Biological structures are indeed a huge thing to consider when managing and
treating pain. But since we are living alongside other people, there are also
many social factors impacting our pain sensation and exposure. Kenneth D.
Craig, OC, PhD, Professor Emeritus of Psychology at the University of British
Columbia in Vancouver, is here to discuss how family connections, culture, and
society largely influences an individual’s expression and lived experiences of
pain. Dr. Kenneth also explains how these psychosocial factors affect
marginalized populations who are typically underserved in terms of pain care
and what he is doing to remedy this long-term problem.
In this episode, we’re discussing the influence of social factors on pain recovery. My guest is Dr. Kenneth Craig. Dr. Craig is Professor Emeritus of Psychology at the University of British Columbia in Vancouver. His research focuses on pain assessment using nonverbal methods in populations with communication limitations, as well as the importance of psychosocial factors in understanding pain and managing pain.
Dr. Craig has been Editor-in-Chief of Pain Research and Management and the
Canadian Journal of Behavioural Science, and has served as President of The
Canadian Pain Society, as well as an active member of the International
Association for the Study of Pain. In this episode, we discuss why social factors
are important when they come into play, how they are related to the lived
experience of pain and how they affect the care of marginalized populations.
Let’s begin and learn about the social influences of pain with Dr. Kenneth Craig.
Ken, welcome.
It’s great to be here, Joe.
Thanks for joining me. It’s a pleasure to speak with you. I was looking over the great paper that you wrote on pain and marginalized groups. As I was thinking back through our evolution on this show talking about biological factors and social factors, we’ve covered that quite in depth.
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People are aware of the BioCycle and the social aspect, but we haven’t covered the social aspect as deeply. Why are the social factors important when we talk about pain experience?
People certainly endorse the biopsychosocial model but most of the emphasis goes on the entrapment of the biology of pain and the psychology of pain. Biology is of paramount importance. We need to know the nature of the injury, the disease or the source of the pain. The biological interventions are first in line and have to be used as effectively as possible but less than 50% of people suffering from chronic pain have a solid biological explanation in tissue damage or disease to account for it.
There is discomfort. Similarly, there are huge individual differences in people suffering from acute pain, ranging from people who are quite stoical and handle it with stoicism to people who are highly reactive and suffer considerably. A lot of that variants can be explained by focusing on psychological factors and social factors but indeed, the psychological factors are probably best explained in terms of the social processes. What we think about, how we think about things and the thoughts and contents of our observations usually have their origins and interactions with other people and what we’re exposed to.
We see the thoughts or cognitions that we have in our head or mind as our own, but there are outside forces that are influencing how we think, feel, and behave.
Maybe the best evidence for that is if the person comes from a family in which there’s an unduly vigorous preoccupation with pain and pain avoidance, the child is somewhat predisposed towards that pattern of thinking. Likewise, parents, other siblings, and people in the nuclear family will model coping adaptive reactions.
You mentioned the person with pain and then you took it maybe one step from there. You took it to the family structure so maybe your immediate spouse, your children, or maybe your parents if you’re a child or an adolescent. That’s more in a social container.
It’s my focus. The biological and the psychological are exceedingly important, but the social has been relatively neglected so that has been what I’ve attempted to focus on. These patterns of emotional reactivity and thinking depend upon biological structures and evolution responsible for the brains we have and the kinds of things that we attend to. That’s very important. We get exposed to the immediate environment early in childhood and so throughout childhood and into adulthood. Those historical events and the life history of the individual are important as is the immediate social context. In my clinical work, I’d always focus on those domains.
How far does the social extend out from that circle? Besides family, there are things like friends, work, and other aspects of society that could influence one’s perception of what’s happening to them.
There’s been a long history of characterizing societies, countries, or regions of the world in terms of their reactivity to pain. I don’t know that my gross generalization has broad applicability. I think it does. We tend to think of people living in the Mediterranean cultures as more reactive than vigorous and pain avoidant than the more stoical people in the Northern parts of the Northern Hemisphere. It’s a very broad generalization of huge individuals and differences in each of those communities. The main differences are likely to stand up.
The broader culture can have an impact on one’s pain experience.
Yes. It is how pain is modeled by other people. People in the family are part of the community, the ethnic group and the society at large so it drifts along in that manner.
Pain exposure is oftentimes a part of pain treatment. Whether it’s graded activity or vivo exposure, there are a lot of different ways that healthcare providers use exposure to pain as a method of treatment. We talked about it probably a little bit here. We’re dancing around it a little bit, but how do those social factors influence the exposure?
I have a model of pain which I’d like to look at, like the temporal sequence, beginning with exposure to pain and the social factors that contributed to it, moving into pain experience to the thoughts and feelings of the subjective experience, and then the expression of pain, how the social factors would influence that. There’s the social world that we interact with such as our family, our friends, the community and health service providers.
At the level of exposure, environments are of variable risk. If you work in an occupation where the risk of injury is substantial like you’re a professional football player or a blue-collar worker in an industry that requires a lot of heavy labor or manipulation of tools, then your vulnerability is increased. It behooves us to focus on minimizing risks for people in those environments. Occupational health and safety experts are very much focused on safety. I mentioned professional football players. I suspect there’s increasing interest in minimizing the risk of exposure to serious painful injury.
In the United States, we had our Super Bowl, so we’re talking about maybe soccer players and American football players who both have somewhat risks to them with regard to injury.
We’re talking about hockey players too.
Also, the impact on the brain and the nervous system.
Big guys are skating at full ski speed or running at full speed. The objective is to smash into the other person. You’ve got a 350-pound person operating and smashing into you the risk of painful injury serving the ball. In these sports, I doubt that there’s much attention given to documenting the long-term consequences of having participated but I’d wager that these players in the Super Bowl are vulnerable to painful injuries as they grow older. I know conceivably, even longevity could be influenced.
There are certainly traumas that they’re experiencing throughout the history of their life and it’s going to have an impact on how their body responds. As I listen to you speak, you mentioned early life experiences may shape how someone experiences pain, how the family unit may inform how someone experiences pain and the broader culture may have an influence on what someone’s experience of pain is.
When I think of the pain experience, for the most part, it’s what is happening inside. You don’t necessarily see that happening. You can see certain pain behaviors but you don’t know what’s going on inside unless you query or ask someone about it. How does the culture or society at large have an influence on one’s expression of pain? Now that I have pain and I either want to share it with someone or communicate with someone, how does the culture
influence that?
In infants and very young children, we know that they’re in pain because they are expressive. Crying, facial grimaces, and bodily reactions have a strong basis in evolution in the sense that these reactions allow other people to know that the baby is in distress and that intervention might be wanted. These are automatic reflexive not necessarily modulated by cognitive higher order or cortical mechanisms. As children grow older, they become more social and learn to communicate in a manner that’s consistent with family and
societal expectations.
Some level of reactivity is appropriate because it allows parents and others to intervene on the child’s behalf but excessive reactions or no reactions whatsoever have the potential to lead to more serious kinds of problems like children who don’t let others know that they’re in pain and people who suffer from what’s known as congenital insensitivity. They’re vulnerable to painful injuries and diseases that can reduce their longevity. These people don’t seem to live as long because they don’t enjoy the benefits of the warns about disease and injury processes that should be dealt with.
Babies and young children are more reactive to pain from almost an evolutionary response to it. As we mature, age and go through the developmental phases, our reactions may be what you term more appropriate or culturally acceptable. Is that the same thing?
Yes. We are finally intuned in our social environment. You and I are working hard to be appropriate in terms of how we define the interview that we’re going through at this stage of the game. It’s the same for pain and pain communications. They get shaped by the society that we live in. No question about that.
Sometimes, depending on where you work in pain management or pain care, in some places, it’s acceptable to allow patients to express their emotions about pain and that may include crying and being very upset. There are other places and maybe with other certain types of health professionals where that’s not encouraged. Sometimes they even see that as the patient is in distress. Crying might equal distress to some clinicians but that’s not necessarily the case.
Most of us are alerted to extreme things. Those that are most distressing to other people are the high levels of reactivity. They truly get the most attention in the literature in part because people whose painful reactions are tampered with become suspicious of people who are particularly vigorous in their reactions. Issues of validity and credibility of the pain behavior of the other person mound.
As a psychologist working in pain clinics, I found that my medical colleagues and the other health professionals there turned to me to provide some judgment concerning the legitimacy of individuals’ complaints. In my research, we spent a lot of time looking at self-report and nonverbal behavior. Self-report is the primary vehicle whereby we assess the subjective experience. My thoughts have gone to the importance of non-verbal expression.
You downplayed the importance of non-verbal expression and human communication. Both you and I are paying a great deal of attention to the facial expressions and the other version. We do that all the time. My generalization for that is that we use that nonverbal information to assess the credibility of the self-report. I tend to think of self-report as more readily manipulated in terms of self-interest.
Nonverbal expression is not quite so readily manipulated and probably is trusted by other people substantially. There’s research evidence-based for that particular claim. Both self-report and nonverbal communication plays very important roles in communication. In the pain clinic, we’re interested in assessing the nature and severity of pain.
I should also talk a little bit more about the subjective experience in the sense that there’s so much emphasis on pain sensation. I like to talk about the complexity of this subjective experience and point out that thoughts and feelings are major components of personal experience as well as sensory input. I don’t want to downplay the importance of sensory input but one can amplify, modulate or diminish the importance of the century and put through emotional reactions and particular thoughts and feelings, which moves us in the direction of therapeutic interventions. You can design therapeutic interventions specifically for century processes, the emotional reaction of the individual and their thoughts.
All three are important areas that probably need to be addressed for someone to reach the level of recovery that they’d want to reach.
The potent medical interventions are oriented to the words pain and sensation so analgesic medications but then you could turn to the emotional reactions of the individual. Most often anxiety and fear but anger and depression can be modulated through pharmacological interventions. Pharmacopia can also be addressed through psychosocial interventions. The psychosocial interventions teach people skills and those skills remain with the individual, even though say the medication is no longer available to them. There are specific interventions evidence-based developed for anxiety and depression at this stage of the game.
There are benefits to having skills where if you leave your medicine at home, you don’t have the medicine but the skills always stay with you. With the whole social topic that we’re talking about, how does this tie in or start to intersect with marginalized groups in our society and how we may be serving or not serving them in pain care?
Hugely, as a general principle, the services are most readily available and used by people in the middle to upper ranks of society and people who live in marginalized communities. Our focus has been on indigenous communities, the LGBTQ population and people with intellectual disabilities and other cognitive deficits of that type.
The documentation in those communities and others like them and the list could go on and on is that pain is not recognized as important. People do not intervene to provide services for them as promptly as they would for people like you and me who are highly functional and adapted and know how to access the resources and attract the attention of other people. We need to think specifically about those socially marginalized communities and what services should be delivered to them.
When you say they don’t have access versus adequate, there are two different topics. Someone can have challenges with access to pain care and then someone could have challenges with receiving adequate pain care. Is it that they’re more challenged to access pain management or once they do access it, it’s not adequate or probably both at play here in some way?
Accessing is a skill. It’s something that you learn as a child. You recognize that you have personal needs. Once you move into the adult years, you recognize that you’ve got to exercise these skills independently and assertively to get care. Another element would be effectively communicating the nature of your distress to other people. My employment in pain clinics has reflected my professional expertise in assessing psychosocial factors.
I would use interviews and brief psychometric devices, paper and pencil questionnaires, to access issues concerning stress, depression, critical incidents in people’s lives, their life history and those kinds of things to establish where they would fit into the painful condition that has led to the person to present themselves as a patient in a health clinic.
When you say skills, that starts the point too. Someone has to have some foundational health literacy or pain literacy to realize what’s happening to themselves and then how to negotiate the healthcare system, which can be difficult in probably most parts of the world when it comes to pain management.
I’ve read proposals, and I don’t think anybody has ever implemented them, but those suggest children should be purposefully exposed to pain to teach them how to effectively communicate the nature of their distress to other people without these excessive reactions that I’ve talked about that illustrates it.
We’ve all experienced an injection when we were younger. There’s an opportunity there to express pain and process pain to a certain extent and what that means. It is interesting to think that these are some of the marginalized groups. We’re talking about millions of people in every country that don’t have access to adequate pain management. We’re talking about social. What does that mean for a society when you have millions of people who cannot access adequate pain management?
That is a topic somewhat separate from how people react and cope with pain when it’s presented to them so healthcare professionals can use strategies that minimize pain and distress in the course of injections. Parents can be taught for minimizing their apparent distress. It has a retaliating effect on the children. I can’t get my head around the complexities of delivering pain management services to a large number of people who are suffering from pain. Also, communities and societies that don’t think in these terms as you and I do.
It’s a large problem. I feel like there’s been an awareness that’s been raised around significant amounts of people with chronic pain, and it’s inappropriately treated with medication or surgeries for certain conditions and things like that. Now that we have all that, we’re starting to look at who’s on the very outside of the circle that we’re missing. They’re not receiving anything like medication, primary care consult, psychology or physical therapy. They’re receiving nothing almost. Those are the quiet lives of desperation that we have yet to say, “There are human beings out there that need adequate care.”
The International Association for the Study of Pain, founded many years ago, has done a wonderful job of spreading the word concerning the importance of a better understanding of pain management to the kinds of communities that you’ve talked about. I’ve sat on the council of IASP and have been impressed by the breadth and diversity of professional and geographical representation in that organization. IASP has done a wonderful job in that respect.
Ken, it’s been great speaking with you. Let everyone know how they can learn more about you and follow your work.
It’s been a pleasure to talk to you, Joe. I would be happy to correspond with other people.
Make sure to share this episode with your friends and family on Facebook, LinkedIn, Twitter, or where everyone is talking about chronic pain and the social aspect of the pain experience. I am most active on Instagram. You can reach out to me there. My handle is @DrJoeTatta.com. Connect with me and I’ll be sure to connect back with you. We’ll see you in the next episode.
Kenneth D. Craig, O.C., Ph.D., F.C.A.H.S., LL.D. (Hon.) is Professor Emeritus of
Psychology at the University of British Columbia in Vancouver, BC, Canada.
Following studies at Concordia University, UBC, Purdue University and the
Oregon Health Sciences University, his academic career has been at UBC. His
research focuses upon pain assessment using nonverbal methods in
populations with communication limitations, including infants, young children,
people with intellectual disabilities cognitive impairments and dementias,
voluntary and automatic control in pain expression, and the importance of
psychosocial factors in understanding and controlling pain, described in the
social communication model of pain.
He has been Editor-in-Chief of Pain Research & Management and the Canadian
Journal of Behavioural Science and has served as President of the Canadian
Pain Society and the Canadian Psychological Association and on the Council of
the International Association for the Study of Pain. Awards include appointment
as an IASP Honorary Member, the Canada Council I.W. Killam Research
Fellowship, appointment as a Canadian Institutes of Health Research Senior
Investigator, the Canadian Pain Society Distinguished Career Award, the
American Pain Society Jeffrey Lawson Award for Advocacy in Children’s Pain
Relief, an honorary LL.D. from Dalhousie University, and investiture as an
Officer of the Order of Canada.
Effective Date: May, 2018
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