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An enactive approach to pain: beyond the biopsychosocial model

Abstract

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.

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Fig. 1
Fig. 2

Change history

  • 20 May 2019

    The original article unfortunately contains error in footnote 2 due to its double entry and interchanged figures 1 and 2.

Notes

  1. 1.

    Extending Merleau-Ponty’s work, Noë (2009) has argued that perception/consciousness is not something that happens inside us. Instead, it is something that we achieve through action in the world that we are always a part of.

  2. 2.

    Umwelt is the world as it is experienced by a particular organism. As described by Thompson (2007, p. 59) an Umwelt is “… an animal’s environment in the sense of its lived, phenomenal world, the world as it presents itself to that animal thanks to its sensorimotor repertoire.”

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Acknowledgments

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.

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Correspondence to Peter Stilwell.

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The original version of this article was revised due to its double entry of footnote 2 and interchanged figures 1 and 2.

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Stilwell, P., Harman, K. An enactive approach to pain: beyond the biopsychosocial model. Phenom Cogn Sci 18, 637–665 (2019) doi:10.1007/s11097-019-09624-7

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Keywords

  • Biopsychosocial
  • Phenomenology
  • Pain
  • Cognition
  • Embodied
  • Enactivism