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Must Pain Always Lead to Suffering?

Pain and infirmity are inherent in life; here are some strategies for coping

By Barbra Williams Cosentino

The Buddhist saying, "pain is inevitable, but suffering is optional," elucidates a fundamental truth: pain and infirmity are inherent in life. Bill Metzo, 85, of New York City, has experienced suffering — losing his father at age seven, a failed marriage, alcohol abuse until he became sober at 40, and ongoing worries about a brother with epilepsy and other impairments.

An illustration of a cross section of a human brain. Next Avenue, difference between pain and suffering
Our brains alert us to emotional distress or suffering through some of the same neural pathways that make us aware of physical pain or injury.   |  Credit: Getty

And three years ago, he had a prostate cancer diagnosis with a not-great prognosis (although his oncologist says he's doing great). He has also lived with chronic pain for many years.

"I convinced myself, and everyone else, that I was tough and invulnerable."

He has had arthritis since his forties, including fused vertebrae in his neck. In addition, his cancer has spread to several areas in his musculoskeletal system and has induced pain.

Moreover, in the past year, he has had considerable discomfort in the area above his sacrum, which has not responded very well to treatment.

"I learned at an early age to deal with physical pain by myself because there wasn't usually anyone around to help me," he says. "I convinced myself, and everyone else, that I was tough and invulnerable."

Managing Without 'Too Much Distress'

And, he adds, "I have rarely experienced both pain and suffering at the same time, and that has made my difficult experiences, while not exactly pleasant, tolerable. So I have been able to manage them without too much distress."

Metzo has led quite "a wonderful" life, with a successful career as an actor who performed on and off Broadway, in regional theaters, and summer stock. He has traveled around the world, and, in the past 18 months, after cancer treatment, he has gone whitewater rafting, horseback riding, and camping in Utah.

He's also ridden a CitiBike through bumpy midtown Manhattan to his radiation treatments, gone hiking and to concerts at Tanglewood in western Massachusetts with his girlfriend of many years.

According to some views of Buddhist theology, the notion of suffering is best captured by the twinning of physical and emotional pain. "I suffered when I gave up my motorcycle at age 81 because my diminished strength began making it difficult to manage the bike," Metzo says. 


"It was a big part of my identity, giving me an incredible sense of freedom, like a cowboy running off into the sunset."

Metzo believes that, as long as he can continue to engage in the things that give him pleasure, he will live with whatever pain is present but without the overlay of suffering.

Understanding Pain

The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage."

In Buddhist theology, the notion of suffering is best captured by the twinning of physical and emotional pain.

Therefore, it was believed that greater pain signified more damage for many years. However, MRIs and other imaging techniques show that two people often react differently to the same pain stimulus and that some people who show severe abnormalities experience little or no pain.

Stanford University physician-scientist Dr. Sean Mackey points out that many brain regions shape our pain perception and that our brains alert us to emotional distress through some of the same neural pathways that make us aware of physical injury. 

The somatosensory cortex is where pain hurts, whereas the anterior cingulate cortex evokes the emotional aspect of pain and how unpleasant it is. Thus, this area is activated by physical pain and emotional distress, such as anxiety, stress or fear. 

The insular cortex, which processes painful experiences and facilitates learning from them, is responsible for interoception, the internal awareness of body sensations.

But how do experts view pain? The now-widely accepted biopsychosocial model is that pain is a dynamic interaction between biological, psychological and social factors unique to each individual. 

Damage to tissue and bodily parts, hormonal imbalances, thoughts, emotions, and social and environmental factors, among others, play a significant role in how pain is perceived and processed.

On Pain and Suffering

An old Buddhist parable says that physical pain is like being shot with one arrow. The person who does not resist physical pain feels only that arrow. However, most people who experience pain add a layer of emotional suffering – "Why me? Will this go on forever? Will it get worse?" 

This anguish is like being shot with a second arrow. When pain sensations are experienced without fear, the sense of suffering is reduced. The work of Eric Cassell, an American physician and bioethicist whose seminal work in the early 1980s opened the floodgates for studies on pain and suffering, is still incorporated into pain research, theory and practice. 

A focus article by the U.S. Association for the Study of Pain chronicled his four main points, using some different terminology but still incorporating Cassell's theses:

Suffering requires self-reflection, the ability to create a personal narrative, and a sense of one's past and present state.

  • Pain and suffering are interrelated but distinct experiences
  • Suffering is a personal and private matter
  • The experience of suffering is characterized by a negative affective valence (Cassell used the word distress)
  • Actual or impending disintegrating or disruption of one's sense of self is an integral part of suffering 

Cassell's definition of suffering requires self-reflection, the ability to create a personal narrative, and a sense of one's past and present state, as well as how their future might potentially be impacted. 

Unfortunately, this inner reflection has been challenged in recent years because those who are not introspective or have dementia can still suffer greatly. The article also emphasized the need for further research to develop clinical strategies to better recognize and mitigate suffering among people living with chronic pain.

A Few Tips for Living with Pain While Minimizing Suffering

  • Utilize Cognitive Behavioral Therapy (CBT) concepts or Acceptance and Commitment Therapy (ACT). Don't "awfulize" or "catastrophize" and assume everything will be awful daily. 
  • Negative expectations can lead to suffering. Even with seemingly ongoing pain, there are bad days, better days, and good days. Try to be mindful of your experience in the here and now.
  • Sometimes, distraction is excellent, but at other times, focusing on the quality and location of the pain (burning, stabbing, diffuse, etc.) is a valuable strategy. 
  • Accepting pain can give you some sense of control over it, which helps minimize some unpleasant emotions – helplessness, rage, despair – that arise.
  • Dr. Ron Siegel, an assistant professor at Harvard Medical School and a renowned psychologist, author, and proponent of mind/body therapies, points out that these powerful modalities can do wonders to alleviate suffering. Mindfulness can break the "pain-fear-avoidance cycle," which tends to amplify pain. 
  • If you use daily or several times-a-week meditation practices, don't turn to it when you're desperate for pain relief; plug it in as a routine part of your day. Meditation is not medicine, but it can be therapeutic.
  • Listen to your body (and your doctors or physical therapists), but do not let your activities be guided by kinesiophobia, the fear of pain due to movement. For some, being too sedentary can prolong disability and pain.

Unfortunately, pain hurts, and there are no magic cures. Instead, use the medication as needed, seek out supportive friends and family and participate in activities that give you pleasure. Practice "an attitude of gratitude" and enjoy the good days, which hopefully are rich and abundant.

barbra consentino, writer
Barbra Williams Cosentino RN, LCSW, is a psychotherapist in Queens, N.Y., and a freelance writer whose essays and articles on health, parenting and mental health have appeared in the New York Times, Medscape, BabyCenter and many other national and online publications. Read More
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