Brain and Mind 1: 209–222, 2000. © 2000 Kluwer Academic Publishers. Printed in the Netherlands.

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Pain and Folk Theory C. RICHARD CHAPMAN, YOSHIO NAKAMURA and CHRISTOPHER N. CHAPMAN University of Washington, Department of Anesthesiology, Seattle, Washington (Received in final form: 20 February 2000) Abstract. Pain is not a primitive sensory event but rather a complex perception and a process by which a person interacts with the internal and external environments, constructs meaning, and engages in action. Because folk beliefs are central to meaning, folk concepts of pain play multiple causal roles in a pain patient’s interaction with health care providers and others. In every case, the notion of pain is linked to a goal-directed behavior that is useful to the person. The wide variation in concepts of pain across individuals suffering with pain underscores the richness and complexity of the pain experience. In some cases involving chronic pain, the patient may form a maladaptive cluster of behaviors around the concept of pain. Patient beliefs and expectations are an important part of many chronic pain syndromes, and patients can benefit from intervention directed at revising the individual’s folk model of pain. Memetics offers a framework for identifying the memes that patients hold and determining whether patient memes fit or clash with provider memes. Key words: pain, medicine, folk theory, consciousness, memetics.

A small town family practice physician greets an elderly patient for whom she has cared for years. This visit differs markedly from all previous encounters with this patient because the patient has developed a distressing facial pain. The pain occurs as repeated, visually obvious paroxysms near her left eye that she describes as intensely painful shocks. Lightly touching the left edge of her nose provokes a paroxysm. She finds it difficult to wash her face. Loose hair blowing in the wind will trigger a paroxysm, she reports, as will some loud noises. Her husband points out that this formerly outgoing, confident woman is quickly becoming an anxious social recluse. Obsessed with her condition, she is beginning to organize her entire life around it. The patient and her husband have two pressing goals for this office visit: a diagnosis and relief from the pain. They are struggling to understand this pain and why it has occurred, and they are worried that it signals the development of a malignant tumor or other life threatening condition. Referral to a neurologist will eventually yield the diagnosis tic douloureux, a rare but well-defined pain syndrome that occurs only in older persons and predominantly in women. Pharmacological and surgical treatments have limited success with tic douloureux, and this particular patient will try various medical interventions for years to come, but with no success. She will continue to suffer with the condition well into the future, apart from occasional and inexplicable periods

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of spontaneous remission. The patient and her husband will repeatedly ask their doctor for new information about the condition, and, unknown to the doctor, they will seek out myriad alternative treatments such as acupuncture, magnet therapy and aromatherapy. Their quest into alternative treatments will entail more than a search for pain relief; they will try to understand the pain and to deal with how it has changed their relationship and their social lives. The patient will struggle to integrate the experience of pain into the personal narrative that is her life. Her notion of this painful condition will eventually become a part of her sense of self. To date, medicine has given little attention to how patients and their families conceive of pain. This is a serious oversight because the moment-to-moment experience of pain is a product, not only of activity in nociceptive pathways, but also of what the patient believes is happening. In the focus article, Resnik rightly calls attention to the importance of folk notions of pain. Here, we expand upon his thinking by offering a three-part commentary on the potential causal role of folk concepts of pain, approaches to the systematic study of such concepts, and we consider the issue in the framework of memetics.

1. The Causal Role of Folk Concepts Resnik briefly reviewed some of the ideas that philosophers and cognitive scientists have expressed about the nature of folk psychology. Under eliminativist accounts of folk concepts, notions such as “pain” distract attention from other concepts that are more useful, e.g., in scientific discussion. This contrasts with instrumentalist accounts in which such a concept may prove to be useful albeit imprecise. Resnik argues that it would impede clinical work with pain patients, were a clinician to hold a strong eliminativist account.

1.1. T HE

CAUSAL INFLUENCE OF THE IDEA OF PAIN

We agree with Resnik that clinical interaction with patients requires rapport and common vocabulary, and that interaction would likely suffer if the clinician attempted to stop all discussions of “pain.” We expand upon that discussion by noting that the folk concept of pain has many causal implications. We may put aside the distinctions among eliminativist, instrumentalist, and realist accounts, and their ideas of what pain is, and simply note that, according to some, the concept of pain might play one or more of the following causal roles: • Perceiving “pain” might lead to immediate protective behavior • Forecasting or expecting “pain” might lead to avoidant and protective behavior • Expressing “pain” might elicit palliative treatment from others • Displaying “pain” might initiate reassuring interpersonal interactions

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• Labeling “pain” might lead a person to construct a meaningful personal narrative This list is not exhaustive. It simply illustrates that the idea of “pain” is linked to a goal-directed behavior that is helpful to the person. The particular patterns of behavior differ according to circumstance, context, and person. Even if the concept of “pain” occurs post hoc, as some eliminativists hold, we believe that it is meaningful.

1.2. C AUSAL

INFLUENCE GENERALIZES

We hold it fundamental that pain experiences generalize. Thus, it would be helpful for a person to have an implicit line of thought that runs as follows: “My shoulder has pain that seems similar to what I experienced when my leg had pain, and because medical care relieved my leg pain, it might help my shoulder.” This generalization from one state to another may lead to a beneficial outcome, and the common thread linking the states is an implicit concept of “pain.”1 Nothing in this account requires any theoretical identity between shoulder and leg pain except that an implicit concept of pain serves as a link. Thus, the notions of shoulder and leg pain are theoretically separable in principle and may yield to vastly different reductionist accounts. Nor does this account require an actual sequence of such thought within the person (i.e., a so-called folk psychology “theory theory” in which folk theories are present in the brain and are instrumental in reasoning). Whether such a sequence happens or not, the implicit generalized link of “pain” is useful because it helps us to understand how the person seeks a beneficial outcome in certain situations. This potential causal role is generally more important in a clinical setting than is a structural definition of pain. Whatever the concept of pain might denote in a reductionistic account, it may still serve such behavioral generalizations. In this perspective, the important question is whether a folk notion of pain serves the person’s implicit or explicit goals. Under such a scheme, a person could form a maladaptive constellation of behaviors around the concept “pain”. For example, chronic pain patients may experience pain with no identifiable bodily injury or harm, yet they may avoid beneficial activities because they fear that physical harm will occur. In this case, one duty of a physician would be to help the person to reform this behavioral link, e.g., by teaching about different kinds of pain (e.g., acute versus chronic pain) and how pain may not necessarily signal bodily 1 One might view our account as being instrumentalist. However, it differs from standard instrumentalist accounts of pain in that we are agnostic with respect to the discussions of the actual role of the concept of “pain” in direct behavior. We hold that the concept “pain” is useful in the larger context of understanding the “meaning” of the behaviors of the person in pain, a context that should be important to physicians. Thus our account posits an intersubjective instrumentality of the concept. This is similar to the view of Dennett, who describes folk concepts as “abstracta – more like centers of gravity or vectors than as individualizable concrete states of a mechanism” (1991, p. 85).

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harm. Such education might gradually revise folk notions without eliminating them altogether.2 1.3. PAIN

AS AN ACT

Much discussion of pain assumes that the proper model of pain is one of sensory experience; Resnik, for example, discusses the importance of pain as a diagnostic sign. There is nothing wrong per se with such discussions, and the potential diagnostic value of a pain is the first concern of every physician when a patient presents with pain. However, we believe that such consideration is incomplete and tends to lead to an overly narrow reductionistic account of pain behavior. Sensory accounts of pain (both folk accounts and scientific accounts) consist of models with roughly the following general scheme: (a) tissue injury or distress happens at a somatosensory (nociceptive) site; (b) that event initiates nociceptive impulse traffic through the spinal cord to the brain; (c) various sites in the brain activate; and (d) after neural processing, consciousness registers the neural signals as sensations and acts upon them. In such a model, pain sensations are different from other sensations such as vision or audition in specific structure (i.e., they use different receptors and brain areas), but not in their general form. That is, steps (a) through (d) are essentially the same. The sensory account of pain leads to various inquiries and conundrums. Classic questions include whether pain is identical to neural activity, whether pains are infallible, how pain may arise without nociception, what brain sites nociception activates, how consciousness represents pain, and so forth. These are interesting and important questions, but we fear that they may direct attention to the structural elements of pain theory while neglecting the personal experience of pain. One of the most remarkable aspects of the pain experience is its diversity and richness across individuals. Resnik writes that pain is “primitive” and that it lacks the phenomenological richness of vision and other sensations. We disagree with this account. Those who work with pain patients quickly learn that the individual experience of pain shows remarkable variation from one patient to the next, and from one time to another for the same patient. Also, unlike other sensations, pain appears to involve an ineluctable emotional component. Much of our visual perception involves no emotion. Pain, however, nearly universally yields an emotional response. Also, pain is not unidimensional in affect; many people are readily able to differentiate qualities of pain. We note below that there is no single folk concept of pain; rather, “pain” serves many different functions. On an eliminativist account, this diversity may reflect confusion. However, we prefer to think that it reflects the functional role, 2 Our account, then, focuses not on veridical questions about sensation but on the utility of concepts. We believe that scientific accounts of pain may replace folk accounts through a process of argumentation, demonstration, and conceptual change on pragmatic grounds similar to that described for traditional philosophical concepts by Rorty (1978–1979, 1979).

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or the utility, of the concept to unify experiences of threat, bodily harm, and suffering. Once we postulate that the concept of “pain” potentially plays different causal roles in different circumstances, we may examine the richness of individual pain phenomena over and above the sensations associated with the experience. Consider a person’s statement, “My back hurts.” A sensory account of such pain would describe the unpleasant sensory awareness along with the central processing that occurred and eventually led to this utterance. The key principle in such an account is that there is a sequential (although not necessarily unique) process of translation that leads from an initial input to an eventual output. This account is a reduction that explains behavioral output in terms of sensory input and processing structures. Such an account naturally leads to questions about how the structures work, whether they are strictly and uniquely determined, and how they correspond to external reality. The actual content of the statement is, by nature, propositional and is, in principle, either true or false (although perhaps not amenable to verification). We envision pain not as an essentially propositional sensory event, but as a process by which a person interacts with the environment (including internal stimuli) and engages in action. Pain is not simply the end point of a sensory path, but a complex action in which the organism processes nociception, constructs meaning, and initiates further behavior (Sullivan, 1999; Chapman and Nakamura, 1999). We do not deny that sensation is important for understanding both the neurophysiology and the phenomenology of pain; but we claim that pain is a complex process with intentional features that both initiate goal-oriented behavior (viewed externally) and that serve to make sense of experience (viewed subjectively).3 From a clinical point of view, this shift in conceptualizing pain is fundamental because it directs attention away from the cerebral question, “What are the characteristics of this pain,” and directs attention instead to the question, “What is the purpose of this pain?” In many cases, this question may have a simple and traditional answer that a mere sensory account of pain provides. In other cases, however, the question highlights that sensory accounts are often inadequate, and it serves to prompt the physician to explore the person’s process of understanding and making meaning of painful experience.

3 We claim that the statement, “I feel pain,” is best viewed not as a locutionary statement (Austin,

1962, pp. 98–99) but as something akin to a performative or illucutionary statement (cf. Searle, 1969, p. 24). It is important that pain language and pain behavior always occur in an interpersonal context, and have meaning only within that context. Thus, we agree with Wittgenstein (e.g., 1958, no. 246) that many of the classic problems involved with a sensory account of pain dissolve when viewed in a larger setting.

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1.4. S UMMARY

OF THIS SECTION

The idea of pain is not the same thing as the physiological signaling of tissue trauma. Many factors shape a person’s concept of pain, including generalization from past experience. This concept, once formed, might play a role in explaining goal-directed behavior in a way that helps both the person and the physician. Folk psychological notions tend to explain mental events in terms of meanings, goals, and desires. We believe that such an orientation is exactly on track with respect to understanding pain, although folk notions explain pain with an overly limited sensory model. This respect for folk models implies neither that folk theory is analogous to scientific theory, nor that folk concepts are immutable to revision based on scientific understanding. However, with respect to pain, folk concepts are helpful insofar as they direct our attention away from a model based solely on sensation and remind us to consider the plans, goals, and personal narrative of the person in pain. 2. What is a Folk Theory of Pain and How Might We Investigate It? The folk theory of pain, as Resnik has characterized it, seems straightforward. He assumes that the general folk psychological concept of pain refers to aspects of conscious experience that are: subjective, qualitative, knowable by introspection, unpleasant, interpersonal, and primitive. These features (when combined) are probably compatible with any given folk theory of pain, but they may not be sufficient to capture how a folk theory of pain can “causally” contribute to the generation of complex human behavior. Resnik’s list of features does not greatly clarify the nature and structure of a folk theory of pain. We submit that, in order to understand the impact of “a folk theory of pain” on the behavior of a patient seeking medical help for that pain, Resnik’s theory needs further clarification. Although discerning what people may think or believe about pain is difficult, we must start somewhere. The first question, then, is “What has research into patient beliefs about pain revealed?” Empirical investigations of a folk notion of pain have attracted little attention to date. Fortunately, however, this is changing, and a few pioneering studies have addressed folk theories of psychological constructs such as pain and intentionality (Aldrich and Eccleston, in press; Malle, 1997). In this section, we offer a few examples that illustrate how one might go about investigating the nature and structure of a folk theory of pain. 2.1. M AKING

SENSE OF EVERYDAY PAIN

Aldrich and Eccleston (in press) investigated common-sense (or folk) understandings that are socially and linguistically available to people who want to make sense of everyday pain. Using Q sort factor analysis, they asked 61 study participants to sort 80 statements characterizing “the culture of pain.” Eight interpretations of

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everyday pain emerged from the Q factor-based analysis. These eight interpretations were patterns of associations for everyday pain that are possible within our culture. They include: • pain as malfunction; • pain as self-growth; • pain as spiritual growth; • pain as alien invasion; • pain as coping and control; • pain as abuse; • pain as homeostatic mechanism; • pain and power. Although these interpretations reflect different ways of making sense of everyday pain, the investigators further identified common themes that cut across the eight interpretations. One invariant theme is the idea that pain must signify or offer meaning. Another set of themes consists of how pain relates to self, and in particular, whether or not pain can change the self. Aldrich and Eccleston (in press) expanded the self-related themes, emphasizing how one protects and legitimizes the self when dealing with pain as a fundamental threat. This reasoning is compatible with the self-oriented description of pain-related suffering that Chapman and Gavrin (1999) have offered. Aldrich and Eccleston’s study (in press) of sense-making for everyday pain yields two important findings. First, implicit accounts or folk notions of pain may be fairly complex and diverse, as the eight interpretations of pain suggest. They certainly do not translate into a single coherent model of how people make sense of pain. Second, although there may be many ways of making sense of everyday pain, all of them share common themes identified in their analyses of sense-making accounts. The themes involve the questions of (1) how pain relates to the self and (2) whether pain can change the self. The assessment of these themes in both general populations and clinical patient populations may prove useful in improving how health care professionals help people with disabling pain. Because Aldrich and Eccleston focused on the nature of everyday pain accounts in a rather general population, we next discuss an approach directed at elucidating the nature and structure of disabling pain beliefs that patients with chronic pain hold.

2.2. I DENTIFYING

AND CHANGING PAIN BELIEFS IN CHRONIC PAIN PATIENTS

Chronic pain is a serious sociomedical problem (Elliott et al., 1999; Andersson, 1999). Even the most sophisticated treatments available for pain relief do not easily improve the conditions of chronic pain patients. The Seattle, Washington Veteran Administration (VA) pain education program provides an approach that seems effective in helping patients regain normal function in their lives (Jacobson et al., 1997). A biopsychosocial framework guides this program.

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The critical component of this program is attention to negative, disabling pain beliefs that interfere with a patient’s optimal rehabilitation process. According to the guiding principles of this pain education program, the first steps are to identify the disabling pain beliefs that chronic pain patients hold and then to work with the patients to modify those beliefs so that the patients are psychologically able to recover from the disabling effects of those beliefs. (For more detailed descriptions of different components involved in this process of rehabilitation, please see Jacobson et al., 1997.) Many patients with chronic pain will come to a pain clinic, expecting to find a cure or at least a definitive medical diagnosis. Unfortunately, most have painful conditions for which physicians fail to identify a pathological cause. The hardest thing to change is the patient’s conviction that there must be something wrong with his or her body – something that physicians could fix if they could find it. Although it may sound heartless, the first lesson that a patient has to learn is that the goal of pain therapy is not to find a cure that makes the pain vanish but rather to find a way to function better with the pain. The goal is not relief or comfort but rather a return from disability to meaningful life activities. This is obviously not easy to do, but with the help from a team of pain medicine specialists consisting of anesthesiologists and psychologists, many patients are able to modify their disabling pain beliefs and eventually learn to live with and cope with pain. Clinical work at the Seattle VA pain program shows that the folk models of pain that patients hold do exert real impacts on their lives. Moreover, it is possible to help patients revise what they believe about their painful conditions and thereby make them more functional. Chronic pain is not just a matter of unrelenting signals of tissue trauma in the nervous system; it is a complex perception that is shaped, in part, by implicit patient beliefs and expectations. These beliefs often have deep roots in culture and societal attitudes.

2.3. S UMMARY

OF THIS SECTION

As we illustrated in this section, behavioral research can gain substantial knowledge about what constitutes a folk theory of pain. There are several examples that one can follow in designing an empirically oriented investigation into a folk theory. As we emphasized in the preceding section, a folk theory of pain can have multiple functions that reflect and support the goal-directed action of a person feeling pain. Like Resnik, we endorse inquiry into a folk theory of pain for its own sake, not only because further knowledge in this area could help clinicians communicate with patients, but also because enlightened clinicians could find new opportunities to intervene in modifying maladaptive beliefs about chronic pain. The folk theories or models that pain patients hold are real psychologically because they produce real effects on how patients act and interact with caregivers and physicians. There are many useful ways to clarify the nature of folk theories of pain. In the next section, we review the memetic approach to identifying and character-

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izing what constitutes a folk theory of pain. We specifically focus on why certain beliefs and ideas about pain persist, even though they are scientifically invalid and maladaptive for a person carrying the ideas. 3. Memetics and the Folk Psychology of Pain Our foregoing considerations show that the subjects of folk beliefs about pain, what pain means under certain circumstances, and how such beliefs can affect patient-provider relationships are complex. Consequently, putting the concept of folk psychology to work in the clinic entails more than simply closing a “translation gap” between patient and provider. The beliefs that patients hold about pain, injury and illness vary with family history, social stratum, education and culture. In an ethnically diverse society such as that of the United States, there can be no single folk psychology of pain. Perhaps more importantly, a folk psychology of pain or something very like it exists in medicine just as it exists in the public. Physicians, nurses, pharmacists and other providers often hold beliefs about pain and pain treatments that are not grounded in science, and in some cases these beliefs are clearly at odds with existing scientific evidence. Folk beliefs on the patient side can interact with folk beliefs on the medical side, and sometimes this leads to suboptimal care delivery. How should one approach the study of folk psychology? We suggest that the inchoate field of memetics offers a useful and efficient framework for understanding the folk psychology that pervades pain medicine. Memetics is a descriptive framework that allows one to conceptualize beliefs and attitudes as living entities existing in a cultural medium. The field derives from a metaphor: memes (the fundamental units of memetics) are to culture as genes are to biology. Moreover, if one takes Dawkins’ radical notion that genes are active agents that use biology to replicate themselves (Dawkins, 1976), then the metaphor allows that memes are active cognitive agents using culture to replicate themselves. Clearly memetics more closely resembles tongue-in-cheek speculation than proper science, but it nonetheless opens avenues for new insights and reasoning. We present it here, not to offer it as a valid model for psychosocial science, but rather as a potentially rich and provocative framework for understanding the nature of folk psychology. 3.1. BASIC

CONCEPTS

Odd though it may seem, one could view beliefs, attitudes and ideas as entities that exist as independent entities in the society of human brains. How beliefs or other mental, conceptual entities adapt and survive within a culture mimics the adaptation and survival of organisms in a physical environment. Dawkins and others (Dawkins, 1976; Moritz, 1990, 1995; Plotkin, 1993; Brodie, 1996) have applied this reasoning to social constructions and ideas, like those that constitute folk beliefs about pain. Their work has generated the field of memetics: the study of

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ideas and concepts viewed as living entities, capable of evolution and reproduction in the collective of social intelligence. Memetics comprises an evolutionary model of social information transmission. A meme is an information pattern, held in one person’s memory (or behavioral repertoire), which can copy itself to another person’s memory. Viewed psychologically, a meme is a cognitive or behavioral pattern that can move from one individual to another. In describing memes, Brodie (1996) said “Memes are to a human’s behavior what our genes are to our bodies: internal representations of knowledge that result in outward effects upon the world . . . Memes are hidden, internal representations of knowledge that result, again along with environmental influence, in external behavior and the production of cultural artifacts.” Memes transmit in many ways from one person to another (including through the public media), but the primary mechanism for such transmission is simple imitation, according to Blackmore (1999). Her model seems to fit the memes that govern everyday patient behavior and provider behavior. Memetics views ideas and practices as units of cultural information that fail or survive across generations in a Darwinian cultural environment. Just as biology views life as the propagation of genetic information, the memeticist views culture as the propagation of human conceptual information. In both cases, evolution promotes the selective survival, generation after generation, of some part of the information. Beliefs about pain and its treatment that patients and providers encounter continue to survive and exert their effects long after they originate. When an idea survives because people pass it on to other people, it qualifies as a meme. Memeticists emphasize that a meme resembles a gene rather than a message in that the transmission is a replication: the person who transmitted the meme continues to carry it. Memes are replicators: they are to society what genes are to biology. They are mechanisms of both social stability and adaptational social change.

3.2. M EMES

AND MEDICAL CARE

The memeticist holds that memes are everywhere, and it is easy to identify them in health care. Curiously, they contradict one another as readily as a list of proverbs because different memes inhabit different contexts in the way that different organisms inhabit different ecological niches. For example, some blue-collar workers, injured in the distant past, complain vociferously of persisting pain and how it makes work impossible. Most, when queried, will reply that the pain means that something is damaged and further activity means further risk of harm. In other words, they believe erroneously that hurt equals harm. In sharp contrast, many injured athletes and musicians believe that one should deny pain from trauma or overuse injury and try to play through it. For them, hurt does equal harm, but they deny the hurt message. Women educated for partner-coached childbirth (who have received the proper memes) typically manage to transcend the pain of labor

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and claim that it is no problem. Uncoached and unprepared women, in contrast, often cry out in agony. Health care providers commonly believe that giving opioid medications to a post-surgical patient who has a history of drug abuse will precipitate an addiction, and they therefore leave the patient to suffer agony that pain medications would prevent. Pain specialists, in contrast, insist that every patient has a right to pain relief, and they point out that addiction depends on social context. All of these cases represent memes at work. Sometimes patient memes fit with provider memes; in other cases, the memes clash. Ideally, all medicine including the prescribing behavior of physicians should be evidence-based, but unfortunately it is not. Late in the 1990s in the United States, for example, a new meme emerged among pain physicians: off-label use of the partial seizure agonist gabapentin to control neuropathic pain (pain originating in damage to peripheral nerves). Despite a paucity of slowly emerging scientific evidence, pain physicians began prescribing gabapentin for virtually every intractable pain on a trial-and-error basis. Such widespread adoption of an arbitrary prescribing behavior, which one can observe again and again in many areas of medicine, illustrates the spread of a meme by imitation. Carr and Cousins (1997) recognized the potential importance of the memetics framework for pain management. Although they addressed scientific publication as a vehicle for memetic replication rather than imitation, they usefully described the replication of a new meme as occurring at an exponential rate, up to the maximum level that the environment will sustain. This produces the familiar S-shaped curve. The gabapentin-prescribing fad nicely fits this pattern. Of course, rapid replication does not assure the long-range survival of the meme, but it does affect the social climate of practice.

3.3. W HEN

MEMES ARE PATHOGENS

Just as biological theorists can account for disease due to microbial organisms, memeticists can account for destructive social forces. Some writers have used memetics to introduce the concept of information disease. A meme can adapt and survive in human culture as a pathogen that threatens the survival of other memes just as microorganisms can cause biological disease (Brodie, 1996). Misinformation, biases and prejudices replicate and fight for survival just as effectively as ideas and beliefs based in scientific evidence. Some memes may act against the good of the individuals who transmit them or against the good of society as a whole, and these are social pathogens that constitute thought contagion. Some of the beliefs that some patients and some providers share appear to be pathogens. For example, many chronic pain patients believe that surgery or some other invasive procedure is the only thing that can cure their pain. They feel angry at doctors who seemingly withhold this resource by refusing to perform surgery or recommend the patient for a procedure. Unfortunately, there exists a cohort of physicians who profit from surgery or procedures and share the belief that

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the proper solution to chronic pain is invasive intervention. The literature does not support this position. When the patient holding the surgical cure meme meets the physician holding the medical counterpart of that meme, invasive intervention results. The cure rate is low, and risk of pain-exacerbating complication such as scar formation and chronic inflammation is high. 3.4. M EMES

AND FOLK PSYCHOLOGY RELATED TO PAIN

The memetics framework holds some useful implications for understanding medicine and public beliefs about health care. We may wish to believe that ideas and practices survive in medicine and public thought because they are true (that is, they have support in valid evidence), but the memeticist insists that memes will survive in any way that they can. What’s more, some memes are pathogens. Just as some organisms manage to evolve devious and seemingly ingenious ways of surviving in a hostile environment (e.g., deception, symbiosis), memes find surreptitious ways of adapting and propagating themselves within medicine. Having a body of supporting scientific evidence, as Carr and Cousins (1997) describe, definitely confers an advantage upon a meme for survival in medicine, but clever memes (including the pathogens) can find many other ways to survive. Consider, for example, the pathogen belief that administering opioid drugs to cancer patients will cause addiction. Extensive evidence indicates that this is incorrect, and multiple policy statements from many august bodies speak against it. Yet this meme continues to thrive. One of its strategies is clever use of public media. Newspapers and television continuously inform the public that one or another celebrity has become addicted to pain killers, occasionally celebrities make public statement about their addiction to pain killers, and now and again one of them dies from an overdose or an accident, again allegedly due to inadvertent addiction to pain medication. No expert ever validates such claims of addiction, and no one ever questions their validity: nonetheless, such assertions are generally false or badly distorted. The impressions that such claims make on health care providers and patients alike is far more powerful than the evidence that science accumulates in journals. The memeticist would emphasize that the “pain medication causes addiction” pathogen will readily stoop to deceit or other tricks to insure its survival. Its only natural enemy is evidence, and evidence lives only in scientific and medical journals. 3.5. S UMMARY

OF THIS SECTION

Memes are conceptual entities (beliefs, attitudes, ways of doing things) that adapt and survive within human culture just as genes adapt and survive in a biological environment. Memetics can help us to see more clearly the nature of folk psychology and the problems that can occur when folk beliefs fail to fit evidence-based medicine. Memes inhabit the worlds of both the patient and the doctor. Some are

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beneficial and others are pathogens. When pathogenic memes in the mind of a patient find a match in the mind of a provider, poor or dangerous health care will ensue. 4. Final Considerations Human pain is an extraordinarily complex experience in accordance with the complexity of the human brain. The patient with tic douloureux cannot experience each painful paroxysm as a raw, primitive event. The condition is a state of her being, and over time she will create a complex network of cognitions that define what this disease is for her and what it means to her. Past experience and social context will shape this understanding, and inevitably the ideas, beliefs and attitudes inherent in the culture that surrounds her will become a part of her, determining not only her personal folk notion of pain but the very nature of the experience itself. Research into the folk psychology of pain is a neglected arena that promises to yield payoffs in both improvement of clinical care and social psychology. The necessary tools and technology for such work are already available. Comparing and contrasting the beliefs that different patient populations hold could prove advantageous. For example, an investigator might compare the beliefs of patients with well-defined conditions such as tic douloureux with those of patients whose condition is ill-defined (e.g., fibromyalgia). Alternatively, one could compare the beliefs of patients matched in social strata and disease but varied over age cohort (e.g., compare adolescent and geriatric back pain patients). A broad map of the beliefs that American society holds about pain would require an extraordinary undertaking, but it would yield information that could help physicians better care for their patients. In addition, it would help those of us who are pain professionals to better educate the American public about this important topic. References Aldrich, S. and Eccleston, C., in press: Making sense of everyday pain, Social Science and Medicine. Andersson, G. B., 1999: Epidemiological features of chronic low-back pain, Lancet 354(9178), 581– 585. Austin, J. L., 1962: How to Do Things with Words, Harvard University Press, Cambridge, MA. Blackmore, S., 1999: The Meme Machine, Oxford University Press, London. Brodie, R., 1996: Virus of the Mind: the New Science of the Meme, Integral Press, Seattle. Carr, D. B. and Cousins, M. J., 1997: Trends in pain management 1987–1996: An evidence-based survey, Curr. Opin. Anaesthesiol. 10, xliii–xlvi. Chapman, C. R. and Gavrin, J., 1999: Suffering: The contributions of persistent pain, Lancet 353(9171), 2233–2237. Chapman, C. R. and Nakamura, Y., 1999: Pain and consciousness: A constructivist approach, Pain Forum 8(3), 113–123. Dawkins, R., 1976: The Selfish Gene, Oxford University Press, London. Dennett, D. C., 1991: Two contrasts: Folk craft versus folk science, and belief versus opinion, in D. C. Dennett (ed.) (1998), Brainchildren, MIT Press, Cambridge, MA, pp. 81–94.

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