The dreaded question inevitably surfaces. From a well-meaning friend, a doctor who has run out of answers, an unknowing colleague, a nosy acquaintance.
The underlying question is clear: “Are you sure your pain isn’t psychological?
But the delivery is always varied: Are you sure you aren’t just stressed? Doesn’t new research show chronic pain is in your mind and not the result of physical damage? Can you tell me about your childhood? Aren’t you too young for that kind of pain?
This is the question that, more than any other question, causes me to visibly cringe, viscerally respond with a turn of my stomach, and stammer a defensive retort back at the questioner. Anger and shame linger below the surface, as my face turns red and I attempt to decide upon an appropriate response:
Sarcasm? Calmly stating the facts of my physical diagnosis and clinically-evidenced symptoms? Changing the subject? Admitting that, of course stress and psychological factors have an effect on how I feel physically just like everyone else?
Many specific instances come to mind….
The doctor who concludes my chronic pain suggests I must have been abused as a child, despite my description of a past filled with love and care.
The friend who kindly states she heard my symptoms are getting worse. And then immediately wonders if I have been feeling stressed lately.
The colleague who sees my absolutely necessary back cushion, and decides I am much too young for such problems.
Underlying all these instances, all these questions, and all these assumptions is a common thread of thought. Perhaps I am in pain, but it can’t be as bad as I say. Perhaps I am in pain, but it must be partly my fault. Perhaps I am in pain, but since I am not getting better, there must be psychological factors at work.
But here’s the thing. I have been on the other side of this question as a counselor in outpatient mental health settings.
The truth is that psychosomatic symptoms are a real and pressing issue that I have clearly observed in multiple clients. And I have noticed an interesting trend: individuals who experience psychosomatic symptoms rarely to never have the self-awareness to know and admit that any of their physical symptoms have anything to do with anxiety, depression, trauma or similar mental health concerns.
There was the client who saw dozens of specialists for symptoms she thought were neurological, but were clearly the result of her severe anxiety. The client with bipolar disorder and hypochondria who racked up thousands of dollars worth of unnecessary medical tests for a mixture of imagined and truly real physical problems. Or the young woman with a history of recurrent trauma in her past whose body has been ransacked with unexplained physical pain since the first incident.
And it may not be you or me, but these individuals exist in large numbers. And so to a certain extent, I get why this question is asked. From a medical, clinical perspective I get it. And in my opinion, the problem is not in the question, but in the implication so often behind the question, in which a weakness is presumed in the individual presenting with pain or illness. The problem is not in seeking to ascertain if psychological factors are present, as they very often are. The problem is in the intonation, the underlying belief that if psychological factors do happen to be present in any large or small degree, then you are less of a person.
So even though my doctor’s assumption that I must have been abused as a child was infuriating, I get why he asked the question, and I think this and similar questions need to be asked. I have seen this correlation myself in clients who sit across from me. So if I believe it needs to be asked, why do I get so infuriated when it is asked of me? I believe the infuriation comes from the underlying associated stigma: the fear that I will be seen as a weaker person if the strains of the world have cause me to fall into physical unwellness. The fear that I will be dismissed and labeled as crazy, a drug seeker, or an outright liar.
Because let’s be honest. Of course depression and chronic pain come hand in hand. Of course anxiety and illness are oftentimes constant companions. Yes, yes, yes, of course stress and psychological issues are factors in physical illness and pain. And we (I) need to get to the point where it is not embarrassing to admit this. Culture and society as a whole need to get to the point where an admittance of stress contributing to physical symptoms is not a mark of some huge flaw or some huge sign of shame stamped on your forehead. Because so often we deny these factors as present so we will be taken seriously and not denied necessary medical treatment.
So where do we go from here? What is the solution? Instead of getting upset at the question, I propose that the underlying assumption needs to challenged by everyone involved. We need to start with the new assumption that all forms of physical illness and injury are affected by stress and psychological factors at some time, in some way. Instead of seeing this as an “either/or” issue – either you have a physical problem OR psychosomatic symptoms – I believe it must come down to an issue of percentages in a rough sense. How much is physical? And how much is psychological? And how are we going to effectively address both sides without causing stigma and shame?
Let me state my opinion again in a different way: All physical symptoms have some degree of a psychological component. It doesn’t matter if you have broken your leg, received a diagnosis of cancer, contracted lyme’s disease, or found yourself smitten by fibromylgia. Back pain, menstrual cramps, a bruised elbow, recovering from a car wreck, or the common cold – in all these situations, stress and psychological factors will have some effect, in some way. Granted, the psychological component may be minuscule in some situations, but I believe, still there. And I plan to go into detail regarding various ways in which this manifests.
This either/or nonsense happens because there is so little knowledge of integration. My doctors don’t integrate a knowledge of my various physical symptoms together let alone a knowledge of the interplay between my physical and psychological health. One doctor addresses my gastrointestinal issues, another my back pain, and still another the nerve issues in my leg. Although they are likely all related in some form or fashion, they are treated as individual and isolated issues. The same problem exists with the intermingling of physical and emotional complaints, which are seen as 100% separate issues instead of inextricably linked strands of the same rope.
Stay tuned for my next post in which I examine in detail various specific ways in which physical and psychological health often intermingle.