Complaining about chronic pain

Complaining about chronic pain

Robert Kugelmann*

Psychology Department, University of Dallas, 1845 E. Northgate, Irving, TX, 75062, USA

Abstract

This paper examines how a group of working class people describes and experiences chronic pain. This

hermeneutical±phenomenological study concentrates on the lived body of pain from three perspectives, drawing oninterviews with 14 people who were attending a pain management program. First I consider the terms in which painis circumscribed in the narratives, stories told in the context of learning to manage pain. These terms are polarities,

ways of specifying and legitimating pain in relation to ``mind'' and ``body.'' Pain, in the discursive polarities thatde®ne it, is the private property of an individual, who must in some fashion prove that pain exists in an objectivemanner. The speaker, in this discourse, stands as the one responsible for the production of pain. In the second part,

the analysis turns to what this discourse reveals about pain as a lived body phenomenon. Here the analysis centersupon the torment of having to inhabit the intolerable, upon how pain unmakes the lifeworld of the su�erer, andhow, simultaneously, people make pain. The place of pain is the body, as body-in-place. The place of pain is at the

boundaries of human dwelling, a kind of non-place, expressed metaphorically as ``prison'' or ``homelessness.''Finally, after these considerations of how pain is described, in part three, I turn to the act of ``saying'' pain, that is,to the narratives as addressed to someone else. The participants were not simply dispensing information; they weresaying something to me. The narratives had the form of complaints. The form of the narratives, in the context of

the pain program, was a quasi-legal call to rectify wrongs. # 1999 Elsevier Science Ltd. All rights reserved.

Keywords: Chronic pain; Phenomenology; Mind±body dualism; Stress; Narratives

To begin, a metaphor: Just as people make love,

they also make pain. Lovemaking involves, especially

in its older, more circumspect usage, practices and in-

stitutions that circumscribe it. The making of love,

then, `ìs both manufactured and natural'' (Merleau-

Ponty, 1962, p. 189). Similarly with pain: Even if the

fall into pain (as happened to some of the participants

in my study) be more literal in one sense than the fall

into love, the fall still occurs in the ``paramount reality

of everyday life'' (Schutz, 1970) that has ready-made

ways of co-constituting it. Pain in its expression, alle-

viation and su�ering is a performance that is as per-

sonal as cultural, as mental as bodily: Just as the

making of love.

Phenomenological analyses of pain have become

established in medical anthropology (Kleinman et al.,

1992; Jackson, 1992; Csordas, 1994; Good, 1994) and

in other human sciences (Van den Berg, 1980; Murphy

and Fischer, 1983; Leder, 1990). Despite the diversity

of types of phenomenological analysis, they attempt to

suspend allegiances to the truth claims of the natural

and human sciencesÐin an act that Husserl (1970)

calls the epocheÂ Ðand they try to describe the `ùpsurge

Social Science & Medicine 49 (1999) 1663±1676

0277-9536/99/$ - see front matter # 1999 Elsevier Science Ltd. All rights reserved.

PII: S0277-9536(99 )00240-3

www.elsevier.com/locate/socscimed

* Tel: +1-972-721-5268; fax: +1-972-721-4034.

E-mail address: [email protected] (R.

Kugelmann)

of meaning'' (Merleau-Ponty, 1962) in the lifeworld,

the domain of everyday existence that is neutral withrespect to the distinctions between nature and culture.One variant of the phenomenological approach is the

hermeneutical±phenomenological (Von Eckartberg,1986), which has been in¯uenced by Foucault's (1972)critique of phenomenology. A hermeneutical±phenom-

enological analysis begins with situated speech andaction as occasions wherein phenomena present them-

selves. The analysis is hermeneutical in that it seeks tograsp the textuality (Stenner & Eccleston, 1994) ofphenomena: speech and action do not mirror or rep-

resent things as empiricism claims nor constitute themas rationalism (such as social constructivism) claims.

Rather, speech and action simultaneously reveal andconceal phenomena, ®nding and constituting them sim-ultaneously. This hermeneutics investigates how discur-

sive and other practices establish the historical aprioris, such as the objects of discourse and the sub-ject-positions from which speakers speak. But a herme-

neutical±phenomenology remains phenomenological inthat it seeks to describe the lifeworld as revealed in

the illness descriptions. In this way, it is not onlyabout speech, but also about the categories, such as``biology'' and ``culture,'' ``mind'' and ``body,'' that

have become sedimented in our dominant forms ofknowledge.

I explore the making of pain as described by 14chronic pain patients (plus one spouse and one boy-friend) in a three-week in-patient pain management

program of a rehabilitation hospital (seeAcknowledgements). Most of the participants had suf-fered work-related injuries to their necks and backs,

with the exception of one man whose neck pain beganafter an automobile accident. I met the interviewees,

who ranged in age from about twenty to ®fty, at theend of Stress Management group sessions, at which Iwas introduced by the psychotherapist, who also

taught biofeedback as a psychology professor from anearby college. I told potential participants that I wasinterested in their experiences of pain and its treat-

ment. The interviews, held wherever there was freespace, were audiotaped with the consent of the partici-

pant. I interviewed most participants twice, with sev-eral exceptionsÐI interviewed two people three timesand three only once. These were working class people,

with one exception, who had been employed as assem-bly line workers, as janitors, warehouse workers, food

service workers. The seven men and seven women rep-resented, although not in equal proportions, the majorethnic groups in north central Texas: 11 Anglos (non-

Hispanic white), 2 African-Americans and 1 Hispanic.The presentation of the results of the hermeneutical±

phenomenological analysis proceeds in three steps.

First is an analysis of discourse, or more speci®cally,of the terms in which pain came to presence in the

interviews. As Jackson (1994, p. 220) writes, ``pain, ina sense, is a language,'' since we know the pain of

others only through expression. Moreover, the termsof the narratives of pain shape, to some extent, whatthe pain is: ``disease as embedded in life can only be

represented through a creative conceptual response''(Good, 1994, p. 163). Because the very reality of thepain was in the interviews so often an issue, as it often

is with chronic pain (Jackson, 1992), I begin with theterms that de®ned pain as a discursive object that cen-ter around the reality of pain. In the second part of

the paper, interpretation moves from the polaritiesthat shape the manner in which pain is revealed to thelifeworld of pain revealed through these polarities.This part of the analysis centers upon the torment of

having to inhabit the intolerable, on how painunmakes the world of the su�erer (as Scarry, 1985 andGood, 1994 describe it) and how, simultaneously,

people make pain. Finally, after these considerationsof how pain is said and of what is said, in part three, Iturn to considerations of the act of ``saying'' pain, a

turn in¯uenced by Levinas (1991), in his insistence thatspeech is ®rst of all an address (the ``Saying'') bysomeone to someone, the basis for speech saying some-

thing (the ``Said''). The participants were not simplyinforming me; they were saying something to me.What they were saying, not surprisingly, had the formof complaints orÐto use an archaic wordÐ``plaints,''

laments and protests. Complaint was, in Burke's(1954) and Bruner's (1990) sense, the genre of theseinterviews.

Analysis of discourse

The stories the participants told had many contexts,the foremost being, for present purposes, the fact that

the telling of the stories happened in an institutionalcontext. These people were students as well as patients,for they were being taught a particular understanding

of pain as well as being diagnosed and treated. Thepain management program taught a biopsychosocialmodel of pain (Vrancken, 1989) that emphasized the

importance of active participation, not simply compli-ance, in treatment. Hence, in addition to occupationaltherapy, exercise programs and lessons in ``body mech-anics'' (the correct ways to lift and move things),

patients also participated in biofeedback, guided ima-gery training, stress management and often individualpsychotherapy. As Saris (1995) describes it, `à narra-

tive of a chronic condition is not simply a story of per-sonal experience. It is, rather, deeply embedded withinvarious institutional structures that in¯uence its pro-

duction as a story'' (pp. 39±40). Many of the partici-pants were being introduced for the ®rst time to thee�ects of ``stress'' upon their pain and their stories

R. Kugelmann / Social Science & Medicine 49 (1999) 1663±16761664

re¯ected their agreement or disagreement with this ex-

planation. In addition to the speci®c institutional set-ting, there were larger cultural categories that shapedthe telling of pain. Studies of the semantics of pain in

various cultures (Kleinman, 1980; Pugh, 1991;Kleinman et al., 1992; Good, 1994) have shown theembeddedness of pain within culture, such that sen-

sations, explanations and meanings vary quite radi-cally. In what follows, semantic polarities that the

participants employed show how pain is socially con-structed in popular American culture in dialogue withcon¯icts between biomedical and biopsychosocial

models of medicine.Chronic pain as an entity has its very existence dis-

puted (Hilbert, 1984; Jackson, 1992; Csordas andClark, 1992), so that the real and the unreal becamethe ultimate polarity in the interviews. The nature of

pain is under constant negotiation, especially aroundissues of ``responsibility for one's condition'' and thepossibility for ``stigma and demoralization'' (Jackson,

1992, p. 138). The interpretations of pain by bothpain-su�erers (Jackson, 1994) and by medical person-

nel (Baszanger, 1997) are not ®xed. According toMurphy and Fischer (1983), people in chronic pain aretempted to ``struggle . . .to be true to one's past, to sus-

tain it in the present and to project it into the future''(p. 294) in a culture that ``regards physiological hap-

penings as independent of one's responsibility'' (p.296), although the ground has shifted since 1983.Eccleston et al., (1997) delineated ways in which pain

is grasped by di�ering social groups. Con¯icts withinthe ``web of blame, responsibility and identity'' turn on``the meaning of chronic pain in the construction of

identity'' (p. 708). The problematic of responsibility,legal, moral and even existential, arises because pain

de®es western categories, challenging and simul-taneously a�rming the dualities that de®ne westernmedicine (Gordan, 1988; Kirmayer, 1988).

These discursive polarities are ways of describingpain, responding to pain, acting in the face of pain,

assuming attitudes toward pain, that are presented ineither/or terms. These terms tend to be taken-for-granted regardless of the speaker's attitude toward

them. Some of the polarities bespeak a dominant nar-rative (White and Epston, 1990) of biomedicine orbiopsychosocial medicine. Other polarities arise from

popular American culture (see Murray et al., 1998).``Real'' in the interviews meant ``body,'' and `ùnreal''

meant ``mind,'' although thought was acknowledged asan active power in itself. Throughout the interviews,pain implied passivity. Being active meant doing things

to lessen pain. Activity went beyond simple compliancewith medical advice; indeed, participants typically heldthat compliance was a form of passivity. Activity

meant what they could do: physical exercise, dietarychanges, avoidance of medication or surgery. ``Mind''

meant initiative and self-determination, ``body''implied passivity and conformity to biomedical treat-

ment.

Stress and relaxation

A polarity of stress and relaxation was ubiquitous in

the interviews. ``Stress'' has become a catchall explana-tory term in popular as well as learned culture(Kugelmann, 1997). The interviewees learned that

stress a�ects pain, and they were taught means, includ-ing group psychotherapy and biofeedback training, toalleviate stress. As James (1950) observed, when an ex-planation correlates with a change in sensations, it

tends to be believed. The discursive polarity of stressand relaxation is inseparable from those educativemeans used to shape bodily practices that instill it.

This polarity links pain with the relatively recent dis-cursive object, stress.Stress explained the e�ects of emotions and interper-

sonal relations on pain. One patient, a part-timepreacher, stated: ``what causes the pain to increase isstress . . .I've seen it happen, me and my wife was com-ing to a little bit of a . . . little argument, and a little

stress would come on, and my knee would start throb-bing.'' He emphasized that he had learned this connec-tion in the pain management program. What counters

pain exacerbated by stress is relaxation, as herecounted: `Ìt stresses you out when they [his son]start arguing with you. So, I told him, Ì'm not gonna

get mad. I'm gonna stay in a relaxed state, but I'mgonna tell you this, you do it again and you'regrounded.''' Instead of getting angry, he practiced the

relaxation technique he learned in biofeedback train-ing. What is distinctive about this discourse is how itputs engineering terms and practices between individ-uals. The e�ect of another person is to alter stress or

tension, which is felt as tight muscles and other dis-turbances. Then various means are available to alterthe felt tightness. Stress explains the interpersonal

dimension of pain in terms of felt tension, a quasi-quanti®able object.This polarity of stress and relaxation reduces diverse

pain-provoking incidents to a common denominator.As the part-time preacher observed: `Ànd tempers,tension, stress, anything like that even ®nancial pro-blems, money problems, all that will cause stress, stress

leads to pain.'' Physical strain also causes stress (amore literal meaning of ``stress''). A constructionworker reported: `Ì used to work all day and it'd

never bother me, and now you can't even go for aboutan hour and I'm being sore . . .Today it was just toosore to, putting up too much stress today.'' Stress dis-

course postulates a mechanism whereby anythingincreases bodily tension and thus pain.In conformity with the pain management program's

R. Kugelmann / Social Science & Medicine 49 (1999) 1663±1676 1665

position, interviewees tended to present relaxation as a

safer method than, or as an adjunct to, self-medication

with drugs and alcohol. As the part-time preacher

described his experience: ``you might get relaxed by the

pill, but it stresses you out . . .Everybody's been asking

me all afternoon, what's wrong with me? Because I

was on the pills. See, if I'd have gone ahead and done

the biofeedback today, I'd have been a whole lot more

alert.'' Unlike drugs, biofeedback relaxes him without

causing drowsiness. ``Relaxation'' is a vague term, so it

is important to notice exactly what practices were

involved. They consisted in listening to audiotapes of

music or of natural sounds, such as the ocean; in medi-

tative practices of quieting the mind; in prayer; in

guided imagery; in biofeedback. While these practices

(with the exception of biofeedback) are time-honored

means of reckoning with su�ering, as Foucault (1972)

argued, two statements can di�er radically from each

other, even though semantically they say the same

thing. To say that meditation is a means of responding

to pain means one thing in medieval Christian or in

Hindu spirituality and quite another in biopsychosocial

medicine. In the religious traditions, one can su�er

pain for purposes of atonement or detachment; in the

stress/relaxation polarity, pain is a disvalue to be man-

aged.

This polarity presents pain as a problem to be

solved. ``Stressed out'' means being irrational, not

using instrumental reason. A food-service worker

recounted how her neck pain worsened when she had

con¯ict with her sister: `Ì just couldn't, the stress just

couldn't from that moment of ®nding out that my

child was gone and that my sister was behind it was

really, just sent me, it took me a long time to calm

down enough to even think about being rational.''

Being rational meant having her emotions under con-

trol. These experiences link pain with emotion, and

they contrast it to instrumental reason. A school cafe-

teria worker put the case this way:

And it's very stressful . . .you have to deal with all

your emotions constantly, because they interfere.

Well, me and my husband argued . . .and I didn't

stop crying till 2, and I then slowed down till I

started talking to the counselor here and I started

back up . . .Because my emotions had overruled so

much, that they had caused me so much pain now,

to tighten the muscles.

Irrational emotions make muscles tense, cause pain

and hinder progress. The speci®c object of this polarity

is muscle tension. Cultural practices from earlier times

are introduced as drug and alcohol substitutes in an

e�ort to lesson the stress in muscles surrounding pain-

ful parts of the body.

Some patients said that learning to relax gave them

some measure of control over pain. The part-timepreacher put it in clearly dualistic terms: ``You can let

[pain] bother you to the point where it will drive youcrazy. You got to learn to take control over the pain,because actually, your pain is just part of your body,

and if your spirit can take over the physical part of it,the physical part can't win.'' Control over pain meansrelease from pain, or it means not being overwhelmed

by pain. Two participants, the substance abuse counse-lor and the veterinary worker, were involved in twelve-step programs, and they saw similarities between their

relationships to pain and to alcohol. In both cases,`ìt'' had control, and their lives were in self-destructivecycles. A veterinary worker stated what she hadlearned about pain: ``You control it. It's up to you.

You choose it or you don't. It's kind of like being analcoholic, you've got to get down as far as you go.You've got to hit your bottom, as they said in AA,

which I did to get here and choose either to get betteror die, despite the doctors, despite the insurance com-panies, despite the money.'' She claimed that she was

no longer helpless and that pain, as a boundary of thepossible, was something she could in¯uence and modu-late. Pain was not simply an overwhelming force exter-

nal to herself, but an entity she could modulate. Thepolarity of stress and relaxation, in brief, takes up inan instrumental way the polarity of mind and body.

Physical and emotional pain

A second polarity involved the identity and distinc-tion between physical and emotional pain. Interviewees

clearly distinguished the two. The part-time preacherdescribed di�culties he had had with getting a de®ni-tive diagnosis for his back pain:

And I go through this period probably for the ®rstmonth of not knowing what's wrong with my back-. . .and my life is revolving around this pain now. In

other words, everybody is revolving around thispain in my back. Well, nobody's found out what'swrong with me yet, so here we are. We're back inthis emotional pain as well as physical pain.

His emotional pain was the anguish of his ignoranceof the cause of pain and the disorder pain introducedinto his family's life. Even when the two pains were

di�erentiated, they were related. A young constructionworker who had spent time in a state prison statedthat he knew how to deal with physical pain because

he had been through other di�cult times: ``So mebeing through all that I had before this, no physicalpain, but I've been through a lot of emotional pain

that I know life's got to keep on going.'' The twopains were distinguished by their causes and by theirtemporal sequence: The physical pain in these stories


always preceded emotional pain. (This sequence wasimportant, signifying the legitimacy of their pain.)

What brings the ``two'' together are the commonways to cope with them: drugs, alcohol, emotional out-bursts, biofeedback, etc. What also brings them

together is the ways in which interpersonal con¯ict canexacerbate them. For the food-service worker, storiesabout her workplace, about her family, and about her

quest for a diagnosis all centered on how the empathyor callousness of others a�ected her pain. Social iso-lation and the indi�erence of others worsened her

pain. A warehouse worker described how after surgeryfor back pain, he had to face the news that hisbrother-in-law had been murdered: ``My wife, she'sreally taking that hard. That's another added thing. I

think stress kind of brings on your pain a little, a lit-tle.'' The pain of the surgery, the residual pain in hisback and the pain of the loss are all pain.

Because the participants had no de®nitive medicalexplanation for their pain, they had no legitimatedaccount which would have resolved the ambiguity

between physical and emotional painÐor shall we sayobscured the ambiguity? The ambiguous character ofpain in the interviews a�ords a glimpse through a

crack in sedimented categories of the real. Mental, aes-thetic and moral pain as real pain has been describedby phenomenological studies (Buytendijk, 1962;Schrag, 1982); the equivalence of di�erent pains was a

mainstay of psychological understanding a century ago(Marshall, 1894), before pain was rede®ned as a sen-sation. However, for the interviewees, this ambiguity

could not be sustained, because pain discourse is sim-ultaneously medical, legal and ®nancial (Worker'scompensation, Social Security, etc. are not extraneous

factors). The warehouse worker's guarded repetitionthat ``stress kind of brings on your pain a little, a lit-tle'' needs to be understood in the context of his hav-ing ®led a claim for disability assistance. To admit

more would, in his own eyes, discredit his claimbecause it would mean that he ``really'' is not in pain.The discourse on emotional and physical pain is sig-

ni®cant as the site of con¯ict over legitimacy of su�er-ing, over continued ®nancial support, over legal actionagainst corporations and governments. The contem-

porary construction of pain cannot be abstracted fromthese considerations. Patients interpret their very sen-sations in light of the politically co-determined nature

of pain.

Positive and negative thinking

Closely related to the polarities of stress and relax-ation and of physical and emotional pain, was a nega-

tive/positive thinking polarity. In this polarity, a self-defeating way of thinking was pitted against a recipefor success, highlighting ways in which a person can be

active against pain, because the polarity claims that

attitude and mood can be willfully manipulated. The

strategy for its deployment is the control of pain

through the control of one's attitude toward it. As the

part-time preacher said: `Àny time that I think nega-

tive, I'm stressed out, I'm not relaxed, I'm in pain. But

if I think positive, then I'm more relaxed, and I'm

ready to go.'' Positive thinking frees him from,

whereas negative thinking keeps him trapped within

the circle of pain. In one statement, he brought

together all the polarities discussed so far: ``To me,

pain is physical and emotional on a person. And the

only way to relieve yourself of pain is ®rst of all, think

positive, O.K. Don't ever think negative. Think posi-

tive. O.K., second of all, keep yourself out of stressful

situations. And as far as your physical pain, learn the

positions that you can get in that will make it a little

bit less.'' This discourse directs attention to a possible

uni®cation and mobilization of personal abilities in the

face of their disintegration. Positive thinking entails

self-assertion, claiming that `Ì'' can do something

against pain; that thought and feeling can be harnessed

to overcome pain.

The young construction worker described his

approach to dealing with pain:

there are two aspects that you can sit there and

look at, the positive side and the negative side,

which I'm pretty much of a positive thinker . . .And

now, I'm hurt and I can't do the things I was

doing, but I don't get so down that I can't still live

it, there's a couple of times that I just felt like giv-

ing up, and but if you give up you have nothing,

no hope, no nothing, you don't have no backbone.

Thinking is within one's power, and negative think-

ing is a sign of having no ``backbone,'' of weak charac-

ter, of one who gives in to strong feelings. The polarity

of positive and negative thinking points to the close re-

lationship between pain and emotions such as grief, de-

pression and despair.

One expression of this discourse of positive thinking

is the notion of being ``strong minded.'' Strong-minded

people are self-reliant, do not express much emotion

and do not want to be dependent on others. They put

up with pain and ``deal with it'' because `ìt's a part of

me'' as the assembly line worker said. Overt expression

of emotion can be a sign of weakness and others might

take advantage of it. The young construction worker

said that he learned to be strong-minded in prison,

where any display of soft feeling was an exploitable

weakness. In this discourse, pain is weakness, because

pain is failure to master one's feelings.

This polarity articulates how interviewees respond to

being hemmed in by limitations that had not existed

for them before. The part-time preacher observed:


``Pain can destroy a person. It can destroy your family,destroy everything you've ever tried to accomplish. I

thought, O.K., I'm never going to be able to work, I'mnever going to be able to do this, never able to dothat. Negative sayings, O.K. I think a person needs to

think positive about it, not negatively.'' This statementdepicts the devastation that occurs when one is con-stricted by pain, and it identi®es these constrictions as

``negative,'' thereby indicating that there is an activiststance that can be taken, that is within one's owngraspÐpositive thinking. One ®nds oneself in a limit

situation, where one can choose the negative or thepositive.One strategy of this polarity is to rede®ne chronic

pain in spiritual terms, a not unlikely possibility, inso-

far as ``positive thinking'' originated within popularAmerican Protestantism and its secularization (Meyer,1980). While none of the patients expected a miracu-

lous cure through the power of positive thinking, thosethat spoke of pain in these terms asserted that painwas in some degree in their own hands. So while the

polarity of positive and negative thinking reasserts thedichotomy of spirit and matter and the ultimate con-trol of matter by spirit, it also and more signi®cantly

claimed that pain is not simply a matter of sensing andfeeling, but also a matter of thinking. In addition tothe pragmatics of positive thinking was an assertionabout the nature of pain.

Spiritual aspects of positive thinking, when commen-ted on, touched on a person's reasons to ``go on.''Positive thinking, in one sense, means having the deter-

mination to go on with life despite pain. Positivethinking re-interprets the negative in positive terms, asif life events were values to which one can assign,

somewhat arbitrarily, positive and negative meanings.In fact, within the polarity, the value assigned is a mat-ter of one's will.This polarity has strong political and economic sup-

port. Yelin (1986) indicates that social science studiesof disability, in focusing on the ``choices'' that workersmake to return to work or not, ``give a nice name to

behavior which as easily may be called malingering''(p. 644). The emphasis on positive thinkingÐand theculture is awash in motivation ``seminars'' and morale

boosting programsÐhas the e�ect of blaming the indi-vidual if he or she does not have an upbeat attitude inthe face of pain. The polarity leaves the social situation

unspoken.

Pain invisible and visible

The most frequently employed polarity was thatbetween the invisibility and the visibility of pain.

Pain's invisibility made it di�cult to understand.``People comprehend what they can see,'' the assemblyline worker noted. Pain is in this way not independent

of its expression and of the persuasive abilities of the

person claiming to be in pain. These considerations ofthe visibility and invisibility of pain help to determinethe kind of discursive object that pain, especially

chronic pain, is today.The invisibility of pain di�erentiates it from observa-

ble forms of su�ering. The veterinary worker stated:``this is an invisible illness . . .Somebody in a wheelchairor somebody who's got a disease, cancer or broken

bones, you know something's wrong . . .And a lot ofpeople: Òh, you're not hurt that bad,' because theycan't see it.'' The lack of obvious evidence for the

existence of pain had social consequences for thiswoman: `Ìt hurts when your family can't make allow-

ances, because it's invisible to them.'' There is, asHilbert (1984) observed, an asocial component of pain.Especially when pain persists after the scars have

healed or time has passed, patients ®nd themselves iso-lated in their pain. Moreover, the invisibility of pain inpart stems from a belief that pain should be acute.

Medical examination can only provide an indicationof abnormality that typically causes pain (Jones and

Subar, 1996). The participants were frustrated whentold that an x-ray or other visualization of the bodyshowed nothing amiss, especially when ®nancial ben-

e®ts or continued treatment hinged on medical evi-dence. As the young construction worker stated:``That's what I got to get through to these psycholo-

gists and to this doctor. I got to get it through theirheads, so that they'll believe me and start looking at it

as a severe pain instead of something that's in myhead or some unexplained reason. I need to makethem try to believe me and that's the hard part.``

Di�culties with interpersonal validation of the realityof pain placed many of these patients in the dilemmaof ``needing'' pain in order to prove that they are in

pain. Precisely because it is invisible, does everyoneinvolved seek to reveal it.

However, pain is also visible. Pain shows itself asbehavior and expression. The assembly line workerdescribed how her children and her ®anceÂ would see

that she was hurting and not let her do some house-hold chore that she habitually did. In another instance,

the veterinary worker's boyfriend, who had studiedmassage, could feel her pain when he massaged herback: `Ì could feel when she was hurting real bad

because her whole body sent signals to me when I wastouching her, and you could feelÐand then there werecertain points in her body like, right at the base of her

spine where there was a big knot.'' Other intervieweespointed to similar experiences, some of which hap-

pened when the patient was attempting to hide all ex-pression of pain.Participants also discussed the visibility of pain in

contexts where it functioned as evidence. A warehouseworker stated: `ìt's frustrating having to try to explain


to someone the pain you have and them not really tak-ing it in full truth. I'm not one to walk around here

and moan and groan and stu�Ðand if that just makesyou think that I have more pain, then you just won'tthink that I have more pain.'' Pain's visibility is its ex-

pression, so that it is a matter of self-display. In thispolarity pain can be shown to others only by showingoneself. Visible pain renders the self vulnerable,

exposed in his or her weakness.As a result of the ambiguous visibility of pain, the

question of belief surfaced. Interviewees complained

about not being believed when they claimed that theywere in pain. But the question of belief went bothways, and many interviewees did not believe whatphysicians or others told them about their condition,

especially when their own experience contradictedmedical authority. A�rmation of their own accounts,especially by medical authorities, a�orded emotional

relief.Often belief had important medical, legal and econ-

omic consequences. The food-service worker spoke of

her dilemma in trying to get worker's compensation,especially after her supervisor failed initially to reporther accident: ``They sent me for di�erent tests just to

see and they also sent me to an orthopedic doctor atthat time and he didn't think that there was anythingseriously wrong. And when I went for my workman'scomp, my attorney would never listen to me because

physically he saw a healthy person.'' Pain is a social,legal, political and economic as well as medical con-dition. But because of what counts as objective in the

contemporary order of things, pain that outlasts themending of bones and tissue is subject to disbelief.

A polarity of mind and body

The above polarities re¯ect contemporary distinc-

tions and divisions between mind and body. Thesedi�erences correspond to those Kirmayer (1988)describes: mind means activity, body passivity. But

body also means real, and mind unreal or imaginary.The conjunction of passivity and reality of the bodyoccurs because body can be o�ered as evidence of the

claim of pain, in the context of ``the person [as] . . .arational agent, which occupies a space within thebody'' (Kirmayer, 1988, p. 79). It is not duality assuch that con®gures this polarity, but a particular type

of duality, that of ``possessive individualism''(Macpherson, 1964) wherein the individual ends at theboundary of the skin. In other times (Brown, 1988)

and cultures (Lock, 1980; Bates, 1996), ``the sense ofself does not end at the boundary of the skin butextends into the family and the intimate social circle''

(Kirmayer, 1988, p. 78). While the existence of thepain management program indicates that there is someacknowledgement of the social dimension of pain, the

repeated claims of the participants to be takenseriously show that they experience pain as primarily

their private responsibility, whose existence they mustproveÐwith medical and legal denotations of ``prove.''This tension between the activity of mind and its ties

with unreality seem to threaten to make individual in-itiatives futile.The polarity of mind and body ®nds expression in

the insistence by participants that they be believed. AsGood (1994), drawing on the work of Smith (1979)writes, belief, as contrasted to knowledge, has a his-

tory, shifting in meaning from relationship to a personto a�rmation of a proposition, this shift correspond-ing to the development of possessive individualism.Belief as a cultural category makes sense in `à climate

in which empiricist theories and sharp con¯ictsbetween the natural sciences and religion were promi-nent'' (Good, 1994, p. 21). For the participants,

``belief'' was the issue because they felt isolated withinthemselves. ``Mind'' in this context means this iso-lation, a shadow side of individuality: Something pri-

vate needs to be made public.

Pain as a discursive object

What kind of discursive object does pain show itselfto be, in light of these polarities? They suggest that

pain is something that must be ``produced'' as anobjecti®able entity: Pain must be brought forth as evi-dence. Not simply being there, it is not self-evident, es-

pecially when chronic and intractable. Pain must alsobe produced in the sense that it must be continuallysustained. This second meaning is clearly a temptation

for those in pain, one often cited in research onchronic pain (McAlary and Arono�, 1988). And®nally, given the character of what counts as evidenceand the manner in which pain exists as an object of

contemporary discourse, pain must be produced in thesense of being endlessly evoked in the dialoguebetween those who claim its presence and those who

compensate for it and treat it. These discursive prac-tices have their institutional setting: pain managementprograms, designed to manage pain, that is, make it

less costly economically and socially. Pain is producedwithin an economic, medical, legal web, a web thatseeks an equilibrium of e�cient functioning.Pain, in these discursive polarities that de®ne it, is a

private possession of the individual that must be pro-duced in an objective manner if it is to be a social rea-lity. The speaker, in this discourse, stands as the one

responsible for the production of pain. Pain is de®nedin such a way as to a�rm and negate, simultaneously,the dichotomies that de®ne it. This ambivalence is not

simply cognitive, re¯ecting as it does the unsettled sta-tus of the individual vis-aÁ -vis the community, especiallyvis-aÁ -vis the economy.


Phenomenological analysis

If the body were in®nitely malleable, its passivitywould be su�cient to de®ne it. But phenomenologi-cally speaking, the body as body-subject is the `Ì can''

(Merleau-Ponty, 1962), or as Csordas (1994) states,``the existential ground of culture.'' Pain, manifested inpart through the polarities discussed above, is not

simply circumscribed by those polarities: They are theoccasion for pain to show itself. What they show is theintolerability of pain and the marginal form of exist-

ence in chronic pain. Perhaps all chronic illness inha-bits this marginal place, as Kleinman (1988) writes:``Chronicity for many is the dangerous crossing of theborders, the interminable waiting to exit and reenter

everyday life, the perpetual uncertainty of whether onecan return at all'' (p. 181). I will develop this themethrough an expanded understanding of embodiment

that draws on the Heideggerian concept of ``being-in-the-world,'' namely, that body de®nes one's primordialplace (Straus, 1980). In this light, pain is not simply a

condition of a private person, but a way of dwelling(and of not dwelling) in the paramount reality ofeveryday life. My emphasis will be on how pain alters

existence (Boss, 1979; Schrag, 1982; Leder, 1984±85;Levinas, 1988).The idea that in pain the world is `ùnmade'' has

exercised a powerful grip since Scarry's (1985) phe-

nomenology of torture. That pain is ``world-destroy-ing'' (Good, 1994, p. 121) has a speci®c denotationwithin the phenomenological traditions, for world

there means the lifeworld, the ground of all particularsub-worlds, including that of the sciences. While thereis no doubting the destructive power of intense or pro-

longed pain, there is a way in which pain is world-making. Sketches of this way exist (e.g., Frankl, 1984;Seymour, 1998), and it entails more than rehabilita-tion. From a phenomenological point of view, pain is

an a�iction within existence (Buytendijk, 1962). Thevery undergoing of pain, the handling of pain, the ex-pressions of pain and the descriptions of pain make

the worlds of pain and in so doing, make the world.Not only is pain ``made'' as a cultural experience andset of practices, pain makes the world, the truth of uti-

litarian thought, for which pain and pleasure are thetwo springs of action. In phenomenological terms,pain is an attunement, a disposition, a way of being-

in-the-world.

Pain and existence: loss and grief

Intractable pain possesses the self insofar as it leavesno aspect of life untouched. In pain, one can ``lose it.''

The veterinary worker felt abandoned when a phys-ician said, ``Here, take this pill'' and o�ered nothingelse. She felt lost to drugs, to drink, to physical and

social isolation and immobility, to depression and des-

pair. The expression ``lose it'' expresses aspects of the

life situations of the participants. The truck driver's

wife stated that her husband ``will never be pain-free.''

She described how di�cult is the adjustment to and

the limitations of his injury and pain, saying, `Ìt's a

grief process.'' With protracted pain, one losses one's

taken-for-granted way of life. That world is right

there, separated from one by an invisible boundary.

One's familiar self and world have ``died.'' The young

construction worker stated:

It's heartbreaking, you have your heart set on

doing something and you've always done it and

you can't do it, it's kind of like when you lose one

of your loved ones, it's not really that bad but it's

something that you do love and it's not there no

more.

A number of the interviewees severely restricted

their activities because walking or being in a car hurt

them, or because they feared that activity would ex-

acerbate their pain or worsen an injury. The school

cafeteria worker observed: ``Pain takes patience away.

Pain takes fun away. You can't just enjoy anything

when you're in pain.'' Some interviewees found them-

selves mourning losses of activities and occupations.

The limits that pain placed on activities implicated,

moreover, the possibilities for being with loved ones.

The truck driver stated: `Ì can't do some things I

would really love to do with [my son] . . .I can't really

get out there and teach him the things I would like to

teach him.''

The grief of pain was sometimes described in terms

of depression (Ruo�, 1996). While depressionÐwith

all the vagaries of the termÐand chronic painÐwith

similar ambiguitiesÐcan be seen as separate syn-

dromes, it is closer to the sense of the interviews to see

them as complementary modalities of same phenom-

enon. Pain signi®es loss of a customary world and of

an ability to do things. The loss is both to the self and

to the world: the loss of self suggestive of melancholia,

as Freud (1963) argued, and loss of the world, of grief.

But the losses are inseparable: In pain I lose aspects of

my world because I can no longer engage the world in

those ways. As we say, ``grief hurts,'' so we could also

say, ``hurt grieves.''

In these narratives came descriptions of things that

brought enjoyment. Just as pain signi®ed `èmotional''

pain as well as ``physical'' pain, pleasure too did not

have a univocal sense. Because of this range of mean-

ing of the terms, these descriptions focused on the

place of love in their lives. A school bus driver/teacher

spoke of working on his boat:

Although I was doing something like that is physi-


cally demanding, it was something I enjoyed andwanted to do, I kind have worked though the pain,

and it strengthened me and made a big di�erenceprobably in a lot of the pain I had too. . . .I like®shing and my Dad's getting old and I wanted to

be able to take him ®shing, so I was going to get a®shing boat, but then I introduced my wife to big-ger boats, and she and I decided that was what we

wanted to do with our spare time.

The boat and the companionship give him reason toendure, and in so doing, make pain less burdensome.

Being with others in enjoyable activities counters theisolation of pain. A hedonistic calculus is less appli-cable to these ®ndings than the insight that being-at-

home and being-with-others are the grounds of dwell-ing (Levinas, 1969; Van den Berg, 1974). Dwellingattenuates pain. The relationship between pleasure and

pain in these accounts again emphasizes the connectionbetween grief and pain: enjoyment and love counterpain.

Pain and being-in-place

``Pain causes you limitations.'' Pain is a way ofbeing-in-the-world or, more speci®cally, a way of``being-in-place'' (Casey, 1993), even though chronic

pain su�erers ``do not long to stay in the province ofpain . . .are unwilling sojourners in that province''(Jackson, 1994, p. 221). The place of pain is, of course,

the body, but it is the body-in-place, that is, within a®eld simultaneously historical, social, political andeconomic. The Heideggerian psychologist Boss (1979)

speaks of pain as one form of ``®nding oneself'' or`àttunement'' (Be®ndlichkeit). This concept elucidateshow participants experienced pain by locating pain intheir worlds. The interviewees found themselves con-

stricted and isolated. The young construction workerexpressed his de®ant isolation: ``you're going to haveto learn how to cope with the pain and the best way to

do it is just yourself.'' The electronics worker spoke oftrying to sleep her pain away with painkillers: `Ànd itwasn't that I was eating that much [that she gained

weight], it was that I was sleeping that much. Before Iknew it, it was Saturday, Sunday.'' Pain as a kind oflimit of their worlds had pulled its noose tightly.Isolated by pain, many of the participants felt disen-

gaged from life. At times, this was expressed in termsof enthusiasm for an insight learned in the pain pro-gram. The preacher hoped to preach about the bene®ts

of biofeedback, and the cafeteria worker hoped toteach body mechanics to fast-food restaurant employ-ees. The preacher felt that pain no longer would form

the inescapable perimeter of his life, and so he antici-pated fuller participation in life in the near future. Atother times, disengagement was expressed in terms of

the invisibility of their condition: Some stated that

while they may be smiling on the outside, inside theyare hurting. So even in the midst of others, they feltmarooned.

Pain is an existential situation. It was described as acon®nement, symbolically as a prison. The school bus

driver/teacher spoke about being housebound by pain:`Òther than my doctor's appointments, I had to stayhome. I felt like I was in prison so to speak, however

that feels, very depressing.'' The electronics workerdescribed her situation: `Ìt's like I'm being slowly tor-tured and it's like there, it's like everything I need is

somewhere, somewhere behind some door.'' The placeof pain was also depicted as a kind of homelessness.

Two of the women feared becoming homeless becauseof loss of earning power in the wake of pain, coupledwith abandonment by family or spouse or employer.

Pain is a kind of ``homelessness,'' because it casts oneout of one's everyday world, bereft of security. Besetwith such anxieties, the veterinary worker consented to

an abortion, which she later regretted. She had fearednot being able to take care of a baby, and said her

boyfriend was `àdamant'' about the abortion. Theelectronics worker also spoke about fears of homeless-ness, of being ``thrown back'' into poverty and crime.

She feared she would not be able to work because ofher pain and that she would not qualify for disabilitybene®ts. Pain, which limits self-reliance, places one in

the limit situation of homelessness: not having a place.A historical a priori for these existential locations is

the social and economic requirement for adults to beself-reliant. For the participants, chronic pain impliedindigence, aptly depicted as either ``prison'' or ``home-

lessness,'' two contemporary versions of the poor-house of earlier times. Both prison and homelessness,as names for the place of pain, have a common el-

ement: In both instances, the person is cut o� from thepossibility of dwelling, of being at home. As Levinas

(1969) writes, dwelling entails enjoyment, independencein dependence on the surrounding world. The part-time preacher stated that he had been surrounded by

his pain: `Ì was in the center. Now I'm on the outside.I'm on the outside and pain is on the inside. And thepain that I had, I was on the middle before.'' Pain as

the perimeter of existential place is signi®cant. Itsuggests that pain itself is a boundary, a limitation.

Pain presents itself as more a non-place, because theplace of pain cannot be abided. Participants describedthemselves as restless. That restlessness, or inability to

maintain any position for a great length of time, wasthe primary way that they showed that they were in

pain. As several of the interviewees stated, in describ-ing how they try to have a positive attitude: `Ì don'tdwell on things like'' the losses that pain entails. This

attitude of not-dwelling is not simply a volition thatone freely accepts or not: It presents itself as intrinsic


to pain itself, such that the taking up of an attitude

such as `Ì will dwell on pain'' is the radical departure,

a basis for heroism, martyrdom and perversity.

The electronics worker recounted a dream she had

that put her in her grandmother's house. Among the

things one could say about this dream, what stands

out is gathering of a community as the occasion of the

end of pain:

Ever since I started this pain, I haven't had dreams

like I used to. I dreamt of this house. It used to be

my grandmother's, at least the living room. It's like

I walk inside and there's this co�n way at the end

and I know it's me. And I go towards it real slow

and it's like everywhere I turn, everybody's in

white. But I keep on going to this co�n, and it's

my arm in the co�n. So, everybody like started

clapping and celebrating and it was like, you know,

I felt it. I felt that happiness in me. I felt it. I'm not

in pain no more you know.

This dream located the end of pain in a ``living

room,'' a place to dwell and to celebrate. The end of

pain was an end to mourning, putting the loss to rest.

Pain attunes one, according to these accounts, to the

gaps and ®ssures of existence, and pain makes the

world by showing how radically contingent and incom-

plete it is, how each person dances on the edge of pre-

cipice. One does not dwell in painÐthere is no living

room thereÐfor one restlessly seeks relief, seeks being

lifted up to common ground. Hence the practices dis-

cussed above, in particular positive thinking and bio-

feedback, appear now as assertions of dwelling:

Thinking achieves distance from the immediate situ-

ation, transforming actuality through perception of

possibilities (Merleau-Ponty, 1963). Biofeedback seeks,

beyond its technological functionalism, a ``dis-appear-

ance'' of the body (Leder, 1990), so that the lived body

can resume its career as the background of everyday

tasks.

The lived body in its pain thus grounds the polarities

discussed above, and in this sense can be said to be the

`èxistential ground of culture.'' At the same time, the

cultural polarities in their dualism reveal the gaps in

the world that being-in-pain manifests. But the phe-

nomenological explication of pain in these interviews

presents a con¯ict with the polarities that describe

pain: For implicit in the polarities, as in many contem-

porary studies of pain that argue that dualism is

merely a bias of modernity, is the position that dual-

ism can be overcome: ``Never think negative!'' Pain as

Be®ndlichkeit invites the darker thought that dualism

is existential. It is not here a matter of a distinction

between the body-as-self and the body-as-object

(Young, 1997), but a tragic sense of things: That there

is something wrong. Gadamer (1996, p. 97) quotes the

Greek physician Alkmaion: ```We human beings mustdie because we have not learnt to connect the end with

the beginning again and this is something we can neveraccomplish.' This is a genuinely disturbing observationfor it tells us that it is not something in particular that

we lack, but rather everything.'' Pain makes andunmakes the everyday world, showing its contingencyand lightness.

A cry for justice

Good (1994, p. 134) writes: `À great many anthro-pological studies of illness have shown that sickness is

universally experienced as a moral event, as a ruptureof the moral order . . .E�orts to bring meaning to suchevents requires not only resort to theodicy . . .but to the

yet more fundamental soteriological issues.'' Theseissues, the meaning of su�ering and hopes for deliver-ance from it, organized the ``Saying,'' the activity of

the participants telling me their stories. I wasaddressed by them, called by them to witness theirpain. The act of making in the face of pain, in con-frontation with how pain tore their everyday worlds

apart, took the primary form of a complaint. Thesecomplaints were ®rst of all plaints or laments abouttheir situations. Second, they were accusations, at

times made against speci®c individuals or institutions,at other times against ``the way things are.'' Third,they were calls for recti®cation. Some participants

spoke as dependents of service institutions. Yet theyalso spoke as people beholding ®rst hand the humaninability to ``connect the end with the beginning,'' and

nevertheless hoping to do so.The form of the narratives, therefore, had the form

or genre of complaint: The statement of a grievance,of grief, wrong, loss and su�ering. Older views under-

stood pain to exist because the cosmos itself was¯awed. The ¯aw has been interpreted in a myriad ofways: Judeo-Christian, Platonist, Hindu, Buddhist

(Illich, 1976). This perception of pain occurred in theinterviews, often expressed in the ambiguities of theword ``wrong.'' Pain is something wrong. Pain was

tied to injustice, not only for actual injuries done, butalso with pleas to be heard. The polarities throughwhich they expressed themselvesÐof mind and body,of negative and positive, of stress and its reliefÐare

culturally available ways of lamenting, of complaining,of crying for justice.The food-service worker described the responses of

her supervisors to her fall and injury: ``But they neveronce said, `Do you have to go to the doctor?' I toldthem I was in pain. I was in tears because I couldn't

sit, I couldn't hardly stand, I couldn't hardly walk, Iwas like, `Please, acknowledge that I'm not well.'''This woman felt wronged: In the ®rst place, there was


something wrong medically that caused pain, and pain

should not be. In the second place, she felt wrongedby her employers and her physician who did notacknowledge or assist her. Throughout the interviews,

most of the patients were not merely describing, theywere pleading. While a few were literally plainti�s in alegal sense, all were plainti�s in existential terms.

Complaints were not necessarily directed against any-one at all. They were instead directed primarily against

the way that they found themselves. The complaintsassert that in one sense, pain is `ùnnatural'': That tobe a human being, to live a human life, is incompatible

with being in pain. This implicit assertion did not stemfrom a desire for perpetual anesthesia, but from a felt

sense of what a good life is. The complaints were notonly about present pain or past wrongs, but also aboutaborted futures, as the electronics worker indicated: `Ì

was going for my bachelor's degree and I had twogood o�ers before I got injured.'' She could not returnto her former occupation, and she felt that despite her

hard climb out of poverty, she was being thrown backinto it, through no fault of her own. At other times,

the complaint was lodged in terms of an archaic dis-course, that of harmony or of natural balance(Gadamer, 1996), as was the food-service worker's:

`Ànd I mean, I was like, God, I hope you're never onthe end of the rope similar to yours because `whatgoes around comes around.' And one of these days,

somebody's going to do you the same way that you'redoing your own employees.'' To cause pain, or to fail

to respond to the pain of another, violates the natureof things, according to this statement. It asserts thatpain is not a fact, but an evil.

Blame occurs in the etymology of ``pain'' (poena,``penalty''), and in the contemporary textuality of pain

(DeGood and Kiernan, 1996; Eccleston et al., 1997).Others were to blame for much of the pain, and someparticipants felt they themselves were to blame. In

other instances, some felt that they were being blamedfor having pain. While scapegoating did not surface inthe interviews, it was an implicit threat felt by many

interviewees, especially in the insistence with whichthey claimed that their pain arose from an accident

and was not their fault. Much of the pleading aboutthe anatomical site of pain must be understood astheir pleading their case.

The question of responsibility thus arose. The sub-stance abuse counselor owned up to his own responsi-

bility for his pain in these terms: ``What's true isyou've let your goddamn health go in the toilet, andyou're trying to blame it on somebody else.'' The

young construction worker ambivalently blamed hisboss and fate for his accident: `Òur boss was pushingus, you know, I ®gure it was just my day to get hurt.''

The medical assistant also expressed ambivalence: ``he[my husband] doesn't blame me for it, you know, but

at times I blame myself for it, but I'll sit there and tell

him and he'll get upset with me for doing that.'' Theelectronics worker emphatically blamed the companyshe worked for: ``They should at least say, `Yes, we're

to blame.' But I haven't heard from anybody. I meanit's just like what am I complaining about.''

In the logic of these complaints, pain isolates a per-son by severing relationships with a community. Whenpain exists, when this rupture of community occurs,

then someone or something is responsible for it: Thisis the thesis, to which there is an antithesis: It was justan accident. However, the question of the cause of

pain arises. In addition to a physiological cause, painraises the question of blame and responsibility. There

are many forms that these questions can take: But theyappear to be endemic to the ``place'' which pain estab-lishes. These questions establish, moreover, the subject-

position of the person caught within the no-place ofpain.With blame comes the question of payment for pain.

This is not simply seeking to exploit pain as a second-ary gain. Rather, it indicates that pain demands an

equivalent in someone else's substance. Thesedemands, which to some observers appear as unrea-sonable expressions of immaturity or malingering or

refusal to take responsibility, address the primarysense of something being amiss in pain. The schoolcafeteria worker asserted that ``the only thing I regret

is that I was never said, Ì'm sorry.' These kids nevercame up to me and said, Ì apologize,' but I just want

the pain to stop. I want my life back.'' An apologywould not give her her life back, would not connectthe end with the beginning, but it would ``set things

straight'' between her and the kids. Payment heremeans, at the very least, `àpology,'' literally the``speech from the defense,'' a response to the su�erer.

The primary response to the other, in Levinas's words,is apology: `Àpology does not blindly a�rm the self,

but already appeals to the Other. It is the primordialphenomenon of reason, in its insurmountable bipolar-ity'' (1969, p. 252).

Recalling that these cries to rectify wrongs takeplace in a pain management program, I conclude that

these stories of complaint resemble legal proceedings.Some of the participants had been or anticipated somekind of legal determination regarding disability, and

the reiterated desire that physicians take them seriouslyonly reinforces the sense that the narratives I heardhad a quasi-legal form. It is as if the interviewees were

pleading their cases before someone who would act aswitness. They spoke from the no-man's land of ``home-

lessness'' or ``prison'' of pain, in a context thatinvolved both determination of proof of pain andrelease from pain. The place of the interviews was sim-

ultaneously scienti®c, medical and legal. Given theseventeenth century origin of ``trial'' (both scienti®c


and legal) in empiricist notions of truth (Latour, 1993),the di�culties of producing the invisible appear all the

more problematic.

Conclusion

In summary, bringing together the ways in which

pain was depicted (the polarities of mind and body),what was said of pain (pain as not being able todwell, revealing the constrictions and inescapablelimits and gaps of the lifeworld, such that in pain

the su�erer is imprisoned or homeless), and thegenre of the stories as complaints, what do we ®nd?Two contradictions appear: First, the polarities pre-

sent pain as private property, a meaning ampli®edby the sense of imprisonment, in the sense that theperson in pain feels trapped with a private reality

that often cannot be brought forth in objective evi-dence. A contradiction appears, because the home-lessness and imprisonment to which the not-dwellingof pain can be compared is not a private reality but

an existential one. The participants in this study ex-perienced pain primarily as their private property,with little cash value, I might add. And in their iso-

lation, the painfulness of pain becomes ampli®ed.But pain, as the study of it as attunement shows, isnot private: It opens up the world in vital if often

awful ways. SoÂma seÂma, the body a tomb, an un-Cartesian duality, ®nds expression in the complaintsabout pain. This insight is essential to the `èxisten-

tial ground of culture.'' As Kleinman (1996), Good(1994) and others have already said, pain and thesu�ering of pain can only be approached in an ade-quate way if we take our bearings by their ethical

and moral dimensions. The genre of the complaint,the laments and accusations of these stories a�rmthat for these people, pain was ®rst of all a moral

question.The second contradiction that emerged in the inter-

views was that between the invisibility of pain, that is,

the di�culties that people in pain have of producingevidence that they are in pain, and the demand for jus-tice that the participants insisted upon. The setting forthe interviews, the pain management program, pro-

vided the courtroom, as it were, for these cries. There,the participants assumed, evidence would have to beempiricist: an x-ray, a diagnosis, an assessment. No

one conspired against them. But the premise of thesetrials, rooted as they are in the Baconian tradition ofwestern knowledge since the seventeenth century, mili-

tated against acceptable evidence being brought forth.Pain became visible, however, in another way: Inresponding to the complaint, by entering into the nar-

rative, at the very least, and witnessing the pain thatshows itself there.

``Painmaking'' like lovemaking is a cultural per-formance which, like its analogue, entails voicingthose things that tear one's world apart, and hoping

to have one's case heard. Like its analogue, itinvolves laments. Unlike love, though, pain is made®rst and foremost in calls for justice, in complaints

against the wrongs that tear apart the paramount rea-lity of everyday life.

Acknowledgements

I wish to acknowledge the hospitality of Dr. GeraldCasenave and Carolyn Love for allowing me theopportunity to meet these people undergoing anintense three pain management program at an indepen-

dent rehabilitation facility in Texas.

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