Abstract
Both patients and clinicians frequently report problems around communicating and assessing pain. Patients express dissatisfaction with their doctors and doctors often find exchanges with chronic pain patients difficult and frustrating. This chapter thus asks how we could improve pain communication and thereby enhance outcomes for chronic pain patients. We argue that improving matters will require a better appreciation of the complex meaning of pain terms and of the variability and flexibility in how individuals think about pain.
We start by examining the various accounts of the meaning of pain terms that have been suggested within philosophy and suggest that, while each of the accounts captures something important about our use of pain terms, none is completely satisfactory. We propose that pain terms should be viewed as communicating complex meanings, which may change across different communicative contexts, and this in turn suggests that we should view our ordinary thought about pain as similarly complex. We then sketch what a view taking seriously this variability in meaning and thought might look like, which we call the “polyeidic” view. According to this view, individuals tacitly occupy divergent stances across a range of different dimensions of pain, with one agent, for instance, thinking of pain in a much more “body-centric” kind of way, while another thinks of pain in a much more “mind-centric” way. The polyeidic view attempts to expand the multidimensionality recognised in, e.g., biopsychosocial models in two directions: first, it holds that the standard triumvirate—dividing sensory/cognitive/affective factors—needs to be enriched in order to capture important distinctions within the social and psychological dimensions. Second, the polyeidic view attempts to explain (at least in part) why modulation of experience by these social and psychological factors is possible in the first place. It does so by arguing that because the folk concept of pain is complex, different weightings of the different parts of the concept can modulate pain experience in a variety of ways. Finally, we argue that adopting a polyeidic approach to the meaning of pain would have a range of measurable clinical outcomes.
Clinical Implications: First, by making a subject’s tacit beliefs about pain explicit it will be possible to create a more open, shared space for pain communication (particularly between clinicians and patients) and support a move away from purely quantitative measures of pain towards more discursive pain narratives. Secondly, the polyeidic view might provide a mechanism for predicting who will do well or badly from cognitive interventions for pain management, allowing more efficient use of healthcare resources. Finally, the polyeidic approach might also contribute to the creation of more nuanced cognitive interventions by elucidating the pre-conscious beliefs that influence a subject’s experience of pain.
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Notes
- 1.
Scarry E. The Body in Pain: the making and unmaking of the world. [New York: Oxford University Press. 1985. 400 p.] provides perhaps the most well-known contemporary defence of the view that pain cannot be captured in language.
- 2.
A word of clarification on the discussion that follows: although we will often phrase things in terms of “the meaning of pain terms,” what we are really interested in in this chapter is pain communication. For those familiar with philosophical distinctions, our interest is in pragmatic content (the complete, context-dependent message a speaker conveys by her utterance) rather than purely semantic content (the literal meaning of words and phrases). Thus, we don’t intend to take a stand here on whether the distinctions we draw are ones that are ultimately best modelled as part of the semantics of pain expressions or are rather part of the pragmatics of pain communication. Although this is a crucial question, we don’t have space to pursue it here, so simply set it to one side.
- 3.
Bourke, J. The Story of Pain. [Oxford: Oxford University Press. 2014. 416 p.] rejects this reifying model, where pain is conceptualised as an entity that can be referred to. Instead she argues for an adverbial approach where pain expressions qualify verbs; as she writes (2014: 7) “pain is not an intrinsic quality of raw sensation; it is a way of perceiving an experience”. See also Tye M. Pain and the Adverbial theory. Am Phil Quart 1984;4:319–327.
- 4.
For an overview of the problems with the Millian view per se, see the entry on “Names” in the Stanford Encyclopaedia of Philosophy (https://plato.stanford.edu/entries/names/).
- 5.
Echoes of Wittgenstein’s worry can also be found in Elaine Scarry’s rejection of the referential model for pain terms. As she writes in The Body in Pain: the making and unmaking of the world [New York: Oxford University Press. 1985, p. 162]: “[P]ain is not ‘of’ or ‘for’ anything—it is itself alone. This objectless-ness, the complete absence of referential content, almost prevents it from being rendered in the language.”
- 6.
Perhaps a better option then would be to reject the view of sensation states upon which Wittgenstein’s objections are premised, whereby they are essentially private, hidden states (i.e., that they are what philosophers would term “Cartesian mental states,” from Descartes theory of mind). We won’t explore this option in what follows but note that this may be the kind of move Wittgenstein himself favoured.
- 7.
As the IASP definition of pain notes (https://www.iasp-pain.org/Education/Content.aspx?ItemNumber=1698#Pain), pain is commonly thought of as an experience “associated with actual or potential tissue damage, or described in terms of such damage”. Though, as Aydede M. Defending the IASP definition of pain [Monist 2017; 4: 439–464] points out, this latter point is probably better phrased as being describable in terms of such damage, rather than requiring actual description in these terms.
- 8.
Furthermore, recent work shows that, in certain kinds of hypothetical scenarios, people are willing to use pain terms to describe a target individual even when it is stipulated that the target has not undergone any relevant injury; see Borg E, Harrison R, Stazicker J, Salomons T. Is the folk concept of pain polyeidic? Mind Lang. 2019. Online first: https://doi.org/10.1111/mila.12227.
- 9.
As Clark (p.184) puts it: “what is the sensory resemblance between the intense freezing pain of an almost frozen foot and the diffuse hot pain of a sunburned back?” [Clark, A. Painfulness is not a quale. In: Aydede M, editor. Pain: New Essays on Its Nature and the Methodology of Its Study. Cambridge, MA: MIT Press; 2005; pp. 177–198.]
- 10.
We don’t want to commit here to a view about whether experiential and affective elements can in fact be held apart or must comprise a single dimension.
- 11.
So, for instance, the idea that pain is, on the one hand, a mental state, but also, on the other, a state which has a (non-brain) bodily location when instantiated, seems to involve a prima facie conflict; see Borg E, Harrison R, Stazicker J, Salomons T. Is the folk concept of pain polyeidic? [Mind Lang. 2019. Online first: https://doi.org/10.1111/mila.12227. 2019] §4, for further discussion of this idea.
- 12.
We might perhaps hope that answering questions (1) and (2) could help to provide an account of pain with a rather greater degree of normative force than that currently deployed in nursing, according to McCaffery and Beebe 1989: 7, whereby “Pain is whatever the experiencing person says it is, existing whenever the experiencing person says it does.” [McCaffery M, Beebe A. Pain: clinical manual for nursing practice. St. Louis Missouri: CV Mosby Company. 1989. 353 p.]
- 13.
See also the 3-way definition of pain in Sternbach R. Pain: a psychophysiological analysis. [New York: Academic Press. 1968. 204 p.], the account of pain as “sensation plus affect,” in Szasz T. Pain and Pleasure: a study of bodily feelings [New York: Basic Books. 1975. 372 p.], and Leder’s account of what he calls “the experiential paradoxes of pain”, Leder D. The experiential paradoxes of pain. [J Med Phil. 2016;41:444–60.]
- 14.
The much-debated issue of “fish pain” is relevant here, as a cornerstone of the argument that fish don’t feel pain is that they lack the requisite neural machinery necessary for consciousness and therefore can’t feel pain. An acceptance of this argument by folk would seem to suggest that they hold that consciousness is necessary for pain.
- 15.
- 16.
Kenny DT, Trevorrow T, Heard R, Faunce G. Communicating pain: Do people share an understanding of the meaning of pain descriptors? [Austral Psychol. 2006 Nov 1;41 (3):213–8] found that the pain descriptor that participants rated the highest was “unimaginable”, which problematizes the use of “worst pain imaginable” as the anchor for the upper end of pain scales and raises the possibility that pain is a dimension (like height or cost) that does not have an upper bound.
- 17.
Price et al. [34], however, had no problem asking patients to compare the intensity of the pain generated by a contact thermode with the intensity of chronic back pain.
- 18.
For the outcomes associated with surgical interventions see e.g., Taylor RS, Taylor RJ. The economic impact of failed back surgery syndrome. Brit J Pain. 2012;6:174–181. See also Brox J, Nygaard O, Holm I, Keller A, Ingebrigsten T, Reikeras O. Four-year follow-up of surgical versus non-surgical therapy for chronic low back pain. Ann Rheum Dis. 2010;69:1643–1648. For outcomes associated with long-term opioid medication, see e.g., Chou R, Deyo R, Devine B, Hansen R, Sullivan S, Jarvik JD, et al. The effectiveness and risks of long-term opioid treatment of chronic pain. Evid Rep Tech Assess (Full Rep). 2014;218:1–219. https://www.ncbi.nlm.nih.gov/books/NBK258809/. Also, Dowell M, Haegerich T, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain—United States. JAMA. 2016;315:1624–1645.
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Borg, E., Hansen, N., Salomons, T. (2019). The Meaning of Pain Expressions and Pain Communication. In: van Rysewyk, S. (eds) Meanings of Pain. Springer, Cham. https://doi.org/10.1007/978-3-030-24154-4_14
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