Understanding Pain

“Understanding Pain: Pastoral approaches to help those who suffer,” by Fr. John Love, The Priest, March 2024. ©OSV. Used by permission. No other use of this material is authorized.

“If you feel pain, you’re alive. If you feel other people’s pain, you’re a human being.” – Leo Tolstoy

Introduction

We meet people from all walks of life in physical pain and spiritual anguish. No one is exempt. As clergy, we will be called to endure many times of trial and questioning that arise from our own very personal experiences of pain. This experience will, in turn, certainly color pastoral advice to those who seek help and counsel. Pain is scientifically defined as an unpleasant physically centered phenomenon, but is there such a thing as spiritual “pain”? Many believe there is, and for those I want to provide insight from both pain researchers and our own rich Judeo-Christian spiritual tradition to help clergy better understand both the science and underlying spiritual meaning of pain to thereby come to the aid of suffering souls.

What is Pain?

Our ability to sense pain is a remarkable evolutionary phenomenon that has the positive effect of allowing one to avoid harm to self and, by way of empathy, to avoid causing unnecessary physical pain in the lives of those around us. The negative aspects of pain are a necessary side effect of this marvelous and fine-tuned evolutionary ability. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage.”¹ In addition to breaking down pain into the two categories of “acute” and “chronic,” there are thought to be at least three different modalities of pain in the human body, and these include (1) nociceptive — a direct assault on the nerve, i.e., a cut or gunshot wound, (2) inflammatory — indirect sources of pain derived from swelling and/or damage of tissue and joints such as arthritis or sprains, and (3) neuropathic — pain which is manifested within problems of the nerves themselves, for example, cerebrospinal and nerve-degenerative diseases.

Even with these helpful distinctions, there are competing theories about the origin, nature, and perception of pain, a topic that has been examined by philosophers, scientists, and physicians. For the ancient Greeks and Romans, experiences of pain, sorrow, and remorse were caused by evil spirits roaming the world as a punishment by the god Zeus.² Aristotle noted that pain was not captured in just one of the sense organs (sight, smell, taste, hearing, and touch) but that it seemed to be the antithesis of pleasure and that it could pervade the entire body.³ A more recent scientific hypothesis proposes that pain begins through dedicated nerve pathways and receptors throughout the body that all lead directly to the brain (the “specificity theory”)⁴ while another model developed by Charles Wall and Ronald Melzack suggests that the opening and closing of specific nerve receptors in the dorsal (thoracic) spine called nociceptors are the primary cause of pain.⁵ More recent attempts to define pain as something more than a purely physical response are evident in the continued work of Melzack, who has proposed that the perception of pain is a multidimensional “neuromatrix” experience influenced not only by nerve stimuli but also through cognitive and emotional factors, including the memories of prior painful experiences.⁶ In a review of the literature on pain, there is a clear evolution — just in the past decades — from understanding pain as a purely physical problem to one that includes emotional and mental (non-physical) aspects and experiences.

When researching physical pain, two issues inevitably arise. The first problem is that pain presents in varying degrees of intensity, and individuals in a study cohort sometimes experience different levels of pain even with the controlled introduction of the same pain stimulus. Are genetics to blame? For example, there is some evidence that, due to a slight variation of the MC1R gene — the pigmentation gene — a redhead encounters more pain during the same dental procedure than does, say, a brunette.⁷ Second, there is no hard and fast scientific agreement on the actual basis for the perception of pain, or how the brain “computes” the sensation of pain. This leads to the second problem: all pain theories are subjective in that they must rely to a great degree on pain sensation reporting as markers for pain response and measurement. These two problems of pain, as vexing as they are, can provide pastoral “starting points” for our thinking and a clue that pain is not experienced as something just physical, and that pain treatment might include psychological or “attitudinal” management in addition to drug therapy. As we shall learn, this is exactly what a couple of researchers from the University of Washington learned in the 1970s when they studied and treated people with chronic pain.

The Treatment of Pain without Medication

Pain medication has been around for over two hundred years (morphine was invented in 1803) and more than three millennia if one considers naturally discovered remedies such as opium, which is thought to have first been cultivated from poppy fields by the ancient Sumerians.⁸ As recently as 2022, about 132 Million million legal prescriptions for opioids (hydrocodone, morphine, methadone, and fentanyl classes) were filled in the United States alone.⁹ The use — legal and illegal — of opioid medications to treat pain is spiraling out of control, causing some scientists to examine if there might be a better way to treat pain. In a discussion of pain theories and therapies that extend beyond the medicinal, I want to mention John Bonica and Wilbert Fordyce, twentieth-century pioneers in the field of the treatment of chronic pain using new techniques for pain management and behavioral therapy. John Joseph Bonica, MD was surprisingly first a Sicilian-American professional wrestler and later, an astute and clever anesthesiologist who developed a team approach to pain management. Among his many accomplishments, Bonica developed the first multidisciplinary pain clinic at the University of Washington and was instrumental in developing nerve-blocking therapies for pain management. Bonica’s colleague Wilbert Fordyce is most known today for developing in 1973 what he termed “operant conditioning” to treat chronic pain without surgical or pharmaceutical intervention. As a scientist, Fordyce was interested in the locus of pain but also wanted to develop practical ways to reduce the perception of pain. To do this, Fordyce worked with patients to identify the difference between “pain behavior” versus “well behavior.”¹⁰ Fordyce — who spent most of his career as a researcher at the University of Washington — felt that most who encountered chronic physical pain tended to develop and operate out of a physio-psychological feedback loop and that doctors would usually respond by first prescribing pain medication. That is, once pain had commenced, the temptation of resorting to pain medication as a first-line treatment would simply reinforce the idea that pain medication would always be necessary. Fordyce held that if certain beneficial behavior modifications that implied “well behavior” (instead of more drugs) were to be introduced when treating pain, then pain indicators (complaints) might be reduced. We understand this thesis from our own experience of physical pain. When we allow negative emotions to enter the picture without considering any positive thoughts or emotions, physical pain tends to manifest itself more acutely. To use a well-worn example, consider your pain at night when the overactive and anxious mind creates scenarios, exactly when the doctor is not immediately available. Isn’t it fascinating that your pain tends to wane in the morning as the sunlight hits your face and warms your body, and when an appointment becomes available? Doctors themselves speak of what is called “waiting room hope,” when pain symptoms magically lessen upon arriving for treatment.

Fordyce’s work has value if we can adapt his thoughts to understanding and helping people who are in spiritual pain. As with physical pain responses, we tend to also adopt “spiritual pain behaviors.” When we are in spiritual or mental anguish, we often spend too much time alone, wasting energy and thinking about our problems, creating negative feedback loop behavior. And this is not just a problem of our parishioners. Ask any bishop, superior, or vicar for clergy and they will share stories of priests who constantly complain of pain symptoms regardless of workload or assignment. To complain about pain is all these clergy know after so many years of chronic and acute distress that may have no apparent observable or medical basis. In any event, by constantly bringing up our problems and spiritual and physical problems to others and spending too much time focusing on the negative aspects of life, we subconsciously and consciously reinforce the notion that we are in mental pain. This is not to say that we should not verbalize our physical and mental pain and suffering and seek help when needed from physicians, priests, and professional counselors. Quite the contrary! But simply complaining about our pain — and not developing a mindset that will seek to overcome our current state of anguish — pushes us into a feedback loop of negative thoughts and behavior. One of Fordyce’s pithy sayings was “Those who have something better to do, do not hurt that much.” A pastoral counselor needs to communicate that one will always better handle illness and injury when the person can focus life on something other than simply obsessing over pain and spiritual anguish. I often think of St. Thérèse of Lisieux in her last year of life at age 24. She was in great physical pain because of advanced tuberculosis. She was being treated by a local physician, but she was also ministered to by her congregation. Her sisters knew she was in spiritual as well as physical anguish and would not allow her to wallow in her room alone. The sisters would wheel her bed out in the corridor of the convent every day so that she could get fresh air and visit with her community.

Is There Such a Thing as Spiritual Pain?

I want to propose that there is such a thing as spiritual pain, sometimes also described as anguish or sorrow. The idea that we suffer and endure pain in life for something greater is powerfully illustrated in the language of the “suffering servant” found in Isaiah 53:3–5:

He was spurned and avoided by men,

a man of suffering, knowing pain,

like one from whom you turn your face,

spurned, and we held him in no esteem.

 

Yet it was our pain that he bore, our sufferings he endured.

We thought of him as stricken,

struck down by God and afflicted.

But he was pierced for our sins, crushed for our iniquity.

 

He bore the punishment that makes us whole,

by his wounds we were healed.

The language of the suffering servant comes to us from the second section of Isaiah as the author seeks to understand the ultimate direction and meaning of a process of purification and renewal during a time of testing. Although most Jewish scholars understand this text as an allegory to understand the collective suffering and fate of the Jewish people, Christians view the text in terms of the prophetic voice of Isaiah foretelling the suffering of Christ, who will later redeem mankind through his suffering and death on the cross.

Reflect also for a moment on the pain of Christ in the Garden of Gethsemane before his suffering and death. This very heart-wrenching but vivid example of the effect of extreme stress causing the excretion of blood droplets could indicate a rare physical phenomenon called hematohidrosis, which can occur with certain blood disorders and times of stress. Through his spiritual suffering, Jesus begins to sweat tears like blood drops (Luke 22:42, 44.) Although it is not clear if this is actual blood or sweat drops “like drops of blood,” the combined effect of profound spiritual agony and physical stress is clearly implied and helps us to understand that spiritual turmoil can indeed have physical manifestations.

After withdrawing about a stone’s throw from them and kneeling, he prayed, saying, “Father, if you are willing, take this cup away from me; still, not my will but yours be done.” . . . He was in such agony and he prayed so fervently that his sweat became like drops of blood falling on the ground.

In both Jewish and Christian outlooks, Isaiah 53 helps locate the biblical connection between present suffering and purification to achieve a higher future good, sometimes referred to as “redemptive suffering.” Fr. William Most makes the following statement about this redemptive suffering while encouraging us to make reparation to the Sacred Heart of Jesus and the Immaculate Heart of Mary:

For sin was the cause of that terrible day on Calvary when she, as the New Eve, shared in the torment of the great sacrifice, and, amidst indescribable pain, brought forth spiritually all the members of the Mystical Body of her divine Son. God willed that Mary should be intimately associated with His Son in bearing the burden of all sin; surely then, her Immaculate Heart, in union with His divine Heart, should receive reparation from us who have caused them such pain.¹¹

Fr. Most refers to the special spiritual and emotional “pain” that Mary bore at the crucifixion, even if this spiritual pain is analogous to physical pain. In preparing this paper, I asked six random diocesan priests if they felt that spiritual pain (not caused by external-physical stimuli) exists. All quickly answered in the affirmative. And yet, not all scientists who study the subject recognize pain with psychological, spiritual, and emotional events. Instead, many pain researchers hold that claims of psychological, emotional, and spiritual pain simply describe something else because this type of pain is not scientifically measurable. In a way, the scientist is correct, and there is no empirical nor observable way to measure the intense pain of suddenly losing a child, the stark diagnosis of terminal illness, or the grinding toll of a marital breakdown or relationship problem. There is no pill to solve the pain brought about by an incident or a series of personal problems leaving a soul with a feeling of emotional emptiness and spiritual darkness. Still, those who treat people in chronic pain know of the psychosomatic connection of pain, and that mental suffering can often also have a debilitating effect on the body. We have all met people who are otherwise physically healthy, but who complain of mental or spiritual problems and begin to exhibit physical symptoms: lack of appetite, headaches, phantom pains, nausea, and insomnia, just to name a few.

Pastoral Counseling Tools to Help You Treat People in Pain

I now want to suggest some avenues of pastoral counseling for those who complain that they are in deep physical pain due to illness or injury, or spiritual pain due to a personal or family problem, crisis, or setback. The first useful thing I will mention is the pain scale. I mentioned earlier that a common element of all pain studies is the observation that pain tends to wax and wane and that it usually resolves after some time. I want to discuss this aspect in a little more detail. One of my favorite memories from growing up in a surgeon’s home is shadowing my father during his evening surgical rounds. In those days, the children of doctors could easily maneuver around hospitals and even enter the surgery ward (so long as we meticulously washed, stood in the far corner, didn’t touch a thing, and remained quiet as a church mouse!). During hospital rounds, my father would ask post-surgery patients about their pain based on a well-known diagnostic tool called the Pain Measurement Scale, which everyone has seen in hospital rooms. Designed to be a point-and-shoot tool for patients who may have trouble verbalizing their pain, the Pain Measurement Scale uses simple pen-drawn visualizations of cartoon faces with increasing anxiety and visible pain. Even today, decades after I watched my father interact with patients, and with all the many fancy computer devices available, the cheap plastic pain scale diagram hanging on the wall is still an invaluable tool, giving doctors or nurses the ability to quickly learn a patient’s pain status and decide to up or lower the pain medication or offer some other sort of advice or therapy to reduce the pain.

I have adapted the Pain Measurement Scale for my own pastoral counseling and have learned some interesting things over the years. When I sense that a person is in great personal pain during counseling, at some point, I will ask a person how much spiritual pain they are in on a scale of one to ten, with ten being the worst pain imaginable. By helping a person with their issue or problem through counseling, I can sometimes help move the needle just one or two clicks down, and that little movement might be enough for the person to regain a sense of determination and purpose in life. They are still in pain, but now they are “smiling through tears.” To illustrate, if a young woman comes to me and announces that, due to the death of her child, she locates her spiritual pain as nine out of ten, it is going to be unrealistic for me or any other minister or counselor to offer much to take away all of the mental pain she is experiencing and get her to a two or three on the pain scale. However, if I can help her move the needle just to seven, this might just give her enough renewed strength and energy to continue to examine her own spiritual realities and pain, and begin a longer, more holistic form of healing that is centered not on trying to obtain a pain-free life, but on more clearly understanding the principle that pain, while not always avoidable, usually lessens over time.

The Communion of Suffering

Some time ago, I was speaking to a lady who had been in constant and unremitting pain for ten years. She made a comment that caused me to consider the power of pain to negatively affect one’s life. She stated: “When you are in chronic pain, time seems to stop, and everything around you that was important becomes secondary to the pain that surrounds you.” It reminds me of the saying posted on my college philosophy professor’s office door from the Greek philosopher Herophilus: “When health is absent, wisdom cannot reveal itself, art cannot manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied.” One of the things that set pastoral counseling apart from traditional forms of professional counseling and psychotherapy is greater reliance on the common elements of Christian spirituality, including the principle that the spiritual elements are brought to the forefront, and thus God is always present and active in the session with both minister and counselee. We are but fellow human travelers offering advice to someone who is often suffering from a specific question, problem, or issue. Even so, we have a formidable skillset based on training and the guidance of the Holy Spirit. We can help people see the redemptive power of suffering. Think about the most powerful moments you have been in physical or spiritual pain and then have been the recipient of healing through good counsel. My guess is that you did most of the talking, and the counselor was there to mostly listen and then gently inject hope and a new perspective into your plight. In a similar light, we must let God’s healing power enter into the conversation by praying with parishioners who come to us for counsel, asking the Holy Spirit to guide them to a new understanding of spiritual pain as a path to sanctity. This is a moment to understand that the priesthood is a communion not only with people in joy, but also a communion with their very sufferings, abjections, and sorrows. Listen to this sage advice from a neurologist who often treats those in extreme bodily and spiritual pain:

It is essential that anyone counseling a person for chronic physical and/or spiritual pain be a good listener, exhibit empathy, and remain nonjudgmental. Assisting the person in gaining insight into their circumstances is often therapeutic and may enable them to make progress toward healing. Psychologists utilize many techniques including cognitive behavioral therapy, but I believe that prayer and contemplation are equally essential to this process.¹²

I want to now highlight something that I have spoken about during many pilgrimages to Lourdes serving as a chaplain with the Order of Malta.¹³ Every year, three Malta associations within the United States invite about 150 sick and dying people to Lourdes to experience healing. Not all are physically healed, but I believe the sick are spiritually lifted and gain a deep sense of renewed faith and hope from the pilgrimage experience. Some of our malades (sick persons) are in deep physical pain, and you can see this in their facial expressions as they move about. Others are in no specific physical pain, but they are coming to grips with a serious or terminal illness and seek miraculous intervention at Lourdes. They may not grimace, but it is easy to see they, too, are in turmoil. Some are angry and confused, others seem at peace, but all are seeking a healing moment. Part of this healing comes from the miraculous intercession of Our Lady, but this healing is also present in the Communion of the Church through the herculean efforts of the Knights and Dames of Malta, our physicians and nurses, and volunteers who are gathered around the malade from the beginning to the end of the week-long pilgrimage.

Through my association with the Knights of Malta, I have learned that caring for the sick not only means caring for physical needs that come with illness and injury, but also ministering to those who are suffering and in deep spiritual questioning and pain. This accompaniment is usually nothing profound. Sometimes, it means saying nothing, and just silently sharing in the suffering. Other times, it seems best to help distract them from illness by sharing a wonderful meal and admiring the beautiful high country of Southern France. Still, at other times, it means facing the demons head-on, attempting to inject renewed faith and hope into the life of a fellow suffering human person. From the General Introduction of the Pastoral Care of the Sick, we read:

Christians feel and experience pain as do all other people; yet their faith helps them to grasp more deeply the mystery of suffering and to bear their pain with greater courage. From Christ’s words they know that sickness has meaning and value for their own salvation and for the salvation of the world.

Sickness is not our natural state. God created us to be healthy. When we become sick, we are also spiritually wounded, and we sometimes wear out and feel so very alone and frightened. When visiting doctor’s offices, we are often undressed or mostly undressed in the presence of strangers. Medical professionals often poke and prod our bodies, and we wince in pain and fear as needles, strange medicinal odors, whirring machines, and unfamiliar medical terms are introduced. This moment is a time of great humility and vulnerability, and it can feel like a walk with Christ, who was stripped of his garments, whipped, and crowned with thorns, creating gashes and wounds on his back and upon his head. In cases of illness, people can change for the worse. In his spiritual and human perfection, Jesus is silent, but when we mortals are sick and injured, we can quite easily become bitter, angry, existentially adrift, and eventually depressed. Some of this anger may even be directed toward clergy, physicians, and families who are simply trying to help. For the humble soul, these moments need not be endured in vain. Sometimes, being sick and in pain can be a time to reassess what is most important in life and to live in a communion of suffering with others who are often in a much worse condition. Entry into the Communion of Suffering with a parishioner or patient on a sick call through words of solace and understanding and the sharing of sacramental ministry is at once a noble and exhausting act, but I think you will agree that it describes the essence of the sacrificial priesthood which draws forth the very best of your noble heart and mind as you pastorally care for those who are lost in acute or chronic pain and a resulting period of spiritual darkness.

Conclusion

I conclude by summarizing three insights. The first comes from the scientific community as we realize that physical pain tends to vary in intensity and duration and is always a very personal experience. The revolutionary work of Wilbert Fordyce demonstrates that chronic physical pain can sometimes be effectively treated without surgery or pharmaceutical intervention. While spiritual “pain” must be understood as analogous to physical pain, the same behavioral principle applies; instead of resorting to addictive or harmful pills and negative thought patterns, simply changing one’s thinking and behavior when encountering spiritual agonies and pains can indeed change one’s mood and outlook. Small degrees of improvement are often enough to give a person in pain renewed vigor and spirit. When we as clergy come to the aid of a person in physical or spiritual pain and help them to shift focus from pain to other more positive things, the resulting relief and renewed joy can be astonishing to witness for both the patient and the pastoral counselor.

Second — related to the good counsel we can offer to those in physical or spiritual pain — one of the unique qualities of spiritual direction and spiritual counseling is that clergy are able to offer something that the physician or pharmacist cannot: a perspective based on a Catholic spirituality that understands the plight of the human condition, and thus understands that not all pain is avoidable and that experiences of pain can sometimes teach us how to become a better person and a more empathetic ear. As the Canadian philosopher and psychologist Jordan Peterson once wryly (more or less) stated, “Are you willing to suffer the little things so that you may not suffer something greater?” Pain can be a teacher, and often serves to redirect one’s gaze toward a higher metaphysical good and even a salutary change in moral bearing.

Finally, related to the above thought is the ecclesial truth that, here in the deep valley of tears, we all share in one degree or another in the mystical Communion of Suffering with Jesus Christ. No one is exempt from physical and spiritual pain, and no one is exempt from resulting occasions of confusion and spiritual darkness. The pastoral minister — as a fellow suffering servant — can gently remind another soul that spiritual anguish can be a way to greater union with the suffering Sacred Heart of Jesus and the Immaculate Heart of Mary. Commenting on the holy life and outlook of Pope St. John Paul II, Archbishop Giuseppe Pittau, SJ once said, “An easy life without suffering has no depth.”¹⁴ Spiritual suffering and physical pain can make a person bitter and lose faith, but with good counsel, experiences of pain can also lead the person to a deeper understanding and recovery of the mystery of salvation.