Pain (2)

Although this page will pick up the threads from Pain (1), I want to mention two comments received already, because they’re relevant to where we go from here.  One was about working with the ideas and assumptions that may be associated with pain, and I shall propose some that I’ve used myself, or supported others in using, and report what happened as a result.  Another interesting comment asked if physical pain and mental pain are different, and in what way.   Both writers seem to acknowledge a physical and a mental component to pain, and to suggest that these two may interact at the level of causation, on the experience of pain, and perhaps figure in its relief.

Although it might be stretching a point to assert that anger, fear or anxiety cause pain, these emotions could well modify our experience of it, lessening it in some cases (as when a badly wounded soldier fights for his life in unarmed combat against an enemy) , or increasing it (as can  happen when the cause of the pain is not obvious to the patient, who fears it may be a sign of impending death).

These and other psychological modifiers I shall explore, albeit not in great detail, and not necessarily as a specialist practitioner in evidence-based pain management techniques.  I therefore welcome other contributors who can challenge, supplement or break new ground in this investigative effort.

*************

In 1970 I emigrated to sub-Saharan Africa (Zambia) on a three year contract in the medical department of a huge American copper-mining consortium.  My job was primarily as a qualified nurse-teacher, but I also had substantial personal hospital nursing experience, including tropical and some emergency medicine and surgery,  gained in UK before setting out for the sub-tropics.  I had never set foot outside the British Isles, however.  I had no knowledge about other countries or cultures, and had earned an examination grade D for “Disgraceful” (Mr “Sniffer” Ellis, my geography teacher) in Geography.

The work involved a lot of hands-on clinical work as well as teaching and I felt reasonably at home in the modern hospital where I was based. This was on the edge of a huge mine “township” where mine employees and their families lived.  Almost all the patients were indigenous African workers and their immediate families.  Most of the nurses were African, though all the doctors were white as were the senior sisters and matrons.

A few months after I started there was a catastrophic underground collapse and flooding in a major section of the mine workings, which were several hundred metres below ground, and full of workers and heavy plant (machinery, earth movers, and giant transporters). About 400 workers were trapped by falling rock along a 1 km long lateral traverse twice as wide and high as a London Underground tunnel.

I was woken in the early hours and summoned to work to help with the recovery and treatment of injured and dead miners.  Within twelve hours, scores of bodies had been raised to the surface, and the hospital was full of crushed and mangled survivors.  The rescue teams were brave, well-trained, and as determined to save the lives of their comrades as miners anywhere in the world.  But the situation was generally ‘organised chaos’.

As I worked with others on the badly injured patients, some devastatingly so,  I was struck by how undemanding the patients seemed to be and,  in the case of patients who weren’t unconscious or anaesthetised,  by their not showing signs of serious physical distress or pain. The same seemed true of the African staff, whose approach to care was not that of the “soothing hand on fevered brow” kind, but brisk, matter-of-fact, and cheerful, whilst observing the simple protocols of African social behaviour.  The concept of ‘sick role’ which is very prevalent in British hospitals even to this day, seemed to be absent.

Professor Michael Gelfand, “one of Africa’s most distinguished medical practitioners”*, founding professor of African medicine at the University of Rhodesia (now Zimbabwe), and author of ‘The Sick African’ (1957) has posited that Africans have ‘a high pain threshold’, meaning that they have a lower susceptibility to pain than white races, the implication being that bantu (negro) races have a coarser and less refined physical and neurological endowment than that of the superior European race, thus lower sensitivity to pain.

This was the received wisdom (amongst white practitioners) at the African hospital where I worked.  I did not believe it then, and Professor Gelfand has himself recanted his opinions (he is now deceased), in the light of his own ethnographic and cultural researches. In my own experience, pain has a different meaning to the African patient than it does to most of us northern Europeans.  Although it may be inconvenient and uncomfortable,  it is generally much less disabling and has fewer emotional correlates (such as fear or anxiety), than it does for non-indigenous people brought up in a different culture.

After the mine accident, men who had endured serious crush injuries or fractures necessitating whole-limb amputations, or major burns, were able to get up from their beds within hours of admission or major surgery without prompting or assistance, to clean their teeth, take themselves to the shower rooms to wash, and to use the toilets unaided.  The level of resilience, self-care and independence was astounding to me.  Little analgesia was required or requested.  This impression I inferred about the meaning and significance of pain for indigenous African people survived my whole experience in Zambia over many years of work there.

However small my justification for a firm conclusion on the matter, I am inclined to think that culture and upbringing is likely to be a key determinant in the human response to pain, alongside psychology.  I confess to not knowing how to proceed with this idea beyond the point stated here.

* Unattributed source, http://en.wikipedia.org/wiki/Michael_Gelfand

About Peter Goble

I am an Englishman aged 77 years, married with 3 adult children. I am retired from professional life which was in mental health and teaching. I have been a (sort of) practising (sort of) Buddhist for about 30 years, and was active in the hospice sector, and more recently served as a Buddhist chaplain specialising (sort of) in mental health. My wife and I now live in north-western France (Normandy).

12 thoughts on “Pain (2)

  1. An interesting story. If responses to pain are so culturally dependent, that suggests that they might be more easily changed with different conditioning than we might assume. Would you agree?

  2. On the broad basis of my experience in Africa, yes I would. But I would qualify that by confessing that most of my experience was that of a white European male health professional observing the behaviour of black African subjects in hospital (and in a health centre I managed and to a lesser extent, in society ‘at large’).

    Those subjects’ behaviour was judged by me as observer to be more tolerant of pain than that of white subjects with comparable injury (or other pain-provoking stimulus) in comparable circumstances.

    The African subjects may well have been experiencing pain as intensely as, or more intensely than, a white Caucasian subject under similar conditions; but may have been better able to conceal their discomfort from me (or each other) than I supposed, and better able to ‘keep calm and carry on’.

    My conclusion may also have been based on an observational error. I might have been oblivious to signs of discomfort that African subjects may manifest as indicators of intense pain, being conditioned to look for other signs (grimaces, groans, restlessness, pallor etc).

    The subjects’ ‘pain-related behaviour’ may well have been modified by my observing them e.g. a wish to ‘save face’.

    Thanks for the question!

  3. I’m interested in pushing you a bit further on this, to see if it has a practical implication for us. Granted the provisionality of your observations, if we assume nevertheless that the indigenous African response to pain is more adequate than the indigenous European response, is there any way we can cultivate any elements of the African response? Or is it too much a product of complex cultural conditions to be imitated in any way?

  4. Having given some thought to your question, two thoughts come to mind. One is the idea that, in my experience, Africans don’t seem to”sweat the small stuff” as much as Europeans. They seem to accept (or perhaps not to notice) the everyday frustrations of a late train, the non-availability of ‘essential’ items of food from a store, or the disappointment of not getting a job. This has been described as ‘fatalism’, but I’m not sure that’s an appropriate attribution. It may be true about pain, for which in the wider African society there are only herbal remedies.

    One thing is pretty sure, African people are much less concerned with clock- and calendar-time. This may have to do with a lack of clock- and calendar literacy.

    For example, the CiBemba word “mailo” (pronounced “mile-oh”) means ‘not today’ i.e. anytime/any day after today; it is usually (mis)translated into English as “tomorrow”, but this is an error, as any Englishman who expects his African cook to return from a day’s leave tomorrow at 0800 in the morning to prepare breakfast has learned to his chagrin.

    “Nomba” (generally translated into English as “now”) actually means at some time in the proximate future. The intensifier “nomba-nomba” implies rather more proximity to the present time that “nomba” i.e. with some mutually acknowledged (but indeterminate) urgency: how much urgency is a matter of contextually implied and inferred meaning, to this particular situation, and considering its specific conditions. Nomba-nomba might be better rendered, “Rather sooner than later”.

    I don’t think these cultural interpretations of time are exclusively African, they probably apply much more widely than I imagine. They are quite precise in their own way, because they have reference to mutually recognised and implicitly acknowledged conditions. They are not in the least ‘casual’, as I’ve come to understand them. They may also have something to do with the uniformity of daylight hours in longitudes near the equator, and a closer sense of the passing of time as judged by the length of shadows, or the position of the sun relative to the horizon. I don’t know.

    Another thought that occurs is the apparent tendency of Africans towards normative behaviour, and their seeming discouragement of too much overt individuation (e.g. possessive attachment to personal belongings; or boastful talk). I learned quickly that, if I talked too much or too loudly in the company of African peers, they would turn aside politely so that I felt ignored, like a querulent child. I learned quickly to moderate my conversational style. Complaining about pain could, in many African contexts, be regarded as childish (if nothing could be done by another person to remedy it). It’s something you have to bear, and learn to manage in your own way. Warmth (application of poultices or compresses), rest, counter-irritation (scratching or abrading) can help, as can ‘cupping’ (a technique I learned as a nurse but which has long since been abandoned – a small glass cup is warmed and applied to the skin; as the air in the cup cools the resultant partial vacuum in the cup causes it to adhere to the skin by suction: this negative pressure helps supply a remote stimulus to nerves which interfere with pain-transmission pathways to the brain). It works for deep pain!

    From the above one might see that language plays an important part in meaning in African culture and social transactions, and is perhaps more nuanced and flexible in African usage than in our own, particularly in matters of precise measurement. I was (gradually) able to adjust to these nuances, more tolerant of what felt were ‘delays’, more open to perceived uncertainty and ambivalence in situations; and better attuned to new and different sources of meaning as they gradually overtook my ‘older’ European ones (i.e. those I had acquired earlier in my acculturation.

    I think I was better able to make those adjustments than many of my European expatriate countereparts were during my years in Africa. I don’t know why that was possible, and I may be wrong about it. I think my re- socialisation through marriage, and a few existential crises I engineered for myself, helped to break down old conditioning to an extent, but it took a long time, and is still ongoing..

    Last word, and more pithily? It’s about how we make judgements, I think. How can we make judgements that take account of the conditions that surround them (and indwell us)?

    It may be about time, not hurrying, or feeling the pressure of time. It may be about not making judgements alone, where to make a judgment with a wider awareness of conditions (in the form of another perspective from another person) might improve it.

    It might be about less individuation (about taking things less ‘personally’), or at least less alienation from others and a less intense sense of being judged by others.

    It’s an interesting train of thought, and I’ll keep at it!

  5. Hi Peter,

    Thank you for these two excellent posts. While I do not have any anecdotes quite as dramatic as that which you describe above, the relief and management of pain (often severe) forms a large part of my daily life working in Theatres, especially when I am looking after patients in the immediate post surgical stage.

    I am always explaining to students how interesting and complex pain can be – it is not just a case of treating with medical interventions (such as Morphine or local anaesthetics). My belief, which I think is backed up by evidence and is certainly my own anecdotal experience, is that the link between psychology and physiology are intertwined in varied and complex ways. Your experience in Africa is fascinating and I am heavily inclined to think that the responses to pain that you encountered would be cultural and not genetic.

    A similar phenomenon that is commonly described in this country relates to the age of the person who is experiencing the pain. This is by no means universal, but there does seem to be some correlation. It seems quite common for younger people to experience (or express) high levels of pain to the same procedure/ intervention that an older person does not – and this is often attributed to being a ‘generational’ effect. The assumption being that people from an older generation grew up during a time when expectations of pain were different, while the younger generations have relatively comfortable lives, with relatively less pain; there is often an expectation that all pain can somehow be eradicated, even after major surgery. As a result, the mere possibility that some pain may be experienced causes significant anxiety, which I also strongly believe has the unfortunate effect of increasing any pain that is subsequently felt.

    In my experience, if somebody is showing significant levels of anxiety (regardless of age) before an operation then there is a very high change that they will experience high levels of pain post operatively – the anticipation of pain seems to create/ increase the levels of pain experienced. A common ‘trick’ when assessing a patients pain is to avoid using the word ‘pain’ and instead ask the patient if they are comfortable. This seems like a bit of a con, but I don’t think that it is. I have witnessed many a time a patient who appears quite comfortable suddenly rolling around in agony once they have heard the word ‘pain’. Some people (health care professionals included) seem to assume that the patient is exaggerating in some way – but in most cases I do not think that this is so. In both cases (expectation of pain and hearing the word ‘pain’) I believe that the levels of pain experienced do increase.

    ‘Managing’ pain, seems to me as much about managing the psychological as it is about managing the physiological – both are important. There has often been a taboo – which I think is slowly being broken down – about discussing the psychological elements of pain. If you explain that pain can be psychosomatic, people (health care workers and patients) can wrongly assume that this means the pain is made up. It isn’t.

    Like everything else pain is an embodied experience and it cannot be separated from our own desires, assumptions, fears and so forth. There are many ways to address this – mindfulness is an obvious, and for many people a very effective, method. I also think that there needs to be more honesty from the medical profession about how far it can reduce pain, which might lead to more realistic expectations from patients. This is happening to a certain degree. Chronic pain management is a good example. 10-15 years ago, if somebody experienced high levels of chronic pain in their arm, which did not respond well to medical interventions, then the doctor would cauterise the nerve, at the level of the shoulder. This would indeed stop the pain, but would render the arm largely useless in the process. Now such action is rarely (if ever) taken. Instead the patient is ‘taught’ to except the pain, and helped to live with it – mindfulness and hypnosis may be employed – but they are also often referred to the mental health services. This would have been unthinkable not that long ago, and while there is still much stigma regarding mental health, it is good to know that somebody can be treated for pain by a psychiatrist without the automatic assumption that they are making it all up.

    I would recommend, for those that have not read it, ‘Teach Us to Sit Still’ by Tim Parks. The blurb goes as such:

    ‘Bedevilled by a crippling condition which nobody could explain or relieve, he confronts hard truths about the relationship between the mind and the body, the hectic modern world and his life as a writer.

    Teach Us To Sit Still is the visceral, thought-provoking and improbably entertaining story of Tim Parks’ quest to overcome ill health’.

    Rich

    1. Thanks, Rich for this very interesting comment, and you’ve updated my rather doddering grasp of modern clinical practice. I agree very much that the psychological aspect of pain, such as various broad perceptions of pain and its place in overall experience, is important in its management. This is something we can develop together in slightly more detail as this topic unfolds. I’m mulling over the content of Pain (3) which will take on board comments that have been made so far, and I’ll appreciate your help in developing it, if you can and want to.

      It’s interesting, isn’t it, that some doctors seem to be quick to take up ‘alternative approaches’ to pain (e.g. psychological techniques and ‘tricks’ like using the word ‘comfortable’ in assessing ‘pain’), and some won’t have any truck with anything that has a hint of ‘alternative’ or ‘ditzy’ to it?

      I’ve noticed that patients tend to fall into two broad categories re pain: there are those for whom pain quickly subsides at a steep gradient and does not persist for long, although it may be intense at first. For those in the other category, although pain loses a little of its initial intensity after a period, it ‘plateaus’ at that level and then persists for a long time, with intervals at which it returns to the original intensity. Have you noticed anything like that in your own practice? It also tends to apply to other intense emotional states like anger, shame, embarrassment etc.

      Can you say a bit more about what anybody expects from a mental health referral of a patient with chronic pain? Is this to exclude concurrent depression, or is there some other line of enquiry or treatment option like CBT?

  6. Great stuff. What about that old chestnut ‘man flu’? Do you think we can draw any broad conclusions there? I tend to be a bit of a wimp myself and and actively seek attention and sympathy when I’m feeling ill.

    1. Hi Barry, I can’t make a case for broad conclusions, but I do like a bit of fussing-over when I’m poorly. At a rough guess, and from my own limited experience, I’d say that 9 out of 10 patients like a bit of TLC when they’re ill, and 1 in 10 are rubbed up the wrong way by fuss. One of the skills of giving TLC (‘Tender Loving Care’) is knowing when it’s time to withdraw it, and how. As a Samaritan and counsellor, I ‘m sure you recognise that scenario, and how it is indeed a matter of fine judgement to carry off well.

      It’s also something of a knack knowing what kind of TLC your client/patient will appreciate, how much, and when. I’m not sure that there’s any formula for making decisions on this, it just comes with experience, and the requisite openness to experience that practice will engender. What do you think? What’s your kind of TLC?

    2. Hi Barry,

      In relation to the experience of pain, I am not convinced that there is much difference between men and women. There are those that think that there is, and the assumption tends to be that Women have a higher pain threshold as a result of being the gender that gives birth. The initial stages after a knee replacement can be very painful – in the absence of a spinal or regional anaesthetic – and both men and women seem to experience and react to this pain in a similar way (in my experience).

      Men can sometimes be more likely to attempt hide pain with bravado (usually unsuccessfully – it’s difficult to supress a wince), where as women seem more inclined to be honest about the pain they are experiencing. However, in the immediate post operative phase most people don’t have the faculties to maintain ‘bravado’ and in this situation the response to pain seems broadly the same regardless of gender.

      It is quite possible that the existence of ‘man-flu’ may be nothing more that a gender stereotype. I am inclined to think that it has little to do with men having lower pain thresholds than women, rather it may be to do with the fact that our need to be nursed/ mothered by our nearest and dearest is greater – again this may just be an unhelpful stereotype.

      Rich

  7. I tended to be more of a sympathiser than an empathiser when it comes to TLC but now I probably empathise more than I sympathise. If we could think of somebody who is in pain on a ledge near the top of a cliff and you are the TLC giver on the cliff top a few feet above. I’ve found that if I sympathise with the person’s pain, saying for example I had awful toothache myself last year, or I lost my dad as well 5 years ago, I feel I sort of get down on the ledge with the person to an extent which is fine to a point, but the focus often turns to you rather than the person in pain who needs the TLC more. If however, you empathise, by really listening , showing concern and trying to understand what the person is going through, it’s almost like you’re leaning down to give them a hand up from the ledge. Sounds a bit corny I know but I think empathising in this way is maybe more helpful and effective.

    1. I’ve always thought of you as an empathiser, Barry.

      Your comment has made me aware of how much I think of TLC as a physical thing: making sure someone feels comfortable, that the light in the room is at the level they would like, that bedding is neither too heavy nor too light, that everything they need is within easy reach, that they are sitting or lying comfortably, not hungry or thirsty; and is there anything else I can do, don’t hesitate to ask, however small (or seemingly big). And the power of presence, and of appropriate touch.

      Working as a healthcare chaplain has made me realise how much I’ve come to rely, as a nurse, on the healing power of touch. Chaplains aren’t allowed to touch people, unless it is ritual touch as in bestowing a blessing. Nurses are losing out on touch in the modern clinical environment: rubber gloves are mandatory so there is scarcely any skin-to-skin contact with patients. The pulse is taken with digital sensors, a clothes-peg-like item attached to a finger and an electronic display.

      Various forms of light massage can have potent effects in relieving pain, and I have long been an ‘intuitive reflexology’ practitioner, and one who has faith of sorts in cranio-sacral massage as a means to integrating energies and promoting health and well-being.

  8. Hi Peter,

    I can certainly see how some people may experience pain intensely with a rapid drop of intensity and other may experience longer periods of slightly reduced pain, but have little experience of this in the longer term. My dealings with patients are invariably short lived – I try to manage the pain as far as is reasonably possible before sending the patient back to the ward, where they receive care on a longer term basis. What I have noticed is that if one is able to ‘break through’ a severe bout of pain then the pain will often plateau out at a more reasonable level – long after the intervention may have stopped being effective.

    The psychological treatments offered to chronic pain sufferers vary and seem to be tailored to each patient. Treatment of depression and anxiety certainly play a part. I imagine that these could be both possible factors in causing pain and the results of long term pain itself – either way they are each commonly associated with chronic pain. Psychological treatments are also provided as a means of helping somebody accept, and live with, existing pain that medical or surgical interventions are unable to treat effectively.

    I have had a quick look at the NHS website, and they have quite a helpful page entitled ‘Living with pain’. Two especially useful links from this page are titled: ‘How to get NHS help for your pain’ and ‘Pain and your emotions’.

    http://www.nhs.uk/Livewell/Pain/Pages/Painhome.aspx
    http://www.nhs.uk/Livewell/Pain/Pages/Longtermpain.aspx

    I would be interested to know what you think.

    Rich
    http://www.nhs.uk/Livewell/Pain/Pages/Emotionaldistress.aspx

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