The Problem of Pain: An interview with author Melanie Thernstrom

When I think of pain—of anxiety that gnaws like fire and loneliness and spreads out in a desert, and the heartbreaking routine of monotonous misery, or again the dull aches that blacken our whole landscape or suddenly nauseating pains that knock a person’s heart out at one blow, of pains that seem already intolerable and then suddenly increased, of infuriating scorpion-stinging pains that startle into maniacal movement a person who seemed half dead from previous tortures—it ‘quite o-ercrows my spirit.’” Further, said C.S. Lewis, “If I knew any way of escape I would crawl through the sewers to find it.”

Lewis, who authored the Christian classic The Problem of Pain in 1940, would, I think, be happy that Melanie Thernstrom has approached this topic in the 21st century. Thernstrom's new book The Pain Chronicles: Cures, Myths, Mysteries, Prayers, Diaries, Brain Scans, Healing, and the Science of Suffering explores human pain in its many dimensions.

Thernstrom is a contributing writer for The New York Times Magazine. When she was 20 years old and an undergraduate student at Harvard, her high school best friend disappeared and was murdered, prompting Thernstrom to write The Dead Girl, an account of the tragedy. She is also the author of Halfway Heaven: Diary of a Harvard Murder. Her work has also appeared in The New Yorker, New York Magazine, The Wall Street Journal, Elle, Food and Wine and other publications. In addition to her work on pain she has written about narrative medicine, murdered college student Matthew Shepard, The Lord's Resistance Army in Northern Uganda and fugitives.

I enjoyed reading Thernstrom’s book and appreciated the opportunity to interview her by email.

1. At first glance The Pain Chronicles seems to feature different themes than your breakout books, The Dead Girl and Halfway Heaven. Perhaps there are underlying similarities or connections you can discern? 

In one way or another in all my work, I have tried to grapple with the fundamental motifs in human life of pain, loss and suffering, although my previous books focused on emotional, rather than physical pain. But of course the two are closely entwined. My first book was a memoir about the disappearance and murder of my best friend. It was a terribly sad story. My second book was an investigation into a murder/suicide at Harvard University, based on the diary of a woman who committed the murder/suicide. The police had recovered the diary from her room after she died and it shows the process of her becoming mentally ill while at college and her failed attempts to get help.

2. How did you amass all the wisdom from the centuries? Your quotes are outstanding. 

Well, I did work on the book for almost a decade! I spent most of the first few years simply reading—and of course had been an avid reader my whole life—so I filed away quotes that related to pain in the back of my mind and when I finally wrote a draft, I often found myself recalling them. I have a particular interest in religion and sacred texts, and was struck by how many religious texts touch on the problem of physical pain.   

3. What gave you the idea to describe Christ’s pain in such vivid detail? 

Christ’s pain is the Pain, so to speak—a central aspect of Christianity and as such a defining element of western society. A book about pain that failed to discuss Christ’s pain would be very odd. I was also particularly interested in the pain of saints and martyrs. 

4. In the book, you write “The idea of pain as spiritual transformation offends me.” Have you had any later experiences (i.e. motherhood) that may have changed this view? 

As I resented my own pain, I was initially reluctant to admit that pain could have any positive meaning whatsoever and found the idea of pain as spiritual transformation disturbing. But I changed my mind in the course of my research as I came to understand the idea of sacred pain, which is present in all major religions. I was influenced in my thinking by a truly marvelous book called Sacred Pain by Ariel Glucklich, a theologian at Georgetown. What is ordinarily disturbing about pain is the way in which seems to obliterate the self, replacing ordinary consciousness with consciousness of pain. But in a religious context it is precisely this loss of self that is valued as something that brings the devotee closer to God and community.

One of the most interesting aspects of physical pain is its enormous flexibility of meaning. Physical pain draws on meaning-making parts of the brain, such as the anterior cingulate cortex and the limbic system. And this is why pain in humans always evokes intense emotion—usually unhappy ones, but, as religious pain demonstrates, not always. 

5. You describe the positive effect of Holly Wilson’s relationship with her doctor. [Wilson is one of several chronic pain patients Thernstrom interviewed and followed during the course of her research.] Should there be more training for doctors in how to relate to patients? What elements would you suggest in this training? 

I think there should be training for primary care physicians in how to treat pain, which is a learned skill that requires specific knowledge that many health care professionals simply don’t have. But there is some evidence that the biggest single factor in successful pain treatment is the relationship with the physician. It’s an open question, however, to what extent creating such relationships can be learned. I observed Holly Wilson’s relationship with her pain doctor—Scott Fishman, the head of the pain clinic at UC Davis—and witnessed the kinds of relationships Dr. Fishman creates with all of his patients. Those relationships stem from the fact that he truly does care about his patients and is invested in their wellness, and patients sense this. I believe that caring, empathy, warmth and goodness are qualities whose presence or absence we are able to read very clearly in one another.  

6. Can you say more about healthy forms of faith? What are differences in cognitive reframing, say, between Christian, Jewish and Islamic persons? 

I was fascinated by the question of the effect of religion on pain, disease and disability. There is compelling evidence that churchgoing is strongly correlated with positive effects. A large study found that regular churchgoers actual live six years longer than others. Many studies have failed to find benefit from private religious practices, such as prayer and Bible reading. But a sophisticated study attempted to distinguish “positive religiosity” (people who feel their illness has drawn them closer to God) from “negative religiosity” (people whose illness makes them feel that God has abandoned them or has made them question God’s existence). It turns out that while positive religiosity appears to help people cope with disease, negative religiosity is associated with distinctly worse health outcomes.   

7. Could you expand on what you mean by “telos decentralizing pain”? (I think this should now be included in the OED.) 

In this book, Disease, Pain and Sacrifice the psychologist David Bakan distinguishes between pain that is telic centralizing (pain that is interpreted as consistent with one’s telos or sense of purpose in life) and pain that is telic decentralizing. Sacred pain is the parodoxical case of pain that is telic centralizing. But for modern secular man for whom pleasure and well-being are so central—for whom happiness is seen as a basic right and goal of existence—pain is usually experienced as telic decentralizing. Suffering is sometimes defined as damage to one’s sense of self. Telic-decentralizing pain is pain that threatens and damages one’s sense of self. 

8.  Do you think severe psychiatric illness (schizophrenia, bipolar, profound depression) can magnify pain? Can you speculate on why so many people who are psychologically hopeless kill themselves, while many (most) in physical pain do not? 

The woman I wrote about in Halfway Heaven who killed her roommate and herself was not in any physical pain. But she suffered from tremendous loneliness—excruciating, deadening, as malignant as any melanoma—and she committed those terrible acts because she was literally dying of loneliness.

Loneliness that is caused by or magnified by mental illness may be the deadliest feeling any of us can ever experience. The relationship between pain and suffering, on the other hand, is much more complex and elusive. I write about some patients who have very grave pain problems, and yet continue to lead fulfilling lives, while others who appear to have much less serious problems are destroyed by them. That is one of the mysteries of chronic pain: why different people cope with it in such different ways. 

9. What are some “riveting” experiences people can use to distract from pain? Do they work?  

Distraction is one of the best techniques for coping with pain. It is certainly the one I use the most often in my daily life, so I was interested to discover functional brain imaging studies that confirmed its efficacy. When patients are given a painful heat stimulus at the same time as a mental counting task, their brains generate much less pain than when their attention is solely focused on pain. It turns out the brain is a very poor multi-tasker, so when the brain has another task to engage in, it doesn’t do nearly as good a job generating pain!  

10. What books/articles/projects are you working on?  

Babies, babies, babies...I have ten-month year old twins!

Thank you, Melanie Thernstrom, for talking about your book with the readers of America.