What is pain for?


We’re told we need pain – without the experience, we risk harming our bodies and living short lives. With pain, and for most people, we learn to not go there, don’t do that, don’t do that AGAIN, and look at that person – don’t do what they’re doing! Thirst, hunger, fear, delicious tastes and smells, the feelings of belonging, of safety and security, of calm and comfort: all of these are experiences we learn about as we develop greater control over our bodies.

Pain is an experience we learn to associate with actual or possible threat to “self”. Let’s take a moment to think about what “self-hood” means.

If I ask you “who are you?” you’ll tell me your name, probably your occupation, maybe where you live and who you live with. Baumeister (1997) suggests our sense of self is about “the direct feeling each person has of privileged access to his or her own thoughts and feelings and sensations.” He goes on to say “it begins with the awareness of one’s own body and is augmented by the sense of being able to make choices and initiate action.” We learn about who we are through interacting with the environment, but also as we interact with other people and begin to sort through our roles, contributions and relationships.

Of course, our sense of self changes over time and is reciprocally influenced by choices we make as well as opportunities (and threats) around us, both environmental and social.

We work really hard to avoid threats to our sense of self. For example, I’ll bet we’ve all seen that person who steadfastly refuses to stop colouring his hair, wearing the same clothing styles as he did in his 20’s, holding on to the same habits as he did at the same age even when he’s now in his 50’s, has a paunch, and still looks for partners 20 years younger than he is…  He still believes he’s that young stud despite the evidence in the mirror. And of course the same applies to women perhaps more so!

So what happens when our mind/body is threatened? How do we know it? And what do we do about it?

In this instance I’m not talking about social threats, though there’s interesting research suggesting that being socially excluded has similar neurobiological effects as being physically threatened (or experiencing pain – though this may reflect the distress we experience when we’re hurt and when we’re socially excluded – see Iannetti, Salomons, Moayedi, Mouraux & Davis, 2013; Eisenberger, 2015). I’m instead talking about threats to our physical body. Those threats may be violence from another person, physical trauma to the body, or the threat of physical harm to the body. When we experience these kinds of threats, and once an aspect of mind/body has disentangled the threat evaluation from whatever other goals we’re currently engaged in, we experience pain. Tabor, Keogh and Eccelston (Pain, in press) define pain in terms of action: an experience which, as part of a protective strategy, attempts to defend one’s self in the presence of inferred threat.

So pain is there to help us maintain an intact sense of self in the presence of threat – threat that we’ve inferred from our context (or drawn a conclusion from incomplete data). It’s part of a system that works to maintain “us” in the face of multiple threats that we encounter.

Tabor, Keogh and Eccleston also argue that pain is an experience designed to intrude on awareness to show that “boundaries have been reached and action must be taken”. Pain is one way our mind/body can give us an indication of boundary – just how much, or how little, we can do. For example, I experience pain when I bend my thumb down to reach my wrist – it’s one way I can learn how far I can bend without disrupting something! The purpose of that pain is to help “me” defend against doing really dumb things, like stretching my thumb out of joint!

Interestingly, when we feel overwhelmed by our pain, when we can’t defend against it (because it feels too intense, has meanings that threaten our deepest sense of self) we tend to withdraw from responding to everything else – our conversations stop, we don’t notice other people or events, we pull into ourselves and ultimately, we can lose consciousness (think of the accounts of early surgery without anaesthesia – the surgeons were kinda grateful when the patient lapsed into unconsciousness because at last they weren’t writhing to get away – see Joanna Bourke’s book “The Story of Pain” for some harrowing stories!).

When we lose consciousness, our sense of self disappears. We lose contact with the “what it is to be me”.

Our sense of self also disappears when we experience pain we can’t escape and we can’t make sense of. Throughout the time while people are trying to label their pain, establish the meaning of their symptoms, and while people are searching for a solution to their pain, people’s experience of both time and “who I am” is threatened (Hellstrom, 2001).

To me, this is one of the primary problems associated with pain – and one we’ve almost completely ignored in our healthcare treatments. All our treatments are aimed at helping “get rid of the pain” – but what isn’t so often incorporated in these efforts is a way of engaging and rebuilding a resilient sense of self. So while the pain may ebb away, the “self” remains feeling vulnerable and threatened, especially if there’s any hint of pain returning.

What can we do better? Perhaps talk about what vision a person has of themselves as a “self”. Help them work towards becoming the “self” they believe they are – or at least helping them express the underlying values that their “self” has previously been expressing. That way perhaps people can find flexible ways to express that “self” – which will make them more capable of living well under any circumstances.

 

Baumeister, R. F. (1997). Identity, self-concept, and self-esteem: The self lost and found. Hogan, Robert [Ed], 681-710.

Bourke, J. (2014). The story of pain: From prayer to painkillers: Oxford University Press.

Eisenberger, N. I. (2015). Social pain and the brain: Controversies, questions, and where to go from here. Annual review of psychology, 66, 601-629.

Hellstrom, C. (2001). Temporal dimensions of the self-concept: Entrapped and possible selves in chronic pain. Psychology & Health, 16(1), 111-124. doi:http://dx.doi.org/10.1080/08870440108405493

Iannetti, G. D., Salomons, T. V., Moayedi, M., Mouraux, A., & Davis, K. D. (2013). Beyond metaphor: Contrasting mechanisms of social and physical pain. Trends in Cognitive Sciences, 17(8), 371-378.

Tabor, A., Keogh, E. and Eccleston, C. (2016) Embodied pain— negotiating the boundaries of possible action. Pain. ISSN 0304- 3959 (In Press)

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20 comments

  1. This post really resonated with me. I wanted to let you know that I’ve hijacked it and referenced it in a post of my own. If you object to the post and the way I’ve referenced your blog, I will, certainly, remove it. https://carlascorner.wordpress.com/2017/02/20/we-have-to-do-better/ I did put a disclaimer that the views expressed were mine and not yours. I always enjoy your posts even though I’m a patient and not a healthcare provider. I find you have a wonderful perspective on so many important topics.

  2. Carla thank you SO much for posting – and I love your blog! Personally I’m not convinced about opioids for most kinds of persistent pain except perhaps cancer pain, and that’s primarily because the studies show there’s little difference to quality of life or disability when opioids are used longterm. Great for acute and postop, but not so much for persistent pain. BUT I think the way the opioid crisis has been handled in the US and Canada has been, at times, obscene. Withdrawing something without supporting people to make a change, and leaving people stranded without support is unethical, no matter how well-reasoned the argument for reducing access is made. To my mind we need greater access to self management, and to manage expectations of people who live with pain – unfortunately our drug treatments are just not very good. For every 4 people treated for persistent pain, only 1 will achieve a 50% reduction in pain intensity, the others will have no change at all. That’s hard to hear – but it’s where our science is at.
    Pain can erode the sense of self. We need to help people rebuild a sense of who they are in the presence of pain, so pain becomes less of the focus and the rest of “who I am” grows larger and more fulfilling.
    Thanks so much for taking the time to comment, it means a lot.

  3. Bronnie, I am always puzzled as to why we tend to reify the experience of pain (i.e. portray pain as a distinct entity or “thing” with agentive properties) and then search for teleological explanations.

    1. I think we use the term “it” or “thing” and reify an experience as a linguistic convenience. Experiences can also be purposeful – hunger encourages us to eat, thirst to drink, pleasure to repeat the circumstances in which we experience pleasure.

      1. But all too often we can forget that our reification of “pain” was done as a linguistic convenience and proceed to ascribe agentive properties to this “thing”.

    2. Sure, we do – but we do this in many situations, when we wish to discuss an abstract experience. Love is the same. Hate. Pleasure. Peace. What alternative would you suggest? Or, rather, how can we counter this tendency and what would that look like in clinical practice?

      1. Bronnie, best that we do not fall into this error with “pain” in the first place (at least in the respected peer-reviewed literature). In clinical practice there needs to be room left for negotiation. All too often clinicians think they are treating a “thing” called pain and forget that there is another person involved in the discourse. The opposite situation also happens when people expect their respective health professional to treat their pain as if it were an isolated distinct entity residing somewhere within them. Your question could lead to a longish discussion!

      2. I certainly acknowledge that many clinicians forget that PEOPLE experience pain, not a foot or a back. Practically, though, by distinguishing between “self” and “pain” I think people living with pain are able to experience a sense of control, can retain their sense of self as intact (because experiencing pain often leads to a sense of loss of self), and can feel less emotionally and cognitively “fused” with all the negatives that experiencing pain brings.
        Clinicians, on the other hand, have mostly been trained from their undergraduate years to view “the body” and body parts as separate from “the person” – and I think we can complicate the discourse around helping people deal with pain unless we begin where clinicians are at and gently lead them towards a different approach. I’ve used a biopsychosocial framework for this, despite its shortcomings, because this seems to be readily understood, if not adopted, by clinicians.
        Given that we begin from a stance where “pain” is thought to be “in” a body part, how do we move beyond this? What are the practical steps clinicians can take? And how do we/they counter the assumptions and language that people living with pain bring with them – ie that pain “invades” the self, that it is an experience that feels as if it’s in a body part, and without the understanding that pain is more than this? Given both people living with pain and clinicians view the problem as this – how best do we begin?

  4. Bronnie, by framing the question – “Given both people living with pain and clinicians view the problem as this – how best do we begin?” – I suggest we have already embarked upon this long journey. We can now take off our blinkers.

      1. Bronnie, in my opinion, the next step is foreshadowed by this insight (a personal communication) from the Hong Kong-based philosopher Associate Professor Saulius Geniusas: “the science of pain remains blind in so far as it proceeds without a methodologically reliable description of what it tries to explain.” The recent interest in critiquing the IASP definition of pain is evidence that all is not well in the burgeoning world of “Pain Science”.

  5. JQ do you think we spend too much time pondering “what it is” and rather less on “what the people who present with pain need/want”? Surely if we listened to the people who present with pain we’ll get a reasonable idea of what is needed. It’s a lot like the philosophical discussions about “what is consciousness” – and this has been going on for how many centuries?!

    1. Bronnie, I agree with you. But I see that people experiencing persistent pain are increasingly being offered so-called Pain Education as a panacea. In my opinion, such education turns out only to be “dumbed-down” neuroscience taught by relative amateurs.

      1. We analysed the comments written on questionnaires by people referred to the Burwood PMC, and found that the majority wrote “I want to understand my pain” as a key goal. That suggests to me they wanted to know the structures/functions that underpinned their experience, at least in part, and to know why their pain persisted and that it was accepted by the person treating them.

        While I share your concern about “Pain ed” and I’ve written about that several times (how different is it from what we’ve done in pain management for…. er…. 30 years or more?!), it does seem to be an important aspect from the perspective of people living with pain.

        HOW it’s done is, of course, a critical question. What we know doesn’t work is “info dumping” or “didactic teaching”. What DOES seem to work is guiding people through a discovery process where information relevant to their experience is highlighted, and where permission to give new information is granted.

        Giving people accurate information (as accurate as we can at this stage of the science) is something I think we all must do, but we need to do it in a way that honours the sense-making capabilities of the person in front of us.

        This solution doesn’t, of course, change our tendency as humans (not just clinicians) to separate the experience of pain from self, or to, as you put it, reify it. That’s part of human cognitive processing, I think. To change that requires something else to replace it, and something else that is able to perform the functions for which we employed this approach in the first place.

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