The reality of pain

Whereas pain had previously been seen as an essential element of the human condition, from the middle of the eighteenth century humanitarians worked to alleviate pain and suffering where possible–especially when that bodily experience was produced or inflicted by various “social evils” (ranging form alcohol to the excesses of the industrial system) or unjust laws.

Ballantyne, T. (2014). Entanglements of Empire: Missionaries, Māori, and the question of the body. Auckland, NZ: Auckland University Press. p. 218

One of the reasons why pain has been so has been so important in defining physiotherapy over the last century is that it is both universal and particular. Pain is experienced by everyone at one time or another, but it is also a phenomenon of infinite variation and granular complexity.

Some aspects of pain can be understood biologically, some as subjective experiences that defy anatomical, physiological and pathological description. Over the years physiotherapists have become adept at understanding the first, and are now starting to embrace the second.

But there is a third dimension to pain that is almost completely ignored, and that is pain as a social construct.

When we talk about the biology or experience of pain, we are saying that the way pain manifests has its roots in our corporeality or cognition. That the body or mind precede the pain experience, and by better understanding the client/patient’s signs and symptoms, we can come closer to understanding its causal mechanisms.

Social constructionism, on the other hand, says that all of these things actually follow on from the way we collectively shape what pain means for us. In other words, the body and mind have no reality that is not already part of a social construct.

Consider Tony Ballantyne’s quote above as an example of this argument.

Ballantyne argues that we can see our modern attitude to pain in the way Western countries turned towards more humane treatment of social ‘deviance’ after the 17th century.

This ‘turn’ gave birth to asylums, hospitals, population surveys, diagnostic testing, rehabilitation, public health, as well as modern policing, town planning, urban sanitation, and a host of other social structures that we take for granted today.

And these institutions were populated by a new class of professional specialists whose job it was to identify social deviance and restore people to the new idea of ‘normal’. (Remember, before the 17th century, ordinary people had no formal status in society, so no idea of ‘normal’ health or wellbeing existed. The idea of the ‘citizen’ was an invention of this period designed to tie people’s newfound rights to their social responsibilities).

One of the most challenging social ‘evils’ of the developing industrial economies of the West was pain, because often it was impossible to connect the experience with an underlying pathology.

The birth of psychology, counselling and psychotherapy can be attributed in part to the need to manage people’s existential pain. But physiotherapy is very much tied to society’s desire to rehabilitate physical pain.

The existence of psychotherapy and physiotherapy prove how deeply social pain is. We know pain is never only subjective or objective, mind or body, but this is the way the professions have learnt to separate it so as to promote their separate professional identities. So the way we think about pain today is very much a function of the way a few elite professions have attempted to codify pain in order to resolve the problem for society.

So physiotherapists look for pain within the body (and, increasingly, in the neurophysiology of cognition – which is still within the body really), while psychotherapists explore its meaning in the unconscious.

It’s important to think just how deeply this idea of pain as a social construct can be, not least because it is a hugely untapped concept in physiotherapy. Take Malcolm Bull’s piece below on the link between poverty, pain, and the recent American election.

“As Davies sees it, the invisible glue that holds these pacts together is physical pain. A third or more of adults in the US and UK report that they are ‘often’ in pain. Most elderly people experience regular pain anyway, but so do the poor, since inequality makes people a lot sicker than they might otherwise be. People in pain don’t have good long or even medium-term judgment: they just want the pain to stop (hence the opioid epidemic). And if it doesn’t go away, they at least want to be able to make sense of it. An injury hurts less when sustained in a battle or a sports game than in a domestic accident, so identifying a common enemy may be as effective an analgesic as anything else. For Davies, the rise of contemporary nationalism is therefore ‘tightly bound up with problems such as physical pain, ageing, chronic illness and a sense of deep pointlessness’. Because the body in pain can be neither fully rational nor at peace, it simultaneously undermines the Cartesian divide between mind and body and the Hobbesian opposition between war and peace, and so threatens the very idea of a rationally chosen, scientifically governed society. Nervous voters make for nervous states”

Bull, M. Can the poor think? London Review of Books, 41(13), 4 July 2019. Source: https://www.lrb.co.uk/v41/n13/malcolm-bull/can-the-poor-think

Whilst it is easy enough to recognise that something like a profession is a socially constructed, abstract concept, it is harder to think of some health problems in the same way. Pain should be easy though, because it the archetypal social construct.

The way we think about it, talk about it, measure it, describe it, and treat it, defines it. These ways give the biology and experience of pain its shape.

Pain eludes simple biological description and attempts to capture its subjectivity, because it is a social construct par excellence.

And the same may be true for all of the biological and experiential ‘truths’ that we think are the basis of physiotherapy.