Belief and Narrative

PAIN DEFINED

© 2005 Museum of Fine Arts, Boston

In William Blake's 1808 illustration to John Milton's Paradise Lost (1667), the archangel Michael expels Adam and Eve from the Garden. Adam steps on a thorn, presumably the first step into a life with pain.

Disagreement can be diminished – if never eliminated – by saying clearly what is meant by the word "pain." While the sportswriter's phrase "agony of defeat" seems clearly hyperbolic, novelist William Styron in his own clinical depression faced a pain that approached the inexpressible. "For myself," he wrote, "the pain is most closely connected to drowning or suffocation – but even these images are off the mark."¹ A certain semantic slippage is native to pain, as Virginia Woolf wrote: "Let a sufferer try to describe a pain in his head to a doctor, and language at once runs dry."² Grids of verbal descriptors have now been validated across cultures in an effort to map language onto pain, but disputes over meaning have marked its history ever since Aristotle classified pain as an emotion.

The International Association for the Study of Pain (IASP) tasked a subcommittee to define pain at its founding in the early 1970s. The committee published its results in 1979. Pain, it reported, is "an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage."³

The IASP definition bears the marks of artful consensus building. It describes pain as both sensory and emotional. The role of the lesion is less than all-determining. Pain, we should note, is not "produced by" but rather "associated with" tissue damage. And damage is not only actual, but also – crucially – potential. The subcommittee then inserts a final variant in a definition already marked by exceptional flexibility. Pain may also include whatever is "described in terms of" tissue damage. Perhaps heartbreaking defeat isn't always or only metaphorical. The IASP definition allows an implicit role for the psyche, for the emotions, and for the cultural networks within which our neurobiology allows us to hurt.

The flexibility of the IASP definition indicates the workings of a quiet revolution. It invokes the traditional Cartesian one-to-one relation between pain and tissue daqmage only for the purpose of reconfiguring the connection as a loose matrix of possibilities. In the 17th century, Descartes devised a stimulus-response model in which the pain impulse runs directly from the site of injury to the brain – as if, in his image, you pulled a rope that rang a bell at the other end. This model of pain has lived on in the popular imagination ever since the invention of clinical medicine.

ALTERING THE SENSATION

In an anti-Cartesian experiment at Baylor College of Medicine, volunteers were told they would receive an electrical shock that might produce pain. The stimulator was in fact set to produce nothing beyond a low humming sound.⁴ The result: 50% of subjects reported pain. The lesson: Ultimately, pain is a subjective experience that does not correlate directly with tissue damage. Nociception, the electrochemical transmission of neural impulses, doubtless possesses qualities that lend themselves to quantitative, objective analysis. The IASP insists, however, that nociception is not identical to pain. Pain, it asserts, is "always subjective" and "always a psychological state."³

Neurosurgeon John Loeser, former IASP president, contends that "the organ responsible for all pain" is the brain. "All sensory phenomena, including nociception," he adds, "can be altered by conscious and unconscious mental activity."⁵The brain that Loeser invokes, moreover, is a conscious, active power looking both inward and outward: inward as it monitors and adjusts neurobiological processes, but also outward as it connects us with the interpersonal world of human culture.

We know from recent studies that ethnicity influences pain.⁶ Gender influences pain.⁷ So do other complex national, religious, and cultural backgrounds. In Japan, for example, chronic lower back pain patients proved to be significantly less impaired – in psychological, social, vocational, and avocational function – than similar patients in America.⁸ Pain, regardless of its source, is as variable across cultures as other experiences with mixed biological and personal significance, from childbearing to disability. As in the case of Adam's misstep re-experienced by generations of Christians who associated pain with their own sins, it is open to the shaping impact of beliefs and even stories.

NARRATIVE AND BELIEF

Stories or narratives are cultural carriers of belief, and beliefs have much to do with pain – especially those regarding cause, control, duration, outcome, and blame. Such beliefs affect not only chronic pain, but also acute pain (even postoperative acute pain). Moreover, personal and cultural beliefs about pain are often linked with strong emotions: anger toward a negligent employer, fear of a catastrophic outcome, hope for financial compensation, and love for a spouse. They can complicate the course of treatment. An accident victim's pain, for example, may be linked with beliefs about cash payouts.⁹

Researchers find that patients function better when they believe they have some control over their pain, when they believe in the value of medical services, when they believe that family members care for them, and when they believe that they are not severely disabled. If you believe that your pain will have a catastrophic outcome, your chances of recovery are worse. Pain beliefs such as the fearful mini-narrative of impending doom that clinicians call "catastrophizing" have been shown to correlate directly with treatment outcomes.¹⁰

Narratives about pain circulate continuously in all cultures. "No pain, no gain" is an American modern mini-narrative: it compresses the story of a protagonist who understands that the road to achievement runs only through hardship. The impact of such stories is less easily measured than beliefs about pain as the precursor of inescapable catastrophes, but their power is no less significant. The new field of narrative psychology focuses explicitly on the "storied" nature of human conduct.

Of course, clinicians and researchers may regard narrative as irrelevant – at best, a time-intensive distraction. This view is rooted less in pragmatic 7-minute-per-patient guidelines than it is in theoretical assumptions dating back to the lesion-centered 19th-century invention of clinical medicine. In dismissing narrative, however, and in reducing it to the status of mere anecdote, medicine has rejected a valuable resource that pain specialists are just beginning to explore.

The reevaluation of narrative within health care today – through innovations such as physician Rita Charon's program in narrative medicine at the College of Physicians and Surgeons at Columbia University – is not a naïve return to pre-scientific vision.¹¹ Narrative does have an important, if underappreciated, place in medicine, from formal case histories to stories swapped around the water cooler. Sociologist Arthur W. Frank in The Wounded Storyteller sees narrative as the sign of a historic shift in medicine. Until roughly 1950, modern medicine was dominated by what Frank calls "the doctor's story": narratives of cure featuring the physician as a hero in the progressive scientific conquest of disease. Post-1950s culture, by contrast, gives new prominence to what Frank calls "the patient's story."¹² Patients construct various types of stories about their illness experiences, from chaos narratives (about lives falling apart) to restitution narratives (about gifts that illness can impart). Although the doctor's story has not vanished, the physician as a superhero seems increasingly archaic in the era of team medicine and malpractice litigation. The story that gets most attention today is the patient's narrative.

Quest narratives bring to the contemporary search for pain relief a legacy as ancient and potent as medieval romance, newly updated with a hot new therapy or pharmaceutical product declared the latest Holy Grail. Stories of confusion feature prominently among chronic pain patients today, as expectations based on the old Cartesian stimulus-response mechanisms repeatedly fail. Chronic lower back pain is often impossible to trace to an organic lesion, such as a prolapsed disk. The narrative that describes pain as a reliable alarm system justifies countless unnecessary surgeries. It cannot, however, begin to explain why the two strongest signs predicting that an American worker will develop chronic back pain are job dissatisfaction and unsatisfactory social relations in the workplace.¹³

CULTURING A NEW UNDERSTANDING

Courtesy of The Wellcome Center for Medical Science

In George Cruickshank's 1818 drawing, "The Gout," theological explanations for pain dwindle to the stature of a comic devil. Here upper-class luxury and gourmandizing self-indulgence are the visible cause of pain, as inexorable as the natural laws that cause a volcano (pictured on the wall) to blow up.

The stories that circulate within cultures instruct us less what to feel and more how to think about pain, and their instructions differ greatly. In the 19th century, England associated gout with the luxurious lifestyles of the aristocracy and idle rich, as reflected in a lithograph by the English satirist George Cruickshank (1792–1878).

The caricatured devil reflects a weakening of theological narratives linking pain with divine punishment, but the well appointed parlor and abundant food (including an exotic pineapple) indicate that pain is now enfolded within a moral narrative in which certain pains are poetically just, a penalty for upper-class indulgence. The class-structured, moralized, indoor culture of Victorian gout contrasts strikingly with the outdoor culture of the remote Sakhalin Ainu people of Japan, who suffer from what they call "bear headaches" (like the heavy steps of a bear), "deer headaches" (like the lighter steps of a deer), and – an affliction that needs no description – "woodpecker headaches."¹⁴ Few Western doctors will ever see a case of bear headache, although they will likely hear stories that attribute headache pain to an urban, multitasked, microchip, dress-for-success lifestyle.

The biology of headaches may be very similar across cultures, but the cultural meanings of headache pain differ greatly in rural Japan and in Victorian England. Knowledge of the complex ways in which cultural beliefs, values, and narratives shape pain is as important as the science of neurons and genetic markers. It constitutes a valuable resource for clinicians in a multicultural environment in which pain is the symptom that most often initiates the doctor-patient visit. It suggests that clinicians might help patients to enhance beneficial beliefs and to identify – and possibly alter – beliefs and narratives that seem to make their pain worse.