Measuring Psychological Pain to Improve Clinical Research and Care

KL: Psychological pain (sometimes referred to as psychic pain or psychache) is the experience of feeling negative emotions that seem unbearable and unending. Some theorists downplay distinctions between psychological pain and physical pain, viewing both as experiences of profound discomfort that affect both the body and the mind. Others talk about psychological pain in very specific terms, as linked to mental illnesses like depression, anxiety, and suicidality. I tend to think about psychological pain as the experience of negative feelings turned up to the max, and that feel inescapable and unending in the moment.

KL: The Psychic Pain Scale was developed with the intention of learning more about the subjective experience of patients with long histories of emotional pain and distress. 

Originally a 20-item scale, the Psychic Pain Scale was first used in Dr. Jane Tillman’s “States of Mind Preceding a Near Lethal Suicide Attempt” study to examine the relationship between psychological pain and suicide attempt history; as it turns out, the relationship was quite strong, with scores predicting suicide attempt history status over and above other known risk factor variables.

Even though the link between psychological pain and suicide attempt history was clear in this study, the scale itself had not yet been subjected to a rigorous psychometric vetting process. Our most recent study, “Assessment of Psychological Pain in Clinical and Non-Clinical Samples: A Preliminary Investigation Using the Psychic Pain Scale,” just published in February 2020, set out to do just that by examining the properties of the scale in 131 adult psychiatric patients and 953 undergraduate students (partnering with our colleagues Chris Hopwood, PhD, at UC-Davis and Evan Good, MS, at Michigan State University). We wanted to determine the reliability and validity of the instrument and assess its internal factors structure, and obtain further support for the scale’s utility for assessing suicide and psychological impairment.

KL: Simply put, the scale was developed to more effectively assess and understand the painful emotional experiences of individuals contending with increased suicide risk. There are several measures already in existence that assess various forms of psychological pain, but it is not always clear how they fit into broader theoretical and clinical models of suicide. Our measure is unique, because it is rooted in the theoretical model of suicide developed by John Maltsberger, who posited that suicidal states of mind begin with an overwhelming sense of negative emotions (“affective deluge”) which then trigger a sense of loss of control and inability to regulate emotions. Together, these experiences make it difficult for an individual to consider possible ways out of their suicidal crisis. Maltsberger’s model describes a process of escalating psychological pain–a high intensity of unbearable negative emotions, and a loss of behavioral control–and the Psychic Pain Scaleis intended to capture this process, and offer a more clinically-grounded perspective on psychological pain that can inform research and improve clinical care.

KL: Subjective experiences of psychological pain are not always something that clinicians ask about when assessing at-risk patients. Clinicians are trained to ask about various risk factors like access to lethal means, whether they have any intent to act on suicidal impulses, and their level of access to support networks, all of which are important; but these are separate from the subjective emotional experiences of the person who is feeling suicidal.

There has been a movement, in part through suicidology expert Dr. David Jobes and his CAMS Framework™ of suicide risk assessment and treatment, to inquire more directly about patients’ subjective emotional experience, in particular psychological pain. When clinicians ask a suicidal individual about their experience of psychological pain, often it’s a relief to have an opportunity to talk about it and it can open up a conversation that ultimately supports alliance-building and a sense of trust.

Our Psychic Pain Scaleisa relatively brief measure that offers clinicians a way to assess different aspects of emotional pain, rooted in clinical theory, and now shown through these empirical studies to be associated with suicidality. The scale gives clinicians a sense of how inundated or immersed in psychological pain a patient experiences themselves to be at a given moment in time. The scale provides an opportunity to start a conversation about suicidality and emotional pain, which can help patients feel heard and understood.

KL: We are currently using this measure to evaluate psychic pain in two new studies, one supported by the Wallerstein Psychoanalytic Research Fellowship and the American Foundation for Suicide Prevention (AFSP) and one funded by the National Institute of Mental Health (NIMH). Both studies evaluate factors affecting short-term prospective risk for suicide. We hope to determine whether an individual’s responses to the Psychic Pain Scale predict the likelihood that they will develop suicidal ideation in the week or two that follows, ultimately allowing us to understand how a clinician may use the measure to assess short-term prospective suicide risk in patients. We are also hoping to collaborate with external clinical treatment sites to study the Psychic Pain Scale in more diverse patient groups, with the goal of understanding whether our current findings in Austen Riggs patients and undergraduates will generalize to other patient populations.