Kipnis' books analyzes our relentless fascination with public downfalls through a handful of case studies: In addition to that of Nowak, Kipnis also dissects the bizarre story of former New York Chief Judge Sol Wachtler (who was arrested after impersonating a Texas private eye in order to intimidate his former mistress), author James Frey's public shaming by Oprah about the fabrications in his memoir "A Million Little Pieces," and Linda Tripp's betrayal of Monica Lewinsky. Kipnis is the author of the provocative polemic "Against Love" and the engaging feminist history "The Female Thing." This most recent offering is a brilliantly written, compulsively readable and remarkably insightful work about the resonance of scandal in American culture.

Salon spoke to Kipnis over the phone from Brooklyn, N.Y., about the meaning of Lisa Nowak's diaper, why we couldn't stand the sight of Linda Tripp's face -- and our insatiable hunger for public downfall.

What makes a good scandal?

There has to be some sort of transgression of behavioral norms. It doesn't have to be a lawbreaking offense -- as we saw in the Dr. Laura scandal. There has to be transgression but there also has to be a secret that's revealed and I think part of the pleasure of scandals is this exposé. It reassures us that there's a world of truth underneath the surface. I try to make the distinction in the book between celebrity gossip and scandal. I have to say that somebody releasing a sex tape by quote unquote accident is not what I would call a scandal. Gossip keeps us interested, but a scandal really touches on the trouble spots and social contradictions and existential problems we're all negotiating and can't figure out or reconcile.

They also reinforce appropriate rules of conduct in society. As the Mel Gibson incident showed, for example, there are certain things you just can't say in public.

These scandals show us where the lines of propriety are. There's the punishment of the transgression, but there's often a certain amount of vicarious pleasure we can take in the transgression itself. There's sometimes a little pleasurable frisson in seeing people violate rules. But in the Mel Gibson scandal there was also the pleasure of the eavesdropping. More and more of these private moments are being revealed through various forms of new technology.

The first section of the book explores the astronaut-diaper scandal from 2007. What made the Lisa Nowak story so fascinating?

It was about revenge and payback. This man had jettisoned her; she took this extreme action of trying to confront this new girlfriend, a response that most of us would censor ourselves from having. It was just so excruciating and humiliating if you had any moment of identification with her or empathy for her. But it also really revealed the importance of good props. I don't know how long the scandal would have played without the notable element of the diaper. You have this icon of American heroism; she's been to space, which is as high as you can get, and then she's supposedly in diapers, which is as low as you can get.

It was so fundamentally humiliating because it brings to mind bodily functions, which are such a fundamental taboo of our culture

The fundamental task of the adult human is self-management. We're supposed to be in control of ourselves and our bodily functions, which isn't always entirely possible. But the thing about the diaper was that it was also this incredibly great metaphor. What you see in the case of Lisa Nowak is this incredible incontinence: Her feelings were too incontinent; she couldn't contain herself. The diaper was the emblem for what happens in so many scandals, somebody who is, in some basic way, not in control of their emotions. And I don't think that's so unfamiliar for most of us. Even if you don't drive cross-country to confront your romantic rival, you may imagine it. Or have murderous fantasies toward him or her.

One of the notable traits of these scandals is the degree of oblivion, of not thinking ahead to possible consequences. A self-destructive imperative is underneath the surface in so many of these cases and I think that's part of what makes them so horrifying and fascinating.

And in the case of the Linda Tripp scandal, it reinforced popular ideas about both the precariousness of female friendship and physical ugliness.

One of the pleasures and horrifying elements of scandal is when they reinforce stereotypes that we're not supposed to have, like the stereotype of the toxic female friendship. One of the things I was interested in with Linda Tripp was all the joking about her ugliness. All the comedians' jokes were about her looks. It mapped onto her betrayal and ugly acts toward a friend, but  there was also something true about them; there was something distressing about the way she looked. What you start to realize is that there was something in conflict in the different regions of her face that made her expression register as off-putting to us. If you looked closely at her mouth when she smiled or talked, the upper lip raised up and she bared this row of attack teeth on the top, which registered subliminally as aggression. It looks like she's about to bite someone. This is somebody who if you look back on the story of her life and her upbringing, it was a really disappointing and troubled family situation. The lack of attractiveness almost seemed like a physical manifestation of her troubled past.

When you discuss James Frey, you write that, since a lot of our traditional scapegoats are now off-limits, we're left looking for new ones -- in this one case an author who invented part of his memoir.

The psychology of the scapegoat is similar to the psychology of what would be called projection, or projective identification. Everything you split off in yourself or disavow in yourself you get to punish someone else for having. I don't think James Frey acted that much more badly than other people do in relation to commerce. He was punished for writing a commercial book, which if you're familiar with publishing, is what authors are supposed to do. In the book, I use this piece that Oprah wrote for O Magazine on her weight gain, "How Did I Let This Happen Again?" as an example of a memoiristic piece of writing to show that nobody is totally capable of telling the truth about him- or herself. To various degrees it's all invention and fabrication.

There have recently been these twin scandals with a lot of parallels, the Jesse James and Tiger Woods adultery stories. Why were they so resonant?

Adultery is the main scandal topic of our time. Many people struggle with monogamy in practice, but we're fascinated by other people's inability to live up to the same vows. And it requires a certain amount of amnesia on our parts to be fascinated and outraged every time an adultery scandal breaks. The fact that we're surprised by the idea that a sports figure has a bunch of girlfriends is itself surprising.

In the cases of Tiger Woods and Eliot Spitzer, do you have to shut off some part of your own intelligence to think that this is not going to be revealed if you're in a public role that presumes you uphold ideals of family values? What does that say about humans' ability to compartmentalize or be capable of split consciousness? What I found interesting in the Tiger Woods scandal wasn't the adultery so much as the parade of women willing to come forward and reveal a lot of private information for their $ 10,000 from the Enquirer or their 10 minutes of fame.

Do you think that the Internet has changed the way we consume scandal?

There are now so many more venues and outlets that require this constant stream of scandalous product. There's also the speeded-up quality of everything and this instantaneous dissemination through cellphones and recording devices. I think the whole public private divide is undergoing a real transformation for all sorts of reasons that I think we won't be able to figure out for a while because we're in the midst of it.

Scandal and gossip have traditionally been linked to the feminine sphere. As you mention in the book, some people argue that women are more susceptible to disgust than men. Do you think that's true?

There's been this historic association between women and moralism, but I think that given the way gender codes are becoming reorganized, I'm not sure that women are more interested in scandal than men are. There's now so little distinction between politics and scandal. You could say beginning when Lyndon Johnson showed the world his appendix scar or when Reagan's colonoscopy records were revealed, politicians' private lives have also become increasingly public.

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Although opponents point to this case and others as evidence that "one size fits all" punishments are ineffective, anxiety about weapons and violence in schools remains high among Americans. In the wake of the 1999 shootings at Columbine High School, high schools in the United States rushed to adopt strict policies and filled schools with armed guards, metal detectors and drug-sniffing dogs. These are now hallmarks of the modern American school. Yet for all these extreme measures, public fears over student safety remain high.

Aaron Kupchik's "Homeroom Security: School Discipline in an Age of Fear" is an attempt to explain that paradox and suggest an alternative to this battle-zone mentality. The product of two years of research, "Homeroom" examines four public high schools comprising different race and class demographics. Kupchik compiled more than a hundred hours of interviews with students, administrators, teachers and police officers assigned to each school. Kupchik's writing is meticulous and even-handed, even praising the officers whose methods he strongly disagrees with.

Salon talked with Kupchik about the lessons of Columbine, his willingness to appear naive, and hopeful signs for the future.

How did these zero-tolerance policies get started and what do they mean?

They started in the '90s, and they were spurred by the federal government's Safe and Drug Free Schools Act, which required schools to implement zero tolerance for certain things like weapons. What schools have done across the country in the last 15 years is to expand greatly what falls under zero-tolerance policies. So they extend to not just deadly weapons and drugs but sometimes fighting and prescription drugs and other types of substances. What they mean is that if you're caught violating this broad rule, there's no discussion and no elaboration of why you did this. No investigation. We just punish you with the one-size-fits-all punishment.

Why are they so detrimental?

We're teaching kids what it means to be a citizen in our country. And what I fear we're doing is teaching them that what it means to be an American is that you accept authority without question and that you have absolutely no rights to question punishment. It's very Big Brother-ish in a way. Kids are being taught that you should expect to be drug tested if you want to participate in an organization, that walking past a police officer every day and being constantly under the gaze of a security camera is normal. And my concern is that these children are going to grow up and be less critical and thoughtful of these sorts of mechanisms. And so the types of political discussions we have now, like for example, whether or not wiretapping is OK, these might not happen in 10 years.

So these policies are giving the kids a civics lesson.

Exactly. As part of my research, I interviewed students, and one of the questions that seemed like a good idea at the start was asking them whether they liked having the SROs [school resource officers] in their schools. For me, having gone to public schools without cops, this really seemed odd to me, to put police officers in peaceful schools. And the students were puzzled by this question, and I quickly realized that it makes no sense to them because it's all they've ever known. It's completely normal. It makes about as much sense as if you asked them, "Should your school have a principal?"

You spent a lot of time in each of the four schools. What are the police officers like who patrol these schools?

They were great. I really enjoyed the time that I spent with them. These are people who care about kids and who work hard for little money to do the right thing. I might disagree with what they do and how they do it, but not with their motives. But their role is an odd one for schools. They don't have a counseling background, and they are just not able to deal with kids' problems the way that some of these problems need. Their day-to-day experience trains them and socializes them to deal with kids in not the most productive manner. And their presence in schools creates a law-and-order mindset to govern schools rather than the type of counseling and democratic mindset that we know prevents crime.

There's still very much a public perception that crime, violence and drugs are on the rise in schools. Has the addition of school resource officers been effective at all?

The jury's still out on whether they've led to a decrease in crime. There have been big decreases in crime, but it's unlikely that the SROs have had an effect on that. There have been only a few studies that have tried to look at effectiveness, and they've been totally mixed. What we do know about preventing crime in schools is that when you have a more democratic and inclusive school, you tend to have less crime. A democratic and inclusive school is one where students feel respected, they feel like they're a part of a school, and where a school deals with students' problems rather than just dismissing them. It's one where the students feel empowered. SROs and zero-tolerance policies do the opposite of this; they erode what we know works.

The Columbine shooting is often invoked as a justification for zero-tolerance policies. But what kinds of changes did Columbine High adopt in the wake of the shootings?

Columbine is central to the way we think about school security. It redefined the tragedy of school crime in a very dramatic way. In the wake of it, what Columbine High did was quite sensible. They invested in counselors. They recognized that kids who do bad things in school are usually kids who have very serious troubles, and so rather than simply kicking them out of school for a week, they tried to reach out to kids who are dealing with difficult issues -- to solve problems rather than just delaying them for a week while the kid's out of school. They turned away from the more zero-tolerance type of policies and toward what I think is a much more effective way of trying to deal with things.

That's pretty surprising. If there's any school where you thought things might become more draconian, it would be that one.

It's also interesting that one of the ways that people try to prevent a "Columbine-like incident," a phrase I heard frequently, is to put up surveillance cameras and put in SROs. But they had both of those at Columbine. We can watch the surveillance footage of the police officers. Now perhaps it would have been even more devastating if they had not been there; we'll never know that. But it certainly didn't prevent things from happening.

One of your proposed reforms is to place non-school-affiliated counselors in schools. Why?

There are good features of having cops in schools. On the balance sheet, I think it is more harmful than beneficial, but one of the good things is that there is somebody outside the school's authority that kids can talk to. But why does that person have to be a police officer? Why can't that person be someone who's trained in adolescent development? Someone who has a good eye for what makes adolescents tick and can deal with their problems as they arise? Why can't be they be someone who can better hold their confidence unless their life or safety is at stake? This could be kind of the best of both worlds.

Some would say these ideas are too naive for the harsh realities of the modern high school.

That might be true. But they've tried their policies, and there are very clear disadvantages. What I'm arguing against is near-universal in American public high schools. There are harmful consequences which I try to detail throughout the book. I acknowledge I don't have to deal with 30 unruly kids as I teach in front of a class. So I have great sympathy for teachers who have to struggle with that misbehavior. That's not their fault. But what I'm saying is that we have evidence-based ways of dealing with that misbehavior that are much more likely to stop it, and we don't use them. So I might be naive, but I'm willing to be, because I see a lot of harm with the current policies.

With a new school year starting, do you see any hope for a shift away from these methods?

In my own state of Delaware, I recently took part in a task force in the state Legislature that led to new legislation that was passed to reduce suspensions and arrests in schools -- to curb zero-tolerance polices. So I do see movement in the positive direction. Another encouraging sign is that I'm talking to you and that people are interested in this. We need to be firm. There needs to be discipline in schools, but we must be much more sensible about how we do it. It seems to me that more and more people are catching on to that, so I am hopeful that things will change.

Justin Sullivan is an editorial intern at Salon.

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Homeroom Security

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One problem with writing the history of celebrity is that that history is not over yet. In fact, you might say that we are living through a period of fundamental change in the meaning of celebrity. The rise of social media (Twitter, Facebook, YouTube) means that you no longer need to have a press agent to publicize yourself; an ordinary person supplying pictures and videos and sound bites of herself is effectively acting like a celebrity in the micro-world of her acquaintances. At the same time, the popularity of reality TV has blurred the lines between celebrity and anonymity from the other direction: reality "stars" have the recognizability of celebrities, but are in no way glamorous or enviable. On the contrary, the purpose of celebrities like Heidi Montag or Snooki from "Jersey Shore" is primarily to be mocked and looked down on -- they are more like our culture's court jesters than the demigods of the silver screen that Inglis grew up with. In his paeans to Marilyn Monroe and Cary Grant, Inglis expresses nostalgia for a kind of celebrity that has largely vanished, belonging to a time when movie stars were "not only larger than the life they represented on screen. They were also somehow representative of their nation, available to all who watched them as picturing the impossible version of the best selves audiences could hardly be in everyday life."

But as Inglis shows in the historical sections of the book, modern celebrity has always been an unstable compound of admiration, envy, and contempt. Lola Montez, the mid-19th-century erotic dancer whose conquests included the King of Bavaria, comes across in Inglis' description as a proto-reality star: "an ungifted, tarty fake who, without any insight into what she was doing, intuited how to make herself into a celebrity while lacking talent, opportunity, birth, and money." If Montez was a celebrity, however, does the same word really apply to some of the other figures in Inglis' history -- like Baudelaire, whom he describes as holding "a singular niche in the pantheon of [French] national celebrity," or, at the other extreme, Mussolini and Hitler ("the dictator is no doubt the supreme celebrity")? As these examples show, Inglis does not distinguish clearly enough between celebrity and related but very different notions like power, fame, notoriety, and renown; he leaves the reader with only a vague sense of where celebrity came from and where it is going. Inglis' confusion, and his noble-mindedness, come across most clearly at the end of the book, when he nominates as the most admirable living celebrity -- Seamus Heaney! There's a man you won't see on the cover of People any time soon.

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A Short History of Celebrity

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According to Thomas Geoghegan, a labor lawyer in Chicago and author of "Were You Born on the Wrong Continent?: How the European Model Can Help You Get a Life," European social democracy – particularly Germany’s – offers some tantalizing solutions to our overworked age. In comparison to the U.S., the Germans live in a socialist idyll. They have six weeks of federally mandated vacation, free university tuition, nursing care, and childcare. In an attempt to make Germany more like the U.S., Angela Merkel has proposed deregulation and tax cuts only to be met with fury on the left. Over multiple trips spanning a decade, Geoghegan decided to investigate how the Germans were living so well, and by extension, what we might be able to learn from them.

Salon spoke to Geoghegan over the phone about Germany's luxurious worker benefits, our own dysfunctional attitudes towards work, and how we can make our lives more like theirs.

People in the U.S. often pride themselves for working more than our European counterparts. Why do we work so much in the first place?

There aren’t any historical or cultural reasons for it. Americans famously had more leisure time than the Japanese back in the 1960s. I would say if you did a survey of most people who are in their late 50s or 60s, they will tell you that they take fewer vacations than their parents did. Now why did that change? It wasn’t because of the Pilgrims. People work hard in America, but there was a period where leisure time was increasing. I quoted Linda Bell and Richard Freeman in an article they wrote about what happened during the ‘90s. There was nobody to stop you from working longer. There was no government check, there was no union check as there is on excessive work as there is in Germany or elsewhere in Europe. These institutional checks are gone. So people feel like lab rats: "If I work an extra 10 minutes over the person in the cubicle next to me, then I’m less likely to get laid off." It’s a very rational response.

Aren’t we at least more productive by virtue of the amount of time we’re putting in?

No. Look at their productivity rates. They’re like ours. I think we understate our hours and they overstate them, because they take so much time off and sneak off early from work. If the productivity rates being reported are officially the same, and if they’re understating and we’re overstating, they’re probably working more efficiently than we are, and maybe the fact that they’re taking time off has something to do with that.

Why is it useful to compare ourselves to the Germans?

Germany has the highest degree of worker control on the planet since the collapse of the Soviet Union. When I saw German labor minister Günther Horzetzky in April of 2009, he said "Our biggest export now is co-determination." He meant that other European countries were coming up with versions of it.

How did Germany become such a great place to work in the first place?

The Allies did it. This whole European model came, to some extent, from the New Deal. Our real history and tradition is what we created in Europe. Occupying Germany after WWII, the 1945 European constitutions, the UN Charter of Human Rights all came from Eleanor Roosevelt and the New Dealers. All of it got worked into the constitutions of Europe and helped shape their social democracies. It came from us. The papal encyclicals on labor, it came from the Americans.

But the Germans have a lower GDP than we do. Doesn’t that mean that our quality of life is better?

One day we’ll get beyond that and see that the European standard of living is rising. You can pull out these GDP per capita statistics and say that people in Mississippi are vastly wealthier than people in Frankfurt and Hamburg. That can’t be true. Just spend two months in Hamburg and spend two months in Tupelo, Mississippi. There’s something wrong if the statistics are telling you that the people in Tupelo are three times wealthier than the people in Germany. Despite the numbers, social democracy really does work and delivers the goods and it’s the only model that an advanced country can do to be competitive in this world. I mean that not just in terms of exports, but in terms of being green at the same time. That we can raise the standard of living without boiling the planet shows how our measure of GDP is so crude.

What are we missing when we measure the GDP?

We don’t have any material value of leisure time, which is extremely valuable to people. We don’t have any way of valuing what these European public goods are really worth. You know, it’s 50,000 dollars for tuition at NYU and it’s zero at Humboldt University in Berlin. So NYU adds catastrophic amounts of GDP per capita and Humboldt adds nothing. Between you and me, I’d rather go to school at Humboldt.

So much of the American economy is based on GDP that comes from waste, environmental pillage, urban sprawl, bad planning, people going farther and farther with no land use planning whatsoever and leading more miserable lives. That GDP is thrown on top of all the GDP that comes from gambling and fraud of one kind or another. It’s a more straightforward description of what Kenneth Rogoff and the Economist would call the financialization of the American economy. That transformation is a big part of the American economic model as it has morphed in some very perverse directions in the last 30 or 40 years. It’s why the collapse here is going to take a much more serious long-term toll in this country than in the decades ahead.

Who is better off in a social democracy like Germany?

Social democracy is good for the middle class even more than it is for the poor. We’ve got it completely backwards here. It’s the relatively educated and well-to-do that do well on European socialism. What’s the cash value of Humboldt education to people who are high school grads? Zero. For the German upper middle class, it’s worth 50,000 a year. That’s the difference. You have to remember, even if there’s universal healthcare, the more educated people always use the system better than the less educated people. They know how to make it work for them.

By some measures though, it's good for everybody. America has this wonderful freedom and openness and this ability to create yourself out of nothing. We’re just much more individualistic a country. I think we have overdosed a little bit on that, but I share that. I’m an America and I’m glad I was born in the U.S. and I always will be. But in terms of receiving the benefits of economic growth and both in terms of enjoying life and enjoying the richness of life in a developed country both in terms of private goods and public goods, quality of life that comes from that and leisure, I think Germany has an enormous amount to teach us.

Can we adopt this German working life in the U.S.? Is it even feasible?

We do things that are more socialist than Europe does, but we don’t call it that. We have some things left over from the New Deal that a lot of European social democracies aren’t even close to, like time-and-a-half for overtime and social security. The single biggest single-payer socialist medical system in the world is in the United States: Medicare. Untouchable. Defended by Republicans. But it’s more socialist than the German health care system. The problem with it is that it coexists with several other systems that are not socialist at all and just pay scandalous windfalls to private vendors.

The whole system is just grossly inefficient. All of those European countries have one system. There’s cost control. There’s no cost control here; there are four or five systems competing simultaneously. To get cost controls, we’re going to have to have one system of payments for everybody. Now either we go to a free market system or a German insurance system or a single payer system. Although I don’t understand how it could happen at the moment, I just see no alternative in the long run except that the U.S. goes single payer across the board. Not because I believe in single payer over these other systems but just because of the facts on the ground. You’ve got to have one system and we aren’t going to trash Medicare. That will never happen.

Thomas Friedman’s "flat world" theory predicts that in the future, all countries will be competing on an equal playing field -- paving the way for highly-populated countries to dominate the world economy. Do you agree with him?

How does he explain the existence of Germany? What country has the highest exports in the world today? It’s the country with the highest wage rates and union restrictions. Germany has become more of a power, not less of a power as the world has become more global. Our problem isn’t competing with China, it’s competing with Germany in China. We’re so focused on China all the time, and low-wage assembly stuff, that we’re missing what’s going on. It’s Germany that’s going in and selling stuff in China that we ought to be selling that would hold down the trade gap between the U.S. and China. It’s not China’s fault; it’s Germany’s. But no one wants to talk about that. Because that would raise questions about the whole U.S. model: Why is this high-wage country beating us? Why are the European socialists beating us? It’s too subversive an idea so we don’t allow in the discourse.

In her new book, "The Pain Chronicles: Cures, Myths, Mysteries, Prayers, Diaries, Brain Scans, Healing, and the Science of Suffering," Thernstrom, a writer for the New York Times Magazine, shadowed doctors and talked with patients about the science and experience of pain. Despite its being so common, she discovered, chronic pain remains a massive medical enigma, hard to treat or even isolate. She met amputees who complained of a constant ache in their missing limbs, women who felt like their entire bodies were bruised when there was not a scratch on them, and hundreds of others haunted by the invisible and devastating burden of constant pain -- all the while pursuing a cure for her own suffering (which turned out to be caused by a degenerative arthritic condition in her spine). Her book examines the human experience of pain through the lenses of science, history, philosophy and memoir, creating a comprehensive and thoroughly engaging portrait of a force that all of us have experienced, but few of us truly understand.

Salon spoke to Thernstrom over the phone about the science behind our suffering, how some people can control pain, and why others are more sensitive than most.

Pain is a very bizarre phenomenon because everyone has felt it, so we all know what it’s like on some level, but at the same time it’s very hard to accurately remember and describe. 

Yes, I find that very interesting. Pain is a non-verbal experience and yet we have only our words to describe it and try to get help. But the fundamental way in which it’s not verbal makes it much more difficult to seek attention and relief -- you have to first persuade your physician that you’re in pain and need treatment, and that can be extremely difficult. 

The amount of pain someone is in isn’t directly related to the severity of their injury. Why is that? 

Pain is a very mysterious phenomenon. We think of it as a very accurate measure of tissue damage, the way certain instruments measure the size of an earthquake and tell you if it is going to be big or small. But pain is not like that at all. It’s more like love, a subjective perception in the brain. Sometimes it can tell accurately how severe the injury is, but often it cannot. 

One of the mysteries of chronic pain has always been, why does it worsen over time? If it was actually an accurate reflection of tissue damage, it should get better over time as the tissue heals. But in fact very often patients’ experience belies that. The chronic pain gets worse as the original injury heals and takes on a life of its own. It causes changes in the brain and the nervous system that lead to more pain. A doctor I talked to compared it to water damage to a house. The longer it continues to leak, the more damage will be incurred, and eventually the house will just collapse. 

But despite the severity of chronic pain, often you have almost nothing to show for it physically. And that makes treating pain really subjective. 

A pain specialist once said to me, you have to value a person to value their pain. So it’s no surprise that poor people and minorities are the least likely to have their pain believed and treated. They also often have the fewest resources to pursue pain treatment. And it used to be in earlier eras -- peaking in the 19th century -- there were all these racist theories about how Africans couldn’t suffer from pain, that they were literally less pain sensitive than white people. The Victorians believed in a hierarchy of pain sensitivity with savages and slaves at the bottom just above animals and then rising up from there. Poor people were less sensitive than members of the upper class and most sensitive of all were white upper-class women. 

However, in contrast to these theories about Africans being less pain sensitive, there is very interesting contemporary research that shows that African-Americans are actually more pain sensitive on average and suffer from greater levels of chronic daily pain. 

Women also suffer from chronic pain at a higher rate. Why? 

All kinds of pain syndromes are more prevalent in women, and women are also more sensitive to pain than men. But there are other issues as well. Women go to the doctor at a higher rate than men, so they are more likely to seek medical attention for pain, but they are less likely to successfully get treatment. There have been studies showing that women are more likely to be referred for counseling or given psychotropic medication, while men are more likely to be prescribed physical therapy or referred for surgery. It seems that men’s reports of pain are often seen as more credible. Also, most pain specialists are male and most pain patients are female, so that is an additional element in play. For women in particular, a great deal of energy often goes into successfully playing the part of someone suffering pain in order to get treatment. 

In your book you describe witnessing a religious ceremony in Malaysia in which pilgrims hung weighted hooks from their chests and performed other rituals that should have been extremely painful--all the while showing no signs at all that they were suffering. How do you explain the fact that some people can undergo experiences like that and feel no pain? 

I was very puzzled by these mystical reports of transcending pain in a religious context. I had read about pilgrims in Hindu festivals mutilating themselves and claiming that they were in no pain or Filipinos enacting these crucifixion rituals at Easter. Honestly, I just didn’t believe it. I knew theoretically that pain is a perception and that the brain can turn it on and off, and in certain states of mind the brain will turn off pain, but it’s very hard to believe unless you see it. 

So I went and witnessed the Hindi festival of Thaipusam in Kuala Lumpur and I saw for myself that they were having fishhooks threaded into their backs and skewered through their cheeks and needles stabbed through their tongues -- and they really weren’t in pain. They didn’t even have any of the involuntary signs of pain. They weren’t blinking, they weren’t tearing up, they weren’t gasping. 

We in the West are familiar with this when there is a threat to survival. A flight-or-fight instinct can turn off pain. This is why, when you read an account of a shark victim, often they’ll say that they didn’t feel that their hand was bitten off, they just noticed the water was filled with blood. 

So is that what happens to these people who are skewering themselves? 

Yes, exactly. But instead of a threat to survival they’re being preoccupied with thoughts of God. But it’s the same thing in a trance. All of their attention is directed toward the thing that they want it to be directed towards, and the pain information is not admitted in. It’s thought to be stopped at the level of the spinal cord. They’re actually not feeling any pain. 

Is knowing that people can choose to reject pain like that useful to doctors who study pain, or to you personally as a pain patient? 

It’s very easy for us all to be able to do it in the case of a threat to survival. But to be able to do it in a voluntary sense, that is much more difficult. These pilgrims have a lifetime of training. They have to really and truly believe that God will take away their pain. It is essentially a very strong placebo effect. When you believe that you have pain relief your brain will make that true by not generating a perception of pain. 

It seems like many treatments for chronic pain do involve a placebo effect. Why is that? 

You need your brain to cooperate with the pain treatment and kick in some of its own ability to modulate pain. Even morphine, the gold standard of pain treatment, relies on placebo for part of its effect. If you give someone morphine covertly, without them being aware of it, it’s one-third less effective than if you say, "We’re putting morphine in your IV now. This is a powerful painkiller and you will feel much better soon." Morphine mimics the brain’s own pain modulation and you want the brain to give you some of its own endorphins and other pain-modulating neurotransmitters. 

But I imagine it must be incredibly difficult if you've had chronic pain for a long time to ever convince yourself that something is going to work. 

That is the problem! Chronic pain patients are very poor placebo responders because they expect to be in pain. And one of the big reasons that treatment works much less well for them is because they’re not getting placebo benefits. 

The brain doesn't just provide positive side effects. The placebo effect also has a sinister evil twin -- the nocebo effect. 

Yes. Nocebo is the other side of the coin. We know placebo generates positive effects like painlessness or other kinds of healing based on belief, but the brain can also create negative effects of the same kind. The ultimate nocebo is death by curse, when people who believe that they’ve been cursed really do die after a few days. That is an actual documented phenomenon. 

That brings up an interesting point, which is that being religious can impact how we interact with pain. What exactly does faith do to pain? 

It’s complex and some of the evidence is contradictory, but basically there are negative forms of religious faith and positive forms. Positive forms of faith, such as believing that pain strengthens your faith or brings you closer to God, actually do help people feel better. But negative religiosity, the idea that illness means God has abandoned me or perhaps doesn’t exist, has the power to dramatically harm the health of pain patients. 

Having studied all of these different ways of dealing and interacting with pain in writing this book, what have you found most helpful for treating your own chronic pain? 

In some ways I feel like I’m still waiting for my treatment to be invented. I guess physical therapy has helped me, and understanding pain has helped because it’s given me a framework to evaluate the success of my treatments. Making the psychological shift that I don’t have to be pain-free in order to be happy was huge as well. I thought at the beginning that I have to have my pain cured in order to be happy and now I feel like as long as it’s modulated and moderated, that that is OK. 

In the West in modern times we don’t expect to be in any physical pain. It’s not part of our sense of life, although it has been for most of history, and so therefore to have pain feels wrong, it feels outrageous, it feels upsetting because it seems like a violation of what we think of as a normal life. So I think changing that sense itself helped me. 

All that said, I would still love to be cured.

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The Pain Chronicles

by Melanie Thernstrom

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