Pain - output of the brain or lived conscious experience?

This is something I have been thinking about for quite sometime and recent conversations pushed me to finish this post. I'm not a fan of saying pain is an output of the brain, and I'll lay out why (please hear me out). I do anticipate some pushback, based on previous chats. Because of that, I want to make it clear that a lack of understanding neuroscience or lack of understanding research is not at issue here. I didn't want to take up too much space in this post on that so I wrote a whole other post about where I'm coming from you can refer to, if so desired. So with that...

The problems I see with 'pain is an output of the brain' or 'pain is a product of the brain'

I see this a lot, I hear it a lot. It's made it's way into mainstream media so it's prevalent even outside pain science circles. I'm not a fan of it, and I'd like to share why. Please hear me out First I'll touch upon the surface of it and then I'll dive a bit more deeply. Superficially, pain is an output of the brain or created by the brain or a product of the brain is conceptually pretty damn close to 'pain is all in your head'. So it's no wonder to me that there is pushback. There is a lot of pushback from people living with pain, understandably so. Especially if their pain has not first been validated and they have not been assured and convinced that their care provider believes their pain is real. I also see pushback from clinicians who are advocating for their patients. Many seem to think saying pain is an output of the brain sends the wrong message and further stigmatizes their patients. This harkens back to pain being 'all in our heads', which implies made up, fabricated, exaggerated, not real - any number of things. Granted, this ties in with a misunderstanding of psychological and social factors, too. But the 'output of the brain' phrase sure doesn't help cross that chasm. (I recently shared some thoughts on the common misunderstandings of the P in biopsychosocial. I have an S in the works, but far better than anything I could ever write, I recommend reading Experiencing Chronic Pain in Society by Lous Heshusius or Meanings of Pain edited by Simon van Rysewyck.)

The pushback I get from some clinicians and my response

Whenever I bring those forms pushback up, I get additional pushback from the clinicians who regularly use the phrase. Also understandably so. But I have used the phrase, too, so be sure I'm not attacking. Often this pushback is in the form of 'it's technically true', that the brain is the processing center and 'decides' if we have pain or not. There are sometimes comparisons to how all of our reality is an output or creation of the brain. And I appreciate that, I might even agree with it all. But that is not how we talk about our human experiences. It's certainly not how we experience the richness, the nuance, the complexity of being human. And we all know that.

Pain is one of many human experiences

When a good friend comes to us grieving because they just lost their spouse or their child, we do not console them by telling them their grief is an output of their brain. When a friend is weeping because of unimaginable loss, we do not say that loss was merely created by their brain. It's just as true as saying pain is an output of the brain, or a creation of it, but doesn't it make you cringe a little? If your best friend's child was in a car accident or mauled by a dog and there was significant trauma, would you tell your buddy as he stood by his child's hospital bed that his kid's pain was an output of her brain? And if you were to, might you think it a bit insensitive and inadequate to explain the richness, complexity and depth of that particular human experience? When you experience laughter or love or happiness or great joy, do you think to yourself 'what a great output of the brain I'm having' or 'man, my brain is creating some good shit today'. My bet is no.  (At least for most of us. I could be wrong, I often am.) It's just not how we talk about ourselves, our lives, our experiences.

An output of the brain, or a lived, conscious experience?

Some will say this is merely semantics. I respectfully disagree on two counts. There is nothing "merely" about semantics, which is literally the study of meanings in language. Our words matter, what they mean matters. Pain has meaning, and the words we use to make sense of it should reflect more of the nuance and messiness and difficulties and lived truths and scientific uncertainty and unknowns of pain. Second, and closely related, saying pain is an output of the brain is devoid of all of pain's reality for the person living with it. It can readily come off as cold, unsympathetic, uncaring. Why? Because living with pain is friggin hard. Pain is emotional, how could it not be.  It is disruptive and distressing.  And, most oftentimes, chronic pain is life changing. So even if the two phrases are essentially saying the same thing (which I don't think they are), the latter is much closer to the truth (and still far from adequate).

The reality of pain

There were times my pain was so great that it was all I saw, all I heard, all I felt, all I experienced, all I lived. Pain swallowed me up and I felt like there was no possible way to get out. It was dark and isolating and terrifying. There were days where there was no light, no ease, no comfort. There were times when my entire existence was about getting through the next minute, the next 3o seconds, the next breath.

To call that an output of my brain robs the entire experience of it's harsh, all encompassing reality.

I lost my career, and with it my identity, my purpose, my self-worth, my role in society, my financial security, my future career prospects. This while I battled systems that tried to prove I wasn't faking it before they would provide help. I fought judgment, stigma and pity and felt shame, emptiness, fear. I was broken. On top of that, sitting was unbearably painful. That meant no driving, no quick trips to the store, no dinners out with my husband, no movies, no coffee or drinks with friends, no travel, no connection to the outside world or the people, places and experiences that mattered to me. My relationship with my husband unalterably changed. I lost friends, I pushed away family. To characterize all of that as an output of my brain strips it of the essence of what pain is, as my dear friend and pain hero Bronnie so eloquently put to me yesterday. There is a difference between pain and the study of pain or the science of pain. Just as there is a difference between consciousness and the study of consciousness. We are fallible humans who do not have all the answers. Even the greatest scientists and clinicians among us admit that (that's what makes them great scientists and clinicians). There is a great deal of uncertainty that must be embraced if we are to go about this pain business honestly.

What about Explain Pain...

This is another form of the pushback I get. I will delve into it in a bit more detail in my next post(s) where I explore pain science education. But I will leave you with this. Pain is an output of the brain is not a Target Concept of the Explain Pain Supercharged (EPS) curriculum. It is not a chapter heading or subheading in Explain Pain.  It is not a chapter heading or subheading in Therapeutic Neuroscience Education or a section in Why Do I Hurt. Pain as an output is explored within a much deeper and richer context. From the introduction of Explain Pain (emphasis mine): 

"Most commonly, pain occurs when your body's alarm system alerts the brain to actual or potential tissue damage. But this is only part of a big story. Pain often involves all of your body systems and all of the responses that occur are aimed at protection and healing."

The next section stresses how pain is normal, how it is complex, how we are not alone and it talks about engaging the brain to understand pain. Similarly, the first Target Concept of Explain Pain Supercharged is "pain is normal, personal and always real". In EPS, too, Moseley and Butler stress that their brain-centric verbiage is an oversimplification. These things are important!

Danger, safety, and alarms

In these texts and in courses the authors of the texts put on, pain is framed in the context of danger and safety and compared to alarms and sensitivity which are responding to information coming in from all aspects of our internal and external worlds.

Now that makes more sense to me. That is closer to my experience, which included things like the stress of worker's compensation and losing my career. It doesn't make it seem like my brain just created pain, producing an output like some machine. And DIMs and SIMs helped me, and still help me, a great deal. As did understanding ALL of my protective systems and bioplasticity and the things I could do to change my experience. I just did a presentation on Creating Safety in Me and we use EPS to develop our EPIc curricula. So I'm not knocking these books and certainly not knocking the authors. Professor Lorimer Moseley played a significant role in changing my life, which is not hyperbole.

Pain biology, lived experience of pain, and the totality of the study of pain

But these books are about explaining pain biology or pain neurophysiology. They lay out our current (and limited) understanding of how pain works and do not purport to entail the totality of the pain experience. They are thoughtfully written, deeply researched, nuanced and thorough texts that stress context, whole systems, and the importance the person living the experience. Epistemology, anthropology, philosophy, phenomenology, sociology, epidemiology, psychology, history, semantics, art - there are many perspectives on pain we could all be drawing from to understand it better. That give a broader picture. No one area of study will ever hit upon the whole. EPS dives into education science, language and storytelling. That stuff is necessary too! It's also important to note that all of the authors involved in these pain science texts have spent a great deal of time listening to and talking with people living with pain: in the clinic, in the lab, and in the real world. Those discussions permeate all of their explanations, all of their courses, all of their writing. The thing I remember most from my earliest interactions with Professor Moseley, when I was still in the depths of my pain and trying to find my way out, was that he told me my pain was real. That I was not alone. That he believed me and knew it must be difficult. That I'd done an amazing job so far. That it takes patience, persistence and courage to live with pain. And the biggest take home for me? That the one thing he wished all people living with pain knew about changing their experience of pain was to love and be loved. I don't remember anything about pain being an output of my brain.

Moving forward

Successful pain treatment takes place when clinicians can breathe the air of pain science, in the words of Sandy Hilton, and infuse it into their interactions and care. And that care should entail the patient being seen as an expert, too. Because they are an expert in pain. They live it everyday. They certainly know what pain is, even if they can't define it or put words to their experience. I assure you that people living with ongoing pain know pain intimately. That lived experience perspective is valuable when formulating a plan to move forward, not to mention finding out where you're moving forward to. Where do they want to go? The answer might surprise you. What patients may not know is pain science, and that's a huge difference. (I want to be clear that I believe the pain biology is immensely valuable, I am not saying otherwise. It's just not the whole picture, and it was never intended to be so.) Reconceptualizing pain on a massive scale, as we need to do, will take time. But I think it does those living with pain a disservice to perpetuate contextless catch phrases that belie the truth of the lived experience. I appreciate that pain as an output made clear that pain is not an input. That pain is different than nociception and there are no Descartes-like pain signals being sent from the fire to the foot to the brain. I agree it is important to differentiate that. But let's not confuse that differentiation with being a definition of or accurate descriptor of the experience of pain. It is not.  

And now I leave you with a lovely, wholly unrelated pic. I just love nature :)