The Painful Truth by Monty Lyman

As I probably said when I wrote about The Remarkable Life of the Skin, I would probably never read popular science if it weren’t written by Oliver Sacks – or by one of my friends. And it would be my loss, because if I didn’t read my friend Monty’s books then I’d have missed out on a lot – and I found The Painful Truth even more fascinating and engaging than his previous book.

As the subtitle says, this is about ‘the new science of why we hurt and how we can heal’ – but it’s also how everything we think we know about pain is wrong. Or, rather, everything I thought I knew; I shan’t tar all of you with the same brush of my colossal ignorance when it comes to science. I’d also blithely assumed pain was largely connected with nerve and tissue damage. Of course, I knew other factors could be at play – pain always hurts more when you don’t know what’s wrong and you’re really anxious – but I hadn’t realised quite how big a role expectation and comprehension play in how much pain we feel. (While being ‘all in your mind’ doesn’t, of course, make pain any less real.)

Vision is not a measure of light and colour: it is designed to make meaningful sense of objects in the outside world. Pain is very similar: it is not a measure of damage or danger but is instead the brain’s unconscious opinion on whether our body is damaged or at risk.

Lyman (it’s easier for me to write objectively about this book if I imagine the author as Lyman rather than Monty!) doesn’t stop at this rather profound re-education on what pain is, of course. The Painful Truth often returns to this fact, and to the idea that pain is there to help not hinder us, and spreads outwards from this starting point. It is so chockful of extremely interesting experiments and facts (for instance – an experiment where strong opioid pain relief was given, but only had significant effect when the patients were aware it was being given; when they were told it hadn’t yet started or had stopped, the pain relief didn’t work). Lyman must have done an astonishing amount of research, and this is the anecdote I keep telling people, about hypnosis:

Highly hypnotisable people are able to respond to questions by ‘automatic writing’, where one hand writes answers to questions without the subject’s awareness. In 1973, the renowned Stanford psychologist Ernest Hilgard tested this out on a young woman – le5t’s call her Lisa – by first asking her to rest her hand in ice-cold water. Unsurprisingly, she found this intensely painful. Lisa was then induced into a hypnotic state, and again her hand was placed into the ice water. This time she reported feeling no pain whatsoever, but while she was verbally describing how relaxed she felt, her own hand continued to automatically write, reporting that she was feeling agonising pain – the same pain she felt when she was not hypnotised.

Yes, I find this rather creepy. But also completely enthralling, and helping shift everything I thought I knew about pain. Elsewhere, Lyman is really interesting on the placebo effect. I think, colloquially, this perhaps dismisses things that are ‘only the placebo effect’ – whereas when it comes to pain, this could be a very powerful solution. And how does it work? I shan’t summarise a whole chapter into a paragraph, but I did find this quote really interesting:

This isn’t the placebo – an inert substance – doing the work; let’s give our brains the credit. It is our belief in the treatment that opens up the brain’s drug cabinet. The active ingredient is expectation. This is neatly seen in the hierarchy of fakery; not all placebos are created equal. Saline injections tend to have a greater pain-relieving effect than sugar pills, and it wouldn’t be surprising if fake surgery is significantly better than both of these. An expensive placebo is more effective than a cheap none. The more dramatic the intervention, the more meaning the patient attributes to the treatment.

It reminded me of a book I read about why people believe conspiracy theories – and it is partly because we can’t cope with the disparity between enormous effect and trivial cause. Nobody has conspiracy theories about assassinations that just missed, but people find it hard to think that an invent that changed the world could be caused by one person with a gun. In sort of the same way, if I’m understanding it properly, our brain expects big results from big actions. And since the brain is the one determining our level of pain, it can answer its own expectations.

This is only a taste of the wide variety of topics covered, each covering a range of Lyman’s own experiences, notable experiments, and a little bit of technical info (which I didn’t always fully understand, but it is far from overwhelming in the book). Among other things, Lyman writes about people who don’t experience pain at all, pain and PTSD, pain after amputation, and the ordeal faced by patients with chronic pain – particularly chronic pain where there doesn’t seem to be any diagnosable cause. What makes Lyman’s writing appeal to me so much is the same thing I love about Oliver Sacks’ books: the compassion. It does help that I know him and know what a lovely guy he is, but I think it would come across anyway. The people he writes about aren’t simply scientific curios, or even patients. They are people with complex lives who are often suffering deeply, or bewildered by the tests they have undergo, or frustrated by no solution being in sight. The only times Lyman is clearly frustrated himself is when writing about medical professionals who don’t have compassion, won’t try to find solutions, or underestimate the consequences of pain.

I was initially wary of telling friends with chronic pain that I was reading a book about pain. I am sure people who suffer in this way are sick of being recommended remedies, usually from people with far less expertise than them. But I think this book would be helpful. While Lyman is very keen to emphasise that The Painful Truth is not a self-help book, it does include some really useful things people who experience persistent pain can do – recognising that, though the responses he lists have a weight of research behind them, the medical profession is often very behind in treatment recommendations. I’ve experienced difficult-to-treat pain over two periods – intense and constant tension headaches one year, and severe RSI over several extended iterations – and I know how exhausting it is to keep going back for diagnosis or treatment when neither seem forthcoming – and that was only over short-term periods. I really hope a book like The Painful Truth can offer some help, even if it isn’t a self-help book. At the very least, Lyman recognises the severity of persistent pain and the impact it has on millions of people.

But whatever your experience with pain is or isn’t, The Painful Truth is an engrossing, well-written, and wide-ranging book. Even if you’d never normally pick up popular science, I think almost anybody would get a lot out of this. It’s always a relief when a friend’s book is genuinely excellent, but even better when they’re as brilliant as this book is. And Monty has my rapturous Instagram messages to prove that I’m saying the same thing in public and private!