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Last updated: Sat, Mar 22, 2025
So far in this section on How We Understand Pain I've focused on how we, whoever we may be, are inclined to understand complex and socially-important phenomena such as pain. Our natural inclinations are often to accept the apparent rather than the complex and the familiar rather than the imagined, since we are what we are and complexity is expensive to cope with in time and effort. (Which also is why science is hard and slow.)
This provides a lense through which you can consider the "common-sense" recommendations you will hear from Aunt Tillie and Uncle Ernie and your physical therapist. Watch for these patterns.
"Start moving," or "Increase your activity," or "Your posture is abnormal." Each of these suggestions can be correct and good, but use caution. They are also all examples of solving a problem by successively approaching a goal.
This is how you solve the problem, say, of opening your blinds. You want to see out, or you want more light. You look to the window and see that there is a cord. You move toward the cord, and if there's something in your way, you step around it. Because you're Homo sapiens, you can pre-plan your path, or you may have learned the best route, but basically you're achieving your goal step-by-step.
When you endeavor to improve your health by moving more or standing more normally, you're using the same strategy. It may indeed be a very good strategy, but maybe not. As you are moving more, you are indeed achieving a goal, the goal of being more active. In fact, when you act less like a person in pain, you are showing the external signs of a healthy person. This is true not only for visible movement, but it is equally true when you endeavor to act more cheerful, to be more attentive to others, and other things that can be difficult to do in pain.
Given that your pain is not directly observable to others, this strategy can make you appear better off through the eyes of others, whether or not you're feeling better in your own, inward-looking awareness.
The advice to move more should be made with awareness that there may be a good reason why you are reluctant to move. As I've tried to show, there are many possible sources of pain that aren't detectable in the doctor's clinic, in the hospital, or in the physical therapist's clinic. Hidden weaknesses aren't seen, they are inferred. It's effortless to make the inference that you're not moving because you lack the will to move. It's effortful to develop physiologically-sound inferences about hidden physiological causes.
Manual therapists, especially physical therapists, strongly believe that movement is an unalloyed good and that more movement is better, and this is very true in general. It is not necessarily true, however, in many pain conditions. Good therapists and good doctors know this. It's important that you (the sufferer) be aware that 1) you are much more aware of your internal reality than anyone else is; 2) what's good for you may not be what's good for people in general; 3) not all professional care providers are good; 4) your acquaintances don't understand your condition. Describe to Aunt Tillie and Uncle Ernie how acting healthy is harmful to you.
The belief that pain sufferers are more in control of their own prosperity than they themselves acknowledge is very common, both among professional care providers and in the culture at large. A number of factors contribute to this belief, including the occult nature of pain-causing conditions, our tendency to believe that our own experience of life is general, and, somewhat paradoxically, our belief in personal responsibility.
If one is crippled by a painful condition, one would naturally, I should think, try as hard as they can to overcome the condition. What strikes me, however, is how often the presumption becomes evident that pain sufferers are not really trying. Much of the psychology-based thinking about this is an attempt to explain the intractability of pain based on psychological factors that are external to the pain system itself. (The Psychological Perspective On Pain. Psychological and Psychiatric Understanding.) I argue against these theories throughout this work, mostly on the basis that the "science" behind them is flawed.
In dealing with professional care providers, bear in mind that the occult and mysterious nature of your condition affects their understandings, and that they may well "carry" the same cultural understandings of pain that your friends, associates, and Reaganites do. I suggest that sufferers express a willing attitude toward therapeutic recommendations, but should not hesitate to predict negative consequences when they foresee them. This approach signals your willingness to try and also raises the issue of negative consequences. If your care provider doesn't respond sensibly to your concerns, you now know where they stand.
I've found it difficult dealing with non-professionals on this issue. Once again I would suggest describing the situation from your point of view. This isn't easy because what you experience is likely to be foreign to the experience of others. Don't be shy, don't apologize, don't accuse, and don't go on and on. I've sometimes found people to first be a little shocked but then somewhat sympathetic if I talk about how pain infringes on my ability to sleep, to empathize with others, to think clearly in general, and other such abilities that most people don't think about. (The Challenge of Living in Pain.) When I tell someone that I always enjoy moving despite the pain, I expect a blank stare in response.
The concept of "personal responsibility" cuts two ways. It tells us, in one direction, that we are masters of our own lives. In the other direction, it puts the burden of responsibility upon each of us when something's not right. Personal responsibility can't be real if there are forces that can master us. People easily understand that someone in a cast can't go on a hike. It's much less obvious that someone who complains about pain may be in the same position as the person with the cast.
Our belief in personal responsibility is an ideological belief, and it is seen as fundamental, not derived from empirical analysis. (Ideological Understandings.) It is in the nature of ideological beliefs that they are hard to reason about and hard to qualify. The personal responsibility belief is also linked to other axiomatic beliefs, including the belief in meritocracy and the belief in a just God. A book-length exposition about personal responsibility, human nature, and other Western ideological assertions can be found in Steven Pinker's "Blank Slate."1
People will suggest that you do what has worked for them or someone they know. All kinds of things. Replace your boot heels. Try horse liniment. Try DMSO. I've actually tried some of these things. I've always interpreted these suggestions as kind-hearted and well-meaning, a verbal gesture of solidarity. I've never been very comfortable about how to respond to such suggestions. They seem to me to reveal more about the suggester than about my condition.