Meanings of Pain edited by Simon van Rysewyk. Springer International Publishing, 2016, 401 pages, £126.50.
Reviewed by Josie Billington (University of Liverpool), Andrew Jones, and James Ledson (The Royal Liverpool and Broadgreen University Hospitals NHS Trust)
In The Illness Narratives (1988), a seminal text for the Medical Humanities, Arthur Kleinman tells the story of Howie, a police lieutenant in his fifties and decorated Korean war veteran – ‘six-foot seven inch, broad-shouldered’ – who has received every available orthodox and alternative treatment for his chronic lower back pain for twenty years. In constant fear that his back will ‘break’, Howie is hyper-vigilant, always waiting for the pain or avoiding making it worse, leading to a self-defeating cycle of fearful vulnerability, withdrawal, isolation and a frustrating anger and hopelessness which is transmitted over time to Howie’s family and physician. ‘Where is the illness?’, Kleinman asks. ‘In the back, all right. But what about its presence in Howie’s sense of self, in his relationship with his wife and mother, in the reactions of his children, in his work setting, in his doctor? The pain is the central idiom of a network of communication and negotiation. In a sense, the network is in pain’:
I am convinced that understanding the meanings of pain and tracing out the dynamics of somatization in the fullness of the life of pain patients will show that there is no such thing as the pain patient. A single ideal treatment for all but a few atypical cases can also be readily shown to be a dangerous myth.
This volume, as its title announces, takes up Kleinman’s concern with the meanings of pain. Emphatically pluralist, not ‘single’ in its outlook, the book incorporates an impressively wide range of disciplines, scientific orientations and research approaches, from neurobiology and psychiatry through psychology (health/cognitive/behavioural) and psychophysics, to philosophy and the humanities.
Divided into four broad sections, the first – perhaps inevitably, given the increasing use of imaging techniques, especially fMRI, to identify a ‘biomarker’ for pain – concerns pain and the brain. Contra the ‘widespread expectation that the field is close to replacing subjective reports of pain with objective measures of brain activity’, Stuart Derbyshire argues that this reduction of pain experience to a pain-brain relationship omits the essential contexts of pain: ‘Part of the trouble arises from treating pain as a private experience when the roots of pain lie in a socially negotiated subjectivity.’ Grant Gillet likewise disputes the standard view of pain ‘as something that goes on “inside” a person’ stressing, instead, the influence on pain experience of cultural stereotypes and practices that ‘shape who we are and how we understand and give an account of ourselves’. Phantom limb pain, for example, might be understood as the psyche’s response not to sensory-motor deprivation itself but to the evaluations and demands associated with that loss. ‘Such demands include the need to cohere with an image-ego – the object we apprehend as we monitor our body states and try to make sense of them – that is liveable with in a world of others.’ The sense made of a damaged or compromised body part, or a place where suffering has been focused, reflects a place in a lived trajectory and the discourses in which that life is immersed. Focusing specifically on ‘The Emotional Perception of Phantom Limb Pain’, Magali Fernández-Salazar, suggests that body-perception may contribute to the development of an emotional and noxious neuro-mental circuit which leads to and intensifies chronic pain. ‘If phantom pain is produced by the mental pain engendered by non-acceptance of the lack of a body part and of the amended body image, then the brain does not cause mental pain; rather, the mind provokes physical chronic pain able to transform neural networks.’
Derbyshire, Gillet and Fernández-Salazar are by no means opposed to neuroscientific exploration of pain which they recognise as currently ‘the most sophisticated investigatory technique’. On the contrary, these contributors welcome neuroscientific findings in the field – the evidence for brain plasticity, the instances of ‘brain-pain’ activity where no pain is suffered by the subject, the lack of a ‘pain centre in the brain’, the evidence for pain being ‘everywhere’ in the sense of activating multiple neuronal groups simultaneously – since these findings are supportive of their broad thesis: that pain, wherever it is felt, involves a complex individualised relation of physical sensation to emotional affect and engages and reflects the whole person as a being tied to experience, learning, environment and culture. As the volume editor puts it, ‘the contributors of the book are united in the view that a better understanding of pain neurobiology is necessary to meet the challenges of pain management’; but neuroscientific explanations are necessarily insufficient and incomplete for leaving out of account the degree to which pain is the outcome of an organism’s dynamic interactions with self and world.
The emphasis of the second and third sections of the book, dealing, respectively, with extant and ongoing qualitative research on pain, and with the ‘moral-philosophical’ meanings of pain, will likely be very familiar to this journal’s readership, given that the predominant philosophical influence is Husserl. ‘The subject of pain is not the body, conceived physiologically, but the person conceived phenomenologically.’ Phenomenological methods have gained currency in chronic pain research precisely in order to address the issue that, as Bustan Smadar puts it, the problem of obtaining a complete picture of the pain sufferer is not methodological merely, and cannot be resolved by a better scaling system for determining and communicating pain levels. The difficulty lies in ‘the evasive and invisible nature of pain’, its continuous intersection with external determinants, and the inexhaustible fluctuations of both pain intensity and its meanings for the sufferer. Chronic pain is a model example of the necessity for emphasising lived experience in medical research and practice, and offers diverse test cases and demonstration of the application of a phenomenological orientation. While specific methods are illustrated – Interpretative Phenomenological Analysis, Experiential Phenomenology – the key value of this section is its reminder of how phenomenology (prioritising inductive thinking over reliance on a priori scientific criteria) can intimately honour first-person individualised suffering while disclosing common patterns or meanings across pain experiences. Saulius Geniusas finds the ‘unmaking’ of the self’s relation to body and world, which has long been recognised as attending chronic pain (Elaine Scarry, 1985), to be inseparable from the reconstitution of those relations which pain disrupts. He identifies the twin processes or de-personalisation and re-personalisation as together forming the ‘essential temporal structures’ of the chronic pain experience. Agustín Serrano de Haro applies Husserl’s account of levels of attention (salient attentional focus, co-attention and inattention) to lived pain, arguing that ‘what is not painful within the current experience, what has another attentional status, is important for determining the scope of pain’. Patient pain assessment scales, limited to classifying the pain experience, omit this complexity and might be complemented, de Haro suggests, ‘on the basis that the intensity of pain always involves a relation with the rest of the field of experience’.
Much of this section and the remainder of the volume is valuably concerned with the implications of the emphasis on lived experience for clinical practice, and particularly on the training of professional carers. Narrative practice is especially important in relation to chronic pain, Ian Edwards argues, for capturing pain’s ‘non-normative realities’ unconstrained by dominant biomedical narratives. Yet, while this approach has become widely accepted in health, ‘the inclination and the skills needed to implement this approach remain much less evident’. Jessie Dezutter, Laura Dewitte and Siebrecht Vanhooren seek to redress the ‘limited attention given to the existential dimension’ in treating chronic pain, especially the loss of coherence consequent upon unemployment, marital problems and social isolation, by encouraging the translation of theoretical frameworks for meaning in life (those of Viktor Frankl and Aaron Antonovsky, for example) to the clinical field. Samantha Bunzli, Anne Smith, Rob Schütze and Peter O’Sullivan, in respect of the epidemic of lower back pain, and Drew Carter in relation to secondary pain affect, are concerned with how ‘making sense’ of one’s pain via informed understanding can amend fear avoidance and catastrophising behaviours and thus disrupt the vicious cycle (disuse, isolation, depression) which magnifies the acuteness of both primary and secondary pain.
The editorial introduction states that, despite the topical arrangement of the book (brain, qualitative research, clinical practice), chapter concerns are interwoven and mutually reinforcing. Certainly, there are rich resonances. Chantal Berna’s interest, quite late in the book, in how spontaneous mental images experienced by patients offer unique insights into qualities of pain experience (‘integrating somatosensory perception, emotion and meaning’) as well as therapeutic potential (via transformative ‘imagery rescripting’), intersects with the focus in early chapters on the psychological power of subjective body-image. This emphasis on pre- or extra-linguistic communication also anticipates Mike Stewart’s later emphasis on working with patient-generated (and often implicit) metaphors within clinical practice to facilitate the reconceptualization of pain. Similarly, there is synergy between John Quintner’s and Milton Cohen’s examination of the dynamics of the clinical encounter by reference to the models of inter-subjectivity proposed by Martin Buber’s ‘I-Thou’ relation and Winnicott’s ‘third space’, and Aurora Meugnot’s and Philip L. Jackson’s fascinating account of the use of virtual reality and intelligent avatars to model interpersonal synchrony and empathic response in exchanges around pain for trainee clinicians. Both in turn look ahead to the chapter by Melita J. Giummarra et al, which considers how vicarious pain experience, while enhancing compassion and motivation to protect and nurture, can produce distressing sensitivity to the suffering of others, ultimately disabling capacity for care by leading to burn-out.
The degree of overlap, however, produces quite a distinct sense of repetition cumulatively, and there seems little awareness on the part of contributors of the degree to which they are often restating positions and orientations already substantially represented elsewhere in the volume. The two chapters which close the book, by virtue of their positioning side by side, are exceptions to this rule: a defence (by Michael Barrot, Eric Salvat and Ipek Yalcin) of the clinical relevance of animal testing in view of new experimental procedures for assessing physiological and emotional pain in animals is pitted against David B. Morris’s challenge to the assumption that animal pain is knowable by humans (however refined the models of experimentation) since animal pain, unmediated by social, personal and cultural meanings, is fundamentally other, non-human. More conscious and explicit dialogue of this kind across chapters might have enlivened the recurrence of ideas and emphases (‘coherence’, ‘meaning’, ‘lived experience’) and worked to shed some repetition (as well as to weed out some typos – proofreading leaves something to be desired across the volume). On the other hand, the commonality of interests among researchers and practitioners who have often begun from very different starting-points, reflects the degree to which there has been a sea-change over recent decades in thinking around chronic pain and its treatment, and the body of work offered by this volume bears admirable testimony to that shift. Yet, given that the book situates itself in relation not only to researcher and clinician demand for recognition of biopsychological approaches to pain, but also to the ‘parallel growth of patient-centred organisations and advocacy groups seeking to integrate patients into research and via alliances and partnerships’, it is notable that the patient’s voice is barely heard in the volume, save in the qualitative studies of Sherrill Snelgrove for example. It is somewhat surprising (albeit useful contrastively), given the volume’s overwhelming emphasis on the fundamental importance of human lived experience, that the volume ends with rodents not people.
It is unlikely that pain specialists will find in this volume perspectives that are entirely new to them. Likewise, those more generally interested in the vexed issue of how lived experience of illness relates to biological explanation of it, will encounter the well-known ‘hard’ problem, as Stuart Derbyshire puts it, of understanding how physicality relates to subjectivity. ‘Trying to read pain subjectivity through objective brain measures attributes impossible features to physics (perspective, memory) and implausible features to subjectivity (having a determined trajectory through time, looking neither backwards nor forwards).’ But this resolutely interdisciplinary book is right to claim the status of being the first report of research in the field that is dedicated to the ‘meanings’ of pain. The editorial introduction states the intended audience to be ‘research scientists, clinicians, patients with pain and caregivers’. It has a deal to offer medical humanities scholars also, as I have suggested, not simply because it seeks to address, via multidisciplinary and multidimensional approaches, the existential aspect of chronic illness that Kleinman was the first to recognise as absent from biological accounts; but because it is open to all that is technologically on offer – including neurobiology – to an understanding of highly personal meanings of chronic pain and how it shapes, or (as Kleinman says) constitutes, is, the individual life.
Those interested in this book and its review might also be interested in the forthcoming special issue of BMJ Medical Humanities, ‘Pain and its Paradoxes’. and this article by Billington, Jones, Ledson, et al, ‘A comparative study of cognitive behavioural therapy and shared reading for chronic pain’.