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Why don’t we take mental pain as seriously as we take physical pain?

A psychiatrist explores cultural bias and the history of medicine

By Mark D Rego

One of the first patients I saw in medical school was an elderly man dying of metastatic colon cancer, which had spread to his bones and was excruciatingly painful. I was shocked and heartbroken when I saw him beg the doctor for more pain medicine than the modest doses he was receiving. When I asked the attending physician if we could increase the dosage, I was told “no, he’d become an addict.” This was incorrect, illogical, and inhumane — as it turned out, the man died in agony. He would have never become an addict and even if he did, he had only weeks to live. If this had happened a few decades later, this same patient would be in hospice care receiving as much pain medicine as necessary. He would live out his remaining weeks with minimal pain.

Questions about treating severe pain began with the use of chloroform in the 1800s. Surgeons wondered if it would interfere with healing or if moral consequences, such as addiction, might emerge. These two themes: interfering with a natural order (in this case, wound healing) and having moral implications, arise again and again in attempts to treat pain.

Nowhere are these issues more prominent than with childbirth anesthesia. The use of chloroform changed the excruciatingly painful process of childbirth for the first time in human history. In spite of this, it took many years to become an accepted practice. Objections ran the gamut from concern about interference with a natural process in dangerous ways, to blocking God’s retribution for Eve’s sin in the garden of Eden (a common belief, explicitly stated in the Bible, about the origin of childbirth pain).

After much contentious debate, childbirth anesthesia was eventually accepted and women now at least have the option of managing the most painful parts of childbirth (there are groups of women and physicians who advocate for “natural childbirth,” that is, without pain medicine. This complicates decision-making for many women). By the 1890s, medical practices saw the tremendous benefits chloroform offered and moved toward routinely treating severe physical pain.

The same cannot be said about mental pain (this generally entails intense, negative emotional states such as sadness, fear, anguish, or guilt). Unlike physical pain, there are questions that remain unresolved when it comes to mental pain. Is it better for us personally if we hold onto mental pain and work through it? Does it matter how we developed the mental pain? Does the way we treat the pain matter (for example, should some pain be treated psychologically and others with medicine, if they work equally well)?

After medical school, I trained to become a psychiatrist and eventually opened my own practice. I was surprised to find that there were still practitioners in the community who told their patients that they would not get better without feeling the pain of their depression. This harkens back to Freudian days in which the meaning of your symptoms held the key to truly getting better. Simply put, in Freudian terms, symptoms arise due to unconscious conflicts. These conflicts are only accessible by tracing the meaning of your symptoms deep into your unconscious thoughts. Treating symptoms alone erases the route to insight and thus blocks your ability to heal.

We now know from both medication treatment, and briefer, more symptom-based therapies like Cognitive Behavioral Therapy (CBT), that working on the meaning of your symptoms is not the only path to getting better. But it took many years to get past the notion that pain — in this case mental pain — was necessary in recovering from common psychiatric disorders. This same path — from Freudian analysis to current treatments — was traversed by anxiety, OCD, mania, and schizophrenia and most other mental health problems.

Although attitudes about the treatment of painful mental disorders invite wide agreement within the psychiatric community, the necessity of mental pain remains an open topic. For example: Should kids have it as tough as their parents did in order to learn the value of work? Should everyone just learn to tolerate painful breakups and losses? Most importantly, when very difficult things happen, must your suffering be just as difficult as the thing itself? In other words, is resilience helpful when bad things occur — or does it merely blunt the pain and prevent you from necessary processing of what transpired?

Where this uncertainty about mental pain is most apparent is in the pain of loss: the loss of a job, the loss involved in illness and disability, and most commonly, the loss of a loved one.

For years, the notions of “delayed grief” or “incomplete grief” implied that a person mourning needed to mourn more intensely to complete the process. Nontraditional approaches to grief, loss, and pain such as mindfulness, which are very popular today, hold that only by opening to, and welcoming, the pain of loss will you be able to move on to a post-bereavement life.

Psychiatric research does not support these ideas. The evidence suggests people whose grief lasts months to years in an intense and unchanging way (the opposite of delayed grief), stand little chance of getting better. In addition, some individuals develop depression on top of their grief.

It is also not the people who display few feelings of grief who get stuck in their mourning process. In fact just the opposite is true. It is people who display the most dramatic initial symptoms (crying, sadness), who suffer ongoing, difficult grief.

In my own practice, a man came to see me whose daughter had become suddenly ill with sepsis and died in just a few days. Now, two years later, he still sobbed for hours a day and felt pain like a knife between his shoulder blades. After some talking, I convinced him to try an antidepressant. Within a week, the knife was gone. By a month into treatment he still cried daily, but only just a little. Though still sad, he began to shift into truly mourning his daughter for the first time. He joined a large support group for parents who have lost children (Compassionate Friends) and even went on to pursue a degree in counseling to help people like himself.

Not all stories have such dramatic endings. But the story is emblematic of severe grief: the kind that occurs after an unexpected, premature, or violent death. Common symptoms do not lessen in the usual time frame. The bereaved cry a great deal; experience painful pangs of loss, poor sleep, poor focus, and lack of motivation. This may be (as it is now labeled) a complex grief reaction or a major depression superimposed upon the grief. In either case, the suffering individual needs medication and special therapy designed to support them, acknowledge their pain, and find a path forward.

In the case of my patient, attempts to allow him to feel his grief even more would only have made things worse. This isn’t unusual: I treated other members of Compassionate Friends. Their stories were remarkably similar.

Labeling this as “complex grief” is seen by many in psychiatry as “pathologizing” normal life. “Why wouldn’t someone be depressed after the loss of a child?” the critics ask. I would answer by asking who wouldn’t be in pain with a leg amputation, a breech baby, or bone metastases? Is mental pain to be tolerated simply because it should happen? Again: Pain is seen here as natural, even moral because it is part of our common human experience.

In my view, what we’ve learned from grief studies, as well as effective treatments for psychiatric disorders, is that mental pain has an analogous role to physical pain. It signals that something is wrong; perhaps very wrong. But that is all. By itself, it adds nothing to our well-being and thus we need not endure it.

Pain is, however, part of life and in tolerable amounts — along with worthwhile experience — is worth pushing through (many areas of personal growth, such as physical training or becoming a better parent or spouse, have this characteristic). There is no panacea for treating pain, mental or physical (the opioid crisis is testament to this, although the problems there have been with excessive doses in chronic, non-severe pain). Therefore, the best way to care for our pain, severe or not, is an open question.

We can now treat much intense mental pain with specific psychotherapies and medication for anxiety, sleep, depression, and other problems. I advocate for medication when significant and/or disabling mental pain arises. Additionally, we must consider the lessons learned about claiming that pain has a special role within nature, or our moral lives. I submit that any such claims be regarded with suspicion.

There will, of course, be many gray areas: child-rearing, physical training, and character development immediately come to mind. In each case the goal must be clear. Some pain may be part of the path to our goal, but it must be not detachable from your goals. For example, discomfort or strain (forms of modest amounts of pain) is necessary in exercising.

Lastly, there is a larger meaning of mental pain: We are united in our inability to avoid it. In this one way we are inescapably together. We share the existential meaning of just how breakable we and the worlds we live in are. Only by cultivating our connections to one another, can we reap any benefit from the universal human experience of mental suffering.

Read original Why Don’t We Take Mental Pain as Seriously as We Take Physical Pain?

Posted on: December 14 2020

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