If You’re Against Assisted Suicide, You Are Either Monstrously Ignorant or Monstrously Selfish, Pick One

Update: some well-needed information and nuance has been added to this discussion by a reader. If you read this post, please also take the time to follow this link to a very thoughtful response.

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Another day, another person generalizing their experiences and decisions to everyone else for no justifiable reason.

Back when I was dealing with more pain than I am now, I thought about assisted suicide. I never got close enough to start going through the nitty-gritty details, but it’s something I would have seriously considered if I had run out of things to try pain-wise. My back pain, back then, was constant and excruciating. A life where that experience was all there was would very likely not have been worth it to me.

Considering that option doesn’t mean, obviously, that I didn’t try to get better. I did try that, and as a result, I have gotten (somewhat) better.

Even so, it makes me very angry when people talk about how they don’t think assisted suicide should be a thing. About how if things hadn’t gotten better, I should have had no choice but to live in constant, excruciating pain.

Here’s what I think: I think that if you’re against assisted suicide, you think other people should have to suffer immeasurably so that you can avoid being uncomfortable. It is uncomfortable to realize that there are people in situations where death is preferable to life. It’s not a happy thought, but it is a true one. I sympathize with wanting to believe that everyone really wants to live, or that everyone really would want to if they really thought about it. What a nice world that would be.

But that’s not the world we live in. The world we live in includes people who live with more pain than they can handle every single day of their lives. It includes terminally ill people who would rather go while they’re still coherent, aware, and not completely incapacitated by disease-induced disability and pain. If that reality makes you uncomfortable, I understand. If you think catering to your discomfort by legally requiring others to endure torture so that you can pretend it’s what everyone really, truly wants deep down inside, you can go fuck yourself.

Make no mistake, that is the decision. When you say you’re against assisted suicide, you’re saying, “That person should have to live in unimaginable pain for an indeterminate amount of time so that I don’t have to face reality”. Which is monstrous.

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Sidenote: yes, legalizing assisted suicide brings with it the potential for abuse. It brings with it the potential for people to be pressured into suicide. That is a big issue, and a complicated issue, but “It’s complicated therefore we should just pretend it’s not complicated by not allowing it at all” is not a solution to it.

Antidepressants Update

So. Antidepressants.

My new psychiatrist has me ramping up on a relatively new drug called Viibryd. It is supposed to have fewer sexual side effects than most of the others on the market. This past weekend, an “um-friend” of mine visited from out of town, on account of which I got very little sleep. Yesterday I switched from 10 mg to 20 mg on the ramp up, and presumably either on account of that or the incredible lack of sleep or both ended up pretty sick and threw up a few times.

I told my psychiatrist and he recommended I stick with 10 mg for longer and see how that goes. In addition to being generally sick the last few days, I’ve had the worst flareup in my chronic pain symptoms I’ve experienced in a long time. It has been a generally miserable couple of days.

I’m not sure what the next go-to strategy will be if the Viibryd doesn’t work. Most other drugs I’ve tried have had little impact and annoying side effects. In particular, my recollection is that most of them, rather than lowering my interest in sex like I was warned about, tend to lower my ability to get hard, but do absolutely nothing to my interest in sex. Wellbutrin, when I tried it, had the opposite effect, but it also led to my feeling jittery throughout the day, and is apparently not effective against anxiety, which is one of my issues.

So we’ll see. Right now I’m just clenching my teeth through all the chronic pain stuff, which I’m anticipating will die down after I’ve caught up more on sleep.

An Open Letter to My Physical Therapist

Alright, first things first: I presume you want to help. You probably wouldn’t have gotten this job if you weren’t interested in helping people with injuries and other physical issues. That’s great.

With that out of the way, I have some issues I’d like to bring up with you. Not everyone in your profession is guilty of doing every one of the things I’m about to bring up, but a lot of you are guilty of a lot of them, and it really needs to stop.

So, without further ado, some constructive criticism from a patient who has, regrettably, become somewhat of a connoisseur of practitioners in your domain:

Dear Therapist,

First, let’s get something straight: I want to get better. I’m pretty fucking sure that I want to get better more than you want me to get better, because I am the person who actually has to deal with the issues that we are trying to address day in and day out. I am the person who decided to set up these appointments with you. I am the person paying for them. If I didn’t want to get better, then I wouldn’t be coming to see you. Proceed with this assumption. If you aren’t making this basic assumption in dealing with me, we are going to have problems.

Second, on a related note, if you ever, ever feel the impulse to remind me that “We really need to start seeing some improvements”, consider that another option is to shut the fuck up. If I think that my problem is bad enough that I am paying money to come to see you, you can safely assume that I am well aware of the benefits of seeing improvements. You can also safely assume that if you decide to remind me of that fact as though the problem is a lack of motivation to get better on my part that I will spend the rest of our appointment fantasizing about stabbing you in the face with a protractor. Repeatedly. Forcefully.

Third, if I’m not reliably doing all of the exercises you prescribe, consider the possibility that it is not because I lack motivation to get better. Consider the possibility that if you prescribe 10 different exercises five times a day, you are prescribing the impossible for most people, and if you can’t acknowledge that, then you probably don’t understand enough about people to be doing a job that involves working with them. Consider, as an alternative to insisting on an absurdly complex exercise regimen, that you could collaborate with me to figure out why a particular regimen poses the challenge that it does, and how we might modify it to make it realistic to expect me to keep up with it.

Third and a half, if you can’t do that, consider that you are giving me (and probably all of your other patients) a tremendous incentive to lie to you about whether or not we are doing the prescribed exercises. Deciding to change physical therapists is a big step, and generally a scarier step than deciding “Maybe I can just do a few of these and say I’m doing all of them and hope for the best.”.

Four, be able to explain and defend the treatment decisions you make. If you prescribe something I have already tried that didn’t work the first time, you had better be able to give me a damn good reason why it’s worth trying again. If you prescribe something that sounds like bullshit, and can’t explain why it’s not, I’m going to lose confidence in you very quickly. Because I have been dealing with the problems I deal with as long as I have, it is not uncommon for me to go to therapists who recommend things that I have tried before, and that I know more about than they do. If it seems like I have done more research on the treatments you are recommending to me than you have, we’ve got problems.

Five, for God’s sake take accurate notes! I will know if you don’t, because when you tell me that things are looking better or worse and I know that the opposite is true, I have no recourse but to assume you are incompetent. This is especially true if I tell you that you are wrong and you refer to your oft-inaccurate notes to back up your claim. It is astonishing how often some therapists have told me things about my own health history in appointments with them that are blatantly inaccurate.

Six, don’t insist on finding a silver lining in a lack of improvement. You aren’t the one in pain, you don’t get to decide for me if the glass is half-full. If I ask you for ways to keep my chin up about stuff, then by all means help me out, but your thoughtless optimism is obnoxiously patronizing coming from the person who does not actually have the affliction. If things aren’t working, then let’s form a new strategy rather than wasting time trying to cobble together hope about the failed one.

Six and a half, for fuck’s sake don’t take your frustration about a lack of improvement out on me. If you get frustrated at me because of the fact that I’m not feeling better, you are complete and total asshole, and I will ditch the protractor fantasy for one involving fire ants and your sensitive parts.

Seven, and I can’t believe this is something I actually need to make explicit, but history has shown that it is: if I ask you what things I can do without aggravating my issues, do not, under any circumstances respond by giving me a list of things I should not be doing. When I ask you about my options for physical activity, I am looking for a list of things that I don’t have to be afraid of doing, and if you respond to that question by giving me a list of things I should be afraid of doing, I hate you.

Eight, ask for my input. ask me what I think about how I’m doing, and about the treatments and exercises you are prescribing. Ask me if I think there are ways the regimen will be hard or easy, and could be improved. You are the professional, and while some of your patients, myself included, will put effort into adding our own input to your ideas on how to move forward, it is entirely within your power to make that easy or difficult. You can ask questions and deliberately give openings for my input, or you can hope that I will find a conversational opening to do so. And you had better want my input, because while you may be the expert on physical therapy, I am the expert on me – on what I can do, what I can’t do, what I have time to do, etc. As I’m sure you’ve figured out by now, every patient and every physical issue is different, and my input is how you know what is different and how it is different.

Nine, if the exercises you give me to do are not working, do not assume that it’s because I’m not doing them. Consider the possibility that maybe your exercises are not working because people are different and what works for one person will not necessarily work for another.

Ten, assume that I am always doing my best. If I’m not keeping up with the exercises, assume that something is making the routine impossible for me to keep up with, and let’s collaborate on modifying the routine. If you think I’m lying to you about whether or not I’m doing the exercises, assume that you have failed to make our therapy sessions feel sufficiently collaborative for me to feel comfortable communicating to you about what I can and can’t do and what I am and am not actually doing. If we really can’t figure out a way to make everything doable, then let’s go over all of the available options for treatment again and figure out what possibilities we have missed.

This concludes our prickly open letter of the day. I hope we’ve all learned something.

Sincerely,

Your Patient

The Chronic Pain-Imposed LDR

In some ways, having chronic pain is a lot like being in a long-distance relationship. Rather, it’s like being in a lot of long distance relationships. It’s like having to be in a long-distance relationship with everything that you love.

I really like programming. I like solving puzzles, I like thinking of new ways to engage people with information, and I like making things pretty and intuitive. You can easily get lost in programming in the best kind of way — you can fall into the zone where there is nothing but the current problem you’re solving and stay there for hours.

Well, most people can. Falling into the zone isn’t much of an option for me, because by the time I’m there, it’s time for me to take a break. Because I have these chronic issues, I have to carefully plan how much I work, how long I sit, what I can do during work breaks to lower the possibility that symptoms will worsen, etc.

In my case, doing anything long enough to get in the zone will get me approximately to the point where I need to stop doing it in order to preserve my health.

In a long-distance relationship, you have to be deliberate about setting time to spend together. You often have to fit interaction into the gaps in busy schedules — gaps which may change between the time you plan for them the time they occur. You may not be able to find as much time as he would like to talk to a partner, and the time that you do find can often feel too short. It can be just enough to remind you how much you enjoy someone — just enough to realize how awesome it is talking to them — and then end.

A lot of times, this is what programming is like for me. If I work just long enough to really get in the flow, it is also just long enough that I have to stop. Just long enough to be reminded how amazing it is to get lost in something, and just long enough to have that feeling of awesomeness taken away at that moment of realization.

And it’s not just programming, it’s everything that has the potential to aggravate symptoms given time. I can do them just long enough to fall in love again, and the point at which I do is the point at which they are taken away, because that’s how my body seems to work.

It really, really sucks.

How to Be Skeptical of Your Own Brain, Part Three: Ideas

 Introduction | Part 1: Chronic Pain | Part 2: Depression | Part 3: Ideas

I manned an Ask an Atheist table regularly when I was in college. A lot of good discussions were had at that table, and the ones I most enjoyed tended to be the ones that focused on a particular point. Someone would say they didn’t believe in evolution, and I would go over the genetic evidence for it (which was and is my favorite); someone would argue that without religion you can’t have morals, and I would explain why their morals had no more objective basis than ours; etc.

Every now and then, though, there would be one of those discussions where every time I made a few points against one of their arguments, the religious person would change subjects. The whole argument would be a game of religious apologist bingo, jumping from “The Bible says God exists” to “You can’t prove God doesn’t exist” to “But you can’t have morality without God” to “But you can’t explain the universe without God” to Pascal’s Wager, etc., etc. No matter how many arguments for a god failed to stand up to scrutiny, the person would just jump to another one.

The strange thing about this pattern, which you see in all kinds of debates all the time, is that people don’t seem to recognize the pattern. When five arguments have been knocked down, the person jumps immediately to the sixth argument, apparently without pausing to consider the possibility that maybe there is a reason the first five “foolproof” arguments have failed. That maybe the problem  is that the premise they’re defending is wrong, rather than that they just haven’t found the one argument that really will be foolproof.

To my mind, the reality in the argument with the Christian at the Ask an Atheist table is that the first five arguments failed for the same reason the next five arguments are bound to fail: because the premise they’re defending is false. Gods don’t exist.

Why doesn’t this occur to more people in these arguments? Why, after the umpteenth argument in a row has failed, don’t people think to ask themselves if maybe the problem is with their premise? Why do they keep searching for reasons why they are correct instead of asking if they are correct?

Well, why did I keep searching for a physical problem with my back when I started experiencing chronic back pain? Why did I keep searching for a problem with me all those times I experienced the emotional pain resulting from depression?

I know the answers to those questions: I kept searching for a physical problem with my back because physical pain begs for a physical explanation. Physical pain instinctively prompts you to ask the question “How am I damaged?”. By the same token, I kept searching for a problem with me when I felt bad about myself because that kind of emotional pain begs the question “What is wrong with me?”.

I think the reason why people search for reasons why they are correct instead of asking if they are correct is because cognitive bias begs the question “Why am I correct?”, not “Am I correct?” in the same way that pain begs the question “How am I damaged?”, and not “Am I damaged?”.

Our instinct is to trust our lived experience. Our instinct is to trust what we perceive — to trust that when we feel hurt, it is because we are hurt, that when we feel bad it is because of something bad, and that when we feel conviction it is because something is true.

I spent years uselessly searching for a problem with my back to explain my back pain, and I spent years uselessly searching for problems with myself to explain why I felt bad about myself, and everywhere you look, all the time, in arguments, people spend tremendous amounts of time asking “Why am I correct?” in response to their bias without even realizing that that is what they are doing. To me, these all look like different versions of the same story, and I think that the same type of skeptical thinking can be applied in each case.

What would it mean to think of bias as an analog of pain? It would mean thinking of bias as an experience produced by my brain based on taking in all of the available contextual data I have about an idea and turning it into a conscious experience of conviction about that idea. In the same sense that my brain will take in an enormous amount of subconscious context before creating a conscious pain experience, I imagine that it takes in context in a similar way before producing a conscious experience of conviction. Also, in the same sense that I can skeptically evaluate an experience of pain and make a conscious decision about whether or not it indicates damage, I can skeptically evaluate an experience of bias and make a conscious decision about whether or not it accurately suggests the validity of an idea.

Let’s do one more analogy:

Imagine that you have a motion-activated security system in your house. If someone tries to break in, it goes off, and you call the police. However, if you have a dog, sometimes your dog might set it off, too. You don’t want your reaction to the alarm sounding to automatically be “Someone is breaking in.”, you want your reaction to the alarm sounding to be “The alarm is going off.”, so that you can then ask “Is it sufficiently likely that someone is breaking in that I should call the police, or did I forget to close the gate to keep the dog upstairs?”. The alarm going off doesn’t mean “burglar”, it means “alarm”, and it’s up to you to decide whether or not that alarm is a sign that your house is being broken into or not.

In the same way that it is better to think “alarm” instead of jumping to the conclusion of “burglar”, I endeavor to think “pain” instead of “physical damage”, “emotional pain” instead of “something wrong with me”, and “I feel conviction about this idea” instead of “this idea is true”.

It is incredibly valuable to identify the experiences, the “alarms”, that cause us to act in certain ways or beg us to make certain assumptions. I wasn’t aware that it made sense to question my experience of pain, physical or emotional, until I realized that pain was a constructed experience that might not be accurate, and therefore deserved to be examined critically. By the same token, we are not able to question our biases unless we are able to separate ourselves from them, look at them, and critically question the conscious experience of them.

If you don’t realize that you are experiencing a product of your fallible subconscious brain when you experience, say, a conviction that a particular deity must exist, then you may end up searching for ways to justify it instead of asking if it is justified. You cannot effectively question the bias “alarm” unless you are aware of it. Similarly, if I didn’t understand that pain is a product of my fallible subconscious brain, then I would still be fruitlessly searching for ways to treat my low back. If I didn’t realize the same thing about emotional pain, then I might still be wasting time trying to find things to fix about myself in response to it.

I want to take a moment here to make sure that I emphasize that when I say we should question these experiences, I don’t mean to say we should dismiss them. Sometimes the alarm going off means there is a burglar in your house. Sometimes your ankle hurts because you sprained your ankle. Sometimes you feel bad about yourself because you really shouldn’t have taken that candy from that baby, or that job at Fox News. Sometimes you feel conviction that George W. Bush was a terrible president because he was, in fact, a really terrible president. The point of all of this is not to say you should instinctively doubt your experiences, but that you should practice instinctively being able to spot them and hold them out in front of you for examination.

In almost exactly the same way that I skeptically examine my experiences of physical or emotional pain, when I experience a conviction that a particular truth claim is correct, I try to figure out why my brain thinks that conviction is appropriate (“Why is the ‘conviction alarm’ going off?”). If I can’t recall the experiences or context that led to the conviction, but I have confidence in it, then, usually, instead of sifting around for justifications, I will simply say that it is my strong impression that a particular truth claim is correct. On the other hand, if I decide I don’t have confidence in the conviction, then I have an opportunity to reevaluate my position.

In light of this process, I have become incredibly fond of the phrase “It has been my impression that [assertion].”. In discussions, this is my way of saying “I have a bias about [assertion] that I trust, but I can’t remember the specifics of how I formed that bias at the moment.”. We so often think of bias as a negative thing, but for the most part I think of it as a useful form of data compression. Deciding to trust a bias isn’t necessarily bad, but it is a decision that should be made consciously instead of automatically wherever possible.

Be skeptical of your brain. See the process. See the “alarms” that prompt you to jump to certain conclusions before jumping to those conclusions. In the same way that I have to routinely ask “Why do I think I am physically damaged?” instead of “How am I physically damaged?” in response to pain, never ask “Why am I correct?” without first asking “Why do I think I am correct?”.

The phrase “Deity X is real.” being put under a magnifying glass, revealing the words “I am having an experience of conviction about an idea. This conviction may or may not indicate that this idea is correct. Do I have any other info to suggest that this conviction is or isn’t the result of this idea being correct?”.

 

How to Be Skeptical of Your Own Brain, Part Two: Depression

 Introduction | Part 1: Chronic Pain | Part 2: Depression | Part 3: Ideas

I wasn’t officially diagnosed with depression until 2008, but when I look back on my life, I can see the beginnings of it started much earlier. Whatever part of my brain is responsible for producing the sensation of guilt has been working overtime for as long as I can remember.

When I was in high school, I tended to respond to the experience of feeling bad about myself by trying to fix things about me. I figured that if I just managed to figure out how to be an ethically flawless human being, I would be happy. I spent a lot of high school and college trying to manage being 100% perfect at honesty or pop-culture-Buddhist emotional detachment. I figured that was the key — I figured people felt bad because they were doing things wrong, and so when I felt bad it was because I was doing something wrong.

So every time I felt bad, it was because I wasn’t being as honest as I could be about this thing or that thing, or because I was attached to people in ways that prevented me from being able to see them clearly. It was because I needed to fix something. In the end, though, no matter how much effort I put into becoming ethically flawless, it didn’t ever seem to make me much happier. In point of fact, it tended to do the opposite.

It took me a very long time, even after I was diagnosed with depression, to understand the size of the mistake I had been making. It’s only in the last few years that I’ve been able to fully articulate the bait-and-switch that happens when I’m depressed — the fact that all of the flaws that I find with myself when I’m feeling bad aren’t the cause of my depression, but a symptom of it. It was more recently, still, that I finally made the connection between depression and chronic pain.

The thing that it took me so long to realize is that the emotional pain that comes from depression is just as unreliable as the physical pain that I experience in my back. I needed to realize that the emotional pain doesn’t necessarily mean I need to fix something about myself in the same way that physical pain doesn’t necessarily mean I have physically damaged myself.

As I discussed in the last section, the process that I have learned to go through when I experience chronic pain symptoms goes roughly like this: when I notice pain, I try to think if anything has happened recently that is likely to have produced an actual injury. If I can think of something, then I treat it like an injury. If I can’t, then I assume that the pain is a mistake.

I almost never ignore pain entirely, but if I suspect it’s not actually due to physical damage, I treat it like a paranoid delusion, rather than something physically wrong. Much like you might try to calm down a paranoid person who is convinced “everyone is after them” by talking to them about why that’s probably not true and trying to calm their nerves, when I judge my pain to be the product of a paranoid brain, I focus on all of the evidence that nothing is actually wrong, I try to reduce stress, and while I don’t completely avoid physical exertion, I do try to keep it relatively mild so as not to further scare my brain. The interesting thing is this: what I have learned to do with respect to depression is almost exactly the same.

When I notice emotional pain, I try to think if there is any actual good reason for it. If I can think of something, then I try to address that. If not, then I treat my brain like it’s being paranoid. The only difference is that where in the case of physical pain the paranoia is resulting in an inaccurate picture of what is going on with me physically, in the case of emotional pain the paranoia is resulting in an inaccurate picture of what is going on with me, shall we say, existentially. I think of emotional pain as my brain’s potentially flawed artistic rendering of the state of my existential self in the same sense that physical pain is my brain’s potentially flawed artistic rendering of the state of my physical self.

The impact of this model on my mental state can be quite powerful. I have had the experience of waking up in a state of pretty severe depression, and thinking “I can’t think of any reason for these feelings to be happening, therefore they probably aren’t accurate, and there is probably no good reason for me to be having them.” and having the depressive feelings dissipate. It isn’t always that easy, but it is, at times, a powerful tool to have in my toolbox.

Even when it doesn’t have an immediate effect on depressive feelings, this model of thinking is an incredibly useful tool for critically examining depressive thoughts. Nowadays, when I feel bad about myself, I understand the problem to be the fact that my brain produces this emotional pain without good reason to do so, and instead of assuming it is a sign that I need to fix something about myself, I assume it’s a sign that I need to do some maintenance on my brain.

Now, when I experience physical pain that begs for a physical explanation or emotional pain that begs for a problem-with-me explanation, I am able, when it is appropriate, to deny them that — I’m able to say “No, this is not a problem with me, it is a problem with you, Brain.”

In the next post: how this same model applies to ideas and arguments.

The phrase “I am worthless.” being put under a magnifying glass, revealing the words “I am having an experience of intense emotional pain. This pain may or may not indicate that something about me is not okay. Do I have any other info to suggest that this pain is or isn’t the result of something about me not being okay?”.

How to Be Skeptical of Your Own Brain, Part One: Chronic Pain

 Introduction | Part 1: Chronic Pain | Part 2: Depression | Part 3: Ideas

Note: for the purposes of this discussion, when I use the phrase “physical injury”, I am generally referring to an injury for which the physical point of origin is not my brain. This is bad terminology, given that the brain is just as physical as the rest, but I haven’t yet been able to come up with a better shorthand.

My back pain became chronic about 10 years ago. I had occasional experiences with back pain before 2004, but none of it was ever the sort of all-the-time pain that I started experiencing after a particularly intense sparring test in kung fu that summer. I experienced what a few doctors would later refer to as a “spasm” of the muscles in my back, and, after the pain didn’t go away quickly, decided to take some time off from kung fu to heal.

I waited, and waited, and waited, but every time I experimented with practicing kung fu again, the pain got worse. Even when I wasn’t experimenting with kung fu, I was in pain. Eventually, I started seeing doctors to try to get some decent diagnosis and treatment for the injury.

One doctor said it was that my vertebrae and my sacrum were out of alignment, and I should do some PT and some exercises and wear an SI belt. That didn’t work. Another doctor said it was a muscle tension thing and recommended muscle relaxants and anti-inflammatories. That didn’t work, either. Another doctor said it was core weakness and I should do some strengthening exercises for my core. That didn’t work, either. Another said it was that my leg lengths were different, another said it was a muscle in an ongoing state of spasm, another that it was networks of muscle knots…

No matter how many different doctors I went to and treatments I tried, none of them ever seemed to consistently help.

After about seven years of trying different doctors and treatments, I started going to a physical therapist who was more up on chronic pain research than most of the others I had been to. He would talk amiably through our PT sessions, and one day in the course of conversation, he said something that completely changed my perspective. He told me that there was almost certainly nothing wrong in the tissues of my back; he told me that the pain I was experiencing was almost certainly not a response to a physical injury.

I hadn’t considered that possibility before, because I didn’t know that this sort of pain could happen without being a response to a physical injury. Up to that point I had been convinced, without even consciously being aware that I was making an assumption at all, that the pain I was experiencing had to be a result of a problem with the tissues in my back.

Physical pain begs for a physical explanation, and because of that I searched for a diagnosis and treatment for a problem with the tissues in my back for years longer than I should have.

The thing I needed to understand about pain is that it is an artificial construct, not a direct feed of information. Pain in your foot doesn’t happen because of tissue damage in your foot, it happens because tissue damage in your foot sends danger signals to your brain, and your brain decides, based on those signals and historical context, that pain is an appropriate response*. Danger signals from the tissues are neither necessary nor sufficient for pain – they are one piece of context out of many that your brain uses to make a decision about whether or not to create a pain experience. Your brain can get danger signals and decide not to cause pain, and it can also decide to create pain in the absence of any danger signals whatsoever.

Metaphorically speaking, there’s an artist in my brain who looks at all of the physical inputs from all over my body, and all of the historical context from my life, and paints a picture that becomes my conscious experience. My pain isn’t a photograph of the state of my tissues, it is an artistic rendering  of the state of my tissues based on what the artist thinks is exciting or important. The same physical input will produce different sensations for me versus for anyone else, and for me now versus for me a year from now**, in much the same way you might expect different artists to paint the same scene with different styles and emphasis.

If I’m going to really take this metaphor all the way, then we could say that the problem with my body is that sometimes the artist gets drunk, and for some reason, when he’s drunk, he gets obsessed with my low back. The pictures he paints, and the pain I experience, do not correlate with what is actually going on in my tissues in any useful way whatsoever, they’re just a bunch of renderings of my lower back in violent red and orange.

For the last year or so of my life, my back pain has been better than at any other time in the last ten years, and I attribute that entirely to the fact that I learned these things about pain and have been able to apply them in useful ways. I may always have some difficulty with back pain, but for me, personally, no doctor or treatment has been as useful as learning about the process of how pain is produced.

My education about pain has enabled me to view my lived experience of pain through a skeptical lens. When I experience pain, I don’t assume that it is because of an injury. In the same way that a person with phantom limb pain isn’t going to worry that they’ve injured a phantom limb, I have learned not to worry that I have injured a part of myself when I experience “phantom pain” in a body part that just so happens to still exist.

In my day-to-day, this means that instead of responding to pain by not doing the thing that “caused” the pain, I respond to it by asking myself if it is likely that the pain is a response to actual damage, or a response to my brain making a mistake. If I think it’s the former, then I treat the pain like it’s an actual injury. If I think it’s the latter, then I use various strategies I’ve developed to accomplish the basic goal of telling my brain that it’s getting things wrong, and slowly increasing my exposure to the things that it mistakenly thinks are causing me damage.

In short, the single most useful tool for me, personally, in managing my chronic pain has been developing the ability to be skeptical of my experiences of pain***.

In the next post: the story of how I came to apply this same type of skepticism to my experiences with depression.

The phrase “Ouch! I hurt my back!” being put under a magnifying glass, revealing the words “I’m having an experience of pain in my back. This pain may or may not indicate physical damage. Do I have any other info to suggest that this pain is or isn’t the result of physical damage?”.

 

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* In reality, the process is significantly more complicated than this — there are, for example, many different forms of modulation that can happen between the tissues and the brain — but I have made this simplified explanation as true to the actual process as I can without going into the less necessary fiddly details.

** Those of you who remember when you got your first cell phone may recall your first experiences with “phantom” cell phone vibrations. “Phantom” cell phone vibrations did not occur for any of us before we owned cell phones — not because our pant legs rubbed against our legs differently, but because our brains had not learned to interpret that type of input as possibly indicating the vibration of a cell phone. Same input, different context, different output.

*** I should note, here, that the strategies I use are not a cure for my chronic pain, but a major help, and that they are generally not easy or quick fixes, but take a lot of work, and that they will not, of course, work the same, or necessarily at all, for everyone. Not all chronic pain works like mine, not all of it stems from a purely neurological source. All pain does come from the brain, not the tissues, whether it’s phantom limb pain, actual limb pain, or pain resulting from the fact that you’ve just lost a limb, and as such I think education about these aspects of pain is probably always useful for chronic pain sufferers, but it will not always work as well as it has for me.

How to Be Skeptical of Your Own Brain

Introduction | Part 1: Chronic Pain | Part 2: Depression | Part 3: Ideas

 

From one thing, know ten thousand things.

— Miyamoto Musashi

 
I was going to try and write an introductory anecdote for these posts, myself, when I realized that another fantastic blogger had already written one perfectly. Before you continue reading, check out this post by Ferrett Steinmetz.

I think about the only other time I hallucinated, having dropped acid on a very hot summer’s night… and I found it disappointing.  Yes, my vision was flexing and distorting, and I witnessed all sorts of curious artifacts as my brain’s visual processing center went into overload – but I quietly dissected each illusion, breaking it down into its interesting components, and in such a way I reduced what could have been a wild trip down into a series of interesting quirks.

I don’t really hallucinate, I don’t think.  I know what my brain is up to.  And today, I realized why:

It’s because I’m a depressive.  I don’t trust my brain.

…

So when my brain starts providing false visual information, I do the same thing: I question it.  I compare it to reality.  And if it doesn’t make sense, I ignore it.

This post and those that follow it will be a series of anecdotes from my own life illustrating my personal journey from (1) learning to skeptically examine my chronic pain symptoms to (2) applying that same pattern of skeptical thought to my depression symptoms to (3) applying that pattern of skeptical thought to my reactions to ideas and arguments. In telling the story, I’m hoping to outline a generalizable model for thinking skeptically about all of our conscious lived experiences as human beings — a model for how to be skeptical of our brains.

It starts, naturally, with Part 1: Chronic Pain.

Being Skeptical of Your Brain, Part One: Introducing the Model

I’ve decided I’m going to try to put together some ideas that might eventually end up as a conference talk. I have some ideas in my head for a basic outline, but they’re not very organized, so my plan is to write about them until they organize themselves.

The talk is going to be about how to be skeptical of your own brain, and is going to mainly center around a model for thinking about our experiences that helps with this. I want to do more research on the model, because while I know there is good science backing it up when it comes to the perception of pain, I haven’t done as much research on it with respect to other forms of perception. At present I feel completely comfortable calling it a “useful” model, but I’m hoping to get to the point where I can call it both “useful” and “pretty well substantiated by research” with respect to all of the ways I apply it.

This post is going to be what I presume will end up being the beginning of the talk. It is an outline of my basic mental model for how tactile sensory experiences (pain in particular) occur and how they can be inaccurate or be misinterpreted.

Here we go:

I think of any experience of pain as a three-step process: trigger, feeling, and explanation. In the first step, the trigger, something activates danger sensors in the skin called “nociceptors” that respond to heat, pressure, or acidity, and those signals are sent to the brain*. For example, when you sprain your ankle, the resulting tissue damage will activate nociceptors in your ankle.

The second step is the translation of those signals into a sensory experience — the feeling: the brain receives nociceptive signals, and makes a decision about whether or not you should feel anything as a result. That decision is based on putting the signals in historical context — has the brain gotten signals like this before? Have they generally been dangerous? Not dangerous? Is it likely they are dangerous now? — essentially, the brain takes your whole life, all of your lived experiences, into consideration and makes a decision about whether or not to produce the conscious experience of pain. When you sprain your ankle, your brain should, if everything is working correctly, decide to produce some intense ankle pain in response to the triggered nociceptors.

The third step is the explanation. A person has a sensory experience and comes up with an explanation for it (e.g. “My ankle hurts therefore I injured it in some way.”).

If everything goes perfectly, then the way that the system works is: the trigger occurs, the brain interprets the significance of the trigger correctly and causes an appropriate and proportionate sensory experience, and then the explanation for that sensory experience correctly identifies the trigger. When you sprain your ankle, your brain should translate the resulting nociception input into a painful sensory experience, and your ideal conscious response is, “Shit, I sprained my ankle!”

In the real world, however, the system does not always work so perfectly. In reality, the first step isn’t even necessarily required. The activation of physical sensors in the skin is neither necessary nor sufficient to produce an experience of pain. Pain can be produced in completely healthy people solely by creating a context in which their brain interprets a situation as dangerous — for example, if you hook someone up to a device and tell them it’s running electrical shocks through their brain, they will experience more pain the more you turn a dial higher, even if the device and the dial do not actually do anything.

Pain research rockstar Lorimer Moseley tells a fantastic story from his own life about how this system can go terribly wrong: he was hiking with some friends one day and felt a mild twinge on his leg, thought nothing of it, and ended up in a hospital having been bitten by an incredibly poisonous snake. One of the effects of snake venom is that it locks nociceptors into an activated position, so the amount of danger signals sent to the brain would have been massive, and yet when those signals got to the brain, the brain had no historical context to indicate such signals were dangerous, and so did not create a correspondingly massive pain experience. In fact, it created almost no sensory experience at all. As a result, Lorimer nearly died. About six months later, however, Lorimer was hiking again and experienced a sudden, massive pain on his leg in the same place as before, and very nearly ended up taking a trip to the hospital until one of his friends took a glance at the leg and discovered that it was only a tiny scratch from a twig.

In both of those cases, the system failed. When the trigger was a snake bite, the brain did not produce a sensory experience that felt anything like a snake bite. As a result, the explanation for the sensory experience did not correctly identify the trigger, and that mistake was nearly fatal. Later, when the trigger was only a twig, the brain interpreted it, mistakenly, as incredibly dangerous, presumably because it then had the context of the near-fatal snakebite informing the sensory interpretation. In both cases, neither the sensory experience nor the resulting conscious explanation of that experience usefully corresponded to the event that triggered the nociception in the first place.

In dealing with chronic pain, the lesson I have needed to learn is this: sometimes my pain has nothing to do with the state of my tissues. Sometimes my experience of pain happens solely because my brain has decided, mistakenly, that something threatening is going on. Sometimes, I need to be skeptical of my own lived experience of pain. Sometimes my pain is a lie.

Additionally, even when my sensory experience is a proportionate response to the state of my tissues, I can get the explanation wrong. For example, the experience of repetitive stress injury often manifests for me as an itching sensation. Occasionally, I will get an itching sensation in an arm and assume it’s RSI symptoms, and then later discover a bug bite. The sensations of mild RSI and bug bites are completely indistinguishable to me.

So, to review, the experience of pain is a three-step process: first, there is the trigger that activates nociceptors (e.g. an ankle sprain, a snake bite, a repetitive stress injury, etc.), then there is the feeling – the physical sensation your brain decides to produce in response to the trigger (e.g. a twinge, a sharp pain, itching, etc.) — and then there is the explanation — your brain’s assumption about what the trigger was (e.g. an ankle sprain, a snake bite, a repetitive stress injury, etc.). If the system works correctly, then the physical sensation corresponds well to the trigger, and the explanation thus implicates the trigger successfully (e.g. “It feels like I hurt my ankle, which probably means I hurt my ankle.”). The system fails when the trigger is not accurately identified. This can happen either because the physical sensation is not sufficiently specific to the trigger to make a reliable determination (e.g. when an itching feeling could be either RSI symptoms or a bug bite), or because the physical sensation does not correspond well to the trigger at all (e.g. a snakebite that feels like a scratch from a twig or vice versa).

This is the mental model that I used to think critically about my experiences of pain. It helps me to make a determination, when I am experiencing pain, about whether that pain represents a trigger that is worth my doing something about (e.g. I actually injured my back and should stop exercising), or I should be skeptical of it (e.g. I have chronic back pain and should probably assume nothing is wrong with the tissues and keep exercising). In the next post, I’ll talk about how I apply this same rough model to other experiences.

If anyone has any thoughts or questions on any of the above, I’m interested in refining it as far as possible, so any input is appreciated.

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* Actually, there are some modulation steps between the sensor and the brain, and some other steps in the overall process, but I’m simplifying for the sake of brevity.

Things Are Pretty Bad

It always seems to be worst in the mornings and just before going to sleep.

It helps to think of depression and pain problems as puzzles to solve. It gives you a path to follow to feel like you’re making progress. Try this thing, then if that doesn’t work try this thing, then if that doesn’t work try this thing, etc.

What’s supposed to happen when you do that is that you eventually try hard enough and find the right thing to try and things get better. That’s how the story is supposed to go. It isn’t how mine is going. If I had actually chronicled all the different things I’ve tried for the physical and mental stuff I’m going through on this blog, there would have been a lot more posts over the last year or two. There have been the different daily routines to minimize physical activity that aggravates my physical conditions, the different strategies for communicating and engineering interactions with people that make me feel satisfied and cared about, all those times some new thing I was trying felt like it was working for a few days before everything went back to feeling like last time.

Somehow, in spite of all the things I’ve tried, I’m still here, feeling physically broken and lonely and exhausted and like I don’t know what options are left to try.

Every now and then I think of a new direction to turn in, and I turn to face that direction and walk forward and bang headfirst into a wall I didn’t know was there. It’s like living in a tiny room, and every time you try to get out the walls press in a little closer.

I am in a dangerous place right now. I experimented with yoga a week or so ago, which seems to have turned out to have been a very bad idea — my tendonitis symptoms have changed in an alarming way is making me wonder if I might not have any time left to put off taking some time off from work, and hoping that will be enough.

In consequence, I’m making an effort to locate friends to crash with in the interim, because although there is a decent chance my savings would last a few months of my being unemployed, I think there is a good chance that my mood would plummet further down than it already has. My bad moments are already dipping into a frequency and extremity of suicidal ideation that I am scared by — a few months with nothing to do but brood would be a brilliant recipe for making those moments more frequent and more dangerous than they already are. I think crashing with friends for a while might be the best way to avoid that escalation.

I am seeing a therapist. I am making an effort to talk to people. I am doing the things that you do, and doing them as well as I can. And I am writing about this because it’s as good a way I know as any to make sure I’m letting people know where I am, and because I think that providing a window into what this looks like and feels like it is as important as providing windows into any of the other aspects of the experience of depression or chronic pain.

A while ago I had a conversation with a friend where I talked about how one of the most frightening things, to me, about the idea of committing suicide was that people might be mad at me for doing so. She told me that the people she knew who had friends who had committed suicide were usually not so much angry about the suicide itself as that the friend hadn’t told them that they had needed help. I have tried, since then, to always make sure that I communicate with people when things are going badly, even when I don’t want to, so that if I ever do end up committing suicide, I won’t have left people feeling that way.

But at this point I don’t know what to ask for. Usually I ask for talking, but right now my voice still isn’t doing that well, so I’m having to carefully manage the amount of talking I do. I guess really what I need right now is to find a way to feel financially and emotionally secure for long enough that I feel like I have the time to rest my body for as long as is needed for it to actually get better.

It still boggles my mind how situational so much of this is. I definitely have depression, and it definitely contributes to how this all feels in major ways, but without the physical shit I’m dealing with, there would be so many additional options for self-care for me. There would be ways of socializing and meeting people, there would be less management of the amount of time I spend talking or exercising or just… existing in certain positions that make certain physical symptoms worse.

If I just hadn’t worn out my voice to the point that it got this way. If I hadn’t gotten so excited about being able to type and code faster at the beginning of this year that it resulted in tendonitis. If I hadn’t gotten so excited about finally finding a form of exercise that I could do and found fun that I overdid that and ended up with these symptoms in my legs as well. If I hadn’t, in the effort to get better, tried yoga, which seems to have ended up making things worse.

If it didn’t feel like just this long process of me trying as hard as I can to get better, and my body responding by finding new ways to get worse.

Truthfully, sometimes I get frustrated that there even are the stigmas that there are against suicide. Shouldn’t I have the right to throw in the towel? Shouldn’t I have the right to say, “You know, this is just too much to expect any person to reasonably handle, and I quit.”

The line between where I am and a set of circumstances in which I could be happy feels so thin. Is so thin. If my body were a little different, a little more resilient. If things had gone slightly different way. If things have gotten better after one of the things I’ve tried. If the yoga had worked.

I went on steroids briefly for my throat. Steroids are a pretty effective short-term treatment for the symptoms of tendonitis, although long-term a terrible idea, because they actually eat away at connective tissue. At the same time, I had been experimenting with friction massage for the tendonitis, and for a few days it felt like that was working well. For a few days I caught a glimpse of just how thin the line is between where I am and the set of life circumstances where I think I could be happy.

With the tendonitis gone, and my voice better, I could work more and stop having to worry about money, and I could meet people, and I could teach coding, and I could write.

But none of those things is simple right now. Some of them are complicated and others are impossible. And I’ve spent a decade always having to wonder if it’s a good idea or a bad idea, physically, for me to go for a walk. For most people that’s the simplest thing. You want to go for a walk, so you get up, and you walk out your front door, and you go.

This isn’t really going anywhere anymore, I’m just talking through thoughts as they come. And I guess this is about the end of them for now. I am doing my best, because I know it will be worth it if I somehow manage to get through this. I know it will, but right now I don’t know how to get there, or if I can.