Stoic advice: chronic pain

Chronic pain[Feel free to submit a question for this column, addressing it at massimo at howtobeastoic dot org.]

K. wrote: I read your response with interest to the person who regretted their back surgery. I have a similar situation, though my first surgery (that messed up my back) was seven years ago, and although I do have regret, and have had it for years (I really think we should be allowed one “undo” in life!) my question is about how much to try and change a particular situation and how much to accept.

Since my first back operation, I have been left with constant, chronic pain which is made worse by sitting, standing or walking. I have gotten a bit better over the past few years, but many things I have tried haven’t helped (or made things worse) and my progress is incredibly slow. I am in a better place than I was a few years ago, but I still can’t do basic things, like go on public transport, work, see a film, or even sit in a taxi (I have to lie down). My question is, how much of this do I accept and how much do I try and change? People are constantly suggesting things for me to try, or recommending practitioners to see, and there are more treatments out there than people in the world, it seems. So how do I work out the subtle line between accepting my ability and pain as it is, and trying new things in the hope of it getting better? I should say that medically, it is impossible to say whether I will or will not get better, but there is the possibility, elusive as it is!

So, in a situation where one doesn’t know whether it can get better or not, is it better to keep trying (for many years) or to just accept what is? 

To begin with, I’m sorry you are having such a tough time. You are right, if life were intelligently designed we would all get at least one do-over. Unfortunately, that’s not the way it works, apparently.

Your situation is actually very similar to that of a famous ancient Stoic who quit the school and went Cyrenaic because he suffered from chronic pain. Diogenes Laertius tells us the story:

“Dionysius, who became a renegade to the doctrine of pleasure, for owing to the severity of his ophthalmia he had no longer the nerve to call pain a thing indifferent.” (Lives of the Eminent Philosophers, VII.37)

Of course, Dionysius [of Heraclea, ever since known as the Renegade…] apparently seriously misunderstood in what sense pain is an “indifferent” for the Stoics: it does not mean that one shouldn’t care or be bothered by it, but rather that one should not allow the pain to define who he is a person, especially in moral terms. Apparently, the confusion between Stoicism and stoicism was alive and well already at that time, in Zeno’s generation!

Pain, even chronic one, is for the Stoic yet another obstacle thrown at us by life, and hence an occasion to test our character, according to Epictetus:

“Provoked by the sight of a handsome man or a beautiful woman, you will discover within you the contrary power of self-restraint. Faced with pain, you will discover the power of endurance. If you are insulted, you will discover patience. In time, you will grow to be confident that there is not a single impression that you will not have the moral means to tolerate.” (Enchiridion 10)

But it is, as usual, Seneca who is capable of seeing things from the most humane perspective:

“‘What then,’ you say; ‘is there no difference between joy and unyielding endurance of pain?’ None at all, as regards the virtues themselves; very great, however, in the circumstances in which either of these two virtues is displayed.” (Letter LXVI. On Various Aspects of Virtue, 14)

And moreover:

“There is great difference between joy and pain; if I am asked to choose, I shall seek the former and avoid the latter. The former is according to nature, the latter contrary to it. So long as they are rated by this standard, there is a great gulf between; but when it comes to a question of the virtue involved, the virtue in each case is the same, whether it comes through joy or through sorrow.” (LXVI. On Various Aspects of Virtue, 19)

Marcus, on his part, strikes what sounds to me like an intermediate note between the stern Epictetus and the more approachable Seneca:

“Death and life, honor and dishonor, pain and pleasure — all these things equally happen to good men and bad, being things which make us neither better nor worse. Therefore they are neither good nor evil.” (Meditations II.11)

The message in all three cases, however, is clear: pain is a highly dispreferred condition, and naturally so. But it isn’t something that should lead us to do unvirtuous things, and indeed should be approached as any another exercise in Stoic endurance.

So far the general philosophy. Let me get now to your specific question: where, exactly, is the line between acceptance and continued hope? To begin with, I’m going to remind you of one of the precepts of modern Stoicism, the so-called axiom of futility as articulated by Larry Becker in A New Stoicism (and I remind you that Larry knows something himself about crippling conditions, so he ain’t kidding):

“Agents are required not to make direct attempts to do (or be) something that is logically, theoretically, or practically impossible.” (A New Stoicism, p. 44)

Let’s apply the axiom to your specific problem. Clearly, it is not logically impossible to find a remedy for chronic pain. The existence of such a remedy would not violate any principle of logic, such as the law of non-contradiction, for instance. As a biologist (though certainly no expert on pain), I would imagine that countering chronic pain is also not theoretically impossible, meaning that there is nothing in human biology that excludes the possibility a priori (as opposed to, say, human powered flight, which is, in fact, biologically impossible).

That leaves us with practical possibility. Some things may be both logically and theoretically possible, and yet a wise person ought not to pursue them because the practicalities of the situation put them squarely outside of one’s reach. For instance, there are neither logical nor theoretical obstacles to me becoming a Wall Street magnate, but — quite apart from the fact that I have no interest whatsoever in such venture — it would be practically impossible. I am past middle age, not sufficiently smart and educated in the pertinent fields (finance, math), and probably not endowed with the sort of aggressive character traits that are required to succeed.

I am not going to insult your intelligence by giving you advice on yet more treatments or approaches you could try. It is not my field of expertise, and I assume you have read plenty on the matter, and talked to more than enough doctors. But it is empirically the case that some people do manage to improve significantly from conditions similar to the one you describe, so the possibility is, indeed, out there.

Should you pursue it or accept your current state of things? The question is often framed, as you did, as a sharp dichotomy: either X or not-X. But the two are not logically antithetical, and the dichotomy is not, in my mind, quite that obvious. I think that, after years of trying and achieving comparatively little improvement, it is indeed time for you to accept the possibility that you may need to live with this condition for the rest of your life. In that sense, Stoic philosophy may be a powerful tool not just to lead you to such acceptance, but also to help you deal with the situation day by day. (That said, remember that Stoicism is a philosophy, not a magic wand.)

But it certainly will not hurt you to keep exploring further possibilities of improvement, so long as they appear to be both theoretically valuable, scientifically speaking (no pseudoscience, please!), and practical (in terms of expected effort-to-results ratio and financially). The best person to decide whether a potential new approach fits these criteria is you, on the basis of your experience, your readings, and in consultation with reputable doctors.

The key thing to keep in mind, however, and what will allow you to balance acceptance and hope, is the dichotomy of control, especially as explained by Cicero in book III of De Finibus:

“If a man were to make it his purpose to take a true aim with a spear or arrow at some mark, his ultimate end, corresponding to the ultimate good as we pronounce it, would be to do all he could to aim straight: the man in this illustration would have to do everything to aim straight, yet, although he did everything to attain his purpose, his ‘ultimate end,’ so to speak, would be what corresponded to what we call the Chief Good in the conduct of life, whereas the actual hitting of the mark would be in our phrase ‘to be chosen’ but not ‘to be desired.’” (III.22)

You are the archer, the pain is the target. You know the rest.

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Categories: Stoic advice

15 replies

  1. As ever an interesting and thought provoking read Massimo. Personally, I experience chronic back pain (possibly linked to having Crohn’s Disease) but on a lower level as such.
    I came across Stoicism a few years ago while trying to address both an interpersonal and intrapersonal dilemma around my ‘difficult’ now late father.
    Initially I endeavoured to focus, in my amateur way, on the four cardinal virtues of wisdom, courage, justice and self-discipline, and discovered they often complemented each other.
    I found the practice of determining things in my control/ not in my control of huge relevance and consequent benefit, and, with much practice, have gradually been better able (still a work in progress) to remind myself that it is not the action, but my reaction that primarily influences my well being.
    These skills I have found transferable to many and varied aspects of my life including managing both my Crohn’s and chronic back pain.
    Also I found reading Viktor Frankl and James Stockdale, as I see stalwarts of Stoicism, both enlightening and a source of encouragment.
    To conclude, may I wish K, yourself Massimo, and all a peaceful and harmonious 2018.
    Eric

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  2. Excellent response, Massimo, and it seems to apply as much to all those frustrations that arise from character flaws in ourselves and others as it does to chronic physical pain. I look forward to learning more from you in 2018. Happy New Year.

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  3. Acceptance is a critical element in addressing chronic pain and in many cases avoiding more iatrogenic pain. It reminds me of Johnny Cash and his situation with chronic jaw pain. I used his quote and story in a piece I wrote on my blog:

    Johnny Cash: “No. I’m not very brave because for five years I didn’t try to take the pain. I fought it. I had a total of 34 surgical procedures on my left jaw. Every doctor I’ve been to knows what to do next, too. To relieve me of pain, I don’t believe any of them. I’m handling it. It’s my pain. I’m not being brave either. I’m not brave at all after what I’ve been through, I just know how to handle it.”

    That quote is a lesson in acceptance and also what can be expected from doctors in this situation.

    Disclosure – I am a physician and I treat addiction and chronic pain.

    George Dawson

    http://real-psychiatry.blogspot.com/2015/06/johnny-cash-on-doctors-and-chronic-pain.html

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  4. I’ve always thought the line from Lawrence of Arabia is quite Stoic: “The trick isn’t not feeling the pain, it’s not minding the pain.”

    Liked by 1 person

  5. I have two critiques of Massimo’s response to this very important question. (NB I also suffer from severe chronic back pain, and have been practising Stoicism for about 18 years).
    1) It seems an error to say Dionysius made some mistake in interpreting Stoic doctrine; the example is given throughout history since then because severe acute pain is a limit case test. If Stoicism is viable it must help in real life, not only in logical arguments over indifferents.
    2) The archer and target analogy does not work in the way you end the reply. The target cannot be the pain.

    In this case it could be pointed out that ‘accepting what is’ and ‘keeping on trying [to find solutions]’ are not mutually exclusive. We can do both.

    I don’t think it would insult anyone’s intelligence to offer practical solutions. Indeed we have recently discussed this in the London Stoics meetings, and I was so grateful for their input. I found Seneca’s suggestion (a form of cognitive distraction perhaps) whereby one brings to mind a succession of virtuous deeds by ourselves or others, a surpringly effective, albeit quite temporary method to relieve pain. For me this was more useful than the many mindfulness approaches that I’ve tried.

    Wishing you well
    Paul

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  6. Paul,

    Thanks for your input, but I have to disagree. First, I stand by my opinion that Dionysius made an error of interpretation. Specifically, he seems to have thought that Stoicism somehow tells you that pain is not debilitating. Of course it is. But if it is not under your control to make it go away then what? I doubt that his move over to the Cyrenaics made it magically disappear.

    Second, I don’t see why the analogy of the archer doesn’t work here. The target is the pain in the sense that your “arrow” aims at making it go away. Your arrow is whatever medical or psychological technique you are about to try. To make the attempt is in your power, to succeed is not.

    I did point out that acceptance and continued search for a solution are not, in fact, mutually exclusive.

    As for insulting intelligence, K. wrote that everyone tells her what to try next, so I assumed that she did not want yet another random guy with no specific expertise to add to the pile.

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  7. Thank you for such a quick reply Massimo.

    As a noted philosopher trained by Zeno himself, I’m not persuaded that Dionysius didn’t grasp the theory. It was his pain which made him question the philosophy. Classic problems within the school weren’t dismissed as misunderstood theory. As D Laertius says about him: ‘For so violent was his suffering that he could not bring himself to call pain a thing indifferent.’ I agree with you that giving up Stoicism won’t have made the pain go away, but perhaps we, as ‘Stoics’, still need need to tackle his challenge directly; I’m suggesting with cognitive help rather than only with the theory of indifferents. Epictetus gives lots of methods for dealing with desires, for example, and even ill health, but not severe pain as I recall. There were a couple of other Stoic methods for pain suggested in the London Stoics group but perhaps you prefer another thread for those?

    Yes, I see you also made the point that ‘acceptance’ and ‘seeking solutions are not mutually exclusive’. I found the archer analogy confusing because we are not aiming for/at pain. It raises a good question about what people with chronic pain might aim for: relief, numbness, distraction, forgetting, ‘normal sensation’…?

    By the way, I do subscribe to the theory of indifferents and am not a renegade myself.

    Wishing you well
    Paul

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  8. As a physical therapist who treats chronic back pain and has a serious, albeit new found interest in Stoicism, this post struck my interest.

    I agree with the importance of “acceptance”, which is the last step in the grieving process. You need to accept that this may indeed be something you will need to learn to manage and not cure. We also have to accept that life is more like a wrestling match than a dance, and is by definition, difficult. I am sorry yours has been more difficult than most. Fortune has dealt you bad hand.

    I also agree with the importance of the dichotomy of control. Make a list of what is within the realm of possibility from a physical, financial, and emotional framework and do what you can do to improve your situation. Check each one off down the list.

    There has been an abundance of ground breaking research on pain neuroscience in recent years. I would encourage you to do what you can do in order to educate yourself on the nature of pain. In short, pain was designed as a self-preservation mechanism. This mechanism creates changes in the nervous system that basically sensitizes the brain to the pain signals. Fear of the unknown and the cause of the pain and making it worse exacerbates the symptoms.

    As a physical therapist of course I have a bias towards exercise. I would encourage you to seek a physical therapist in your area that 1) has a basic understanding of pain neuroscience 2) utilizes a bio/psycho/social approach “treats the whole you” 3) can implement a graded exercise program 4) highly skilled in a hands on manual therapy approach. Even if the exercise and manual therapy doesn’t help your pain, at least you have done what you can do so that the pain does not rob you of your mobility and the ability to function in society as you will be able to move about better with stronger more flexible muscles. You will also learn to exercise in manner that does not exacerbate your symptoms, giving you a sense of self efficacy knowing you are able to do something to improve your condition. A sense of self efficacy is extremely important in the management of your symptoms. It’s important you find the exercise enjoyable or you won’t adhere to the program.

    I agree with the last quote as well. It is probably more important to be “process oriented” rather than “outcome oriented” as the process of getting better is up to you, but the outcome, as so many things in life, is not. I wish you the best in your journey.

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  9. Paul,

    Glad to hear you are not a renegade! But sorry, I’m going to stick with my interpretation of Dionysius’ departure. Of course we don’t known enough about what happened, but if someone says something along the lines of “my pain is such that I cannot be indifferent about it” that someone seems to me to have very clearly misunderstood what a dispreferred indifferent is. Is he saying that the pain makes him an immoral and unvirtuous person? Because that would be problematic. If not, then he was confused about the concept of indifferents.

    I’m not sure what you mean by the need for Stoicism to tackle this challenge directly. Stoicism (as I wrote here: http://tinyurl.com/ycnpca4p) is a philosophy, not a type of physical therapy (or an all-purpose magic wand). Obviously someone like K. needs to seek the best medical expertise, engage in meditation exercises (if they help), and so forth. But she also still needs (I think) a philosophy of life to help her put things into a broader perspective and guide her general choices. That’s where Stoicism comes in, not in the direct treatment of pain, or any other physical or mental condition.

    Wishing you well too, and a happy new year!

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  10. Decades of experience with low back pain and study of the subject have led me to Cory’s views on the subject. There’s probably nothing wrong with my lower back other than it’s hypersensitive to pain, resulting in routine aches and occasional prolonged spasms. Recommendat

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  11. ….Recommendations for lower back exercises are just one more reason to exercise regularly, which I should be doing anyways. Low back pain isn’t necessarily worse than musculoskeletal pain in other areas and I find it much less painful than, for example, calf or hamstring pain. But a bout of low back pain can make moving around exceedingly difficult. Hence, the large amounts of time and resources people are willing to put into overcoming low back pain. While my lower back is a nuisance, Fortune has so far allowed me to escape the constant, chronic pain K. must endure, and she has not placed any other physical barriers on me. Reading stories like K.’s reminds me how comparatively easy Fortune has made it for me to lead a virtuous life. Fortune has given me no excuses! I would recommend to K. that she try those back exercises, per Cory. I incorporate exercises aimed at my lower back in my biweekly strength training sessions. I’ve never regretted devoting 30 minutes or so to a strength training workout a couple of times a week. They always make me feel like I’ve accomplished something, even if I have no way of immediately knowing what, if any, benefits I derived from the workout.

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  12. As a supplement, I’d like to link an essay which was written by a Stoic who suffers from chronic pain. http://modernstoicism.com/in-praise-of-chronic-pain-a-stoic-meditation-by-marco-bronx/

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  13. Several years ago, I too suffered from chronic pain and was powerless to do anything about it. I consulted with many physicians, who did treat me, but warned me that the worst of the pain would be temporary, and advised me to tough it out. I ultimately had to accept the pain for years, and it is still there, but has, over time, decreased to the point where it is just a minor nuisance. It is probably one of the factors that led me to come to Stoicism. Although it’s not much of an issue to my life now, it was, at one time, so bad that I considered suicide, and the only thing that stopped me was that I didn’t want to leave my wife and son.

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  14. Thanks for sharing the article Jasper. I really enjoyed the read.

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  15. Thank you! This is just how I’ve been trying to think and to live for the nearly twelve years I’ve been disabled and largely bedridden from Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (and a few other conditions). The piece is sensitive, relevant, and helpful in a way that few writings on the subject are.

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