Why Is It So Hard to Talk and Write About Pain?
Problems in communicating pain
In The Body in Pain, Elaine Scarry makes the point that no one is ever more metaphysically certain than when they are in pain. After all, it is hard not to be a materialist when you’ve just struck your thumb with a hammer. I remember how affected I was by her idea, though, that the converse is also true: to hear about another person’s pain is to have doubt.
At first, I found this concept hard to believe. Pain is an almost universal experience; with the exception of a few people with rare neurological disorders, everyone feels pain. Babies respond to pain instinctively. Toddlers can recognize when someone else has a boo-boo. Surely pain is more likely to lead to feelings of sympathy than doubt.
The more I read and thought about it, though, the more I realized that certain types of pain are more likely to cause doubt. Pain that isn’t visible, that isn’t written plainly on the body, makes people wonder if the pain is real. We can all look at a scraped knee and say, “that must have hurt!” but sympathy is much more fleeting when the pain is invisible. “Not tonight, honey, I have a headache” is not a cliche about pain, but about making excuses.
I never expected to be in chronic pain. I was a relatively healthy thirty-eight year old man who, over a period of a few months, went from feeling “normal” most days to having pain constantly. I saw many doctors and had many tests. No one could find any cause for my pain. The good news was that I wasn’t dying; the bad news was that they couldn’t cure me.
My experience with chronic pain and health care isn’t unusual, so I won’t bore you with details. What has come to interest me is how hard it is to communicate about pain. Whether it is to family members, friends or medical professionals, I have difficulty expressing my pain.
When you first see a specialist about pain, you are usually presented with some sort of chart like the one pictured above. The “Universal Pain Assessment Tool” combines a numeric scale, a set of pictorial representations (the Wong-Baker Facial Grimace Scale), and words to allow the patient to convey their pain to the practitioner. Some doctors use this tool, others use a subset, but every medical facility I have been to uses some version of these tools.
At first glance, the numeric scale seems easy to use. The patient simply has to rate pain on a scale from no pain at all to worse pain imaginable. The problems in using the scale, though, appear almost immediately. At either extreme—no pain or worst imaginable—the patient isn’t likely to be filling out the form. Why would someone with no pain come to a doctor’s office for pain treatment? And why wouldn’t someone with the worst pain imaginable be in the emergency room?
Further problems with the numeric scale become apparent the more one uses it. The first is consistency. Is pain level six the same for an athlete recovering from an injury as for an elderly woman in a wheel chair waiting in the same office? More importantly, is either the same as what the doctor would think of as level six? If the doctor considers level six as bearable but the patients think of it as significantly limiting quality of life, what kind of care will the patient receive?
Consistency is difficult even for an individual. What does it mean for a person to rate a headache the same as a pulled hamstring muscle? Is the patient meant to rate the level of pain, the level of disability it causes, or some other measure? Another difficulty is around the differences in levels of pain. It isn’t clear whether the scale is meant to be even—with the difference between levels one and two the same as between eight and nine—or logarithmic like the Richter scale for earthquakes. If the patients don’t know what the scale is truly measuring, how can we answer it usefully?
The more often one fills out a numeric pain scale, the more questions come up. Eventually, patients begin to wonder if we are communicating anything at all. Other pain scales are fraught with the same issues. The Wong-Baker Facial Grimace Scale, for example, allows doctors to communicate more easily with patients who may not be able to use other scales (children, for example). But if the worst pain possible corresponds with tears, then we’ve all experienced the worst.
If numbers and pictures don’t work, maybe language can come to the rescue. Surely a language as rich in vocabulary as English would give us the tools to describe something as common as pain. Indeed, the language has ample words to describe pain. Consider this list from a pain assessment I recently had:
aching, throbbing, shooting, stabbing, gnawing, sharp, tender, burning, exhausting, tiring, penetrating, nagging, numb,miserable, unbearable
The words themselves are interesting. They range from the literal (tender) to the metaphorical (gnawing) to the violent (stabbing). There are some that might seem odd (shouldn’t something numb be painless?) and some that are nearly synonymous (how does shooting differ from stabbing?). There are a couple pairs of descriptions that imply degrees (tiring vs. exhausting or miserable vs. unbearable).
Of course, as descriptive as words are, they can be notoriously vague when describing a private experience. If one patient’s sharp pain is another’s penetrating pain, the assessment begins to break down. And patients can rightly wonder if this list—or any such list—can accurately describe the entire panoply of pain.
Even if a perfect scale could be designed, it isn’t clear that it could ever overcome the obstacles that prevent us from explaining our pain. Ultimately, it isn’t really about pain—though that is the root. The problem is suffering. All of the personal, cultural and biological factors that make us unique make it almost impossible to convey our inner experiences to other people. When it comes to pain, then, at some level we may always suffer alone.