A hierarchy of pain? NYC Therapists Discuss

This is the second in a series of conversations completed by our NYC therapists. The conversation, discussing the tendency in psychotherapy towards establishing a hierarchy of pain and suffering, was completed over a series of days.

Matt: While I'm not sure the five of us have ever talked about this explicitly, I'm certain you all encounter something as therapists that I do frequently in my practice: There is a tendency to compare one's suffering with other people's--the homeless person in the street on the way into our therapy office; the friend from way back who experienced real abuse.

"My parents never beat me and here I am in a some therapy office in Tribeca crying about my life” is a recent example from my own therapy work.

There's probably a lot going on there. Assuming you see this in your work, what do you have to say on the matter?

Heather: There is a lot going on there, so much it's hard to know where to start. Especially since once I follow that train of thought, I often end up in some pretty different places with my therapy patients.

For some I think it is a well meaning attempt at perspective, a desire to stay grounded in the reality of the fact that, sure, things could always be worse, I’ll try to be grateful for what I have. For others, I think they historically have been told by some pretty significant people in their lives that their pain is not real or important so I think they have learned to not look for much comfort or understanding from the people in their life around that pain. I work with a lot of highly adaptive people who have had to ignore their pain and just keep pushing forward in order to survive. Additionally, there can be a denial of how bad things are and were, and a pull to not really sit with how painful that pain is. To actually stop to look at the pain can be a hard thing to do and I think it’s scary to examine and feel the pain; it can feel like a Pandora's box. Lastly, I think it's really intimate to get close to that pain with another person, even (or especially) in the therapy room, and to experience it with them and show them the feelings that come up around it.

Matt: I have such a hard time with "things could be worse" but you're reminding me that that's actually often an awfully healthy thing to say to oneself. My reaction, of course, is to how often I hear that in therapy as part of the problematic project of shutting down one's own right to feel and express pain. I thought at first when I read this that in other areas of medicine (insomuch as therapy is part of that tradition) we don't say, "It could be worse" but then I recalled the experience of being a parent and our interactions with the pediatrician. Helping bring perspective to an anxious parent (and child) is a big part of that work, and so too for us as therapists. Part of what our therapy patients are grasping for, in some instances, is a sense of their capacity to handle this, an awareness that they are bigger than this moment.

That said, I'd like to hear from others on the ways this presents as a kind of self denial, a way for someone to say in therapy, effectively, there is a hierarchy of pain, and mine ranks as "less than." What does everyone else think?

Karen: I think this of kind of statement can be a way to explore the impact of our tendency to compare and judge ourselves against others, the pain of others, how this may isolate us as both givers and receivers of help. It is an opportunity to wonder, What does this way of thinking produce for the patient emotionally? How is it adaptive but also how may it be limiting? It is a clue as to how a person may have been socialized. I’m always curious here about the cultural piece and using that as context. There are so many potential responses to this type of opening from a patient and I think I also attach some meaning to it in that this is a person who holds their pain close to them or may be a bit detached from the way things are impacting them or have fears about talking about their pain.

Rachael: I just met with someone who noted her pain goes from high to low. She is so used to being fine and the same time not. I work with others that disassociate from pain and we have to bring it to the surface. They’ve become skilled at hiding it.

It’s such a challenge to slow down to be with the pain and not run past it or compare it with others’ pain. With the right help, we can manage the pain that perhaps felt so unbearable long ago. I have a new second chair in my office and I often think of it holding the pain, the experience that produced it, so we can give it its voice and space.

Kiran: I'm struggling with this question. I try to see pain as both a collective and unique experience at the same time. The person who can't get his or her work done and is feeling pain around it--it's real. The person who just lost a parent, his or her pain is real. When I first started practicing as a therapist I had a lower threshold for holding unique pain for what it is--I had my own hierarchy. As my work continues my threshold seems to have expanded in terms of holding less judgement around someone's experience of pain. This work has also forced me to see pain on a continuum. The person who is crying in the office because someone said something "not so nice" to them may feel kind of silly, however I'm wondering what is this attached to? Is there more to this pain than is evident on the surface? What are the other layers of pain sitting there.

Matt: Loving all of your responses and loving how different they are from how I was initially thinking about this. I'm being reminded of the ways that we can talk about "situations" in the abstract (in this case "someone" who minimizes his or her pain). I love that I'm being remind of two things that are really the same thing: being curious (for eg I like what Karen says, if I can put a twist on it--being "culturally curious" in the sense of both the culture of the family and culture more broadly) and remembering that everyone is different. I framed this issue as a sort of "Oh, I bet you all have heard this one before!" and it's true, you have, and yet everyone is so different and there’s so much more going on than meets the eye. We don't need to try to change/ fix this but rather look at it and into it, offer ways of complicating it or new ways of seeing it. Like in everything else we do.