Sociology of Health d Illness Vol. 17 No.

2 1995 ISSN 0141-9889

Transcending the dualisms: towards a sociology of pain Gillian A. Bendelow* and Simon J. Williams^
'SSRV University of London ^Dept of Sociology University of Warwick

Abstract Theories of pain have traditionally been dominated by biomedicine and concentrate upon its neurophysiological aspects, both in diagnosis and treatment. Hence, scientific medicine reduces the experience of pain to an elaborate broadcasting system of signals, rather than seeing it as moulded and shaped both by the individual and their particular socio-cultural context. Although pain lies at the intersection between biology and culture, naaking it an obvious topic for sociological investigation, scant attention has been paid to understanding beliefs about pain within the study of health and Ulness. A major impediment to a more adequate conceptualisation of pain is due to the manner in which it has been 'medicalised', resulting in the inevitable Cartesian split between body and mind. Consequently, the dominant conceptualisation of pain has focused upon sensation, with the subsequent inference that it is able to be rationally and objectively measured. Yet as well as being a medical 'problem', pain is an everyday experience. Moreover, sociological and phenomenological approaches to pain would add to, and enhance, existing bodies of knowledge and help to reclaim pain from the dominant scientific paradigm. In this paper, it is argued, firstly, that the elevation of sensation over emotion within medico-psychological approaches to pain^can be shown to be limiting and reductionist. Secondly, we attempt to show how insights from the newly-emerging sociological arenas of emotions and embodiment provide a framework which is able to both transcend the divide between mind and body and to develop a phenomenoiogical approach to pain. Finally, in order to bring the meaning of pain into fuller focus, we draw attention to the importance of studying theodices and narratives, as well as the cultural shaping and patterning of beliefs and responses to pain.

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140 Gillian A. Bendelow and Simon J. Williams lotrodnctioD Pain is never the sole creation of our anatomy and physiolo^. It emerges only at the intersection of bodies, minds and cultures (Morris 1991:1). The field of pain has traditionally been dominated by biomedidne and concentrates upon the neurophysiological aspects in much of diagnosis, research and treatment. Hence, scientific medicine reduces the experience of pain to an elaborate broadcasting system of signals, rather than seeing it as moulded and shaped both by the individual and their particular socio-cultural context. Although pain lies at the intersection between biology and culture, making it an obvious topic for sociological investigation, it has rarely been adequately addressed, although there are notable exceptions. For example, it could be argued that pain has always been an implicit, if not explicit theme within sociology, particularly if we accept the concept of emotional pain which could be said to underpin Durkheim's work on anomie and suicide (1897) and Marx's concept of alienation (1867). Rather more recently, Foucauldian approaches such as Amey and Neill (1983), have addressed the transformation of the conceptualisation of pain in childbirth from a one-dimensional space based upon physiology to a two-dimensional space which encompasses subjectivity. Similarly, Nettleton (1992), in her study of dental pain, has emphasised how paradigms of pain have shifted from the anatomical to the psychosocial spsL<x. However, it could be argued that, whereas these insights are helpful, by emphasising the socially constructed nature of pain, they may perpetuate in yet another form the mind-body dualism by reducing the body to a discursive construct. Moreover, the notion of two dimensional pain does not, in our view, adequately capture its multidimensional or multifaceted nature. In this paper, we argue that a major impediment to the conceptualisation of pain is the manner in which it has been 'medicalised*, resulting in the inevitable Cartesian split between body and mind. Of course, in characterising the biomedical model in this manner, we fully recognise it has been subject to critique from those working within the area of pain; including the anaesthetist Bonica (1953) who advocated multi-disciplinary pain clinics; the pioneering work of Wall and Melzack (1965, 1993); and in the development ofthe hospice movement (see Mann 1988). Moreover, in their desire for sociological imperialism (Strong 1979), medical sociologists may perhaps in the past have been guilty of unfairly caricaturing the biomedical model (Kelly and Field 1994). Nevertheless, we argue that the dominant conceptualisation of pain has focused upon sensation, with the subsequent inference that it is able to be rationally and objectively measured. Yet as well as being a medical 'problem', pain is an everyday experience and whilst the medical voice is a valid one, other voices, especially
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Transcending tbe dualisms 141 those of the subject are often lost in 'the neglected encounter between pain and meaning' (Morris 1991:2). Moreover, sociological and pkenomenoiogical approaches to pain would add to, and enhance, existing bodies of lmowledge relating to the study of pain and help to reclaim pain from the dominant scientific paradigm. Henc, the aims of this paper are three-fold. First, we argue that the elevation within medico-iychological approaches to pain of sensation over emotion can be shown to be limiting and reductionist. Secondly, we attempt to show how insights from the newly-emerging sociological arenas of the body and emotions provide a framework which is able to both transcend the divide between mind and body and to develop a more adequate phenomenological approach to pain as a lived, embodied experience. Finally, we also draw attention to the importance of studying the meaning and the cultural shaping of pain; paying particular attention to narratives and theodicies of pain, and the social and cultural shaping of 'pain behaviour'.

Limitations of the medico-scientific approach to pain This section does not aim to present a comprehensive review on the medico-psychological literature on pain, but to highlight the limitations of an exclusive focus on the sensory (noiceceptive) elements of pain perception. The tension between pain as emotion and pain as sensation emerged with the doctrine of scientific medicine. Within this scientific paradigm, the dominant traditional theory of pain, as described in most textbooks of neurophysiology, neurology and neurosurgery and taught to medical students largely as a matter of fact, is known as specificity theory. Here, the proposition is a straightforward one, namely that a specific pain system carries messages from pain receptors in the skin to a pain centre in the brain ~ a theory which was first classically described by Descartes in 1664. The specificity theory underwent little change until the nineteenth century, with the emergence of physiology as an experimental science. During 1894-5, von Frey published a series of articles (described in Melzack and Wall 1988) in which he proposed a theory of the cutaneous senses. He expanded Muller's concept of a single sense of touch to four major cutaneous modalities - touch, warmth, cold and pain - each with its own special projection system to a brain centre responsible for the appropriate sensation. This theory was expanded during the next fifty years to form the basis of modem day specificity theory, with the separation of modality being extended to peripheral nerve fibres. The 'pain pathway' is thought to be within the spinothalamic tract ascending in the anterolateral quadrant of the spinal cord (Keele 1957). The location of the 'pain centre' remains a source of debate, but was proposed by Head (1920) as being in the thalamus, with the cortex being assumed to exert inhibitory control over it.
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142 Gillian A. Bendelow and Simon J. Williams At the turn of the centuiy, Freud was developing the foundations of a new theozy which would eventually help explain how bodily symptoms such as pain could develop as a result of deep emotional dbtress or conflict. Simultaneously, a furious battle raged between the neurologists Von Frey and Goldschdder over physiological aspects of pain specificity, whilst another viewpoint was put forward by H.R. Marshall (1895), a philosopher and psychologist, who insisted the affective processes are parallel with the sensory, rather than being totally dominated by them.

Since the 1960s, however, the work of Melzack and Wall (1965, 1984, 1988) has challenged the model of specificity theory. During the first half of this century, the theory generated influential research and effective forms of treatment but is often presented unproblematically, as if it provides answers to all pain problems. Wall and Melzack (1984) claim there are many implicit physiological, anatomical or psychological assumptions in specificity theory, which fail to provide answers to various 'insoluble puzzles'. For example, the location of pain may be different from the location of damage; pain may persist in the absence of injury after healing; the nature and location of pain changes with time and that there is no adequate treatment for certain types of pain, especially idiopathic pains in which there is no sign of issue damage and no agreed cause (such as low back pains and migraines). Whereas physiological specialization for pain sensations can be identified, in that neurons in the nervous system are specialized to conduct patterns of nerve impulses that can be recorded and displayed, psychological specificity cannot be demonstrated in the same way. No neurons in the somatic projection system are indisputably linked to a single, specific psychological experience. Consequently there is no satisfactory definition which can encompass the diversity of perceptions: The word 'pain' represents a category of experiences, signifying a multitude of different, unique experiences having different causes, and characterised by different qualities varying along a number of sensory, affective and evaluative dimensions (Melzack and Wall 1988:161). Melzack and Wall developed and refined the alternative model of the Gate Control theory, which hypothesizes that psychological and cognitive variables (heavily influenced by socio-cultural leaming and experiences) have an impact on the physiological processes involved in human pain perception and response. The basis of the gate control theory is that a neural mechanism in the dorsal horns area of the spinal cord: . . . acts like a gate which can increase or decrease the fiow of nerve impulses from peripheral nerve fibres into the central nervous system. Somatic input is therefore subjected to the modulating influence of the gate before it evokes pain perception and response (Melzac and Wall 1984:222).
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Transoendisg the dualisms 143 The degree to which the gate increases or decreases sensory transmission is determined by the relative activity in nerve fibres, and by descending influences from the brain, so that cognitive or higher central nervous system processes such as attention, anxiety, anticipation, and past experiences exert a powerful influence on pain processes (Melzack and Wall 1984:230) so that there is an increased emphasis on psychological and cognitive variables. Although the gate-control theory sig^ials the end of the mind/body split with regard to pain, the biological remains dominant over the social. Psychological research into pain according to Merskey and Spear (1967) involves the distinction between 'organic' and 'psychogenic' pain: Organic pain: . . . pain which is largely dependent upon irritation of nerve endings or nerves, or else due to a lesion of the (xntrai nervous system, including some possibly patho-physiological disturbances like causalgia [Referred pain distributed along a cutaneous nerve which persists long after an injury to that nerve.] Psychogenic pain: . . . either pain which is independent of peripheral stimulation or damage to the nervous system and due to emotional factors, or else pain in which any peripheral change (e.g. muscle tension) is a consequence of emotional factors (1967:19). Elton et al. (1983) point out that all 'organic' pain has a psychological component and simplistic links between emotional factors and 'psychogenic' pain are inconclusive and reductionist. The same criticisms can be made of the 'so-called' 'pain-prone' personality as described by Engel (1958). He investigated the childhood histories of his patients and presented a profile of the 'pain-prone' personality which, he claims, suggests an 'ambiguity' towards pain, supposedly discernible by any of the following features: (a) Childhood needs: in which pain is linked to crying and being soothed by the matemal figure; (b) Punishment by parents: in which pain relieves guilt and produces expiation forgiveness and reunion. (c) Aggression and power in childhood: self-inflicted pain being seen as a fomi of control over aggression. (d) Loss of a loved one. (e) Pain enjoyed in a sexual context (Engel 1958:43). Despite the fact that most of the population has probably experienced at least one of these factors at some point in their lives, the notion of the 'pain-prone personality' has profoundly influenced perceptions of the emotional component of pain. It may also be to blame for the categorization of pain lacking well-defined physiological causes as ''imaginary' with inevitable stigmatising consequences.
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144 Gillian A. Benddow and Simon J. Williams The study of perception within psychology is conconed with the extraction of perceptual cues from sensory inputs in order to distrngiiish and convert them into meaningful precepts. It is heavily embedded in psydiophysics, using expenmental methods which inflict (usuaUy noxious) stimuli on sub>jects. From the mid-nineteenth century onwards, investigations were made of psychological responses to phy^cal stimuli, attempting to chart the limits of sensation using analogies from physical science, which equated individual sensations with atoms. Subsequently, a body of work on thresholds and tolerance has emerged (a threshold is defined as a minimimi amount of stimulation to which observers will report they have experienced a sensation. It is measured by the experimenter increasing the intensity of a stimulus, such as a pinpoint of light or touch on the skin, until the observer reports an awareness). The focus on psychological factors in pain perception led to many experimental studies most of which are clinically controlled trials, involving the infliction of pain on subjects to measure pain threshold and tolerance. For example, evidence has been produced to demonstrate statistically significant relationships between anxiety or depression and pain, often using measures of pain thresholds produced by pain stimulators on (often paid) volunteers, usually undergraduate students. These type of studies form the bulk of material published in joumals such as Pain and The Clinical Joumal of Pain. The experimental nature of these studies does not allow the social context to be taken into account, with little emphasis on the subjectivity of the perceiver. The use of experimental techniques results in a process that is 'dehumanising' and the ethical implications of inflicting pain on subjects in these studies are rarely discussed. Within the discipline of psychology, the gate-control theory has been influential in expanding the rather narrow focus on pain tolerance and thresholds, which forms the dominant approach within the study of pain perception. Traditionally, there is an assimiption that pain can be rationally and objectively measured by pain scales. Subjective interpretations have been included in measures of pain, such as the Visual Analogue Scale, but the interpretation is of sensation. The McGill Pain Questionnaire, developed by Melzack (1975), goes some _way to addressing emotional aspects of pain by requiring respondents to choose from lists of words describing various aspects of their pain, including affect. However, in general, there is a tendency to relegate the emotional component of pain to psychiatric conditions, which again perpetuates the mind-body divide. The chronic pain syndrome, defined as 'an ongoing experience of embodied discomfort that fails to heal either naturally or to respond to normal forms of medical intervention' (Kotarba 1983:5), becomes difficult and frustrating for both patient and physician. Usually the only effective treatment is seen to be through either a psychiatrist or behaviourially orientated psychologist, but this is only viewed as possible with the wellO Basil Blackwell Ltd/Editorial Board 1995

Transcending the dualisms 145 motivated, by eliminating so-called 'rewards' which have, in the past, resulted from pain behaviours, and substituting what are described as more 'constructive' activities (Tyrer 1986). Although the behaviourial approach takes some account of social context, it is usuaUy the professional rather than the lay interpretation. The primary role of medicine is to treat and alleviate pain, but traditional medical approaches are unable to claim complete expertise over the relief of suffering; something which may in large part stem from the failure to transcend the Cartesian mind and body dualism upon which Westem medicine is premised. This is not to deny the substantial body of work presenting evidence of the role that psychological factors play in pain perception and response. Suggestion, distraction of attention, evaluation of the meaning of the situation and the feeling of control over potential injury have all been shown to affect pain thresholds and tolerances (see Elton et al. 1983 for a detailed summary). However, much of the research on pain continues to concentrate on psychophysical experimentation which has both theoretical and methodological limitations, particularly in isolating its subjects from the contexts in which they live. We live with the legacy of the notion that 'real pain' is something that is acute with an easily observable physiological pathology which is strongly imbued in beliefs about pain, both in its experience and its treatment (Bendelow 1993). The etymology of the word 'pain' demonstrates a much broader view than is commonly suggested by the biomedical paradigm. For example, according to the Oxford English Dictionary, the word pain encompasses the following dimensions, stemming from the Latin term poena meaning punishment: 1) an unpleasant feeling caused by injury or disease of the body; 2) mental suffering; 3) (old use) punishment e.g. on pain of death. In Greek, the word used most often for physical pain is (algos), which derives from roots indicating neglect of love (Procacci & Maresca 1985:201). Another Greek word is (akos) meaning 'psychic pain' from which we derive the English 'ache'. A wider conceptualisation of pain is possible within medicine and is demonstrated by Vrancken (1989), in a study of eight academic pain centres in the Netherlands. She identified the following five broad approaches: the somatico-technical approach; the dualistic bodyorientated approach; the behaviourist approach: the phenomenological approach, and finally; the consciousness approach. However, Vrancken's study would suggest that multidisciplinary theories of pain are more developed in the Netherlands than in Britain and the United States. Generally, the Westem model can benefit from the philosophies and practices of alternative systems of healing as they may offer the potential to transcend the Western mind-body dualism in a quest to integrate the physical, emotional and existential dimensions of our being. For example, traditional Chinese medicine sees health as a state in which the energy of
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146 Gillian A. Benddow and Simon J. Williams the mind, body and spirit are in harmony. This en^gy, known as Qi (pronounced chee) flows around the body along twelve main meridian lines linked to internal organs. If the flow of Qi is blocked or upset, treatments such as acupimcture aim to correct the imbalance by adopting a holistic approach. As well as *body make-up* and *phycal conditions*, the section on 'How to analyse causes of disease' in The Barefoot Doctor's Manual (Revolutionary Health Committee of Human Province 1978) list the following factors as equaUy signiflcant: (i) Nervous and emotional make-up; (ii) Extemal physical factors such as radiation, civil war, etc; (iii) Chemical factors; (iv) Extemal biological factors such as pathogenic viruses, tapeworms etc, and; (v) Climactic factors such as wind, cold, heat and humidity which are thought to affect the body's resistance (1978:25-6). This model contrasts vividly with the more mechanistic dualistic model adopted by Westem medicine, which is unable systonatically to take on board the etiological role of social or emotional factors in the same way. The idea of pain being an emotional ^iperience, the obverse of pleasure, is in fact a much older conceptualisation than it being a physical sensation, and can be traced back to Plato's (429-347 BC) deliberations of extremes and opposites (e.g. hot/cold) etc. in The World of Forms. The dichotomy was developed by Aristotle (384-322 BC), and given different weightings of significance so that he regarded pleasure as merely the absence of pain. He did not regard pain as a sensation but as *a passion of the sour. Westem culture is imbued with the notion of 'pain as growth', which does not distinguish between emotional or physical pain and literature, theology and philosophy aboimd with considerations of this nature. Once the subjective element is included, the notion of pain 'measurement' becomes increasingly problematic, and is vividly illustrated by Ludwig Wittgenstein during his considerations of logical positivism in Tractacus LogicophUosphicus (1921). He relates how he recorded the word 'empfiding' (toothache) continuously over several days in his diary, but questions whether the severity of the pain can be considered to be of the same quality in each instance, a fundamental dilemma of any measurement of pain. In summary, the elevation of sensation over emotion in traditional medical and psychological approaches results in the lack of attention to subjectivity, which in tum leads to a limited approach towards sufferers and a neglect of broader cultural and sociological components of pain. In other words, a far more sophisticated model of pain is ne^ed; one which locates individuals within their social and cultural contexts and which allows for the inclusion of feelings and emotions. Hence it is to this that we now tum.

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Transcending the dualisms 147 The body, pain and emcrtioBs: truu^nding tbe dualisms

As we have suggest^ pain is simultaneously both physical and emotional, biological and phenomenologically embodied. Moreover, it is mediated by culture and thus transcends the mind-body divide. It is in this respect that, in seeking to develop an adequate sociological approach to pain, we believe important insights can be gained from recent developments in two related areas: namely the sociology of emotions and the body - particularly phenomenological approaches to embodiment. In particular, they offer a way out of the strait jacket of traditional dualistic thinking and point the way towards a phenomenological approach to pain as a lived and embodied physical, emotional and existential experience. As Tumer (1992) argues, a phenomenology of the body or 'embodiment' has particular importance for medical sociology as it provides us with a sensitive and sophisticated perspective on issues such pain, disability and death. As he points out, this phenomenological approach to the 'lived body' has been influenced by a diversity of traditions, including Lebensphilosophie, philosophical anthropology and existentialism. For example, in bis book Phenomenology of Perception, MerleauPonty (1962) developed a conception of human embodiment which attempted to overcome this duality between mind and body. MerleauPonty argued that it is not possible to talk about human perception without a theory of 'embodiment' as the 'perspective' from which observation occurs (Tumer 1992). That is to say, our perception of everyday reality depends upon a 'lived body': 'Man taken as a concrete being is not a psyche joined to a organism, but a movement to a fro of existence, which at one time allows itself to take corporeal form and at others moves towards personal acts' (Merleau-Ponty 1962, quoted in Tumer 1992:56). From this perspective, human beings can be seen to have a dual nature; one which is succinctly captured within the German language between the terms Lieb which refers to the animated living, experiential body (i.e. the body-for-itseif), and Korper which refers to the objective, exterior, institutionalised body (i.e. the body-in-itself) (Tumer 1992). This also resonates with similar distinctions made by writers such as Piessner (1970) and Berger and Luckman (1967): namely, that each of us is a body and has (i.e. experiences) a body. These distinctions expresses the essential ambiguity of human embodiment as both personal and impersonal, objective and subjective, social and natural. Moreover, it also serves to highlight the weakness of the Cartesian legacy for sociology, which has resulted in an almost exclusive treatment of the human body as Korper rather than simultaneously both Korper and Lieb, Indeed, in our view, it is this emphasis upon the phenomenology of the body as a 'lived experience', one in which the objective body {Korper) is not treated as separate from
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148 Gillian A. Bendelow and Simon J. Williams the inner sensations of the subjective body {Lieb), which seems to have particular relevance for the s o d o l t ^ of pain as an 'embodied' expenence. In this respect, Leder's (1984-5, 1990) work is particularly important in our view. In a stimulating philosophical investigation into the 'absent body', Leder has attempted to develop a phenomenological approach to pain as a form of bodily tfys-appeaidaxce. Leder draws attention to the ways in which our bodies are normally phenomenological absent from view. As Leder explains: Whilst in one sense the body is the most abiding and inescapable presence in our lives, it is ako characterized by absence. That is, one's own body is rarely the thematic object of experience . . . the body, as a ground of experience . . . tends to recede from direct experience (Leder 1990:1). Yet as Leder also points out, this normal mode of bodily disappearance tends to be profoundly dismptl in the context of factors such as pain, disease and death. Here the body becomes a central aspects of experience, albeit in an alien and dysfuncticmal manner. In other words, in contrast to the 'disappearances' that characterise ordinary functioning, the body, in the context of pain, suffering and death, a[y5-appears. That is to say: The body appears as a thematic focus of attention, but precisely in a dys state - dys is from the Greek prefix signifying 'bad', 'hard' or 'ill', and is found in English words such as 'dysfunctional' (Leder 1990:84). Leder goes on to illustrate this issue through a phenomenological approach to pain as a lived and embodied experience. Here he draws attention to the sensory intensification which pain brings into play, its episodical temporality and the effective call which it establishes; factors which together lead to the peculiar hold it has over our attention. Yet as Leder also notes, pain, like any other experiential mode, cannot simply be reduced to these immediate sensory qualities, rather, it is ultimately a matter of being-in-the-world. As such, pain re-organises our lived space and time, our relations with others and with ourselves. In other words, the full phenomenological import of pain can only be grasped when located within this wider frame of reference. In this respect, pain affects what Leder terms an intentional disruption (i.e. pain's intensity renders unimportant projects which previously seemed crucial) and a spatiotemporal constriction (i.e. self-reflection and isolation). Consequently^ the body in pain emerges as an alien presence which exerts upon us a telic demand. This telic demand can, in tum, be further sub-divided into a hermeneutical and pragmatic component. At the hermeneutical level pain and suffering give rise to the quest for interpretation, understanding and meaning, whilst at a pragmatic level, the telic demand of pain is to get rid of or to master one's suffering; instead of just acting yrom the body, I act toward it in the hope of finding relief. In particular, this hermeneutical
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Transcending the dualisms 149 moment and the quest for meaning point to a cmdal role which narratives of suffering and theodicies of pain play for the individual in coming to terms with their situation. This is something to which we shall retum and discuss more fully in the next section of the paper. Yet as Leder notes, whilst the study of pain demands the dissolution of dualities and draws attention to the relatedness of self and world, mind and body, a phenomenology of pain must also confront and account for the enduring power of such categories. In this respect, the alienating and privatised nature of pain seems to shatter the self into a series of lived oppositions. As Leder states: 'Whereas in day-to-day events we are our body without hesitation, suddenly pain renders the body disharmonious with the self Such times, along with those of hunger, exhaustion, disability and approaching death, can be seen as experiential antecedents to dualism' (1984-5:262). Here the painful body emerges as 'thing-Hke'; it 'betrays' us and we may feel alienated and estranged from it as a consequence. Thus whilst, at an analytical level, the study of pain may demand a transcendence of dualistic thinking, at the phenomenological or experiential level it may perpetuate these very dualisms. Similarly, Kotarba (1983) takes a phenomenological approach in his attempts to reconstmct the process of becoming a 'pain-afBicted' person. Analyses of self-perceptions are made in order to trace the continuity of personal identity. Using pain biographies of people who have sought treatment, Kotarba (1983) identifies three stages tn this process: 1. 'Onset' - here pain is perceived to be transitory, and able to be dealt with by diagnosis and treatment. Pain is diagnosed as 'real' by physician, having a physiological basis; 2. 'Emergence of doubt' - at this stage treatment may not work, there is an increase in specialist consultations, but the patient is still in control in attempting to seek the best care available; 3. 'Chronic pain experience' - after the shortcomings of treatment, patients may retum to lay frame of reference and to the chronic pain subculture (Kotarba 1983:243-244). Kotarba claims to have tapped into the 'fundamental essence' of the chronic pain experience. In particular, Kotarba draws attention to two themes in the 'chronic pain career': the clinical and the experiential. TTiese themes are echoed in Mishler's (1984) delineation of the two voices of the medical (biomedical, clinical information) and lifeworJ(J (social, contextual information). Although these experiences are not mutually exclusive, there is an implied hierarchy in which the former is often assumed by health professionals to be routine and nomiative, whereas the latter is more likely to be perceived as 'irrelevant', or even 'dismptive' and hence is quickly 'silenced'. More recently, Bazanger (1989), in an exploration of the phenomenological approach to pain, notes the importance of recent sociological
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150 Gillian A. Benddow and Simon J. Williams work which is concemed with the connotation of 'living with' illness and concentrates on the experience of the sufferer - see Bury (1991) for a recent review of this literature). This, she argues, restores the ilhiess to the patient, is a welcome reaction to what she terms the 'medicocentrism' of theorists such as Parsons and has largely stemmed from what Gerhardt (1989) terms the 'negotiation model' of illness within the interactionist paradigm in medical sociology. As Bury (1982) has suggested, chronic illness can be usefully con(^tualised as a form of biographical disruption, a concept which suggests that the meaning and context of chronic illness are not easily separated (Bury 1991). Here, two types of meaning may usefully be distiguished. 'Meaning as cons^uence' refers to the practical problems which chronic illness poses in daily life ranging from getting aroimd, to issue of work and income. 'Meaning as significance', in contrast, refers to the symbolic connotions and imagery surrounding chronic illness; issues which may differ according to different segments of the cultural order (Bury 1988). In the present context, sociological work conceming the meaning and experience of painful conditions such as rheumatoid arthritis has been particularly significant. Weiner (1975), for example, draws attention to the uncertain nature and character of pain in rheumatoid arthritis, and the socio-psychological strategies which people draw upon for tolerating this uncertainty. For example, symptoms may suddenly flare-up for no apparent reason, leaving the individual not only incapacitated but bereft of explanation, whilst other days may be relatively tolerable or 'painfree'. Faced with such variability, sufferers are, in Weiner's (1975) temnis, left to juggle to hope of relief against the dread of progression, and they may tread a precarious and tortuous path between the activity imperative of 'keeping up' or 'keeping going' and the physiological imperative of 'giving in'. Locker (1984) reaches similar conclusions in his small-scale study of the lives of 24 rheumatoid arthritis sufferers. In addition, sociological research in this area has also drawn attention to the relationship between body, self and society in chronic illness (Herzlich and Pierret 1987), the assault upon self-identity (Charmaz 1983), and to the search for meaning and explanation (Williams 1984, Kleinman 1988) - Leder's (1990) hermenuetic moment - of which we will have more to say in the penultimate section of this paper. A sociology of the body can provide extremely useful insights for the understanding of pain but it is worth bearing in mind that there are.limitations in the material, not least that it is often assumed that 'the body* is an undifferentiated body, presumably white, male, and unaffected by age or disability. Although the lived experiences of women of diHerent classes and colour described in Emily Martin's Woman in the Body (1987) are often alluded to, many theoretical feminist contributions to embodiment, particularly in the area of health care, have been marginalbed or ignored. The fact that mind and body are fully interfused in pain also points to
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Transcending tbe dualisms 151 another fundamental issue: nan^ly, that physical experience is inseparable from its cognitive and emotional significance. It is for this reason that pain can be used to describe not only physical agony but emotional turmoil and spiritual suffering (Leder 1984-5). As Scheper-Hughes and Lock (1987)

argue, emotions affect the ways in which the body, illness and pain are experienced and are projected in images of the well and poorly functioning social and body politic: 'Insofar as emotions entail both feelings and cognitive orientations, public morality and cultural ideology, we suggest that they provide an important "missing link" capable of bridging mind and body, individual, society and body politic' (1987: 28-29). In this respect, explorations of sickness, madness, pain, disability and death are human events which are literally 'seething with emotion' (Scheper-Hughes and Lock 1987). Thus emotion is seen as the mediatrix of the three bodies phenomenally cxperiiced, social and the body politic - which ScheperHughes and Lock (1987) identify, and which they unify through the notion of the 'mindful body'. Thus grief, for instance, is an example of emotional pain which is inseparable from its 'gut churning, nauseating experience', whilst physical pain bears within it a 'component of displeasure, and often of anxiety, sadness, anger that are fully emotional' (Leder 1984-5:261). Emotions therefore, like pain, lie at the juncture between mind and body, culture and biology and are often considered crucial to our survival by their 'signal function' in relation to danger (Hochschild 1983). Hochschild highlights the common practice among social scientists either to ignore emotion, altogether, denying it as a tenable concept; or to subsume it under other categories. The reductionist features of organismic models of emotions are largely superseded for Hochschild by the interactionist model, which emphasises how emotions take place within a social context and involve both mind and body. In this respect, Denzin (1987) insists that 'scientific' study of emotions is not possible and stresses the term 'emotionality', which he defines as the process of being emotional. He draws on the philosophical works of Heidigger, Sartre, and MerleauPonty in order to show how this 'lived quality' and intersubjectivity is of paramount importance, locating the person in the world of social interaction in which all emotional experiences involve refiection, feeling, cognition and interpretation. However, no emotional experience is ever exactly the same and is open to constant reinterpretation and meaning depending upon the particular social and cultural experiences which shape them. Moreover, Denzin asserts that the study of emotionality 'requires a conception of the human body as a structure of ongoing lived experience' (1987:3); a suggestion which is equaUy relevant to the study of pain as an embodied experience. The relevance of a sociological approach to emotions in the study of health and illness is emphasised by Freund (1990), who argues that the Durkhemian legacy of the non-reducibility of 'social facts' to biological facts' has resulted in a lack of acknowledgement of the body in
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152 Gillian A. Benddow and Simon J. Williams sociology. To understand that biologx can be socially constructed leads to a unification of the cognitive and the physical aspects of emotions, giving rise to: An existential-phenomenological perspective which emphasises subjectivity and the active expressive body [which can be] used to bridge the mind-body-sodety splits that characterise both fields [biology and sociology]... a focus on the emotionally expressive, embodied subject, who is active in the context of power and social control, can provide a useful approu;h for studying distressful feelings, society and health (Freund 1990:452). Yet this plea for the recognition of the impact of human emotional states on medical treatment which is at the heart of a more holistic unckrstanding of pain is not new. In his book The Broken Heart: the Medical Consequences of Loneliness (1977), Lynch presents evidence to demonstrate the liaks between cardiovascular disease and emotionally distressing life events. He uses medical technology to demonstrate emotional states, for example electro-encephalographic (EEG) pattems showing dramatic improvements when a nurse holds a patient's hand. In a later work. Lynch (1985) develops his thesis further, using a Foucauldian analysis to understand how the doctor-patient relationship has become divorced from its social and economic context. He predicts the growth of 'new clinics' in which the process of 'disembodiment' of symptoms will be accelerated by the generalised use of computer graphics, and emphasises the need for a philosophical shift away from the vision of the human body purely as a group of sophisticated mechanisms. Having outlined the nature of a phenomenological approach to pain and the necessity of integrating mind, body and emotions, it is to a more detailed consideration of^ the meaning and cultural shaping of pain that this paper now tums. The meaning aiid cultural shapi^ of pain In his recent book The Culture of Pain (1991), Morris argues that a medicalised view neglects the important insights of pain which can be gained through an appreciation of art, literature and culture. In this respect, pain can be said to have had a 'dual history', and the task is to integrate, these medical and cultural discourses on pain rather than to allow the former the dominance it has hitherto enjoyed over the latter. As Illich (1976) notes, in traditional cultures: '. . . pain was recognised as an inevitable part of the subjective reality of one's own body' and was made tolerable by integrating it into a meaningful setting. In contrast, the growth of industrial society and the high value placed on anaesthesia has resulted, so Illich argues, in a loss of awareness of self and a lost metaphysics:
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Transcending the dualisms 153 Cosmopolitan civilisation detaches pain from any subjective or intersubjective context in order to annihilate i t . . increasingly painkilling tums people into unfeeling spectators of their own decaying selves (Illich 1976:271). Yet irrespective of this 'lost metaphysics', it is clear that the cultural meanings of illness shape suffering as a distinctive moral or spiritual form of distress: Whether suffering is cast as the ritual enactment of despair, as paradigmatic moral exemplars of how pain should be bome (as in the book of Job), or as the ultimately existential human dilemma of being alone in a meaningless world, local cultural systems provide both the theoretical framework of myth and the established script for ritual behaviour that transform an individual's affliction into a sanctioned symbolic form for the group (Kleinmann 1988:26). In this respect, culture fills the space between the immediate embodiment of disease as a physiological process and its mediated and meaning-laden experience as a human phenomenon (Kleinmann 1988). As Kleinmann puts it: 'Illness takes on meaning as suffering because of the way this relationship between body and self is mediated through cultural symbols of a religious, moral or spiritual kind' (1988:27). Moreover, these idioms of illness and distress (Nichter 1982), in tum, are a product ofa dynamic interplay or dialectic between bodily processes and cultural categories, between experience and meaning (Kleinmann 1988). In short, in the context of human illness and suffering: 'experience is created out of the dialectic between cultural category and personal signification on the one side, and the brute materiality of disordered processes on the other' (Kleinmann 1988:55). Pain, as a fundamental form of human suffering and distress, lies at the very heart of this dialectic. As Williams and Thorn (1989) suggest, the formation of pain beliefs are thought to be a major component in the perception of pain. These they define in the following manner: A subset of a patient's belief system which represents a personal understanding of the pain experience . . . these beliefs develop through the assimilation of new information (e.g. diagnoses, symptoms, emotional reactions) with pre-existing meaning and action pattems held by the patient (Williams and Thorn 1989: 76). Their work suggests that personal beliefs about afifiiction may well be discordant with scientific understanding, and vary from representations offered by health professionals, thus affecting 'compliance' with methods of chronic pain treatment. Using their Pain Beliefs and Perception Inventory (PBAPI), Williams and Thom identify three dimensions of pain beliefs; namely, self-blame, perception of pain as mysterious and beliefs
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154 GiUian A. Benddow and Simon J. Williams about the duration of pain, which, in tum, were found to be associated with subjective pain intensity, poor sdf-esteem. scnnatization and psychological (^stress. As Prid et al. (1991) show, in relation to chronic pain, patients need to find a meaning for their symptoms, even if it is 'dysfunctional' from an orthodox (scientific) viewpoint. Without such a meaning feelings of despair and isolation may devdop. These explanations for suffering may be linked to deeply entrenched religious or a spiritual beliefs, even if an individual does not follow any particular faith, and punishment and selfblame are conmion themes. Whilst these beliefs may seem inappropriate and even anti-therapeutic to the physician, they may nonetheless preserve a sense of self-identity for the sufferer in the face of the impersonal rationality which bio-medicine may seek to impose. Thus pain poignantly thrusts upon us questions such as 'why me?', 'what purpose does it serve?' which demand answers. In this respect, pain is open to a variety of interpretations and meanings which go far beyond the sheer hurt of its original presencing. On the one hand we may experience pain as a constriction of^ our essential possibilities and come face-toface with our vulnerability, finitude and the untimely nature of our death. As the very sensation of something wrong, or bad, pain may be identified with moral evil, the result of an extemal, malignant force, or as punishment for our sins (Leder 1984-5). Here, as Tumer (1984, 1992) notes, the concept of theodicy in Weber's analysis of religion - the classical problem of explaining a 'just' God in an 'unjust' world - addresses key questions of meaning which are inevitably associated with aspects of our embodiment such as pain, suffering, sex and death. As he states: There are fundamental aspects of human experience which are transcultural or universalistic and which point to a shared ontology. The discussion of theodicy and morality in religious doctrine points to these fundamental human experiences, of which pain and suffering seem to me primary illustrations (Tumer 1992:252). On a darker note, it is also possible that the very meaning of pain may be the negation of all meaning. Here, as Scarry (1985) suggests, pain may serve to 'deconstruct' or 'unmake' our habitual world: the sheer severity of pain may negate all interpretation. Similarly, Hilbert (1984) suggests that the main problem for those with chronic pain is that they are bereft of adequate cultural resources for organising their experience; what Hilbert terms the 'aculturation' dimension of chronic pain; one which recalls Durkheim's concept of anomie (Baszanger 1989). Here, as Hilbert suggest, what is needed is to find a 'natural home for chronic pain in culture'. Yet on the other hand, as Leder (1984-5) notes, it may also signal something positive. In this respect pain may bring us to an authentic recognition of our own limitations and possibilities. It may also be creative, not only in the sense of childbirth but also in terms of physical,
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Transcending the dualisms 155 emotional, artistic and spiritual achievements, or it may serve as a catalyst for much needed changes in our lives. In this respect, Carmichael (1985) advocates using pain rather than becoming a passive victim of it: Constructive use of pain can only be achieved if we can see the pain as an ally - if we confront it. The natural response is to express; the social response is to suppress. Fearing it, distancing it, protecting ourselves from it, makes it stronger. The more you push it away the more it pushes its hooks into you . . . you need to confront it, enter into a dialogue with it, asking it what it is saying to you . . . anger can provide a substitute for pain, but may be used destmctively rather than constructively . . . permanent anger is a stuck form of pain. What is useless is denial or avoidance of pain; we need, as Camus advised in The Plague, to root ourselves in our distress (Carmichael 1985:9). A number of sociological and anthropological studies have analysed these narratives of suffering and idioms of distress, and have attempted to examine how this is explained and legitimated both by individuals and societies (Herzlich 1973, Herzlich and Pierret 1987, Williams 1984, Kleinmann 1988, Williams 1990). For example, Kleinmann (1988), in his book The Illness Narratives, analyses the personal and social meanings of pain through a number of illuminating case studies in which pain may come to symbolise vulnerability, the pain of living, or the frustration of desire in the individual's life world. As Kleinmann notes 'The recurrent effect of narrative on physiology, and of pathology on narrative is the source of the shape and weighted of lived experience. That felt world combines feeling, thought and bodily process into a single vital structure underlying continuity and change in illness' (1988:55). Similarly, in his study of rheumatoid arthritis, Williams (1984) argues that people with chronic illness undergo a process of what he temis 'narrative reconstruction'; one in which an individual's biography is re-organised in order to account for the onset of their illness and their changing relationship to the world in which they live. This identification of cause, drawing upon lay theories conceming the aetiology of illness, theories which supplement biomedical explanations, is part of an on-going process of coming to terms with chronic illness and attempting to re-establish meaning and order in the individual's world. In particular, Williams demonstrates the way in which people's beliefs about the aetiology of their affliction (RA) need to be understood as part and parcel of a far more complex and imaginative endeavour in which identified causes represent 'not only putative connections between the disease and antecedent factors but also narrative reference points between the individual and society in an unfolding process which becomes profoundly disrupted' (1984:175). Thus Williams shows how his initial question 'Why do you think you got arthritis?' was translated by his respondents into a form of narrative reconstruction regarding their changing relationship to the
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156 Gillian A. Benddow and Simon 3. Williams world in which they live and the genesis of their illness within it. As Williams states regarding his respondents: . . . finding no meaning in the medical view and having no overarching theodicy or cosmology, [they] elaborated reconstructions of their experience in such a way that illness could be given a sensible place

within it. These reconstructions bridge the large gap between the clinical reductions and the lost metaphysics. Once you begin to look at causal models as narrative reconstructions of the genesis of illness experience in the historical agent, moral or religious, or indeed, political and sociological factors become central to elucidating illness experience and rendering intelligible the biographical dismption to which it has given rise (1984:197). Thus, for one of Williams' respondents, workplace toxicity was identified as a causal factor in his rheumatoid arthritis; something which could only be imderstood in terms of his image of society as place of exploitative relationships and power inequality. For another, in contrast, the genesis of her illness was located wiUiin the relationships constitutive of social being and womanhood. Finally, another respondent located the genesis of her illness in the transcendental realm of God's purpose and her intrinsic relationship to a suffering God. As these examples serve to illustrate, it is through these narratives and theodicies of illness and pain that people attempt to understand and locate the meaning of their suffering and to effect a realignment between body, self and society. Additionally, however, any investigation into the nature of pain must also include philosophical consideration of the capacity of humans to inflict pain on both their own, and other, species. The need to understand by what perceptual, process it is possible for one human being to stand beside another in agonising pain, and not to recognise that s/he may be inflicting that pain, is evoked as a central issue in a powerful linguistic analysis of the nature of pain by Scarry (1985). Her book. The Body in Pain: the Making and Unmaking of the World, suggests that torture is an extreme event parallel to war. The object of war is to kill people, whereas torture mimes the killing of people by inflicting pain. Scarry maintains that torture is an imitation of death, 'a sensory equivalent, substituting prolonged mock execution for execution' (1985:27), which is made more frightening by its 'acting out' properties. By inflicting bodily pain, torture destroys and replaces personal language with the objectification and 'deconstruction' of the body and the person. Arguing polemically, both torture and war can be regarded as essentially masculine phenomena, counterpoised to feminine ways of thinking, understanding, acting and feeling (see Belenky 1986; Ruddick 1990). This highlights the importance of an approach to perceptions of pain which is sensitive to the social constmction and influence of gender. Culture, of course, not only shapes the interpretation and meanings we
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Transcending the dualbms 157 attribute to pain, but also the responses to it which we fashion. In this respect, as Freidson states: 'Individuals, of course, differ among themselves in the way t h ^ respond to pain . . . but as a sociologist I am more interested in the evidence that responses to pain are predictable on the

basis of group membership and that social meanings ascribed to pain are shared by members of groups (1970: 279-80). It was the physician, Beecher (1959), who was one of the first to stress the impact of the cultural meaning of pain on its perception and response. He found that injured combat soldiers, during World War II, reported little or no pain associated with their wounds, despite serious tissue trauma. Having established that they were not neurologically impaired, he concluded that their perception of pain had been altered by the deep emotional trauma they had experienced and the motivation of being able to retum home. Medical anthropologists have also emphasised the cultural meanings and dimensions of pain (Kleinmann 1988) and pain behaviour, thus extending the analysis of pain in important ways. Helman (1990), for example, puts forward the following propositions: 1. Not all social or cultural groups respond to pain in the same way; 2. How people perceive and respond to pain, both in themselves and others, can be largely influenced by their cultural background; 3. How, and whether, people communicate their pain to health professionals and to others, can be influenced by cultural factors (Heiman 1990:158). In order to clarify whether pain is expressed as a symptom or not, Helman suggests a useful distinction between 'private' and 'public' pain. Reactions to pain are not simply involuntary and instinctual, but take place within a social context, and contain a voluntary'component in that action to relieve pain may or may not be sought, and the help of others enlisted or not enlisted. Certain cultural or social groups may value stoicism the face of pain. Hence, keeping pain private, or expressing it publically, may be either desirable or undesirable when viewed within the context of a particular social groups belief and value systems. Moreover, cultural beliefs and values may serve to 'normalise' experiences of pain which for others may appear problematic. For example, Zola's classic study (1966) of reactions to illness by Italian-Americans and Irish-Americans, is still quoted as one of the bestknown study of the relationship between culture and pain. The Italian response in the study was identified by Zola as a defence mechanism to cope with anxiety by expressiveness and expansiveness, by repeatedly over-expressing it and thereby dissipating it, whereas the Irish response was to ignore or play down the symptoms, particularly of pain - itself a different type of defence mechanism. A similar study by Zborowski (1952) examined the cultural components of the experience of pain
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IS8 Gillian A. Bendetow and Simon J. Williams amongst Italian-Americans, Jewish-Americans and largely Protestant 'Old Americans', ^ a i n revealing marked differences between these groups. The Italian group were described as laying great emphasis on the immediacy of experiencing pain, especially on the actual sensation, but quickly forgot their suffering once it had gone. The Jewish group were said to be

mainly concemed with the meaning and significance of the pain in relation to their health and welfare - their anxieties were concentrated on the implications for the future of the pain experience. In contrast the 'Old Americans* were described as much less emotional and more detached in reporting pain, often having an idealised picture of how to react, and tzying to avoid 'being a nuisance*. More recently, Kotarba (1983) has contextually situated pain through an analysis of how pain is managed in occupational Ufe. In this respect he contrasts two occupational roles where physical capabilities are paramount and pain constutes a major threat; namely, those of professional athletes and manual workers. As Kotarba shows, in athletics, an 'average' level of pain can be expected and, as such, it is seJdom disclosed. As ICotarba states: The pain-afflicted person may decide to conceal the experience of pain from potentially critical audiences if the soda] and emotional costs resulting from disclosure outweigh the perceived benefits. The benefits of pain disclosure include access to health care, sympathy for one's suffering and help in adjusting to the contingencies affiected by the pain. But the costs of pain disclosure, as leamed through experience, can be perceived as overwhelming. Certain reactions of critical audiences may elicit feelings of shame and guilt (1983: 134-5). It is here, as Kotarba points out, that recourse to the 'athletic sub-culture' serves as an important framework and point of reference for the individual in knowing whether to disclose pain (and if so, to whom), or to conceal it (and if so, how; e.g. through pharmacological drugs and/or interactional strategies etc.). In contrast, a manual worker, at first sight, may have less reason to conceal pain. However, as Kotarba points out, the rewards for disclosure may be less relevant than the symbolic costs involved in doing such as the threat to one's self-image and identity, one's fitness for work, and one's capabilities as a bread-winner. Here, in contrast to athletes, Kotarba suggests that workers find the resources for handling such situations - which include the circulation of information about treatments, the folk prescription of alcoholic beverages as painkillers etc. - in what he terms the 'tavern culture'. As Kotarba shows, for athletes and manual workers, pain is a familiar feature of their normal everyday lives: athletes risk injury in training or competition, whilst manual workers risk the perennial threat of jobrelated accidents or back-ache. In other words, these two occupation subO Basil mackwell Ltd/Editorial Board 1995

Transcending the dualisms 159

culturesregardpain as a 'normal' dimension of life; one which, according to Kotarba, gives rise to a 'chronic pain sub-culture'. However, important though these studies are in drawing attention to the sodo-cultural dimensions and shaping of pain, many have been criticised for crudely reinforcing ethnic stereotypes. Perhaps more importantly, accepting that these studies took place in a particular time and context. Bates (1987:48) points out that many of these studies have tended to be rather coUectivist and deterministic in orientation; portraying the individual as a passive entity who simply responds to sociocultural forces - Kotarba's (1983) study, mentioned above, being one of the few exceptions in this respect. In contrast, there is a need for a far more interpretive approach to these issues, one which, whilst recognising the cnidally important role which social and cultural factors play, accords a far more active, critical and refiective role to the individual who draws upon their own lay knowledge and beliefs in shaping both their interpretation and response to pain. In this respect, more recent approaches in medical sociology which stress illness 'action' (Dingwall 1976) rather than 'behaviour' may represent the most fruitful way forward. Moreover, as mentioned above, gender is also important in this resp>ect. In the literature of pain perception, for example, either gender is not seen as a variable of any significance, or females are thought to have 'lower thresholds' than males. Indeed, the focus on sex difference in 'thresholds' and 'tolerance levels', appears to be the only issue regarding gender and pain perception to have received any systematic attention. Gender differences are most likely to be recorded in sensitivity to experimentally induced pain. For example, a recent experiment which inflicted a noxious heat stimulus on a 'normal' sample of undergraduate men and women (Feine et al. 1990) concluded that there was a biological basis for the lower thresholds of the women. Whilst asserting this finding as the most 'logical' explanation, the authors suggested that another interpretation could be that men delay responses more than women. Using in-depth interviews and visual imagery in order to develop a phenomenological approach to understanding pain beliefs, Bendelow (1993) found that both men and women attributed females with a 'natural' ability to cope with pain, lacking in men, and explained in terms of their biological and reproductive functioning. In summary, if we are to move beyond dualistic notions of mind and body, reason and emotion, then pain, a fundamental aspect of the human condition, needs to be 'reclaimed' from exclusive biomedical jurisdiction and relocated at the juncture between biology and culture.
Discussion

This paper has attempted to demonstrate how the medico-scientific approach has dominated the study of pain to the latter's detriment. Not
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160 GilUan A. Bendelow and Simon J. Williams only has this severely limited the conceptualisation of pain by creating false dichotomies, but it has also given mectidne the imposnble burden of trying to relieve conditions which stretch beyond tbe realms of its capabilities. Rather than the reductionist categorisation of 'symptoms', a person's pain pervades every aspect of their lives and calls for an ai^oach which sees pain as physical and emotional, biologiical and cultural, even spiritual and existential. Moreover, cultural and historical factors lead one to question the homogeneity of the word 'pain', as Morris shows when he attempts to distinguish betwwn 'Victorian hysterical pain and Nazi Holocaust pain, pagan Stoic pain and medieval Christian pain' (1991:6). Pain may also take on positive qualities linked to physical, emotional, moral or spiritual achievement or atonement. Contemporary medical practice reveals a somewhat 'mixed bag* surrounding the treatment and management of pain. As we have discussed earlier, the widespread acceptance of Melzack and Wall's Gate-control theory, along w i ^ other influences such as the hospice movement has shifted the pain paradigm and increased the emphasis on cultuiu] and psychological components together with the need for a multi-disciplinary approach. Vrancken (1989) has shown how, at least in the Netherlands, very difTerent approaches exist within academic pain centres and identifies a wide range from the somatico-technical and the dualistic bodyorientated perspective through to behaviourial, phenomenological and 'consciousness' approach, which may incorporate existential, as weli as physical and emotional aspects. Equally, we acknowledge the anguish and distress involved in attempting to alleviate pain in the clinical context. However, these more enlightened approaches to pain are by no means universal, and we have argued that the field of pain perception has traditionally been dominated by medical and psychological research resulting in parallel divides between mind and body and emotion and sensation, and a 'faulty-machine' model of embodiment. Moreover, these dichotomies have also been shown to limit and restrict treatment and therapy. Feelings, emotions and embodiment must be regarded as crucial to experiences of pain. As Turner states: If we recognise pain as an emotional state, then we immediately begin considering the idea of the person as an embodfed agent with strong affective, emotional and social responses to the state of being in pain . . . [this draws] . . . attention to a neglected aspect of the sociology of health and illness for which a theory of embodiment is an essential prerequisite for understanding pain as an emotion within a social context (Turner 1992:169). Yet one of the central paradoxes of pain is that whilst at a philosophical level it may demand the dissolution of such dualistic thinking, at the phenomenological level of experience they may be re-erected, as pain, in its negative mode, can serve to alienate or estrange us from, and thus 'objecO Basil Blackwell Ltd/Editorial Board 1995

Transcending the dualisms 161 tify' our bodies. Hence a phenomenological investigation of pain should be alive to these contradictions and the paradoxical nature of pain as an embodied experiaice (Leder 1984-5, 1990). A more holistic understanding of pain is clearly relevant to medical practice on a number of different levels. At the pragmatic level of coping with chronic pain for which there is no physical patholo^, it may help to alleviate the stigmatiitatioa of the 'psychogenic' pain patient, by aslcing searching questions about the role of emotions, both to those suffering from pain, and ttw professionals who treat them. For example, we need to ask whether emotions are seen as a component, a consequence, a cause or a concurrent problem and to consider the subsequent implications. As social scientists, the recognition of emotion as an integral organising principle of our lives, rather than something we fear and hide from, is essential, and has serious ramifications. Historically, we should have leamt the lesson that potentially serious implications stem from the separation of reason and feeling, not only for medical practice, but for human culture in general. Instead of the hopes of a new and better world based upon reason which Descartes envisaged - one which signified an end to ignorance and superstition - the ultimate implications of rationality can be seen in the more sinister light of '. . . the sheer rationality of Auschwitz, where the mathematical idea of a final solution bore witness to a terrible flaw in the philosophical foundations of modem Westem civilisation' '(Lynch 1985:309). Bauman (1989) reaches similar conclusions in Modemity and the Holocaust, arguing that, rather than seeing the holocaust as an aberration, it represents the fullest expression of modem rationality in all its repugnant glory. We have argued then, that important insights from the sociology of emotions, the body and chronic illness can be seen as the foundations upon which to build a sociology of pain. Both the sociology of the body and emotions are newly developing fields which offer the potential for understanding pain as a social and embodied experience. In addition, whilst important insights stem from previous work on the experience of chronic illness, pain still represents a relatively neglected aspect of the literature, although the relevance of a sociology of pain to the study of chronic illness is axiomatic. As Comwell (1984) has demonstrated, 'lay' knowledge of health and illness are grounded in people's common-sense ideas and ways of life. Consequently, they may confiict with scientific, rational and technical perspectives, which regard them as irrelevant. This, however, is far from the case as the physical reality of pain is always mediated by social and cultural factors. Although specific pain stimuli may provoke attention from the individual, such responses are mediated by the interpretive work of self and others drawing upon lay health knowledge and beliefs which give these stimuli 'subjective' meanings. They may also vary according to factors such as class, gender and ethnicity (Bendelow 1993). These factors
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162 Gillian A. Beodelow and Simon J. Williams all affect how pain is perceived, experienced, reacted to, and physically, mentally and emotiofially. In addition* they have also been shown to affect treatment and outcomes of pain therapy (Williams and Thorn 1989; Priel et at, 1991) as well as other forms of health care. Moreover, as we have seen, these beliefs are crudal to the individual and their search for meaning in the face of their suffering. This is particularly pertinent in relation to chronic pain syndromes, where pain can represent either inner or outer conflict. As sociological studies of the experience of chronic illness demonstrate, people in pain, of whatever type, need the legitimacy of their pain and suffering accepted by others, both medically and socially. This search for legitimation is part and pared of a parallel search for meaning and explanation, involving a process of narrative reconstruction in the face of the biographically disruptive nature of pain and suffering. Here pain takes on certain symbolic qualities and along with an understanding of emotions and embodiment, the inclusion of narratives of pain gives an emphasis to possibly the most neglected voice of all within the medical encounter, the subjective voice of the patient or sufferer (Kleinmann 1988). As well as being a mcdicalised phenomenon, pain is, of course, an everyday experience Unking the subjective sense of self to the perceived 'objective' reaUty of the world and other peoi^e. In this respect, the impact of culture affects and informs the experience of pain, which constitutes an integral, yet hitherto poorly researched part of health and illness. Moreover, both its exploration and explanation demand the dissolution of dichotomous thinking which has impeded a unified understanding and recognition of its cultural and biological elements. As Morris (1991) argues, by integrating the medical and cultural discourse of pain, we can transcend the false dualisms which it has been forced into, thus 'reclaiming' pain from the exclusive jurisdiction of medicine. Moreover, by recognising the limitations of pain 'measurement', analgesia and anaesthetics, we could not only increase our understanding of pain, but also help to release medicine from the impossible task of providing a 'pain-free' existence.
AckDOwledgemoits This paper has been through many drafts, and there is inevitably no limit to what can be encompassed in a paper of this natutv. but we would like to thank Mildred Blaxter and the reviewers for their helpful comments. References Amey, W. and Neill, J. (1982) The Location of pain in natural childbirth: natural childbirth and the transformation of obstetrics. Sociology of Health and Illness. 7. 375-400.
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