Pain’s Description: Beginning Grammar and Biological Philology

In her article, Wierzbicka (2012) asserts that a key goal of studying pain is being able to create an empathic bond and understanding between the person with pain and the other, particularly with a clinician. But what are the key aspects of pain that a patient wishes to convey or be understood? The quality of pain, exactly what area hurts, to begin with. But additionally, as many have argued before, the empathic understanding of pain requires much more than this. As we have argued, one must know the metaphoric dimensions of pain, associated fears (such as the meaning of the pain in the local ethnophysiology), trauma associations, and the status of the particular type of pain as idiom of distress in that culture (Hinton & Good, 2009a, 2009b; Hinton, Howes, & Kirmayer, 2008). Let me give an example.

In the Cambodian language, neck pain is a very common complaint (Hinton & Good, 2009a; Hinton, Um, & Ba, 2001). It is referred to as “cok” (literally “blocked”) or “rooy” (“sore”). The term “cok” conjures the local understanding of the source of neck pain: that blood and “khyâl,” a wind-like substance, have risen in the body and are distending the neck vessels to the point that they may rupture, among other disasters, and that a plug has formed in the neck, worsening pressure—traditional treatment often involves “coining” the neck with medicated oils to remove the blocks. In this way, the very term for “pain” in the culture conjures up certain fears associated with the local understanding of the physiology of pain. And neck soreness in the Cambodian language is associated with many other metaphors. A Cambodian may say to another, “Don’t carry that burden all alone on that stick balanced at your shoulder” (kom reek khluen aeng), meaning that the person should discuss his or her problems and let others help with the burden. These and other metaphors cause interpersonal distress to tend to be somatized as “neck pain”—and neck pain to be read as a potential sign of interpersonal and existential distress. Moreover, neck pain may elicit traumatic memory—and be generated by it. During the Pol Pot period, one of the most hated labors, and one that was experienced by almost all Cambodians, was being forced to do dam building though starving. This involved carrying loads of dirt balanced at the neck at either end of a pole for many hours each day, ultimately causing thick calluses at the base of the neck. Neck pain is a somatized memory of the Pol Pot period owing to these meanings, a generic encoder of that time period, a somatic chronotope. Yet still, neck pain is part of the physiology of generalized anxiety and particularly worry—among trauma victims worry episodes are particularly likely to induce somatic symptoms such as neck tension by biological processes (Hinton, Nickerson, & Bryant, 2011)—and one must know whether for the particular Cambodian patient worry episodes about certain problems produce episodes of neck soreness by those biological processes.

As this analysis shows, to attain an empathic understanding of pain for a particular individual is complex and involves an analysis of multiple semantic dimensions, as well as a consideration of the very biology of emotion—for example, that of worry in a trauma victim. In certain cultures certain body areas may be hypersemiotized and a key part of these semantic networks may be united through the idea of “pain” in that bodily area. Pain often unites biology, semantic networks (metaphor, local ethnophysiologies), and trauma memory—and that trauma memory may be personal or societal. I would suggest that pain understanding must consider these semantic and biological dimensions. This is the analysis that leads to empathy and therapeutic intervention—and witnessing. One must ask: Why pain in this area? Does pain in this area that has this quality have a particular meaning for this group? What is that meaning? This meaning may be metaphoric, an indirect sign of interpersonal or existential distress, or ethnophysiological, indicating a feared physical condition. Or the pain may be associated with traumatic memory—or actual physical injury.

Knowing the quality of the pain, its location, and its temporal pattern is just the beginning of the analysis. Instruments such as the McGill Pain Questionnaire represent a first step in analysis. A true biologically informed philology of pain must examine the various meaning dimensions and biological aspects described above. The natural semantic metalanguage (NSM) approach suggested by Wierzbicka is an abstract grammar of pain that, like the McGill Pain Questionnaire, helps to locate and define pain quality, but leaves out much that is critically important for empathic and effective treatment of pain. Wierzbicka’s suggestions about how to revise the McGill Pain Questionnaire are instructive in improving this first step of analysis. But this leaves unanalyzed the cultural and other dimensions of analysis.

Wierzbicka concludes with the universalist claim that “the minilanguage based on empirically discovered universal human concepts enables us not only to access a universal human perspective on the human condition, but also to truly understand the English concept of ‘pain.’” (2012, p. xxx). As I have tried to illustrate above, I think this view is an overstatement; it is acultural. What is the meaning of “back pain” or “fibromyalgia” in contemporary American culture? There is not pain in general, but particular pains in specific body areas that increase and abate, and that pain experience is embedded in dense narratives of meaning and semiotic networks of significance, in a particular life history and cultural context; that pain experience is subject to the laws of biology; and that pain experience results from complex interactional loopings that tie together these disparate ontological zones. What we need is a biological philology of pain, not just a simple grammar of it. The grammar is a key beginning, but must be recognized and acknowledged as a beginning, not an end.