In this interview, Mandeep and her physician discuss her history of migraine headaches. Mandeep notes there seems to be a link between stress and her headaches. The goal of the assessment is to determine whether her symptoms might be due to a strong anxiety-laden feeling that is triggering bodily symptoms in the form of headaches. Many patients with nociplastic symptoms have learned automatic and unintentional defence mechanisms to avoid facing painful conflicting feelings, such as intense anger toward a person for whom they also have love and affection. During the interview, the physician points out when Mandeep is using a defence mechanism to avoid her emotions and encourages her to become aware of the avoided feeling so it can be experienced and expressed freely rather than cause symptoms.

Doctor: “You were telling me how you got a migraine after you had an argument with your partner. Let’s look at this together to see what happened. Can you tell me how you felt toward your partner for calling you demeaning names?” (The doctor encourages Mandeep to explore a strong feeling.)

Mandeep: “Well, I understand why he did that. He’d had a long day and he was tired.” (She is using a defence mechanism—rationalization—to avoid her feeling, instead of expressing how she actually feels.)

Doctor: “That may be the case, but how did you feel toward him for insulting you?” (The doctor tries to block the defence and encourages Mandeep to face her feelings.)

Mandeep: (Sighs.) “I guess I was a little annoyed.” (She expresses some feeling but uses defences of minimization and hesitance to avoid facing her anger fully. Some skeletal muscle tension is present, indicated by the sigh.)

Doctor: “You sound a little hesitant. Could you say if you were or weren’t annoyed?” (The doctor points out and blocks the defence of hesitance.)

Mandeep: “Really, I was annoyed. I was frustrated with him!” (She stops using the defence and starts to get closer to her feeling of anger.)

Doctor: “And how do you feel that sense of frustration in your body?” (The doctor encourages the somatic experience of the feeling of anger so it can be expressed fully.)

Mandeep: “I actually feel a migraine starting.” (Getting closer to her underlying feeling triggers a vascular smooth muscle response, a manifestation of bodily anxiety. The patient is over her threshold of emotional tolerance.)

Doctor: “So, your partner hurt you by calling you names and it made you angry at him. But instead of feeling the anger, it has now turned inward and is causing a migraine. Is that how things typically work for you?” (The doctor offers a cognitive recap of the link between feelings, defences, and symptoms.)

Mandeep: “Yes, that actually makes sense. I can see that the same thing happens a lot with my supervisor, too! And the headache is starting to fade a little now.” (Sighs.)

Doctor: “So, if we have an honest look at your anger, without it becoming a headache, how do you feel that anger toward your partner in your body now?” (The doctor again encourages Mandeep to face her feeling of anger.)

Mandeep: “It’s like a heat rising in my chest, and I just want to reach out and give him a good shake and tell him to stop insulting me! And now the headache is completely gone. That’s so strange. But I feel bad for wanting to hurt him.” (Mandeep is now in touch with and expressing the inner experience of anger and guilt she has been avoiding, which reduces symptoms.)

Doctor: “That makes sense. It sounds like you really care about him and don’t want to damage him, but he did something hurtful to you, and these angry feelings were so real that your body went into an anxiety state and attacked you with a migraine! Here’s where psychotherapy can help: to identify similar patterns and come up with healthy ways to assert yourself in the future so you don’t have to suffer headaches in these situations. Would you like to give it a try?” (The doctor again recaps the process of how avoided emotion causes symptoms and comes up with a plan for the future.)

Readers are encouraged to consult the literature to review additional examples of emotion-focused interviewing techniques.8,9,16,20