Our September LMCC meeting took place on Wednesday, September 27 at 5:45pm in UNC’s newly renovated HHIVE Lab (Greenlaw 524) and via Zoom. We discussed Encountering Pain: Hearing, Seeing, Speaking, edited by Deborah Padfield and Joanna M. Zakrzewska (UCL Press, 2021). Specifically, we discussed:
- “Foreword” by Rita Charon (pp. xxxv-xxxvi)
- Chapter 1: “How to Listen for the Talk of Pain” by Rita Charon (pp. 33-45)
- Optional but suggested reading: “Introduction II: What is Pain? A Neurobiological Perspective” by Maria Fitzgerald in conversation with Deborah Padfield (pp. 17-29)
If you missed the meeting, you can still access the text on the Readings page of this site!
You can also access the recording of our meeting here,
Our next meeting will take place on Wednesday, October 25 at 5:45pm in UNC’s HHIVE Lab, Greenlaw 524. If you can’t attend in person, you can attend in real-time via our usual Zoom link. We will send out an announcement soon with more information for that meeting.
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Selections from Encountering Pain: Hearing, Seeing, Speaking, (UCL Press, 2021), edited by Deborah Padfield and Joanna M. Zakrzewska:
Charon, Rita. “Foreword.” Encountering Pain: Hearing, Seeing, Speaking, edited by Deborah Padfield and Joanna M. Zakrzewska. UCL Press, 2021, pp. xxxv-xxxvi.
Fitzgerald, Maria and Deborah Padfield. “Introduction II: What is Pain? A Neurobiological Perspective. Encountering Pain: Hearing, Seeing, Speaking, edited by Deborah Padfield and Joanna M. Zakrzewska. UCL Press, 2021, pp. 17-29.
Charon, Rita. “How to Listen for the Talk of Pain.” Encountering Pain: Hearing, Seeing, Speaking, edited by Deborah Padfield and Joanna M. Zakrzewska. UCL Press, 2021, pp. 33-45.
Some key passages:
“Foreword” by Rita Charon (pp. xxxv-xxxvi)
“The experts in this landmark conference [the ‘Encountering Pain’ conference] were the patients themselves. We physicians, nurses, chaplains, physical therapists, acupuncturists and meditation trainers were the students of those who live with pain” (Charon xxxv).
“When will medicine recognise the urgency of pain? When will doctors be trained to diagnose especially those treatable causes of pain? What might shift our tendency to blame patients for their own distress?” (Charon xxxv).
“[W]e came, unusually quickly, to be able to witness one another’s stories and to be able to change our own concepts of patienthood and doctorhood. We broke through into a shared language of pain, finding ourselves partners across the divides of culture and power towards a state of care…. [E]galitarian conversations about pain and suffering can expose fresh means of improving healthcare” (Charon xxxvi).
Optional but suggested reading: “Introduction II: What is Pain? A Neurobiological Perspective” by Maria Fitzgerald in conversation with Deborah Padfield (pp. 17-29)
Deborah Padfield: “In this interview, I want to try to untangle exactly what pain is, the process of seeing and perceiving it; and question whether the process of perceiving it can actually change how you experience it” (Fitzgerald and Padfield 17).
Maria Fitzgerald: “I consider that pain is an experience. It is an emotional experience that arises because of activity in specific neuronal pathways in the periphery of your body, and also in your spinal cord and in your brain. So, I see pain as the result of neuronal activity in specific brain areas. However, I absolutely understand that other people see pain differently and some people see pain in a much broader context than that” (Fitzgerald and Padfield 17).
Maria Fitzgerald: “Without getting very pedantic – we do have to be a bit careful with language here – generally speaking, biologists when they’re talking to each other they talk about ‘nociception’, which is not a word that most people use. It basically means the perception of a noxious stimulus, i.e. tissue-damaging stimulus. The reason that they use ‘nociception’ rather than ‘pain’ is because they do acknowledge that pain is a human emotion, whereas, nociception is a neurobiological process. However, in order to improve communication, we tend to use the words interchangeably, which does create confusion, but I think we can deal with that confusion” (Fitzgerald and Padfield 18).
Maria Fitzgerald: “The difficulty is that in some cases an injury leads to pain goes on and on, so that it is not just a life-preserving reaction nor does it have protective benefits; sometimes it doesn’t even seem to have a clear origin, like a wound. It is this kind of pain that we don’t understand enough about, but which causes great suffering and is extremely important” (Fitzgerald and Padfield 19).
Maria Fitzgerald: “Another thing to understand about pain is that our brain, our central nervous system, has the ability to switch pain off or inhibit it. Again, if we go back to this basic biological need for self-preservation there are situations that we can see specifically in animals, where the obvious pain behaviour will be suppressed if the animal needs to do something else that, in evolutionary or biological terms, is more important. For instance, that might be to eat or, as I said, to run away. Therefore, we definitely have within us, within our brain, the ability to switch pain off or dampen it down” (Fitzgerald and Padfield 19).
Maria Fitzgerald: “This is a kind of feedback loop, if you’ve got information originally from a wound of some kind, which activates neurons and activates the brain; the brain can then send information back down to the spinal cord and switch off the information at the point of entry” (Fitzgerald and Padfield 20).
Maria Fitzgerald: “However, I think that it has led people to a conclusion that, if not false then certainly unsubstantiated, that pain can be created by the brain itself. This is the idea that pain, if you like, has no reality, there is no noxious input which is activating those areas, and that the pain has become a fiction or creation of the brain. I’m not convinced that there is any actual real evidence of that” (Fitzgerald and Padfield 20).
Maria Fitzgerald: “It’s quite evident that many aspects of our experience and the context in which we are in will modulate the experience of pain. What I meant was that I’m not convinced that pain can be entirely created by the brain as a fiction if you like, as a fantasy, as a psychosis” (Fitzgerald and Padfield 20).
Maria Fitzgerald: “But in the end, fundamentally pain is the most intense sensation that we experience. It is not surprising that events that happen in our life, which are extremely unpleasant and cause us a great deal of unhappiness, should be associated with pain and the same language used. However, I do think there is a problem with assuming that they are really the same and assuming they should be treated in the same way” (Fitzgerald and Padfield 21).
Maria Fitzgerald: “I can’t help feeling there is a reason why we have a set of physiological reactions that we associate with unhappiness. There is the emotion, but there is also the fact that we can’t seem to breathe, you feel like something is crushing your chest, you feel agitated, you can’t sleep, etc. These things are all part of the emotion of unhappiness and grief, but they are also the reaction. These are the instant reaction that your body has if it’s hurt and I just wonder whether in a sense our brain is almost interpreting them in the same way even though, as rationalists, we know they are different” (Fitzgerald and Padfield 22).
Maria Fitzgerald: “It [the language of pain] is the best language because it is universal … everyone understands pain, everyone experiences it, and everybody knows it’s aversive and life threatening and bad – there’s nothing good about it. What better language to use when you want to explain how horrible you feel? However, whilst it may be effective on a personal level, clinically it causes confusion” (Fitzgerald and Padfield 22).
Maria Fitzgerald: “So, you asked me the question of whether the context and the emotional state of a person might influence the amount of physical pain that they feel. I think that the answer to that is definitely yes. That has been shown in many, many studies and there are many things that will affect the amount of physical pain that we feel. For example, you and I might be given exactly the same highly controlled noxious stimulus, exactly the same spatial dimensions, same temperature on exactly the same part of our body. And yet we might well, when asked to score or rate our pain experience, from 1–10 or 1–100, put them at completely different points. Because pain is not an absolute event it is something that we have learned, how we score our experience will depend enormously on our past experiences of pain” (Fitzgerald and Padfield 22-23).
Maria Fitzgerald: “One of the interesting things about looking at pain processing in new-born infants is that there are already pain-related genetic differences between them and they have also experienced different environments in the uterus. So, despite the fact that they have relatively little postnatal experience compared to older children, you can already see quite a lot of inter-infant, inter-individual differences in the reactions to a noxious stimulus. As we grow up, a combination of life experience and genetic background determines our own particular sensitivity to noxious stimulation” (Fitzgerald and Padfield 24).
Maria Fitzgerald: “[T]here should be no assumption that one reaction is right, and one is wrong. Some people seem genuinely stoical about pain but that is not always good, it may be that they ignore important messages that are telling them that something isn’t right. Similarly, people who are oversensitive should not be thought to be attention-seeking or hysterical, as there is a likelihood that they genuinely have more nociceptive input coming into their central nervous system. They could have more brain activity to the same stimulus as someone else” (Fitzgerald and Padfield 25).
Maria Fitzgerald: “Every single living creature responds in a very reactive way to a noxious stimulus. Therefore, as a biologist it is fascinating to understand the pathways that underlie these reactions, while also recognising pain as fundamental to the human condition” (Fitzgerald and Padfield 26).
Maria Fitzgerald: “It is such a fundamental desire to avoid pain, not only on our own account but also on behalf of others; we don’t want other people to feel pain either. That is such a powerful thing. To me it is more interesting than any other sense – taste, vision, hearing – which are all incredibly important, I don’t in any way want to belittle them, but they do not have the power of pain. It has the ability to destroy people’s lives. Neuroscientists are beginning to map the pathways, and we should be able to control it better soon. That’s why I’m so fascinated by it” (Fitzgerald and Padfield 26).
Maria Fitzgerald: “I would honestly say that the PAIN CARDS have an important role to play, as the patient does not need any language; they can just see the pain in a picture, decide whether it seems to be appropriate for their pain and just give it to somebody, who can look at it and begin to understand what it is that they are feeling. I guess both parties may need a visual imagination, but to me it would be really useful” (Fitzgerald and Padfield 27).
Maria Fitzgerald: “Biologically we are programmed, in a way, for pain to be associated with an injury and to go away when the injury goes away. We are all aware that pain can go on and on, but we are a little impatient of it in others. It becomes increasingly difficult for the sufferers to describe how they feel to their colleagues and friends who do not have the pain. So, to my mind, visual images would help a great deal” (Fitzgerald and Padfield 27).
Maria Fitzgerald: “If people realise that it is not their fault, it is not that they are going mad, but that instead, for reasons that sadly we don’t yet understand, some pain neurons begin to fire their pulses, without an input. Us neuroscientists need to discover ways to stop them from doing that. That is what I mean by taking a very mechanistic approach: you park the emotion to one side and just think, if we could get in there and stop those neurons from behaving like that then maybe we could relieve a lot of suffering” (Fitzgerald and Padfield 28).
Maria Fitzgerald: “There are also neurons that are in the brain and which are normally responsible for dampening down, or inhibiting, and stopping pain from getting too bad – these neurons can also go wrong so that instead of dampening pain down, they can start to enhance it and make it worse” (Fitzgerald and Padfield 28).
Chapter 1: “How to Listen for the Talk of Pain” by Rita Charon (pp. 33-45)
“Unremitting pain is among our most pressing contemporary health dilemmas. Adding to the infectious disease plagues of current and earlier centuries and neck-and-neck with the today’s coeval plagues of chronic multisystem illness, untreatable pain – cancer pain, war veterans’ post-battlefield disorders and the sufferings of trauma survivors – has become the signature disease of our time” (Charon 33).
“Pain is an etiologically democratic force: it does not discriminate among biological disease, the effects of war, the results of trauma, the sequelae of poverty, the result of mental illness or the consequences of natural disasters” (Charon 33).
“Susan Sontag describes the contemporary threat that ubiquitous representations of pain can dull the sensations of spectators to its reality. The bombardment of movies, video games and internet sites depicting graphic wholesale violence has concerned teachers and psychotherapists for decades; such excessive exposure to other people’s pain threatens to alter viewers’ thresholds for the unacceptable. In contrast to regarding the pain of others, witnessing the pain of others can advance a true acknowledgement of experienced suffering” (Charon 34).
“Witnessing the pain of others is a reciprocal act. Such witnessing can afford relief and recognition for the sufferer. And, when authentic, such acts embroil the one who witnesses in some degree of suffering” (Charon 34).
Geoffrey Hartman and Dori Laub: “They emphasise the requirement that the one listening should not treat the testimony as simply data or information, but rather that the witness enter the effort of the one giving testimony to find and articulate the core of the experience being relived (Felman and Laub 1992). When the listener is able to achieve such authentic listening, he or she is exposed to the presence of the evil suffered, getting ‘second-degree’ trauma, or what those who work in trauma care call the ‘traumatisation of the listener’” (Charon 35).
“How powerful an act it is to tell of one’s pain. Through the process of articulating the world of suffering in the presence of one committed to authentic listening, the teller meets and recognizes the suffering self, perhaps helping the process of reintegration of the suffering self with the knowing self” (Charon 35).
“Within healthcare professions and the lay public, there is a growing realisation that pain is an intersubjective event. Not only is the transaction a reciprocal one with suffering on both sides, it also brings the full subjectivity of both sufferer and witness into pain’s act. The only instrument that can register the presence and intensity of pain is the human witness, because pain has no objective outward signs or biological markers that can be measured and confirmed” (Charon 36).
“We might consider pain to be, primarily, a semiotic phenomenon…. we can but treat pain as a signal from deep inside one person that is emitted first to alert the sufferer that some damage is underway and then to communicate its presence to another, if only to the anonymous reader” (Charon 36).
“‘Intersubjectivity’ refers to the contact possible between two persons, not when they are present in their social or bureaucratic or economic roles but when they are present as their full selves, as that entity they refer to when they say ‘me’” (Charon 36).
“Psychoanalysts have deepened the meaning of intersubjectivity in another direction, describing the human being’s capacity to pierce the boundaries of another’s self, often wordlessly, towards experiencing that other’s inner world” (Charon 37).
“So, to say that pain is an intersubjective phenomenon means that it is constituted by several entities – the consciousness of the sufferer, of the witness, of the sufferer’s entourage, sometimes of the one who has caused the pain to begin with. Recognising the intersubjectivity of pain calls for many fundamental changes in routine healthcare: family members require intensive care for their own wounds. Clinicians need expert care in response to their own sense of loss, sometimes guilt, always sadness. In the presence of trauma or violence, the perpetrators of the suffering must also be called upon to give accounts of themselves, either as individuals or in collective acts of reconciliation. Because pain is a universal truth in a life lived in time, all involved as witnesses of anyone’s pain come to recognise their own futures in the pain of another. Such universalising of the existential being-in-time profoundly changes the nature of the relation between sufferer and carer, calling us to discover our standing as fellow mortals in the face of time” (Charon 37-38).
“Because pain is a multimodal experience without commonly understandable or sharable metrics, anyone finds it hard to describe his or her own pain…. Words come slowly to most persons who try to articulate what their pain feels like…. Even with words at the ready to articulate a sensation, some patients may withhold from their physician a description of pain because of their fear of what it might connote” (Charon 38).
“By our use of his own visualised representations of his body in our conversation about his illness, we were able to stay focussed on his phenomenal experience of his symptoms without escaping to abstract pain scales or hackneyed overused adjectives. We were working from his database of sensations towards a far more explicit and accurate shared understanding of what he was going through. In this case, the use of a complex metaphor tipped me off to the depth of work this patient was undertaking to undergo and represent to me his bodily sensations” (Charon 39).
“Doctors are trained to make decisions, and many of them are intolerant of ambiguity or uncertainty. The premature jump to closure, often leading to a faulty conclusion, is the casualty of the refusal to live in doubt” (Charon 40).
“Since patients’ memories of having been ridiculed or scorned have long lives, lack of skill in listening to patients and respecting their concerns may diminish the effectiveness of care throughout a patient’s career of illness” (Charon 40).
“Listening for pain requires personal commitment, bravery, generosity in the use of the self and a battery of hard-won skills. These skills are necessary in all realms of healthcare, from intensive psychoanalysis to routine primary care. Perhaps the clinicians with most need for and most benefit to be gained from the rudiments of training for listening are ‘clinicians of the body’ who practice their discipline without a psychological or mental-health focus on emotions, language or relationships. They are often the ones to whom are offered those first, tentative, pivotal descriptions of pain” (Charon 40).
“My colleagues and I in the Program in Narrative Medicine at Columbia University in New York City have introduced the practice of teaching the skills of close reading and creative writing as a means towards deepening the listening capacity of our learners” (Charon 41).
“Narratively trained clinicians use these skills in routine practice, writing their impressions of a complex encounter with a patient to discover themselves what they have perceived about the patient. Showing what they’ve written to the patient proves to the patient their desire to understand and often deepens what the patient chooses to share next: it is a narrative path towards clinical intimacy and trust” (Charon 41-42).
“The next step in this creative pedagogy is to recognise the parallel between close reading or looking and close listening…. Imagine how such radical listening might change what happens in the clinical setting, the political setting, the religious setting, the highly polarized and divisive settings that now are endangering us all” (Charon 42).
“Think how clinical care for pain might improve with deep attention to the language of pain. With commitment and skill on the part of clinicians to listen unguardedly for the pain, and with risky willingness on the part of patients to tell of what they undergo, the ground of care will shift. Gates of trust will open to allow truth to be spoken and heard. Creative efforts will be poured into the larger purpose of letting one person’s lived experience be heard and comprehended by another. Patients will feel confident that their clinicians really want to know all the salient dimensions of their suffering and not only those that deal with physical or biological aspects of their situation” (Charon 43).
This post’s featured image is Figure 0.3 from “Introduction II: What is Pain? A Neurobiological Perspective,” p. 29. The image is “a photomicrograph of a section through the dorsal horn of the spinal cord” and is attributed to Dr. Stephanie Koch, Senior Research Fellow, UCL.