An enactive approach to pain: beyond the biopsychosocial model
We propose a new conceptualization of pain by incorporating advancements made by phenomenologists and cognitive scientists. The biomedical understanding of pain is problematic as it inaccurately endorses a linear relationship between noxious stimuli and pain, and is often dualist or reductionist. From a Cartesian dualist perspective, pain occurs in an immaterial mind. From a reductionist perspective, pain is often considered to be “in the brain.” The biopsychosocial conceptualization of pain has been adopted to combat these problematic views. However, when considering pain research advancements, paired with the work of phenomenologists’ and cognitive scientists’ advanced understanding of perception, the biopsychosocial model is inadequate in many ways. The boundaries between the biological, psychological, and social are artificial, and the model is often applied in a fragmented manner. The model has a limited theoretical foundation, resulting in the perpetuation of dualistic and reductionist beliefs. A new framework may serve to better understand and treat pain. In this paper, we conceptualize pain as a 5E process, arguing that it is: Embodied, Embedded, Enacted, Emotive, and Extended. This perspective is applied using back pain as an exemplar and we explore potential clinical applications. With enactivism at the core of this approach, pain does not reside in a mysterious immaterial mind, nor is it an entity to be found in the blood, brain, or other bodily tissues. Instead, pain is a relational and emergent process of sense-making through a lived body that is inseparable from the world that we shape and that shapes us.
KeywordsBiopsychosocial Phenomenology Pain Cognition Embodied Enactivism
We would like to acknowledge the two anonymous reviewers who worked with us to create a more coherent and rigorous argument. Thanks to the many who discussed these ideas with us, providing feedback and support. The Canadian Chiropractic Guideline Initiative (CCGI) funded clinical research that inspired this work.
Compliance with ethical standards
Conflict of interest
The authors declare that they have no conflict of interest.
- Baggs, E., & Chemero, A. (2018). Radical embodiment in two directions. Synthese, Online. https://doi.org/10.1007/s11229-018-02020-9.
- Bandura, A. (1997). Self-efficacy: The exercise of control. Self-efficacy: The exercise of control. New York: W H Freeman/Times Books/ Henry Holt & Co..Google Scholar
- Bartz, R. (1999). Beyond the biopsychosocial model: New approaches to doctor-patient interactions. The Journal of Family Practice, 48(8), 601–607.Google Scholar
- Benner, P. E. (1994). Interpretive phenomenology: Embodiment, caring, and ethics in health and illness. Thousand Oaks: Sage Publications.Google Scholar
- Bennett, M. R., & Hacker, P. M. S. (2003). Philosophical foundations of neuroscience. Malden: Blackwell Publishing.Google Scholar
- Benning, T. (2015). Limitations of the biopsychosocial model in psychiatry. Advances in Medical Education and Practice, 347. https://doi.org/10.2147/AMEP.S82937.
- Buchbinder, R., van Tulder, M., Öberg, B., Costa, L. M., Woolf, A., Schoene, M., Croft, P., Buchbinder, R., Hartvigsen, J., Cherkin, D., Foster, N. E., Maher, C. G., Underwood, M., van Tulder, M., Anema, J. R., Chou, R., Cohen, S. P., Menezes Costa, L., Croft, P., Ferreira, M., Ferreira, P. H., Fritz, J. M., Genevay, S., Gross, D. P., Hancock, M. J., Hoy, D., Karppinen, J., Koes, B. W., Kongsted, A., Louw, Q., Öberg, B., Peul, W. C., Pransky, G., Schoene, M., Sieper, J., Smeets, R. J., Turner, J. A., & Woolf, A. (2018). Low back pain: A call for action. The Lancet, 391(10137), 2384–2388. https://doi.org/10.1016/S0140-6736(18)30488-4.Google Scholar
- Carel, H. (2016). Phenomenology of illness. New York: Oxford University Press.Google Scholar
- Clark, A. (2016). Surfing uncertainty: Prediction, action, and the embodied mind. New York: Oxford University Press.Google Scholar
- Cohen, M., Quintner, J., & van Rysewyk, S. (2018). Reconsidering the International Association for the Study of Pain definition of pain. Pain Reports, 0, 1. https://doi.org/10.1097/PR9.0000000000000634.
- Colombetti, G. (2010). Enaction, sense-making, and emotion. In J. Stewart, O. Gapenne, & E. Di Paolo (Eds.), Enaction: Towards a new paradigm for cognitive science (pp. 145–164). Cambridge: MIT Press.Google Scholar
- Crick, F. (1995). The astonishing hypothesis: The scientific search for the soul. New York: Simon & Schuster.Google Scholar
- De Jaegher, H., & Di Paolo, E. (2007). Participatory sense-making an enactive approach to social cognition. Phenomenology and the Cognitive Sciences, 6(4), 485–507.Google Scholar
- Descartes, R. (1972). Treatise of man. (Trans. Thomas Steele Hall). Cambridge: Harvard University Press.Google Scholar
- Deyo, R. A., Mirza, S. K., Turner, J. A., & Martin, B. (2009). Overtreating chronic Back pain: Time to Back off? Journal of American Board of Family Medicine, 22(1), 62–68. https://doi.org/10.3122/jabfm.2009.01.080102.Overtreating.Google Scholar
- Gallagher, S. (2017). Enactivist interventions: Rethinking the mind. New York: Oxford University Press.Google Scholar
- Gallagher, S. (2019). Precis: Enactivist interventions. Philosophical Studies (Online First). Oxford University Press. https://doi.org/10.1093/oso/9780198794325.001.0001.
- GBD 2016 DALYs and HALE Collaborators (2017). Global, regional, and national disability-adjusted life-years (DALYs) for 333 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2016: A systematic analysis for the global burden of disease study 2016. The Lancet, 390(10100), 1260–1344. https://doi.org/10.1016/S0140-6736(17)32130-X.
- Gibson, J. J. (1977). Theory of affordances. In I. R. Shaw & J. Bransford (Eds.), Perceiving, acting, and knowing (pp. 67–82). Hillsdale: Erlbaum.Google Scholar
- Honkasalo, M.-L. (1998). Space and embodied experience: Rethinking the body in pain. Body & Society, 4(2), 35–57.Google Scholar
- IASP. (1994). Task force on taxonomy. Classification of chronic pain. Descriptions of chronic pain syndromes and definitions of pain terms.Google Scholar
- Karos, K. (2017). Hell is other people: On the importance of social context in pain research. The European Health Psychologist, 19(1), 290–296.Google Scholar
- Käufer, S., & Chemero, A. (2015). Phenomenology: An introduction. Malden: Polity Press.Google Scholar
- Loeser, J. D. (1980). Perspectives on pain. In P. Turner (Ed.), Clinical pharmacology and therapeutics (pp. 313–316). London: Macmillan.Google Scholar
- Loeser, J.D. (2006). Pain as a disease. In: Handbook of clinical neurology. Amsterdam, Netherlands: Elselvier, pp. 11–20. https://doi.org/10.1016/S0072-9752(06)80006-0.
- Manzotti, R. (2016). No evidence that pain is painful neural process. Animal Sentience, 3(11).Google Scholar
- Martínez-Pernía, D., Huepe, D., Huepe-Artigas, D., Correia, R., García, S., & Beitia, M. (2016). Enactive approach and dual-tasks for the treatment of severe behavioral and cognitive impairment in a person with acquired brain injury: A case study. Frontiers in Psychology, 7, 1–8. https://doi.org/10.3389/fpsyg.2016.01712.Google Scholar
- Martiny, K. (2016). Embodying investigations of cerebral palsy: A case of open cognitive science. Københavns Universitet.Google Scholar
- Maturana, H. R., & Varela, F. G. (1980). Autopoesis and cognition: The realization of the living. Hingham: Reidel Publishing Company.Google Scholar
- Maturana, H. R., & Varela, F. J. (1987/1992). The tree of knowledge: The biological roots of human understanding (Revised ed.). Boston: Shambhala Publications Inc..Google Scholar
- Melzack, R. (2001). Pain and the neuromatrix in the brain. Journal of Dental Education, 65(12), 1378–1382.Google Scholar
- Melzack, R., & Wall, P. (1965). Pain mechanisms: A new theory. Science, 150(3699), 971–979.Google Scholar
- Morris, D. B. (1993). The culture of pain. Los Angeles: University of California Press.Google Scholar
- Moseley, G. L., & Butler, D. S. (2017). Explain pain supercharged: The Clinician’s manual. South Australia: Noigroup Publications.Google Scholar
- Nagasako, E. M., Oaklander, A. L., & Dworkin, R. H. (2003). Congenital insensitivity to pain: An update. Pain, 101(3), 213–219.Google Scholar
- Newen, A., Gallagher, S., & De Bruin, L. (2018). 4E cognition: Historical roots, key concepts, and central issues. In A. Newen, L. De Bruin, & S. Gallagher (Eds.), Oxford Handbook of 4E Cognition (Vol. 1, pp. 1–16). Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198735410.013.1.
- NIH. (2017). National Institutes of Health: Development of a Device to Objectively Measure Pain - Small Business Innovation Research Grant. https://grants.nih.gov/grants/guide/rfa-files/RFA-DA-18-012.html. Accessed 3 December 2017.
- Nijs, J., Apeldoorn, A., Hallegraeff, H., Clark, J., Smeets, R., Malfliet, A., et al. (2015a). Low back pain: Guidelines for the clinical classification of predominant neuropathic, nociceptive, or central sensitization pain. Pain Physician, 18(3), E333–E346.Google Scholar
- Nishigami, T., Wand, B. M., Newport, R., Ratcliffe, N., Themelis, K., Moen, D., et al. (2018). Embodying the illusion of a strong, fit back in people with chronic low back pain. A pilot proof-of-concept study. Musculoskeletal Science and Practice, (July), 1–6. https://doi.org/10.1016/j.msksp.2018.07.002.
- Noë, A. (2004). Action in perception. Cambridge: MIT Press.Google Scholar
- Noë, A. (2009). Out of our heads: Why you are not your brain, and other lessons from the biology of consciousness. New York: Hill and Wang.Google Scholar
- Prinz, J. J. (2004). Gut reactions: A perceptual theory of emotion. New York: Oxford University Press.Google Scholar
- Ratcliffe, M. (2008). Feelings of Being. New York: Oxford University Press. https://doi.org/10.1093/med/9780199206469.001.0001.Google Scholar
- Reid, D. A. (1996). Enactivism as a methodology. Proceedings of the Twentieth Annual Conference of the International Group for the Psychology of Mathematics Education, 4(January 1996), 203–210.Google Scholar
- Rowlands, M. (2010). The new science of the mind. Cambridge: The MIT Press. https://doi.org/10.7551/mitpress/9780262014557.001.0001.Google Scholar
- Ryle, G. (2009). The concept of mind. New York: Routledge.Google Scholar
- Sapolsky, R. M. (2017). Behave: The biology of humans at our best and worst (ebook). New York: Penguin Press.Google Scholar
- Stendera, M. (2015). Being-in-the-world, temporality and Autopoiesis. Parrhesia, 24, 261–284.Google Scholar
- Stilwell, P., & Harman, K. (2017a). Contemporary biopsychosocial exercise prescription for chronic low Back pain: Questioning Core stability programs and considering context. Journal of the Canadian Chiropractic Association, 61(1), 6–17.Google Scholar
- Stilwell, P., & Harman, K. (2017b). ‘I didn’t pay her to teach me how to fix my back’: A focused ethnographic study exploring chiropractors’ and chiropractic patients’ experiences and beliefs regarding exercise adherence. Journal of the Canadian Chiropractic Association, 61(3), 219–230.Google Scholar
- Stilwell, P., Hayden, J. A., Des Rosiers, P., Harman, K., French, S. D., Curran, J. A., & Hefford, W. (2017). A qualitative study of doctors of chiropractic in a Nova Scotian practice-based research network: Barriers and facilitators to the screening and Management of Psychosocial Factors for patients with low Back pain. Journal of Manipulative and Physiological Therapeutics, 41(1), 25–33. https://doi.org/10.1016/j.jmpt.2017.07.014.Google Scholar
- Svenaeus, F. (2001). The phenomenology of health and illness. In S. K. Toombs (Ed.), Handbook of phenomenology and medicine (pp. 87–108). Norwell: Kluwer Academic Publishers.Google Scholar
- Synnott, A., O’Keeffe, M., Bunzli, S., Dankaerts, W., O’Sullivan, P., & O’Sullivan, K. (2015). Physiotherapists may stigmatise or feel unprepared to treat people with low back pain and psychosocial factors that influence recovery: A systematic review. Journal of Physiotherapy, 61(2), 68–76. https://doi.org/10.1016/j.jphys.2015.02.016.Google Scholar
- Thacker, M. (2015). Is pain in the brain? Pain and Rehabilitation - the Journal of Physiotherapy Pain Association, Summer, 201(39), 3–3.Google Scholar
- Thompson, E. 2014. The embodied mind: An interview with Evan Thompson. Fall 2014. https://tricycle.org/magazine/embodied-mind/. Accessed 15 Dec 2017.
- Toombs, S. K. (1990). The meaning of illness: A phenomenological approach to the patient-physician relationship. Rice University.Google Scholar
- van Dieën, J. H., Flor, H., & Hodges, P. W. (2017). Low-Back pain patients learn to adapt motor behavior with adverse secondary consequences. Exercise and Sport Sciences Reviews, Ahead of Print. https://doi.org/10.1249/JES.0000000000000121.
- Varela, F., Thompson, E., & Rosch, E. (1991). The embodied mind: Cognitive science and human experience. Cambridge: MIT Press. https://doi.org/10.1111/j.1468-0149.1965.tb01386.x.Google Scholar
- Vlaeyen, J. W. S., de Jong, J. R., Sieben, J., & Combez, G. (2002). Graded exposure in vivo for pain-related fear. In R. Gatchel & D. C. Turk (Eds.), Psychological approaches to pain management (pp. 210–233). New York: Guilford Press.Google Scholar
- Ward, D., & Stapleton, M. (2012). Es are good: Cognition as enacted, embodied, embedded, affective and extended. In F. Paglieri (Ed.), Consciousness in interaction: The role of the natural and social context in shaping consciousness. Amsterdam: John Benjamins Publishing. https://doi.org/10.1075/aicr.86.06war.Google Scholar
- Whitehead, A. N. (1933). Adventures of ideas. New York: The Free Press.Google Scholar