Last updated: Mon, Nov 18, 2024
This section contains a sketch of the different perspectives or approaches that are available to us for understanding pain. Since we have different methods of appraising situations, different people will use different methods in different situations. The cognitive approaches that are most quick and natural for us are ill-suited for understanding complex and multi-faceted conditions such as pain.
In the current section I discuss ideas centered around understanding as it applies to pain. Understanding guides action. Understanding of pain is problematic. While pain is vividly present and real to the one who experiences it, it's largely hidden, or at least masked, from others. It is mostly up to the sufferer to experience and deal with it, which can be very lonely and cold. Nevertheless, we live socially. If our pain affects us, it affects those around us. When we reach out for help, we become exposed to the understandings of those whom we ask for help. At the same time, to the extent that we are disabled by our pain, we increasingly depend on the support of others.
The pain sufferer's own understanding of their pain is important for several reasons. Some of these are purely practical. We need to know what actions will most likely be to our benefit and what actions will be self-harmful. Some reasons are less practical, less obvious, but still important to our life experience. Pain commonly affects our capabilities and our social and economic roles. We can become other than what we once were. How do we then see our own identities? Why has everything turned bad? We are constantly exposed to the attitudes and beliefs of others who see our condition only through a cloud. What do we make of it when an MD says "I can't find anything wrong with you. You should take some Mindfulness training?" How do we deal with, say, a mother who's convinced that we'd be better off if only we were more active? Does the cultural image of the malingerer fit us? Or, even worse, is our pain a pretense for the benefit of a psyche that has given up on us? All of these scenarios are real. All come about because of beliefs about pain that are widely spread throughout our culture.
If your pain doesn't affect your behavior, it won't affect those around you. The relationships that you've built over perhaps many years, the relationships that you look to for support, entertainment, encouragement, and other things, won't be affected. But this isn't common with severe and chronic pain. Those around you will react, but how they react will depend upon their understanding of your condition. What will your kids think when they hear that your doctor can't diagnose you, can't find an explanation for the symptoms that you claim? How about your boss and your co-workers? We make a distinction between those who deserve special accomodation and those who don't. That distinction is based on beliefs about the individual involved and beliefs about the nature of their condition. Some of us like to believe that we are immune to the opinions of others, but in fact it is emotionally stressful to get negative feedback from others. And pain sufferers must cope with this emotional and social stress at a time when they are already stressed by their pain.
A pain sufferer will typically call on multiple care providers for help. Each variety of care provider has some particular training (medical doctors, physicians' assistants, physical therapists, clinical psychologists, acupuncturists, etc.). In many cases the care provider's licensing scheme requires them to study and advocate a particular understanding of pain. I'm thinking especially of medical doctors and clinical psychologists. The fields that require specified training about pain teach different sets of beliefs and understandings. But even where training tends to homogenize beliefs, there is variation among practitioners based on the practitioner's experience and even on their personality characteristics. Their beliefs will be reflected in their diagnoses, in their explanations and instructions, and in their treatment recommendations. Trained and licensed care providers are not immune to notions about pain that have a non-scientific basis.
The sufferer will also experience treatment by institutions such as hospital systems, clinics, workers' compensation systems and the Social Security system. These institutions, all bureaucracies, behave like bureaucracies in their treatment of pain sufferers. That is, they have rules and procedures that have been developed based on the needs of the institutions and understandings of the nature of pain.
In all these realms, understandings of pain affect the sufferer personally or institutionally. I've often found myself wondering, "Why are these people behaving so strangely?" Doubtless they weren't, as they saw the situation, but it still left me disoriented and disempowered. The generic answer to that question is that they are acting in a way that is consistent with their beliefs.
It's common to think of statements (assertions) as being either correct or not, black or white, or perhaps to think that a fact is either scientific or not a fact at all. The process of pain science is more-or-less about separating the true from the false. Its object is to find, as my wife sometimes says, "true facts" about pain and to discard all the rest--or at least to put the rest off to the side. Such concepts about truth do work well with systems that are either sufficiently well-understood or sufficiently simple. Pain, I think, is not like that.
Consider, to start, the complexity of your pain system, with nearly 100 billion neurons and 100 trillion connections potentially involved. At the level of cells and synapses it is far beyond our capability to even map the system, much less to understand the significance of such a map if we had it. Add to this the fact that these tiny neurons are in turn extraordinarily complex, with scores of different types of complex protein widgets building and moving and exchanging additional scores of types of signaling molecules, modifying themselves and each other over time.
Consider next that many of the questions that we are ultimately most interested in (for example, what can be done about suffering?) don't exist at the level of neurons, much less at the level of molecules. Understanding how a particular receptor molecule is built or how it functions isn't obviously linked to any of the human concerns that motivate our interest in this receptor.
Consider the human concerns that motivate our interest in pain. Consider pain itself,
[a]n unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.1
Pain science can say many things about pain, but pain itself is experienced. If this definition, developed by the International Association for the Study of Pain, is fundamentally reasonable, then understanding pain requires understanding what human experience itself is, what the nature of consciousness is. So far we have partial answers. We know sensory neurons, the spinal cord, the pain network, the ACC that is active when certain events occur and is believed to be involved in such-a-such function--a description of processes that occur internally when we receive certain types of stimulation. The human experience that we are ultimately interested in is subjective. We can observe our own experience, we can infer that of others, but it's entirely a different thing to understand the human effects of experienced pain.
More subtly and perhaps more importantly, natural language provides the words and thus the concepts that we use to think or talk about these commonplace human experiences. Natural language provides terms that we all "understand," but that have very broad, culturally-infused and imprecise meanings. When we use the word "pain" or the word "anxiety" or any of the other words we use in both scientific and common discussion about these things, we are using large words, words with broad meanings and many implications. We are often unaware of these connections, and there is no firewall that separates their defined scientific or technical meaning from the associations that we inevitably have with them.2
"Pain" itself is a good example of this. You've seen already (Acute and Chronic Pain) that there are at least two major types of pain, acute and chronic. The two types of pain differ in how they feel, what evokes them, which brain centers are activated and so on. Scientific understanding of why we perceive them both as "pain" or of what the commonalities and distinctions are is very limited. Yet pain research is full of studies that clearly investigate only one of these types (usually acute pain) but nevertheless discuss results as if they apply to pain in general, that is, to any pain. Conspicuously lacking are discussions that draw attention to issues around the generalizability of results or to the seapage of meaning within these very broad words.
What we know about the pain system will continue to grow, but the truth or accuracy of our understandings of pain will always be a matter of degree, not a matter of true or false:
I think that understanding is central to the experience of being in pain. Pain exists with or without understanding, but understanding modifies the experience. Even if you should try to deal with your pain entirely without communicating about it, your experience is flavored by your understanding. You have ideas about what's going on inside of you and about how you should respond to it. Is it serious or not? How long will it last? What should I do about it? That last question comes up not only in medical contexts, but whenever you interact with someone and your pain is part of the interaction—when it limits what you're willing to do, when it affects your mood, when someone asks how you feel. What do you know and what do you say?
The work of scientific and medical researchers ultimately should determine what is known and agreed about the nature of your condition and the appropriate ways to respond to it. They are subject to the fuzzy nature of truth about pain. Scientific procedure includes techniques for grappling with uncertain truth, especially in the domain of statistical hypothesis testing and experimental design. This domain is well-understood and is shared by other areas of science, medicine, and engineering. I give a very brief nod to this subject in following sections. With other aspects of truth, controlling the quality of knowledge is less well-understood and more difficult. These other areas include the subjectivity of the phenomena that are the focus of interest, the lack of scientific vocabulary with well-defined meaning, the enormous cultural burden of moral and political concerns related to pain (see Folk or Cultural Understandings), and the large economic stakes at play.
The people with whom you interact, from your intimate partner to your medical caregivers, have their own understandings, and their behavior towards you very much depends on their understandings. They have ideas about what's going on inside of you, about how they should interact with you in light of that, about what the facts of your condition are and how they should respond to it. Some of their understanding is based on science, some (in the case of medical care providers) is based on institutional policies and arrangements, some based on pervasive cultural beliefs, some based on their personal experience with pain or with people in pain. Some is simply a reflection of their personalities and their general beliefs about human nature.
I've made these ideas a subject of this work because of my beliefs about beliefs: 1) that beliefs about pain are an important determinant of pain experience; 2) that many questionable and even demonstrably incorrect beliefs about pain and related issues color the lives of pain sufferers; 3) that improving the quality of beliefs about pain is a low-cost, low-risk way to improve the lives of pain sufferers and those they share the world with, including those whose ministrations we depend upon and whose incomes we provide.
I don't think this is something to be left to the experts. My reasons should become clear if you continue into this book. The sense of frustration that I've had about this in the past has been sharpened rather than blunted as I've researched this project. If I've made my points well, you will see as you explore succeeding sections that the perspectives of pain professionals, reasonable though they may be in their internal logic, are not always what you or a disinterested party might have them be. I believe that you will be well-served by having an informed perspective of your own as you continue to live your challenging, unchosen role.
Within this section...
How We Understand Anything (Last updated: Mon, Nov 18, 2024)
Intuitive or Instinctive Understanding (Last updated: Thu, Sep 12, 2024)
Folk or Cultural Understandings (Last updated: Sat, Aug 24, 2024)
How We Misunderstand (Last updated: Wed, Aug 28, 2024)
Scientific Understanding (This page is incomplete.)
Psychological and Psychiatric Understanding (Last updated: Tue, Jul 30, 2024)
Ideological Understandings (Last updated: Thu, Sep 5, 2024)
Or skip to...
The Psychological Perspective On Pain (Last updated: Mon, Feb 24, 2025)