Thoughts on the privacy of pain – #1

Gordon, also known as “Whipped Peter”, a former enslaved African American man, shows his scarred back at a medical examination, Baton Rouge, Louisiana, on 2nd April, 1863. The scars were the result of whipping during his time as an enslaved person at a Louisiana plantation. (Source: Wikimedia Commons)

A reason for thinking that pain is private – hidden to external observers – is the uncertainty that affects our judgements about the pain of others.

When someone appears to be in pain, it seems self evident that what matters is not the pain behaviour that we observe, but the pain experience that lies ‘behind’ the behaviour. We find it natural to say that ‘pain is private; we infer it only inconclusively from the behaviour.’

We naturally think: first-person experience is certain; third-person observation is uncertain. The person in pain has privileged, or immediate, access to his or her pain. Doubt is excluded in the first-person case.

Is this thinking correct?

Following the philosopher Wittgenstein, doubt in the first-person is excluded, not because pain is a private experience, but because the practice of pain excludes it. In the practice of pain, the individual has the role of expressing pain experiences; these expressions include a diverse range of verbal and non-verbal behaviours. In the swing and play of the practice, we treat these behaviours as authentic. To introduce doubt here would alter the practice of pain; importantly, it would undermine our concept of the person.

In clinical settings, this is reflected in McCaffery’s maxim that “Pain is what the person says it is, and exists whenever he or she says it does.” This brings the person to the fore, and makes patients the authority in their pain experience. This approach to pain assessment is also aligned with the principles of patient advocacy and ethical clinical treatment.

Why can’t a person be wrong about his or her own pain? The reason Wittgenstein proposed is that assigning the individual the role of expressing pain means there is no gap between what the person sincerely says her experience is, and what it really is. If we are trying to determine the effect of pain on a person’s quality of life, it is what the person says, and not anyone else, that is correct.

The point is not that the individual feels pain only she can feel, but that we treat her as a person, and on the basis of her behaviours, including self-report, assign to her particular sensations, thoughts, and moods. The ‘privacy of pain’ reflects not the intrinsic privacy of pain experience, but our practice of pain based on the notion of a person whose behaviours are treated as authentic expressions of pain.

Still, a person’s utterances may only partly signify the complexities of pain experience, and some situations warrant people be careful what they reveal. Some pain behaviour may therefore reflect perceived best interests, and this is contextual. Care-delivery in pain settings can involve a threat to the caregiver, and is conditional on the authenticity of pain behaviour. As observers of pain behaviour, we are sensitive to signs of exaggeration, suppression, or malingering. Thus, fine shades of behaviour are important in the evaluation of ‘what is going on’ in the setting of pain, and lead our relation to each other as persons. The practice of pain does not always connect behaviour and pain experience in a rigid way.

Navigating these complexities can make patient-clinician interactions challenging.

The meaning of coping with chronic pain – video presentation recording

Presented at the International Network for Research into Psychosocial Adjustment to Long-term Conditions (INRePALC)

1st International Online Networking Event
13th–17th September, 2021

Session Description: Let’s discuss what it means to cope with chronic pain – this is not a data presentation. Instead, I attempt to create a sense of enquiry and self-reflection on how to take the meaning of coping with chronic pain and apply it in the clinic. Thinking about what we do, and what the doing represents in the clinic, can be rewarding.

Meanings of cancer-related pain – Australian Pain Society Annual Scientific Meeting, April 2021, Topical Session

Presented and recorded at the Australian Pain Society Annual Scientific Meeting, April 2021 virtual event

Topical Session
3C: Meanings of Cancer-Related Pain
Tuesday, April 20, 2021
11:15 AM – 12:30 PM

Session Description: Cognitive factors are important determinants of cancer-related pain experience. Simon van Rysewyk describes how cancer-related is particularly sensitive to cognitive factors and describes some common cognitions that people with cancer-related pain have and how they influence patient outcomes. Xiangfeng Xu (Renee) presents on the cultural and social factors that influence cancer pain management of Chinese migrants and what culturally congruent strategies may be implemented to improve their pain outcomes. Melanie Lovell compares levels of suffering in people with cancer-related pain versus non-cancer chronic pain, highlighting differential meanings of existential or spiritual distress and mood dysfunction. Lovell outlines management approaches to cancer pain and suffering that are not responsive to analgesia, such as meaning- or peace-centred therapies.

Session Objectives:
At the end of the session, attendees will know:
– Common meanings of cancer-related pain and what meanings influence specific patient outcomes
– Common meanings of suffering in cancer-related pain and the relationship between these meanings and non-cancer chronic pain experience and mood dysfunction
– Effective approaches to diagnosis and management of cancer-related pain symptoms, including interventions based on meaning
– Impact of culture on Chinese migrants’ perspectives and responses to cancer pain and recommendations for clinical practice

Presenter Duties
Chair: Dr Simon van Rysewyk, University of Tasmania
Organiser/Presenter 1: Dr Simon van Rysewyk, University of Tasmania
Presenter 2: Dr Renee Xu, University of Sydney
Presenter 3: Associate Professor Melanie Lovell, University of Sydney

Spiritual Well-Being in People Living with Persistent Non-Cancer and Cancer-Related Pain

7L9A9829

Another excellent paper in the Pain Medicine special issue I guest edited with Melanie Galbraith, John Quintner and Milton Cohen –

Spiritual Well-Being in People Living with Persistent Non-Cancer and Cancer-Related Pain
Melanie Lovell, Mandy Corbett, Skye Dong, Philip Siddall

Existential and spiritual factors are known to play an important role in how people cope with disability and life-threatening illnesses such as …

Source: Spiritual Well-Being in People Living with Persistent Non-Cancer and Cancer-Related Pain

‘Meanings of Cancer-Related Pain’

Sculpture by Fabio Viale

Australian Pain Society Annual Scientific Meeting, April 2021
virtual event

Topical Session
3C: Meanings of Cancer-Related Pain
Tuesday, April 20, 2021
11:15 AM – 12:30 PM

Session Description: Cognitive factors are important determinants of cancer-related pain experience. Simon van Rysewyk describes how cancer-related is particularly sensitive to cognitive factors and describes some common cognitions that people with cancer-related pain have and how they influence patient outcomes. Xiangfeng Xu (Renee) presents on the cultural and social factors that influence cancer pain management of Chinese migrants and what culturally congruent strategies may be implemented to improve their pain outcomes. Melanie Lovell compares levels of suffering in people with cancer-related pain versus non-cancer chronic pain, highlighting differential meanings of existential or spiritual distress and mood dysfunction. Lovell outlines management approaches to cancer pain and suffering that are not responsive to analgesia, such as meaning- or peace-centred therapies.

Session Objectives:
At the end of the session, attendees will know:
– Common meanings of cancer-related pain and what meanings influence specific patient outcomes
– Common meanings of suffering in cancer-related pain and the relationship between these meanings and non-cancer chronic pain experience and mood dysfunction
– Effective approaches to diagnosis and management of cancer-related pain symptoms, including interventions based on meaning
– Impact of culture on Chinese migrants’ perspectives and responses to cancer pain and recommendations for clinical practice

Presenter Duties
Chair: Professor Jane Phillips, University of Technology, Sydney
Organiser/Presenter 1: Dr Simon van Rysewyk, University of Tasmania
Presenter 2: Dr Renee Xu, University of Sydney
Presenter 3: Dr Melanie Lovell, University of Sydney