All Pain Is Psychological

The other day a doctoral student was talking about a client’s experience of "physical" pain and wondered to what extent it was “psychological”. Before addressing this issue for the benefit of supervision, I reminded her why it was that, although her question made sense in a colloquial way (and for this client, it made particular sense), from the vantage point of a sophisticated conception of psychology, properly speaking, all pain is psychological. Thus, I encouraged her to substitute the term “mindset” to capture what she was thinking.

The deep confusion that surrounds this issue stems from two places. First, there is the historical and philosophical confusion surrounding mind-body dualism. The confusion here largely stems from Rene Descartes who very clearly divided the world into two substances, the mental and the physical. For Descartes, the “mind” was the rational, self-conscious, thinking portion of the psyche. It was given by God and separated us from the rest of the universe. In Descartes world, the stuff of emotion and feeling were generally thought of as animal-like, which also meant more machine-like and essentially non-mental. (According to Descartes, performing surgery on, say, a dog, would be fine, because they are essentially robotic.)

The second domain of confusion is with the term psychology, and the fact that it means so many different things. For example, for the famed behavioral psychologist B. F. Skinner, psychology was essentially synonymous with behavior. Skinner argued behavior/psychology existed in two broad domains, which he labeled overt (that which was observable by others) and covert (that which was not). For Skinner, the pain of a toothache was considered “covert” behavior. (Although Skinner’s radical behaviorism definitely had errors, the modern formulation is much closer to Skinner than Descartes).

My doc student did not have either Skinner or Descartes explicitly in her mind when she used the term. She was using the term in a modern colloquial sense, whereby psychological roughly translates into one’s mindset (attitudes, defenses and expectations), which is believed to be separate from the actual sensory experience of the “physical” world, whether it is outside (e.g., seeing a dog) or inside (sensing hunger or pain) our bodies. There is some validity to the point that our mindsets can often be separated from our direct experiences, but it is not helpful to call the former psychological and imply that the latter is not.

An example might help clarify. When my daughter Sydney was younger, she had a bit of a needle phobia. Anytime she got whiff of the idea she might need a shot, she went into a bit of a panic. I recall one particular time at the doctor’s office when she was about four. My wife had previously instructed them about Sydney’s anxieties, but they were busy and did not coordinate it well. So, the nurse brings in the shot stuff and then, rather than giving it to her right away, is called away to do something else. Sydney now knows she is getting a shot and in the next few minutes she goes ballistic and is essentially inconsolable. Finally, she gets exhausted and we sort of distract her, and, boom, she gets the shot—and she barely reacts at all.

Most of the time, Syd was a happy child!

Using the commonsense definition of “psychological” as Sydney’s mindset (roughly translating into her attitudes and expectations, and the emotions that follow from them), we can see that her pain was mostly “psychological” in this sense. That is, her distress was much more a function of her mindset than it was the actual shot. Indeed, she demonstrated almost no reaction to the actual shot, but decompensated for 15 minutes as a function of her anticipation of the shot. And, likewise, it was the case that my sense of my doc student’s client was that the way she was thinking about her pain was generating a lot of additional stress that might be dramatically reduced if she thought about it differently. (See here for a blog on the various levels and ways of thinking about pain, especially chronic pain).

So, if the distinction between one’s direct experience and “psychological mindset” makes sense, why can’t we leave the commonsense definition alone? Because it contributes to a Descartes’-type error (see Damasio’s Descartes’ Error) that creates massive confusions about the relationship between the mental and physical worlds. From a modern philosophical-psychological perspective, it is incoherent to consider Syndey’s experience of the actual shot, that is her first person phenomenological perspective of the sharp “prick” of the needle actually entering her arm, as “physical” (or non-mental or whatever), and her thoughts about the experience as psychological (or mental or whatever).

Syndey’s actual experience of the shot—just like your experience of actually reading this blog—existed in what some call the theater of consciousness (ToC; for those philosophical inclined, I like and am using Bernie Baars’ conception of this). Her ToC, your ToC, my ToC and everyone’s ToC is a psychological phenomenon. It is an emergent mental property of the brain. Emergent mental properties are things like thoughts, feelings (both sensory “physical” and emotional), and goal oriented actions. Note these mental entities can be either implicit (nonconscious, not on the ToC stage) or explicit (conscious, part of the ToC). (Here is a blog on how to think about the mind).

The bottom line point is that pain (and everything you consciously experience) is part of the ToC, and the ToC is psychological. Thus, the title of the blog—all pain is psychological. That it is psychological, of course, doesn’t make it less “real”. In fact, as the movie The Matrix suggests, the only thing you have and will ever have direct access to is your subjective phenomenology. In some ways, then, it is the most real thing that there is.

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Teaching and the New Behaviorism

My Dog Is Quite a Character

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P. S. Some readers may be wondering about the term "psychological pain", referring to being depressed or in great distress, but not in "physical" pain. This distinction is also problematic for the same reasons. Technically, the terms "sensory pain" and "affective pain/distress" would be a better disctinction. See the levels of pain blog mentioned earlier.