making sense of everyday pain

Making sense of everyday pain

Sarah Aldricha, Chris Ecclestonb,*aPain Management Unit, University of Bath, Bath BA2 7AY, UK

bNational Hospital for Rheumatic Diseases, Upper Borough Walls, Bath BA1 1RL, UK

Abstract

A social constructionist analysis is reported of how sense is made of everyday pain. Q factor analysis is usedwithin a critical framework as Q methodology. Sixty-one participants completed the procedure. Eight factors or

accounts of everyday pain were derived. These are reported as pain as malfunction, pain as self-growth, pain asspiritual growth, pain as alien invasion, pain as coping and control, pain as abuse, pain as homeostatic mechanismand pain and power. Common to all of the accounts is the theme of how pain relates to self, and in particular, of

whether pain can change self. This theme is expanded and discussed in terms of how self is protected andlegitimated in a context of pain as a fundamental threat. Implications of this study for how to understand theexperience of àbnormal' pain are discussed, as are possible new research routes. 7 2000 Elsevier Science Ltd. Allrights reserved.

Keywords: Pain; Self; Social construction; Q-methodology

Introduction

Pain is a central and ubiquitous part of human ex-perience. It is an e�cient reminder of the boundariesof physical and mental possibility (Bolles & Fanselow,1980). Although pain is a common, everyday occur-

rence, research attention in the social sciences hastended to focus on the clinical case and the context ofàbnormal' pain (e.g. Baszanger, 1992; Garro, 1994;

Eccleston et al., 1997). Making sense of the experienceof pain within a clinical or medical discourse is oneamongst many of the stories available in culture (Mor-

ris, 1991; Del Vecchio et al., 1992). However, mappingthe diversity of the culture of pain should allow a com-

prehensive view of how people broadly make sense of

pain. O�ered in this paper is a social constructionistanalysis of the accounting practices used in makingsense of èveryday pain'.

Recent analyses of pain as a cultural event havestressed the importance of language and history in theconstruction of its meaning (Scarry, 1985; Morris,1991; Sullivan, 1995). Building upon this tradition,

pain may best be understood by further researchingthe local cultures in which it is negotiated and rep-resented. It is this complex of social, cultural and lin-

guistic forces that frames the topic of thisinvestigation. Two principles of analysis helped tosteer this investigation of `pain culture'. First it was

assumed that the multiplicity and diversity of under-standings and representations of any topic are dynamicand negotiable. Texts always emerge from a wider tex-

tuality of meaning (Geertz, 1993; Stenner and Eccles-ton, 1994). Second, as Beryl Curt (1994) stresses, such

Social Science & Medicine 50 (2000) 1631±1641

0277-9536/00/$ - see front matter 7 2000 Elsevier Science Ltd. All rights reserved.

PII: S0277-9536(99 )00391-3

www.elsevier.com/locate/socscimed

* Corresponding author. Tel.: +44-1225-826-439; fax: +44-

1225-826-381.

E-mail address: [email protected] (C. Eccleston).

textuality of meaning is never free-¯oating but is

always grounded within moral and political domainsthat have been constructed and socially sedimentedover time.

The archive of knowledge and practices of any sub-ject can be scrutinised in the accounting and represen-

tational practices that construct that subject (Foucault,1989). The texts that signify meaning can be in anyform: discourse, conversation, music, dance, gesture,

image, or even the absence of these as in the silencesbetween words and/or people (Parker, 1990, 1992). Wehave access to a large number of fragments of expla-

nation available to us at any time. This does not meanthat identities can be constructed at a whim, or that

we can simply talk ourselves in or out of being(Sawicki, 1991). Rather, it means that sense can onlyever be made in a limited number of ways, and that

some stories or texts will have a greater currency thanothers (Shotter and Gergen, 1989), whereas other stor-ies or texts will be harder to understand and justify

(Stainton Rogers and Stainton Rogers, 1992).Central to the practice of making sense of the world

is the prevalent modern idea of a coherent and consist-ent self (Foucault, 1991, 1992; Gergen, 1991; Harre,1991a). This modern `self' is contained within physical

and representational boundaries. This embodiment ofself has become, within Western medicalised techno-logical cultures, the site of political, moral and social

disputation (Foucault, 1991; Harre, 1991b; Turner,1992). The body is the centre or focus of explanation

and representation. The body must be explained anduncovered for what it can tell of `reality'. It is oftenonly with a clinical gaze that the anatomy of the body

and self can be represented and pathology displayed(Armstrong, 1984).

The body remains a dominant metaphor and modelfor self. It provides defensible boundaries that must beprotected against attack or invasion. Katz and Shotter

(1996) have argued that when the embodied self comesunder scrutiny for possible disease or damage, othernonmedical possibilities to understand self or `ways of

being', are silenced by the dominance of the clinicaldiscourse. Pain, in particular is absorbed in contem-

porary clinical discourse into the technology of diagno-sis and treatment.This positioning of pain as primarily diagnostic is

played out not only in medical discourse but in every-day representations of pain and analgesia (Scarry,1994). Dominant in these representations is the idea of

pain as an attack upon the body and person that typi-cally arises from outside of the body and is often itself

embodied as a malevolent aggressor (Kern, 1987).This investigation explores the diversity of under-

standings that are socially and linguistically available

in making sense of everyday pain. Any understandingor theory of how people make sense of pain regarded

as `abnormal' must be informed by an understandingof pain as a `normal' everyday phenomenon. This

study, designed to explore the culture of normal pain,will probably ®nd accounts in which pain is commonlyunderstood as an aversive and unwelcome indicator of

a body in need of repair. It is possible, however, thatthe very dominance of this account masks or occludesother ways of understanding and living with pain. The

aim of this study is to allow for the emergence of suchother possible meanings of pain.

The study

Researching diversity requires an approach thatforces variability rather than one that attempts to con-

trol or reduce it. A study of individuals or even adescriptive statistical study focussing on samples of in-dividuals would be inadequate. Q methodology was

chosen from a series of pattern analytic methodologies(e.g., high class, di�erential function analysis, etc), thatif applied within a critical framework can permit botha di�erence and commonality in accounting of experi-

ence (Brown, 1980). Q methodology generates the ex-pression of understandings through the structuring ofa large number of culturally derived statements. The

statements represent a `` . . . thought maze throughwhich the subject's attitude wanders, attaching itself tothis idea, rejecting that one and ignoring others''

(Brown, 1980, p. 31). This approach has the addedbene®t of allowing the unexpected to emerge; Ideasthat are culturally opaque to the researcher or whichare obscured from view can gain prominence, some-

times challenging the researchers' own assumptions(for further discussion of this topic see StaintonRogers, 1991). In what follows the process of sampling

from culture, of preparing materials, is as important asthe sorting of ®nal items. In addition, the participantswho help with this research are not described or

revealed by the results; rather they are collaborators ininterpretative analysis of a shared social and linguisticculture of pain (Mulkay, 1985).

Sampling

Cultural analysis is necessary at the very ®rst stage

of Q methodology. This involves sampling the culturefor talk about pain to create a set of sortable state-ments (Stephenson, 1986). Having identi®ed that pain

is talked about in limited ways in our culture, thestudy was designed to identify possible accounts ofpain. Ideas were ®rst generated from pain researchers

and clinicians: for example, pain as a sign of disease ordamage, pain as spiritual redemption or as punish-ment. Speci®c statements for this study were generated

S. Aldrich, C. Eccleston / Social Science & Medicine 50 (2000) 1631±16411632

by `trawling' multiple reservoirs (but also ponds andpuddles) of text where talk about pain was likely to be

found. These included medical, psychological andother academic texts, popular and professional mediaand focus group conversations.

The aim was to collect approximately three timesthe number of statements required for the ®nal Q setbecause it is suggested that this will ensure coverage of

the majority of possible texts of the issue under scru-tiny (Stainton Rogers, 1995). The search generated 222statements, which were then checked for similarity and

intelligibility. Duplications were removed. The state-ments were further checked for intelligibility by twocolleagues, and removed or reworded to ensure simpli-city and comprehensibility. Balance was ensured by the

comparative method of sorting the statements from thedistinctive perspective of, for example, stereotypicalfeminists, Marxists, or sado-masochists (Stainton

Rogers, 1991, p. 130). Using this procedure, a ®nal Qset of 80 statements was reached.

Participants

Participants were selected for diversity. E�orts were

made to include members of groups who might beexpected to have divergent understandings of everydaypain (Curt, 1994, p. 121). With Q methodology therepresentativeness of the sample of participants is not

at issue as participants are sampled to access a con-course of ideas rather than a population of people.Participants were drawn from a wide background, with

enlisted participants being asked to suggest anotherpossible participant in a limited `snowballing' tech-nique. Participants described themselves in a variety of

ways, such as by profession (e.g., architect), by hobby/enthusiasm (e.g., keep-®t enthusiast) or by health/ill-ness status (e.g., chronically ill). In all, 95 people

agreed to be participants of whom 61 responded withcompleted packs by the deadline. The incomplete re-sponse grids from eight participants were excludedfrom the study. Fifty-four complete sorts were included

in the analysis.

Analyses

Each Q sort (response grid) was entered into PQMethod 2.0 (Smolck, 1997), a programme speci®callydesigned for Q-factor analysis. Each Q sort is corre-

lated with each other Q sort and the resulting intercor-relational matrix is then subjected to a principlecomponents analysis, with the solution then rotated

with a varimax procedure (Stainton Rogers, 1995). Theresultant factors from the PCA each indicate a re-sponse pattern that is statistically orthogonal to the

other factors. A `best estimate' sorting pattern is calcu-lated which is known as the factor sort. In addition,

one or more of individual participants sorting patternsmay load highly (>0.6) on the factor. These individualsorting patterns are known as exempli®catory sorts. (In

statistical terms the ®rst factors extracted have highereigenvalues, accounting for larger percentages of thetotal variance).

The analysis revealed eight factors. Interpretation ofthe factors is enabled by three forms of summary in-formation: (a) the factor sorts, (b) comments on state-

ments of the participants who provided exempli®catorysorts, (c) biographical and other information o�eredby these participants. It should be stressed that theseeight accounts or stories are patterns of associations

that are possible within our culture of everyday pain.No claim is made for these being the only accountspossible, or that these are stable to one person or one

setting. Q methodology provides the means for partici-pants to endorse or reject a collection of ideas thattogether provide a coherent account that is able to

make sense of everyday pain (Stainton Rogers, 1991).

Account 1: pain as signal of malfunction

Nine participants' Q-sorts exemplify this factor. The

dominant theme of this account is of pain as a sign ofserious damage that requires repair. The statements``Pain signals that the body machinery is going wrong''and ``When you have a pain, the most important thing

is to know why you have it, what is causing it'' bothregistered strong agreement at (+6). This agreementwas tied closely to a perceived need for action to

reduce the pain or ®x the damage: also endorsed at(+6) was the statement ``If you have a pain you oughtto do something to make it better''. This need to take

remedial action is particularly important if the painseems to be located in places that may indicate aserious threat. The statement ``Pain in some body

parts, for example the head or chest, should be takenmore seriously than other pains'' receives strong agree-ment at (+5). Likewise pain that is other than transi-ent requires attention; ``Pain is serious if it goes on for

too long'' is positioned at (+5). This account con-structs pain as diagnostically useful. Indeed, oneshould communicate about the pain in order to avoid

su�ering; ``People should say when they have pain,they shouldn't have to su�er in silence'' receives strongagreement at (+5). Typical comments on these highly

endorsed statements were:

Find the cause: don't su�er!That way lies the cure.

And then you can get to the bottom of it.

Diagnosing the cause of pain was not necessarily thetask of professional medicine; ``Pain is a medical pro-

S. Aldrich, C. Eccleston / Social Science & Medicine 50 (2000) 1631±1641 1633

blem, it should only be treated by doctors'' receivesdisagreement at (ÿ2). Participants commented:

Not if you know what the pain is and have got ridof it yourself before.If it is undiagnosed, get medical help.

Responsibility lies with the person in pain to tellothers about it and to make decisions regardingwhether expert medical help is required, and our tech-

niques for dealing with pain have increased. Forexample, the statement ``We don't know what pain istoday in the UK, compared with people living say a

hundred years ago, or for people in the third world''receives agreement at (+3) and produced commentssuch as this one:

I would much rather have a tooth pulled today,rather than years ago.

This responsibility also extends to ensuring that they

do not cause pain by neglecting, abusing or overusingtheir bodies, as well as by failing to respond to expertmedical advice. For example, the statement ``People

bring pain on themselves, if you don't take care ofyourself properly you can expect to get pain'' isendorsed at (+4). It is recognised, however, that some

pains are inevitable. ``There are some pains you canexpect, like headaches and muscle pains'' is endorsedat (+3). Further, not all pains are regarded as due toirresponsibility, as is evidenced by the endorsement of

the statement at (+4) of ``Many people have pain whodon't deserve it''.In this account pain is instrumental in the method

of repairing a malfunctioning body. Statements thatsuggest other uses for pain (e.g., for pleasure or self-control) are not endorsed or rejected where they do

not refer to repairing a physical body.

Account 2: pain-as-self-growth

Three participants' Q sorts exemplify this factor. Inthis account pain is an inevitable, essential and enrich-ing part of life for both men and women. The pos-itions of strongest agreement (+6) are occupied by

three statements stressing the centrality of pain tohuman experience and its value to us: ``Pain is as el-emental as ®re and ice, it belongs to the most basic

human experiences that make us who we are'', ``Thereare some pains you can expect, like headaches andmuscle pains'', and ``Pain is essential to being alive, we

couldn't survive without it''. One participant whosesort exempli®ed this factor stated that

Pain is a natural part of our everyday being.

There is agreement with ``You can't separate outphysical, mental and emotional pain'' (+4), becausepain is an integral part of emotional life: endorsed was

``The greatest things in life, like love, are tinged with

pain'' (+5) and rejected at (ÿ5) was `Ìt is a basic

human right to be pain-free''. To not feel pain would

be to deny an elemental aspect of experience. To per-

sist in trying to avoid or escape it does not then make

sense; strongly disagreed with at (ÿ4) was ``Whatever

the pain, if it's yours it's unbearable and you should

do anything you can to get rid of it''. Certain types of

pain should be welcomed for the lessons they are able

to impart, particularly those pains associated with

achievements or developments. ``For some experiences

like having a baby or running a marathon, pain is

such a part of the experience that not to feel it would

be to miss out'' is endorsed at (+3).

Shared with account 1, the diagnostic utility of pain

is also endorsed, re¯ected in the agreement at (+4)

with three statements: ``When you have a pain, the

most important thing is to know why you have it,

what is causing it'', ``Pain in some body parts, for

example the head or chest, should be taken more

seriously than other pains'' and ``Pain is serious when

it goes on for too long''. However, rejected was the

professionalisation of pain as the preserve of medical

doctors who are able to cure. Pain is not pleasant, but

as one exemplar put it, it is `ìndispensable''.

Pain is intrapersonal, not interpersonal; it is con-

tained within the self. Any intentional or unintentional

sharing of pain is rejected: the statement ``When I am

in pain, my family and everyone around me su�ers'' is

rejected at (ÿ3). Nor should someone in pain expect

that others would respond to clamorous or exagger-

ated accounts of su�ering: ``The only way to get others

to take your pain seriously is to shout loudly about it''

is also positioned at (ÿ3). Strength is gained throughpain and in response to pain. ``The ability to withstand

pain is important to your self-respect'' receives strong

agreement (+5). This statement generated the com-

ment:

I tend to play down pain: `Ì'm all right'' Ð even if

it bloody hurts.

Self-control over this pain is paramount and hence

pain is not to be feared above all things: ``The experi-

ence of pain is more frightening even than death'' was

rejected at (ÿ4). Pain is not in¯icted by an outside

mysterious or religious force and is not a way to ato-

nement or redemption. In¯icting pain for sexual plea-

sure is disagreed with at the extreme (ÿ6). Equally

disagreeable is the idea that one can or should in¯ict

pain on others, either for obedience or for punishment:

``Sometimes one needs to in¯ict pain to promote obe-dience'' was rejected at (ÿ6) and ``Punishment through

pain helps people to learn right from wrong'' was

rejected at (ÿ3).Central to this account is the idea that pain is a fun-

damental aspect of life, something that needs to be


understood (and may aid treatment), but if it is underone's own control pain can be a means to self-knowl-

edge and development and a mark of mental andemotional strength.

Account 3: pain-as-spiritual-growth

One participant's Q-sort exempli®ed this factor. Hereports that his religious experiences in¯uenced his pat-tern of sorting. This account is predominantly in¯u-

enced by Christian religious thought. Pain is notregarded as a medical issue or as a problem for treat-ment by health-care professionals: the statement ``Pain

is a medical problem, it should only be treated bydoctors'' was rejected at (ÿ6). Pain is elemental, anessential aspect of the human condition. Whereas inAccount 1 it was part of having a `body mechanism',

and in Account 2 part of having an embodied self, inthis account it is an intrinsic part of possessing a`soul'. Pain can make the su�erer stronger through the

growth of the spirit or soul, by the strengthening ofthat which is `God-like' within us. The statement``Pain is a way to spiritual redemption, we must su�er

in this life to be saved in the next'' is strongly endorsed(+6).This is not an account in which self-punishment or

self-harm should be practised to bring one a releasefrom sin. Pain is not a relief to the self, but an oppor-tunity for the self to give way to God. Hence the state-ment ``When we feel unhappy, worried or angry,

hurting ourselves can bring some relief'' is stronglyrejected (ÿ5). That pain could be in¯icted by God (orhuman agencies) as a means of control receives the

strongest rejection; the statements ``Punishmentthrough pain helps people to learn right from wrong'',and ``Sometimes one needs to in¯ict pain to promote

obedience'' are both positioned at (ÿ6): to judge andpunish is the role of a merciful God. Rather, su�erersshould accept that pain will come to them as a central

part of the experience of being human; ``Pain is as el-emental as ®re or ice, it belongs to the most basichuman experiences that make us who we are'' isstrongly endorsed (+5). Through uniting their pain

with the su�ering of Christ at the Cruci®xion, su�ererstrans®gure both their pain and themselves into some-thing `God-like'.

The acceptance of pain will not mean gainingfavours in the after-life such as time in purgatory, orreceiving easy access to heaven; rather it represents a

communion with the risen Lord in a deeper under-standing and experience. The one participant who gavethe exempli®catory sort comments that we must:

Su�er in order to be free in this world.

In this way we will escape the bodily and base `self'.Pain will take us away from our selves; strongly agreed

with at (+6) was ``Pain raises us to a higher plane ofunderstanding and experience, it is mind altering like a

drug''. In this peak experience in which the sins ofembodiment are transcended, the pleasure of movingcloser to oneness with God can exist at the same time

as pain. This is also the only account where the state-ment ``Extremes of pain can be associated withextremes of pleasure, the agony and the ecstasy'' is

endorsed strongly at (+4). To su�er and die is the ulti-mate act of sacri®ce, and death to the `self' is the endto the sel®shness that separates us from God. The par-

ticipant with the exempli®catory sort commented onthe previous statement:

Jesus on the cross before the Resurrection.

This change is not temporary, but a permanent andpositive trans®guration. The item asserting ``Once youhave experienced severe pain you can never be the

same as you were before'' is endorsed at +4. Theessence of the `self' or soul is changed, but the changewill have been valuable and positive.Not all of the statements endorsed convey a positive

evaluation of the pain experience: the statement ``Painmakes you a prisoner, you are isolated and are nolonger free to do what you want, when you want'' is

endorsed at (+5). Possibly this negative appraisaloccurs because pain, through its transforming proper-ties, removes the `self' from its normal, public, worldly

existence to a more private and internal realm of thespirit, where what matters is only the soul's relation-ship to God. If you unite your su�ering with the cruci-®ed Christ you are drawn closer to Him. Personal

freedom within this account is not a valued concept;what matters is willing obedience to God. For thisreason, long-term pain is not seen as problematic, it

may even provide an opportunity for spiritual growth.The statement ``Pain is serious when it goes on for toolong'' is rejected at (ÿ4).This account is similar to account 2 in its concern

with growth and development. However, the growthand development is of a soul towards God rather than

of a self-knowledge. Pain is a valuable connectionbetween the su�erer and God. Although pain is clearlya negative experience, there is much to be gained.

Account 4: pain-as-alien-invasion

Three participants' sorts loaded onto this factor.This account may best be described through the con-cept of `Pain as alien invasion'. It bears some simi-

larities to the metaphor employed by Herzlich (1973)that regards illness as a `destroyer'. In this accountpain is a speci®c and dangerous kind of destroyer: a

strong, malign external power which threatens to takeover and wholly overwhelm the su�erer. Pain as analien invader should be avoided at all costs as there is


nothing to be gained from it and almost everything to

lose. Statements referring to pain as related to plea-

sure, as a caress, as a way to make people happy or to

®nd redemption were all strongly rejected. There is no

strength to be gained by pain; rejected at (ÿ4), for

example, was the statement ``strength of body or char-

acter is impossible without the experience of pain''.

One participant with an exempli®catory sort commen-

ted on this statement:

what a dreadful British `sti� upper lip' attitude.

Pain is not a valuable part of life experiences. The

statement ``For some experiences like having a baby or

running a marathon, pain is such a part of the experi-

ence that not to feel it would be to miss out'' is

rejected at (ÿ4) and produced the comment:

I resent the implication that it is normal for birth to

be really painful.

Although pain is not in any way valuable, it is

accepted in this account that pain is a part of life and

will a�ect all people, regardless of gender. It is also

accepted that pain can have an a�ect even when one is

unaware or unconscious. However, the recognition of

the inevitability of pain is not a comforting one: ``The

experience of pain is more frightening even than

death'' is endorsed at (+4), and led to comments such

as:

It can feel overwhelming Ð out of control,

increases feelings of helplessness.

Here pain is to be feared above death. It can over-

whelm and engulf one. ``When you are in pain, you

can think of nothing else, it takes you over comple-

tely'' receives strong agreement at (+5). It changes the

sense of self: ``Pain has consequences for our image of

ourselves, it makes us di�erent people'' receives the

strongest agreement at (+6). Such a change is perma-

nent, more like a transformation than a passing phase;

the statement ``Once you have experienced severe pain

you can never be the same as you were before'' was

also endorsed at (+5). Pain has the power to change

people forever and should not be used against others.

Most strongly rejected at (ÿ6) were the statements

``Punishment through pain helps people to learn right

from wrong'' and ``Sometimes one needs to in¯ict pain

to promote obedience''. The only possible positive ben-

e®t from pain is that it may promote sharing relation-

ships. Highly endorsed were the statements that

support a social function for pain such as ``people

should say when they have pain, they shouldn't have

to su�er in silence'' at (+5) and ``Sharing pain can

deepen relationships and bring people together'' at

(+6).

In this account pain is a malign, external and agentic

power that is to be feared and avoided at all costs. It

threatens identity and can engulf the self, changing itperhaps permanently and for the worse. The only posi-

tive aspect to the experience of pain is the empathygained through the shared experience of su�ering.

Account 5: pain-as-coping-and-control

The sorts of four participants exempli®ed this factor.

In this account, pain is located in the body and maybe an indicator of damage to the body. ``All pain is inthe head, it is something that happens in the brain'',

for example, is rejected at (ÿ6), more strongly than forany other factor, producing the comments:

What about broken limbs?Tosh! How is it possible?

Pain is also indiscriminatory in its e�ects, as gender,poverty, history and the media do not a�ect a physicalexperience. The statement ``You can't separate out

physical, mental and emotional pain'' is rejected at(ÿ4) and ``Pain signals that the body machinery isgoing wrong'' receives agreement at (+5).

There is nothing mysterious about it; here ``Pain is amystery, we don't really know much about it or howto relieve it'' is strongly rejected at (ÿ5). Instead it

gives us information about the body. As with accountone, pain can be an indicator of damage and has diag-nostic utility: ``When you have a pain, the most im-

portant thing is to know why you have it, what iscausing it'' receives strong agreement at (+6). Thediagnostic element in this account is, however, di�erentto that of account one. Here, one can monitor pain for

signs that action may be required. For example, ``Con-tinuing to do things that hurt means that you aredoing more harm'' was placed at (+4). ``Pain in some

body parts, for example the head or chest, should betaken more seriously than other pains'' was placed at(+3). And ``Pain is serious when it goes on for too

long'' was placed at (+6).The idea that pain is an inseparable, often useful,

and sometimes fundamental part of the many valued

human experiences lends additional support to thepositive role pain may achieve in diagnosis. In thisaccount, ``For some experiences like having a baby orrunning a marathon, pain is such a part of the experi-

ence that not to feel it would be to miss out'' receivesstrong agreement at (+5). As it is central one canlearn to use pain, it can be helpful. For example, ``You

can learn to perform or compete in pain, it is the onlyway to succeed'' is endorsed at (+3). Likewise, ``Noth-ing good can come of pain, to enjoy pain you must be

a masochist'' is rejected at (ÿ3) with the participantcommenting:

A lot of good can come from pain. It is there to


help us and make us learn from it sometimes. Painhelps me when I play tennis.

Here pain does not engulf or take over the su�erer(as in account four), one is able to control the painand hence ``People should not give up, you shouldn't

give in to pain'' is agreed with at (+5). Pain is not afundamental challenge to self and will not change oneforever: strongly rejected at (ÿ6) was `Ònce you have

su�ered severe pain you can never be the same as youwere before'' is strongly rejected (ÿ6),In this account pain is fundamentally a physical ex-

perience of the body. It is something that is useful andshould be attended toward, either because it may indi-cate damage, or because it can be useful. Overall it is

controllable and does not change anything fundamen-tal about oneself

Account 6: pain-as-abuse

One participant's Q sort exempli®ed this factor. Painin this account is a negative experience that is in¯ictedupon one from powerful others, who are normally

male. ``Men are responsible for the majority of painsu�ered in society'' was endorsed at (+5), and``Women are born to su�er pain, for men pain is acci-

dental'' was endorsed at (+4). These statements werepositively endorsed only in this factor. Other factorsshowed a strong disagreement with these statements,

predominantly at (ÿ5) or (ÿ6). The place of this abusewith pain is in the family; ``The family is a machinefor the production of pain'' and ``We learn about pain

through childhood and life experiences'': both receivestrong agreement at (+6). The participant whose sortwas exempli®catory commented on this statement:

Some families seem to make a culture of bearingpain in a martyr-like way. I believe it totally con-ditions how you express pain or your fears about it.

Pain is as terrifying an experience as it was inaccount four, the di�erence being that in account fourit was pain itself that was agentic, whereas here thepain is a tool of torment used by powerful others.

``The experience of pain is more frightening even thandeath'' is placed at (+3). It has no spiritual value andis not a penance for sins committed. It is something

that is to be avoided or solved not a normal part oflife to be endured. For example, ``Pain is a life experi-ence like any other and it is up to us to see it as a task

to be accomplished and make the best of it'' is stronglyrejected at (ÿ5) with the comment:

I come from a family who have this view and it

sickens me, as though you are worthless if youwant to express pain or fear of it.

Underlying the fear of pain is the idea that pain can

engulf and imprison the self. ``Pain makes you a pris-oner, you are isolated and are no longer able to do

what you want, when you want'' is endorsed at (+4).It can a�ect one in fundamental ways: ``When you arein pain, you can think of nothing else, it takes you

over completely'' is highly endorsed at (+6). The com-ment passed was almost fatalistic:

even when you are trying to exercise the `mind over

matter' thing, its still the pain that makes yourcharacter/behaviour change. Some pains are just allconsuming.

This account rejects all statements that regard painas being a necessary part of achieving something good,or of coping with pain leading to increased self-respect.

Instead, the resistance achieved is through controllingone's public response to pain and through controllingone's performance while su�ering. Three such state-

ments receive such strong endorsement: `Ìf you have apain it is better just to pretend that you don't, particu-larly in social situations'' (+5), ``You can get used topain after a while, so that it no longer bothers you''

(+4), and ``You can learn to perform or compete inpain, it is the only way to succeed'' (+5).In this account the experience of pain does not

make us better, wiser or more spiritual people. It doesnot change one but can take us over, engulf and impri-son us. Usually, this state of violence against the self is

brought about by powerful others against a personwho ultimately learns to live with oppression.

Account 7: pain-as-homeostatic-mechanism

The sorts of three participants exempli®ed thisaccount. This account is similar to account one, but ismore informed by biological and evolutionary ideas ofthe `body as self-regulating organism' rather than ideas

of the `body as self-monitoring machine'. Pain is fun-damental, it shows us that we are alive and is elemen-tal like ®re and ice. It thus makes no sense to wish for

a life devoid of pain so the statement `Ìt is a basichuman right to be pain-free'' is rejected at (ÿ5).Account seven, which regards pain as a homeostatic

mechanism, has clear similarities with other pain nar-ratives. As with other accounts, pain is a sign ofdamage and can have a diagnostic meaning. It func-tions as a warning to protect the organism from injury.

``Pain signals that the body machinery is going wrong''and ``Pain is essential to being alive, we couldn't sur-vive without it'' are positioned at (+6). As with other

accounts, it is of prime importance ``to know why youhave it, what is causing it'' (+6) so that action can betaken to avoid the threat, internal or external. As with

account one, the explanation for pain and the actionto be taken do not automatically belong to the pre-serve of medicine; The statement ``Pain is a medical


problem, it should only be treated by doctors'' isrejected at (ÿ4). In short, the account of pain as

homeostatic mechanism recognises that pain maymean a variety of things: it ``can occur without anyinjury'' (+4), and it may be due simply to `wear and

tear' as indicated by agreement with the statement ``Itis normal to get more pain as you get older'' (+4).Some pains are regarded simply as inescapable accom-

paniments of living: For example, ``There are somepains you can expect, like headaches and musclepains'' is endorsed at (+3). Other pains, however pre-

dictable, may be self-in¯icted and due to stress ortiredness. Both positioned at (+3) where the state-ments ``People bring pain on themselves, if you don'ttake care of yourself properly you can expect to get

pain'' and ``Pain catches you when you are at yourweakest''. They produced the following commonplacecomment:

Personally when I am tired or under more pressurethan usual, I do have more discomfort.

Some pains are, however, more serious. The statement

``Pain in some body parts, for example the head orchest, should be taken more seriously than otherpains'' receives strong endorsement at (+5).

The possible responses to this broad understandingof the di�erent meanings of pain are also variable.There is agreement with the idea that pain should not

be fought or resisted: ``Pain hurts more when you tryto resist it, the best thing to do is give in to it'' receivesthe strongest agreement for all the factors at (+4)(elsewhere at +2 to ÿ4). ``Continuing to do things

that hurt means that you are doing more harm'' (+5)is also more highly endorsed than elsewhere. It makesno sense within this account to in¯ict pain upon one-

self. Once it has occurred, however, it is also not sensi-ble to resist or ignore it, because pain is a naturalmechanism for the promotion of healing and stasis.

Resisting it does not mean putting life on hold as``Pain shouldn't stop you from doing what you wantto do'' receives agreement at (+4).

In this account pain can imply harm, but notalways, so it is important to ®nd out the cause. How-ever, pain is a natural mechanism of the body andoften arises normally due to ageing or pressures of life.

One should listen to it and not resist, but also notallow it to interfere with everyday life.

Account 8: pain and power

Two participants' Q-sorts exempli®ed this account.This is an account in which pain is perceived in thebroadest sense as su�ering. ``You can't separate out

physical, mental and emotional pain'' is positioned at(+5), where this statement receives the strongest agree-ment of all the factors. ``Pain can occur without any

injury'' receives very strong agreement at (+6), and a

mechanistic or causal model of pain is explicitly

rejected. ``Pain is a medical problem, it should only be

treated by doctors'' is positioned at (ÿ6) with com-

ments such as:

Don't accept biomedical model of pain.

Some pain has no cause.

Pain is not always bad, ``Nothing good can come

of pain'' receives negative endorsement (ÿ3). Indeed,

taking control over pain and using it against oneself

is possible here; pain can be psychologically useful

as a `release'. The two statements suggesting this

possibility receive stronger agreement in this factor

than in any other. ``Sometimes when we are really

angry it would be a pleasure to in¯ict pain on the

person who is making us mad'' receives agreement

at (+3) and ``When we feel unhappy, worried or

angry, hurting ourselves can bring some relief'' is

endorsed at (+4).

In this account, however, positive value is far less an

inherent property than a variable result of the human

control over pain. It is important to know who is able

or willing to in¯ict pain. Statements referring to the

spiritual or religious use of pain are rejected at (ÿ6).The calculated use of pain in producing some advan-

tage or power over others is also particularly rejected

as unacceptable and abusive. Pain should not be used

to promote obedience (ÿ3), to keep the peace (ÿ3) orto stop us from being complacent (ÿ4). It is also not

useful as a method of moral education: The statement

``Punishment through pain helps people to learn right

from wrong' was negated at (ÿ4) and attracted the

comment

This is a human rights abuse.

Again, it is not the presence or absence of pain that is

an issue of rights: ``It is a basic human right to be

pain-free'' was rejected at (ÿ3). Rather, at issue is the

political act of using pain in coercion. This political

account extends also to those in the business of pain

and pain relief; the statement `Pain is a booming

business which drug companies can use to make even

more money' is placed at (+5).

When pain does occur, it can be resisted: ``Pain

shouldn't stop you from doing what you want to do''

is agreed with at (+6). When resistance is impossible

or ine�ectual then ``Sharing pain can deepen relation-

ships and bring people together'' (+4). Comments

included:

This can be so in an empathic sense as [in] those

who have been tortured.

Although pain can be used as a means of gaining

emotional control, and as a vehicle of empathic shar-

ing, it is not a necessary condition for self-improve-


ment or achievement: ``No pain, no gain'' was stronglyrejected at (ÿ6) and attracted the comment:

Rubbish!.

In this account pain is a central part of su�ering,

but the more important issue concerns who is causingthe pain. Pain can lead to a sharing of experience andcan be used as a way to control other aspects of su�er-ing, but when in¯icted by other people it is an unac-

ceptable abuse of power and human rights.

Discussion

The most striking ®nding of this study is the sheerdiversity and number of di�erent accounts of everyday

pain. In all eight accounts, however, there is the ideathat pain must signify or that pain must o�er meaning.This meaning-making process has as its main topic therecurring theme of the relationship of the experience of

pain to the person experiencing it. In particular, atstake in all of the accounts is the power pain may haveto change the person. Before more detailed discussion

each account will be summarised brie¯y from the per-spective of the relationship of pain and self.

Account one: pain as a signal of malfunction, is

similar to other illness narratives where the body islargely understood as a machine that has developedfaults. Pain is the sign or signal of possible damage.

It is a predominantly negative experience, but onethat is not central to self unless it persists.Account two: pain as self-growth, holds that pain

can be both negative and positive. It is somethingthat is fundamental to life. It o�ers the opportunityfor the self to grow and develop and change theperson for the better.

Account three: pain as spiritual growth, also holdsthat pain is fundamental. It is a negative experiencethat will not change the self, except at an extreme

where one can abandon the self altogether andachieve a positive transformation through su�er-ance.

Account four: pain as alien invasion, regards pain asan inescapably negative experience, one that has thecapacity to overwhelm the self and change it perma-nently for the worse.

Account ®ve: pain as coping and control, has painas a negative experience, but one that has positiveuses in allowing the person to control it and use it

to an advantage. It will not change the self as onecan control it.Account six: pain as abuse, again regards pain as a

wholly negative experience, and one that can engulfand imprison the person. Self is not fundamentallychanged but covered or hidden as one is forced to

live with a pain that proves inescapable.Account seven: pain as a homeostatic mechanism, is

similar to pain as described in account one. Here,however, pain is fundamental and useful in main-taining the body. It is a negative experience that

nonetheless has positive uses, but the positive usesdo not change the self.Account eight: pain as power, has pain as a negative

experience. What matters here is not pain but onlythe person who experiences it. The main issue iswhether one has control over pain or whether pain

is being used to control the person. Pain in¯icted asabuse can change the abused person, in both posi-tive and negative ways.

We recognise that these eight accounts are not a com-plete set of cultural narratives as they are restricted bythe items and respondents available. There were somerestrictions with our application of Q-methodology

that should be noted. After preliminary attempts, wejudged that some populations were not easily accessi-ble, primarily due to our resource restrictions (e.g.,

prisoners convicted of violent crimes and prostitutesspecialising in pain and punishment). In addition, anattempt to work with a nonverbal respondent was not

successful. Other studies could be focussed on increas-ing access to people without a voice.

Everyday selves in pain

The possible meanings of everyday pain in ourculture are rich and varied. In making sense ofeveryday pain, as with other narratives or stories of

health and illness, pain signi®es disorder (Herzlichand Pierret, 1985; Hilbert, 1984) and the possibilityof a pain induced panic. The common metaphor ofthe body as a machine forms the foundation for

that which is disordered (Harre, 1991b; StaintonRogers, 1991). Stainton Rogers (1991) in particularfound in one study that the prevalent `body as ma-

chine' account contained the idea that illness is dueto a breakdown in physical function that can becured by the natural repair mechanisms of the

body, aided by medicine. This dominant accountalso appeared in our study where pain is a signi®erof malfunction in both a complex mechanical body(account one), and in a self-regulating living body

(account seven). In these two common accounts ofembodiment the self is held in separation from thebody. This is also found in narratives of chronic

pain, in which su�erers report persistent pain overa long period of time (Del Vecchio Good et al.,1992). In an earlier study with chronic pain patients

we found that patients ®rmly interpret their pain asa sign of a mechanical fault. To interpret pain asother than a mechanical fault opens up the possi-


bility of being (or feeling) blamed for pain and suf-

fering (Eccleston et al., 1997). However, in this pre-vious study, this common account of pain as a signof a body in need of repair was closely tied to the

idea of a powerful and technological medicine andanger at its failure. Items endorsing the importanceof a powerful and technological medicine did not

appear in these accounts of everyday pain.Self is also held as separate from the experience

of pain in other accounts. Notably where pain con-cerns abuse or the potential for abuse the self mustremain intact in the face of this experience and not

fundamentally be a�ected by it (accounts six andeight). Similarly, in account ®ve, although the pain

is negative, it is controllable and thus not to befeared. The fear in these three accounts is notdirectly about pain, but the idea that one will lose

control of it (or the means of its production) andhence lose the self within pain. This fear is also atthe forefront of account four where pain is clearly

positioned as an entity that can be de®ned by itsseparateness from self and its ability to invade,

overwhelm or engulf.Only two accounts of pain have a di�erent under-

standing of self in relation to pain. Account two, in

which the self may be developed by pain, and accountthree, in which the self can be given over to pain if itbrings one to God. Bendelow, (1993,. p. 283) also

reported similar accounts of pain as in some way use-ful or protective to self: for example, she discusses how

pain can have `` . . .a `signal function' by providing asystem of warning the body and could even be per-ceived by both men and women as being productive,

as in successful childbirth''.Pain signi®es threat to the self in more ways than

the marking of possible damage to the body; it rep-resents a threat to the legitimacy of self. Kleinman etal. (1992) has argued that it is the resistance to the

delegitimising force of pain in Western technologisedculture that best captures the experience and struggleof chronic pain su�erance. Where pain persists the

patient resists delegitimation of their identity and ex-perience, seeking to legitimate su�ering (Garro, 1994).

In the well-documented case of chronic pain, what isat stake is the self as rational and competent. Whenpain and self become irrational, the experience of pain

becomes unreliable and the person experiencing painbecomes a challenge to the dominant ideology of mod-ern technical medicine (Kotarba and Seidel, 1984;

Sharpe et al., 1994).For the patient with chronic pain, the political ex-

perience of managing the delegitimation and relegiti-mation of self has the e�ect of containing pain withina corporeal or physical narrative (Baszanger, 1989,

1992). Ironically, however, the threat to the self is notcontained to the physical body; many other aspects of

identity can and often are brought into question (Pin-cus et al., 1993; Eccleston and Crombez, 1999).

Chronic pain functions socially to fold self inwards,almost as a form of social implosion.The roots of this dynamic ability of pain to chal-

lenge self are carefully cultivated in the culture ofeveryday pain. The resistance to the delegitimising pos-sibilities of pain is not speci®c to the extreme case

scenarios of pain in torture or abuse; resistance to thedelegitimisation of self is a constant and everydayoccurrence in the face of pain. Perhaps a de®ning fea-

ture of pain is its intrinsic ability to change self. It isthrough pain that one experiences the extreme self-focusing limits to the possibilities of being (Leder,1990; Sullivan, 1995). Pain is fundamentally threaten-

ing (Eccleston and Crombez, 1999) and this threat isto core identity. Pain can disassemble self, leaving astate of panic, which by de®nition is uncontainable

and requires social negotiation and social management.Where panic arises it is due to a self under threat, athreat that cannot be ignored and needs a socially

ordering response. What is important about pain isnot the pain but the challenge or threat to self.Refocusing pain as an aspect of self has a number of

implications for the practice of pain management andfor the socio-cultural study of pain. First, ideas of selfand identity are underdeveloped in orthodox paintreatment. These deserve clinical research attention in

respect to the processes involved in forming pain re-lated disability and distress (Aldrich et al., in press)and in attempts to address the disability and distress

of chronic pain (McCracken, 1998). Second, the ideaof pain as a containment or con®nement of the possi-bilities of self is in need of further conceptual develop-

ment. In particular we will need to understand morefully how pain, despite its ubiquity, tends to invisibilityin popular culture (Scarry, 1985, 1994; Morris, 1998).More study is required on how and in what form

everyday pain and analgesia are represented. Third,sorely needed is a research emphasis on the micropoli-tical construction of pain and pain related action.

Although we are beginning to sketch a picture of painas a discursive political event that informs the socialconstruction of self, there is still precious little detailed

work that describes how meaning is created and givenagency in environments of power.

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