Where are pain and pleasure experienced: in the mind, the brain, or both? What communicative value do pain and pleasure have? These are the questions that Thomas Szasz attempts to answer in his book, Pain and Pleasure: A Study of Bodily Feelings.
Pain and Pleasure is Szasz’s first of thirty-four books. It was published four years prior to his now famous book, The Myth of Mental Illness. In Pain and Pleasure, we see some of Szasz’s ideas about mental illness coming to form. For example, Szasz writes in a footnote about his thoughts on how psychoanalysis relates to medicine:
It seems to me that from the point of view of scientific clarity it would help to restrict the scope of “medicine” to those sciences and techniques that are based on and that use the physicochemical frame of reference. Other sciences, which study human experiences in different frames of reference (such as those of history, sociology, linguistics) would be subsumed under the label “sociopsychology” and would complement “medicine” in the study and change of man.
In Pain and Pleasure, 2nd ed., the publisher includes a new preface by Szasz written in 1988, as well as an article by Szasz on some thoughts about chronic pain and its communicative value. The preface and the additional article alone are worth reading and may be more valuable than the entire book itself.
Pain as Communication
In the reprinted article, Pain in a New Perspective, 1975, Szasz explains his understanding of pain:
Although I shall not define pain—because I do not believe that all “painful” states contain some essence, “pain,” that is definable—I should like to explain my use of the term. In referring to my own pains I shall mean that I feel pain; in referring to the pains of others, I shall mean that they report, to me or someone else, that they feel pain. This approach may seem wholly subjective and hence inappropriate for scientific work. I believe, and I hope to show, that it is neither. The anatomist may, to be sure, study brains; the physiologist, electric impulses in nerves; and the pharmacologist, the responses of subjects to drugs. But these men do not, in my opinion, observe or study pain any more than engineers who build television transmitters and repairmen who fix television receivers observe or study the events that newscasters report on the screen.
Pain as Drama
Szasz says his approach to understanding pain is based on personal, human experience of man as a social animal. He writes:
A dramaturgic-existential approach to pain recognizes not only man’s subjectivity, but also his profound dependence on other persons. In other words, existence is at once private and public, concealed and revealed — depending on the identities of actor and audience. Private experiences are those in which we attend to our own inner plays, as in dreams. When we display these experiences by words or action, our selves become actors in a public drama witnessed by and involving others. In short, my approach borrows psychoanalysis from psychiatry, role theory from sociology, and existentialism and linguistic analysis from philosophy. Out of this mixture, I have tried to fashion a coherent dramaturgic-existentialist perspective on personal experience and conduct, including that which we call “pain.”…Since pain is a complex emotion (I distinguish it from discomfort or distress, which are the proper terms for describing the unpleasant effects of the newborn), a psychological approach to the study of pain must consist largely of observing the ways in which people pay attention to or heed pain in various situations.
By dramaturgy, Szasz means:
…the malingerer says “I am sick,” when, in fact, he is not; the (non-psychiatric) physician says “I am an expert in the diagnosis and treatment not only of bodily diseases but of personal problems as well,” when, in fact, he is not; and the psychiatrist says “I am an expert in the diagnosis and treatment not only of mental diseases but of bodily ailments as well,” when, in fact, he is not. The malingerer plays the sick role, the (nonpsychiatric) physician the role of the psychotherapist, and the psychiatrist that of the physician. The upshot is a vast confusion of roles, each impostor trying desperately, often coercively, to authenticate his role and compel its acceptance by his audience.
For Szasz, there is no difference between pain experienced “in the body” and pain experienced “in the mind”. Actually, for Szasz, there is no such thing as “mind”. The mind is a metaphor for heeding of minding something. Pain is an emotion we display that has meaning to others in our social group.
From the point of view of the experiencing person, there is no such thing as “psychogenic pain.” Individuals always ascribe their pains to some disease or dysfunction of their bodies.
Szasz analyses the communicative meaning of reporting pain and the situation that a physician faces when confronted with a person in pain. He says:
A man may thus complain of pain in his penis and implore the doctor to “cut it off.” If his request is not met, he may amputate his own penis. To be sure, such persons are diagnosed as suffering from the “disease” called “schizophrenia.” But does schizophrenia “cause” and “explain” pain in the penis in the sense in which coronary insufficiency “causes” and “explains” pain in the left arm? And can “schizophrenia” be treated and thus the penile pain be relieved? The answer to both of these questions is: No. In this type of situation, the physician is not confronted with a disease that causes or is manifested by pain; instead, he is confronted simply with pain, or with a complaint of pain, or with a painful person, or, last but not least, with a person who tries to make the physician suffer. The treatment or control of pain here poses a different problem from that encountered in standard medical practice.
Szasz says that people with chronic pain often seem to want to make a life career out of being in pain. He writes:
The second type of pain situation in which the usual medical approach fails is exemplified by the severely depressed and agitated person who complains of annoying bodily feelings, such as itching, headaches, lack of appetite, insomnia, backache, and so forth. Such a person has adopted—fully or partly, permanently or temporarily — the career of being sick and in pain. He does not want his pains allayed or relieved. What is the physician’s task in this situation? Whose pain should he control: the patient’s, that of his relatives tortured by the patient’s complaints, or his own pain, generated by his inability to help the patient?…One thing strikes the careful observer of patients with chronic pain, especially in cases without organic illness: they are individuals who have made a career of suffering. At one time such persons may have been attorneys or architects, busboys or businessmen, models or maids; but when their careers fail or no longer suffice to sustain them, they become “painful persons”; or to paraphrase the French diagnostic term “tic douloreux,” they become “hommes douloureux”; or to put it in Latin, they become “homini dolorosi.”
Szasz points out that his observations are not new, Freud wrote about pain and how playing the sick role of a painful person may be the only meaningful role that one can or wants to play in life.
This is how Freud summed up his understanding of why Fraulein Elizabeth von R. complained of pains without being demonstrably ill and which yielded to no medical treatment:
> ‘Here, then, was the unhappy story of this proud girl with her longing for love. Unreconciled to her fate, embittered by the failure of all her little schemes for reestablishing the family’s former glories, with those she loved dead or gone away or estranged, unready to take refuge in the love of some unknown man—she had lived for eighteen months in almost complete seclusion, with nothing to occupy her but the care of her mother and her own pains.’
This, in my opinion, is one of the finest and most important paragraphs in all of Freud’s writing. Free of psychiatric jargon and of psychoanalytic pretense, Freud here reminds us, in plain but persuasive language, that playing the sick role may, for some people some time, be the most gratifying pursuit open to them.
Helping People in Pain
Szasz, the humanist, tries to understand a person’s suffering on that person’s own terms. He says:
The humanistic physician must try to understand such persons and see their life from their perspective, not his. To choose pain, suffering, and doctoring as a career means attending to the dysfunctions of the body and their repair. Many physicians dislike treating such patients. That is their privilege. A physician is not obligated to treat anyone whom he does not wish to accept as a patient, except in certain emergency situations. He may either refuse to accept the person as his patient or, if he has accepted him, he may dismiss him from his care. To my mind, this constitutes no more of a “rejection” of the patient than his being told that a mailman does not deliver cars. On the contrary, such a communication is an important clarification of the physician’s role. Indeed, I believe that the imperfect definition of the role of healer in contemporary society is an important reason for the prevalence of certain kinds of painful complaints.
When writing about how to help suffering persons, Szasz says the task of the psychoanalyst is to treat,
…the client as a person responsible for his life rather than as a patient not responsible for his lesion, by treating pain as an idiom rather than as an illness, and by substituting his own dialectic and discursive language for the client’s rhetoric and nondiscursive language. If such an enterprise is successful, it is not because the therapist has succeeded in controlling the patient’s pain, but because the patient has decided to become another kind of person.
One of the more interesting aspects of this book is Szasz’s reflections on people he has worked with in psychoanalysis who were suffering from chronic pain.
In one example, Szasz helps a young woman with intractable chronic pain. Her pain started shortly after her mother died suddenly and father her father then killed himself. She was thirteen when this happened and began experiencing severe back and joint pain afterward.
Szasz helps the young woman see how her pain is connected to her loss of significant objects in her life. Her parents were taken suddenly from her and her body is the only significant object she has left. It as if her body is telling her to pay attention to it lest it is taken away from her as well. As she makes the connection between her anxiety about losing the only significant object she has left, that is her body, she begins to experience less pain. She allows herself to form new object relations. Szasz writes:
This case illustrates several communicative meanings of pain. Not only was the pain initially a request for help, addressed first to the older sisters and later to physicians, and subsequently an aggressive, frustrated complaint of “You see, you still have not done anything for me . . .”; but it had still another function as a warning signal of an impending danger. It was as if the patient, having lost both parents, had no really significant object left to lose other than her body. Then, as if to make sure that she would not be taken by surprise again as she was by the death of the mother, she experienced the warning signal in a chronic manner…The patient was greatly improved after about one year of treatment. Pain occurred very infrequently. Instead, a much broader spectrum of human emotions was experienced, and she could regard these as reflections of her relationship with the people about her. She was no longer alienated from her family. She concluded that they had little in common, and she now had a consciously more distant and more comfortable relationship with them. She also entered a training program for professional work from which she obtained much satisfaction.
In two separate cases, women come to Szasz complaining of itching of the vulva. Szasz writes about women’s unexplored sexual longings and how they connect with such itching.
A young woman in analysis developed itching of the vulva concurrently with an interest in exploring her genitals. She experienced a sensation in the genital region which was described as “a feeling like a little worm turning’, She wondered what was there. This woman had no recollection of ever having masturbated, which was an activity, she thought, indulged in only by boys, since she equated it with manipulation of the penis. She examined herself in the mirror, felt puzzled by her own experiences, and said: “If only I could see something there”. Another woman patient developed an itching of the vulva without, however, the feelings of puzzlement and the wish to explore mentioned above. In this case, the symptom seemed to have a predominantly communicative meaning pertaining to the analytic situation. This was a way to call attention to her genital organs and longings, without being completely explicit about them. In both of these cases, the itching disappeared in a matter of a few weeks, in the course of discussing and working through the pertinent psychological material.
Szasz sees pleasure as a way of expressing delight in oneself or another person. For Szasz, both pleasure and pain are experienced only by persons, not simply by bodies. The way a person allows himself to feel and express pleasure is determined to a large degree by that person’s particular circumstances he finds himself in.
The communicative meaning of “pleasure” may be compared and contrasted with the communicative meaning of “pain.” The latter usually expresses an accusation directed toward a significant person or a demand for some sort of help from him. Similarly, the symbol of pleasure in this context refers to a significant (human) object, and it expresses the idea that the relationship is, or has been, good (satisfying).
When speaking of pleasure Szasz contrasts the language we typically use for pain to the language we use for pleasure. He points out that we talk about the pleasure a person experiences, but speak about pain as if it is in a certain part of the body. He says this is because pleasure typically does not entail a request for someone to do something, while expressing pain often does contain a request for assistance.
On this Szasz writes:
It was noted that pain is a call for help and a command to take action to relieve the sufferer. Now, if we wish to take action, we must know something about the danger which we wish to remove or alter. To distinguish between “organic” and “psychogenic” pains is, from this point of view, eminently useful, since it enables the physician to decide whether or not to take action toward the body. By the same token, since pleasure does not mobilize the recipient of the message into action, there is no need and no motive to try to find out very much about its source or nature. This is reflected by the absence in our language (lay as well as medical) of terms which locate pleasure in various body parts or which assign it to the mind (e.g., we speak of headaches but not of headpleasures).
Pleasure and Pain is one of Szasz’s more academic works. Even so, I found it to be a worthwhile read. Reading Pleasure and Pain helped me to think more deeply about subtle forms of communication in life. For the student of Szasz, it offers insight into how his thinking and writing has evolved over time.