"There are more things, Lucilius, likely to frighten us than there are to crush us; we suffer more often in imagination than in reality."
- Lucius Annaeus Seneca, Moral Letters to Lucilius, 13-2
I drive a nice car. I keep it in good order - it needs servicing, oil changes, coolant top-ups, tires when the tread gets low, and a good scrub after I drive through puddles because I have the mind of a child. I depend on my car for my work, to do my errands, and to get me where I need to go - I could do all of these things in any other car or even get someone else to do them for me, but my car is My Car, that's why I like it. So it's possible to imagine my surprise and visceral horror when I was driving down the freeway one night and the check engine light flicked on. It's a creepy thing to happen - there wasn't a ping, no chirp from the dash, it was just there, glowing solid amber against the backlit figures and needles on the dashboard. I looked at it, and it looked back at me, as inscrutable as the shadowed side of a mountain and as ominous as a notification that you have a new message in your MyGov inbox.
What did it mean? Was something wrong? How severe was the issue? How much would it cost to fix? How long would I be without my car? Would I need a new car?
In the absence of knowledge, my mind reached with questions - I ran the whole spectrum of likelihoods, checking the make and model of my car and what faults were more or less probable, looking up the repair costs, doing mental math to add the cost of labour to those figures, thinking about time, my schedule, the impacts it would have. I thought and thought and thought myself into a panic, and I rang the mechanic the next day. His voice was calm, collected, and professional - bring it in, I'll take a look at it. I cleared my schedule. I drove my car to his shop in a cold sweat. I handed over the keys, equally sweaty, and sat in his office while my car rolled into his workyard and out of my sight.
I sat in the waiting room for thirty minutes. I looked at the balance in my bank account - I could always take a vacation in two decades time. I thought about the expenses I'd needed to cut back on - I could always buy rice and beans and eat that for two months to save. I thought about my partner - we can always have our wedding reception at McDonalds with the $230 dollar nuptial package. In the midst of all of this, the mechanic came back and gave me his pronunciation.
What was the problem? A thermostat issue.
Was it serious? No.
How long would it take to fix? It was already fixed.
How much would it cost? Nothing.
I was stunned. It felt like a band had been loosened from around my chest and that I could breathe. Of all the things I'd imagined this being, this wasn't one of them. This was so small as to be insignificant. Why had I been so worried? Without clarity, and in my ignorance, my terrified simian brain had manufactured mechanical monsters so much more terrible than what was actually happening. Fear was what had spanned the gulf between the limit of my knowledge and the infinite universe of outcomes that lay beyond, and just like the explorers of the Golden Age of Sail, I'd filled the unknown corners of my perception with dragons.
I'm writing this down for three reasons. Firstly, because I am human and that I make mistakes. Secondly, because I had allowed my imagination to run wild and compound my suffering into something viscerally monstrous, I'd given myself so much more stress than I needed. Lastly, and the reason which is most cruelly ironic, because this is something that happens to people who are in pain and who come to see me in the clinic. People, whether young or old, working or retired, sporting or otherwise active, all seek something more than resolution of their problem - they seek clarity and peace of mind. Without orientation to the issue, it’s difficult to see a way out, and there’s a lot to be said for how people get in those situations and how to get out of them.
There, you see - I’ve managed to turn a problem with my car into an Aesop about clinical practice! Let’s continue.
Warning Lights
In my case, I was in such a state because the check engine light was on, and there was no other information for me to go off of. A car’s dashboard has some information on it, like speed, engine tachy, the temperature of the oil, and the amount of fuel remaining. A car’s dashboard does not have a diagnostic readout that tells you precisely what’s wrong and where. The thing is, a car does actually have this capability - if you buy an OBD scanner you can plug it in and access the car’s system where error codes are stored. Mechanics actually do this as a routine diagnostic, because it’s so much more efficient than taking apart and assessing each and every component of a running engine. That’s one important distinction between mechanics and physiotherapy - a mechanic’s patient is usually shut down and turned off while they’re operated upon. You can’t really turn human beings off and then reboot them.
So, if a car has the means to tell you what’s wrong, then why doesn’t it? The simple answer is that telling someone what’s wrong doesn’t tell them how to solve the problem. How am I supposed to know whether a thermostat issue is serious or nonsevere, or even how to change a thermostat in the first place? Another issue is that by telling people what’s wrong, it introduces the risk that the driver will voluntarily ignore the issue and drive on, confident in their triage of the problem. This is an issue because of and for one reason - it’s an issue because telling people what’s wrong with them absent any contextualising information doesn’t give them any explanatory decisionmaking power - it doesn’t empower them and it doesn’t help them take charge of their situation. In fact it can even make them feel less empowered because even though they have a name for their issue, they don’t know how to evaluate it beyond that. It’s also a problem because if you think something is low-stakes and you’re happy to drive on regardless, you don’t know if the problem is precipitous of a larger issue. Is the thermostat fault because of an electrical problem, because of a component issue, because of a problem with another component? I don’t know this, but if I know it’s a problem with a thermostat and nothing more, I might just drive on.
Warning lights are good to tell you what’s going on, but they can’t tell you everything. Symbols, lights, sounds, and other indicators compress meaning down to the point where it’s easy to digest quickly and effectively, which is important when you’re driving at speed on the freeway in the dark and in the driving rain. We use symbols, warning lights, and other itemised pieces of information to make quick sense of the world around us in as efficient a manner as possible. Letters, words, sentences and paragraphs themselves are an expansion of meaning using compressed symbols that indicate sounds combined to form phonemes, words, and contextually informed meaning. The problem with this is that warning lights aren’t just seen, they’re felt as well.
The Problem of Pain
Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. That’s the definition of pain given by the International Association for the Study of Pain. It’s worth noting that this is just one definition. There are so many different studies into pain - how pain affects our decisionmaking, how our emotional state can affect how we perceive discomfort, how the same stimulus can produce different pain ratings in different people, or even in the same person in different contexts. For the purposes of continued discussion, let’s consider the postulate that the sensation of pain is a compression of meaning - pain itself indicates discomfort, but it doesn’t provide information on the nature of that discomfort beyond it being there. It lets you know that there’s an issue, like the warning light on an engine, but it can’t tell you more than that because humans don’t have an OBD port that a doctor can plug a machine into and have it spit out error codes.
The problem of pain is in its relational quality - there’s very often no linear or proportional relationship between the discomfort someone’s feeling and the presence of actual tissue damage. This is due to the physiological, neurological, psychological, and personal dimensions of pain as well as someone’s discomfort and their perception of it. In clinic, it’s possible to handle this by explaining that there are two dimensions to the problem at hand - what we feel, and what there is. What we feel might be very severe, nearly agonising, and in that severity there’s a distress at profound discomfort and a visceral desire to get out of that state. What there is might not be all that serious at all - patients have routinely reported pain more severe than anything they’ve ever experienced on first presentation, only to have that pain resolve almost immediately within days. Conversely, patients can also state mild discomfort, only to find profound damage, degeneration, and potential deficit. Pain feels the way it does because of its emotional and perceived component as much as its sensory and actual component - the unpleasantness can cause distress and distress is disorienting.
Being in pain is a disorienting experience - all of a sudden, the fundamental basis of assumptions that comprised an individual’s worldview have been upset by a noxious event that’s based within themselves and from which they cannot escape. They can’t park their car and borrow their girlfriend’s Mazda 3 (or Getz, Swift, Golf, Focus, or other guinea-pig-sized-hatchback) to get away from this issue. Put a person in sufficient pain and distress and that person, once otherwise a functional member of society, will turn into a wild, panicky, gnawing animal willing to chew off its own leg to get away from that pain. How many times has a therapist heard someone say that their leg, arm, or head hurts so badly they want to cut it off? The cure for this is clarity - to orient someone to their discomfort, to their body, and to their plan. To tell them that what is there is something that can be investigated, addressed, and controlled sooner rather than later, and to provide resolution to their problem and their pain.
Information Resolution
Every time we compress meaning using a symbol or truncation, we lose the nuance of the information we’re compressing. It’s like summarising a sentence and then expanding it again, shrinking a photo and then blowing it up, or even crushing a piece of paper into a ball and then opening it back out to full size. Every time we do this, we lose information. How often have we read a quote that’s been stripped of its context, only to realise the truth is something a little less flattering? Can’t think of an example? Go look up “David Horne Lucky Country” if you don’t believe me.
The same problem occurs in regular language. Think of the word love. You love your mother, your partner, your job, your pet, and lasagne. Do you want to do the same things to your mother and your pet that you would to a plate of lasagne? I hope not. (Maybe you involve lasagne in what you do with your partner but that's none of my business because it's outside my professional purview.) In being informed by a person’s emotional context, pain inherits the same vulnerabilities as other emotionally informed sensations and feelings. Pain is a low-resolution aggregate warning sensation that can be overridden and recontextualised depending on our thought processes and mental state. That’s not to say that it’s not that bad or can be ignored, just that our body and conscious mind’s means of making sense of situations and sensations is necessarily put through a series of filters which can confound and confuse meaning.
Does this mean you can’t trust your pain? No - you can trust the sensation, but you also need to evaluate it. It’s entirely possible to interrogate painful and unpleasant sensations and make sense of them, in fact it's necessary. This is the advantage a human body has over a car - a person has some lived experience and a somewhat realistic perception of their capabilities that they can use to orient themselves to their discomfort. Am I in pain because there’s something structurally wrong with me, or because I’ve just done some heavy lifting these past few days? Do I have a prolapsed disc in my neck, or was I just sitting up in front of the computer getting a report done for a few hours more than I was used to? Just like a warning light, there’s usually more to it than meets the eye.
Genie Light
A check engine light isn’t always amber. Sometimes it can turn red, and sometimes it flashes. This is your car’s way of telling you to pull over to the side of the road and call someone with a flatbed before your engine goes above and beyond what it was designed to do in a short span of time. Like this, pain and discomfort can develop from something general to something more serious. It’s important to note that serious issues rarely arise in isolation - there’s usually a precipitating history of increasing or fluctuating problems or a specific event like trauma that leads to a red light coming on. That’s why it’s important to evaluate discomfort in the context of its history as well as the context of the individual, and that’s why it’s important to get those yellow lights checked out as well.
Is an amber warning light likely to be a severe emergency? Not really. Is it still something worth checking out to make sure everything’s okay? Yes, that’s why the light is there, so that you can get on top of small, nonserious issues and handle them before they have the chance to fester and cause problems elsewhere in the system or which can otherwise affect the running of your car. You might be out a little money, you might be out a little time, you might be off the road for a day or two while the issue gets put in hand, but you’ll have an understanding of what’s going on, and someone to talk to if you have more questions.
A warning light, just like pain, is an indication to get something seen to sooner rather than later. It might not be as immediate, serious or expensive to deal with as you might fear, but by having someone experienced look over the issue and talk out the facts, the link between the warning what’s going on becomes clear, and clarity is the basis of peace of mind.
And you really can’t put a price on that.
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