or “I don’t want to be judged” all denote worry and anxiety.
Pointing out that they have feelings about their feelings starts the exploration. They may still have very real concerns, especially if emotional expression takes all their spoons, leaving none left for damage control, relational repair, or even the walk home. So start small with their worry about fear, or their anxiety about anger. This conversation will begin to map the client’s thought process, emotional vocabulary, and even self-concept.
The need for validation is instrumental here. If the client is truly in a situation where they can’t let the dam break, they still need a sluice to relieve pressure, and that’s the role of therapy. The therapeutic container makes room to yell into the void. Some inexperienced therapists can feel uncomfortable with this, especially if they believe that therapy is supposed to be about self-soothing and self-regulation.
But what we’re talking about here is a client with a physical ailment that cannot be soothed, who is constantly being forced to self-regulate. To be able to complain, or sigh, or growl, or swear, or sob, without social risk, or expectation to “keep it all together,” opens the door. Even if we’re not at the heart of it yet, and we’re just expressing the meta-emotions, the catharsis has begun.
Internal Obstacles To Processing Emotion
By building rapport and an emotionally safe container, counselors help their clients lean into emotional expression. Yet clients with chronic pain sometimes have an extra layer of reinforcement to their emotional shielding, especially if outward expression causes physical discomfort.
For some, this can present as emotional stoicism, whereby they feel their emotional process yet minimize their response to it. For others, it may not be so conscious, as many who struggle with chronic pain may inadvertently depersonalize. As a mild form of dissociation, clients who depersonalize may feel distant from their sense of self, perceived experience, and physical body. They may describe feeling like a puppeteer behind the eyes, or like they’re numb to their physical awareness until they force themselves to focus on it.
This unconscious process occurs when a stimulus is taxing for so long that the mind attempts to tune it out. Yet unlike an annoying sound that fades into the background, the client’s mind-body connection becomes muted, and with it their bodily experience of emotion. This often creates a very cerebral relationship with emotion, as all that’s left is a hollow cognition.
Emotions can hurt in more ways than one. Imagine a spike in heart rate and breathing that cascades into muscle spasms, tremors, limb weakness, and even joint flare-ups. Clients with an autoimmune disease already contend with tissue inflammation, and to make their arthritis worse, this prolonged inflammation hypersensitizes nociceptors, increasing the felt experience of pain itself.
Clients with hypermobility issues like Ehlers-Danlos Syndrome (EDS) may dislocate a rib from crying too hard, or their throat may close if they have a wandering trachea. People with gastrointestinal issues may get hit by IBS, nausea, or stomach pain. Emotional overload can even lead to epileptic seizures, shutting down from sensory overstimulation, migraines, brain fog, and if that weren’t enough, losing multiple spoons of energy for that day.
To help, Jon Kabat- Zinn authored a number of incredibly valuable books, including his must-read Full Catastrophe Living: Using the Wisdom of Your Body and Mind to Face Stress, Pain, and Illness. Taking a grounded approach, the mindfulness exercises he presents expand a client’s sensory awareness, making room for the pain, as well as the sensations eclipsed in the background.
This kind of pain management goes beyond simply trying to “tough it out” to accept the sensation as part of a broader experience, including other physical senses and emotional responses. Experientially, clients can often feel surprised by the breadth and depth of their feelings behind the cloud of dissociation and the fog of pain. Cognitively, we all know there are other senses being activated, and other emotions being felt, but experientially we lose sight of that when we’re blasted by a migraine or disconnected from our body.
Many clients may not accept emotional processing for the sake of emotional processing alone, which is where the concept of emotional utility can help. On an evolutionary level, our emotions instinctually help us survive. On a physiological level, crying is homeostatic, regulating the heart rate and releasing oxytocin, providing a felt sense of relief. On a psychological level, processing our emotions helps us move through our contextual understanding of who we are in the world we inhabit. On an affirmative level, expressing our feelings validates our sense of self. On a virtuous level, emotions act as a compass to our values, pointing to important facets of life worthy of our attention. In essence, our emotions play many important roles in our physical health, mental health, and life satisfaction.
Following the physical impact of emotions, there’s also the added psychological strain of being a person with chronic pain, and there’s a lot of diversity around what that means. There’s a huge difference, after all, between people born with a lifelong condition and those who became disabled through trauma, accident, or old age.
Experiences of identity incorporation, social exclusion and alienation, as well as grief and loss, vary a great deal. For some, their lived experience may be just that: An experience. A part of their life that they have to manage, but not the main focus. For others, their condition may play a huge role in their identity, especially if they lean into advocacy work. For others, still, it’s something they don’t want to define them, and actively push back against.
How central the pain is to a client’s therapeutic process depends largely on how much they’ve incorporated it, or how much they’ve individuated from it. Is this an experience they’ve always had? Or something they’re slowly learning to live with? Or a pain that’s new, immediate, and demanding? Do they see themselves as someone weathering a storm, or the storm itself? Do they count the many branches of a tree, including those severed and broken, or do they feel like a sawn-off stump, unable to regrow?
The gambit of emotions here is raw, as we’re exploring empowerment and disempowerment, resistance and capitulation, acceptance and surrender. For some, their feelings may be clear, or muted, or complicated, as hope folds in with fear, and anger sparks passion, and guilt attaches itself to everything to make one feel guilty for feeling sad, or upset, or anything at all.
Each client will have a distinct existential relationship to pain, which can fluctuate depending on their capacity. The balance between how much energy you have to draw from and your current level of overwhelm doesn’t just impact your feelings; it impacts your perspective about your feelings and your willingness to deal with them.
Some days pain can feel like a deterrent, a detractor, and a very real disability, and on other days it can feel like a challenge and even a source of insight. There may not always be enough spoons for every session, and sometimes there may be too many forks to think. That’s a part of this journey. Just remember that emotional process work is about being present, sans external or internal judgment.
The more a counselor can adapt their therapeutic approach to their client’s specific pain needs, the more they’ll be able to help their client respond to themselves with compassion.
Alex Stitt, LMHC
Writer & Contributing ExpertAlex Stitt is a nonbinary author, queer theorist, and licensed mental health counselor living in Hawaii. As a proud Queer Counselor, they work to educate professionals in the mental health field interested in working with LGBTQ+ populations. Their textbook, ACT for Gender Identity: The Comprehensive Guide, demonstrates how to apply Acceptance and Commitment Therapy to gender self-actualization.