A vital question is one that can make a significant difference to your understanding, your beliefs, your decisions and ultimately your actions. This affects your quality of life.
At the Understand Pain Workshop I encourage questions. The session is for the attendees to glean as much information and practical know-how as they can. So on being asked a classic pain question, the opportunity presented itself to nail one of the biggest misunderstandings.
Arguably the belief that pain is related to tissue state beyond any other association is the problem. On hearing about the latest knowledge about pain, the person can then find themselves in no man’s land. This is the intellectual point in time when you can be caught between two models, the old and the new. Which do you believe? The old often runs deep. It can feel really uncomfortable too. We are surrounded by the biomedical explanations in the media, with adverts, from those around us and healthcare providers.
So what was the vital question asked at the workshop? It was simply put: is this all in my head? The question came off the back of being presented with the latest thinking and science of pain — not that this is in, or should be considered to be exclusive. In other words, pain science is really a conglomeration of fields of study such as basic neuroscience, cognitive sciences, social psychology, consciousness science and perceptual studies to name but a few. As ever, for science to move forward, we need to ask great questions. This is where contemporary philosophy delivers with the likes of Andy Clarke and Jakob Hohwy amongst others.
To understand pain is to understand being human. Our strengths, our weaknesses, our biases, our attentional scatter, our changeable emotional states, our inability to suffer skilfully (due to society encouraging us to try to avoid something that is unavoidable) and our tendency to live by illusions of the mind instead of reality. Escaping from our bodies is something we learn early in life, as we climb into our minds to avoid turbulent emotions. Who ever gets taught how to face these challenging emotions? Society encourages the exact opposite. The short-term cover ups or fixes.
We will be sure to try to meet our needs for relief. We can do so in a healthy way or an unhealthy way. Lacking any tangible or obvious options, it is understandable why one would reach for something unhealthy: alcohol, cigarettes, drugs, sweet stuff, or another way of trying to feel better in that moment. The problem is that this does not last because the problem has not been addressed. Only by courageously facing and seeking to transform suffering do we experience sustained change in a desired direction.
There are a number of pain facts we can use to help people understand their experience. For example:
- Pain and injury are poorly related
- Pain is related to perception of threat
- Several of the major influences upon a pain experience (and the actions you take) include emotional state and tiredness
- Pain, as with any conscious experience, is the brain’s best guess
- Pain is embodied
- Pain is embedded in society
- What you are focusing upon determines your quality of life
Looking at this list and more, and considering the position of the biomedical model that seeks damage or pathology to explain pain, the gap becomes apparent. Whilst the biomedical model plays a role in identifying such damage and pathology to determine whether a surgical or medical approach is necessary, it does not provide answers to why pain experiences vary so much.
How is it that a paper cut can be so painful? Why can we feel pain in fresh air in the case of phantom limb pain? How does someone run on a broken ankle? How can someone be impaled yet feel no pain? And so on. One simple way to consider pain and injury is by the fact that the former is subjective and cannot be seen, whereas the latter is objective and is usually identifiable. The way that the injury, pathology or lack of observable damage is experienced will depend on context, existing biological state, prior experience, the impact in terms of perceived limitations, expectations, and beliefs about pain and injury. There’s a lot more, but this covers a good amount of ground for now.
Pat Wall (one of the forefathers of modern pain medicine and science) in 1979 and John Loeser (the originator of the biopsychosocial model) in 1982 both described the lack of relationship between pain and injury, so this is not new thinking. It is simply that society has gone with another, simpler and if I am cynical, financially convenient explanation(for many stakeholders — those that treat using the biomedical model & pharmacological companies). Loeser said:
“Physicians and patients usually harbor a concept of pain that involves a linkage between body damage and the pain reported by the patient. This is an inadequate concept that leads both physicians and their patients into unnecessary difficulties in the management of chronic pain.”
On being presented with the seemingly new thinking about pain, some people then make the assumption that the clinician is suggesting it is somehow in their mind or their head. On doing so, they have missed a couple of key points: pain is always embodied and pain is whole person.
Pain is always embodied
Pain can only be experienced in the body, or where the body should exist (and a representation continues to exists in the nervous system) in the case of phantom limb pain. Pain involves the brain, our thinking, our emotions and hence our mind, but it is always felt in the body. It is never imaginary, and anyone who suggests that this is the case does not understand pain.
Pain is whole person
It is the whole person who feels pain, not the body part. If my knee hurts, my knee does not go off to seek help, I do. Much like if I am thirsty, my mouth does not go to get a drink, I do.
Considering that it is the whole person, it follows that how they are in any given moment will impact upon how they experience pain and the choices that they make to relieve their pain. This is why it is vital to treat the person, and not the body part or simply a condition. Oliver Sacks, the great neurologist and writer, said this from the outset. Many other great physicians and clinicians have agreed and achieved results as a consequence. I live by this notion, knowing that to focus on the person and their needs is the way forward. To focus on the pain leads to poor outcomes.
The definitive answer
The answer to the question, ‘is it in my head?’, or, ‘is it in my mind?’ is no. Pain involves many body systems (most of the biology of pain is not where you feel it) gathering information. The brain interprets this sensory data in the light of what has already been and is known before generating a prediction of the most likely causes of that data — a best guess (see a great talk here from Anil Seth). This is both whole person and embodied as explained briefly above. Understanding this is a key step in the right direction, and part of an overall understanding of pain that allows the person to engage fully with the necessary practices, training and actions that permit progression, living and overcoming pain.
On we go as ever.
Please do share this article with fellow clinicians, friends, and others who need to understand pain.