Philosophy of Pain
Part I: Language
We all know what pain is and I doubt anyone would deny to have experienced the unpleasant phenomena. However, although it is a universal experience it is not a shared one. Where there is pain there can be doubt. Language alone cannot make it shared. Pain as a physical response functions within our bodies the same way, but we all interpret pain differently and we also cope with it differently.
Language is limited because pain is a private and subjective experience. How can someone that experiences a migraine share the experience with someone that has only experience the occasional minor tension headache? Can words really bridge that gap in experience and internal interpretation?
The primary methods we use to share pain with others is pain behavior and language. In fact, if a person neither exhibits pain behavior not uses pain descriptions we would not be able to determine they were in any pain at all. This leads to all the problems that face those with Invisible Disabilities. Depending on pain behavior can be a faulty way to determine pain. If I sprain my ankle I will likely limp and that will indicate pain in that area. Unfortunately someone with chronic pain is always experiencing a level of pain and when that pain is considered tolerable to them they may no longer exhibit any pain behavior to indicate that pain. Therefore even if they are able to describe in detail their pain experience, that experience can be easily doubted if they are not also showing some sort of behavioral indication of that pain. Having others doubt the pain experience can greatly hinder treatment.
Language is used to create a pain narrative in order to share the experience of pain and this narrative will include indications of intensity, duration and type. So even though we lump these experiences under the term 'pain', the experience differs in Intensity (mild, severe, moderate), Duration (constant or periodic), and type (ache, stabbing, throbbing) and of course Location.
Even a doctor that constructs a pain scale, must include a description of each level on that scale in order to make some sort of real indication of the patients level of suffering. What I consider to be a 5 on the pain scale used, someone else could easily see as being an 8. When I first encounter the pain scale used by doctors I was frankly amazed... since I rarely go below 7 according to that scale, but on my own scale of reference I made 5 mean tolerable, not overly affecting my ability to function, but cannot be ignored. There is no direct way to measure a person’s suffering. If the chronic pain sufferer understates their pain, according to their subjective scale, then the doctor may not fully address the issue at all. If I am in enough pain that I have troubles walking but to me this is tolerable pain because its location is very specific and thus does not affect everything I do and only limits specific things. Would that make this pain lesser than the individual who would rate this higher on a pain scale? Same limitations but a vastly different interpretation. Frankly, when it comes to chronic pain we are looking at a vastly different world view that simply does not match up to normal, periodic, pain experiences.
Sometimes these constructs and scales seem inadequate and we must use metaphors to try and add clarity. 'It feels like my bones are grinding together', 'Or it feels like someone is stabbing me repeatedly in the chest'. Some of these metaphors can be quite creative and also can differ from culture to culture. In Nigeria such descriptions were used: 'it seems as if pepper were put into my head' or 'things like ants keep creeping in various parts of my brain'. Cultural beliefs may also hold a reluctance to share pain at all and can lead to doctors minimizing pain in a patient whose culture tends to react stoically to such experiences or those that consider intolerance to pain to be a weakness.
However, no matter how detailed and specific our pain narrative may be (and really, no one goes into that much detail) there remains no direct way to measure it. There is no physical indicator of pain intensity or personal tolerance. Even if two people describe a pain in their foot to be a constant, dull throbbing sensation, there is no way to determine if one is experience a more intense pain than the other. Even if the physical intensity is identical, they may also interpret that pain differently. For one with a high pain tolerance the experience could be easily ignored, and one with a low pain tolerance may be limping and proclaiming that it cannot be ignored.
Pain tolerance presents a problem, especially since chronic pain suffers tolerate a lot of pain regularly and so intolerable pain they do complain about may be minimized by doctors. For if someone does not exhibit pain behavior or use exaggerated pain vocabulary, a doctor may decide that the patient is not in enough pain and therefore not given anything to alleviate it. Pain tolerance is in fact merely the ability to ignore pain better, or deal with it more easily. Perhaps gained by years of chronic pain and learning to function with a certain baseline. The sensation is still there, coping with that constant sensation becomes increasingly difficult if no aid is provided and doctors expect the person to just handle it or deal with it. For a chronic pain sufferer tolerable pain may be described as less painful than the same pain experience by one that does not feel pain daily. But does that imply doctors should pump the patient that complains the most with pain killers for an injury that is short term and simply ignore the quiet patient that explains their pain in detail but less vigorously, and constantly suffers? The most apt personal experience I have of this phenomena occurred when I and a co-worker both were burned from a deep fryer. My collegue had a minor burn on the side of her hand, but for her the pain was intense and she exhibited the expected behavior from feeling that much pain. As expected, she was provided with pain killers while the burn healed. I, on the other hand, dipped my upper hand into the grease itself receive second and third degree burns. I exhibited to pain behavior at all and calmly informed my co-workers of the injury while running it under water. The skin lifted up and bubbled and was extremely painful. I did not go into shock. I waited a long time at the ER for treatment, was told how to handle the injury to prevent the inability to move my fingers and sent home, without the aid of any painkillers. A mistake I did not make again. A mistake that occurred because I have Fibromyalgia and had learned it was best to minimize how much pain I was in around people and especially doctors, due to how they see people with chronic pain coming in for pain relief. In this case, the injury I sustained was a great deal worse, but the treatment I received was quite a bit less.
Language simply cannot bridge the gap between the private lived experience and the shared experience. But we can try.
Part II Phenomenology of pain
Drew Leder in "The Absent Body" (1990) has some interesting insight to the lived experience of pain. According to Leder, normally the body is experienced as an absence, in a continual process of self-concealment and temporary revealing. When a part of the body is not being used it falls into the background and we hardly know it is there. Likewise our internal body is rarely felt, aside from grumbling in our stomach and so forth. With the eruption of pain the background region becomes thematized. Leder points out that pain has an episodic structure. Leder states, "Even pain of a more chronic nature are often marked with an episodic nature, changing in their character and intensity according to one's activity, position, or visceral periodicities." (p.72). Interesting enough pain does not follow the process of adaptation as does other stimuli. The sun may blind a person walking out of darkness, but soon the eyes adapt. Leder claims, "Pain receptors, on the other hand, adapt a little or not at all." (p.72).
I think there is a process of adaptation in the chronic pain sufferer, although it is hard to be aware of the process, since the pain remains although at a different intensity. An example to show this would be the use of pain killers. While the person is on the pain killers they feel little pain, or less than usual anyway. As soon as they cease to take the pain killers they are soon confronted with the full intensity of their pain; this then dims as the body adapts and the mind copes. It would seem that since painkillers dim the pain they also nullify the adaptation the chronic sufferer has developed. When they go off the painkillers the body again feels the full intensity of the pain physically present within the body. This will lower in intensity as the person 'gets used to the pain' or the body adapts as best it can to a stimulus that does not end when it should.
In regards to chronic pain Leder does suggest that a person can become accustomed to a particular level of pain. Therefore the longer someone endures pain the more one develops a certain pain tolerance. The chronic pain sufferer constantly experiences some pain, and mild to moderate pain is easier to ignore and tolerate than more uncommon episodes of severe pain. Mild pain becomes the normal lived experience of the body. This is a curious phenomena but one I quite understand. People always ask how someone with chronic pain can function in the day to day world and perhaps part of the answer, but not the only one, is simply that the baseline pain is part of their normal life. In the sense that Leder says the body is experiences as an absence, the lived experience of the chronically pained body simply is not. That baseline pain makes the chronic pain person aware of their body constantly and thus it is more extreme pain that is Thematized. Imagine what that must be like for a moment. If you are the ghost in the machine, you really don’t pay attention to the machine when it is running well. You can walk through the world and not have a bodily or spacial awareness like those in chronic pain do. They feel movement, they are aware of how position increases discomfort and they specifically alter their movements according to this awareness without thought. That lived experience of pain is quite different for just that fact alone, but then there also consequences to baseline pain physical awareness in that it distracts a person. Pain demands focus and even mild to moderate chronic pain demands.
Leder then goes on to discuss how pain has a 'affective call' and a 'quality of compulsion'. Pain calls us to act, because that is the normal functional role it has in the body. Pain has an intentional disruption: "Prior to the onset of pain, the lived body of the (person) is an openness upon the world" and s/he "lives from his (or her) body to the world." (p. 74). When in pain however, "the painful body becomes that to which he (she) attends." (p.74). This creates an "absolute split between one's sense of one's own reality and the reality of the other persons." (p.74).
Pain also has what Leder calls a spatiotemporal constriction. Pain creates limitations and "We are no longer out there in the world, but suddenly congealed right here." (p.75). This involves motor restriction as "Space loses its normal directionality as the world ceases to be the locus of purposeful action." (p. 75).
Finally pain "exerts a telic demand upon us," (p.77) and we seek the means to end the sensation. Within this demand Leder draws a distinction between the hermeneutical and the pragmatic moment. In the hermeneutical moment, "Suffering gives rise to a search for interpretation and understanding." (p. 79) We try and discover the cause of the pain and involve ourselves in a quest for diagnosis through medical professionals, friends or other means. And naturally there is the pragmatic goal, to rid ourselves of the pain through some treatment, or to master it. I would say that the pragmatic goal is an obvious response to pain, but the interpretation of the experience often plays a greater role, especially if the pain is in fact and endless condition within the body.
Part III Chronic pain
Pain is an important factor, as a disruption, to our lived experience. The hermeneutical and pragmatic goal Drew Leder refers to in the Absent Body are indeed important aspects to the pain experience. It is only natural that when we are struck suddenly with such a physical disruption we would seek the cause of it and fix the problem. A problem arises when the quest for meaning, diagnosis and understanding is inhibited, simply because the pragmatic goal of ending the pain sensation does not exist. We are faced with the dire fact that the pain will always be there. Obviously, this is a concern that arises with chronic pain. Because pain is private and cannot be measured, it can be doubted. If a medical professional cannot find the physical cause for the sensation, they may suggest it is psychological. This leads for a greater struggle for meaning and understanding within the sufferer. Is it possible to doubt your own pain? In a way, it is. When no explanation can be found, no concrete verification of the experience, even the patient may begin to believe it is 'all in their heads'.
Not only can pain not be shared, to the point of being doubted, but it can also severely affect a person's relationship with others. This means, although the experience is private, it can be inter-subjective as chronic pain can affect family, co-workers, friends and care-givers "and such persons in turn shape the experiential world of the sufferer." (p9, Good, Pain as Human Experience) People close within the sufferers support group may doubt the reality of their pain, to the point that they may be accused of being chronic complainers, or feel as such.
Isolation is not entirely due to the fact that pain cannot be shared, but because the lived world of the chronic pain sufferer is what someone else can only understand through a transitory moment of pain. Normally when the pragmatic goal of ending the pain is achieved, the memory of it fades with perhaps only an echo of what it felt like emotionally as a reminder of it. How does one then extrapolate from that brief moment in time to imagine that moment extended indefinitely?
As Drew Leder points out, pain has a way of fixing us in the moment; it fixes us into the now and so "With chronic suffering a painless past is all but forgotten." (p76, Leder, Absent Body) Although the experience of pain may be demanding of the attention, in the moment, once the pain diminishes the memory of it soon dims. Someone cannot comprehend how it is to live with enduring pain, because they cannot clearly recall how pain affected them in the moment of the experience, let alone a moment of longer duration. Often our memory of past physical pain is the memory of what caused the incident and how it was resolved, rather than living the moment of pain clearly. Perhaps it is equally difficult for a chronic pain sufferer to image a pain free existence. If our baseline pain changes how we physically become aware of our bodies, how then do we remember a time when we were not so aware of how we moved in the world?
Even though pain is usually episodic, the chronic pain sufferer is always aware of some pain in some location at some intensity. The are constantly aware of their 'pained body', such that a certain amount of discomfort or consideration to position and intensity of pain because automatic, with some minor pain being just a barely noticed background to everything else. This 'attention' and awareness of the body that is lacking in normal functioning. And this makes the pained body grounded into the present state of affairs, where they can no longer bodily remember what it felt like to have no pain, nor can they conceive of a future with no pain. They may recall being able to do activities they no longer can, but they cannot remember how it felt to move without being quite aware of that movement through pain.
However, being grounded in this pained awareness of body, does not mean they are fixed in the present moment. No quite 'living in the moment'. In fact, the pained body, and even the body experiencing episodic pain, experiences time itself differently. Because of this grounded feeling in the body, perception of reality outside the body is altered. Time in particular, becomes distorted. When experiencing intolerable pain, time seemed stretched to infinity and moving unbearably slow. The sufferer is locked into that pained experience, to the point of excluding all other considerations. With enduring pain, everything becomes a time consuming act. At other times, time seems to be rushing while they are unable to keep the pace. A great deal of guilt can result from not being productive or filling time as efficiently.
Pain gains it immediateness of our attention from its intensity and the intensity determines how much focus we pay to it, how much effort we put into making adjustments because of it. Mild pain becomes a tolerable and easy to ignore experience and thus it really does not exert that much of a demand for attention in the chronic sufferer. It might not even be mentioned. Moderate pain would be seen as pain that exerts a constant demand for attention, thus impairing focus and ability to function, perhaps limiting movement. Yet for the chronic sufferer, even this is pain that there remains a level of functionality, which becomes the more important factor within the scale. Function and Cannot Function.
Part IV Body semantics
With the chronic pain sufferer pain goes beyond the physical and involves a great deal of personal interpretation. It involves self doubt and creating a new identity that makes sense as they re-orient themselves in the world.
"Individuals with the same pathology may develop vastly different disabilities because the pain has different meanings for their lives... the site of the pathology may be precisely the same, yet the course is likely to be quite different." (Good, p10)
The meaning a person subscribes to their pain can be vastly different from individual to individual. It can be dependent on their work, available health care and support programs and relationship with family and friends. Meaning can also be affected by age and gender. People who believed they were young and fit may be faced with a new body image that does not meet up to their standards, or the perceived standards of society. They can doubt their identity, their body and even their sanity until they can ascribe some sort of meaning to the chronic pain experience.
With the initial onset of chronic pain the quest for interpretation follows a particular pattern. The first step is to seek diagnosis. This can be a long drawn out process, which can in many cases cause the person to doubt themselves. Un-named pain is disturbing. It becomes very important to find a label for the pain, to acknowledge that it is real and not imagined. The "chronic pain sufferer presses on, constantly seeking a name for their suffering, an image that will name its source and allow it to be set off from itself." (p.43, Good). Initially, when the disease is named the person will feel relief, having their pain officially acknowledged and the hope of treatment. However, if there is not a clear cause, then often there is not a clear treatment. Progressively with treatment "the answer becomes 'more holistic', more 'ambiguous', less clear." (p44, Good) And then there must be an ongoing process of finding ways to accommodate pain, instead of alleviating it. And so there is a pain narrative for every chronic sufferer; a story of diagnosis, treatment and coping.
The chronic pain sufferer interprets their own flesh differently and consequently their lives reality changes. The pained body feels a profound dualism while at the same time being grounded to the moment. A distinction between mind and body immediately arises from pain. The pain is in your body, with some sort of duration, intensity, location. Your mind has to interpret it, give it meaning, discover a way to tolerate it and cope with it. The body becomes the Other; a separate entity from your mind, that are in conflict. It is an enemy to how a person lives in the world. The body now has limitations. Instead of being embodied, living through the body without noticing they are doing so, they are now confined into flesh with new limitations to always be aware of. The mind may want, but the body can't perform. The body is something that has failed the mind.
The body in no longer under their control. The perception that it is no longer going to cooperate with the persons will and desires. That it is an obstacle. Thus the pained body leaves the person feeling no longer integrated. With the desire to preserve their identity, they see themselves as separate from the pain. While the body is a limitation and an obstacle, the mind is still the same. So the 'I' and the 'ego' remain intact, but seen as separate from the flesh. Thus chronic pain transforms the lived body, the embodied body, 'in which self and body are unified and act as one in the world, to the object body, where the body is a source of constraint and is in opposition to self'.(p104, Good)
Part V Invisible In the World
Due to the private nature of pain, the inadequacies of language, chronic pain can be isolating. When going through the process of diagnosis the sufferer experiences a great deal of self doubt and learns to underestimate their own pain and to feel guilty for their inability to cope. Chronic pain is an invisible disability. The sufferer can conceal from others the pain experience. At times, the sufferer can 'pass' for healthy, for free of pain, to others. Even though they cannot function as they once did, as other do, they can appear to be. In an attempt to live a 'normal' life, the life they once had, they may not only hide their pain, but also try to function at the same level as everyone else, what they believe society and their family requires of them.
What I believe about pain tolerance is not that is some innate skill we have but rather pain tolerance is learning to mask out pain and not to exhibit pain behaviours, so that no one can tell and we can get through the day. Pain tolerance does not mean no pain, and when we do not exhibit pained behaviours that likewise does not mean we are in pain.
The chronic suffered feels a great deal of guilt when they come to the inevitable conclusion they cannot keep the pace with others, with the perceivedstandard of society, or the perceived desires of their family. When "the pace of life increases, stamina becomes more important to participation in every aspect of society, and what was once regarded as an ideal level of energy gradually comes to be regarded as normal." (p90, Wendell) This desire to hide chronic pain, to create a facade, arises from the stigma of disability and the overall denial of weakness. It is further complicated by body image and the perceived body ideal for the genders. The stereotypical strong virile man, for one. "Most people learn to identify with their own strengths (by cultural standards) and to hate, fear, and neglect their own weakness." (p 91, Wendell).
The pain suffer learns to underestimate their pain early on. They learn to hide it from others in order to meet perceived standards. They also discover that no one, not co-workers and not even close family, truly want to hear the stark truth and "learn that most people do not want to know about suffering they experience because of their bodies." (p91, Wendell)
The chronic pain sufferer is constantly seeking meaning to their pain and how to cope. One coping strategy is in fact creating a facade of well being for others to see. However, to deny the effects of pain leads to guilt for failure to meet expectations and this can lead to depression. Pain is not merely a sensation, it is a meaning-giving experience that affects identity, reality, the perception of the body and the lived experience in the world.
Wendell, Susan. The Rejected Body, 1996
Good, Mary-Jo DelVecchio. Pain as the Human Experience. 1992.
Leder, Drew. The Absent Body. 1990