Explaining pain to patients does not always work out as well as you would expect . There are many reasons why sharing this gift of science may not be effective and identifying the reasons and best clinical practice will take a mountain of clever research. One reason may well involve whether the owner/maker of the pain understands it as a process or an entity. A process is changeable, dynamic and has a start and a finish. An entity is something with an independent existence. I believe many people consider pain an entity, so to them it’s independent of the many things which are agents in the emergence of pain. To them it’s an entity that can be unleashed and can come in and occupy their body, and it attaches itself to them like mistletoe on a tree sucking the life out. They don’t want to own it but the link is too strong. They want you to find the body mistletoe and get rid of it. Some people think of cancer the same way.
An alternative view is that pain is a process. If it was an entity there should be an answer to “where was the pain before you experienced it and where does it go when its gone”? We perhaps think of ourselves as entities and it may be only natural to think of pain as an entity too. Perhaps we could consider ourselves as processes and pain as a process within a process?
I have two questions and I need some help:
- Are you a process or an entity and does it matter? And pain?
- In Explain Pain education, we often try to objectify pain to make sense of it via physical means and physical imagery. In doing this, do we risk making it more of an immovable object, an entity with permanence ?
This blog post links to the recent noinotes
Dear David and Friends,
Fantastic blog. Your thoughts have helped me brought forward some thoughts that I have had about why some patients are able to grasp the concept of pain and others remain stuck in the MRI, the EMG, the x-ray, and the physical diagnosis. I have to say that my medical models of tissue or organ dysfunction ( which I have been trying hard to change) are ones that are still, to a large part, based in entities, i.e.: A disc in the back, a bug attacking my throat, a rogue cell out of control and attacking my body, etc. Where processes are involved, it is in two primary ways: one the entity uses its own or co opts my own processes to attack me; or I marshall my own processes to attack the entity. It is hard do change that model given the consistent and very effective marketing and training models of traditional medicine. I am in a process, hopefully of changing that.
If we think, however, about most of the very serious public health problems facing us ( obesity, metabolic diseases, chronic disability/pain, mental health impairments, etc.), the core source of these are not in some attacking entity, but exist, in most part, in behaviors and beliefs that are self directed by our own processes . If any entity is involved in these destructive processes, they are not internal but external forces that affect those internal processes: cultural norms, taught behaviors, advertising, societal interactions and expectations, etc.
The treatment of entities lend themselves to be easily transferable to another entity ( medication, surgeon, etc.). They lend themselves to an external locus of control. The treatment of processes most likely means that you have to do something about it yourself. You have to marshall your own stores of self discipline, effort, and devotion of time. There has to be a strong internal locus of control that allows you to take charge and belief in your own self efficacy. In those patients who I have seen been successful in managing the process of pain, it has been those who either came with that strong internal locus of control or who with training and education were able to find it. The treatment of any of the public health concerns I mentioned above have not responded well to treatment by entities unless behavioral change (neuroplastic change) has been part of the entity’s program.
Am I an entity or a process? I am both. I am an entity bound up in a lot of processes, some good and some bad.
Another question however is: Is nociception a process or an entity?
Very philosophical question!
Firstly, I would have thought that I am an entity, but then on the other hand I’m a bunch a physiological processes which without I wouldn’t exist so I’m not sure…. I’ve heard in a couple of places (including on Oprah so it must be true!), the idea that we are all “spiritual beings having a human experience” – but then that doesn’t really resolve the question either…
Pain is (if you listen to the IASP anyway) an experience, which by definition is a process….but then my headaches certainly have a “life of their own” so maybe pain is an entity?
I’m not sure there actually is an ‘right’ answer to either of these, or if it even matters… I wonder if what matters most, is how the two match up – or don’t as the case may be….
I’ll try to explain:
1. If someone sees themselves as a entity and pain as an entity, does this lead to a confrontation, the butting of heads, a “coming up against it” a need to defeat or conquer it?
2. If person = entity and pain = process, would this mean its like something has got hold of them, its pushing them around and maybe taking them for a ride?
3. If person = process and pain = entity, would this be a roadblock, something that gets in the way and hinders someone getting where they want to be, like hitting a brick wall?
4. If person = process and so does pain, what happens when the two combine? Does it create an explosion? Does one cancel the other out? Do they lose their sense of identity with it?
It would be really interesting to know which of these 4 ‘categories’ most patients fall into to… Or if different types of pain are viewed as processes (eg: headache) versus entities (eg: sprained ankle)? Is this distinction based in causality (ie: no diagnosis = process, with diagnosis = label/entity) or in time? Maybe it really does take on a ‘life of its own’ when it’s been around a while? Also of interest would be if patients who cope well in the presence of pain tend to be in a different ‘category’ from those who are particularly distressed by it. And can one change category?
I wonder if, in pain education, we might be able to listen for how the person views both themselves and pain and then be really clever with linguistics to help the patient 1) make peace with the pain / 2) learn to go with the flow / 3) find the right way around the problem /4) absorb the issues as needed? (A metaphor for each category)
Could we make sense of pain using process imagery, as well as object imagery, on a case by case basis, depending on what might “undo” the conflict that exists in the patients own unique “object vs process” situation?
A very abstract answer…best read with a clear head and caffeine on board!
I have recently been introduced to the mandala which portrays the way in which all things are interconnected. I have found that Eastern philosophies offer more room for understanding connections and processes – rather that the Western way in which I have been taught. Perhaps embracing the Eastern view of health might enable us to change our own views, and help us with using more creative language to “explain pain”. I have also seen that some patients benefit from the education I provide, while others incorporate it into their already “warped” view of themselves and pain. We need to find a way in which we can really come to grips with how patients view themselves and the world, in order to use appropriate language which makes “sense” in their worlds.
Many thanks. This is helpful as we try to improve the Explain Pain outcomes, even though reconceptualisation of pain currently has the best outcomes for treatment for chronic spinal pain.
For me -I conceptualise myself as a process and so is pain – I guess that is what evolution is all about. If time would freeze I would be an entity. However, someone going through a painful heath experience will meet many entities – the MRI, the diagnosis, the clinic, the pictures on the clinic wall, the insurance company, the money paid, the patient’s view of the health professional, the pills – these are entities and as Louise has suggested above, may act as roadblocks and enhance notions of pain the entity.
And then the fight often starts – as John notes with the use of “attack”. Why attack a process that is part of you (unless it has gone really really crazy). Self discipline, effort and time devotion to get to know yourself and your neighbours seems more appropriate. (Might stop a few wars too!). Perhaps some of the entities met along the way could be reconceptualised as processes. ?Moving towards a mandala.
Thanks for your thoughts David. I agree that Pain is a process, but is nociception? I can perceive it as both. I would like your thoughts.
Hi john, i have been thinking about this while devouring a custard tart. To me it’s a process, an ever changing adapting process to defend the individual and the species. I am not sure of the turnover of TRP channels but it must happen continually and quickly – maybe a day or so.
Then I realised how I teach nociception and how i make it an entity by my words, lecture notes, drawings. I need to update my teaching. I am interested in how you see it as an entity.
I hope that you enjoyed your custard. It is now a spectacular late summer Friday afternoon and I decided to start the weekend early with a beer or two. As a result, your neurological processes may be a little keener than mine.
But I would not go about changing your lectures yet. My thoughts on nociception are similar to those about light: is it a particle or wave? Well light has properties of both. I think that nociception has the same duality. In my mind the production of neural activity due to impending or actual tissue damage is an entity. The receptors in the skin, muscle, etc. that are physically stimulated by ongoing or potential damage are producing an action potential. To me that is quantifiable, reproducible, and observable and would qualify as a physical entity. However, the response generated by that action potential can be highly variable depending on the person, environment, past experiences, etc. What happens after that primary neuron becomes a process with lots of variables that make measurement, reliable reproduction, etc. much more problematical.
Back to my beer. Have a good weekend David. Johnb
Thanks John et al.,
What has been really helpful for me here, a prephilosophical soul, is to realise that this is not semantics, it is important for the content and delivery of educational therapy and these discussions should continue. I have struggled with the recent shifts to consider pain as a disease, which of course makes it an entity and limits the key changeability criteria of a process. I am thinking I can go along with nociception as having both entity and process criteria. It has no start and finish either.
I hope you are aware what a big question you are opening up here for us – pondered upon for thousands of years by the greatest philosophers and other wise seekers – as you are asking us to reflect on our essential identity (who we really are)!
However, I do think the questions you are raising here are very relevant indeed in relation to pain, what it actually ‘is’ and how to relate to it and work with it with our patients – and indeed within ourselves because if we don’t get it, how ever will we be able to embody it and convey it in our work?
Being aware of the danger of my response sounding potentially even more confusing, I believe we need to firstly acknowledge the genuine complexity and depth of this endeavour. My attempt to answer your question is this: “I am both – entity and process”; and pain too is a process that is very much embodied in the person and therefore often experienced as an entity. And yes, it does matter! Why? Because with this approach we are again trying to blow that ‘old friend duality’ right out of the water.
In a specific meditation we use here at Limbus practice with some of my ‘persistent pain patients’ who are sometimes also working with Daniela, a psychotherapist, it says: “I have a body and I am not my body” – which we can also transfer and say: “I have pain and I am not my pain”. This way we are still deeply acknowledging the challenging experience of a patient’s pain whilst helping them not to identify with it. Rather than splitting the answer in two and wanting an ‘either/or’ response to your question ‘is it process or entity?’ I am proposing this: ‘both/and’, meaning: I am and pain is ‘a process embodied’ or ‘an embodied process’, if you like.
In relation to your second question it has been my experience that working with metaphors and imagery works wonderfully well to help my patients to visualize more complex issues around their struggle towards healing and have not found that it contributes negatively in making pain more of an ‘entity’. Of course, if a patient is revealing this kind of thinking, for example by saying he/she is wanting to ‘get rid off the pain’ I will use my understanding ‘to explain Pain’, including illuminating and educating them on what I think it actually is (‘an embodied process’). Therefore I think that even though the use of metaphors might at times support the ‘belief’ that pain can be seen as an entity by the patient, the more important positive effect of using metaphors is that it helps us as practitioners to understand what the patient is experiencing. If the person feels we have truly heard and understood what he has expressed of his suffering and pain through the use of metaphor, we have created a foundation of trust and empathy from which we can then help the patient to shift the belief pattern towards one in which the pain is understood more as an ‘embodied process’ rather than being understood as ‘an entity’.
I am looking forward to your thoughts on this!
Could it be an either/and instead of an either/or type answer or is it possibly a false dichotomy?
Sometimes it’s useful as a clinician to view/describe aspects to the client from one p.o.v -entity/noun and sometimes it’s useful to view/describe it from another p.o.v – process/verb … and sometimes it’s useful to view it from a quality/adjective p.o.v.
When I talk to my client they want to know content (entity (it’s a feature inside of their body)) and context (process (determined by processes inside of their body that rely on structures (which are entities)) but there is also the feature of how I tone (adjective) that discussion and is not the placeboness or noceboness of our communication entangled partially with the content and it’s delivery?
I know the pain is not a qualia concept and agree with it in parts but does everything that is adjective like in nature (neither a process nor an entity) reside under the qualia umbella?
I found this helpful ..Alfred Whitehead 1923 I think …The philosophical idea of misplaced concreteness is very useful http://en.wikipedia.org/wiki/Reification_(fallacy)
Most people in the chronic pain clinic population (that i encounter) are ‘encultured’ into this state and no amount of explaining processes and physiology helps . The practical problems that many people are dealing with are sociological/educational/behavioural/motivational all processes but the thing that keeps many stuck is that this idea of an external concrete thing we/they assume is a mechanical ‘thing’ . Pain feels like the concrete thing that is the problem rather than a defence mechanism that is awry.
In the physio world, I do think this process (link below) and motivational approach has to be a better model to work from than the courses i have just skimmed through at the back of the physio comic .http://www.healthchange.com
Kim Allgood – President – The Purple Bucket Foundation Inc.
Having thoroughly enjoyed every word of the above blog, I feel obligated to add my own thoughts as they come from 20 years of the Chronic Pain ‘process’.
I believe “pain” is an entity and “chronic pain” a process. Pain is felt after injury and surgery, mostly with proper treatment and rest, it goes away with the healing of said injury and or surgery, thus an ‘entity’.
Pain that develops into something more has “become”. Neurological signals and messages passing between the site and brain, have created a ‘process’.
Should the question not be about pain rather than the person being an entity or a process?
Give a pain patient a piece of their favourite cake, or a couple of scoops of ice-cream on a flat plate. Sit beside them with a serving for yourself. The rules are very simple – eat and enjoy, but; no spoons, no forks, and no fingers. Once you’ve devoured your little snack, ask them if they felt any pain while they ate, (neither of you are allowed to clean your face until after the question has been answered) 🙂