Self and selfish prejudices shape the life stories we share with the world and ourselves. The good news: internal calculations will help us better understand our true identity.
Published on December 8, 2021 | Commentator Jessica Schrader
There is no doubt that in our culture, mental pain is different from physical pain. To better understand this, we can look at the interesting history of treating body pain. As we will see, the patterns we have observed in this history are even evident in the debate about mental pain. For our purposes, mental pain includes strong negative emotional states, such as sadness, fear, pain, or guilt, as well as severe anxiety and complex states, such as mental illness.
One of the first patients I saw in medical school was an old man who died of metastatic colon cancer. Colon cancer had spread to his bones and was very painful. When I saw him begging the doctor for more painkillers than the moderate dose he received, I was shocked and sad. When I asked the attending doctor if we could increase the dose, I was told, "No, he will become addicted." This is incorrect, illogical, and inhumane—it turns out that this person died in pain. He will never be addicted, even if he is addicted, he will only have a few weeks to live. This is my introduction to the fact that for most people, in addition to human suffering, suffering also has a moral component.
The use of chloroform in the 1800s caused problems related to the treatment of severe pain. Chloroform acts like anesthesia, and is the first medicine that can effectively prevent severe pain caused by surgery. Nonetheless, surgeons want to know whether it interferes with healing, or whether there will be moral consequences, such as addiction. These two themes, which interfere with natural order (in this case, wound healing) and have moral significance, appear time and time again when trying to treat pain.
The chloroform story does not end with surgery. The use of chloroform changed the extremely painful process of childbirth for the first time in human history. Nevertheless, it took many years to become a recognized practice. The objections range from fear of disturbing natural processes in dangerous ways to preventing God’s revenge for Eve’s sins in the Garden of Eden (a common belief that clearly states in the Bible the origin of pain in childbirth).
After many controversial debates, childbirth anesthesia was finally accepted, and women can now at least choose to deal with the most painful part of childbirth. However, the debate about what is natural and better for mothers and children makes this decision fraught with anxiety and guilt for many women.
Unfortunately, this is not the case for mental pain. Unlike physical pain, when it comes to mental pain, there are still some unresolved problems. If we persist in mental pain and overcome it, is it better for us personally? Does it matter how we produce mental pain? Does the way we treat pain matter? For example, should some pain be treated psychologically, and should some pain be treated with medication?
After graduating from medical school, I received training as a psychologist and finally opened my own clinic. I was surprised to find that practitioners in the community told their patients that if they did not feel the pain of depression, they would not get better. The idea is that treating symptoms alone will eliminate this pathway to unconsciousness, thereby preventing your ability to heal.
We now know from medications and shorter, more symptom-based therapies, such as cognitive behavioral therapy (CBT), that studying the meaning of symptoms is not necessary to get rid of depression. However, it took many years for people to overcome pain—in this case, mental suffering—is a concept necessary for recovery from depression and other common mental illnesses.
Although the psychiatric community has reached a broad (but not universal) consensus on the treatment of painful mental disorders, the necessity of mental pain in daily life is still very controversial.
The most obvious place of this uncertainty is the pain of loss-the most common is the loss of a loved one. The most difficult end is severe or persistent grief, which has caused most of the controversy.
For many years, the concept of "delayed grief" or "incomplete grief" meant that a person in mourning needed to mourn more intensely to complete the process. Many current methods of dealing with grief also believe that only by opening up and accepting the pain of loss can you continue to live a life of bereavement.
A certain combination of being open to your feelings and coping is definitely the best approach. But for severe or long-term grief, psychiatric research does not support these grief or open more concepts. Evidence shows that if people’s grief lasts for months to years in a strong and constant manner (as opposed to delayed grief), there is little chance of getting better. In addition, some people suffer from depression in addition to sadness. Again, for many years, we believe that the greatest pain of grief is natural, and you have to experience it as if it were a moral requirement.
In my own practice, a man came to see me and his daughter suddenly developed sepsis and died a few days later. Now, two years later, he is still sobbing for several hours a day, and he feels pain like a knife between his shoulder blades. After some conversation, I persuaded him to try antidepressants. In less than two weeks, the knife was gone. After one month of treatment, he still cried every day, but only a little bit. Although still sad, he started to mourn his daughter for the first time. He joined a large support group (sympathetic friends) for parents who lost their children, and even went on to study for a degree in counseling to help people like him.
Many people in psychiatry label it as "complex grief" and consider it to be "pathologically" normal life. "Why don't anyone feel depressed after losing a child?" the critic asked. I would ask who does not feel pain from amputation, breech baby, or bone transfer? Can mental pain be tolerated just because it should happen?
My common experience with my own patients and patients referred by therapists is that when their depression and anxiety are treated, their treatment results will be better. The pain of depression declared the problem, but after that it only hindered the growth needed to surpass it.
My point in this discussion is that mental pain is often dismissed or unnecessary scrutiny. Therapists, especially doctors, should be sensitive to psychological pain, especially anxiety. Doing so does not mean taking medicine. This may mean talking, suggesting a few days off, suggesting that they confide in friends or family, or even treatment. But this does mean that the therapist should help in some way. To call the person's symptoms "just worry" is to ignore them as common and less serious symptoms.
In my opinion, what we have learned from grief research and effective treatment of mental illness is that mental pain has a similar effect to physical pain. It indicates that something went wrong; it may be very wrong. Just like in physical illness, we must learn to judge when mental pain is excessive and useless to the patient. We have learned-mainly-in common mental illness, but not in the ups and downs of ordinary life.
There is no doubt that we should not treat every bit of mental pain as we treat physical pain. This will still leave a lot of spiritual experience and should be considered unnecessary pain.
As professionals, we should always intervene when there is severe and/or disabling mental pain. In addition, we must consider the lessons learned about the claim that pain has a special role in nature or in our moral life.
Mark Rego, MD, is a psychiatrist with a broad background in the practice and writing of articles about mental illness. Dr. Rego is a clinical assistant professor at Yale School of Medicine and has taught students throughout his career.
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Self and selfish prejudices shape the life stories we share with the world and ourselves. The good news: internal calculations will help us better understand our true identity.