Wilberg on Wednesday - The Illness Is The Cure pt 14/46

The Failure of Biomedicine
to Explain Pain

One of the most common and important aspects of illness that biological medicine can’t explain is pain. The standard biomedical model of pain is called nociception and deals with the neurons that ‘detect’ pain, which are termed ‘nociceptors’. This term is relatively new – in the past one spoke of ‘pain receptors’. This term was abandoned because of its all too obvious questionability. For how can neurons ‘receive’ or respond to pain ‘signals’, when pain as such is essentially a subjective experience. So instead of pain receptors neurologists speak now of nociceptors, a term derived from the Latin noci (meaning ‘hurt’) and emphasise that what these receptors ‘detect’ is not actually pain as we experience it in real life, i.e. subjectively, but actual or potential injury or damage to external or internal tissue and organs.

As for how the actual subjective experience of pain comes about, this is explained by the nociceptors transmitting signals to the brain via the spinal column. The brain then responds by ‘allowing’ or ‘producing’ a subjective experience of pain. Yet how the brain can ‘produce’ a subjective experience of any sort – in this case pain – is left unexplained by this ‘explanation’. Instead, the pseudo-explanation implicit in the old idea of ‘pain receptors’ is simply reversed, i.e. rather than having to explain how a neuron can detect a subjective experience such as pain, what is now left unexplained is how it can create such an experience as a result of tissue damage - particularly given that biology regards bodily tissue itself as basically insentient. The result is that biomedicine now claims that the true ‘source’ of pain is neither localised nerve receptors – nor is it wherever you actually feel pain in your body – but lies precisely where you don’t and cannot feel it – in the brain. Thus the pain you actually feel in your toe after stubbing it, for example, is, according to this model, nothing but a subjective illusion or sensory hallucination created by the brain through a neural mechanism. This standard biomedical ‘explanation’ of pain is maintained despite the fact that:

• 1.  It is counter-intuitive, running contrary to our lived experience of the source and site of pain.
• 2. It offers no explanation at all of how the brain can produce a subjective experience of pain.
• 3. It is premised on the idea that pain is a consequence of physical injury or damage, and so cannot explain why, for example: “…about 65% of soldiers who are severely wounded in battle and 20% … report feeling little or no pain for hours or days.”
• 4. It does not explain why “…no apparent injury can be detected in 70% of people who suffer from chronic low back pain...”¹.
• 5. It does not explain why even the most acute of pains can spontaneously arise and then subside without any identifiable physiological change occurring.
• 6. It does not explain why hypnosis and acupuncture can alleviate or even completely eliminate pain without any pharmaceutical or surgical intervention – even to the point of facilitating entirely pain-free surgery without any use of anaesthetics.
• 7. It does not explain acute, chronic or recurring symptoms of muscle pain (myalgia) or nerve pain (neuralgia) for example in the form of fibromyalgia, or of facial and trigeminal neuralgia – where there is often no evidence of damage to muscle tissue or to the nerves or nerve sheaths.
• 8. It does not explain many forms of common pain – for example particular types of headache with no clearly identifiable physical cause. Seeing them as a result of ‘stress’ does not explain why someone leading a generally stressfully life should experience just one particular type of pain (or any other illness symptom) or why they do so at a particular time or times and not others
• 9. It does not explain the experience of ‘phantom pain’ – pain experienced in the region of amputated limbs where there are no longer any neural pain ‘receptors’ or ‘nociceptors’.

Points 3 and 7 present just a few of many examples in which – contrary to and in a way wholly unexplained by the standard neurological theories of pain – either injury occurs without pain or pain is experienced without injury.

Just as biomedicine seeks to ‘explain’ illness without first of all asking or seeking to ‘explicate’ what ‘illness’ or ‘disease’ essentially is, so also does it seek to ‘explain’ pain without first of all asking the most basic question of all – what essentially is ‘pain’? Yet as Martin Heidegger points out:

“All explanation reaches only so far as the explication of that which is to be explained…” [my stress]

So: “What good is all explaining if what has to be explained remains unclear?”²

Pain is a perfect example of the basic philosophical quandary of biomedicine as such – namely the failure of all its explanations of illness to address and incorporate its lived, subjective dimension, and the chicken-egg question this gives rise to: namely is the felt subjective experience of ‘dis-ease’ (of ‘feeling ill’) a mere effect of ‘being ill’ – of having some ‘objective’ physiological disease or disorder? Or could it be that it is the other way round? This is the essential question that is avoided in biomedical explanations of pain. For whereas in ordinary language we speak of ‘painful’ life experiences or of feeling emotionally ‘pained’, ‘wounded’ or ‘hurt’, biomedical science discards this everyday language of life for neurological terminologies and explanations which seek to reduce pain to an effect of purely ‘physical’ or ‘physiological’ phenomena – yet without any explanation of how the subjective experience of pain arises from them. Indeed simply by turning the pain into an object of scientific or medical explanations, biomedicine implicitly rules out in advance any attempt to explicate the essentially subjective character of pain and instead turns this into a mere ‘secondary’ phenomenon arising from purely ‘objective’ neurological mechanisms.

“The idea of one basis for science and another for life is from the very outset a lie.” Karl Marx

By simply shunting off both painful life experiences and ‘emotional pain’ into a second and entirely separate life domain from bodily pain, the biomedical explanation of pain is classically dualistic – not just separating ‘mind and body’, the ‘psychic’ and the ‘physical’, but also and above all separating life itself from what is claimed to be a true account (logos) or ‘science’ of life (Greek bios) – namely what is called ‘biology’. Then again, by turning pain into an object of biological and neurological explanation however, not only does biomedicine entirely fail to explain its subjective essence, it also ‘shoots itself in the foot’ when it comes to treating pain – so-called ‘pain control’ or ‘pain management’. For not only doctors but also patients tend to turn their own subjective pain into an object – into something they ‘have’. This is unfortunate for the patient, because the bearability of pain and our capacity to live with it depends principally on our capacity to be the pain we experience rather than experiencing as some thing or ‘object’ affecting us.

‘Being the pain’ – becoming it – is the most effective way to stop experiencing it as some sort of bodily entity or object separate from our self and therefore ‘causing’ us to suffer in a way over which we actually have no control at all except through medication. Instead it allows us to identify with the pure awareness of pain – an awareness which is not itself anything painful. Indeed, actively choosing to intensify our awareness of pain – even the most acute pain – can, paradoxically, alleviate pain suffering – as well as releasing insights into its source in our lives (see Case Example 1).

From the perspective of Life Medicine, pain is first and foremost an experience of the subjectively experienced or ‘lived’ body and not the so-called ‘physical’ body or any of its organs, not least the brain. For if the assumptions of ‘brain science’ itself are followed to their logical conclusion, what we perceive from the outside as the human physical body and its internal organs – including the shape and form of the brain itself – is ultimately but a subjective perceptual ‘phantasm’ constructed and projected outwards by the brain. This is the sort of philosophical reductio ad absurdum to which, as Heidegger indicated, ‘reductionist’ brain science ultimately leads – both in general and in relation to pain. For taken to its ultimate conclusion we end up with a worldview in which there is nothing we perceive or experience that can count as real except the brain, even though, paradoxically, our very perception of that organ we call ‘the brain’ is, according to neurological models of perception itself, nothing but a construction of the brain. Despite these philosophical paradoxes we see an increasing flood of media propaganda for so-called ‘brain science’ – a science that identifies who we are as human beings with our brains is evidence for this – and a useful prop for manufacturers of brain-altering drugs, including what can be highly addictive analgesics or ‘pain killers’. The term itself is an interesting one – akin to the term ‘killer cells’ or the notion of ‘fighting illness’. In contrast we have the following words of Seth and of Ivan Illich taken from the appendices of this book.

“… pain and suffering are also obviously vital, living sensations – and therefore are a part of the body’s repertoire of possible feelings and sensual experience. They are also a sign, therefore, of life’s vitality, and are in themselves often responsible for a return to health when they act as learning communications.” Seth (see appendix 6)

“A myriad virtues express the different aspects of fortitude that traditionally enabled people to recognize painful sensations as a challenge and to shape their own experience accordingly. Patience, forbearance, courage, resignation, self-control, perseverance, and meekness each express a different colouring of the responses with which pain sensations were accepted, transformed into the experience of suffering and endured. Duty, love, fascination, routines, prayer, and compassion were some of the means that enabled pain to be borne with dignity.”

“The pupils of Hippocrates distinguished many kinds of disharmony, each of which caused its own type of pain…Pain might disappear in the process of healing, but this was certainly not the primary object of the … treatment. The Greeks did not even think about enjoying happiness without taking pain in their stride … The body had not yet been divorced from the soul, nor had sickness been divorced from pain. All words that indicated bodily pain were equally applicable to the suffering of the soul.” Illich (see appendix 7)

To be sure, the use of ‘pain-relieving’, ‘pain-killing’ or analgesic drugs is a godsend for many people, though most of these (for example aspirin and opiate based drugs such as codeine or morphine) are not modern pharmaceutical inventions but based on natural plant remedies (willow bark or the poppy plant) which have been known about for millennia. Yet the effectiveness of such drugs in itself tells us nothing about the experience of pain, its effect on patients’ lives – or its source in their lives. Pain may, of course, be a direct result of tissue and nerve damage, whether through inflammation, injury or surgery. Yet this does not explain the immense subjective variation in individual pain sensitivity and tolerance.

On the other hand, in the case of headache for example, pain, experienced bodily, may serve to quite literally ‘bring to a head’ painful emotional states and experiences. From the perspective of Life Medicine bodily pain in general almost invariably serves to localise in a more or less acute or chronic way what might otherwise be experienced as a more or less amorphous, unconscious and non-local sense of dis-ease connected with painful life events or experiences. Yet to suggest, as biomedicine does, that some experiences of pain are purely ‘psychogenic’ – implying that they are somehow subjectively ‘imagined’ by the patient just because they have no identifiable anatomical ‘cause’ – is to deny the essentially subjective nature of all sensations of bodily pain, whether we ‘explain’ them biomedically – as produced by the brain – or not.

The complete failure of biomedicine to explain the nature of pain is perhaps one reason why, apart from pain specialists, physicians in general tend to be rather disinterested in the patient’s subjective experience of pain – except as a sign or symptom of disease they can objectively identify or diagnose. It also explains why in medical literature relating to different forms of surgical procedure, one almost never finds so much as a single mention of how patients themselves actually feel after their surgery – even on such a basic level of how much pain they experience and for how long. Thus an operative procedure may, in biomedical terms, be deemed entirely ‘successful’ even if a patient experiences intense pain for weeks, months or even years following surgery – thus totally ignoring the damage that pain itself (and other side effects of biomedical intervention) can inflict on a patient’s life. That is not to say that pain killers will not be liberally prescribed – yet this too is often done without a thought for or mention of their own side effects or addictive properties.

All this fits uneasily with the Hippocratic oath of ‘Do no harm’. In all too many cases, this harm actually begins with the very first consultation with a biomedical physician, if, as is so often the case, the physician completely fails to hear and empathise with the emotional pain which the patient is, in so many cases, simply seeking an attentive and empathic ear for. To find that a physician has ‘no time’ – in all senses of this term – for any subjective or emotional dimension of the patient’s communication having to do with their life outside the consulting room is a form of empathic failure the experience of which is in itself a painful and harmful one. Yet it was only thanks to the pioneering work of Michael Balint ³ – now rarely recalled, recognised or applied – that doctors were introduced to the idea that not only their own clinical training but also their own personal psychological defences may play a crucial role in leading them to completely block or filter out any element of a patient’s communication that might touch a raw or painful emotional ‘nerve’ in their own life and psyche.

Such expressions as ‘touching a raw nerve’, ‘feeling hurt’, or speaking, for example, of a life event or experience as having been ‘painful’ or ‘excruciating’ – far from being merely metaphorical, show us how the everyday language of life offers us a better guide to the essence of pain as such – as pain – than any biomedical ‘explanations’ of it as some purely bodily and neurological process. For such explanations, as we have seen, actually explain nothing about the experience of pain – and in effect reduce it to a sensory hallucination conjured up by the brain – thus making nonsense of ‘scientific’ distinctions between ‘real’ pain on the one hand and so-called ‘phantom’ pain or ‘psychogenic’ pain on the other. Nor do such explanations help us understand many cultural and religious phenomenon, for example how a torturer may be compensating for an inability to feel their own emotional pain by inflicting physical pain on another, or why in certain cultures, ritually self-inflicted pain is not seen merely as some of form of penitential act or ‘self-harm’ but is understood instead as a medium of mystical religious experiencing – connecting the worshipper to the pain of a revered martyr or even that of God himself. Finally current explanations of pain fail to explain the well-attested ability of yogins and fakirs to experience neither bleeding nor any pain at all even whilst piercing their own flesh – or how the use of acupuncture has been proved capable of preventing any experience of pain during surgery, thus eliminating the need for either local or general anaesthetics.

More importantly however, biomedical and physiological approaches to bodily pain deny it any intrinsic meaning or healing purpose. Yet pain can serve many important healing purposes besides ‘nociception’ – registering actual or potential tissue damage.

Examples:

• Allowing painful life experiences and emotional pain – ‘inner pain’ – to be experienced in a more intense bodily way and brought to a focus through painful bodily sensations.
• Allowing an otherwise only vague or dimly experienced sense of dis-ease in one’s life to become more sharply and more acutely felt through the experience of bodily pain.
• Allowing the individual to express and elicit an indirect empathic response to their otherwise unrecognised or unfelt inner pain – their ‘inner scream’ – through such expressions of physical pain as grimacing and groaning, writhing of the body or ‘screaming with pain’.
• Allowing the individual to obtain temporary relief from their inner pain through conventional forms of bodily pain relief.

All these purposes of pain serve to prevent not just the human body but the human being from suffering on-going or further ‘damage’. Conversely, even where pain is related to actual tissue damage, this may be because it is the only way the individual is currently able to more fully experience, express and communicate their inner emotional or existential pain. This is also the reason why some individuals do engage in intentional and conscious self-harm – seeking a temporary sense of release from their inner pain through creating sensations of physical pain. On the other hand, a period of acute physical pain may also occur after the painful life issues behind it have been resolved – offering a sense of final cathartic release from them.

As a result of its failure to explain pain, the most important question never asked by biomedicine is whether the experience of pain can be approached as a form of healing meditation – rather than simply just as a sign of something ‘wrong’ or an object of pharmaceutical medication. So the idea that a form of ‘pain therapy’ may lie in consciously choosing to identify with or even intensify sensations of bodily pain – to give them more attention and awareness rather than less – is never for a moment considered – even though it is in this way alone that we may come to deeper insights into those painful aspects of our lives (and not just our bodies) the experience of bodily pain may itself be an awareness of.

Worse still, if there is no recognition on the part of biomedical physicians for the emotional pain people experience in their lives, who knows just how many times morphine eventually becomes necessary as a substitute for the empathy that is both craved by and denied to patients – and that long before their inner, emotional pain or ‘life pain’ finds expression as bodily pain.

References:

1. Melzack and Wall, The Challenge of Pain, Hardmondsworth: Penguin Books, 1982
2. Heidegger, Martin Zollikon Seminars,
   Northwestern University Press, 2001
3. Balint, Michael The Doctor, His Patient and the Illness Churchill Livingstone, 1957.

Example: a brief case of headache

A patient complained about having a bad headache at the beginning of a session with her therapist and just before she was about to go on holiday with her partner. Asked when the headache had started she reported having woken up feeling fine but then worrying about the holiday. This was because she had promised her partner not to take any work-related books with her, knowing he was afraid that reading them would preoccupy her for too much of their time together.

However, whilst packing before the session she had realised that she really would like to take at least a couple of her books along with her – but also felt bound by the promise she had made to her partner not to do so. In other words it was the inner pain, fear and guilt about a desire whose result might be to hurt her partner that triggered the headache.

When her therapist suggested that she might resolve this relational dilemma by indeed taking a couple of books with her – but at the same time resolving not to get lost in reading them at the expense of spending time with her partner – she immediately realised that this could indeed offer a practical way of reconciling her desire not to hurt or cause pain to her partner with her equally sincere wish to enjoy at least some time reading her books. When she came to a decision in the session to follow this suggestion and to also share and negotiate a new compromise and new promise with her partner she became aware that her headache had totally disappeared.