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A Life Larger than Pain

The Pathway from Resignation to Renewal

by Erv Hinds, M.D. (more about this book and author)

Chapter 3: Pain Does Not Equal Suffering
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The thing that causes our suffering is also causing our endurance, which is bringing us hope.

–ROBERT K. HUDNUT[14]

WE COMMONLY ASSUME that pain and suffering are virtually the same thing. But they need to be differentiated. Pain is the body's response to tissue injury–or, as with heartache, the spirit's response to emotional injury. Suffering is our emotional response to pain, whether from bodily hurt or heartache. However, not all suffering is experienced equally. In large part suffering is determined by cultural background, support systems, individual psychological makeup, and spiritual beliefs.

Specific research exists concerning cultural differences in pain, suffering, and spirituality. Some of it dates from 1965 by Harvard Medical School's Richard Sternbach and Bernard Tursky, who studied different responses to pain among old Americans of Protestant-British, Jewish, Italian, and Irish descent.[15] They discovered significant differences in the way Italian and Hispanic Americans outwardly respond to pain as compared with Protestant British Americans. This is awkward to discuss in our current climate of heightened sensitivity toward ethnic differences and racial minorities. But in fact, the way we are raised, our neurosignatures on our belief systems, and our remembered wellness do affect the way we respond to pain.

Such investigations are not intended to create and reinforce stereotypes. Rather, they suggest that pain is only pain as we know it. Our upbringing

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and our heritage contribute to our perception of pain, and therefore to our ability to endure it. They also influence our views of treatment, and whether we include or exclude spiritual belief and religious tradition in the ways we adjust to pain.

For example, guilt is frequently associated with pain. Images of a wrathful god bent on punishing wrongdoers haunt some sufferers, especially those from conservative or fundamentalist Judeo-Christian backgrounds. But guilt is counter-productive to helping us deal with and move beyond the physical and psychological immobilization resulting from chronic pain. Within the same religious traditions, there are role models of people who turned away from the burden of guilt and toward the power of prayer.

Pema Chödrön, an American woman who converted to Zen Buddhism, became a Tibetan nun and founded the Gampo Abbey in Cape Breton, Nova Scotia, the first Tibetan monastery in North America established for Westerners. In one of her books, When Things Fall Apart: Heart Advice for Difficult Times, she juxtaposes Western and Eastern ways of handling pain. One approach avoids it; the other "leans into it." The differences are profound. All of us naturally fear pain and try to avoid it at any cost. "Generally speaking, we regard discomfort in any form as bad news." We do not realize that the situations of pain and suffering are teaching moments. We automatically hate them and try to escape from them. "This very moment is the teacher."[16] For the Tibetan Buddhist, suffering is a given, one of the basic truths of life. The Westerner tries to avoid pain and suffering, swinging wildly between extremes of fear and hope instead of calmly accepting the impermanence of these temporal realities.

good and bad suffering

Most of us live in fear of suffering. In our American culture, it is the thing we try hardest to avoid. Pain must therefore be eliminated, because pain inevitably causes suffering, and we presume that suffering is always bad. It will deny us the life we want. It will be unbearable.

If we change our responses to pain, however, we can change the nature of our suffering even without eradicating the pain. We tend to think only

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a cure will do. In a few fortunate cases, a cure can be accomplished, eliminating the injury and the pain associated with it. But in many cases, a cure is simply not possible. What then?

Perhaps healing in its broadest sense means recovery from unbearable or meaningless suffering, which shuts us down and renders us unable to function. Physical recovery to some degree is necessary and important, but true healing encompasses psychological and spiritual restoration as well. To address healing–not just the reduction or elimination of pain–we must address all three dimensions of mind, body, and spirit.

I have strengthened my own spiritual foundations especially in seasons of change and crisis, when I have been forced to reevaluate everything in my life and identify what matters most in order to make wise choices. Although my path remains within the Christian tradition, I delight in learning from the wisdom of others' spiritual paths. I am privileged to work in a colorfully multicultural area of the country, where on a daily basis I am stimulated by the insights of those from other ethical and religious traditions. I have learned to value an authentic spiritual frame-work regardless of the specific teachings it comprises. This enables me to encourage my patients to draw from their own heritage or current convictions in developing a perspective that is larger than the pain consuming them.

I have witnessed again and again the centrality of one's spiritual perspective in breaking the destructive power of the pain cycle. Western medicine has grown increasingly sophisticated in its ability to pinpoint the causes of pain and develop highly specialized techniques for alleviating the pain. But even with this technological prowess, it is usually just palliative. It can dramatically change the level of pain, but unless it cures the problem by eliminating the injury, it cannot eliminate the pain entirely. Therefore, the patient remains vulnerable to the entrapment of the pain cycle. Breaking this cycle requires more than better technique.

How does one cope with pain when it cannot be eliminated? Certainly, by doing everything possible to minimize the pain and its effects. We continue to invest social resources heavily in accomplishing this goal. But just as important as coping with chronic pain–if not more important, given the now-documented benefits of spiritual approaches to physiological

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problems–is the transformation of suffering. It is possible to change our response to pain so that suffering has a redemptive effect, leading to a life larger than the pain, rather than a destructive effect that reduces life to the narrow confines of the pain. In our society, we know very little of such transformation. Many of us are not even aware that it is possible, because we are so distracted by the rush for immediate gratification in our attempts to escape pain and suffering. Yet for thousands of years, the great religious traditions have passed from one generation to the next their accumulated wisdom on this very subject.

I have often wondered why in this age of information we remain so short-sighted to the richness of our spiritual traditions in teaching us how to live, how to cope with infirmity, and how to die. In the past, these traditions have had power to shape existence just as effectively as our technologically advanced society–in some respects, even more so. Why do we feel that in the timeline of history, our brief minute on earth is where the answers will be found? Why do we not look back on the record of human experience with suffering, seeking with wonder and awe the insights of those who have endured pain and suffering and found wisdom to prevail with dignity–whether monks of medieval Europe, Native American healers, Tibetan Buddhists, or prisoners in concentration camps and the Gulag. We spend time and money on the latest trends while neglecting the richness of our spiritual traditions and their power to change our experience of illness, pain, and suffering. This is a tragic mistake.

In dealing with pain, we have opportunity to stand on the shoulders of those from past times and other cultures. I am not recommending that we all take courses in comparative religion and folk healing. Rather, I am suggesting that we get back in touch with whatever is authentic for each of us spiritually, taking time to reflect on what is ultimately important. The immediate-gratification impulse of our society shipwrecks on the shoals of pain.

In my work with patients–which involves what they teach me as much as my treatment of them–I have noticed a striking commonality in the diversity of religious traditions. I am no specialist in comparative religion, but the gathered wisdom of our spiritual teachers seems to converge in the difference between "good" and "bad" suffering–or what I would like to

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call redemptive versus destructive suffering. Those who remain trapped in the pain cycle suffer destructively. Those who break out of it suffer redemptively. One tears down the self and leads to further harm; the other builds up the self and leads to a new kind of wholeness. Each is based in a contrasting set of responses to pain. The power to choose between these responses depends on neither physical strength nor mental acuity. It lies in the province of the spirit. This is why spiritual resources are so absolutely vital to dealing with the problem of pain.

the difference spirituality can make

Recognizing and acting on the spiritual dimension of pain can ease suffering instead of increasing it. This reality became clear in treating Isabel Lujan, an attractive, Hispanic woman who was thirty-five when she came to see me. Prior to an automobile accident the year before, she had been slim, athletic, and outgoing. Her personal charisma was matched by her keen intelligence. When the accident had occurred, it set off a complex of problems with her neck and lower back. She developed significant whiplash, resulting in chronic neck pain, headaches, and muscle (myofascial) pain.

For a year and a half Isabel had been going to a myriad of physicians and several orthopedic surgeons. She had been to neurologists and neurosurgeons for headaches and her other problems. All of them had looked at her body and done neurological examinations. They had evaluated her symptoms and prescribed very specific treatments. All this time she continued to have significant pain in her neck, arms, and one of her legs.

When Isabel came to me, I did a complete history and physical with a neurological examination and physical assessment. I also added her sleep history, family history, a history of what she used to like to do and what she can't do now, and a psychological evaluation. All this time her husband was part of the discussion.

I noticed that Isabel wore a crucifix around her neck. I asked her how she was managing, what it was that was helping her get through these difficult days of pain and lack of sleep. Prayer, she answered. We expanded on that subject and discussed her belief system. I asked if she

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would be willing to see a Catholic priest, who is also a Jungian psychologist, for guidance in dealing with discomfort and pain from a spiritual point of view. She said she would. Then we set out to make a plan about how to approach her pain and the crucial aspect of reactivation from being trapped in chronic pain. We discussed how to begin treating her sleep deprivation without narcotics or medications such as Valium. We began the process of examining her by doing different procedures that might give us some idea of how to treat her pain.

We discussed the importance of exploring cognitive-care principles. The dominant theme in her healing blueprint, however, was the intertwining of her spiritual belief system and exploring how her pain and suffering might increase her faith as well as her ability to help her family members.

Since that time I have seen Isabel once, and we have started her on medications to nudge her into better sleep. She is seeing the Jungian priest, and they have worked on some cognitive skills, meditation, hypnosis, and ways to integrate her spirituality into her suffering in a positive, effective way. We have begun to organize appropriate physical therapy and reactivation. The overall goal has been to give Isabel a sense of hope for the future and a new context for her chronic pain, involving her family, culture, and religious faith–a context that will help her turn her problem into a positive opportunity.

Sometimes adversity and pain initiate a process of purification–the unimportant or superfluous is drained off in the pressure of crisis, clarifying, and strengthening what remains. Classic patterns of spiritual purification suggest that there is always an increase of stress and a heightening of internal conflict before spiritual transformation takes place. Those in chronic pain have been given a difficult gift in the acceleration of this process.

If life is going well for you and physical or emotional pain is not an issue, it's easy to structure your life around the pursuit of success in conventional terms–career advancement, improving investments, getting more out of relationships and leisure time, planning vacations, and acquiring more sophisticated electronics. Perhaps this way of life is what the Apostle Paul was concerned with when he warned, "Do not be

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conformed to this world, but be transformed by the renewing of your mind."[17] It's very hard not to be hungry for power and money when you're successful.

In this age of specialization, we have become accustomed to separating the body into its distinct systems and organs and then hiring a specialist to diagnose and eliminate the problem. Yet no body part is an isolated organ or appendage, complete unto itself. Each is a part of the interconnected whole. I doubt that we will ever understand this unity completely.

Researchers have made tremendous strides in identifying the complexities of the mind-body relationship. The intricacies of brain and body invite respect and awe; the interrelation of mind, body, and spirit invites wonder. When pain attacks the body, it affects the mind and the spirit as well.

Yet studies show that epidemiology and spirituality remain distant strangers in much of conventional medicine. According to a poll, health professionals are far less religious than the general public. Nearly three-quarters of the U.S. population agreed with the statement, "my whole approach to life is based on religion," compared with only one-third of psychologists and fewer than 40 percent of psychiatrists. Sixty-three percent believe it's good for doctors to talk to patients about spiritual faith.[18]

David Larson, president of healthcare research for the National Institute of Health, states that less than one-half of one percent of published health research studies includes any basic variables of spiritual or religious commitment.[19] Studies that do take these variables into account show that despite medically-established bias to the contrary, over four-fifths of the general population associate religion and spirituality positively with both physical and mental health. Yet these religious variables are rarely discussed in professional medical networks, and clinicians and researchers continue to exclude religion from their work.

Education about spiritual variables, and openness to their potential role, can enable healthcare providers to become more effective healers. Some people tend to dismiss these variables as just another placebo–something with no scientific benefit, such as a sugar pill, that results in improvement. But even this simple phenomenon is a reminder that

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healing takes place that is not attributable to pharmacological ingredients or administered medical procedures. Perhaps the faith factor does at times function like a placebo–but it is different in a crucial respect: placebos almost always have a declining effect, but the faith factor can result in progressive and lasting improvement.

Growing interest in the interrelationships of spirituality, psychology, and health have put pressure on healthcare professionals to improve care by acquiring the necessary knowledge and skills to handle spiritual variables in practice. Some practitioners are skeptical of the value of religious beliefs simply because of their upbringing and personal experience. Others may oppose the mix of religion and medicine because of the dangerous risks of so-called faith healing; stories regularly hit the news of parents who refuse medical treatment for their children with preventable or curable illnesses. Nevertheless, physicians accept responsibility all the time to care for people who have habits and addictions they disapprove of or consider dangerous, such as alcoholism or heavy smoking. At the very least, they can accept the reality of a patient's belief system as one more factor in the mix. Compared to outright hostility or absolute avoidance, even such reluctant acceptance would be a step in the right direction.

There is a strong case to be made for the wisdom of healthcare professionals in practicing acceptance rather than judgment of a patient's spiritual beliefs. First, it is counter-productive to dismiss spiritual beliefs simply because of personal disinclination or distaste. At a basic level, that dismissal is really no different from indulging in dislike of an obese patient rather than endeavoring to understand the reasons for the obesity. Perhaps more importantly, however, discounting the potential of faith as a positive factor in wellness may very well withhold healing power from the patient.

Sometimes the spiritual dimension is neglected simply because we lack a common understanding of spirituality–it means so many different things to so many different people. For some, it has nothing to do with organized religion. For others, spirituality is defined by and inseparable from a specific religious system. The vast number of religious traditions and endless permutations of sectarian differences within them is confusing. And religious affiliation and belief tends to be viewed as a

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private matter, so that asking about it seems like an intrusion on intimately personal matters. Some professionals are wary of appearing to proselytize, especially when they are encountering people in a highly vulnerable state.

However, incorporating spirituality in medical care can be as simple and basic as treating those in pain and suffering with dignity. This is a way of affirming each individual as a whole human being, not simply a medical problem to be solved. I often tell patients going into the operating room that the O.R. staff is interested not just in their safety and comfort but in their dignity as well. Acknowledging their endurance of adverse circumstances is a way of honoring the whole person. When people are made to feel worthy of individual attention and respect, the severity of their pain tends to lessen. When they are not treated with dignity, suffering usually intensifies.

Honoring patients at their time of death is another way of acknowledging the human spirit. When we're very young, most of us subconsciously believe we will live forever. With a chronic illness or diagnosis of a terminal disease, we lose that naiveté. The fragility of life and the fact that we are here for a temporary moment in time is poignantly clear–but this recognition can become fertile ground for inner growth. Until Elizabeth Kübler-Ross published her groundbreaking book On Death and Dying in 1969,[20] it was not acceptable to talk about this subject with patients in a direct and straightforward way. Healthcare professionals tend to distance themselves from dying patients–perhaps from the discomfort of not knowing what to do once patients are beyond help. But this is the very time when patients need assurance that we will not abandon them in this important part of life–the process of leaving it.

working with the pain

Dr. Paul Brand devoted his life as a doctor to treating sufferers of one of the most feared and despised illnesses in human history: leprosy. His vantage point was unique; few Western doctors have experience in treating this contagious disease. Dr. Brand has lived half of his eighty years in the West, and half in India and other developing countries. I know of no other physician who has such a long track record in contrasting approaches to the medical treatment of pain across two very

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different societies. His experiences, recounted in the extraordinary book Pain: The Gift Nobody Wants, co-authored by Dr. Paul Brand and Philip Yancey,[21] help explain why some people are better able to cope with pain than others. It has less to do with physiology and individualized pain thresholds than we might think.

When Brand began his work, it had been commonly assumed that leprosy caused body parts simply to rot away–thus the characteristic facial disfigurement and loss of fingers and toes which have made lepers the object of loathing and revulsion. Brand knew, however, that the loss of body parts was rooted in the lepers' inability to feel pain in those particular body parts. Because the disease destroyed their nerve endings, they were unaware when damage was being done. Brand saw people casually reach their hands into a fire to retrieve a dropped object, or run on a broken foot, oblivious to the devastating effects on flesh and bone. Even when they were made aware of the damage and warned to take precautions, they were so desensitized by the lack of pain that they inevitably repeated the damaging behavior out of mere convenience, incurring permanent loss.

These observations fed Brand's conviction–and the central insight of his book–that "pain is no invading enemy, but a loyal messenger dispatched by my own body to alert me to some danger." Ironically, it is a gift. Ignoring or suppressing it leads to destruction. Learning to work with it reaps healing benefits.

Brand's observation of cultural differences in how people experience pain is revealing. "I was amazed by the fortitude of East Indian patients and their calm attitude toward suffering," he remarked. "Even after sitting in a crowded waiting room for hours, they did not complain. To them, pain was part of the landscape of life, and could by no means be avoided. Karma philosophy dulled any sense of unfairness about pain; it simply had to be borne." By contrast, we are obsessed with limiting pain. Unless we are aware of and on guard against this obsession, we lose the kinds of coping skills so strikingly evident among Brand's patients.

Our comfortable, materialistic lifestyle in the United States has led us to believe that we have the right and the power to avoid hardship. We feel

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entitled to the good life, and we feel betrayed when it is denied us. "The average Indian villager," comments Brand, "knows suffering well, expects it, and accepts it as an unavoidable challenge of life. In a remarkable way the people of India have learned to control pain at the level of the mind and spirit, and have developed endurance that we in the West find hard to understand. Westerners, in contrast, tend to view suffering as an injustice or failure, an infringement on their guaranteed right to happiness."[24]

We see pain not as a messenger, but as an enemy to be feared and avoided at all costs. Americans, who represent 6 percent of the world's population, consume 67 percent of its manufactured drugs. Yet there is little evidence that Americans feel better equipped to cope with pain and suffering. In India, according to Brand, society "has no illusions about controlling discomfort: In a country where the climate is harsh, tropical diseases abound, and natural disasters roll in with each typhoon, no one can pretend to 'solve' pain. Nonetheless, over the centuries, the culture has discovered ways to help its people cope. A society that lacked many physical resources was forced to turn to mental and spiritual resources."[25] Rather than trying to solve pain by eliminating it with technology and drugs, we would do well to listen to it and then search for the most effective ways to manage it.

Human suffering consists of outer conditions (the painful stimuli) and inner responses, which take place in the mind. Although we cannot always control the outer conditions, we can learn ways to control our inner responses. Cultures in the developing world may lack modern analgesics, but their traditional belief systems, family structures, and community support help them cope with pain. We in the "civilized" West try to manipulate our world, but natural disasters show us that we lack control and that our manipulation is often counterproductive. The same is true of our frantic attempts to control pain and manipulate the environmental and physiological factors that give rise to it. Despite our success in limiting suffering, the intensity of our drive often produces counterproductive results in coping with pain.

The ability to accept misfortune with peace of mind is a testimony to the spiritual capacity of humankind. Pastor and philosophy professor Diogenes Allen describes our common tendency to respond to suffering

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egotistically, with indignation and self-pity–"why did this happen to me?" If we allow this initial response to lead us into genuine reflection, we encounter the hard reality that we are physical beings, part of the natural order and therefore vulnerable to injury, illness, and decay. Although this recognition is humbling, it also points to the realization that we are more than just physical beings. We can transcend our material limitations–and in this sense, we have a spiritual dimension. This dimension is what gives us the ability to rise above "the psyche's self-serving mechanism" in responding to difficulty: "When the flow of our self-regard is painfully interrupted...reflection can lead to a new awareness of our limitations, and it may even lead to our acceptance of such limitations."

We all have opportunities to experience both sides of adversity–closing down or opening up. One choice leads to a narrow existence, dominated by stress; the other leads to a life of greater significance–an existence centered beyond the struggle. The crux of this choice, I believe, lies in the realm of the spirit.

Pain catapults us into the realm of the spiritual by forcing us to re-evaluate questions of meaning and purpose. What is all our striving for, if it leads to loss and bitter disappointment? Why do some people suffer from illness and injury while others enjoy good health and full mobility? Asking these questions will not necessarily lead to definitive answers. But they will lead us to a decision point that demands an answer from us: whether to remain trapped in negativity or to choose to move beyond the pain.
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Steps FOR THE Path:

separating emotions from raw physical pain

1.

Today, I would rate my general pain level as:

0

1

2

3

4

5

6

7

8

9

10

pain free

excruciating pain

2.

Reflect on how your family responded negatively to their pain and suffering. Check all that apply:



Responded to their pain by becoming inactive and withdrawn.



Tended toward hand-wringing and doomsday thinking about the future, focusing only on the worst that could happen.



Invested energy in pointing blame instead of taking personal responsibility to do something positive about their circumstances.



Medicated their pain with drugs, alcohol, or self-destructive cycles of behavior, intensifying their suffering.



Allowed their obsession with pain to erode their relationships and increase their isolation from family, friends, and social circles.



Viewed religious and/or spiritual influences in their life only as triggers for guilt and shame or sources of disillusionment and hypocrisy.

3.

Reflect on how your family responded positively to pain and suffering. Check all that apply:



Engaged in activities that distracted them from pain.
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Remained positive and hopeful about the future, viewing present struggles as opportunities for personal or spiritual growth.



Exhibited self-reliance instead of dependency in creating positive ways of responding to their suffering.



Pursued alternative approaches to alleviating pain instead of looking for a magic formula in the next new drug or technique, easing their suffering.



Reached out to others in spite of their pain, drawing inspiration and hope from their relationships with family and friends and stimulation from social interaction.



Integrated religious convictions or spiritual practices as sources of meaning and purpose, giving them a larger frame-work for understanding suffering.

Other:

4.

Suffering is the emotional response to a physiological problem. Once we recognize that we have the power to choose our responses, we can change the nature of our suffering. Reflect on how your family, cultural, or religious background has affected your present responses to pain.


[14] Robert K. Hudnut. Meeting God in the Darkness. Ventura, CA: Regal Books, 1989, p. 229.

[15] RA Sternbach and B Tursky. Ethnic differences among housewives in psychophysic and skin potential responses to electroshock. Psychophysiology 1965(1): 241-246.

[16] Pema Chödrön. When Things Fall Apart: Heart Advice for Difficult Times. Boston: Shambhala, 1997, p. 12.

[17] Romans 12:2, NRSV.

[18] Tom McNichol. The New Faith in Medicine. USA Weekend, April 5-7, 1996, pp. 4-5.

[19] DB Larson et al. Scientific Research on Spirituality and Health: A Consensus Report. Rockville MD: NIHR 1988.

[20] Elizabeth Kübler-Ross. On Death and Dying. New York: Scribner, 1969.

[21] Paul Brand, Philip Yancey. Pain: The Gift Nobody Wants. Grand Rapids, MI: Zondervan, 1993.

[22] Ibid.

[23] Ibid., p.80

[24] Ibid., pp. 187-188.

[25] Ibid., pp. 233-234.

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