Friday, May 17, 2013

Melzack and Katz, Pain. Part 3b: Pain is not receptor stimulation

The paper, Pain.

Part 1: Pain. First two sentences
Part 2: Pain is personal
Part 3a: Pain is more than sensation: backdrop

The next sentence in the abstract is,
"Pain processes do not begin with the stimulation of receptors."
Biomedical models of pain
Pain science is generally taught as if it were a short story, with a beginning, middle, and end.

In the beginning were the nociceptors. They were stimulated. The signal went up to the brain. The infant recoiled as its brain registered the input. The child learned to avoid light sockets and stove elements. The child fell, broke his arm, broke her collarbone. It healed easily with no disturbance of function. The person who bore up under ordinary childhood trauma learned to bear up under any sort of adversity, thrived, built a life, died of old age. The person had a normal pain system. At one end of it are nociceptors, and at the other end, death, and in between there are occasional warning bells and maybe operations for this or that, joints that wore out and needed replaced, an appendix that burst while a teen, a couple pregnancies and normal deliveries perhaps.

This is the standard, third person narrative that biomedical researchers use as their frame for "normal." They have to start somewhere, you see. They exist outside of it, and they study pain as if it were a thing, like a bug. Like a noun. They have to pretend it's a thing, because their true quest is to try to figure out how to measure "it," so they can develop ways to fix it.

The problem arises with pain that is outside "normal" - it's hard for them to study whatever exists outside the usual narrative. What's the cause? They look hard for the cause. They are still looking for causes. Which is fine. But a gap exists, where, if there is no apparent cause, pain must be the patient's own fault somehow. 

Biopsychosocial models of pain
Melzack and Katz are saying, no no. Au contraire.
Pain is not a "thing." Pain is a perception. Pain is not a noun, it's a verb.
A person whose nociceptive capable fibres are stimulated, no matter what age, is already a person with a life and a brain and an intrinsic sense of self, whose existential questions will always elude answer, no matter how attractive the hypothesis, or how socially accepted or covered with gilding they may be. [Like the insides of churches in Europe.]
That sense of self will feel itself to have been attacked on some level of its function, and will have learned to cope, or not, depending on how it was raised and what its genetic foundation was to begin with.
Pain is a process that enters into the conscious awareness of an individual, whose brain is already processing everything as perception, according to whatever foundational pathways it has already developed and learned to favour.
That individual was born innocently into a context that preexisted him or her, a context which was, and still is, also a verb, comprised of other individuals, with processing brains that are also more verb than noun. Life moves. Life is the ocean. An individual is a river with mighty currents and undertows. Nociception is a little stream into it, but it's not the ocean, not the river, not the currents. 
Sometimes the context, the family, the cultural container, the relationships, the job opportunities and working relationships, provided the right mix of circumstances and opportunities for a learned, robust resilient response to emerge from that person's brain. Sometimes, it didn't. And doesn't. And won't.
Sometimes the person's own genetic foundation is sufficient to mount a successful resilient and robust response to a pain perception in spite of the random circumstances of birth and life. Sometimes it isn't. Sometimes the individual has the means and options available, in the moment, to consciously choose an action that will decrease or eliminate his or her pain. Sometimes, he or she does not.

My take
As humans, we end up embedded into a context of cobbled up social, cultural, familial and community ties and obligations. Our illusion usually is that we have chosen our lives. The truth is that usually our psychosocial lives have chosen us, and we either blithely, or numbly, or in some combination, follow the traces of a culture we're born into, speak its language, follow its mores, adhere to its morals (or at least try to), pray to its god or gods, and die upon its bosom.
Melzack and Katz are aware of all this, and how shaped we all are by all of it. They're saying, look, it's not the pain patient's fault they have chronic pain. Life is an ongoing dance between an individual and the forces which have shaped that individual and the pulls and tugs upon that individual by everyone with whom they are connected, not only their biology, not only the genetic array they were born with. It's called "life," and it has the beginning, middle and end. And every life has a context - every individual has a psychosocial environment that preceded, and will outlast, her or him, and with which that individual must interact. Yes, yes, we know we can't "treat" the whole frickin' culture, but let's at least factor it into the picture. Let's make a new, more realistic model that includes it all! 

Let's teach them a little bit about water cycles..

That way, when a person comes to us with pain that won't go away, we can use this model that doesn't objectify them or refuse to acknowledge them as subject in the midst of their own life. Life is interaction. You know that's true. It's true even at the fundamental, biological level. So, c'mon people: We can't treat people as though they were identical objects. Or bugs. At least not when they're awake and trying to understand why they have pain. We have to have a pain model to use when we interact with live, awake people, so we can help them begin to understand that not only is their pain not their fault, but that it isn't anyone else's fault either, particularly;  a model that helps them see that they have a sense of self, illusion though that may be, and that it has considerable leverage in there. That they might place their sense of self in various domains, consider their own existence from various perspectives. That they might begin to unravel the tangle within that they may have never even known existed. That they do have a locus of control. That they can begin to move again, maybe only their perspective, at first; then, maybe, eventually, physically too. A perspective that they possess, and must embrace, and learn to wield. 

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