A Letter to Normals from a Person With Chronic Pain

 Having chronic pain means many things change, and a lot of them are invisible. Unlike having cancer or being hurt in an accident, most people do not understand even a little about chronic pain and its effects, and of those that think they know, many are actually misinformed. In the spirit of informing those who wish to understand: These are the things that I would like you to understand about me before you judge me.

 Please understand that being sick doesn’t mean I’m not still a human being. I have to spend most of my day in considerable pain and exhaustion, and if you visit, sometimes I probably don’t seem like much fun to be with, but I’m still me, stuck inside this body. I still worry about school, my family, my friends, and most of the time; I’d still like to hear you talk about yours, too.

 Please understand the difference between “happy” and “healthy”. When you’ve got the flu, you probably feel miserable with it, but I’ve been sick for years. I can’t be miserable all the time. In fact, I work hard at not being miserable. So, if you’re talking to me and I sound happy, it means I’m happy. That’s all. It doesn’t mean that I’m not in a lot of pain, or extremely tired, or that I’m getting better, or any of those things. Please don’t say, “Oh, you’re sounding better!” or “But you look so healthy!” I am merely coping. I am sounding happy and trying to look normal. If you want to comment on that, you’re welcome.

Please understand that being able to stand up for ten minutes doesn’t necessarily mean that I can stand up for twenty minutes, or an hour. Just because I managed to stand up for thirty minutes yesterday doesn’t mean that I can do the same today. With a lot of diseases you’re either paralyzed, or you can move. With this one, it gets more confusing everyday. It can be like a yo-yo. I never know from day to day, how I am going to feel when I wake up. In most cases, I never know from minute to minute. That is one of the hardest and most frustrating components of chronic pain.

Please repeat the above paragraph substituting, “sitting”, “walking”, “thinking”, “concentrating”, “being sociable” and so on, it applies to everything. That’s what chronic pain does to you.

 Please understand that chronic pain is variable. It’s quite possible (for many, it’s common) that one day I am able to walk to the park and back, while the next day I’ll have trouble getting to the next room. Please don’t attack me when I’m ill by saying, “But you did it before!” or “Oh, come on, I know you can do this!” If you want me to do something, then ask if I can. In a similar vein, I may need to cancel a previous commitment at the last minute. If this happens, please do not take it personally. If you are able, please try to always remember how very lucky you are, to be physically able to do all of the things that you can do.

 Please understand that “getting out and doing things” does not make me feel better, and can often make me seriously worse. You don’t know what I go through or how I suffer in my own private time. Telling me that I need to exercise, or do some things to “get my mind off of it”, may frustrate me to tears, and is not correct. if I was capable of doing some things any or all of the time, don’t you know that I would? I am working with my doctors and I am doing what I am supposed to do.  Another statement that hurts is, “You just need to push yourself more, try harder”. Obviously, chronic pain can deal with the whole body, or be localized to specific areas. Sometimes participating in a single activity for a short or a long period of time can cause more damage and physical pain than you could ever imagine. Not to mention the recovery time, which can be intense. You can’t always read it on my face or in my body language. Also, chronic pain may cause secondary depression (wouldn’t you get depressed and down if you were hurting constantly for months or years?), but it is not created by depression.

Please understand that if I say I have to sit down, lie down, stay in bed, or take these pills now, that probably means that I do have to do it right now, it can’t be put off or forgotten just because I’m somewhere, or I’m right in the middle of doing something. Chronic pain does not forgive, nor does it wait for anyone.  If you want to suggest a cure to me, please don’t. It’s not because I don’t appreciate the thought, and it’s not because I don’t want to get well. Lord knows that isn’t true. In all likelihood, if you’ve heard of it or tried it, so have I. In some cases, I have been made sicker, not better. This can involve side effects or allergic reactions, as is the case with herbal remedies. It also includes failure, which in and of itself can make me feel even lower. If there were something that cured, or even helped people with my form of chronic pain, then we’d know about it. There is worldwide networking (both on and off the Internet) between people with chronic pain. If something worked, we would KNOW. It’s definitely not for lack of trying. If, after reading this, you still feel the need to suggest a cure, then so be it. I may take what you said and discuss it with my doctor. If I seem touchy, it’s probably because I am. It’s not how I try to be. As a matter of fact, I try very hard to be normal. I hope you will try to understand. I have been, and am still, going through a lot. Chronic pain is hard for you to understand unless you have had it. It wreaks havoc on the body and the mind. It is exhausting and exasperating. Almost all the time, I know that I am doing my best to cope with this, and live my life to the best of my ability. I ask you to bear with me, and accept me as I am. I know that you cannot literally understand my situation unless you have been in my shoes, but as much as is possible, I am asking you to try to be understanding in general.  In many ways I depend on you, people who are not sick. I need you to visit me when I am too sick to go out. Sometimes I need you help me with the shopping, the cooking or the cleaning. I may need you to take me to the doctor, or to the store. You are my link to the “normalcy” of life. You can help me to keep in touch with the parts of life that I miss and fully intend to undertake again, just as soon as I am able.

I know that I asked a lot from you, and I do thank you for listening. It really does mean a lot.

ramblings 4

My blog had quite a lot of views and comments yesterday which made me happy for a little while but I was in a deep funk and still am in a deep funk. I don’t know why but I should stop reading about suicidal stuff because it is giving me ideas. I know I already have them in my head but I keep thinking, if I am not suicidal, then should I kill myself? As the saying goes, you should NOT kill yourself when you ARE suicidal. Mostly that is because you are thinking irrationally. But if you have been thinking irrationally for so long, does it become rational at some point? That is where my thinking is heading. I tend to think about killing myself nearly every day. I have yet to act on it for various reasons. Usually it is an in the moment type of thing but lately I have been thinking of a plan and a date. I KNOW it is because of the time of year. Every late September/early October I get seriously depressed, more so than anything. Since 2005 I have planned my death every single year without fail. I don’t know what it is about this time of year that makes me want to kill myself. I know that baseball season is over and that saddens me to no end. I no longer see pitchers on the mound and balls and strikes being called. Right now it is Postseason but I know that baseball will truly end by mid-October. Around that time is when I always think of ending my life.

I don’t know why this time of year brings me to my knees. I just don’t feel like life is worth living anymore. It is a seasonal pattern but doesn’t fit the usual SAD (Season Affective Disorder) criteria (mostly because I have recurrent depression throughout the year anyways). If it did fit, I probably would not be so crazy this time of the year. I’d get a light box and be done with it. But this is something more. I call it the black dog as I show more signs of depression than at any other time of the year. I just feel so worthless and guilty that all I can do is think about my own demise. The physical symptoms I get is more psychological pain, lethargy, fatigue, loss of pleasure and loss of interest (also known as anhedonia), loss of appetite, crying for no reason, worthlessness, guilt, etc.

I don’t know what takes me out of the black dog. Sometimes it is just perseverance, sometimes it is just means extra support from my therapist and psychopharm. I also have the hospital when it gets too much to bear, but I only use that as the last resort. Some people would say that is not right but I have had over thirty hospitalizations over the past twenty years that I know when I need to be in and when I don’t.  Though there is some literature saying that the hospital is under-utilized for suicidal patients the same can be said that it is over utilized as most clinicians do not know how to treat suicidal clients. And that bothers the hell out of me because there is (going on my Jobes soapbox) there is an assessment form easy to use and is applicable to all modes of therapy called the Suicide Status Form (see Jobes, 2009). If more clinicians used this, there would be less hospitalization and suffering and possibly less suicides. Granted my therapist tries to use this during each suicidal crisis but I wave her off. Not because I am a hypocrite, but because it was my idea and not hers mostly. Could this save my life? Possibly but the thing that bothers me is that she only uses one piece of the form. If you are going to use the form, use the whole of it. It will make your notes easier and all you have to do is have each person sign it (it is a collaborative effort on both the client and clinician parts). I love this ingenious form but I hate it when it is not used properly. But then my therapist has known me for upteen years now so knows what information to get from me to get me away from my suicidal thinking. Another form that is NOT used at all that should is the psychache form by Richard Holden at Queen’s University in Canada. That I have used to monitor my psychache and even modified the form for my needs. Every journal I have has the psychache scale in it. I would reproduce it here but it’s not kosher and I don’t want to get in trouble with the web police for copyrighted information. Holden wrote the article in 2001 and it is printed in the Canadian Journal of Behavioural Science, 33(4), 224-232. I find Jobes and Holden to be the best suicidologists in the world because they have come up with assessments that are clinically useful and empirically validated.

In the thick of the Abyss

I don’t know why but the past few days have my mood going down and down instead of in the opposite direction despite the changes in my circumstance. I now know how Poe felt when he wrote I am wretched and know not why. “My feelings at this moment are pitiable indeed.  I am suffering under a depression of spirits much as I have never felt before.  I have struggled in vain against the influence of this melancholy-you will believe me when I say that am still miserable in spite of the great improvements in my circumstances.  I say you will believe me, and for this simple reason, that a man who is writing for effect does not write thus.  My heart is open before you if it be worth reading. Read it.  I am wretched and know not why.  Console me-for you can. But let it be quickly or it will be too late.  Write me immediately. Convince me that it is worth one’s while -that it is all necessary to live, and you will indeed prove yourself my friend.  Persuade me to do what is right. I do not mean this- I do not mean that you should consider what I now write a jest-oh pity me! For I feel that my words are incoherent- but I will recover myself.  You will not fail to see that I am suffering under a depression of spirits which will [not fail to] ruin me should it be long continued.” edgar allan poe

 I truly think that I am a bad person who just deserves evil things to come at me not good. I can’t understand why though. People say that I write good but I think it’s crap. I am supposed to have this editorial position but yet I don’t think I should have it despite the person who wants me to have this job thinks I should. I know she is a better judge of character. I just can’t see anything but darkness right now and for someone to tell me that there is a light at the end of the tunnel, well let’s just hope they don’t because I know I will dope slap them. There is no light as far as I can see. Today is a dreary day and it should make me happy but instead it just eases my gloom because it’s how I feel. I started feeling down Sunday and it’s now Tuesday. I don’t see my mood changing. What is worse is that I had an impulse to put a rope around my neck this afternoon soon as I got home from forcing myself out. It quickly went away but the thought unsettled me. I guess it doesn’t help that I can do this at anytime, anywhere I choose. It won’t take much to do. I just need the guts to do it. I am going down this road and it is horribly painful. I had another incontinent episode today so that further brought me down. You would think I would be used to pissing my pants but I am not. Yesterday I got awarded being disabled and I can’t help but think that I am been demoralized because of it. I no longer feel like I have a right to anything, much less life. It is the price you pay with a damaged nerve and damaged mind. I can’t go back and change things but I can at least appreciate things more. I just hope I am fit enough for the task ahead with this writing that I am doing but I am not so sure.

Writing has always been something that I do to pass time and it has worked well. When I am not writing, I am deeper in the abyss. There have been studies on it but I can’t think of who the guys are right now. Not that it really matter to you, my reader. I have wondered always if I am too smart for my own good. Maybe I am. Maybe I’m not. I don’t know anymore. I just know my heart is broken and I don’t know what caused it to be this way. I am just so damn downhearted and it is just getting worse.

is suicide caused by psychological pain

Since 1949, Edwin Shneidman has done extensive research in the field of suicidology.  He began his research by looking at suicide notes in the coroner’s office in Los Angeles (Shneidman, 1996).  During his intensive research, he came up with the term, “psychache” to refer to the mental pain, which, when intense, makes life so horrible and horrendous, that the sufferer can only think about suicide as the only option out of his/her misery.

Psychache can be defined as “hurt, anguish, soreness, aching, psychological pain in the psyche, the mind (Shneidman, 1996).”  Risk factors associated with suicide are only relevant as far as they can relate to psychache (Shneidman, 1993, 2005).  Dr. Shneidman believes that the true cause of anyone’s thoughts of killing themselves derive from this “psychache.”

During my research for this paper, I concluded that literature concerning the cause for individuals to resort to suicide is sadly lacking.  Most of the assessment scales for determining suicide risk focus on basically, two concepts as proposed by Rosenberg  (1999), action based and affective based interventions. 

Action-based interventions can include items such as a “no suicide” contract, increase sessions or phone check-ins, and, if appropriate, hospitalization. 

Affective based interventions focus on feeling and thoughts that are behind the suicidal ideation. 

Attempts have been made by several researchers for implementing a framework for something close to a “standard” for treatment care that is not determined by litigation (Brown, Jones, Betts, & Wu, 2003; Joiner & Rudd, 2000; Joiner, Walker, Rudd, & Jobes, 1999; Kral & Sakinofsky, 1994; Rosenberg, 1999; Rudd, 1998; Rudd, Joiner, Jobes, & King, 1999; Sommers-Flanagan, Rothman, & Schenkler, 2000; Walker, Joiner, & Rudd, 2001).  Discussion of litigation is not the objective of this paper, so if the reader is interested, Brown et al (2003) would be the work to which one is referred.

The frameworks provided by these researchers have provided many useful scales in determining risk and lethality of suicide, but do not include the assessment of psychological pain.  In Range and Knott’s (1997) analysis of twenty assessment instruments, not one of the twenty examined includes an assessment of psychological pain.  One reason for this is the subjectivity on the individual’s emotions, thoughts, mental state, and experience (Kral & Sakinofsky, 1994).  According to Kral and Sakinofsky (1994), suicidologists are in general agreement that “predicting suicide for a given individual is that, like many human states, the suicidal state has a temporal, fluctuating dimension”.  They propose that the evaluation of psychache experience, the psychological state of the suicidal person, is the key to accurate risk assessment.

Psychache is subjective.  A person is not going to feel the exactly the same way for any length of time.  However, if the level of perturbation (mental anguish) increases in intensity for too long, the individual is going to feel a need to escape from the anguish and despair by any means necessary, including by not existing any more.  If suicide is seen as the only option, the only form of escape, lethality of a suicide attempt is high risk.  Kral and Sakinofsky (1994) have stated that treatment of perturbation will reduce lethality and treatment of lethality ideation will reduce perturbation as these two states can feed off one another (Kral & Sakinofsky, 1994). 

A scale to the assessment of suicide risk would be to have a scale of the person’s needs and current psychological pain.  Dr. Shneidman believes, as do I, that when psychache is intense, perturbation is intolerable, and one or more psychological needs are thwarted or blocked, suicide is seen as the only option of relieving the psychache (Shneidman, 1999).  He has based these needs on described by Henry Murray’s (1938) Explorations in Personality. Shneidman has developed 20 psychological needs.  These needs are weighted and the total sum is 100 (see table 1 for an example).

Table 1

 

Murray Need Form

­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________________________________
Subject: ____________________Sex: _______Age: ______Rater:________Date:_______

­­­­­­­­­­­­­­­­­­­­­­­_______________________________________________________________________

_____   ABATEMENT          The need to submit passively; to belittle oneself.

_____  ACHIEVEMENT      To accomplish something difficult; to overcome.

_____  AFFILIATION         To adhere to a friend or group; to affiliate.

_____  AGGRESSION         To overcome opposition forcefully; fight, attack.

_____  AUTONOMY           To be independent and free; to shake off restraint.

_____  COUNTERACTION                       To make up for loss by retrieving; get even

_____  DEFENDANCE        To vindicate the self against criticism or blame

_____  DEFERENCE           To admire and support, praise emulate a superior

_____  DOMINANCE          To control, influence, and direct others; dominate

_____  EXHIBITION           To excite, fascinate, amuse, entertain others

_____  HARMAVOIDANCE          To avoid pain, injury, illness, and death.

_____  INVIOLACY                        To protect the self and one’s psychological space.

_____  NURTURANCE       To feed, help console, protect, nurture another.

_____  ORDER                     To achieve organization and order among things and ideas

_____  PLAY                                    To act for fun; to seek pleasure for its own sake.

_____  REJECTION             To exclude, banish, jilt, or expel another person.

_____  SENTIENCE             To seek sensuous, creature-comfort experience.

_____  SHAME-AVOIDANCE       To avoid humiliation and embarrassment

_____  SUCCORANCE       To have one’s needs gratified; to be loved

_____  UNDERSTANDING                        To know answers; to know the hows and whys.

100

(Shneidman, 1999; used with permission)
References:

 

Brown, G. S., Jones, E. R., Betts, E., & Wu, J. (2003). Improving suicide risk assessment in a managed care environment. Crisis, 24(2), 49-55.

Joiner, T. E., & Rudd, M. D. (2000). Intensity and duration of suicidal crises vary as a function of previous suicide attempts and negative life events. Journal of Counseling and Clinical Psychology, 68(5), 909-916.

Joiner, T. E., Walker, R. L., Rudd, M. D., & Jobes, D. A. (1999). Scientizing and routinizing the assessment of suicidality in outpatient practice. Professional Psychology: Research and Practice, 30(5), 447-453.

Kral, M. J., & Sakinofsky, I. (1994). Clinical model for suicide risk assessment. Death Studies, 18, 311-326.

Murray, H. A. (1938). Explorations in personality. New York: Oxford University Press.

Range, L. M., & Knott, E. C. (1997). Twenty suicide assessment instruments: Evaluation and recommendations. Death Studies, 21(1), 25-58.

Rosenberg, J. I. (1999). Suicide prevention: An integrated training model using affective and action-based interventions. Professional Psychology: Research and Practice, 30(1), 83-87.

Rudd, M. D. (1998). An integrative conceptual and organizational framework for treating suicidal behavior. Psychotherapy, 35(3), 346-360.

Rudd, M. D., Joiner, T. E., Jobes, D. A., & King, C. A. (1999). The outpatient treatment of suicidality: An integration of science and recognition of its limitations. Professional Psychology: Research and Practice, 30(5), 437-446.

Shneidman, E. (1996). The suicidal mind: Oxford University Press.

Shneidman, E. S. (1993). Commentary: Suicide as psychache. Journal of Nervous and Mental Disease, 181, 147-149.

Shneidman, E. S. (1996). Suicide as psychache.New York and London: New York University Press.

Shneidman, E. S. (1999). The psychological pain assessment scale. Suicide and Life-Threatening Behavior, 29(4), 287-294.

Shneidman, E. S. (2005). How I read. Suicide and Life-Threatening Behavior, 35(2), 117-120.

Sommers-Flanagan, J., Rothman, M., & Schenkler, R. (2000). Training psychologists to become competent suicide assessment interviewers: Commentary on Rosenberg’s(1999) suicide prevention. Professional Psychology: Research and Practice, 31(1), 99-100.

Walker, R. L., Joiner, T. E., & Rudd, M. D. (2001). The course of post-crisis suicidal symptoms: How and for whom is suicide “cathartic”? Suicide and Life-Threatening Behavior, 31(2), 144-152.

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