The English word ‘Pain’ has its roots in the Latin poena meaning ‘punishment, penalty or retribution’. No surprise then that we have created a rich vocabulary based on the metaphor PAIN AS ENEMY. At NOI we believe that optimal linguistic expression of a pain state is as important as optimal movement expression. To achieve this we, amateur linguists, have turned to the world of metaphor research for guidance, in particular Lakoff and Johnson’s work “Metaphors We Live By”(1980). To understand how to use this, we must first understand the notions of primary and secondary metaphors.
IDEAS ARE FOOD, LOVE IS A JOURNEY AND PAIN IS ENEMY
These are primary metaphors (we have adopted the convention of writing PRIMARY METAPHORS in all caps – we’re not yelling at you!). Primary metaphors are concepts that we are not usually aware of, but they powerfully influence our language as the basis for secondary metaphors. For example, from the primary metaphor IDEAS ARE FOOD we have the language (secondary metaphors) my brain is fried, or I’ll stew on that or you pea-brain!
See if you can find some secondary metaphors arising from the primary metaphor LOVE IS A JOURNEY? You don’t think of the primary metaphor LOVE IS A JOURNEY when you may say we are at a crossroad darling, or we have hit a brick wall, but the primary metaphor has certainly influenced your language.
So, from PAIN IS ENEMY we get the secondary metaphors of fight pain, attack of back pain, burning, stabbing, shooting, pain killers, anti-inflammatories, the pain is killing me and so on.
But PAIN IS ENEMY is ever so wrong!
Homo Sapiens got this one wrong. Pain is not enemy; pain protects us. It’s part of what makes us who we are, and tragically we may die an early death if we can’t experience pain. A little bit of pain can even be nice – think of the gratifying ache after a day spent undertaking enjoyable and productive physical activity.
PAIN IS PROTECTOR is better
Pain is protector is a more apt and biologically correct primary metaphor. But the secondary metaphors which run off it are nowhere near as developed and as numerous as those emerging from PAIN IS ENEMY. We do have ‘you can be sore but safe’, ‘your hurts won’t harm you’ and ‘know pain, know gain’ to begin with though. I’ve also suggested ‘pain softener’ instead of ‘painkiller (why kill the thing that protects you?) and a colleague has suggested ‘movement enhancing medicines’ rather than ‘anti-inflammatories’. Nice and much more functional!
PAIN AS INVADER
As a side step from PAIN IS ENEMY, reflect on PAIN AS INVADER with secondary metaphors of like a knife in me, burning inside, deep in there, red-hot poker in my back, and so on. These secondary metaphors need to be heard and acknowledged, and warrant some analysis. A simple, but powerful first step is always to ask ‘what do you mean by…?’. The very nature of metaphors is that they can have different meaning to different people – how you as a therapist interpret like a knife in there might be different to how the patient does. There’s also likely to be benefit to exploring the use of a metaphor with the patient. Again, it’s like a knife in there will have been uttered by the patient many times, and ‘said’ it internally even more. The work of Lakoff and Johnson (1980) would suggest that we can ‘become’ the metaphors we use over and over – is there a more accurate, less threatening, linguistic expression that you could offer a patient to replace the invasive knife? Often just the awareness of their use of the metaphorical knife (remember, primary metaphors can shape our perceptions and actions without us ever being aware of them) might be enough to create some change and reconceptualisation – if the patient updates their own words then so much the better.
But… what a challenge to shift a primary metaphor!
So much of the health industry runs off, and profits from PAIN IS ENEMY. And while promises of quick fixes for acute pain abound, persistent pain states struggle to find resolution. The underlying ENEMY primary metaphor does nothing to help these complex pain states such as persistent post-surgical pain, pain in neurological disease, child or adolescent pain and male and female pelvic pain.
We’ve introduced the idea of primary and secondary metaphors at many talks, presentations and courses, to doctors, surgeons and therapists of all stripes. We’ve also frequently heard from these front line pain clinicians that ‘my patients don’t use language like that’! But, in nearly every case, we’ve received calls or emails from these same clinicians after they return to the clinic and start listening to patients again, often along the lines of ‘all of a sudden, I realised that when a patient is talking about their pain, nearly everything they say is a metaphor … and … I never stop to think about what they might actually mean!’
Reconceptualising pain and changing primary metaphors isn’t easy. But if we start to carefully listen for the secondary metaphors we hear in the clinic, and think about the primary metaphors that might be influencing them, then respectfully offer to explore – with the person – new language, we are making a start.
– David Butler