Bring focus To The Interaction
It’s been some time since I’ve written a blog post and I’d like to thank the Physio Network for inviting me to contribute.
In this post I’d like to draw attention to some recent publications and potentially a movement in the positive direction that they indicate in the field of pain management.
The first that I’d like to highlight is the submission by Milton Cohen et al proposing an updated definition of pain.1
The new definition is stated as: “Pain is a mutually recognizable somatic experience that reflects a person’s apprehension of threat to their bodily or existential integrity.“
The argument goes that there are multiple issues with the existing IASP pain definition. The paper spells them out in historical context and I would encourage everyone to read the paper in full. For our purposes here, I will focus on the issue of the existing IASP definition privileging the role of the observer. This creates an objectification of pain as something that can and may need be externally validated by another. For my pain to be pain, do you need to be able to agree that I am indeed in pain? The new proposed definition gets around this by describing pain as being mutually recognizable. In other words, the person in pain recognizes that they are in pain, and the observer can also recognize it to the degree that they themselves have experienced pain or can recognize expressions of this experience.
This subtle, or maybe not to subtle, change enables the focus to shift to the “intersubjective” space. This is the space in which we interact with one another and is the workspace of care. One’s pain cannot be shared. All that can be shared is the expression. In turn, what is shared between the person in pain and the clinician lies within the realm of the interaction.
The next work that I’d like to highlight is that of Saulius Geniusas on the phenomenology of pain.2 Phenomenology is defined as those things that are essential to the experience of pain. It is not only descriptive, as in what is it like to be in pain. It is the structural components are essential to the experience of being in pain.
Geniusas states it in the following:
“In short, chronic pain is a rupture that unsettles four of our most fundamental relations:
- the relation between the self and body,
- the person’s self-relation,
- the relation between the self and the surrounding world, and
- the relation between the self and others.
Pain is a de-personalizing experience, in these four fundamental ways.”
Additionally he argues that a re-personalization must also occur in which the individual rebuilds each of these relations within the new context of being in pain.
“besides marking the subject’s withdrawal from the common world, chronic pain also resettles the subject in a new world, which one now needs to inhabit. In short, my claim is that there is no chronic pain, which is not de-personalizing and re-personalizing.”
It is important for me that the ruptures that are described are all of relations or interactions. One does not relate to their own body, the vessel of living, in the same way as before. The do not relate in the same way to themselves with the same confidence in their roles or the view that they have of themselves and how they function in the world or with others.
This fits nicely with the proposed definition of Cohen et al. It lies within the experience that can be expressed in the world to others.
The 3rd work that I’d like to highlight is by Bronwyn Thompson and her research group.3
Bronnie’s qualitative research have focused on gathering descriptions from people who are living well and successfully with chronic pain and have recorded the narratives that the subjects described as being important in that regard.
Several interesting narrative patterns were identified:
- People with chronic pain described their main concern as being a disruption of a sense of self-coherence and a need to re-occupy their sense of self.
- Re-occupying a sense of self was described as a sequential pattern of making sense of the pain, deciding that the benefits of seeking valued occupations were worth the costs, and flexibly persisting through use of occupational engagement and coping.
While Bronnie’s paper is one of theory generation (in other words we don’t know if impacting these patterns through interventions will improve a person’s ability to live successfully with chronic pain) it is important in that it is in line with this idea of a rebuilding of roles of personhood through the relations that have been impacted.
These 3 papers reflect a growing trend towards recognizing the importance of the interactions that occur in the “intersubjective space” as well as a potential shift in the targets of interventions directly toward successful interactions.
I feel that this gives a sharper focus that can often be lacking in the Bio-Psycho-Social framework when the focus is on the often vague or overly broad risk factor reduction, to one of a goal directed focus on specific aspects of impacted interactions.
How might your approach differ when the target of your intervention shifts from a BPS risk factor, like catastrophising or fear avoidant behavior, to an interactive target aimed specifically at an impacted interaction?
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1. Cohen M, Quintner J, van Rysewyk S. Reconsidering the International Association for the Study of Pain definition of pain. PAIN Reports. 3(2):e634, March/April 2018.
2. “Phenomenology of Chronic Pain: De-Personalization and Re-Personalization,” in Simon van Rysewyk (ed.), Meanings of Pain. Dordrecht/New York: Springer, 147-166, 2017.
3. Bronwyn Lennox Thompson, Jeffrey Gage & Ray Kirk (2019): Living well with chronic pain: a classical grounded theory, Disability and Rehabilitation, DOI: 10.1080/09638288.2018.1517195