Pain in one form or another is probably the most common symptom presented to healthcare professionals and has long been a subject of biomedical and psychological interest. More recently, biopsychosocial theories of pain have also emerged. The work of Melzack and Wall (1965, 1968) in describing and refining ‘gate-control theory’ has been very influential in extending the study of pain beyond a measurable concept to one which is highly individual in the way it is experienced. However, this work has been set within a naturalistic framework, and only much more recently has a sociological analysis of pain been attempted. While students in the natural and social science disciplines have access to discrete bodies of knowledge, students in the health professions, and indeed people searching for explanations for their own pain, tend to make use of an eclectic mix of theoretical and practical work. This can, however, lead to confusion over seemingly disputed territory and conflicting arguments and conclusions. Making sense of the competing arguments may be a difficult task for people not versed in appraising different forms of evidence. With that in mind, this volume seeks to be accessible without being simplistic.

To that end, I will begin by clarifying how certain terms will be used in the book. ‘Clinicians’ or ‘health professionals’ are used as generic terms for physiotherapists, nurses, doctors, etc., working in clinical practice. The phrases ‘long-term condition or illness’ or ‘chronic disease or illness’ reflect how the terminology has changed as ideas about those living with these states of health have changed. I tend to employ the terms used in the studies I cite, but in other places adopt the common distinction between ‘disease’ and ‘illness’: the former understood as a medically diagnosed condition, the latter as the experience of living with health problems. However, it must be acknowledged that there is no clear boundary between ‘normal’ and ‘pathological’, and it is this that frequently results in tensions in health and healthcare.

You will also come across concepts that are problematised in some parts of the book but used uncritically in others, such as that of diagnosis. Similarly, in some places it may seem that binary oppositions such as that between acute and chronic pain are not being challenged as false divisions. These concepts and distinctions are so universal and hegemonic that the English language does not always offer alternative terms that would allow us to recognise the contested nature of the dominant discourse that surrounds them. Where relevant, I have highlighted the contested nature of these concepts, but elsewhere, in order to avoid repetition, I have left them unchallenged.

Finally, the word ‘experience’ is used frequently throughout the book, and its meaning may appear to be somewhat taken for granted. Unless interpreted differently in relation to the studies cited, I adopt the definition given by Kleinman and Seeman, who argue that ‘experience’ is not ‘a deep and individual subjectivity’, but rather represents ‘the intersubjective, felt flow of events, bodily processes, and life trajectory which always takes place within a social context’ (2000: 234). Here the link between the personal, the cultural and the social is acknowledged: experience does not take place in a vacuum, but is mediated by cultural and social structures, which will be utilised to explore individual narratives.

Much of the medical research on pain has been conducted using quantitative methods, and although this provides information on large numbers of people, it tends to lack context. Sociological research in the area has mainly utilised qualitative approaches. This does not produce results that can be generalised to the wider population, but it does give us insight and understanding in relation to the world of those living with pain, the meaning it has in their life, and how they make sense of it. It can also seem that the results of such research are usually negative, but, as C. S. Lewis states, ‘Pain hurts. That’s what the word means’ (1940: 105). It may be that those who are in the most extreme forms of pain, or those whose pain is not managed well, are more likely to take part in research that gives them a voice.

If you suffer from pain, particularly long-term pain, you may find that parts of this book, or the individual stories it presents, resonate with your own experience, or help you to understand or make sense of your life. Unfortunately, though, you will not find a new treatment to try, or anything that will ease your pain. The book is an exploration and examination of various facets of pain from a sociological perspective. There are many authors and researchers on pain whom I have not cited, and one criticism of the study may be that I have neglected a classic text or respected authority. My focus here is on an exploration of pain that attempts to be illuminative, rather than exhaustive, in its use of the literature.

My own interest in exploring pain began in the late 1980s when I was researching women’s experience of in vitro fertilisation (IVF). I interviewed a woman and her husband who had – at great expense, both financial and personal – gone through three cycles of IVF, all of which had been unsuccessful. It was then discovered that the woman suffered from endometriosis, which meant that the IVF could never have worked for her. Her husband told me that his wife had always experienced very painful menstruation, which they had repeatedly informed health professionals about, and which should have led to a faster diagnosis and treatment prior to IVF. However, his wife’s pain was never taken seriously; she was fobbed off and told that the pain was psychological and caused by her inability to conceive. This is a story I have heard many times since, as will become apparent later in the book. At the time I was left wondering how a symptom such as severe pain could be totally ignored and trivialised in the management of a patient, particularly when treatment is proving unsuccessful. It was some years later that I had the opportunity to explore these issues further, when I started research with other women who had been diagnosed with endometriosis. I discovered that the way pain is experienced and managed is highly complex and multi-layered, with assumptions and value judgements made by those experiencing pain, by those treating them, and by their significant others.

More recently I have been involved in teaching a module on the sociology and psychology of pain to health professionals studying for an MSc in pain management. The assessment involved students taking an aspect of practice relating to pain (anything from a case study to an area of health policy) and analysing it using the psychological and sociological concepts introduced in the module. Students could quite easily apply psychology to their chosen topic, but frequently had problems in seeing the relevance of sociology to what they perceived as the very personal nature of experiencing pain. However, when they discussed their assessment topics with other students and staff it usually became apparent that there were situations where a sociological analysis was a useful tool in the understanding of pain. This book is the culmination of those discussions with students and of my research, both empirical and theoretical, in relation to pain over the past fifteen years.

Bendelow (2000) argues that the most salient role for a sociology of pain is to deconstruct the rigid objectivity of the biomedical model, and to restore pain to those who actually experience it. This is what I hope to achieve by using a range of sociological concepts and empirical studies to explore the subject. Nearly 50 million Americans report suffering significant or severe chronic pain, and those with the worst levels of pain – around 40 million – have poorer health status, use more health services, and suffer more disability than those with less severe pain (Nahin, 2015). In Europe approximately 20 per cent of the adult population has chronic pain and, besides the physical and emotional cost to the individual and their family, managing it is estimated to cost more than €200 million (Van Hecke et al., 2013). A systematic review of the incidence of chronic pain in the UK suggests that between one third and one half of the adult population are affected by it, with between 10.4 per cent and 14.3 per cent reporting pain that is moderately or severely limiting (Fayaz et al., 2016).

Away from the wealthier countries of the West, chronic pain is becoming a greater health problem, as lower rates of infectious disease mean more people live into old age. Chronic pain is associated with female gender, older age (although the incidence of lower-back pain decreases with age), ethnicity and lower socio-economic status (Bridges, 2012). Fewer than 20 per cent of chronic pain sufferers attend a specialist pain clinic (Van Hecke et al., 2013). Physically, emotionally and economically, long-term pain is one of the most pressing public health issues of the twenty-first century, and is likely to become more so with greater longevity, as people spend more years of life with some degree of incapacity.

Chapter 1 sets the scene by providing an overview of pain in its historical context, some of which still has relevance today. Pain has been viewed over the centuries as a punishment from God and as evidence of sin, particularly the sin of carnal knowledge, through to Enlightenment theories, the hegemony of the scientific method, and recent explanatory models such as the neuromatrix.

In Chapter 2 we move towards a sociological paradigm by considering the work of some of the founding thinkers in sociology, as well as more recent developments in the study of pain that have moved away from the theoretical positions of the past towards more relational approaches.

Chapter 3 is concerned with the experience of pain. It starts by considering some of the ways in which sociologists have conceptualised pain, for example as biographical disruption. Here we review some of the sociological work that has captured the lives of people living with pain, how it affects their families, and the stories they tell to make sense of their experience and to inform others of its impact.

Chapter 4 moves away from the individual to think about care and carers. It looks at the provision of services, both public and private, and the pluralistic nature of provision. Here we also consider the perspective of those who live with, and perhaps care for, a person in pain.

Since the way in which pain is experienced and interpreted is not universal, Chapter 5 explores the structures of diversity and the ways in which they influence the experience of pain. The impact of gender, age and ethnicity on the experience of pain will be the focus of this chapter. However, the importance of not essentialising any one social categorisation, and not treating people as powerless agents in relation to their culture or gender, will also be acknowledged.

Chapter 6 will consider those whose pain is marginalised, and the way they describe their own experience and make sense of it in the context of their lives. Many people never receive an explanation for their pain. The consequences of being labelled as having ‘unexplained pain’ and the way that people respond to it – for example by striving to be believed and viewed as credible patients – will be explored using recent qualitative studies on the experience of painful conditions.

In Chapter 7 we move away from discussing the physical pain that is the focus of most of the chapters. For some individuals, and some health professionals, the pain they experience or encounter is emotional, and recently attention has been drawn to suffering as a painful part of life. While avoiding a dualistic approach to pain as being either physical or emotional, this chapter will look at some of the recent research on emotional pain and suffering. It will also reflect on the increasing medicalisation of that suffering.

Chapter 8 will turn from the person in pain to consider the perspective of the health professionals who treat them. It will examine how health professionals interpret and respond to pain, contrasting this with the patients’ perspectives discussed in previous chapters. How the meaning of pain and its interpretation may differ between patients and their doctors will be shown to influence the quality of communication during health consultations, and may also affect treatment.

Finally, in the Conclusion, I bring together the topics of the previous chapters and draw some conclusions about viewing pain through a sociological lens.