Rethinking Pain in Person-Centred Health Care

Around Recovery

Stephen Buetow

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000339390
• Edition: 1
• Topic: Sciences sociales
• Subtopic: Études du développement mondial

This book explores how person-centred health care could be refined to help persons alleviate pain-related distress and construct pain as a potentially positive experience. Rethinking Pain in Person-Centred Health Care is a fascinating contribution to the multidisciplinary literature on person-centred health care, pain and ethics.

Traditionally, Western intellectual culture has downplayed the intuitive and emotional, promoting instead rational, natural-scientific perspectives. Applied to pain, an instrumental approach promotes the immediate and effective relief of pain, due to the widespread suffering and expense it can cause. However, different persons experience pain in different ways and Buetow moves beyond a commitment to eliminate pain to exploring how benefits of pain could include creating and managing meaning from pain. Rather than always looking to put pain behind them, persons may flourish by moving around pain, through pain, into pain and above pain. Buetow argues that this model depends on adopting a person-centred approach to health care, focusing less on the condition of pain and more on mobilizing the persons who present with, and manage, pain.

This book will be of interest to professionals and academics/researchers in the fields of psychology and psychiatry who have a special interest in people with persistent pain conditions. It will also be an invaluable resource for physiotherapists, chronic pain consultants in secondary care and GPs.

1 Introduction

It is easy to demonize pain. As a “four-letter word” loaded with negative connotations, pain is widely agreed to be an “unpleasant sensory and emotional experience.” According to the definition of pain revised in 2020 by the International Association for the Study of Pain (IASP), it is a personal experience, “associated with, or resembling that associated with, actual or potential tissue damage.”¹ This experience commonly motivates persons to seek immediate relief through health care they have been enculturated to understand in terms of biomedicine.² Positive connotations of pain appear largely absent from this discourse.³ This book offers a more affirming perspective on “pain,” as shorthand for physical pain.

It suggests how persons can give meaning to pain that, unique to each person, is not necessarily unpleasant. In common with pain, unpleasantness is a sensory and emotional experience whose meaning similarly depends on what it indicates and its inner value. Health care has a pivot role to play in enabling persons to create and manage these constructions of meaning. Its management of meaning is an opportunity for persons to flourish in ways that include moving toward or “around recovery.” The latter movement allows persons to live as fully as possible with pain that is typically unwanted and cannot be relieved.

Around the world, hundreds of millions of persons live daily with horrible pain that often persists and negatively impacts their quality of life. Their predicament speaks to limitations of, and disenchantment with, modern pain management, including epidemics of overtreatment and opioid abuse; undertreatment; and clinician burnout. While the dominant, biomedical gaze can also feel dehumanizing, modern science⁴ is yet to meet public expectations, whose seeds it has sown, to eradicate pain.⁵

However, seeking to eliminate pain does not do justice to the capability and will of persons to create value and meaning from pain and optimize how the pain feels. Person-centred health care could pick up pain management that stumbles on its own treadmill of biomedical reductionism driven by managerialism. Rather than de-illuminate scientific research and evidence-informed practice, this model expands the spotlight to expose more clearly that all human beings require a multidimensional, tailored response to pain that they do not necessarily experience as aversive or a problem to fix. To meet this need, person-centred health care looks to help them create and manage meaning from pain. This support comes from considering equally their moral interests. As moral agents, persons less perceive pain as inherently a problem than conceive of pain as an experience whose nature they construct and to which they can choose how to respond. In a life worth living, they are already intrinsically motivated to move around or even beyond recovery, especially when pain does not “hurt” as defined by a negative experience.

Experiencing pain in different ways in different situations, persons require customized approaches to manage it. Recognizing limits to the need for and capacity of modern science and technology to conquer pain, this book aims to enable persons to (re)frame and utilize pain experience in context-relevant and personally meaningful ways. It looks less to eliminate pain than relationally support health care to harness pain as a creative and energizing source of meaning and flourishing in daily life. With no correct meaning of pain to discover, persons can interpret and bring meaning about in interaction with the world in which they live. An organizing theme of this book is that movement to dislodge pain from meaninglessness characterizes this interaction. For persons in pain, such movement can take place around, into, through and above pain. Person-centred health care coordinates this movement. However, before further introducing this care model, I want to discuss background issues that relate to contemporary constructions of pain and its management, and locate the meaning of pain in the realm of choice and hence taste.

Paradoxes of pain

Millions of persons struggle daily with pain that is thoroughly unpleasant and sometimes “a more terrible lord of mankind (sic) than even death itself.”⁶ No less deniable is the tremendous burden that pain often imposes on families and communities. However, the apparent unpleasantness of pain does not do justice to the maligned “place of pain in the space of good and evil.”⁷ Beyond the importance of the unpleasantness of most acute pain to human survival is the indivisibility of pain from the need to live fully. Not only is pleasure mixed with pain, as inscribed on the 16th-century painting Cupid Complaining to Venus,⁸ but many persons choose to participate in painful activities for pleasure, as a form of personal expression or to maintain the status quo.⁹

These persons willingly pay for this participation¹⁰ (and future pain care for resulting injury). They value living fully above the risk or reality of harm, for reasons including escape into a different world in ways that bring their body back to their attention and enable them to fully appreciate pleasure fully. Moreover, persons dislike pain itself less than lack of choice around the circumstances in which they experience pain. Indeed, they may have an instinct to risk experiencing pain, which is easily satisfied. As 19th-century Russian novelist Fyodor Dostoyevsky added, there will always be something to cause pain and “Man is sometimes, extraordinarily, passionately, in love with suffering; that is a fact.”¹¹ Others, such as Søren Kierkegaard, have noted a similar “desire for what one fears”; but where does this leave the health care professional?

Pain relief has always been at the heart of health care. In Greek mythology, Epione, the wife of the god of medicine, Asclepius, embodied it. Epione was the goddess of the soothing of pain, and her name itself means relief from pain. In their healing spirit, clinicians are taught to relieve patient pain and its negative impacts as primordial objectives of care delivery. Reducing the burden of pain requires them to attend to its type, duration and circumstances, including its source and the response it elicits. Yet, more important than looking to eliminate the sensation of pain is their role in modulating with clarity how pain is contingently enacted. Relief from unwanted pain requires attending to pain as an idiosyncratic, relational experience that grants a range of contextually embedded interpretations, which can include good aspects, in and across persons.

One reason that interpretations vary is that different persons exposed to the same pain stimulus from the same disease or injury report experiencing different levels and qualities of pain under disparate conditions.¹² The same person can experience the same pain stimulation differently over time and across settings, in a manner not corresponding with (neuro)physiological evidence of the state of their body tissues. Regardless of its nature, pain depends then on sensory perception embedded in and set off by embodied interactions of persons with the world. Whilst “pain is an opinion,”¹³ it emerges not only in the brain but also in bodies and the environment as a situated sensory evaluation.

Taste

Flavoured by multisensory signals across social, cultural and historical contexts, pain becomes a self-modulating taste.¹⁴ Acute pain appears to improve physical taste and the potential to experience gustatory pleasure.¹⁵ However, a broader definition of taste goes beyond an ability or faculty to signifying an embodied, aesthetic judgement from patterns of choice over time and settings. The assessment of pain based on feelings depends on the situational hermeneutics of pain as an experience lived through persons being in the world, in which they move within and across private and public spaces. This movement helps to account for differences in sensitivity to and tolerance of pain as an elusive experience that is painful but not necessarily negative under one or more conditions.

The first condition is that in choosing to notice pain as a physical sensation, as raw data processed by sensory receptors, persons resist judging or resisting it. Secondly, persons may choose to experience the pain sensation as affectively neutral or positive, as, for example, when pain feels enlivening. Thirdly, persons may be unaware of experiencing pain despite knowing they are in pain. They may become used to living with pain they do not identify as a source of suffering¹⁶ or, in the acute situation, the pain may accompany emotions that destroy self-awareness.¹⁷ When persons are conscious of pain, they may engage with it as a challenge rather than look to avoid it as a threat.

Persons may work with pain, for example, during childbirth or in religious practices such as flagellation. Despite self-generating and retaining some control over pain in these situations, persons can distil from t...

Table of contents

• Cover
• Half-Title
• Series
• Title
• Copyright
• Dedication
• Contents
• List of illustration
• Acknowledgements
• 1 Introduction
• PART I The need for change
• PART II Person-centredness, meaning and unpleasantness
• PART III Moving forward
• Index