An Evolving Problemby Mark Grant MA
Morris (1991, p270)We talk about pain as though we are all talking about the same thing. Yet history reveals pain is different for every person who experiences it, and understood differently in different times and places. For example, if you lived 2000 years BC, you would have lived in a pre-scientific society, dominated by religious thought and you would understand pain within this conceptual framework. You would not think of pain in physical terms so much as spiritual. If you had an affliction you would be more likely to regard it as a punishment from the Gods, best cured with prayer.
But if you lived in 20th century native Africa, you might understand pain in social terms, as a signal that things were not right with your neighbour, or as the product of a spell, and the best treatment might involve making your peace. If you live in a 20th Century industrialized society, you probably understand pain as a signal of physical pathology best treated by a combination of drugs, surgery or other medical interventions. Different eras, different cultures emphasize different aspects of pain. Clearly, our understanding of pain and how we treat it is subject to the ideas and cultural and historical norms of the era and culture in which we live/are situated.
In the west pain is generally agreed-upon as an experience which involves more than just physical sensations. It is now recognised that pain, particularly chronic pain, involves a combination of physical, psychological and neurological factors. also involves psychological factors, ie; thoughts and feelings as well as neurological factors, eg; changes in patterns of neural firing. But this understanding is relatively new, and marks a significant break with tradition; for the last 300 years, up until about 30 years ago, pain was primarily thought of as a physical problem. Where did our modern understanding of pain come from?
We owe our concept of pain to Rene Descartes, who first thought of the body as a machine. As obvious as it seems to us, this idea was quite radical to our forebearers and it paved the way for new ways of thinking about pain and its causes. We can see the basic template for the idea of pain as a signal of physical pathology ('Specificity Theory') in Descartes' 17th century definition of pain:
"Fast moving particles of fire ..the disturbance passes along the nerve filament until it reaches the brain..." Descartes (1664)
Descartes' ideas were part of a trend toward a more scientific approach to understanding human ills. During the renaissance, greater freedom of thought, increased communication (via the invention of the printing press ) and a more secular society, allowed a rational scientific approach to flourish. In the next few hundred years this approach facilitated great advances in understanding and treating pain and disease. Prior to the renaissance, the trend had been to locate the causes of disease outside the body but with the rise of medical science the causes for pain and illness were increasingly understood in terms of physical injury and thus located inside the body.
Although Descartes tends to get blamed for the mind-body split to be fair, its enduring popularity probably stems from a number of factors including the initial success of the scientific method. Western medicine, which is founded on the scientific method, is based on the idea that man can control nature; that this control is possible through knowledge and the belief that the scientific method is the only way of arriving at such knowledge (Worsley, 1997). This world-view has been very successful. It underpins most of the great advances in medicine of the last two or three centuries.
These ideas had direct and practical implications for the treatment of pain. The study of pain focused on looking for the physical mechanisms for pain, consequently scientists spent decades looking for "pain fibres". The treatment of pain also tended to focus on physical interventions such as attempting to interrupt pain pathways. Nerve blocks and cutting nerves was popular. Although these treatments were not effective, the notion that pain could be "fixed" by a surgical procedure persisted (Winston, 1991).
In 1975 the International Association for the Study of Pain, a scientific organization comprised primarily of physicians, and the 'holder of the flame' regarding scientific approaches to pain, felt it necessary to define pain. They defined pain as, "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." This definition tells a story.
Firstly, their definition of pain as in part an emotional experience, marked a departure from traditionally thinking of pain as a physical problem. Secondly just the fact that they needed to define pain reflects that our understanding of pain is an evolving concept. However, despite this pronouncement, old ideas persist. Many people still act as though pain is understandable purely in terms of physical causes, for example, compensation doctors who dismiss pain when the cause cannot be found, or doctors who refuse medication for the same reasons.In summary, how we understand pain is determined by science. Like it or not, science is a product of and determined by culture. Culture changes and is different from one place to another. Pain is thus not a fixed concept in terms of time or space, but an evolving thing.
You might also think about the implications of this: We know that pain involves both physical and psychological discomfort and that in the initial stages, the treatment of pain focuses on attempting to remove the physical causes of pain. However, when treatment fails, suffering increases. Why? Because we understand pain as a sign of physical injury and have been brought up with the idea that if this can be treated, the pain should go away.
As a result of the changes in the conceptualization of pain, changes in its treatment have occurred: most notable has been the rise of Multidisciplinary approach. Treatment of pain involves combination of medical treatment including drugs and surgery, physical therapy, and psychological approaches such as Cognitive Behavioral Group therapy etc. Cutting nerves and pathways was replaced by methods for modulating inputs e.g., relaxation, hypnosis, acupuncture and pain-management aids such as TENS, heat packs etc.
Remember however, that the western world's scientific view of pain is very much a product of one intellectual tradition, which is not necessarily shared by much of the rest of the world. For example:
"The distinction we westerners make between 'physical' and 'mental' illness is not one most people in the world recognize, for they explain even a great deal of individual illness, especially abnormal illness, not in terms of the world of nature, but in terms of supernatural forces. They do not, though, regard all illness as solely due to such forces, rather there is an interdependence between nature, supernatural, society and the person.
(Worsley, 1997 p169)Which is the 'right' way of understanding pain? There is truth in each approach, to some degree, they all are valid. I believe it is more important to think about the implications rather than in terms of right or wrong. To the degree that our theories or ideas are incomplete, inadequate or just plain wrong, our treatments will be of limited efficacy. Thus, while indigenous approaches are recognised as effective with some kinds of pain, they recognise that Western medicine is ineffective with psychosomatic pain (Worseley, p226)
Despite changing conceptualization and more sophisticated treatments, and the fact that an estimated 90% of chronic pain can be controlled with existing treatments ( e.g., Salerno & Willens, 1996) chronic pain remains a huge problem; it is estimated that in the USA one family in three contains someone suffering from pain, chronic pain sufferers are two to ten times more likely to commit suicide, the economic costs associated with unrelieved pain run into the billions. (Bolund, Marzuk, Fox, Fishbain et al 1991). A recent editorial in the clinical journal of pain, described chronic pain as "a medical and social emergency." (Wilson 1996).
David Morris, a social anthropologist, has also argued that chronic pain represents an immense invisible crisis at the centre of contemporary life (in the west). Morris believes that this crisis is due in part to the limited view of pain handed down by traditional medicine (Morris, 1991, p 5).
This information is provided by Mark Grant to assist you to participate actively in your treatment and cope with chronic pain in the best way possible.
Mark Grant is a psychologist, specializing in the management of chronic pain and trauma. His advice is based on many years of clinical experience working with persons affected by chronic pain and trauma.
Mark has also conducted research regarding a multi-modal approach to pain management. He is the author of two self-help tapes which use accelerated learning principles for sufferers of chronic pain and stress: Calm and Confident based on EMDR and Pain Control, based on EMDR. He has also spoken at numerous international conferences and workshops about pain management.
