This post was originally published in in August 2021 for PainSci members only. In May 2023 I made it public and integrated into the deep-dive article Mind Over Pain: Pain can be profoundly warped by the brain, but does that mean we can think the pain away?
For today’s premium post, I am going to get a bit ranty. I’ve been thinking a lot about what kind of content to give to paying subscribers, and I think one way to make that content a bit more “special” is to let my freak flag fly more freely. In the early years of PainScience.com (2005-2012), I was much more of a radical, snarkier. I have seriously toned that down over the years, which is mostly a good thing: I’ve been getting older, wiser, subtler.
But the snark is still in strong in me.
The idea of “resilience” has been overused and abused in the world of pain medicine, and someone should pound the table about it a little bit. Today that someone is me. Bang bang bang!
This post was inspired by this tweet from @DrCopps:
“I feel like ‘resilience’ has just become medicine’s way of victim-blaming people who burn out instead of actually enacting structural change.”
I think Dr. Copps was speaking more generally, and not about my own world of pain medicine, but it got me thinking about how this applies to things like unexplained chronic pain, back troubles, or injuries that won’t heal.
Talking about resilience is just fine for many patients in the worried-well category: people who are mostly healthy, but struggling with a new painful problem, can really benefit from some strong reassurance.
But not everyone. For many others, resilience talk is tone-deaf, preachy, ableist bullshit that completely ignores elephants in the room.
When resilience is worth talking about
The concept of resilience is often genuinely needed as the antidote to widespread fears of musculoskeletal fragility, and especially spinal fragility. This fear is routinely flamed by healthcare professionals who don’t know any better, who like to blame painful problems on glitchy anatomy and biomechanics (“structuralism”) way too much, rather than the much messier reality.
In that context, resilience can definitely be a handy concept. It might be applied by telling a patient something like this:
“Back pain does not mean your back is fragile and degenerated. In fact, spines are extremely strong and resilient… even with substantial signs of arthritis.”
In other words: you are strong and resilient, pain doesn’t mean you’re wrecked, you got this. That kind of reassurance can probably help a lot of people.
This theme has emerged as one of the main ways to talk to people about their pain in a way that acknowledges the neurological reality: pain is thoroughly modulated by the brain, and often aggravated by excessive pessimism and anxiety based on bogus beliefs. If the anxiety and pessimism can be relieved, if the bogus beliefs driving them can be corrected, great, by all means: embrace “resilience.”
When resilience talk is clueless garbage
Some healthcare professionals are so eager to dispel myths about fragility that they forget that there are other reasons why people get pessimistic and anxious. They may well be struggling with chronic pain and injuries for much more profound reasons than “I’m afraid poor posture will destroy me.”
Many people actually are not resilient … and trying to convince them that they are sounds like empty propaganda to them.
The whole reason that many people are in trouble in the first place is that they have high vulnerability for reasons that are hard or impossible control: metabolic syndrome, maybe a genetic gift of chronic pathology, or a sleep disorder, an addiction or two, and let’s not forget overwhelming stresses from poverty and social injustice. And so on and on.
For people like this, it often seems like they just have to glance at a tendon wrong and it bursts into flame. Maybe in some fantasy world where 80% of their problems are solved, they could be easily reassured. But the idea of resilience usually sounds hollow to these patients.
It also sounds privileged. It’s a luxury to be in a position where being told that you are tougher than you think is all you really need to feel better. Many people are just nowhere close to that.
And then there’s the really tough cases
That’s just normal unhealthiness. Don’t forget everyone with unexplained chronic illness/pain — and there are millions of us.
Most days my own body feels about as resilient as a burning house of cards. If a healthcare professional tried to convince me that I am more resilient than I think, my impulse would be to laugh. Or punch them.
Okay, truthfully, I would just roll my eyes. Inwardly. I am not actually very confrontational.