Publications
APS Bulletin • Volume 14, Number 2, 2004
Pain as Path
Mark Sullivan, MD PhD, Department Editor
“Pain Makes Me Feel Real”—The Psychological Functions of Pain
Department editor’s note: When we question why we must feel pain, most of us turn to the evolutionary value of acute pain. It protects us from injury and forces us to rest and allow healing to occur. We often do not consider the psychological functions of pain. This is partly because we do not understand there are experiences worse than physical pain— experiences for which physical pain is indeed the antidote. Some individuals, often those who suffered severe childhood maltreatment, feel unreal or dead, and must awaken themselves with pain. Others are so angry they can’t stand it. As Princess Diana explained about herself in a BBC documentary, “You have so much pain inside yourself that you try and hurt yourself on the outside because you want to help.”
Below are excerpts from BRIGHT RED SCREAM: Self-mutilation and the Language of Pain* by Marilee Strong (Penguin Putnam Inc., New York, 1999), in which those who intentionally produce pain by injuring themselves describe their experiences.
As the first-person stories and narratives of the cutters make clear, they hurt themselves not really to inflict pain but, astonishingly enough, to relieve themselves of pain—to soothe themselves and purge their inner demons through a kind of ritual mortification of the flesh. Rather than a suicidal gesture, cutting is a symbol of the fight to stay alive. As a woman who has been cutting on and off for three decades told me, “I always felt I’d die if I didn’t cut.”
[Daphne explains] “Sometimes I self-injure to make myself feel something because I’m just totally numb. Other times I cut to make myself numb because I can’t deal with what I’m feeling. I mostly do it when I’m angry. Maybe I was raised not to be angry, or show anger. But whenever I’m mad, I find myself to be at fault so I punish myself. The anger builds up, higher and higher, until something has to happen —and for me, that something is self-injury. I concentrate on the cuts, on the blood, and it calms me. But I’m also always scared somebody is going to walk in and see what I’m doing and send me to the hospital.”
Barbara’s earliest memories of self-injury involve burning her fingers with matches in the attic and cutting her hand. Barbara’s mother noticed her daughter dressing the cut and told her it wasn’t “bad enough” to require a Band-Aid. Those words—emblematic of her mothers’ lack of nurturance and the painful reversal of their parent-child relationship—still resonate for Barbara 40 years later. For when she hurts herself, she can’t stop until her wounds are “bad enough.”
“If I bruise myself, I have to reach a certain pain level,” she explains. “If I burn, I have to have blisters. If I cut, it almost always requires stitches. And each time has to be a little worse than the last. I think the hope is that if I hurt myself bad enough I won’t have to do it anymore. But I never reach that point.”
For Barbara, cutting and burning is a form of self-punishment but also a form of control, a survival strategy to keep her emotions in check and prevent herself from falling apart. “It allows me to keep going-because I certainly wouldn’t want to become like my mother and stop functioning, or go completely crazy on the manic, angry side like my grandmother,” she says. “It’s like I try to keep on this tightrope. I never let myself get too high or too low because I knew I was my dad’s favorite and I wanted to be what he wanted me to be: somebody who didn’t show emotions. The nice, stable, everybody-can-lean-on-you person.”
[Cutters] use razor blades, knives, shards of glass, needles, and scores of other implements to intentionally inflict wounds to their own skin, most often on their arms. They cut themselves sometimes weekly, sometimes less frequently, sometimes daily. They may also burn their skin, bang their heads, punch themselves, break their own bones. But they do not hurt themselves as an act of suicide, nor are they masochists. They are secretive and their activity is often unknown by those around them. Shame, rejection, and the disparaging labels they face when they are dismissed as simply “crazy” or “psychotic” or “attention seeking” all conspire to keep them silent, isolated, underground.
Cutters are not necessarily identifiable by the obviousness of their suffering. They can be found in foster homes, prisons, and psychiatric hospitals, but they are also in the best neighborhoods and private schools, in colleges and in the workplace. Self-injurers are often bright, talented creative achievers-perfectionists who push themselves beyond all human bounds, people-pleasers who cover their pain with a happy face.
Doctors, lawyers, nurses, Sunday-school teachers, artists, singers, poets, teenagers, and grandparents were among the cutters interviewed for Bright Red Scream. A recent informal sample questioning of junior high school girls at a private school in one of the nation’s poshest zip codes (the adolescents’ parents including Fortune 500 CEOs and movie stars) revealed that every one of the girls knew someone who had self-mutilated.
“I remember what it felt like to see the blood,” recalls Lindsay of her first cutting experience at age 14. “It’s weird to say this, but it was beautiful. It was as if the entire outside world had closed and everything was calm and quiet and peaceful. I cut very shallowly that first time—there was barely any bleeding—but it was enough then. For a few moments it seemed as if the poison in my blood was leaving—calmly, submissively. I was in control of it. It felt like rain.
After the tranquility wore out, I was terrified at what I had just done. It scared me and I thought I was crazy. But I knew that those few moments had released me from the chaos in my head. And I knew that I could do it again.”
Cutters almost uniformly report the same sequence of events and emotional states before and after episodes of self-injury. Cutting bouts are generally precipitated by an experience—real or perceived—of loss or abandonment. Self-injurers are acutely sensitive to abandonment. Because they never properly attached to and then separated from their early caretakers, they live in a perpetual state of separation anxiety so unbearable it feels annihilating. Their sense of themselves and the ability to control their lives has been dictated so much by external events that they believe their very existence depends on how others perceive them. Alone, as Lindsay so heartbreakingly put it, they see nothing in the mirror. Cutting is really a remarkable, ingenious solution to the problem of “not existing.” It provides concrete, irrefutable proof that one is alive.
Feelings provoked by the sense of loss or abandonment—tension, anger, rage, fear, anxiety, panic—build to an overpowering crescendo. Cutters are unable to communicate their discomfort to others in order to draw support and have internalized no soothing image of a safe, loving caretaker to draw upon to nurture themselves, calm their fear and anger, and regain a sense of control. They are left feeling helpless, overwhelmed, and utterly alone. Because their emotions cannot be expressed or integrated, they have to be discharged in some other fashion. Strong feelings simply can’t be dealt with on a mental level but seem instead to demand action.
In response to emotional overload, many self-injurers slip into dissassociated states. At the moment of cutting, most self-injurers feel no pain and are generally oblivious to their surroundings. Some are not even aware of the act itself and are shocked, like Andrew, the Scottish chemistry major, to later discover their wounds.
Despite the extreme level of anxiety and agitation, and the degree to which consciousness and memory are often splintered at that moment of cutting, the extent of injury is usually strictly controlled and carefully executed. Either the pain of cutting (whether consciously experienced or not) or the sight or sensation of flowing blood—no one is sure which, maybe both—snaps them back into normal consciousness and conveys what John Kafka calls the exquisite experience of sharply “becoming alive.”
“I felt as if I was isolated from the world, dead, with no emotions at all,” says Lindsay. “The blood told me I was alive, that I could feel. I needed to see those bad feelings bleed away. Also, I couldn’t cry, and bleeding was a different form of crying.”
After cutting, they feel calm, reintegrated, “real” again, and often fall into restful sleep. However self-destructive the act may seem, they have moved from a place of passive helplessness to active control. Some look upon their wounds with pride as true battle scars, tests of their strength, courage, and survival. More often, though, when the peace and euphoria recedes, they are filled with shame and regret. They hate that they seem to need it so much, that they can’t stop, that they feel addicted to a behavior others would consider crazy and grotesque. Cutting only temporarily distracts them from a more intolerable inner pain. The demons are held at bay for just a short while. The conflicts that gave rise to the behavior live unresolved below the surface, and will be back to do battle again.
After several weeks of cutting, Lindsay’s ability to tolerate any bad feelings rapidly declined, and she began slicing her skin whenever she felt scared or felt like she had no control. “I did it when I was afraid my friends didn’t like me anymore,” she says. “I did it when I was worried. I did it if I got a bad grade. I even did it if I had cavities. As soon as I began to feel bad about something, the thought popped into my head and I had to cut. I just kept thinking that the sooner I cut, the bad feeling would go away so why wait?”
Even the shame she felt after a cutting bout made her want to start all over again. “I realized I didn’t have to feel, I didn’t have to suffer, because I could cut,” says Lindsay. “But afterwards, after I bandaged and cleaned myself up, the shame set in. I hated myself for having done something so strange. I hated myself for not being able to deal with my feelings. I hated myself for not having control and being afraid and risking someone finding out.”
Editor’s conclusion: These stories prove the truth of the Karl Marx maxim I have previously cited: “The only antidote to mental suffering is physical pain.” These stories remind us there are things worse than being in physical pain, such as feeling dead, feeling unreal, and hating yourself. Injuring oneself to produce pain can be a way, though temporary and addictive, out of these feelings.
* Excerpts from BRIGHT RED SCREAM by Marilee Strong, copyright 1998 by Marilee Strong. Used by permission of Viking Penguin, a division of Penguin Group (USA) Inc.
Reference
Strong, Marilee. (1998). BRIGHT RED SCREAM: Self-mutilation and the language of pain. New York: Penguin Group (USA) Inc.
Please direct your comments or suggestions about this article or department to Mark Sullivan, MD PhD, Department Editor, at sullimar@u.washington.edu.