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An enactive approach to pain: beyond the biopsychosocial model

DOI:10.1007/s11097-019-09624-7
Authors:
Peter Stilwell at McGill University
Peter Stilwell
Katherine Harman at Dalhousie University
Katherine Harman
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Abstract and Figures

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.
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An enactive approach to pain:
beyond the biopsychosocial model
Peter Stilwell
1
&Katherine Harman
2
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
1
Faculty of Health, Dalhousie University, 5869 University Ave, PO Box 15000, Halifax, NS B3H
4R2, Canada
2
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.
... The consequences of this can be observed from the metaphorical to the practical: pain resists definition, classification and, crucially, effective treatment when it persists (Williams et al. 2020). Our understanding of pain, from a scientific perspective, has broadened considerably in the last 10 years (Moayedi and Davis 2013;Williams 2016;Karos et al. 2018;Seymour 2019;Stilwell and Harman 2019;Tabor and Burr 2019;Kiverstein et al. 2022). No longer constrained to the detection of damage, the experience of pain spans biological, psychological and sociocultural realms (Raja et al. 2020). ...
... Put another way, under the BPS model, only the ontology of a disorder cuts across levels, not its epistemology; ontology being concerned with 'what things are', and epistemology being concerned with 'how we come to know' that which is (Bateson 1971, 442). Moreover, in pain research, although intended as a philosophy of care, the translation of the BPS model in theory and practice plays out under the shadow of pain's paradoxes (Stilwell and Harman 2019). That is, where integration is sought, compartmentalised targets are found; without a truly integrative model to guide action (Borrell-Carrió et al. 2004), bio-psycho-social elements are pursued with 'eclectic freedom' (Ghaemi 2009), reduced to disembodied risk factors to be separated, investigated and treated (Moseley and Flor 2012;van Hecke et al. 2013;Johnston et al. 2019;Apkarian 2011). ...
... Yet, for a significant number of people, the experience of pain persists (Fayaz et al. 2016). In the present context, and in keeping with recent embodied (Tabor et al. 2017;Stilwell and Harman 2019) and predictive accounts of pain (Büchel et al. 2014;Tabor and Burr 2019;Kiverstein et al. 2022), this apparent 'stickiness' of aversive experience (Borsook et al. 2018) is related to a continued anticipation of threat to the self. The persistent anticipation of threat involved in pain has been attributed to various mechanisms, from maladaptive learning and aberrant precision allocation in reward processing (Seymour 2019), to an altered landscape of affordances (Stilwell and Harman 2019). ...
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... Stilwell et al. advocate the use of enactive metaphors to assist conceptualisation of pain through the lens of "metaphordances"-connecting enactivism to a more dynamic view of metaphor (91,98,99). Metaphordance encompasses possibilities available to a person for action ("landscape of affordances") specific to a person's body and experience ("field of affordances") and life-stage and socio-cultural practices (affordance space). ...
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... This highlights that we collectively create niches with material arrangements, but also socially inherited practices and convictions that we need to consider in order to understand the prevalence of chronic pain (Johnson & Woodall, 2022). Processes contributing to the generation and maintenance of chronic pain are not restricted to some evolutionarily determined traits, which we can hardly alter, or the inner workings of patients (Coninx & Stilwell, 2021;Stilwell & Harman, 2019). This becomes most prominent when studying the effects of individuals entering different socioclinical niches. ...
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... This would result in the integration of biological factors first and then the consideration of psychosocial factors. It could lead to segmenting the biopsychosocial model (mBPS); whereas the biopsychosocial model is a whole and not segmented model [29][30][31]. Taking into account red flags alone is insufficient since other factors such as symptom progression, comorbidities, prevalence of pathology, etc. must be considered (see Appendix D). However, knowing which red flags are found in the SSPs remains unavoidable. ...
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