The Problem with Pain
I’ve known James for quite a few years. In his mid 40’s now, James is morbidly obese and, according to his doctor, and the doctors that came before, he is unlikely to see 50. He’s been discharged or referred out by more than one physician because the cause of his malady is the food he eats. Specifically, the kind and volume of food. He eats bad food, and lots of it. So he is “noncompliant” with treatment recommendations.
Even though he is quite bright, James continues to put the things in him that perpetuate, and even increase, the pain he is in. He is “treatment resistant.” A medical term indicating he is not following the advice of physicians who are recommending evidenced-based practices.
Earlier in my career I’ve done the same thing. I’ve referred clients out of my practice to higher levels of care because they didn’t follow my clinical recommendations. I’ve said stupid things like, “they haven’t hit rock bottom.” When the truth is they had been bouncing off rock bottom for years.
The medical community, and society as a whole, seems to treat pain that is self inflicted in a completely different light than the individual who is in pain caused by an outside uncontrollable force. Those who experience a drug overdose are treated quite differently than those who, say, have been in a car accident.
An EMT asked me recently, “How many times do think we should Narcan a person?” They were referring to an individual who has received Narcan more than a dozen times in the last year. Implied in his question is another question: “When are they going to stop their stupid behavior?”
But the brain doesn’t differentiate between self inflicted and other inflicted pain. The brain (and the body) just see pain as pain. And when pain is on board, relief is the primary goal. When we put our hand on a hot stove, the brain and body work just fine: we yank our hand away and make a mental note to be more careful next time. But chronic pain is another story.
Those who experience chronic pain have another experience altogether. Chronic pain literally changes the brain. Our neural pathways become more sensitive, kind of like turning up the volume, on the pain. So what was a 5 on a 10 point pain scale now feels like an 8. That pain activates a stress response and increases our cortisol levels. This is pretty unhelpful. Pain also reduces our attention and working memory. Also unhelpful. It heightens our emotional reactivity, thereby pushing the logical center of the brain to the back seat. Again, unhelpful. Studies have also shown an actual reduction in gray matter, literally shrinking the brain and causing structural changes to the brain and spinal cord.
So we ask James, “Why don’t you stop eating junk food? It is literally the source of all of your pain.”
While that is technically true, the junk food does one little thing before it causes pain. It provides relief. Relief comes first. Relief comes quickly. Ask anyone who has developed maladaptive relationships with chemicals or behaviors. They will tell you the relief comes even before the chemical or behavior is engaged. Just the anticipation of relief causes actual relief.
If you hooked up a fMRI to an individual with substance use disorder and poured them an alcoholic drink and set it on the table in front of them, their brain would light up as if the chemical were already in the body. That’s how much the brain doesn’t want to experience pain. That’s how valuable relief is. The brain will experience a literal chemical response without a chemical stimulus.
So we ask the overdose patient, “Why don’t you stop putting that poison in you?”
Speaking of pain, you know what’s painful? Judgment and condemnation produce shame, which is incredibly painful. Emotional pain and physical pain are linked and overlap in a dozen different ways.
Patience, understanding, acceptance. When experienced, those things produce relief. And yet we oftentimes condemn the individual for seeking the only relief they’ve ever known.
We use a word in the chemical dependency world: Recovery. That’s assuming they had balance and peace beforehand. And they are on a path to recover what they lost. But my anecdotal experience is that many of those individuals don’t need to recover, they need to build the house from the foundation up for the first time in their lives.
It would be like someone handing you a scalpel and expecting you to know how to perform a surgery. “We gave you a scalpel, what’s the problem?”
Maybe we ought to consider that relief should come with the solution. Maybe everyone deserves relief, whether we determine the pain was self inflicted or not. I’ve learned over the years, both personally and in my work, that pain is a lousy teacher. And yet I wonder: How many of our laws, policies, procedures, interventions, and solutions are motivated, in part, by the fact we’re just mad at the individual? Maybe more than we care to admit.
