A commentator recently opined that: “For the record, it has long been known that people can see their pain either as a threat or as a challenge. Our role as clinicians is to encourage the latter” and as often happens I started pondering.
Living with persisting pain for most of my adult life, along with working clinically in this area, and now researching and teaching clinicians about pain, I have a really broad view of pain from various lenses. One of the lenses is my own experience. Pain is defined as ‘unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’ (IASP) – note that pain is always ‘unpleasant’ and ‘sensory’ and ’emotional’. Always.
Pain is emotional
Emotions are a pretty useful part of human experience. Philosophers characterise three ways we’ve theorised about emotions: “The Feeling Tradition takes the way emotions feel to be their most essential characteristic, and defines emotions as distinctive conscious experiences. The Evaluative Tradition regards the way emotions construe the world as primary, and defines emotions as being (or involving) distinctive evaluations of the eliciting circumstances. The Motivational Tradition defines emotions as distinctive motivational states.” (from Stanford Encyclopedia of Philosophy). In other words, the way we conceptualise emotions can lead us to think of them as feelings, judgements or motivations. The unpleasantness element of pain typically means we’d consider the emotional aspect of pain to be one we’d like to avoid or withdraw from. But of course we have plenty of examples of people who willingly and regularly do things that hurt – think runners, boxers, people lifting heavy weights, cold water swimmers… oh and even more commonplace, people eating hot chilli!
A challenge?
Pain can therefore be both unpleasant in sensory and emotional terms, and yet not something we inevitably seek to avoid. For those people who do painful things, is the pain they’re experiencing a threat? Clearly not, or they’d probably stop doing them. Is pain a challenge? hmmmm, let’s take a look at that.
The Cambridge Dictionary defines challenge these ways (click) – I’ll take the top two.
1. (the situation of being faced with) something that needs great mental or physical effort in order to be done successfully and therefore tests a person’s ability:
2. an invitation to compete or take part, especially in a game or argument:
This might be the sense in which ‘challenge’ is being used in the quote above from this commentator. Being faced with something that needs great mental or physical effort – but the arguable part might be in the second part of this definition: ‘in order to be done successfully’ – What does success look like? Who is defining success? Is it person with pain or a clinician or a researcher…? People who do hard core sports (or eat chillis) might view their pain as a ‘challenge’ – or not.
I’m also puzzled by the second sense of challenge – ‘an invitation to take part’ – because, like it or not, when you have pain you’re ‘taking part’ – there’s not much choice in the matter. The question that comes to my mind is ‘what am I taking part in?’ My life? Your treatment?
Are there really only two options when it comes to living with pain? Do we either treat our experience of pain as if it’s a threat, or it’s a challenge? Nothing else?
I think there is another alternative – and possibly more, besides, but for now let’s look at just the one. That third alternative is to treat pain as neither a threat nor a challenge, but simply as an unpleasant sensory and emotional experience that is present.
A little like growing older – that’s not a threat, nor a challenge, it just is what it is: aging. I’m not threatened by getting older, it’s definitely different for me from when I was a young woman (in so many good ways as well as not so good!). Aging beats the alternative! Aging is also not a challenge – after all, who wins at aging? Aging is what it is. A process of change over time.
Implications of ‘threat’ or ‘challenge’ dichotomy
If we think of pain as a threat, we end up doing a lot of things to avoid or get rid of it. After all, it’s scary and might limit our autonomy. It might mean the end of life as we know it. At the same time, if we think of pain as a challenge, we might end up spending a lot of time trying to overcome it, maybe to get rid of it or ‘do’ life in spite of it – almost as if we can pretend pain isn’t there, or try to confront or control pain so it doesn’t interfere with our life the way we think it should go.
An analogy: aging
Lots of people take the same approach to aging. They’re scared of it, so try to avoid any signs of aging – spending inordinate amounts of time and money chasing ‘age-denying’ treatments to stay ‘young.’ Others attempt to meet aging as a challenge – “I’m not going to be that old person, so I’m going to do X, Y, Z” – and this approach can look a lot like the things people do if age is seen as a threat. Even if the ‘challenge’-orientation has a bit more of a positive spin to it, the process of ‘overcoming the challenge’ takes loads of energy, time, and commitment, and yet we still end up old. Or dead.
Curiosity
I like the idea of being an old wise woman. I might not be very wise, but I do like the idea of being curious about aging. Respecting the accumulation of knowledge, experiences, trial and error learning, successes and failures, and being curious about what’s happening in my body, to my body, to my place on this earth. I’m being curious about the way wrinkles are forming, how the cataracts I’ve developed have come about, the way I make choices about where I will and where I won’t put my time and energy. What I care about, and what I no longer care for. Aging isn’t a threat, or a challenge, it’s a process of being.
Similarly, after a life living with pain, pain for me is a lot about being curious about what’s going on. How it feels. Where I feel it. How it’s changing over time. I’m curious about how I relate to my pain as I get older. I’m fascinated by the many different ways I’ve found to live alongside aching, burning, pressing, gnawing, flickering and always unpleasant pain. I have no idea about what life might have been like without pain. I think I’m living a really good life doing things that align with what matters to me. I don’t treat my pain as either a threat or a challenge because it simply is what it is. There are times I make allowances for my pain in my life because I will experience a flare-up. There are other times when I don’t bother because the things I want to do mean more to me than the flare-up. In both situations, pain is just there doing what it does. And, just like my changing capabilities as I get older, there are times I’m frustrated at not being able to do what I want to – like having to wear glasses to see! I adapt to wearing glasses and accept they’ll fog up when I open my oven door; I adapt to my pain being more intense after traveling from NZ to the UK (FWIW that’s 36 hours including transit times), because I want to get to the UK to have a holiday. Controlling or avoiding pain would get in the way of doing that travel.
Should I, as a clinician, encourage people with pain to view their pain as a challenge? I’m not convinced I should. I’d rather help people figure out ways to do what matters to them, in all the myriad ways those values-based actions can be expressed. Looking to the pragmatics of workability: is what this person is doing helping move them towards the things that matter in their life, or not? For some, where a treatment reduces pain, this might be the very thing. For others, like those with fibromyalgia (or migraine, CRPS, chronic low back pain, neuropathic pain….) for example, treatments to reduce or eliminate pain might not be available, so maybe spending energy on a hiding to nothing ‘meeting the challenge’ is time poorly spent. The decision should not be mine to make – my job is to help people work out for themselves which path they want to take and to present all the options fairly.
More info on curiosity:
Cervera, R. L., Wang, M. Z., & Hayden, B. Y. (2020). Systems neuroscience of curiosity. Current Opinion in Behavioral Sciences, 35, 48-55. https://doi.org/10.1016/j.cobeha.2020.06.011
Gruber, M. J., & Ranganath, C. (2019). How Curiosity Enhances Hippocampus-Dependent Memory: The Prediction, Appraisal, Curiosity, and Exploration (PACE) Framework. Trends in Cognitive Sciences, 23(12), 1014-1025. https://doi.org/10.1016/j.tics.2019.10.003
Kashdan, T. B., Stiksma, M. C., Disabato, D. J., McKnight, P. E., Bekier, J., Kaji, J., & Lazarus, R. (2018). The five-dimensional curiosity scale: Capturing the bandwidth of curiosity and identifying four unique subgroups of curious people. Journal of Research in Personality, 73, 130-149. https://doi.org/10.1016/j.jrp.2017.11.011
Szumowska, E., & Kruglanski, A. W. (2020). Curiosity as end and means. Current Opinion in Behavioral Sciences, 35, 35-39. https://doi.org/10.1016/j.cobeha.2020.06.008
Threat:
Robinson, M. D., Irvin, R. L., & Asad, M. R. (2024). Threat sensitivity in emotion dynamics: Negativity effects and sex differences. Behav Res Ther, 178, 104542. https://doi.org/10.1016/j.brat.2024.104542
Unruh, A. M., Ritchie, J., & Merskey, H. (1999). Does gender affect appraisal of pain and pain coping strategies? Clinical Journal of Pain, 15(1), 31-40.
van Vliet, C. M., Meulders, A., Vancleef, L. M., & Vlaeyen, J. W. (2018). The opportunity to avoid pain may paradoxically increase fear. The Journal of Pain, 19(10), 1222-1230.
Emotional distress and LBP onset:
Collins, S., McDevitt-Petrovic, O., & Henderson, E. (2023). Can emotional distress induce acute low back pain? A systematic review. Physiotherapy Practice and Research, 44(2), 177-186. https://doi.org/10.3233/ppr-230737