A Life Larger than Pain

The problem began when she herniated a lumbar disc. Due to increasing weakness in her right leg, the neurosurgeon performed a disectomy. Unfortunately, she developed some scar tissue around nerve roots after the operation. This consequence led to a different but more severe pain than she had originally endured. In an attempt to alleviate this new pain, she underwent yet another surgical procedure. There was some temporary relief within a few weeks, but the pain came back again, this time in a slightly different pattern–nagging, constant, and lacerating. The problem just won't go away.

I can hear in the tone of her voice and see in the lines of her face that she is disillusioned and afraid. She has done all the right things, but they did not help her with her pain and suffering. In fact, she now has more intense pain, of a different quality, than she had prior to entering the healthcare system. Depression has set in; she has trouble sleeping; she cannot concentrate on her work as she once did; and she has no energy for relationships.

The pain seems to be taking over her life. She is worried about how she is going to keep her business going, because there is only so much she can delegate, and the stakes are high. But she is fresh out of medical and emotional resources for dealing with the pain. The surgeon who performed her back operations is out of ideas. There is nothing more he can do for her, she is told. She is angry at the feeling that others simply expect her to get over it. In fact, she suspects that some think it's all in her head. This is especially frustrating for a woman who has spent her adult life priding herself on her clear-headed realism. It is humiliating to feel that she is perceived as a hypochondriac. She didn't get this far in life by feeling sorry for herself or making up problems–quite the opposite. But the pain is beyond her control, and no matter what it only gets worse. As a last resort, she has been referred to the Pain Center in Santa Fe.

During our initial visit, in the process of listening to her story and performing a thorough neurologic and physical exam, I become convinced that her pain is all too real and her depression profound. I conclude that placing a needle at the scarred nerve and injecting anti-inflammatory medication under x-ray guidance (a transforaminal

the problem that won't go away

The lead article in U.S. News and World Report, March 17, 1997, was titled "The Quality of Mercy. Effective pain treatments already exist. Why aren't doctors using them?"[2] The writer cited the staggering costs of unrelieved suffering: 34 million people in the country suffer from chronic pain. Each year, millions seek relief at hospitals or pain clinics. Back pain, migraine, and arthritis rack up medical charges amounting to $40 billion annually. Chronic pain accounts for one-fourth of all sick days taken–50 million lost work days.

The American Academy of Pain Medicine estimates that pain costs the American people $120 billion each year.[3] Only one-third of persons suffering with chronic headaches seek treatment. Nearly 90 percent of all diseases are manifested through pain.

The experience of pain is a reality for every human being. It will happen to each of us: today, tomorrow, years from now in the aging process, or through the suffering of a loved one. Biologically, pain is a virtual certainty–as universal as eating and sleeping.

One in five Americans currently lives with chronic pain. At least 14 percent of these sufferers have headaches severe enough to miss work and to qualify them for some disability. Millions of Americans have low back pain or pain associated with whiplash, Herpes zoster, peripheral neuropathies, cancer, or with chronic diseases such as AIDS, diabetes, and arthritis.

I propose that we rethink how we approach pain, how we try to alleviate it, and how we understand it. I would like to question our conventional assumptions and responses by exploring how much they are influenced by cultural values we have uncritically assimilated. I want to point out that over time, and across other cultures, this problem has been dealt with in very different ways–and, in many cases, more creatively and effectively than in our current society, which seems to focus narrowly on the goals of pleasure and immediate gratification. Within the borders of our own country, there is enough cultural diversity and richness to offer significant opportunities for cross-cultural observations of the

and dying reflects the dearth of ways our society offers for preparing and undergoing this universal experience.

In the United States, advertising feeds our dependence as consumers by conditioning us to believe that staying healthy is a complicated matter beyond the grasp of the average person. We are obsessed with maintaining physical health, as if vitamin supplements, carefully calibrated exercise, the perfect blend of herbal remedies, pain killers, and a trillion dollars annually invested in medical expertise are necessary to prop up our fragile existence. I wonder if most of us would do just as well by practicing periods of solitude, silence, and simplicity.

In Western society we tend to speak about body, mind, and spirit as separate categories. In the last few decades there has been a trend toward holistic integration of these components of the human person, largely because we have treated them in isolation from one another. In Santa Fe, where I live, the communal melting pot is strongly flavored by Native American cultures. Compartmentalizing existence is alien to Native Americans, who view such Western fragmentation with wry amusement. To them, reality is all one, and everything in life has a spiritual basis. Body and mind are not spoken of independently from the spirit.

The Native American's spirituality is the entire matrix for their existence. They see this spirituality in animals, trees, and nearly everything that goes on in life. The processes of body and mind follow naturally from the spirit, at the center of this matrix. Pain is not an alien and fearful enemy but a natural dimension of life in this world, an aid in preparing for life in the next world.

shifting perspective

Medical sociologist M. H. Becker speaks about the new cult of physical fitness, diet, and maintaining one's best chance for health.[4] The current emphasis in healthcare promotion is risk reduction, self-discipline, and motivation to attain health. Becker says this new focus fosters a dehumanizing self-concern that substitutes personal health goals for more important human society goals. It is a new religion in which we worship

movement has had a profound influence in helping millions of people to become functional members of society again. Although it is spiritually based, it uses concepts and language that include a wide spectrum of belief and unbelief in a divine being while affirming a reality that transcends the individual. Stepping outside one's own framework is crucial, because self-deception is what keeps the addict from recognizing and managing addictive behavior. By affirming the need for a greater power within a supportive group therapy setting, the AA program frees people to look beyond themselves and embrace powerful opportunities for healing.

The recovery movement blossomed as alcoholics discovered that through this experience of pain and suffering, their lives became more meaningful than they had been before the onset of the addiction, because the consequent personal growth extended into all aspects of life. In this process of overcoming, many individuals discover new and untapped potential.

Entrenchment in chronic pain is not unlike alcohol dependency in that sufferers are consumed by a concentration on self–specifically, they are fixated on the body. The technical term for this is "somatically-focused." If pain patients can get outside themselves by redirecting their focus onto a greater power, they can begin to break the stranglehold of their entrenchment.

Pain physicians can help entrenched chronic pain patients to focus beyond the body through interdisciplinary therapies. Behavioral psychology, physical therapy, and cognitive treatment–to name just a few–create fertile ground for a patient's individualized recovery process. They help individuals get outside the framework of their pain and view it from a distance, giving them the chance to see glimmers of color beyond the dark and gray world to which they have been confined.

In 1988, Dr. John Riley and his colleagues at Brown University studied the association of a chronic pain diagnosis with physical impairment (i.e., the inability to do certain kinds of work).[5] They found that many patients believe pain automatically implies impairment. Yet the bedrock of treatment for chronic pain–reactivation or increasing appropriate

though I was detoxing from standard chordal patterns. I didn't want any jazz harmonies that came from the brain instead of the heart."

This is a striking illustration of a reversed perspective on pain: from an enemy that shuts down options to a catalyst for new directions. Although we would not wish such an agent of change on anyone, we can celebrate what emerges from the suffering. "Rarely has a jazz album come so directly from the heart," raved Teachout. Chronic fatigue changed the way Keith Jarrett played his music, and something new and lovely came from it.

Reframing reality involves letting go of previously held expectations of what life would be like. This is a painful and difficult process. But it contains the seeds of hope, because it nurtures openness to what may be given to us in the present. From the ashes of dashed hopes, new ideas and hidden gifts may emerge. Some gifts are all the more precious because they are unexpected.

Those in constant pain don't have the luxury of ignoring the difficult lessons of life. Because they are forced to live outside their comfort zone, they have an opportunity to glimpse what lies behind the veil of everyday reality. For some, this will be a sense of eternity, renewing their perspective on the here-and-now. For others, it may be confronting head-on the issues of personal growth they have been avoiding, or changing priorities while there is still time to focus on what ultimately matters.

*     *     *

At the end of our initial consultation, my new patient leaves with a prescription for temporary pain-relief and another appointment. Next time we will explore cognitive skills for dealing with pain, such as biofeedback, hypnosis, and relaxation. I will discuss with her some ways in which she can gradually become physically active again, both in working around the pain and in working through it. We will review the anatomy and physiology of her pain problem, so that she understands what kinds of procedures might decrease, or down-regulate, her pain. And I will begin listening for her spiritual kernel.

Steps For The Path:

evaluate your perceptions of pain

To help you experience what you are reading, an interactive section- containing self-test exercises, questions for reflection, and suggestions to help strengthen body, mind, and spirit for pain relief–follows each chapter. You may find it helpful to use a separate journal or spiral-bound notebook as a place to record the steps you take along the path to a larger life. In addition to recording responses to questions at the end of each chapter, try writing in your journal frequently. Record what a good day is like and what a bad day is like. Observe any initiatives you made to manage pain, and when it seemed that the pain was managing you.

Choose a minimum level of regular entries, such as simply rating your pain on a scale of one to ten each day. This step alone can give you a sense of accomplishment in moving forward, helping to offset the sense of being trapped or stuck. When you look back across days and weeks, you may notice helpful patterns. Write them down.

If you are inclined to do so, pray about the steps you take to move from entrenchment to renewal. Consider asking a friend to encourage you by meeting with you regularly to talk about how you are doing with the Drag-Down Ds (see chapter two). Tell your doctor or healthcare provider what you're doing and what you're learning from it.