Pain – or disability?

One of the fundamental distinctions we need to make when working with people who experience pain is to understand the difference between experiencing pain – and the behaviour or actions or responses we make to this experience. This is crucial because we can never know “what it is like” to experience pain – and all we have to rely on as external observers is what we see the person doing. Differentiating between the various dimensions associated with our experience of pain makes it far easier to address each part in the distinct ways needed.

Let me explain. We know the current definition of pain – an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in such terms (IASP, 1979). One of the key points of this definition was to remove the need for nociception as a requirement for pain to be present. So when we unpack what we understand about pain, the first step is to recognise that it’s an experience. Something we can never share with another person – just like we can’t share joy, the taste of a great craft beer, or what a lover’s touch is like.

We therefore have an inexact relationship between two concepts: nociception, or the biological mechanisms at play until the point at which we are conscious of pain; and pain, or the experience of what it is like to have an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in such terms.

But wait, there’s more. Given that this experience is a subjective, internal and personal experience – how do we know when someone is experiencing pain?

When I ask students, their answer is “oh you can see grimacing, wincing, or they tell you” – and it’s true! But let’s notice something: they’re all behaviours. Things people do, either involuntarily or voluntarily, to signal that they’re sore. Behaviours or actions are not a direct indication of “what it is like” to experience pain. Like nociception and pain, there is an inexact relationship between what someone does when they’re experiencing pain – and their resultant behaviour. So we now have three somewhat overlapping concepts: nociception (biology), pain (experience), and behaviours (actions). They overlap because there is no direct 1:1 relationship between these concepts – although in some cases it may seem like there is.

What else influences our pain experience? If you’ve been paying attention to my blog these last few weeks, you’ll know that thoughts or beliefs and emotions also influence both our experience of pain and our behaviour. For example, if we know that the pain we’re experiencing is for good (such as post-surgical pain after hip replacement), we tend to be more forgiving, or at least more willing to experience it than if someone attacked us with a scalpel down some back alley! We have plenty of evidence that simply knowing the supposed cause, and something about the biology of pain, can help people to feel a little differently about it (emotions), and to move differently (behaviour) (Moseley & Butler, 2015; Tegner, Frederiksen, Esbensen & Juhl, in press), while emotions in both experimental and clinical studies have been shown to strongly affect pain intensity – and subsequent behavioural responses (Orenius, Raij, Nuortimo, Naatanen, Lipsanen, & Karlsson, 2017). Once again, the relationships are not exact – which is almost always the case when we’re studying complex systems!

Because thoughts, beliefs and emotions have both impacts on nociceptive processes and on pain experience and behaviours, I’ve depicted them as overlapping (if there was a way to show this in 3-D believe me, I would!).

But wait, there’s more!

We know context makes an enormous difference to a person’s experience of pain AND the behaviours they take in response to their pain. While contextual factors don’t directly influence nociception, these factors do influence thoughts and beliefs, emotions, and behaviour. For example, we know that in adolescents with pain, parental responses influence the amount of treatment seeking (Stone, Bruehl, Smith, Garber & Walker, 2018); and that spouses or partners of people living with pain can affect both pain intensity and behaviour because of the way they interact (Burns, Post, Smith, Porter, Buvanendran, Fras & Keefe, 2018). We also know that in different communities, responses to pain can differ: people who pursue body suspension (being pierced and suspended by hooks) are supported by those around them to “hang in there” (no pun intended!). Factors such as legislation make a difference to pursuing treatment, while treatment itself can perpetuate disability and may even increase attention to pain.

Why bother explaining all this?

The implications of understanding these associations are quite profound. Firstly, nociception is a small but important contributor to our pain experience. Most pain starts with a nociceptive stimulus, even if it ultimately ends up less influential than cortical ‘interpretive’ processes. Secondly, the experience we have of pain is something we can’t share – and thirdly the only way we can begin to infer that another person has pain is via their behaviours, or what they do. This means pain measures like the visual analogue scale, FACES scale, numeric rating scale are not direct measures but are used by people to give a message about their pain. All behaviour is influenced by both our thoughts/beliefs and emotions and contextual factors including who is nearby, past responses they’ve made to our messages, what’s normal or expected in various contexts, and the purpose we believe our behaviour will serve. And of course, many of the influences and behaviours we do are not things we’re consciously aware of because we’ve been doing them since we were born.

So when I think about what we might do to help someone with their pain, I firstly acknowledge that I can’t directly influence someone’s own experience. I’m working to influence what they do about their pain, their relationship to their pain, their beliefs and understanding, their emotions and how they communicate this to other people around them. And to me, the first step is being ready to hear what people believe about their pain. Only after I’ve successfully conveyed this to the person can I ever begin to come alongside them to help them change what they do.


Burns, J. W., Post, K. M., Smith, D. A., Porter, L. S., Buvanendran, A., Fras, A. M., & Keefe, F. J. (2018). Spouse criticism and hostility during marital interaction: effects on pain intensity and behaviors among individuals with chronic low back pain. Pain, 159(1), 25-32.

Moseley, G. L., & Butler, D. S. (2015). Fifteen years of explaining pain: The past, present, and future. J Pain, 16(9), 807-813. doi:10.1016/j.jpain.2015.05.005

Orenius, T. I., Raij, T. T., Nuortimo, A., Näätänen, P., Lipsanen, J., & Karlsson, H. (2017). The interaction of emotion and pain in the insula and secondary somatosensory cortex. Neuroscience, 349, 185-194.

Porreca, F., & Navratilova, E. (2017). Reward, motivation, and emotion of pain and its relief. Pain, 158, S43-S49.

Stone, A. L., Bruehl, S., Smith, C. A., Garber, J., & Walker, L. S. (2018). Social learning pathways in the relation between parental chronic pain and daily pain severity and functional impairment in adolescents with functional abdominal pain. Pain, 159(2), 298-305.

Tegner, H., Frederiksen, P., Esbensen, B. A., & Juhl, C. (2018). Neurophysiological pain-education for patients with chronic low back pain-a systematic review and meta-analysis. The Clinical Journal of Pain.


  1. “I firstly acknowledge that I can’t directly influence someone’s own experience.” Bonnie, I cannot agree with you on this point. I would argue that you cannot but help influencing, for better or for worse, someone’s own experience when you assume the role of their therapist. In fact you do acknowledge this phenomenon when you argue above that “[We] know context makes an enormous difference to a person’s experience of pain AND the behaviours they take in response to their pain.” The other important issue is that of the “privacy” of the experience, which is foregrounded in our recently published paper wherein we reconsider the IASP definition of pain, where the challenge is “… to embrace pain as a shared experience.”

    1. I would argue that “sharing” pain is problematic. This argues for high levels of empathy, whereas the research shows this leads to burn out amongst healthcare professionals.
      Better to show compassion, which has different brain circuitry and allows the carer to understand someones suffering and to take action to help relieve that suffering. This has been shown to be a sustainable mode of care.
      I think that therapists are already going through great challenges, in changing the way they are now being asked to help those with pain. I know this paradigm shift is necessary, but the demands are great as new and complex models need to be understood and assimilated.
      I have been attempting to use a BPS model for about 8 years now and whilst interesting it is also quite exhausting as more and more plates need to be kept spinning, all the time knowing that actual reductions in pain severity are proving difficult for everyone. Reading blogs can be empowering, but can also create a sense of inadequacy, the feeling that others have nailed it whilst you are struggling away and it is all a bit messy.
      We need to show ourselves self compassion going forward as these are indeed challenging times.

      1. Hi Graham, I agree – compassion is what’s needed, and to do this I believe it’s necessary to use mindfulness, to be fully present without judgement, to acknowledge what is. It also means stepping back from taking responsibility for change: I can offer an opportunity, work hard to help people resolve their ambivalence about change, help uncover intrinsic motivation for change, help identify important values, be a cheering squad or coach on the side, but in the end it’s not my life and I don’t know everything there is to know about the person I’m sitting with. And that means keeping the door open if it’s not the right time for them to take action. I hope people can see that I’m willing to help, but it’s their life and they make the ultimate choices (because people always do).
        Pain reduction isn’t my aim: living a full, rich life aligned to values is what I hope people will gain after seeing me. And I certainly don’t have it nailed because I’m constantly discovering more that I need to know, more I can add, more I can develop. That’s what makes this work endlessly fascinating, challenging and ultimately rewarding. It’s as much about developing myself as a person as it is helping others step towards what’s important in their lives.

      2. Graham, of course empathy can be problematic for health care professionals but it may well be the very foundation upon which they base their practice in the pain medicine area. It can be a steep learning curve for those who are not trained to cope with the fall- out from truly intersubjective engagements.

      3. Hi Graham and all,

        I feel like I can significantly influence pain intensity in chronic patients. Not every one of them, but certainly the majority. To achieve this, I have largely discarded the BPS approach and have been learning a lot from those outside the healthcare industry. It can be a lot more simple and rewarding than we are led to believe. Therapist skill > patient education. That’s the key.

      4. Hi Bronnie, In the past I used the VAS to measure pain intensity, but then I found a better way. If I am congruent, this allows patients to be the same way, and they will tell me exactly what’s happening, without feeling any need to ‘prettify’. They feel no pressure to please me by reporting improvements that don’t really exist. I’m aware of the old “yes it’s helping” and yet they keep coming for another 12 months with the exact same “yes it’s helping”. That gets picked up on the radar. But statements such as “I haven’t had any pain in the last 3 weeks. I’ll call you if I have problems” can be trusted.

      5. Kinda – and not. There are many variables influencing whether someone will say they are happy with their treatment – and even whether they’ll return for more. These may well not be the treatment itself. Congruence is probably part of the picture, but without further research exploring this in much more depth (replication studies, long-term follow-up, control groups, random allocation yada yada) I’m going to hold getting super excited. Great for the patients who appreciate your approach, but not perhaps something for everyone all the time.

  2. I think I’ve made a distinction here between influencing the experience vs influencing beliefs, emotions and contextual factors – I acknowledge that I influence these latter factors, but I argue that nobody can directly influence the experience per se.
    With respect to your paper on pain as a shared experience, I beg to disagree although I think I understand your perspective. If babies can experience pain and demonstrate withdrawal (nocifensive) behaviour in response to nociceptive stimuli, I can’t see why adults can experience pain in the absence of anyone else. I think this is a discussion that needs to be had in a future blog post. I agree, context certainly influences pain experience – but again, indirectly in terms of beliefs and attitudes towards the experience, and in responses to that experience.

    1. Bronnie, you seem to be arguing against the IASP definition of pain, where it is clearly suggested that emotional factors (which you can and do influence) are inextricably bound to the sensory component of that experience.

      1. Not at all – but we can only influence emotions indirectly. I cannot “make” you happy. You interpret what I do and appraise it and in turn this generates an emotional response (this is the fundamental cognitive behavioural model). So, just as I cannot “make” you sore (although social rejection may elicit this response – but again, only indirectly through appraisals) I cannot “make” you feel any emotion. That’s something you generate.

  3. Bronnie, would you expand upon the direct versus indirect distinction you have drawn? It seems a highly artificial one to me. Thanks.

    1. It’s probably not a discussion to be had in this space – I’d suggest reading some of the classic psychological texts looking at the evolution of cognitive and behavioural approaches to firstly mental illness, and then as they have been applied to pain. Relational frame theory is also relevant, and the way we define “behaviour” and how these concepts are constructed in our neurobiology.

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