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Key points
- Mental suffering often has a lower priority in our culture than physical pain.
- The issue is complicated by loading mental pain with meaning and morality it does not have.
- Interventions for mental pain can range from acknowledgment to medications, but should not include dismissal because it is "normal."
There is little doubt that in our culture, mental pain is regarded differently from physical pain. To better understand this, we can look at the interesting history of treating physical pain. As we’ll see, the patterns we observe in this history are even evident in debates about mental pain. For our purposes, mental pain includes intense, negative emotional states such as sadness, fear, anguish, or guilt, as well as severe anxiety and complex states such as psychosis.
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’ll 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. This was my introduction to the fact that for most people, pain had a moral component other than human suffering.
Questions about treating severe pain began in earnest with the use of chloroform in the 1800s. Chloroform, which works like anesthesia, was the first drug that could effectively prevent severe pain from surgery. Nonetheless, 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.
The chloroform story does not end with surgery. 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. However, debates about what is natural and presumed better for mother and child make this decision fraught with anxiety and guilt for many women.
The same progress is unfortunately not the case with mental pain. 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?
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. Treating symptoms alone, the thinking goes, erases this route to the unconscious and thus prevents 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 necessary to get better from depression. But it took many years to get past the notion that pain—in this case, mental pain—was necessary for recovering from depression and other common psychiatric disorders.
Although there is wide (but not universal) agreement within the psychiatric community about the treatment of painful mental disorders, the necessity of mental pain in everyday life remains highly debatable.
Where this uncertainty is most apparent is in the pain of loss—most commonly, the loss of a loved one. It is the most difficult end of the spectrum, where severe or unremitting grief reside, that causes most of the controversy.
For years, the notions of “delayed grief” or “incomplete grief” implied that a person stuck in mourning needed to mourn more intensely to complete the process. Many current approaches to grief similarly hold that only by opening to, and welcoming, the pain of loss will you be able to move on to a post-bereavement life.
Some combination of remaining open to your feelings and coping is surely the best approach. But for severe or protracted grief, psychiatric research does not support these notions of grieving or opening more. 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. Again, for years we saw the worst pain of grief as natural and you had to go through it, as if it were a moral imperative.
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 two weeks, the knife was gone. By a month into treatment, he still cried daily, but only 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.
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?
A common experience I had with my own patients and those referred by therapists was that their therapies went much better when their depression and anxiety were treated. The pain of depression announced the problem but after that was just in the way of the growth needed to move past it.
My point in this discussion is that mental pain is too often subject to either dismissal or unneeded scrutiny. Treaters, particularly physicians, should be sensitive to psychological pain, especially anxiety. Doing so does not mean giving medication. It could mean talking, advising a few days off, suggesting they confide in a friend or family member, or even therapy. But it does mean the treater should help in some way. Calling the person’s symptoms “just worry” is to dismiss them as common and unserious.
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. Just as in physical disorders, we must learn to judge when psychic pain is excessive and of no use to the patient. We have—mostly—learned this in common mental illnesses but not in common life with its ups and downs.
Make no mistake, we should no more treat every blip of mental pain than we should physical pain. This still leaves a large swath of mental experience that should be considered as unnecessarily painful.
As professionals, we should always intervene 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.
