Virtual Special Issue

The sociology of pain
Editorial by Jane Richardson

Pain is certainly the result of a biochemical process. But nerve pathways and bodily reflexes do not tell the whole story. Pain is also a subjective experience, perhaps an archetype of subjectivity, felt only within the solitude of our individual minds. It is, in addition, always saturated with the visible or invisible imprint of specific human cultures. We learn how to feel pain and learn what it means….. [W]hat matters most about pain – at least outside the laboratory – may well be the personal and social meanings with which we and our surrounding culture endow it.
(David Morris, The Culture of Pain, 1991: 15)

Pain is not just a concern of medicine, but is also an everyday individual experience – hence the involvement of writers, artists and philosophers, as illustrated by David Morris, in attempting to understand and give it meaning. It is fifteen years since Bendelow and Williams (1995) argued for the importance of a sociology of pain, suggesting it to be a relatively neglected area within the sociology of health and illness. They called for an approach that understands pain as a social and embodied experience influenced by culture. The papers in this Virtual Special Issue show that, while the sociology of pain is often subsumed under the sociology of chronic illness – and indeed has contributions to make to this field - it can also be seen as a distinct area in its own right.

Bendelow and Williams’ (1995) paper provides an excellent overview of and introduction to some of the concepts arising in this Virtual Special Issue. They outline different approaches to pain, from the biomedical to the Foucauldian, arguing for other voices than simply the medical to be heard. They suggest that a sociology of pain needs to take account of the sociology of body and emotions, in order to see pain as an embodied experience, and also needs to incorporate the meaning and culture of pain and pain behaviour.

Culture and context

The papers in this issue include those that have taken both medical categories and sociological categories as their starting points, perhaps highlighting the pragmatic nature of research in this area. Continuing the notion of pain as an individual, embodied experience within a particular culture I have grouped the papers according to the culture or context that is their focus. Clearly there are overlaps between the categories – the nature of pain means that it is experienced across all areas of a person’s everyday life. These categories show where a sociology of pain can contribute to wider areas in the sociology of health and illness. There are also similarities in the experience of pain across the different contexts which contribute to a distinct sociology of pain.

Pain in the workplace and in industrial society

Ewan et al. (1991) is one of the earlier papers included in this Virtual Special Issue, reflecting its subject matter of RSI (Repetitive Strain Injury), which was endemic in Australia in the early 1980s. The paper explores the experience of living with an uncertain painful condition, including physical restrictions, changes to identity, and delegitimation, all of which are also common to other contested painful conditions. RSI, as an invisible, uncertain and ambiguous condition, is not recognised within a culture which expects pain to have an explanation, to respond to treatment and hence be short-lived. Thus disbelief of the reality of their experience for this group of women came not only from doctors, but from friends, family and colleagues, leading those who had stopped work to further isolate themselves socially. In addition to the ambiguity, uncertainty and chronicity of RSI, the authors point to the politicisation of the condition as a contributing factor in the ‘amplification of the experience’. This article is important in grounding individual experience of a condition in the culture and socio-political discourse through which it is experienced. There is a place in sociology of health and illness for studies which seek to build on this approach, particularly in the case of work-related pain.

The next two articles, Roderick (2006) and Turner and Wainwright (2003), continue the focus on pain and injury in the workplace, through exploration of professional football and ballet – in Wacquant’s (1995) terms ‘body-centred performance trades’. As Roderick points out, most sociological work in this area has been related to industrial work environments, thus the focus on other work environments is illuminating. 

Roderick takes an interactionist approach, exploring how injury is socially created through the meanings associated with the workplace (a professional football club). This paper contributes to work on the invisibility of pain, and the related areas of legitimacy and stigma. Playing ‘through pain’ and disregarding injuries is normalised within the culture of professional football. Being believed or not is thus a key part of the experience of injury in this context. Roderick interprets players’ behaviour in terms of Goffman’s (1963) distinction between discredited and discreditable stigma, with players seeking to manage the information they present in order to avoid becoming discredited. He suggests that players learn to conceal pain, or, conversely, to reveal the full extent of pain, depending on the situation. This perhaps finds parallel in descriptions of ‘ordinary’ people who conceal their pain from their families but find it necessary to present the pain to healthcare professionals in order to be taken seriously.

Turner and Wainwright’s (2003) contribution shares with Roderick a focus on a vocation which depends on the physical capacity of the body. They view the ballet as more than simply a place of work, but as a place where social bonding occurs. The issue of ageing is an intriguing one in the context of ballet: as the authors note, most professional ballet dancers ‘retire’ before the age of 30, having started in very early childhood. Injury can be seen as disruptive to the sense of a youthful self that is closely tied up in performance, showing the importance of understanding the concept of biographical disruption in context and in relation to cultural expectations.

Wilkin (2009) approaches the problem of low back pain from a very different perspective, one which locates the problem in modern industrial societies. He takes a realist view towards the body, rejecting positivism for reducing the body to physical aspects, and interpretivism for reducing it to discourse. For realists, back pain is seen as something constructed through discourse but that has a physical reality beyond this. In a wide-ranging argument, Wilkin explores three areas: the symbolic power of the chair, the impact of industrialisation and capitalism as a system for producing furniture. Wilkin’s paper is predominantly theoretical but also suggests very practical solutions to the problem of back pain in the widespread adoption of ergonomically acceptable furniture within a capitalist market. The contribution of this paper lies in its broad approach to the problem of back pain and in locating the solution not with individuals but with the state.

Pain in the context of health care

Baszanger (1992) addresses the crux of the problem of pain in the context of healthcare - pain as a private sensation, communicable only by the person with it, necessitating the need for healthcare professionals to ‘decipher’ the pain and respond to it.  Physicians in the two pain treatment centres she studied had different ways of understanding chronic pain – different operational knowledge – which led to very different doctor-patient relationships. She argues for the importance of cognitive knowledge in understanding medical actions and doctor-patient relationships.

The exploration of pain as a subjective experience is continued in May et al.’s (2004) examination of three conditions in the context of primary care, including chronic low back pain. Conditions in which the patient’s subjectivity is at the forefront of the consultation make evaluation of the patient and the doctor’s response to them important. May et al. used an innovative form of secondary analysis of an aggregated qualitative data set to explore the doctor-patient relationship in the context of these conditions. They draw attention to the lack of agreement of conceptual models within the doctor-patient encounter and the implications of this for ‘patient-centred practice’, questioning the assumption that patient centred practice necessarily leads to better health outcomes. The disjuncture between the different conceptual models was much more apparent in the context of back pain, centring around patients’ views of back pain as mechanically based versus doctors’ views of it as psychosocially based.

Ong and Hooper (2006) explore the role of concordance in therapeutic relationships, through accounts of low back pain sufferers in consultation with various healthcare professionals.  Their paper is important because it focuses not just on doctors, but on other healthcare professionals in relationship with patients, a growing area of interest in the context of multi-disciplinary care.  The contested nature of back pain is important to consider in therapeutic relationships. Ong and Hooper conclude that while various dimensions of these relationship need to be considered, so too does the wider context within which they take place. They also tentatively suggest that a concordant relationship may not actually produce the most cost-effective outcome, while a discordant one may still produce an appropriate clinical outcome. Thus they question whether concordance is an outcome or a process, which has particular implications for chronic pain, where outcomes are less clearly defined and may be contested.

Skelton (1998), in common with the authors of the previous two papers, focuses on back pain, arguing that it is common in the general population and in general practice, and therefore offers opportunities for patient education. He applies the concept of the ‘hidden curriculum’, originally developed to explore what schools teach to pupils implicitly through everyday actions, to the doctor-patient encounter, as an example of a non-formal educational setting.  Advice from GPs (general practitioners) focused on individuals and their lifestyles, ignoring wider social factors that may have contributed to the problem. It was simplified, repeated and only differentiated on the basis of perceived class or gender. Skelton suggests that patients’ views of health may be broader than this and that they may choose to employ bodily self-control as part of this wider view rather than simply because the doctor has educated them to do so.

Illness communities

Pain is the primary symptom of endometriosis, the focus for Whelan’s (2007) contribution to this issue. Endometriosis also has much in common with other painful conditions, including its invisibility, uncertainty, lack of known cause and resulting lack of legitimation. Whelan borrows Barker’s (2002) graphic term ‘epistemological purgatory’ to describe the experience of sufferers of chronic conditions with no ‘objective’ symptoms. She sets her paper in the context of what she terms the ‘delegitimation theme’, focusing on how women ‘complain’ and make claims about their symptoms. Whelan’s work makes an important contribution to the literature on patient communities, but takes this one step further to examine the ways in which the common experiences articulated in these communities are used to challenge medical knowledge, resist delegitimation and make claims. Whelan draws our attention to the contradiction in patients’ accounts, in that they recognise their own embodied experience as a ‘solid foundation for knowing’, but do not recognise the clinical experience of healthcare practitioners. Furthermore, their own experience is evaluated through medical claims and through others’ experience. Whelan suggests this represents a difference between epistemic principle and epistemic practice and suggests that further research is needed in other ‘communities’ to explore and compare their epistemic strategies.

Biographical context

I make no apologies for including in this issue Bury’s (1982) classic work introducing the notion of biographical disruption. Bury’s observation that recognition and legitimation of symptoms is problematic when those symptoms are familiar and widely experienced in the general population has particular implications for conditions in which pain is a major symptom.

Sanders et al. (2002) use Bury’s (1991) distinction between significance and consequence of the meaning of illness, in explaining how older people saw the symptoms of osteoarthritis, including pain, as a normal part of ageing and hence not biographically disruptive, but still disruptive on a day-to-day basis. Their paper provides a fascinating introduction to the interactions between ageing, disability and chronic illness, which, as the authors suggest, is an area needing further research. The individual and social context in which symptoms are experienced has implications for how those symptoms are interpreted and may or may not lead to seeking healthcare.

Continuing with the context of biographical factors, Richardson et al. (2007) explore the experience of pain in the family. The authors suggest that the concept of ‘support’ is more appropriate to chronic pain than ‘caring’ to describe the role of family members. This support is very much dependent on the context, and is flexible and dynamic, responding to the fluctuating and uncertain nature of chronic pain. These characteristics of pain make the giving and receiving of support a complex process, in which roles and responsibilities are continually renegotiated.

Bendelow’s (1993) article is unusual in the sociological literature on pain in focusing on the role of gender. She addresses two important issues: the role of emotions in conceptualisations of pain, and gendered notions of pain. She demonstrates how pain is not simply confined to physical sensation but incorporates emotional, spiritual and existential notions, as people seek to find a meaning and explanation for pain. The idea of women as ‘naturally’ better able to cope with pain emerges from her interviews, associated with women’s biological functions, and underpinned by social and cultural expectations. These expectations may lead women to ignore pain, and also, to be ignored when they do express it. Bendelow suggests that this may also be the case for those who are disadvantaged in the social structure in terms of class, race and age, in addition to gender. These areas remain underexplored in the sociology of pain.

Approaches to a sociological understanding of pain

Communicating pain

The difficulties inherent in ‘measuring’ or understanding another person’s pain are explored in many disciplines concerned with this topic, and sociology is no exception. As sociologists, we may have been guilty of writing about the indescribability of pain and the difficulties that sufferers have with putting the pain into words, while continuing to ask research participants to do this near impossible task.  As Smith, drawing on Scarry (1985), points out, ‘pain’s resistance to language is central to what it is’ (2008: 1004). Smith explores how respondents view the researcher when attempting to communicate their pain through a questionnaire which requires them  to ‘translate’ their experience into someone else’s linguistic categories, in turn translated into numerical scores. Thus engagement with an ‘imagined researcher’ through writing in the margins (‘marginalia’) is an attempt by respondents to communicate their experience fully.  Smith suggests that the subject matter of the questionnaire is linked to how strongly respondents attempt to engage with the imagined researcher: in conditions which are contested and not well understood, such as fibromyalgia, communication is problematic yet essential. She calls for a more critical alignment between the phenomenon of pain and the data that attempts to represent it, suggesting that attending to marginalia may offer a way to do this, as well as moving towards a more inclusive and collaborative approach.

Methods for exploring pain

Methods used in this collection include the familiar and well-used, for example, in-depth interviews, alongside the more innovative. Bendelow, for example, uses a mixed approach of questionnaire and interview but also uses visual images in her interviews (in a similar way to vignettes) to elicit beliefs and attitudes about pain. Richardson et al. use in-depth interviews, but in conjunction with diaries and family member interviews. A form of ‘matched-pair’ design, whereby patients were interviewed along with the clinicians whom they had consulted, is described by Ong and Hooper. Secondary analysis of existing qualitative data is employed by May et al. and Baszanger makes use of ethnographic methods, including participant observation, alongside interviews. It is also interesting to note that two of the papers in this collection are what might be termed ‘insider’ research. Whelan suggests that her research on women with endometriosis was only possible because of her own status as a sufferer, while Roderick’s access to professional footballers was facilitated by his own four-year career in the profession.

Lawton (2003), in her review of research on lay experiences of health and illness, refers to medical sociologists’ fondness for the in-depth interview and the challenge of finding new ways to collect data.  She suggests that research interviews, and the narratives they produce, limit what we can know about people’s experiences of illness. A broader range of methods may be able to give a fuller picture of this experience, including everyday, bodily aspects of illness and managing illness. This need for methods beyond the research interview is equally applicable to pain, particularly given the documented difficulties with articulating pain experience. The range of methods used by authors featured in this issue suggests that medical sociology is well placed to meet this challenge.

Conclusion

The papers in this issue show that the sociology of pain can be considered as both a distinct area, and one that contributes to the broader field of the sociology of health and illness.

First, the papers have highlighted the characteristics of pain and their implications for sufferers. Pain is relatively invisible, leading to tensions in revealing/concealing it. The subjective nature of pain leads to a need for communication and potential for its being contested. The everyday nature of pain leads to greater potential for delegitimation and stigmatisation. Pain is uncertain in terms of everyday symptoms and unpredictable in biographical terms. Secondly, the papers have shown how the context or culture within which pain is experienced shapes how it is understood and the meanings that are given to it. Thus pain in the workplace is interpreted and expressed in a different way to pain in the family or pain in a community of people with similar experiences. The interpretation and expression of pain by individuals may vary according to biographical factors such as gender and age. Again, the nature and characteristics of pain underlie the individual and social experience. Finally, the papers have shown the importance of approaches and methods to studying pain that take account of, and are appropriate to, its features. 

None of the characteristics of pain is unique, but, taken as a whole, they create a distinct and distinctive experience, a distinctiveness which provides a focus for a sociology of pain.