THE VALUE OF PAIN IN OUR CULTURE
If one is in training for a competition, whether a piano competition or the Olympics, it is considered reasonable to develop a regime of activity that takes up an exorbitant amount of one’s time. This time is perceived as reasonable because it is devoted to a social goal toward which others will be devoting similar amounts of time. In addition, the activity is supervised by a coach, so that the seemingly excessive demand is monitored by another person.
When runners reach a certain point of exhaustion, dubbed “the Wall,” they are advised to push beyond it until they get their second wind. This exemplifies the cultural approval of the concept behind competitive performance: How much pain or exhaustion can you take? So we see that it is our society, not the lone individual, that has set the standards for training as well as for victory.
If an individual takes it upon herself to see how much pain she can endure, inflicting that pain by intentionally wounding her body, we call this “illness.” Specifically, we call it “self-mutilation.” There is no socially acceptable goal; there are no limitations; no one else is involved. If this self-inflicted pain were to occur on an island inhabited by a lone person, we might even designate it “entertainment” of a desperate sort, or compensation for the lack of interpersonal stimulation available. But if it happens amid others who are available for contact, or stimulation, then it is designated as being outside the area of good mental health.
In much the same manner, one who is starved by a famine, emaciated by that starvation, is not thought of as mentally ill but rather as a victim of environment and circumstance. It is when someone starves herself amid plenty, with no restrictions, that we define this as mental illness, specifically, anorexia nervosa.
The intense desire to prove to one’s self “How much pain can I take?” with no outside motivation, or limits, suggests that the individual has lost all realistic sense of goals, or solutions to her problems.
The self-mutilator is usually a step further removed from cultural suggestion than the anorexic or obsessive-compulsive-disordered individual. The latter two often began with a culturally acceptable goal. For one, it was to do things diligently, meticulously; for the other, it was to lose some weight. Both began that way but then were unable to stop, even as their behavior reached pathological and self-destructive levels. The self-mutilator, on the other hand, does not usually begin with a specific cultural message as the basis of her behavior but invents this behavior spontaneously and impulsively, out of a need to seek relief from mental pain.
No Pain, No Gain
Shari was twelve years old when she came into treatment. She was a committed gymnast who had attended her first tryouts for the local gymnastics team at the age of nine. Her coach saw her as having a powerful though small body. He interviewed her parents, to see if Shari’s hereditary musculature could be determined from their appearance. He requested that both parents be present at an afternoon interview scheduled in late August, before the term began, telling them that he wanted their approval for the “strenuous dedication” he would require of their daughter.
The warm August day provided the incentive for the light, casual clothing they would wear, revealing the muscular shoulders, arms, and legs the coach was hoping to see on Shari’s parents. He was not let down. With his encouragement, both told stories of their high school and college athletic exploits, and of rooting enthusiastically for their older son on the high school football team. The coach was delighted. He had parental encouragement, parental role-modeling, and a bonus of hereditary musculature.
Shari learned fast and well. She was excellent on the bar, the horse, and at all manner of somersaults. But after the first two years, Shari’s mother read an article on the danger to physical growth when girls engage in intensive gymnastics throughout puberty. Shari’s mother was five foot seven, and her husband six foot three. Shari was not growing at a rate that suggested she would reach her mother’s height. Her pediatrician indicated at her next school checkup that Shari was in the lowest eighth percentile of height for eleven-year-olds. Her mother was shocked.
“How could ninety-two percent of children be taller than my daughter when my husband and I are both relatively tall people?” she asked the doctor.
He responded with a query: “I’ve noticed that Shari’s musculature is quite developed, even overdeveloped, for her age. Is she involved in athletics to a great degree?”
“She is involved in gymnastics, and I know this year the girls have started lifting weights to increase their prowess in different events. The coach even requested—or it might be more accurate to say demanded—that we get her a set of dumbbells for extra practice at home. We drew the line when she requested a barbell.”
The pediatrician explained that nothing was wrong with their daughter medically. She was in good health, though surprisingly short, considering her parents’ respective heights, but she might have a growth spurt that would make all this a moot point. He asked whether there was anything in Shari’s behavior that worried her parents, such as friends, social play, anything at all? On her way home in the car, his question stayed in Shari’s mother’s mind—she was worried about Shari’s situation.
Mrs. A. reported to her husband what the pediatrician had told her about her daughter’s height and the discussion they had had about her involvement in gymnastics. They called Shari in and broached the subject of lessening her involvement in gymnastics, and Shari became what they later described as “hysterical.” In a pre-interview consultation, Mr. and Mrs. A. told me that Shari even threw things randomly around the room, including her five-pound dumbbell, which punctured the wall at the two points where the disks hit.
Mr. and Mrs. A. consulted me at the suggestion of their pediatrician after he saw Shari the following year for a checkup and discovered that she had grown less than an inch. During the year in between checkups Shari’s parents had been unable to persuade their daughter to decrease her involvement in gymnastics, and she had in fact increased it. They were feeling helpless but were afraid to remove her from the program. The coach had reassured them that Shari wasn’t working harder than the other girls he trained but she was doing better. He told Shari that he was considering her for captain of the team after her twelfth birthday.
Feeling outnumbered by their daughter and her coach, and possibly other members of the team as well, the parents finally sought help. As Mrs. A. put it, “She has no other life outside of gymnastics. And with puberty on the way, I don’t see how she will move on to anything like a normal adolescence.”
Mr. A. spoke next. “Shari has been told that we never intended for her to spend her young life pursuing an Olympic Gold Medal and we see that it’s narrowed her life and may have permanently stunted her growth. Shari replied that if her growth is permanently stunted, ‘It’s too late anyway!’ She is quite emphatic. We have also discovered that she has scratchmarks on both her upper arms. We asked if she had gotten into an argument with another girl. She shrugged off the question, saying that it happened when she slid against a piece of equipment. We can both see that the parallel lines on each arm are in a configuration which could only come from scratching herself.”
“What is your reaction to her scratching herself like that?” I asked him.
“We can’t tell if something’s gone wrong with her gymnastics, or she’s trying to punish us to ward off our attempts to reduce her activity there, or if she’s angry or getting emotionally disturbed from the whole situation,” Mr. A. said anxiously.
“We know that this age is full of changes for most girls and it’s hard for us to tell if this is the beginning of something terrible or just part of puberty. What worries us most is we know that she’s lying to us about the scratches, and worse than that, she backs us down because she’s so adamant about her lies. Then, bang! her bedroom door slams. We know her coach doesn’t know about the scratches and that we might jeopardize her chances of becoming captain of the team if he thinks we’re withdrawing her involvement. So we are scared of having a sick child, and guilty about getting her started in this whole business nearly three years ago. I must admit we’re also afraid of Shari’s anger and unhappiness if it turns out that we ruin what she has accomplished for nothing.”
Mrs. A. took up the story. “We know how hard the coach pushes all the girls—you know, ‘No pain, no gain,’and all that rubbish. I’m afraid that she’s become so good at ‘pain’ that she’s got all of it mixed up with ‘gain,’ and she may be using pain in a cockeyed way to feel like she’s achieving something.”
Shari’s mom had interpreted the situation correctly. Her daughter had become part of a subculture that aligns pain with achievement. Even though the nature of the pain specified in the well-known sports slogan is the result of the struggle to perfect an exercise, it’s not a big leap to apply the use of pain in other ways; to resolve inner conflicts and problems, for instance.
Shari was coaxed into coming to see me by her mother. Shari, no doubt, believed that seeing me would get her parents off her back and finally stop them from interfering with her gymnastics.
She entered the office with a sturdy, erect posture, stating by her body language that there was nothing wrong with her, and her parents were just two anxious people who couldn’t cope with her success at gymnastics. I gestured to the couch and chairs; she sat down on the straightback chair, the one I call “the resistance chair.”
I was aware that the person who had influenced her most for the past three years—her coach—was direct and forceful. So I introduced myself briefly and then stated, “This appointment has been made because your parents believe that you have begun to hurt or damage yourself as a way of resolving your conflicts, that is, whatever bothers you.” I asked her to roll up her sleeves.
Looking more anxious, she did so. Four parallel tracks appeared on each arm.
Rolling up my own left sleeve, I took my right hand, and, using my four fingers, made four scratches on my left arm in the same place as her deeper, red scratchmarks on her left arm. I didn’t say anything but waited for her response.
She stared at me in disbelief. She went on staring at my arm with its pale scratches, then looked at her own arm with its red, angry scratches. Tears began to flow. She remained silent for a few moments, then looked up at me sadly. “Am I crazy?”
I told her, of course, that she wasn’t crazy. That she was trying to solve what bothered her by pushing herself even harder, as she’d learned to do in the past three years. At the same time she was telling herself to accept the by-products of her efforts, fatigue and pain—especially pain.
“You have been taught that if you ache, that means you’ve tried hard enough. You have mistakenly interpreted that to mean that the ‘ache’ is the solution to problems. Even an achievement in itself.”
“Well, sometimes I feel so bad that I don’t know what to do. At least I didn’t do the kind of damage that would prevent me from my workout.” She looked at her arm again. “See, they’re only scratches. They hurt when I did them, but they won’t stop me from being strong and coordinated on the mats.”
“We should make what upsets you into words.”
“What if the words sound stupid or bad?”
“They usually just sound stupid or bad in your head, before you’ve said them to someone else who understands them, then they don’t sound that way and you feel better.”
She looked at me, curiously and timidly.
“Is that why people go to therapy?”
I nodded.
“Do you know what they are, these thoughts and feelings that get you so upset?”
“I think I know some of them. If I tell them to you, then I won’t want to scratch myself anymore?”
“I think that the better you get at figuring out what they are, and then telling them to me, the less you’ll be tempted to hurt yourself.”
Shari was identified early in her disorder. She was also very young. These factors allow a patient to be more receptive to her therapist’s suggestions and less resistant to treatment. It was clear to me that Shari used self-mutilation as a way of keeping her doubts and fears about herself in check. There had been no time for normal adolescent emotions in her highly pressured life as the star of her team.
Shari’s use of scratching to punish herself for faltering and to reinforce her gymnastic training served as a red flag to her parents that she was in trouble. At this point of early intervention, she has only a tentative investment in her behavior. If she can form a strong therapeutic alliance with me, I can gradually help her to communicate her feelings. This process would compete with her need to hurt herself.
In Part Two of this book, we will see how this actually plays out in treatment.
The Hero Disguise
Brian was a senior at a competitive college. He was captain of the wrestling team, a cross-country runner, and a weightlifter. Aches and pains were no strangers to Brian. After a cross-country run, sometimes his legs hurt so badly that he had to walk downstairs backwards. Arm and chest pains from benchpressing prompted the purchase of a backpack; he was too sore to carry his books from class to class. Painful knots in his neck and back muscles after a wrestling match would have him on an athletic massage table for an hour a day.
Brian always understood that unlike a basketball player, he could not make a living after college as a wrestler, runner, or weightlifter. Yet these activities took up so much of his time that his grade point average was suffering. He was sent to therapy by his wrestling coach, who was notified by the dean of students that Brian had been kicking in windowpanes on the ground floor of the administration building. He was caught when he cut the top of the arch of his foot so badly that he severed tendons and needed orthopedic surgery in order to regain the use of his toes again, to walk properly. The surgeon noticed that in addition to the crippling wound he was repairing, Brian had many other long scars across the tops of both arches. Apparently, this last cut was the first one he could not “walk away from.”
Brian was referred to me by the student counseling center for what the doctor thought was delinquent behavior. It turned out to be quite a different matter.
I explained to Brian at our first meeting that the surgeon had found many cuts on his foot, and that his socks seemed to have a reddish tinge that looked like it couldn’t be washed out. I asked if he would please take off his sneakers so I could see his socks.
Brian was surprised by my request but nevertheless took off his sneakers to reveal white athletic socks with a pinkish hue. “This pair too, huh?” I commented.
“What do you mean?” He looked hurt.
“The report that accompanied the doctor’s report was from the dean. It stated clearly that you were thought to be kicking in windows on the ground floor of the administration building. I don’t think you’ve got a beef with the administration since they have given you a full scholarship, haven’t they?”
“Yes, but what do you mean by kicking in windows? Are you suggesting that I do this all the time?”
“I’m suggesting that you’re not doing it to do damage to the building but to do damage to your foot.”
Brian appeared shocked. “Why would I want to do damage to my foot? I’m an athlete. Without my foot, I’m nothing. I lose my scholarship.”
“But what if you didn’t get caught and you only made non-damaging cuts on your foot; would you lose your scholarship then?”
“Not if it didn’t interfere with my ability to wrestle, run, or lift.”
“So it might be important to continue to kick in windows? Does it hurt when the glass cuts your foot?”
“Yeah, it hurts.”
“Is that good? Do you seek that pain?”
“You’re making me sound crazy.”
I wondered whether Brian was jealous of the wealthier kids and perhaps concerned about his future.
“Your GPA doesn’t suggest that you’re going to graduate school easily, anyway. What happens to you next year?”
“I don’t know!” He became tearful. “A lot of the other guys have parents who will set them up in businesses of their own or get them jobs with big-deal companies they know the owners of. You’re right. I have nowhere to go next year. I am tough; okay-looking, I guess. I’m in pretty good shape, but that doesn’t cut it after graduation. This May is like a cliff I’m going to fall off, into nowhere.”
“Is that why you’re cutting your foot, kicking in windows? I think that it solves a lot of problems for you. It takes care of your anger about the unfairness of life, and the pain and blood distract you from thinking about the future, and prove to you that you can take whatever ‘pain’ life will throw at you after graduation. You’re good at taking pain, aren’t you?”
All six foot four inches of this trim but very muscular young man shook with sobs.
“Yeah, I’m good at taking pain! I need it, so I never forget to be prepared when it’s coming. And it’s gonna come. Because next year I’m going to be nothing! I could come back here for a few days in September and relive who I used to be. But it’s really over for me. College was a setup. I couldn’t get higher grades if I wanted to. I’m one of the biggest, strongest, but definitely not the smartest, not even smart enough to be here.”
I picked up his foot and put it on my knees to look at it. “Looks like you’ve done this at least six times. Maybe we should find a better way to get rid of the ‘cliff’ waiting for you in May.”
Brian and I met regularly for the rest of the school year. He told me about the old movies he had watched with his dad while growing up in Massachusetts in a former factory town. His father, a man toughened by years of physical labor, loved John Wayne movies; as they watched, he would often exclaim to his son, “You’ve got to bite the bullet! That’s a real man, a hero—no whimpering and whining when he gets hurt!”
Many of Brian’s friends had tattoos, earrings, and other piercings. Among the athletes it was as important to brag about how much it hurt as it was to brag about their sexual exploits. Acceptance of pain was deemed bravery among the young men, just as it had been by his father.
Earlier, I stated that in most cases one does not begin with a culturally acceptable, “healthy” behavior, and cross over the line to what we call “psychopathological,” yet in Brian’s case this is what happened. Brian had to prove to himself that he was manly enough to survive life’s pain without flinching. His own feelings of anxiety were threatening to pierce the tough facade, so, rather than lose his heroic self-image, he used his tolerance of pain to keep it together.
In therapy, Brian learned that he could express his feelings verbally instead of having to “bite the bullet.” Given the opportunity to share his fears about his future, he was able to calm down, stop cutting himself, and develop a reasonable plan that included summer school, a part-time job, and financial aid toward a master’s in physical therapy.
_______
When self-mutilation has its beginnings in what is culturally acceptable, as it did with Brian, and can be interfered with by treatment early on, the outlook is better than if the self-mutilating behavior is truly an invention of the individual, devoid of societal origins. In the first case, the individual can consciously trace the roots of this behavior to something of which he is aware, rather than having to probe the unconscious deeply to find out what the behavior symbolizes. When the self-mutilation is more seriously hidden from the individual, it usually represents the “glue” that holds a fragile personality organization together.
Unfortunately for young people like Shari and Brian, culturally approved pain has a place and a presence in our society. It will always be with us in one form or another. As long as competition and heroic tasks exist, bravery, danger, and pain will exist in tandem, side by side. We must be vigilant, however, lest we as a society go overboard in confusing achievement with, and conferring status on, the endurance of pain.