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Defining Pain

Hello fellow Pain Geeks!

Welcome to July 2022's theme of Defining Pain.

This is our 2nd time exploring this theme and we are really excited to be covering it again. Last year we explored IASP's definition of pain, the old and the updated version as well as the challenges surrounding the process of bringing forth the definition. If you want to go back and see what we read, you'll find them in our library, under this theme of 'Defining Pain'. 

This time we are going to take a little side-step from defining Pain and look at the definition of suffering.

The definition of suffering, according to Wikipedia:

“Suffering, or pain in a broad sense, may be an experience of unpleasantness and aversion associated with the perception of harm or threat of harm in an individual. Suffering is the basic element that makes up the negative valence of affective phenomena. The opposite of suffering is pleasure or happiness.”

The definition of Pain according to IASP 2020:

“An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”

Both of the papers we look at this month address Eric Cassell’s seminal work on suffering and his construct of suffering as well as some of the critiques that have yet to really be integrated into modern pain research.

Eric Cassell defines suffering as:

“Suffering occurs when an impending destruction of the person is perceived; it continues until the threat of disintegration has passed or until the integrity of the person can be restored in some other manner”.

He adds:

“Most generally, suffering can be defined as the state of severe distress associated with events that threaten the intactness of the person”

Cassell also believed that in order to suffer one must be self-reflective, to create the narrative of suffering. However this is something that has been critiqued as it excludes (some) humans (ex.neonates) and non-humans from the experience if the are unable to self-reflect or construct a narrative.

Stilwell provides us with an interesting critique and a chance to reflect on how we experience things. He says, we have pre-reflective experiences and then reflective experiences, pre-reflective being in the moment, not being analyzed. He also aims to define and differentiate pain-related suffering. 

Pain and suffering seem to be inextricably linked. They are both universal experiences and something we can all relate to to one degree or another. They are both experiences that evoke an array of emotions and behaviours from the experiencer and the observer. 

Like with pain, we often want to believe that our suffering has meaning, is a means to an end, can be a good thing; something to give us depth and perspective. This will often send us down a path of searching, for the reason or the why. This can be especially true during times of great suffering or prolonged suffering. The thing is though, it might have meaning and it might not. Maybe we choose for there to be meaning behind it, or choose for it not to. I think both ways can be helpful or unhelpful, depending on how that functions for us in our lives. 

I have lots of questions when it comes to suffering, like: 

Is suffering a choice?

When someone says suffering is a choice, it can bring up lots of reactions. In some ways it can be seen as linking-in to a neo-liberal agenda. The basis for "individual responsibility" and the "pull-up your bootstraps mentality", that our problems are ours to fix and we have to choose to come out of that space. We know that this can be damaging to people who aren't in a position to help themselves. On the other hand it can be seen as a source of great empowerment. An idea that says we actually have total control over our experiences and that we can generate the experience we want for ourselves. That it is not something external put upon on, but something internally created by us. Suffering could show us where are the most unexpressed and how a change might be in order. This would be a type of meaning of course. 

Is suffering something deserved? Suffering is often seen as something deserved, a sort of moral punishment. If we are not creating it than it's been given to us. 

Is suffering random? Is there no function for suffering?

Is suffering, like pain, so poorly understood, so poorly defined, that it just becomes a minefield for stigmatization. If we understood it better, could treat it, would we give it much thought? Like the way diseases that are better understood become less stigmatized. 

Imagine if we could treat suffering, what would that look like? 

Is suffering normal? Just a part of the human condition, that doesn't need to be changed? If we had no suffering, would we have any happiness?  

Well, as you can see, this is a complicated topic, but very relevant when it comes to working with people in pain who are also suffering. I apologized if I've confused you with my thoughts! I’m really looking forward to reading these papers and seeing how my thoughts to take more shape by the end of this month.

What questions do you have about suffering?

What beliefs do you currently hold? 

 - Christine & the Pain Geeks Team

The readings: 

Humanities Piece: Frida Kahlo: Without Hope

Stilwell, P., Hudon, A., Meldrum, K., Pagé, M.G. and Wideman, T.H. (2021). What is pain-related suffering? Conceptual critiques, key attributes, and outstanding questions. The Journal of Pain. doi:10.1016/j.jpain.2021.11.005. Get Access Here

Bueno-Gómez, N. (2017). Conceptualizing suffering and pain. Philosophy, Ethics, and Humanities in Medicine, 12(1). doi:10.1186/s13010-017-0049-5. Get Access Here 

 

The aim of this paper is operationalize the construct/definition of pain-related suffering. So, this statement tells me that there are many different kinds of suffering and apparently suffering related to pain is something distinct.

Since there is pain-related suffering, than there is certainly suffering unrelated to pain, as well there is pain without suffering. 

I’m thinking about an ankle sprain, something acute, with a high likelihood of recovery within a relatively short period of time. There are certainly people who would suffer with that especially if the ankle sprain is keeping them from activities they love, like a professional athlete with an important game coming up, or perhaps someone who signed up for dance lessons all summer that start the next day. But there will also be a group of people where an ankle sprain, albeit painful for a time, doesn’t interfere with their life really. I suppose they are not suffering.

Is suffering the layer the makes pain a problem for someone? Can you live with persistent pain and not suffer? It makes me think about Professor Bronwyn Thompson's Paper: Living well with Chronic Pain. This paper demonstrates that there are groups people who live well with their pain. They do this by "re-occupying their self", deciding to turn from "patient to person" and "flexibly persisting" in the things they are engaging with in life. 

 Abstract (Stilwell et al. 2021):

Suffering holds a central place within pain research, theory, and practice. However, the construct of pain-related suffering has yet to be operationalized by the International Association for the Study of Pain and is largely underdeveloped. Eric Cassell’s seminal work on suffering serves as a conceptual anchor for the limited pain research that specifically addresses this construct. Yet, important critiques of Cassell’s work have not been integrated within the pain literature. This Focus Article aims to take a preliminary step towards an updated operationalization of pain-related suffering by 1) presenting key attributes of pain-related suffering derived from a synthesis of the literature and 2) highlighting key challenges associated with Cassell’s conceptualization of suffering.

We present 4 key attributes:

1) pain and suffering are inter-related, but distinct experiences,

2) suffering is a subjective experience,

3) the experience of suffering is characterized by a negative affective valence, and

4) disruption to one’s sense of self is an integral part of suffering.

A key outstanding challenge is that suffering is commonly viewed as a self-reflective and future-oriented process, which fails to validate many forms of suffering and marginalizes certain populations. Future research addressing different modes of suffering − with and without self-reflection − are discussed.

 So what exactly is pain-related suffering? I guess we’ll get a clue soon!

- Christine & the Pain Geeks team

Bueno-Gómez from the department of Philosophy, Ethics, and Humanities in Medicine has a paper here that is trying to understand the connection between pain and suffering. She puts forwards definitions in order to help us better grasp the concepts, do better research, and provide better treatment. This is a paper very much in the philosophical method, which will make it a challenge to us non- philosophers. So please, be kind with your self, give yourself time to read this paper and perhaps make a list of words you do not understand to come back to at a later time. 

Here are some terms that I came across, that I will link resources to/provide definitions for to try to ease the burden of complex new material. 

Philosophical Methodology: In its most common sense, philosophical methodology is the field of inquiry studying the methods used to do philosophy. But the term can also refer to the methods themselves. It may be understood in a wide sense as the general study of principles used for theory selection, or in a more narrow sense as the study of ways of conducting one's research and theorizing with the goal of acquiring philosophical knowledge. Philosophical methodology investigates both descriptive issues, such as which methods actually have been used by philosophers, and normative issues, such as which methods should be used or how to do good philosophy. [Wikipedia]

Non-essentialism: non-essentialism in philosophy is the non-belief in an essence (from Latin esse) of any given thing, idea, or metaphysical entity (e.g. God). Non-essentialism might also be defined cataphatically (i.e. affirmatively; see cataphatic theology) as the belief that for any entity, there are no specific traits or ground of being which entities of that kind must possess in order to be considered "that entity." [Wikipedia]

Essentialism: Essentialism is the view that objects have a set of attributes that are necessary to their identity.[Wikipedia

Non-naturalistic: Naturalism presumes that nature is in principle completely knowable. There is in nature a regularity, unity, and wholeness that implies objective laws, without which the pursuit of scientific knowledge would be absurd. Man’s endless search for concrete proofs of his beliefs is seen as a confirmation of naturalistic methodology. [Britannica]

Epistemology: The philosophical theory of knowledge.

Epistemology aims to answer questions such as "What do we know?", "What does it mean to say that we know something?", "What makes justified beliefs justified?", and "How do we know that we know?". [Wikipedia]

Ontological: Ontology is the branch of philosophy that studies concepts such as existence, being, becoming, and reality. It includes the questions of how entities are grouped into basic categories and which of these entities exist on the most fundamental level. Ontology is sometimes referred to as the science of being and belongs to the major branch of philosophy known as metaphysics. [Wikipedia]

Normative concept: Theorists working on metaethics and the nature of normativity typically study goodness, rightness, what ought to be done, etc. In their investigations they employ and consider our actual normative concepts. But the actual concepts of goodness, rightness, and what ought to be done are only some of the possible normative concepts. There are other possible concepts, ascribing different properties. [Source here]

If anyone finds any particularly good resource for understanding the terms above or any other terms they came across while reading this paper, please share them! This will be so helpful! 

 Happy Reading!!

- Christine & the Pain Geeks Team

Frida Kahlo Without Hope

This isn't the first time we've looked at a Frida Kahlo painting here on Pain Geeks. It would be strange not too. She is so on brand, and this month especially on theme. Just the title alone really makes me think... is this a synonym to suffering? Is suffering to be without hope, can you suffer and be hopeful? 

But beyond the title, we see so much. We see a bed-ridden person, stuck, arms "pinned" beneath the sheets, not available for use. 

We see a what looks like a "gluttony" of food, but it's not that. It's not an indulgence or connected to her desires. It was apparently on orders from the doctor, that she must eat. The image of foie gras (also a usual symbol of excessive desire or luxury) comes to mind. But, here she is the duck, being fattened. Forced to eat beyond her desires. And the structure bearing over her to make sure the process stays in place. No escape. Oppressed by an easel no less. 

What I read about this painting was that the sun in the Aztec mythology represents human sacrifice and the moon represents womanhood (Kahlo apparently endured multiple miscarriages).

The steeled, resigned face of Kahlo adds so much to mood of this painting. It seems as though the fight in her has left, she lies without hope.... 

What do you see? 

How does this painting make you feel? 

Let us know here of in the community section! 

 Check out the painting here

 - Christine & the Pain Geeks team

 

 

Resources

Extra readings, videos, podcasts and blogs to help you navigate this theme.