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CHAPTER 1
Hell
Although the world is full of suffering, it is also full of the overcoming of it.
— Helen Keller
Hell is defined as the life-condition of suffering. When fully immersed in it, all we know is misery, our energy falling so low we become nearly incapable of taking any action to help ourselves feel better.
In such a state we tend to view almost everything, even positive events, in a negative light. When our suffering is extreme and prolonged, we may become inconsolable, leading to one of the worst consequences of being trapped in the life-condition of Hell, social isolation.
The more isolated we become, then, the more we flatten out, eventually becoming mere two-dimensional versions of ourselves — lethargic, sometimes even paralyzed versions that we hardly recognize — as we lose our ability to think clearly and with good judgment. We begin clinging to reasons why we can't solve our problems and blame our unhappiness on the problems we can't solve.
We even sometimes come to feel we're worthless or disgusting and try to numb ourselves with alcohol, drugs, food, sleep, and the like. Alternatively, sometimes feeling worthless causes us to lash out at others, the impulse to destroy ourselves expanding to include those around us as well.
Sometimes, on the other hand, we suffer in silence, living a life of such quiet desperation that no one, not even our closest friends and family, suspects how overwhelmed we've become. At other times our suffering is so awful, so intense, it leaks out of our every pore, preventing us from hiding its existence from anyone.
But whether expressed or concealed, mild or severe, lasting decades or only the briefest of moments, the one constant feature of the life-condition of Hell — of suffering — is that it prevents us from thinking about anything else. All we have room left to want — in fact what we want sometimes even more than life itself — is to escape it.
* * *
Though she no longer wanted to kill herself when April followed up with Ash in his office three days after being discharged from the hospital, she still felt worthless and hopeless and had difficulty finding pleasure in anything. She felt little motivation to take care of herself. "I have no reason to move on," she told Ash.
She was still convinced that her ex-husband was the reason she was depressed. For the last year and a half since he'd left, she'd persisted in her attempts to reconcile with him but had succeeded in provoking only one response — a handwritten letter mailed in an envelope with no return address in which he explained that he had moved out of state specifically to get away from her. Despite this, April still felt it was possible that their marriage could be saved.
"How exactly do you envision that happening?" Ash asked her.
"I'll move wherever he is. I'm sure I could get a job at the local hospital." When he pointed out that her answer failed to address the real issue — that her ex-husband no longer wanted to be married to her — she insisted she could make him see that they were still right for each other. Yet when she went on to describe what she hoped their reconstructed relationship would look like, she talked only in vague platitudes, her voice devoid of emotion. Even when Ash got her to admit just how angry she was about the way her ex-husband had left her, she didn't actually sound angry. In fact, to Ash she seemed switched off in the same way she'd described her ex-husband had seemed to her when she'd confronted him in person shortly after he'd left. When he remarked on it, she said that this was the way she'd always sounded, which made him wonder just how long her depression had been going on prior to the dissolution of her marriage.
"What made you decide to marry him in the first place?" he asked her after a moment.
"He asked," she answered simply. Though they'd known each other for only two months, she'd said yes before he could change his mind. "He was just so generous."
But almost immediately after they were married, his generosity seemed to vanish. He began to abuse her verbally, calling her fat and stupid. She'd completed her master's degree in education and worked with physically disabled children at a local children's hospital, a job she loved. But he'd tell her she worked with disabled kids because they were "at her level." He seemed to have no interest in her needs or in pleasing her. She wanted children. He wouldn't even consider it.
She'd been able to refuse him nothing, however. She'd been reluctant to act against her principles, she said, but she'd found herself able to bear her own disgust more easily than his.
This imperative to avoid all conflict with him soon bled into other areas of her life. She began to dread crowds — a problem that had plagued her mother — and became shy and nervous in social situations.
Intrigued to learn that her mother had been agoraphobic, Ash began questioning her about her childhood. How had she grown up? What had her relationship with her parents been like? She told him she'd been an only child and had felt anxious as long as she could remember. Her father had worked at the loading docks of their small New England town and had hardly spoken to her at all during her childhood. Her mother, in contrast, had demanded that April remain at her side constantly. April would have to come home from school immediately every day to be with her — to buy her food, to cook her meals, to clean up around the house. She used April, in sum, as a shield against the world.
A shield, April said, that she held close only so she could get a better view of the things she wished to criticize: Why did April bite her nails so incessantly? Why did she suck her thumb until she was nine? Why didn't she try harder to make friends? Why was she so fat? April hated that she couldn't stand up to her mother, that she couldn't answer these criticisms. But no one ever knew it. Despite her mother's constant belittling, April remained incapable of becoming angry with her.
"Why, do you think?" Ash asked her.
"I didn't want to make her even more critical of me than she already was. I still don't. There's only so much disapproval I can take."
"And her criticisms don't make you angry?"
She shrugged.
"Seems hard to imagine they wouldn't," Ash said.
"What good would getting angry do me?"
"Feelings are rarely that rational. It's hard to just turn them off."
"I don't think I'm having any feelings I turn off."
"Maybe. Or maybe you're turning them off so quickly you don't realize you're having them."
One corner of her mouth curved in a half-smile. "How would I be doing that if it's as hard as you say?"
"Touché," he said. "So here's another thought: if you won't let yourself get angry at your mother but you are actually angry at your mother what can you do? Get angry at someone else. Someone safer."
"Who?"
"Yourself."
He reminded her she'd said to him in their first session that she knew she was overeating at least partially to punish herself. But now he was wondering if there was more to it, if she was feeling so much rage that she was overeating to transform herself.
"Into what?"
"Into the ugly beast your mother spent so much time deriding," Ash said. "The ugly beast your husband ran so fast and so far from. The ugly beast you believe yourself to be."
* * *
"She could be depressed just because she's overweight," Ash told me. "But what would that make the core delusion of the world of Hell? That you can only be happy if you're thin ...?"
"No, I agree, not broad enough," I said. "I wonder, though, if it is connected to her low self-esteem."
Ash shook his head. "That doesn't seem likely either. Poor self-esteem may increase your risk for depression, but people with healthy self-esteem get depressed all the time."
"True."
There was a pause.
"Okay, what about this," I said. "What if she wasn't just afraid of her mother's disapproval? What if she was afraid her mother was going to abandon her? Maybe that's why she could never get angry with her. Maybe she figured having a terrible mother was better than having no mother at all. And maybe that's the same reason she became suicidal when her husband left. Maybe having even a jerk for a husband is better than having no husband at all — because maybe she believes she can only be happy if she's loved."
Ash thought for a moment, then shook his head again. "For one thing, it's probably true that she can't be happy if she's not loved. It's probably true for all of us. But even if it weren't true, it still can't be the belief that creates the lifecondition of Hell."
"Why not?" I asked him.
"Because people who are loved suffer all the time," Ash said.
The Difference between Pain and Suffering
Where pain is defined as an unpleasant physical or emotional sensation, we would argue that suffering is defined as a response to pain, a way of experiencing that pain. Specifically, it's the experience of being overwhelmed, or defeated, by pain. Indeed, studies argue that at a neurological level pain and suffering are separate experiences. Pain arises from activity in two separate areas of the brain, one called the posterior insula, which registers the sensation of pain (its quality, intensity, and so on) and the other the anterior cingulate cortex, which registers the unpleasantness of pain. We know this because patients who've sustained damage to their anterior cingulate cortex will feel the sensation of pain but not its unpleasantness. Astoundingly, they feel pain but aren't bothered by it. Suffering, we could therefore say, occurs when the intensity of pain becomes so unpleasant — when the activity in the anterior cingulate cortex becomes so great — that it becomes intolerable.
"But when does pain ever not cause suffering?" Ash asked.
"All the time," I said. "Are you suffering when you exercise? Or when you have your blood drawn? Or when you have a headache?"
"I guess it depends on the headache."
"Exactly. Not all pain causes us to suffer because not all pain is intolerable. Unpleasant, yes, by definition, but not intolerable."
First and foremost, what makes the unpleasantness of pain intolerable is its intensity. One the other hand, the point at which we can no longer tolerate pain — meaning the intensity at which it starts to make us suffer — varies so much from person to person that pain intensity alone can't be what causes pain to become intolerable. (When researchers plunge the hands of test subjects into freezing cold water, the length of time the subjects are able to keep their hands submerged differs in some cases by as much as four minutes). In fact, pain tolerance even varies from moment to moment in the same person. Studies show, for example, it's increased not only by a good mood, but also by anger and even cursing. We're also better able to tolerate pain that's harmless compared to pain that represents tissue damage, and pain that's caused accidentally compared to pain caused with an intent to harm.
Interestingly, this seems to be true not just for physical pain but also for emotional pain. Perhaps this isn't too surprising, however, as the regions of the brain that physical and emotional pain activate are mostly the same. This is probably why, for example, Tylenol, a pain reliever that acts on the central nervous system, alleviates not only the pain of a smashed finger but also the pain of hurt feelings. In a very real sense, physical pain is just emotional pain mapped to a body part.
"Meaning the core delusion of Hell should be a belief that makes both types of pain intolerable," Ash said.
"Exactly," I said.
* * *
At the end of their session, April noticed a book lying on Ash's coffee table titled Love's Executioner by Irvin Yalom. She asked him if it were a manual for therapists with lovesick clients like her. Ash told her the book contained ten case histories from the author's psychiatry practice, and that he'd written it as a guide to healing for both patients and practitioners alike. April went out and bought a copy the next day.
That weekend at 2:00 am. Ash received a page to a number he didn't recognize. He dialed it immediately. "Hello, this is Dr. Ash."
"You hate me!" a voice yelled at him. "Why didn't you tell me that was how you felt?"
"April —?" He could hear the sound of pouring rain in the background, the howl of wind.
"I read your book! I can't believe you feel that way about me!"
"I don't understand what you're talking about. Slow down. Tell me why you're upset."
"I hate you, too!" She was sobbing. "I just can't believe it. You're just like all the rest!"
Before he could reply, she hung up.
The next morning Ash pieced together what had happened. In one of the early chapters in his book, Yalom describes how revolted he'd been by of one of his female patient's morbid obesity. He even goes so far as to express mock outrage that overweight people would dare to impose their bodies on the rest of society, confessing he hates everything about them, "their absurd sidewise waddle, their absence of body contour, their shapeless, baggy dresses." Once having admitted his prejudice, however, he writes about becoming determined to challenge it. Ash reasoned that April must have projected herself into the role of Yalom's patient — and Yalom's abhorrence of obesity onto him.
He tried to reach her several days in a row but never heard back. Then when she failed to show up for her next appointment on time, he became nervous. She'd always arrived early, and he feared her tardiness now was a message, that she was trying to tell him in a way she thought would be hurtful that she wanted to terminate therapy.
Ten minutes after their session was supposed to have started, however, he heard a rustling in the waiting room. He opened his office door and looked out, and there she was, sitting in a corner next to a pile of magazines, arms crossed in front of her, fuming. She looked like a petulant child, waiting, presumably, for him to come out and notice her.
He spent the next fifteen minutes coaxing her into his office. Once inside, he found her sullen and edgy, and for the first time since he'd known her, visibly angry. She wasn't so much angry at him anymore, she said. She'd spent the week sorting that out, her intellect arguing with her emotions until her anger had at last relinquished him as its target. But once uncorked, it was sprouting like blood from a slashed artery, splashing against everything near, and she had lost all ability to stem it. She felt like she wanted to kill someone — anyone — she told him, and it bewildered her.
Then, staring away from him, in a voice seething with rage, she began to list the faults of all the people who had populated the inner circle of her life. Her ex-husband was an alcoholic. Her father was cold and indifferent. Her mother was too needy. She spoke without hesitation or apology. She confessed the true extent of her negative feelings for each one of them in detail, feelings that had been buried so deeply and for so long that their existence took her by surprise. When she finally concluded her diatribe, announcing that she was "sick of being so nice all the time," Ash knew he'd witnessed a remarkable alteration. She'd finally begun to turn her anger outward, away from herself.
They spent the next few weeks processing what had happened and identifying appropriate ways for her to express her anger. The work was difficult as her anger often reoriented on him. But it was also productive, and soon she was reporting she'd become able to express her anger to others outside the confines of his office. She began to feel more in control of herself. Her weight steadied, and at long last her depression began to lift.
Then several weeks later she called to tell him that her mother had died. In between hysterical sobs, she told him she was afraid she was going to kill herself and desperately needed his help. "I don't have any more tricks up my sleeve," she wailed. "I'm done. There's nothing left. I don't know what to do."
"Tricks?" Ash asked. "What kind of tricks? Tricks for what?"
"To make someone love me."
The True Cause of Suffering
"Because she doesn't believe she can," Ash announced.
"What, you mean make someone love her?" I asked.
"Yes! I can't believe I didn't think of this before. It's learned helplessness. The core delusion of the world of Hell is that you're powerless."
"Powerless," I repeated. Then: "Over what?"
"Over your problems. That you're powerless to solve them."
"What problems?"
"All of them!" Ash said. "Any of them. Any problem that matters."
"Any problem that —" I stopped. "Obesity, poor self-esteem, a loveless existence! Any problem that causes you pain. That's it! It's not a belief we have about pain that makes it intolerable. It's a belief we have about ourselves — that we're powerless to end it."
(Continues…)
Excerpted from "The Ten Worlds"
by .
Copyright © 2018 Alex Lickerman and Ash ElDifrawi.
Excerpted by permission of Health Communications, Inc..
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