Depression is a natural result of chronic pain. Can learning to accept the pain help?

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As much as we would like to avoid it — and as much as we try to — pain is an inevitable part of life.

For 20% of adult Americans, physical pain in particular is not just an occasional occurrence, like it is for many of us, but a core part of their experience. That’s an estimated 51 million people in this country alone who live with chronic pain.

One Group Therapy reader wrote to us about what it’s been like for him to live with chronic pain:

“I have failed back surgery syndrome, which has had me going from a directorship position with a large nonprofit to housebound for the past seven years. Every year my pain somehow increases, and with every increase in pain my depression worsens.

How do you manage depression when chronic pain keeps you from having even the simplest of social interactions (like talking to someone in a grocery aisle) because you can hardly leave the house?”

My heart goes out to this reader and anyone else whose well-being is at the mercy of constant discomfort. This newsletter will look at common experiences of people with chronic pain, how it affects their quality of life, and how sufferers can learn to access ease and acceptance.

“It’s very hard to wrap your mind around all of what is potentially lost or not possible or going to be challenging for you if you’re living with chronic conditions or pain,” said Asher Pandjiris, a psychotherapist in Massachusetts and host of the podcast “Living in This Queer Body.” “I am in this continual process myself, of grieving and accepting and coming to terms with it, and then grieving again.”

What it’s like to live with chronic pain

Chronic pain lasts for more than three months but may go on for years. It can happen alongside a chronic health condition, like arthritis, or it may persist beyond the usual recovery period after surgery, like what our reader has experienced.

Other common causes of chronic pain are back pain, migraines, and conditions such as cancer, multiple sclerosis, fibromyalgia, shingles, irritable bowel syndrome, lupus, and nerve damage (neuropathy). Other times, chronic pain doesn’t have an obvious culprit, making it all the more frustrating for people to get the care they need.

Chronic pain looks and feels different from person to person, but here are some common experiences from those who live with it, according to our experts:

Social isolation

“One of the most significant experiences is one of isolation, whether it be physical or emotional, or a disconnection from the world that you knew,” Pandjiris told me. “I think a lot of people saw what that felt like during the pandemic. It was very shocking to people who were suddenly enduring a kind of isolation that many people who live with chronic pain or invisible symptoms experience daily.”

Many people with chronic pain feel misunderstood, even if their loved ones are supportive, prompting them to isolate themselves.

There’s this feeling of “no one understands what I’m going through,” said Rona Maglian, an Orange County psychologist specializing in chronic pain.

The fear of pain can also cause you to avoid being social, and being in pain is also just extremely exhausting, so it can be really hard to muster the motivation to go out and see other people, said Fadel Zeidan, associate professor of anesthesiology in the division of pain medicine at UC San Diego.

“Let’s say you get invited to the company picnic. There’s a fear of not only pain but of embarrassment, that they’ll see me grimace when i get out of my car. When they ask me to play volleyball, I’ll have to say no and explain why,” Zeidan said.

Having your pain minimized or questioned

Unfortunately, many people with chronic pain find that they aren’t believed by their healthcare team, and sometimes even their friends and family.

This is especially true for women and people of color. According to an online survey of more than 2,400 U.S. women with a variety of chronic pain conditions, 90 percent felt that the healthcare system discriminates against female patients, and almost half were told the pain was all in their heads. It’s common for women with menstrual pain caused by conditions like endometriosis and fibroids to be dismissed by doctors, researcher Amy Miller told Consumer Reports.

And half of medical students in 2016 held one or more false, racist beliefs about people of color, such as “Black people’s nerve endings are less sensitive than white people’s” and “Black people’s skin is thicker than white people’s.” That study showed that trainees who believed that Black people are not as sensitive to pain as white people were less likely to treat Black people’s pain appropriately.

Pandjiris, who lives with autoimmune-based chronic health issues, linked the invalidation of chronic pain to health-ism, or the insistence that a person’s health is entirely their responsibility. “Say someone is expressing pain that is confusing to a medical doctor, or confusing to friends, or to their boss. Part of our ableist culture is to attribute a kind of moral failing to being in chronic pain, and that can lead to having your pain minimized, questioned, or attributed to something that is supposedly within your control — ‘you’re anxious so you’re in pain, you’re sitting too much so you’re in pain.’”

Depression and anxiety:

An estimated 35% to 45% of people with chronic pain also live with depression, much higher than what’s seen in the general population. Chronic pain can also lead to anxiety, and no wonder — you may be constantly worried about how bad the pain will get, how long it will last, and how it might affect your relationships and financial security.

Researchers have long posited a reciprocal relationship between pain and depression: chronic pain is depressing for the reasons discussed above, and depression can cause pain in the body. In fact, psychological pain and physical pain activate some of the same brain regions and involve similar neurotransmitters.

“When you feel like there’s nothing left in your control — no control over your body, the limitations chronic pain has over your life — it can very quickly lead to someone feeling hopeless,” Maglian said.

Pandjiris finds that depression and anxiety can be a result of “unsupported grief” among people with chronic pain. It’s the kind of grief that accompanies your life changing suddenly because of pain, or looking completely different than what you’d hoped for yourself. When doctors or loved ones minimize your pain, it can also contribute to grief and depression.

“If that grief isn’t respected and validated and rallied around by people who are in your life,” they said, “and you live in a culture that is deeply ableist and values productivity above all else, [depression] is just an inevitable experience.”

How to live more fully with chronic pain

An entire industry has sprung up around the treatment of chronic pain, accounting for billions and billions of dollars spent each year, from pain management clinics to painkillers to physical therapy. Though there are many people legitimately working to help people manage their discomfort — and many patients who need these medicines to treat their pain — chronic pain is a market that’s been capitalized on in devastating ways; 44 people died each day on average in 2020 from overdoses involving prescription opioids, and countless other lives have been affected by the opioid crisis.

Instead of focusing on how the medical establishment tends to perceive and treat chronic pain, I want to offer some thoughts from our experts on how you might begin to accept it.

“One of the promising therapies in pain management right now is mindfulness training,” Zeidan said. “Mindfulness, unlike other therapies like Cognitive Behavioral Therapy (CBT), doesn’t try to get you to change your attitude toward the pain, but instead accept the fact that you will be in pain.”

I asked Zeidan what this can look like in practice.

Imagine you’re bending over to tie your shoe and pain shoots up your leg, he said. You acknowledge the feeling (the actual contours of the sensation — tingling, heat, level of intensity — not the thoughts related to the feeling), and come back to the breath over and over. This increases your ability to regulate thoughts and emotions that can make the experience of pain worse, helping you from spiraling into catastrophizing thoughts, like “What if this pain gets worse?” or “What if it throws off all my plans for the week?” Zeidan said.

This makes me think of the Buddhist concept of the “second arrow”; the first arrow is the painful or frustrating event itself, and the second arrow is how we respond to it, or the story we tell ourselves about the first arrow — thoughts like “I can’t do anything anymore” or “My life is ruined.” Being mindful of the second-arrow thoughts by noting them and not internalizing them as fact can prevent further suffering.

For Pandjiris, acceptance is about assuming that their life — and their body’s ability to do certain things — will be unpredictable. “I have to assume that when I’m approaching things like a vacation, or a move, or some kind of big deviation from the regular schedule, there will be things I truly can’t predict. Instead of praying or hoping that I won’t be in pain for the week that I really need to not be in pain, I have started really trying to account for the possibility of my body’s needs and take care of them, plan for them. I try to accept that things might go differently than I’d hoped, and lean into the knowing that it isn’t any sort of failing on my part.”

When working with clients who live with chronic illness and/or pain, Pandjiris supports them in identifying what’s in their control and what’s not. “We can’t control when and how our pain shows up, or that friend who always forgets to do the thing that makes life easier for us,” they said. “But we can control the way we relate to our own vulnerability. We can attempt to alleviate the pressure we put on ourselves to show up perfectly all of the time.”

An answer for our reader

Our reader asked how he can manage his depression when his chronic pain prevents him from being able to connect with other people.

This is what Pandjiris had to say:

“What you’re experiencing is real. There must be a lot of grief there, and I want to validate the fact that you’re managing depression as a result of the world we live in, not as a result of your own failing or inadequacy.

“It also sounds like a lot of the pain is not visible to a lot of people. The exhaustion that comes along with being disconnected from the world, and having to explain why that is happening, is too much sometimes and makes the depression very understandable.

“Zoom is a helpful tool, but as all of us have discovered, virtual communication only gets us so far. But when our bodies cannot leave the house and we can’t engage in the way we want them to, then my advice based on experience is to use these virtual tools in the smartest way possible. Make sure that the interactions you’re prioritizing are kind, fun, or supportive — people you can cry with and complain to. No conversations or hangouts where you already feel drained before you get on a call.”

Maglian echoed the importance of engaging with people who either understand your experience or try really hard to understand. She recommends looking for therapy groups, peer support groups, or interest groups. Engaging in advocacy, like getting involved with a disability justice organization, can also be empowering and connect you to people with similar struggles, she said.

“One of the other biggest things I talk about with clients is finding ways to take the pain off center stage in your life,” Maglian said. “If you’re doing things that you think you should be doing to get better, it won’t sustain you long enough through the challenges of chronic pain. The way to shift your focus from pain in your life is to think about what you value. What will keep you going when life feels impossible? Freedom? Creativity? Family? This will give you purpose and meaning outside of your pain.”

Until next week,

Laura

If what you learned today from these experts spoke to you or you’d like to tell us about your own experiences, please email us and let us know if it is OK to share your thoughts with the larger Group Therapy community. The email GroupTherapy@latimes.com gets right to our team. As always, find us on Instagram at @latimesforyourmind, where we’ll continue this conversation.

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More perspectives on today’s topic & other resources

Sufferers of chronic pain have long been told it’s all in their head, but research shows that assumption is wrong. In this Guardian piece about chronic pain and long COVID, Linda Geddes explores the growing realization that pain can be a disease in and of itself, one that the pandemic may have worsened.

While doctors take an oath to do no harm, there’s a good chance their unconscious biases can seep into how seriously they take your pain. In this TED Talk, Physician Sheetal DeCaria explains how perception impacts medical care and treatment -- and calls for health care professionals to pay more attention to how they do their patient checkups.

It’s very likely that there’s someone important in your life who lives with chronic pain. How should you support them? Buzzfeed (RIP) collected advice from mental health professionals and people with lived experience of chronic about how you can begin the conversation with loved ones about how they would like to be supported.

Other interesting stuff

In May, the US surgeon general suggested that social media is contributing to a mental health crisis among the nation’s youth. But social media can be valuable to young people too, helping them build friendships and receive social support from peers. So what’s a parent to do? This Wired piece offers some guidance on how to talk with kids about social media and mental health.