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Last updated: Fri, Sep 13, 2024
In the 1963 film "The Fortune Cookie," sports cameraman Jack Lemmon falls while filming a professional football game from the sidelines, when the star running back is chased out of bounds. Lemmon's brother-in-law, played by one of my favorites, Walter Matthau, is an over-the-top lawyer who browbeats Lemmon to feign serious disablement in order to win a cash settlement. The film's treatment is comedic, and in the end Lemmon is a good guy, Matthau is thwarted, and balance is restored to the universe.
The Fortune Cookie is just one of many films that treat of feigned pain and disability. These treatments go far back into the era of silent film before 1928. Sometimes the mood is light, othertimes serious. Sometimes they depict cheats who try to make a livelihood from fake traffic accidents. Othertimes they are tragic, as in "The Secret Garden" and many, many others that feature a character who is wrongly bed-bound not through conscious scheming but by some tragic malfunctioning of his spirit, or by the well-meaing but harmful solicitousness of care providers.
There are as many such stories as there is public appetite to experience them. They're based on the imaginations of screenwriters, and are not constrained even by the science or medicine of their time, but instead by the narratives that audiences would accept. Many films based around these ideas were created in the decades immediately following World War II, when psychoanalysis was prominent in the public imagination.
Narratives about pain and disablement pre-date motion pictures and don't always originate in the minds of young writers. When anesthesia became practical, in the 1840s, it seems to have stimulated discussion about pain and race, gender, and other differences. Intellectual authorities of the time told their audiences that the wealthy, women, and "Anglo-Saxons" were more sensitive to pain. Native Americans, the poor, and Blacks were constitutionally less sensitive. Presumably this originated in the "social Darwinism" of the time that justified colonization, unequal income distribution, and other causes of the social Darwinists.1
In the United States of the 1950s and 1960s there was increasing concern about justice, fairness, and costs as the social safety net was slowly woven. Time magazine published the concerns of an economist, Barbara Wooten, in 1956: "The concept of illness expands continually at the expense of the concept of moral failure....The significance of this question of who is sick and who is sinful cannot be laughed off as 'merely semantic.'"2 Seeing pain as sinful, a moral lapse, converts pain from a reason for compassion into a reason for scorn.
In this environment there was again interest in group differences. The cultural anthropologist Mark Zborowski in the 1950s and 60s published research in which he found that "Old Americans" had an accepting and matter-of-fact attitude towards pain and expression of pain. They tended to withdraw under intense pain, and to cry out or moan only when alone. Jews and Italians, on the other hand, tended to be vocal in their complaints and openly seek support and sympathy. The underlying attitudes of the two groups, however, appeared to be different. Jews tend to be concerned about the meaning and implications of the pain, while Italians usually express a desire for immediate pain relief. The behavior of the Italian patients was seen as nonconforming by hospital staff, who preferred restraint and self-control.3 4
Concepts that originated in behaviorist psychology also made their way into the cultural consciousness in the mid-20th century. Behaviorist psychologist John B. Watson (1878-1958), sometimes called the "father" of behaviorism, wrote an influentional childrearing manual recommending that parents establish rigid feeding schedules for their children and give them a minimum of attention and love. If you comfort a crying child, he wrote, you will reward him for crying, and thereby increase the frequency of crying behavior. The ideas in his manual found acceptance at least in part because such notions have existed in many cultures over many millenia. (Methodological Challenges in Psychology explains the nature of the behaviorist perspective. A Rational Model of Emotion and Pain contrasts behaviorist models of pain with models based on modern neuroscientific research.)5
Cultural understandings related to pain can interact in rather complex ways. In a text on pain assessment, Drs. M. D. Sullivan and J. B. Braden discuss the relationship between pain and depression in modern psychiatric practice.6 They assert that pain sufferers often resist a diagnosis of depression in part because the sufferers see it as a way to dismiss the role of pain in their suffering. Sullivan and Braden go on to assert that in legal proceedings that determine compensation or remediation for pain, the adjudicators can be prejudiced by a depression diagnosis. The authors then assert that "societies appear to hold individuals less responsible for somatic [bodily] symptoms than for psychological symptoms." They suggest that this tendency may be reinforced by Western medicine, which strongly favors "objective" (observable) criteria over subjective symptoms, such as those presented by pain sufferers. Continuing their analysis, the authors assert that those who suffer may choose (consciously or unconsciously) to express their suffering as somatic for these cultural reasons.
The question of "somatization," the expression of suffering as bodily symptoms, is complex. There is ample reason to treat the idea skeptically. Many psychiatrists and psychologists are critical of the idea for a variety of reasons. I explain this in later sections, such as Pain, Behavior, and Psychology. Drs. Sullivan and Braden describe a rather elaborate set of relationships among institutions and beliefs, which seems to be widely accepted among the professionals who are concerned about such things. Relatively little research exists, however, on the true nature of these relationships and the consequences of them in the lives of pain sufferers, particularly when contrasted with the great amount of research that has been done in an attempt to establish the clinical legitimacy of somatization.
There is also strong comcern in the culture about the question of nature versus nurture. The question sometimes seems to be whether we are born with our inclinations and abilities, or whether these are learned, and therefore amenable to education and child-rearing practices. It seems to be widely felt that, the more we behave "by nature," the less room there is for freedom and responsibility. It's also widely felt that this question has implications for economic and social justice. Neuroscientist Steven Pinker was so concerned about these feelings that he wrote his book "The Blank Slate" about the question and its implications.7 He bemoans that "Any claim that the mind has an innate organization strikes people not as a hypothesis that might be incorrect but as a thought it is immoral to think."8
Questions about human behavior and human thinking aren't only of concern to Steven Pinker. Major institutions, such as law systems, are based upon tenets about the reasonable person. Most Christian theologies have explicit dogma about the nature and abilities of the mind (or soul or spirit), and about the role that it plays in our relations with others, including our relationship with a supreme being. Such beliefs tend to be challenged by modern science. (See Ideological Understandings for more about this.)
Finally, cultural beliefs exist about various aspects of pain treatments. The use of narcotics is one of them. I well remember one of my very first visits to a pain clinic. The young doctor had just moved from an associate professorship at OHSU, Oregon's medical training center, into one of the state's major health care systems. I was one of his first patients. In the clinic he stood behind a lectern and starting asking strange questions about "MS Contin" and such-like things. It reminded me of the Three Dog Night song "Momma Told Me Not To Come." ("What's all these strange questions they're asking me?") I had no knowledge or opinion, and I sat rather vacant while he intently observed my demeanor after each such question. He was apparently vetting me for drug-seeking.
I left the clinic with a prescription in hand. When I handed it to the pharmacy clerk she uttered the word "morphine." I was astounded. I remember thinking, "That's what they give to soldiers who are about to die." I think I acted up. I was shocked because I thought the prescription was telling me that my situation was dire. That was my experience of the ideas I had soaked up about narcotics through films and TV.
To be clear, I now believe that narcotics use is an important tool in coping with a condition that does, indeed, have dire consequences. (The Challenge of Living in Pain.) Narcotics no longer frighten me, but I've had many bizarrely upsetting interactions with otherwise prudent and sober physicians on the topic.
The message of this page is that all of us have many ideas that relate to pain and the pain sufferer, and that these ideas often enter us without much or any screening. As an example, I want to quote at length from Wall and Melzack in their 1988 book, "The Challenge of Pain" on the topic of narcotics in pain treatment.
More nonsense on narcotic addiction is written by both doctors and the press than on any other medical matter. The undoubted occurrence of addiction had led to a mass hysteria about its danger which has been very harmful for patients as well as for addicts. The reaction to intravenous narcotics by the great majority of normal experimental subjects who are not in pain is one of discomfort. One of the present authors has experienced this a number of times during pain tests and found the sudden onset of a flying drunken feeling with nausea and headache to be distinctly unpleasant and not at all fitting the popular expectation of a pleasant dream state. Patients in acute emergent pain frequently receive one or more injections and they experience a powerful relief of both their pain and anxiety and often drift off to sleep. A survey was made of the consequences of such injections given to many thousands of Israeli casualties in the Yom Kippur War [(1973)]. Not a single case of narcotic addiction was found among these men in spite of the fact that most were in the age range most commonly at risk for social addition.9