Just Behavioural: Pain, Psychiatric Patients and Possible Responses to Them. (Part One.)

It seems like a weird question to ask how you can know if someone is in pain or not.

Not that this has really stopped philosophers from continuously asking it, and many of them answering along sceptical lines; you cannot ever know another’s pain, you can only guess at or surmise it. (PI 246)  But this is not what I’m talking about. As my philosophy tutor, Bob Hargrave, used to say, the only possible response to a philosopher who claims they can seriously entertain the possibility that someone screaming and writhing under a torturer’s implements isn’t actually “in pain”, is to back away from them slowly. (This goes along with a certain, and largely justified, fashion of seeing most philosophical problems as being abstract and irrelevant to our lives: of course we constantly treat other people’s pain as something obvious and indisputable, whatever the philosophers decide between them is hardly going to have much bearing on that.)

What I’m talking about, though, are the kinds of situations I now encounter all the time. Where a patient on the ward is doubled up, clutching their stomach and the response of the nurses and doctors is simply to label it as “behavioural”-  the polite, medicalized way of saying “they’re just faking it to get attention.” Instead of responding to their pain, instead of comforting them (or offering some other kind of relief),  we simply have to work out how to manage their problematic behaviour. They very much look like they’re in excruciating pain, but we know that they’re not, so treating them as if they are is inappropriate.

At best this kind of response can end up with patients feeling horribly abandoned, frightened and alone, at worst it can be fatal. One of the patients on our ward said that the worst thing about being “mentally ill” was that no-one took anything you said seriously. At a previous hospital she had been treated at, this patient had almost died of appendicitis because no-one would believe her cries for help, or that the crippling pain in her stomach she reported to them wasn’t just a fabrication.

This is where philosophy becomes acutely relevant, because one of the things which leads people to respond to psychiatric patients in this way is, in my opinion, their being in the grip of a dodgy picture of how “pain” works. This picture is a particular, and very seductive, way of filling out how one might regard “pain” as referring to some kind of “object”; of “constru[ing] the grammar of the expression of sensation on the model of ‘object and designation.’” (PI 293.)

As Wittgenstein rightly shows, seeing this “object” as somehow mental, gets very sticky, very quickly.* But there is another way of taking the term “pain” as designating an “inner object”, one which does not have these associated problems, and one which (at least partially because of this) seems more popular among those untrained in academic philosophy. This is to see our concept “pain” as referring to a physiological fact about a person, a way which not only means that you can know with a high degree of certainty whether or not someone is in pain, but even perhaps that you can know it better than them, especially if you are nurse or a doctor. Stephen Mulhall notes (in his discussion of the physiological in Wittgenstein, 2007) that we are “constitutionally inclined to conflate the psychological with the physical, the inwardness of the mind with the inwardness of the body”, and that we “picture human skin as if it were the interface between mind and body, as opposed to between body and world.” If this is true of us as humans more generally, it must be even more so of medical staff; people who are required to spend their time uncovering the mysteries of bodies and what goes on within them, people who are fixed on the “organic causes” of various psychiatric conditions, and the like.

It’s important to note here, however, that this view is not the one which views the term “pain” as referring to a fact about our brain physiology, it’s far simpler than that. “I have a pain” or even just “Auooaghwwh” means something like “some part of my body is damaged in an appropriate way, either through injury or illness.” Since pain has no meaning apart from referring to that  physical damage, if you make either of the above “claims” without it, then you are either somehow mistaken or just straightforwardly lying, presumably for attention or some further end.

It’s not hard to see what’s wrong with this view if you think about your own pains. When we scream out in pain, we are not making an empirical statement about our physiology in that particular location, we are in pain; we don’t infer the existence of but instead have pain in that location, or perhaps in no location at all, or so strongly it feels like it is in all locations. If you asked any of the nursing or medical staff I work with whether or not they thought “being in pain” either directly meant (or was only possible if) you had tissue damage of a certain sort, meaning your pain receptors were fired up in that area, I think most of them would answer negatively. This view shapes behaviour in more subtle ways than that: it is less the explicit standard people refer to in making judgements about whether or not someone is in pain, and more the background picture which determines their reactions to “pain behaviour”, (and indeed is the only view which could lead someone claiming pain, but without a “physical cause” of that pain, to be straightforwardly accused of lying.) This picture that means staff on the ward can often fairly unanimously agree that someone screaming that they feel like they are dying is “just behavioural”, since there’s nothing “wrong” with them, without ever having to make what this view of pain entails explicit. (Something which would end up ruling out any kind of psychosomatic, or even just psychic, pain altogether.)

[For Part Two click here]

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