Wednesday, September 06, 2006

Suffering's strange lessons - The New Republic

Pain Principle
by William J. Stuntz

The date was December 31, 1999--my personal Y2K. I was driving my family home from a vacation and got a flat tire. I pulled the car over and started to change it. (Dumb move: I'm more the kind of person who breaks things than the kind who fixes them.) Something nasty happened at the base of my back. Ever since, my lower back and right leg have hurt, usually a lot.


The specialists, most of them anyway, don't know what to do with me. Medical practice is all about snapshots: Measure the patient's condition, prescribe the treatment, then measure again. That approach works for static, on-off problems with easy fixes. But pain isn't static, it isn't on-off, and there are no easy fixes. Chronic pain is like a living, breathing thing with a mind and will of its own; it grows and moves and adapts. The snapshots--and most of the specialists--miss that. So each doctor clicks the shutter and applies the relevant specialty's preferred fix: this drug, that surgery, some new exercise program. Afterward, when I still hurt, they tend to get frustrated. That's usually when I'm diagnosed with Failed Patient Syndrome. 


I used to think the "chronic" part of chronic pain was the really bad part. Now I'm not so sure. Neverending pain wears you down; it's exhausting. But, on the whole, I think I'd rather have constant pain than the variable kind. 

If that sounds bizarre, bear with me. Pain is largely about the gap between expectation and reality: the distance between what you feel now and what your mind tells you you're supposed to feel. As reality slides downhill, expectations slide, too. Which makes reality feel less awful. Several times during the past half-dozen years, my baseline pain level has kicked up--say, from a 3 on a 0-10 scale to a 7. (Doctors love that pain scale, which is one more example of the snapshot problem.) At first, it feels horrible: 7 is bad news; walking around feeling that kind of pain all the time can be sheer hell. But, after a while, you get better at dealing with it. The bigger pain starts to feel smaller; 7 becomes what 4 once was. And 4 starts to feel like 1; it's just background noise--the pain equivalent of elevator music. I don't remember what it feels like to get out of bed in the morning, stretch, walk to the bathroom, and feel no pain in my back. For me, that older and happier baseline has disappeared. 

That sounds sad, but it isn't. Forgetting the world of easy stretching and long, pain-free walks has been a great mercy. My mind doesn't tell me I'm supposed to be pain-free. Instead, it tells me to expect bad times. Which means I'm no longer quite so disappointed when bad times come. 

Something very important follows from this. Hope hurts; optimism amplifies suffering. The pain-free, healthy world is gone; this is my world now. If I can make those long-ago sensations vanish, a portion of my pain vanishes with them. One cannot feel the absence of a nonexistent thing. Let the thing become real again, and its absence stings. Norman Vincent Peale, apostle of the theology of positive thinking, got it wrong: Pessimism is power. Hopelessness turns out to be surprisingly good medicine. 


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