Pain and Depression

I’ve decided to take the month of August off. I’m confronting head on, for the first time in my nearly 38 years, the fact that depression has been a frequent visitor in my life.

I’m a fairly private person, and I choose not to expose much of myself on this platform because my personal life is generally not relevant. However, I’m choosing to share this with you now for two reasons which I write about below. Heads up, this is long -- I made up for skipping a July newsletter! I wrote and and re-wrote this several times because it feels like such an incomplete piece of writing. However, I'm reminding myself that I'm not writing a book, and I'm not trying to win awards. I'm only trying to share perspectives on dealing with chronic pain that are beyond what our medical institutions and traditional healthcare offer. Thank you in advance for taking a read.

(For better context, when I refer to pain, I'm referring to chronic pain, not acute. And when I refer to depression, I'm referring to longer depressive episodes not just having a bad week.)

First, I have found it enormously helpful to have conversations with others about what I’m going through. It's helped me realize: I’m not alone, there’s nothing wrong with me, and there are many of us dealing with various forms of depression. I’ve had friends and clients with whom I’ve shared this personal information share back with me personal stories about their own struggles with depression or struggles living with a loved one with depression. So I want to pay it forward and be open to you, so that YOU can feel seen, so that YOU can feel comfortable talking about it, so that YOU don’t feel alone or broken if you’re having, or have had, your own struggles. It also serves as a reminder that what’s on the surface is just the surface. Oftentimes, I receive comments about me having everything figured out because of my lifestyle and the way I present myself. I understand these comments to be both compliments toward me while also being a reflection of what the other person feels they are lacking. I hope by sharing this with you, you can remember that you are not lacking in anything. I have my stuff, you have yours, and they (whomever else you compare yourself to) have theirs too.

Second, as I’ve been trying to understand my own feelings, I'm realizing that it's no different than how I feel about working with those who have chronic pain. Pain education -- giving someone the tools and vocabulary to relate to their pain -- is paramount to functioning with pain.

Depression and pain both involve a complex relationship between an objective stimulus (clear cause or trigger) and a subjective response (internal feelings).

For example, if you’re in the throes of depression because your spouse passed away 6 months ago, the passing of your spouse is a clear objective stimulus, and your feelings of depression are the subjective response. If you’re experiencing low back and leg pain because you know there’s a herniated disc pressing against a nerve, the herniation is the objective stimulus and the feeling of pain is the subjective response. This makes sense, as it seems to be a clear relationship of cause and effect.

But actually, the relationship is oftentimes not so straightforward. Just think, why can one person move on after the passing of a loved one while another falls into a years long depression? Why is someone bed-ridden from a disc herniation while another doesn’t even feel it? Why does financial stress send one person to suicidal depression while another can just hire a financial advisor and manage? Why can someone stay active with knee arthritis while another is incapacitated? The objective stimuli are the the same, yet different people have different subjective responses. This variation in how we feel and behave as humans in response to things that happens to us is the nature of subjectivity, and that subjectivity is the amalgam of literally millions of factors that make us individuals, from genes to experiences and everything in between. But not only does the relationship between stimulus and response vary between individuals, it varies within one person’s experiences. One month, you can barely feel your arthritis, and the whole next month it flares up. One month you feel on top of the world at work, and the next month you’re so down you can’t leave the house — and there are no seemingly reasonable explanations for either situation.

All of this complexity means that pain, like depression, does not follow a detectible algorithm.

Yes, we can sometimes detect patterns. “When it’s raining my arthritis flares up” or “When winter approaches, I slip into a depression." But it’s not usually that simple, and anyone experiencing either condition will tell you, once you think you have the equation down, something happens to disprove it, and you’re back to the drawing board.

The relationship between an objective stimulus and subjective response gets even more complex when you understand that an objective stimulus isn’t even necessary to elicit a subjective response.

In other words, you may experience depression even though nothing depressing happened to you. This can cause confusion, ambiguity, and distress. Is it me? Or is it something else? Did something happen that I don't realize? A friend of mine explained her depression like this: it's like when you get cold in your apartment in the middle of winter and you have no idea if the thermostat is broken or if it's you that's the problem, and it feels like there's no way to find out.

The idea that there can be something wrong without a specific cause, is a hard pill to swallow. It’s an even harder pill to swallow when it comes to physical pain. You may experience pain even though nothing in your body sustained any actual damage. There may be no singular physical cause for your physical pain.

I believe this sense of ambiguity is much less tolerated for physical pain than depression for two reasons. We're still stuck in the bio-medical approach to pain which dictates that there must be tissue damage for something to hurt. AND, we have a preconceived notion that we ought to be physically painless at all times. We think we’re not supposed to hurt. That’s like saying we ought to be happy all the time, that we’re not supposed to feel sad. We all know that’s not how the emotional spectrum of life works. Why then do we have different standards for our physical spectrum?

In either condition, we may endlessly search for the “why” because if we know the problem then we can formulate a solution. When there is no "why", we get stuck. How can we fix the problem if we don’t know what the problem is? Searching for the cause, to avoid just bandaiding the symptoms, can be really important and useful. But, I’m suggesting that sometimes neither of those options are sufficient for chronic pain.

For those with depression, there’s this amazing thing out there to engage in called psychotherapy. You talk to a therapist to help you put the pieces of your puzzle together — it’s a very humanistic approach that involves a relationship of trust and deep introspection. Sometimes you can uncover a cause but it’s rarely so direct. Sometimes you can be prescribed meds but that’s a symptom modifier. Most times, it’s just a better understanding of ourselves and who we are when experiencing these conditions. It’s this mucky middle ground stuff that most of us (myself at the center of the group) don’t like because it’s not definitive.

It’s hard work, but physical pain experiences could truly benefit from the same lens. It’s not always about fixing the pain. If we keep approaching the body like a machine that needs to be fixed, we will come to a dead end time and time again. It’s about how we relate to the pain experience and how we function with it. Of course, we absolutely need to utilize known treatments for relief and we need tools to help mitigate future flare ups (chronic pain and depression have all the same proven modifiers — diet, exercise, sleep, medications, community, mindfulness based practices — best done in some combination). But at the end of the day, it’s our relationship to the pain that might need our attention more than the endless hunt for the why.

I’ve been thinking about it like this lately: your relationship to your pain is a sculpture and you are the artist. Your piece of art is ever evolving and never finishes as you come back to it time and time again to change it, mold it, add to it or take away. Even your relationship to your sculpture (relationship to your relationship - very meta) will shift and change. Sometimes you may be inclined to smash it into a million pieces, and sometimes it feels perfect and ready for display. Most times, it’s somwhere in between.

*It's not lost on me that many people experience depression as a consequence of dealing with chronic pain. I acknowledge that and hope to write more about it in the future. As I mentioned, this is not a complete piece and only offers a limited perspective looking at pain and depression from a very specific lens.

xoxo
keep moving