ArticlePublisher preview available

An enactive approach to pain: beyond the biopsychosocial model

September 2019
Phenomenology and the Cognitive Sciences 18(1)

DOI:10.1007/s11097-019-09624-7

Authors:

Peter Stilwell

University of Southern Denmark

Katherine Harman

Dalhousie University

We propose a new conceptualization of pain by incorporating advancements made by phenomenologists and cognitive scientists. The biomedical understanding of pain is problematic as it inaccurately endorses a linear relationship between noxious stimuli and pain, and is often dualist or reductionist. From a Cartesian dualist perspective, pain occurs in an immaterial mind. From a reductionist perspective, pain is often considered to be “in the brain.” The biopsychosocial conceptualization of pain has been adopted to combat these problematic views. However, when considering pain research advancements, paired with the work of phenomenologists’ and cognitive scientists’ advanced understanding of perception, the biopsychosocial model is inadequate in many ways. The boundaries between the biological, psychological, and social are artificial, and the model is often applied in a fragmented manner. The model has a limited theoretical foundation, resulting in the perpetuation of dualistic and reductionist beliefs. A new framework may serve to better understand and treat pain. In this paper, we conceptualize pain as a 5E process, arguing that it is: Embodied, Embedded, Enacted, Emotive, and Extended. This perspective is applied using back pain as an exemplar and we explore potential clinical applications. With enactivism at the core of this approach, pain does not reside in a mysterious immaterial mind, nor is it an entity to be found in the blood, brain, or other bodily tissues. Instead, pain is a relational and emergent process of sense-making through a lived body that is inseparable from the world that we shape and that shapes us.

Moving from the biopsychosocial Venn diagram (a), to a schematic of a dynamic person (adapted from Maturana and Varela (1987/1992); the outer circle represents an organism and the inner circle represents the organism’s nervous system) coupled to a changing environment (b)

…

Schematic of two embodied and autopoietic people (e.g., yellow = clinician, blue = patient) structurally coupling, resulting in sense-making and altered self-regulation (represented in green). Post-coupling sense-making and self-regulation may take many forms (or shades of green), such as brief reflection on the patient’s condition from the clinician’s perspective, or threat-based attribution and meaning from the patient’s perspective. This schematic is inspired and adapted from the work of Maturana and Varela (1987/1992) and Øberg et al. (2015)

…

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An enactive approach to pain:

beyond the biopsychosocial model

Peter Stilwell

&Katherine Harman

Published online: 30 April 2019

#Springer Nature B.V. 2019, corrected publication 2019

Abstract

We propose a new conceptualization of pain by incorporating advancements made by

phenomenologists and cognitive scientists. The biomedical understanding of pain is

problematic as it inaccurately endorses a linear relationship between noxious stimuli

and pain, and is often dualist or reductionist. From a Cartesian dualist perspective, pain

occurs in an immaterial mind. From a reductionist perspective, pain is often considered

to be Bin the brain.^The biopsychosocial conceptualization of pain has been adopted to

combat these problematic views. However, when considering pain research advance-

ments, paired with the work of phenomenologists’and cognitive scientists’advanced

understanding of perception, the biopsychosocial model is inadequate in many ways.

The boundaries between the biological, psychological, and social are artificial, and the

model is often applied in a fragmented manner. The model has a limited theoretical

foundation, resulting in the perpetuation of dualistic and reductionist beliefs. A new

framework may serve to better understand and treat pain. In this paper, we conceptu-

alize pain as a 5E process, arguing that it is: Embodied,Embedded,Enacted,Emotive,

and Extended. This perspective is applied using back pain as an exemplar and we

explore potential clinical applications. With enactivism at the core of this approach,

pain does not reside in a mysterious immaterial mind, nor is it an entity to be found in

the blood, brain, or other bodily tissues. Instead, pain is a relational and emergent

process of sense-making through a lived body that is inseparable from the world that

we shape and that shapes us.

Keywords Biopsychosocial .Phenomenology .Pain .Cognition .Embodied .Enactivism

Phenomenology and the Cognitive Sciences (2019) 18:637–665

https://doi.org/10.1007/s11097-019-09624-7

*Peter Stilwell

peterstilwell@dal.ca

Faculty of Health, Dalhousie University, 5869 University Ave, PO Box 15000, Halifax, NS B3H

4R2, Canada

School of Physiotherapy, Faculty of Health, Dalhousie University, 5869 University Ave, PO Box

15000, Halifax, NS B3H 4R2, Canada

Content courtesy of Springer Nature, terms of use apply. Rights reserved.

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Patricia Benner

No evidence that pain is painful neural process

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Riccardo Manzotti

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Andy Clark

Phenomenology of Illness

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Havi Carel

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Shaun Gallagher

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Embodying the illusion of a strong, fit back in people with chronic low back pain. A pilot proof-of-concept study

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Objective: This proof-of-concept pilot study aimed to investigate if a visual illusion that altered the size and muscularity of the back could be embodied and alter perception of the back. Methods: The back visual illusions were created using the MIRAGE multisensory illusion system. Participants watched real-time footage of a modified version of their own back from behind. Participants undertook one experimental condition, in which the image portrayed a muscled, fit-looking back (Strong), and two control conditions (Reshaped and Normal) during a lifting task. Embodiment, back perception as well as pain intensity and beliefs about the back during lifting were assessed. Results: Two participants with low back pain were recruited for this study: one with altered body perception and negative back beliefs (Participant A) and one with normal perception and beliefs (Participant B). Participant A embodied the Strong condition and pain and fear were less and both perceived strength and confidence were more than for the Normal or the Reshaped condition. Participant B did not embody the Strong condition and reported similar levels of pain, fear strength and confidence across all three conditions. Discussion: An illusion that makes the back look strong successfully induced embodiment of a visually modified back during a lifting task in a low back pain patient with altered body perception. Both participants tolerated the illusion, there were no adverse effects, and we gained preliminary evidence that the approach may have therapeutic potential.