Where Does it Hurt? Pain and its Killing
Dr. Mark Fisher
Friday 13 September 2019
Summary by Frank Kelley
Mark Fisher’s introduction to psychoanalysis took place during the 1970s when he worked at Oxford University for eight years. After many years of teaching and practice, Mark resigned as NHS professional lead in psychotherapy during November 2013. In July 2014 he became a member of a new analytic grouping, The School of the Freudian Letter. He has a private practice in Liverpool.
Mark regularly reads newspapers from the USA and has followed the opioid crisis. It has been estimated that within a recent two-year period, more Americans died from prescribed opioids and various other pain killers than in the entire Vietnam War. The Sunday Times reported on Britain’s opioid crisis and wrote about how we are sleepwalking towards carnage in our communities (24 February 2019).
Mark founds the work of Irene Tracey helpful in understanding pain. She is a neuroscientist and holds the Nuffield Chair of Anaesthetic Science and is the Head of Department of Clinical Neurosciences at the University of Oxford. She wrote that one in four adults in the UK and Europe are regularly presenting to medical services with pain. They are invariably treated with medication and often for long periods.
Mark values the way psychoanalysis deconstructs binaries such as ill/well, normal/abnormal, psychotic/neurotic and pain/pleasure. Treating binaries as if they have fixed boundaries can lead clinicians to use treatments which are more likely to contribute to their own wellbeing than their clients’ health.
Freud thought these boundaries are all fuzzy. Slips of the tongue cross the boundary of the conscious and unconscious. The secondary gain we get from the attention of others when we are ill fuzzes the boundaries of pain and pleasure. Lacan’s belief that we are mad deconstructs the binary of neurotic and psychotic.
To give a clearer picture of this kind of deconstruction where categories become liminal and boundaries fuzzy Mark summarised two plays by Dennis Potter.
In Karaoke a playwright, an obnoxious man, overhears words he has written spoken by a woman in a bar. At another meeting she acts the plot of his play. He then intervenes in her life in a way that makes him look crazy. The playwright drinks more and more to relieve his abdominal pain. His health worsens and he has three months to live. He falls in love with the woman from the bar and leaves money in his will to her and her mother. This is the first altruistic act of his life. He also donates his head to a cryolab.
In Lazarus we are in a business dominated dystopia three hundred years in the future. The playwright’s head is stimulated and neural activity returns. We can see his memories on a screen. A media mogul digitises and sells these memories. We do not know if this head is sentient and whether these memories are genuine and if he had been sexually assaulted when he was four years old.
For a psychoanalyst there can be a clear boundary between the conscious and unconscious. This happens when repression is successful. It is when repression is unsuccessful that the boundary is less clear. The unconscious does not have just one time, place and experience of the body. The unconscious has multiple realities. What can be powerful at one time is not at another. So somebody’s pain can be differently distributed across time and place. There is a plurality of conscious thoughts and a plurality of unconscious thoughts about pain and they will all be related.
Asking where does it hurt seems a simple question. To kill pain is a misnomer and the term pain killer is itself ambivalent. Opioids control pain and they can kill. They can paradoxically make pain worse and can have complex interactions with other medications.
In the USA whole families have been wiped out through opioid use. There is a five year difference in life expectancy for people in London compared with people who live in Blackpool. In poorer areas like Blackpool more opioids are prescribed. So where does it hurt is also a class, economic and geographical question.
There is now pressure on GPs to prescribe fewer opioids and this is leaving patients furious and uncared for. The recommended alternatives are meditation, CBT and Mindfulness. All of these are less acceptable to people in poorer areas. Karl Marx famously said religion is the opiate of the masses. It now seems that opioids are the opiate of the masses.
Thank you to Dr. Mark Fisher for inviting us to think about such an important topic. He did so in his customary manner of the simple expression of complex and profound ideas. You can read more from Mark on his blog at https://simonmfisher.blogspot.com