I have been catching up on my summer reading: Haider Warraich. (2023). The Song of Our Scars: The Untold Story of Pain. New York: Basic Books, 309 pp.
Haider Warraich, MD, has provided an account of our relationship with pain and suffering that is a “physician heal thyself” moment and narrative. Warraich’s work is a powerful combination memoire and biological-clinical briefing on the distinction between acute and chronic pain. Now an assistant professor at Harvard Medical School, the author experienced a life altering back injury while he was in medical school. Suffice to say, the results were an entire encyclopedia of pains, extending from acute to chronic and back, and providing the reader with a compelling narrative of what medical science does not know about pain. Warraich has a way with words and catchy phrases. For example, regarding pain, “The human brain is not just staffing the ticketing booth as the [pain] circus – it is the ringleader” (p. 10). Just so.
Warraich argues: “To course-correct our approach to pain, we need to change the story of chronic pain – pushing back on the voices attempting to convince us all pain is catastrophic and life threatening and needs immediate attention over everything else right now” (p. 253). And yet the good doctor acknowledges that pain puts the person in pain in prison (p. 78). Chronic pain mirrors incarceration (p. 78); and, as for acute pain, the house is on fire and the patient is in it. Summon emergency services!? Elaine Scarry’s The Body in Pain (pp. 232 – 233) is quoted approvingly as additional reading demonstrating that pain presents as requiring urgent attention. Pain resists language, and, when inflicted, for example, in torture, can destroy one’s humanity and integrity and world, requiring long, arduous, and doubtful recovery.
Warraich provides a series of engaging briefings on aspects of pain. The reader gets three basic distinctions differentiating: acute from chronic pain; pain as such versus painful emotions such as fear (e.g., pp. 54, 65), which this reviewer would gloss as “suffering”; and pain in the context of the relationship between mind and body.
Acute pain is exemplified by such experiences as an appendicitis, a broken bone, closing the car door on one’s finger, or dropping a brick on one’s toe. Ouch! In contrast, chronic pain is morning body ache and other intermittent and recurring aches, cramping from irritable bowel syndrome, osteoarthritis, hard-to-describe headaches, or the consequences of multiple back surgeries to the spine. Chronic stress – the boss is a bully, the kids are misbehaving, the spouse is having a midlife crisis,the commute back to the office is unavoidable, the toilet is clogged – results in chronic pain (p. 177). “When people become trapped in the clutches of chronic pain and chronic stress, their lives become engulfed in an eternal, inextinguishable fire – a fire as ferocious as the one that drives the hunger for profit that fuels many modern pharmaceutical giants” (p. 179). Thanks to neuro-plasticity (a key distinction further defined below), chronic pain reorganizes the nervous system. The body expresses the imbalance, the dis-equilibrium, of the mind and its emotions (the latter, admittedly, not distinctions covered in medical school in any detail). Chronic pain stops being a symptom of an injury and it takes on a life of its own, presenting as if the pain were a disease in itself instead of a signal of an underlying or related bodily injury. Chronic pain leads to suffering, a term that Warraich mentions but does not explicitly elaborate. For example, if pain is the dentist hitting an exposed nerve, suffering is being in the waiting room anticipating the dentist hitting the nerve.
According to Warraich, medicine is very good at anesthetizing the mammalian nervous system against such acute pain, but the use of the same anesthetics and analgesics against suffering is a deal with the devil. It might work in the short term; but be sure to read the fine print. The road to hell is paved with such agreements, which, it turns out, is a redescription of the opioid epidemic. In the following, Warraich writes “pain”, but it would be more accurate to say he means “suffering”: “The confluence of advances in medicine and a barrage of pharmaceutical companies marketing directing to doctors and patients birth a movement that deemed suffering unacceptable. As spiritual voids gaped inside those economically left behind and loneliness became a way of life, people in pain [i.e., suffering] kept being sent exclusively to doctors’ offices and pharmacies [for opioids to numb the pain]” (p.147). Loneliness is indeed painful, and poverty is definitely bad for one’s health, but not in the same way as a toothache or appendicitis – loneliness and poverty are chronic and make a person cry real tears of frustration, isolation, neglect, and anger. Yet the suffering is not localized like a toothache or peripheral injury, but seems to pervade the head and chest, calling forward a sense of being burdened by something imponderable and diffuse throughout one’s upper body. In chronic pain and the suffering brought forth by chronic pain, instead of the injured organism telling the brain of the peripheral injury in the limb by means of a pain signal upward to the brain, the brain (or, to be exact, the thoughts in it) are sending the signal in the other direction – downward – telling the organism to hurt. This may be specific, if there is a specific injury able to express the suffering, but more likely the pain points are diffuse and mobile – hard to define lower back pain (e.g., Warraich’s injuries), headaches, irritable bowel syndrome, autoimmune disorders. In short, acute pain is the organism telling the brain it (the skin or peripheral limb) is hurting; whereas chronic pain is the brain telling the organism it is hurting. However, the message is highly susceptible of distortion. In some ways, chronic pain can become the memory of pain, which may or may not indicate a current injury. Chronic pain can become the fear of pain itself, expanding into pain in the here and now. In short, opioids are effective in treating acute pain but are ineffective and harmful – I would say “a deal with the devil” – in treating chronic pain (p. 174).
The poster child that not all pains are created equal is phantom limb pain. Documented as early as the American Civil War by Silas Weir Mitchell, individuals who had undergone amputation, felt the nonexistent, missing limb to itch or cramp or hurt. The individuals experienced the nonexistent tendons of the missing limb as cramping and even awakening the person from the most profound sleep due to pain (pp. 110 – 111).
Fast forward to modern times and Ron Melzack’s gate control theory of pain marshals such phantom limb pain as compelling evidence that the nervous system contains a map of the body and its pains point, which map has not yet been updated to reflect the absence of the lost limb. In effect, the brain is telling the individual that his limb is hurting using an obsolete map of the body – the memory of pain. Thus, the pain is in one’s head, but not in the sense that the pain is unreal or merely imaginary. The pain is real – as real as the brain that is indeed in one’s head and signaling (“telling”) one that one is in pain.
One question that has not been much asked is whether it is possible to have something similar to phantom limb pain even though the person still has the limb functionally attached to the body. For example, the high school football player who needs the football scholarship to go to college because he is weak academically but actually hates football. He really incurs a painful soft tissue sports injury, which gets elaborated emotionally and psychologically, leaving him on crutches for far-too-long and both physically and symbolically unable to move forward in his life. Thus, due to the inherent delays in neuroplasticity – the update to the map is not instantaneous and one does not have new experiences with a nonexistent limb – pain takes on a life of its own. That is the experience of chronic pain – pain has a life of its own – pain becomes the dis-ease (literally), not the symptom. What then is the treatment, doctor?
Warraich radicalizes the issue of pain that takes on a life of its own before suggesting a solution. After providing a short history of opium and morphine and opioids, culminating “in the most prestigious medical school on earth, from the best teachers and physicians, we [medical students] were unknowingly taught meticulously designed lies” (p. 185), that is, prescribe opioids for chronic pain. The reader wonders, where do we go from here? To be sure opioids have a role in hospice care and the week after surgery, but one thing is for certain, the way forward does not consist in prescribing opioids for chronic pain.
After reviewing numerous approaches to integrated pain management extending from cognitive behavioral therapy and acceptance and commitment therapy (ACT) to valium, cannabis and Ketamine – and calling out hypnosis (hypnotherapy) as a greatly undervalued approach (no exteranl chemicals are required, but the issue of susceptibility to hypnotic suggestibility is fraught) – Dr Warraich recovers from his own life changing back injury in a truly “physician heal thyself” moment thanks to dedicated PT, physical therapy (p. 238). If this seems stunningly anti-climactic, it is boring enough to have the ring of truth earned in the college of hard knocks, but it is a personal solution (and I do so like a happy ending!), not the resolution of the double bind in which the entire medical profession finds itself (pp. 188 – 189). The way forward for the community as a whole requires a different, though modest, proposal.
Let us allow Dr Warraich to speak for himself: “I have come to believe a good doctor has an almost magical quality to feel what their patients feels – to see how they view the world, understand where they have been and what they’ve have seen all in an instant – as well as the knowledge and expertise to respond ethically to what they see from the other side. This superpower has a name: empathy” (p. 238). Never underestimate the power of a good listening. “’Mental distress may be perhaps the most intractable pain of all,’ she [Cicely Sanders] wrote, and the answer to it was not always more drugs, because for some ‘the greatest need is for a listener’” (p. 159).
Putting pain in the context of the relationship between soul and body, the body in pain expresses the suffering of the soul. While psychiatry and neurology do not even believe in the soul, they do begrudgingly allow that there is such a thing as “mental status,” which, for example, can be compromised by the hormonal imbalance of puberty, existential anxiety, jet lag, alcohol, delirium, or other insults to the organism such as blunt trauma, which, in turn, implies a conscious mind to have such a mental status. Here’s the issue: humans are neurons “all the way down,” but then the neurons start to generate consciousness – consciousness generates meaning – meaning generates language and relatedness, language and relatedness generates community, culture, art, literature, science, and humanity. However, there are numerous details that need to be filled in here, which are still the target of inquiry and ongoing research, and you won’t learn or be allowed to study them in medical school. I hasten to add that if you are experiencing a compromised mental status due to delirium, don’t call a hippie or professor of comparative literature – you need a medical doctor!
Notwithstanding my whole-hearted endorsement of Dr Warraich’s contribution – get multiple copies of this book and give it to your friends to read – this is not a softball review. Three criticisms come to mind.
First, Warraich rightly criticizes Rene Descartes’ (1596 – 1650) abstraction of the mind (including consciousness and consciousness of pain) from the body. Having divided the unity of the human being into two parts, mind (soul) and body, Descartes then needed a way to explain the communication between them. The mind obviously does not direct the body the way the pilot of a boat steers the craft. Absent neuro-pathology, the mind and the body are a near perfect unity. The body is the perfect servant of the mind – it prepares a cup of tea without my having to communicate the desire as if to a separate entity. It just knows and starts boiling the water. Descartes solution was to propose the pineal gland as the seat of the soul in the body. Warraich does Descartes one better by developing an entire narrative about the brain’s posterior insular cortex and anterior insula, identifying a novel kind of neuron, a von Economo neuron (p 63), from which pain emerges as an emotion generated by a physical sensation. An ingenious solution, which, however, is still a category mistake. What is missing – and here it is not Warraich’s issue but a general shortcoming of philosophy of science – is an account of emergent properties such as, for example, how mental states come forth from physical processes and, just as importantly, how mental states cause physical ones (as when one literally worries oneself sick).
Second, as regards the personal parts of the author’s narrative, pick a story and stick to it. The personal narrative starts out that the potentially life changing back injury is described as tissue damage (p. 5) – the painful consequences of which should never be underestimated. But by page 91 this is redescribed as a “broken back.” Literally? The value here is in describing how the patient’s relationship to pain influences his life and how Warriach has to transform his relationship to pain in order to recover his life as a medical doctor and his contribution to healing. Of course, one could have both tissue damage and a broken back. Here highly recommended reading, in comparison to which Warraich is a modest contribution, is Arthur Kleinman’s The Illness Narratives. Stories about how chronic pain transforms one’s life, including (for example) how repeated surgeries result in a “failed back” (which technically is different than a “broken back”). Such narratives are bound to give the reader pause that medical science (or even comparative literature) understands the relation between mind and body.
Finally, regarding the magical quality of empathy, I am a strong advocate of empathy, having published extensively on its applications. Never underestimate the power of empathy, and Warraich properly calls out the “empathy gap” in medicine (p. 244). But Warraich gives empathy a bad name in that he leaves empathy vulnerable to the critique that the above-cited magical power of empathy leads to compassion fatigue, empathic distress, and burn out. It can and does. This requires treatment too. Human beings are a complex species. They can be kind, generous, and empathic; but, as painfully demonstrated by the opioid epidemic, they can also be greedy, grasping, aggressive, territorial, bullying, experts in know-it-all-ism that obstructs listening, and exploiters of politics in the negative sense. The short empathy training is to drive out all these negatives, and empathy naturally and spontaneously comes forth. People (i.e., doctors) want to be empathic and will be so if given half a chance. The challenge is that the healing professions are constantly exposed to pain, suffering, trauma, and patients who can be difficult and unempathic precisely because they are in pain – or because they were difficult people prior to getting sick or hurt. A rigorous and critical empathy knows it can be wrong, breakdown, or misfire, so such an empathy also knows it can be validated. This reviewer believes Warraich’s compelling narrative may usefully have begun where it ends – with empathy and how empathy made a difference in his recovery and his daily life in the world of corporate medicine and at the Veteran’s Administration (VA). The VA has been criticized – “taken heat” – for not addressing post-traumatic stress disorder (PTSD) until it is dismissed and returns as substance abuse, but, based on Warriaich’s reports (p. 248), the VA is doing breakthrough work in integrated pain management, meditation and hypnotherapy, ACT, reduction in prescribing opioids, and they may become a model for other providers. Dr Warraich’s matriculation in the college of hard knocks of chronic back pain gives him standing to elaborate such an empathic approach, and perhaps he will do so in a follow up publication.
Additional Reading
Lou Agosta. (2018). Empathy Lessons. Chicago: Two Pairs Press.
Arthur Kleinman. (1988). The Illness Narratives. New York: Basic Books.
Elaine Scarry. (1985). The Body in Pain. Oxford: Oxford University Press.
(c) Lou Agosta, PhD, and the Chicago Empathy Project
Categories: talk therapy
Empathy Lessons 