“Yeah, Doc, I drink. I drink a lot. Some nights I drink a case of beer and a half pint. Can’t sleep if I don’t drink. Relaxes me. Pure and simple. Numbs me up like novocaine.”

A toothless grin.

“It’s the feeling of floating away. I don’t know, I just keep coming back to it. Stuff goes in, feel a little flushed, a little rush, then I go somewhere else, you know? I just kinda float off on a cloud for a while. Things back here hurt. I don’t have a job. I can’t buy my kids stuff. I can’t provide. I’m nothing, Doc. I’m nothing to nobody.”

One tear, sliding silently down the weathered cheek like a raindrop after a crashing, lightning-filled storm.

“It just feels good somehow. I know that’s weird. My mom freaked the first time she found out I do it. Oh, I don’t know, whatever I can find. My Dad’s box cutter, a kitchen knife. Razor blades are the best. I watch myself do it, you know? I sort of float over myself, watch myself cut. The lines are neat, sharp, clear. But it’s the blood that helps me. Watching the blood trickle down makes me feel something. It makes me feel human. It just- I don’t know- it just makes me feel something. Anything.”

A recent conversation with a friend made me revisit a concept that I return to over and over again in my professional life.

“We all just want to be significant. We all just want to know we matter.”

Simple concept, that. Self-worth. Self esteem. Mattering to your friends, your family, your spouse, your children, your employer. Should be a given, shouldn’t it? We’re all created, we all have a place here, and we all matter. At least we should.

What keeps some people from feeling that they really matter? What drives them to drink, to inject themselves with toxic substances and to incise themselves in neat, orderly rows of red ooze?

Pain. The common denominator is pain.

No, I’m not talking about the pain I felt when my doctor jabbed my knee with a needle last night to give me relief from unneeded fluid buildup. I’m not talking about the pain you feel when you hit your thumb with a hammer or burn yourself on a hot stove. I’m not even talking about the pain after surgery for the cancer that you now know will eventually kill you.

I’m talking about that deep, aching, throbbing, existential pain that makes you question why you are even here. Why you are alive at all. Can’t relate? I am so glad you can’t.

That kind of pain burns a hole in your soul like change hanging heavily unspent in a pocket. It demands to be felt. It will not go away. It eats at you, day after day after day, making you question your values, your worth to your children and your ability to contribute anything of value to the world at large. It wears you down like a slow-moving glacier, cold and heavy and relentless, sliding over the once-green bumpy mountainside of your life and reducing it to one, long, perfectly smooth expanse of nothing. It leaves no distinguishing marks. You become nothing. You are nothing.

And so you fight desperately to spend that pocket change, to trade it for something shiny and new, something that will make you feel good for a minute, an hour, a day. You try with all your might to melt that glacier, knowing full well that it is too large, too heavy, too wide and deep to extract from the hillside of your life below. You push up and out, but feebly. You take the last breath from the last air in the last pocket, and you resign yourself to the fact that no one will even know that you were here. You are nothing.

So you drink. You can quit anytime you want to. You’ve done it a thousand times. But you don’t.

So you push the plunger one more time, biting the rubber and holding it tight, feeling the inescapable, orgasmic flush of absolute pleasure that will kill you. You don’t care if it does, because for this one moment, this one beautiful moment in time, all is right in the world and God Himself is sitting here with you, stroking your sweaty forehead and easing you out of the world you’ve come to hate.

So you cut. You make the lines fine, evenly spaced, surgically precise. You wait for the first drop of blood, the first small rivulet that stands up for one second, supported by its own surface tension, that same surface tension that has kept your life intact for one more day. You watch the blood trickle down, a small red river of pain, tiny, tiny pain that flows out of you and is controlled by you and is something that you can deal with. Something that you can see, and feel, and hide from others for just one more day.

Maybe tomorrow will be better.

Maybe tomorrow the pain will go away.

Greg Smith is a psychiatrist who blogs at gregsmithmd.