# [Beneath Psychology] Case study on chronic pain: First insights, and the remaining challenge

In [the last post](https://www.lesswrong.com/posts/JpY7uztEdTF7HSDrT/beneath-psychology-introduction-part-2-the-solution-and-what) I took the seemingly-naive stance that "pain is just information" and "can't actually be a problem", implying that painful situations can be dealt with without suffering by just looking through the pain towards the reality at which it points. I did give an example of how this allowed me to quickly resolve an episode of pain-induced-suffering when others couldn't, but that one is admittedly a bit of an outlier and most cases aren't so simple. Today, we're going to start looking at a case that isn't so simple.

I was talking to someone through private messages on a forum for a shared hobby, and his chronic pain issue came up. Rather than acute pain from a burned hand, this was incessant pain from a medical procedure gone wrong a year prior. This procedure resulted in nerve damage, and therefore pain that feels "like every kind of pain all at the same time". The pain was so intense in the first day that the nurse was crying from seeing how much he hurt. They ended up prescribing him so much pain killers that his teeth literally started falling apart. Even still, that amount of pain drugs was only enough "for a little bit until \[his\] body got used to it".

The question, is why he didn't just respond to the pain by saying "Oh wow, something is wrong. Okay. *What's wrong?*" \-\- and then, once he figured out the answer to that, pivoting to "Ooh, neat sensations that don't mean much of anything. Anyway..."

The obvious but mostly worthless answer is "Because it hurts!". It's easy to empathize because we've all been there, but until we learn to square that experience with the reality that we don't have to suffer just because of pain, we're not going to be able to help people reconnect to reality -- and might be those people unwittingly gas-lighting others into suffering unnecessarily.

So what *exactly* is stopping him (and ourselves, when we feel similarly) from simply facing reality? Where does this desire for pain killers come from, given that they aren't exactly healing his body? Why is he suffering, rather than simply mourning loss?

What do we have to say, and how do we have to say it, such that we can navigate from here to where he *can* and *does* simply face reality? Until we can use our understandings to navigate successfully, they're not worth much. So how do we do that?

Like the last challenge, we know that it's a solvable problem because it was in fact solved. At least, partly. He described the change as "a huge improvement" and "Light-years ahead of where I was". His pain killer use dropped overnight from "norco+crazy strong stuff 3x/day" to "norco and the crazy strong stuff at most once a day". I didn't get a complete resolution here, but that has a lot to do with the fact that he lost motivation to work further on reducing his suffering, and instead started doing things that made the pain *worse* \-\- but the reality better, in expectation.

First, I'll share the beginnings of the transcript, then give some more hints about what to look for and where to look. The neat thing about this one is that because the entire intervention is in text, I can share essentially all of it and there's no hidden body language working behind the scenes.

The following transcript has been lightly edited for obvious typos and had some parts snipped/redacted for anonymity/privacy, as well as pulling out the interspersed unrelated conversation about our shared hobby. Nothing has been reworded or summarized, and what is left represents and essentially complete and raw depiction of the whole thing.

> OCT 11    
> other-guy: I used to hike in the mountains and camp it bushcraft all the time. Bring a backpack and sleep under a tarp, maybe build a raised bed. Until I got sick.
> 
> Jimmy: What kind of sick?  
> 
> other-guy: My doctor was giving me an infusion to treat my rheumatoid arthritis, and I had a terrible reaction to it. Put my whole body in the worst pain ever and affected my muscles. I had a hard time moving my arms, and my legs became really weak, so it's really hard for me to walk now. I can use my arms better, but sometimes it's like my mind won't connect with them. Lost about 20lbs of muscle in almost two weeks. Couldn't work because of it, so that's why I'm broke, and I just keep going to physical therapy to try and get better. It's been a long battle.  
> 
> Jimmy: Jesus.  
> 
> other-guy: Sorry for the long story haha. They say it will take up to 3-3.5 years to completely heal. If I heal. So far, I'm at just over a year.  
> 
> Jimmy: The story is short, but holy shit, that sucks. It's like getting hit by a bus, only without ever doing something stupid like standing in the street without looking. At least there's a likely healing in 3-3.5 years.  
> 
> other-guy: That's honestly the worst part. If I was speeding or something and crashed, like you said, doing something stupid, then I could accept it. But I just did what the doc told me. Some parts of it I will probably have forever, like the dystrophy. It triggered myotonic dystrophy that basically attacks muscles, so I will always have to watch my heart to make sure it's not attacking it. Same with my lungs and eyes. Most of the pain should go away though. They're not sure about the mind-to-muscle connection though, which causes the trouble moving sometimes. The meds they gave me to treat everything affected my teeth, so I had to get some of them pulled and replaced. It just kind of affected everything.
> 
> Jimmy: Not that this one would have been avoidable, but IME "doing what the doc said" isn't as safe as you'd think it should be. I'd have a couple pretty significant medical issues gone much worse if I had done what doctors said all the time. For future reference, "Uptodate" is where doctors are supposed to look to stay on top of the research, and there are Iranian sites that will allow you access for free. For example, here's one that might be relevant to you: https://medilib.ir/uptodate/show/7480  
> 
> Jimmy: ChatGPT is also pretty useful for figuring out what to even search for and summarizing things. Here's one it found based on your description of the problem: https://medilib.ir/uptodate/show/7501
> 
> OCT 12    
> other-guy: Wow, that's amazing! Thank you! I had no idea you could do that. I'm gonna be digging into all that for sure. Thank you. Docs wanted to give me a different infusion to try and help, and I'm like fk off, no way. And they want to do spinal surgery to attach some wires that shock and disrupt the pain signal to my brain so I wouldn't have the pain. I didn't trust that either. Even the pain pills they gave me took the pain away for a little bit until my body got used to it, and they won't prescribe anything else. But that's what caused the teeth problems—changed the pH in my saliva or something that made some of them chip and expose the pulp (pretty much the nerve), and I had to get new teeth. Even though I brush 3x a day and only had 2 cavities in my life, the stuff they gave me ruined them. I'm really tired of doctors at this point.  
> 
> other-guy: It's crazy how relevant those two are to my situation. Thank you again. 🙏 This is great!  
> 
> Jimmy: Hopefully they help. That resource was a godsend when my wife was dealing with her pregnancy complications, so now I tell everyone I can. It'll shut you out after four articles, but it just takes clearing cookies, then you can read more. I just open a new incognito window every time to make it easy.  
> 
> Jimmy: What's the pain issue, exactly? What happens if you don't take the pain meds?  
> 
> OCT 13    
> other-guy: Good to know. Thank you. Idk how to clear cookies, but incognito I can do haha. If I don't take them, then pain from the Parsonage-Turner syndrome it caused gets a lot worse. It's basically a pain in my chest, almost armpit area, and down my arm into my hand that feels like road rash or like I burnt my whole arm. Pain from drug-induced neuropathy gets worse—it’s like pins and needles everywhere but way worse than when your foot falls asleep—and mostly a deep muscle pain becomes terrible in my legs and arms. It's like when you're working out and trying to get one more rep in, but the muscle hurts so bad like it's gonna tear or pop.  
> 
> other-guy: All of this pain is constant. I feel it all the time, but it's kind of dull. It's bearable at least. If I miss a dose of pain meds, then it gets terrible, and I almost panic because it's like IDK what to do to get rid of it. The day this happened, I went into the ER, and they kept me overnight. They gave me five doses of Dilaudid (I think that's how you spell it), and one of the nurses was crying because she didn't know how to help. Nothing was working. I couldn't stay still from the pain; I couldn't focus; I kept grunting and screaming. That first day was the worst pain I've ever felt. I would rather deal with a perforated ulcer again and have surgery for it again instead of being in that pain again.  
> 
> Jimmy: Interesting. It sounds like that infusion really fucked with your nerves.  
> 
> Jimmy: Between the "mind-muscle disconnect" and the overwhelming pins-and-needles thing.  
> 
> other-guy: In a couple weeks, I'm having a test done to test for permanent nerve damage. I also get these jolts or twitches. Like sitting down, I'll all of a sudden kick my leg up, or I've actually smacked my face when my arm twitched while looking at my phone haha. I cut myself all the time cutting food from random twitches. It's the worst at night, trying to fall asleep, and I'll get full-body ones that hurt. It's like when someone gets shocked in the hospital on TV—my whole body jolts up.  
> 
> other-guy: Man, I'm so sorry to share so much with you. Besides doctors, I haven't told anyone this much. Just tell my friends I'm having troubles, and family knows a little bit more but not much.  
> 
> Jimmy: How do they test for "permanent"?  
> 
> other-guy: They will do some sort of EMG. They will poke me with a bunch of needles that test for electricity in the muscles, I believe. Something like that. I had one done about a year ago, and this one is to see if anything is better, worse, or the same. It's not the most enjoyable test in the world haha.  
> 
> Jimmy: I've had that test, I think. Might be somewhat different, but poked with needles listening for electrical activity in muscles.  
> 
> Jimmy: That was related to the first time I'm really glad I didn't do what the doctor said I should do. I had a bulging disc pushing on my spinal cord, and the doctor wanted to do a total disc replacement (at like... 20).  
> 
> Jimmy: The second opinion I got was literally "that's crazy!" So I went with the second surgeon and walked out of that surgery the same morning.  
> 
> other-guy: Wow, he probably suggested that just for more money. It's hard to trust anything they say these days. The Dr. that told me to get the infusions literally dropped me as a patient after it happened. Prescribed something, told her it's not working, and she said, "Well, it should be." I told her it's not, I need something else, and she dropped me, said I was too difficult, and canceled my appointments with her.  
> 
> other-guy: Took me about four months to get into another Dr. Took another 4 or 5 to figure out what was going on, and new things keep happening. Didn't get into the pain clinic until maybe six months ago. That helped a lot at first, but now I'm used to the pain meds, so they're not as effective. He won't prescribe anything else, and IDK how to ask him for something new in fear of sounding like a druggie. Sorry, back on subject. What caused the bulging disc?
> 
> Jimmy: That's a good question, and I don't have a short/good answer. It runs in the family, though. My dad and brother had the same surgery. Grandpa had back issues too, but that surgery just fixed it.  
> 
> Jimmy: I was back wrestling by the end of the quarter, and I've had essentially no back issues since. Dealing with doctors has been very frustrating for me in general though. I'm not sure if it was money for that guy (I'm sure it didn't help) or just standard incompetence.  
> 
> Jimmy: I've had to humiliate a couple doctors by rubbing their noses in the data to get them to do what was needed even without going against their monetary interests.
> 
> other-guy: One dentist I went to said we have to pull all the bad teeth and do implants. Whole thing would be 16k about. Went to another dentist, and he said save the teeth, just need to do crowns. Total is about 6k. That's including the deep laser cleaning.  
> 
> other-guy: I think doctors are like the Internet. Search your symptoms, and you find 15 different answers. Go to 15 different doctors and probably get 10-15 different answers. I'm glad your back is better. That's not something to take lightly. One thing I can't stand is back pain and back problems. Every single movement triggers the pain, and a lot of times resting only does so much, barely takes away the pain.  
> 
> Jimmy: Heh. I haven't had so much issue with dentists, but mostly because I don't go much I guess.  
> 
> Jimmy: I didn’t go for 15 years, and the dentist was freaking out, saying my mouth was going to be full of cavities. He only found 2, and then I didn't go back to get them filled for like a year, and then a different dentist at that place said, "Eh, I wouldn't even call those cavities," and didn't recommend fillings.  
> 
> Jimmy: And then again with another not-quite-filling-like thing that they didn't see by the time I went back in. So my approach to dentists has kinda become "just wait until they forget about the problem, and see if they see it again next time."  
> 
> Jimmy: Is your back pain related to this infusion thing, or just a separate thing you've had to deal with before?  
> 
> OCT 14    
> other-guy: Dentists are new to me. Only had a couple cavities as a kid, not since high school until all this crap. The back pain is unrelated. I don't get it often either. I used to lift a lot and was lifting really heavy. Something happened to the bench, and it slipped out of the angle it was set at, causing me to drop the weight but tore both rotator cuffs and something to my back.  
> 
> other-guy: It barely bothers me anymore, but when it does, I absolutely hate it. The rotator cuffs bother me more than my back does.  
> 
> Jimmy: Geez, that sucks.

Okay, so how do we go about this?

The insight that suffering is distinct from pain is important, but what happens if you just tell him "Suffering is distinct from pain"? What if you tell him "You need to accept the pain, then you will no longer suffer!"?

I think it's pretty clear to everyone that "accept the pain" is easier said than done, and that "intellectually knowing"[^j3pm6ikf14q] that suffering is eliminated by acceptance is not in general sufficient.

It's insufficient because it presupposes that he *should* stop suffering. What if we don't presuppose that he should, and instead, notice why he *isn't* \-\- despite having a brain which seems capable of processing information and making decisions. What might happen if he *did* "just" accept the pain? What about from *his* perspective? Might he know something we don't?

He actually tells us why[^0ez5ba20a9vc] he can't accept it. Did you catch it?

> "That's honestly the worst part. If I was speeding or something and crashed, like you said, doing something stupid, then I could accept it.".

If it was just from him doing something stupid, then he could accept it. It wasn't, therefore...

Accepting that he could do "everything right" and *still* end up whacked like that is a terrifying thought. [There is no safe defense, not even science](https://www.lesswrong.com/posts/wustx45CPL5rZenuo/no-safe-defense-not-even-science). Until he learns this -- which is not at all obvious, hence the need for the post -- then going on with his life like "Oh well, shit happens, nothing to see here!" would be missing something very important -- and setting himself up for being blindsided again. It seems pretty reasonable to want to avoid that.

It doesn't seem like much, and it wasn't much, but putting to words this "worst part" and validating the idea that "Yeah, that does suck, and it's actually not your fault, and here's what you can do to try to deal with this newfound aspect of reality", is actually active ingredient here. We're confirming "No, you're not missing anything, yes, this really is how it is, and here's how to get started orienting to it" -- and once he knows that, he no longer has that reason to postpone accepting the situation for what it is. By negating that reason, we've already taken a big chunk out of the problem by the time he's finished explaining what the problem *is.*[^hue9ugv6p1]

He says a few other things in this section of the transcript which give clues to where he's coming from and why this might be a tricky situation for him to navigate. Don't worry if you can't articulate exactly what these things tells us, just pay attention to the sense you get when reading over the transcript. Where would *you* have to be coming from in order to say these things. Do you notice a few lines jumping out as "important", in some way?

  
There are multiple things going on here and it's not realistic to expect to see them all in advance (I didn't), let alone plan a step by step intervention, so don't worry about getting everything. What *can* you see? What *might* be there? Or if you don't think you see what the answers are, what *questions* might you ask, in order to figure out what is happening?

Next week, I'll share the rest of the transcript, along with annotations showing where I was coming from and how I chose what to say when.

[^j3pm6ikf14q]: What we refer to as "intellectually knowing" differs from what we call "alieving" in meta level.When you're afraid of ghosts and "believe ghosts aren't real", you might say that you "intellectually know" that ghost aren't real which is to say that you think the belief that "Ghosts are real" is false -- and perhaps silly.When you say you "alieve" in ghosts, that's another way of saying that you sure act like you believe ghosts are real -- and dangerous -- but you don't want to say that you believe ghosts are real and dangerous, because that would be stupid. And I mean... we can't believe anything stupid, right? That would make us stupid!We don't actually need two different terms once we recognize that 1) sometimes we actually believe stupid things, and that 2) "intellectually knowing" a thing refers to a belief about what beliefs are true -- and that this is distinct from believing the thing.Later in this sequence we'll go through an example of how keeping track of this meta level distinction and noticing when we're believing seemingly stupid things can resolve "irrational" fears. 

[^0ez5ba20a9vc]: Well, one of the reasons why. 

[^hue9ugv6p1]: The rest of this conversation takes longer in significant part because I wasn't able to immediately intuit what the other big block was.