Western+'medicalisation'+of+pain+...+Have+we+lost+touch?

**Student no.**: n5740487  **Tutor**: Sarah Jordan  **Topic:** How culturally 'clued-in' are our primary and emergency service providers? **Warning: This post contains explicit images and links to images which some people may find confronting.**

//‘In a context where pain and suffering are not understood to have value, that attitude can create more suffering, even in conditions meant to alleviate suffering, such as in biomedical situations. In contrast, where pain and suffering are understood to be valuable, such as within a religious context, those experiences can be used for spiritual transformation; the luminal state that pain can induce contributes to this process.’// - Norris (2009, p. 22).

**Artefact** The following is a link to an online BBC news article relating to an incident in the United Kingdom which saw a man tried for child cruelty after reportedly pressuring two young males to perform self-flagellation as part of a Shi’a Muslim religious ceremony.   news.bbc.co.uk/2/hi/7568953.stm The ceremony, which takes place during the Islamic month of Muharram, is termed Ashura which translates as 10 (being the day of the month that it falls upon) and commemorates the death of Abu Abdullah Husayn ibn Ali (Husayn) - the son of the prophet Mohammad. As part of this ceremony some Shi’ites perform acts of self-flagellation or other forms of bodily mortification in an attempt to empathise with their martyr (Pierre, Hutchinson & Abdulrazak, 2007). The image below shows a Shi’a Muslim man performing self-flagellation with a bladed whip (//zangir-zani//) for Ashura.

(SOURCE: http://serr8d.blogspot.com/2009/12/what-bloody-hell.html)

**The Issue** As described by Shilling and Mellor (2010) in their exploration into the impact of the Western orientation to pain, the Western medicalisation and instrumentalisation of pain has reduced it to something that is unproductive and with only a deconstructive capacity. This is important for current day health care services as it highlights the importance of culture in an individual’s experience and expression of pain.  For me, the question that the article in focus poses in relation to the topic of pain is whether it is appropriate to apply the Western view of pain as something to be avoided to situations that are completely removed from our cultural understanding, and whether this view can negatively impact on the care and treatment of those in pain.

**Literature Review** According to the Australian Bureau of Statistics (Australian Bureau of Statistics, 2006), at the 2006 census 1 in every 4 Australians were born overseas. Almost half of these, or 1 in every 7 Australians, were from a non-English speaking background (Queensland Government, 2008). Australia’s multiculturalism brings its own challenges and signifies the importance of being sensitive to the large variety of beliefs, religions and cultures that will inevitably be encountered in primary and emergency health care. As described by Sutherland (2002), in general people are ethnocentric believing that their own culture is the ‘right’ or normal way of doing things and other cultures are therefore deemed inferior in comparison. It is also important for health care providers to take into account this inherent ethnocentrism when considering their approach to situations as those described in the artefact above and in the care of patients from different cultures. Andrews (as cited by Sutherland, 2002, p. 275) also noted that ‘Ethnocentric beliefs by health care providers have resulted in ... failure to adequately provide pain relief, and arrest of parents accused of child abuse because of culturally based practices’.  McCaffery (as cited by McCaffery & Pasero, 1999, p. 17) define pain as ‘whatever the experiencing person says it is, existing whenever the experiencing person says it does’. It other words, pain is multidimensional and a very personal and subjective experience which cannot be measured, only observed. Furthermore, pain expression is a learned behaviour beginning from childhood and there are a number of factors which contribute to how, when or even if an individual will react to or express pain (Briggs, 2010; Narayan, 2010). This further adds to the concept of pain as a personal experience. While the Western, biomedical approach to pain may prescribe it as something to be avoided at all costs, some cultures use pain in a variety of forms for spiritual ends to achieve sacred states or healing; or within cultural frameworks to produce cultural identity, relationships and community (Norris, 2009; Shilling & Mellor, 2010; Cole, 2004). Bendelow and Williams (1995, p. 84) described the Western ‘medico-psychological’ approach to pain as one which focuses on ‘sensation over emotion and neglect[s] the wider socio-cultural context of pain’ while at the same time being ‘unnecessarily limiting and reductionist’. <span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">Further to this, research conducted into the area of trans-cultural care and the impact of culture on the provision of adequate pain relief has found disparities in the quality of pain treatment and management. This is outlined in a systematic review of 35 empirical studies carried out by Cintron and Morrison (2006) that found that minority patients in the United States were more likely to receive inadequate pain relief due to their pain being underestimated by health care providers. There are also many anecdotal examples of situations where culture or ethnicity have presented as barriers to appropriate and effective pain management in the clinical environment. One of the more notable of these is in the case of a young Amish boy whose appendix burst before he spoke a word about being in pain due to Amish cultural norms of stoicism (Davidhizar & Giger, 2004). <span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">Although fairly narrow in design, recent research into pain management across cultures has focused on experimentally controlled pain studies to determine the differences in the pain experience across ethnic groups. Such research has shown the possibility of minor differences in pain thresholds and tolerance across ethnic groups, however it is likely these differences can be attributed to other psychosocial factors including coping styles (Campbell et al., 2005). This same research also found there to be little difference in the perception of pain sensation and the point at which it becomes painful. This provides no basis for the disparities seen in pain treatment and management across cultures. <span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">Briggs (2008) outlined a number of limitations with the experimental research design widely used to investigate ethnic differences in pain tolerance and thresholds. These include that the experimental data is collected from healthy individuals, often uses a small sample size driven by convenience, and that participants are often second or third generation immigrants. At the same time however Briggs did note the 1996 retrospective review of analgesic prescription across cultures undertaken by Ng et al. which found that while Asian, black, Hispanic and white patients all self-administered comparable amounts of opioid, there were inequalities between prescribed doses. <span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">A 2-month collaborative enquiry into cultural attitudes toward pain carried out by Lovering (2006) found a wide variety of beliefs about pain quite separate to that of Western beliefs. Some of these included that pain was inflicted by witchcraft or the evil eye; caused by the power of ancestors; or that that the tolerance of pain would bring greater reward in the afterlife. This study was carried out in a clinical setting and included a female group of hospital employees from differing cultures. The preferred method of treatment for pain also differed across cultures with the use of herbal treatments and traditional, faith or religious healers was common. It was also not uncommon for the use of narcotics to be culturally unacceptable or only acceptable as a last resort. <span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">Pesek, Helton and Nair (2006) describe health and wellness as a state that encompasses the mind, body and spirit. They also recommend a holistic approach to patient care that combines both medical knowledge and traditional practices. The importance of traditional healing techniques in the treatment of pain – providing these have no detrimental effect – have widely been recognised for their spiritual healing ability. Stewart-Williams (as cited by Narayan, 2010) explains this placebo phenomenon as being a case of what we believe helps does help.

<span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">**Cultural and Social Analysis** <span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">In their paper exploring the sociological approach to pain, Bendelow and Williams (1995) argue that one of the main barriers to effective pain conceptualisation is that it has been ‘medicalised’. This medicalisation does not allow for the ambiguity or subjectivity of pain and has resulted in the ‘Cartesian split between body and mind’ (Bendelow & Williams, 1995, p. 84). Modern medicine and science can be more closely aligned with the concept of monoism than with mind-body dualism, so it is seemingly irrational for the Western approach to pain to have taken this direction. To allow effective pain conceptualisation they recommend a shift in pain treatment from the medical paradigm to one inclusive of sociological and phenomenological factors. This would encompass the social and cultural contexts of pain, returning it to a subjective experience rather than one only concerned with physiological aspects. <span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">Further to this, it’s necessary to take into account the different uses of, and beliefs relating to, pain across cultures. Described by Durkheim (as cited by Shilling & Mellor, 1995, p. 522), pain has been used in a constructive manner throughout history through ‘rituals of asceticism and mortification invested with the intention of intensifying religious commitment’. This is made evident by the plethora of cultural practices which involve pain such as the practice of teeth sharpening by the Mentawai people of Indonesia; body piercing as part of the Hindu festival of Thaipusam; the Shi’a Muslim ceremony of Ashura described above; or the practice of corporal mortification by members of the Opus Dei. <span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">While education would seemingly be the appropriate course of action to improve primary and emergency service provider’s knowledge of their patients, it is impossible for all of the intricacies of each patient’s cultural belief systems to be taught. Instead it would be advisable to encourage health care providers to be culturally sensitive and encompassing of their patient’s belief systems. <span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">Even though it may not be instinctive to Western health care providers, it may be necessary to encompass home remedies or cultural healing techniques, or to address the patients’ fears relating to drug addiction resulting from the treatment of pain by analgesic drugs. This would allow ‘buy-in’ to be achieved from the patient, ensuring that adequate care is provided in a culturally acceptable manner. Giordano, Engebretson and Benedikter (2009) describe the end goal of culturally sensitive care as having an open and honest clinician/patient relationship which accommodates mutual decision-making creating an environment whereby the patient is empowered and the health care provider is enabled. It is important that all people receive equal, adequate and culturally acceptable treatment for their pain.

<span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">**Analysis of the Cultural Artefact** <span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">While an extreme example, the chosen artefact is a good example of the consequences of cultural misunderstanding. I chose this particular artefact as it triggered me to consider how I reacted to the practice in question and, more specifically, to the cultural use of pain. It also brought into question what preconceived attitudes towards pain I have developed. Admittedly, my initial reaction was one that more closely aligned with the ‘medicalised’ view presented throughout the analysis in that I viewed pain as something to be avoided at all costs. This changed the more I researched the topic as I realised that my attitude was lead by the Western norms that I have grown up with and by a lack of understanding due to ignorance. <span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">While I still find it difficult to put aside my ingrained ethnocentrism and accept some of the practices I came across in my research, I now realise that it is important to view them in the socio-cultural context that they are performed. I was also taken aback at the research findings which indicate that there are inequalities in pain treatment across different ethnic groups. This highlights the necessity for further education of Australian health care providers. I can, however, sincerely say that I have learned the importance of culturally sensitive health care.

<span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">**References** Australian Bureau of Statistics. (2010). //Migration, Australia, 2009-10:// //Australia’s diverse population.// Retrieved from http://www.abs.gov.au/ausstats/abs@.nsf/mf/3412.0

Bendelow, G. and Williams, S. (1995). Pain and the mind-body dualism: A sociological approach. //Body & Society, 1//(2), 83-103. doi: 10.1177/1357034X95001002004

Briggs, E. (2008). Cultural perspectives on pain management. //Journal of Perioperative Practive, 18//(11), 468-471. Retrieved from http://www.afpp.org.uk/books-journals/Journal-of-Perioperative-Practice

Briggs, E. (2010). Assessment and expression of pain. //Nursing Standard, 25//(2), 35-38. Retrieved from http://nursingstandard.rcnpublishing.co.uk/

Campbell, C. M., Edwards, R. R. and Filligim, R. B. (2005). Ethnic differences in response to multiple experimental pain stimuli. //Pain, 113//, 20-26. doi: 10.1016/j.pain.2004.08.013

Cintron, A. And Morrison, R. S. (2006). Pain and ethnicity in the United States: A systematic review. //Journal of Palliative Medicine, 9//(6), 1454-1473. doi: 10.1089/jpm.2006.9.1454

Cole, J. (2004). Painful memories: Ritual and the transformation of community trauma. //Culture, Medicine and Psychiatry, 28//, 87-105. doi: 10.1023/B:MEDI.0000018099.85466.c0

Davidhizar, R. and Giger, J. N. (2004). A review of the literature on care of clients in pain who are culturally diverse. //International Nursing Review, 51//, 47-55. doi: 10.1111/j.1466-7657.2003.00208.x

Giodano, J., Engebretson, J. C. and Benedikter, R. (2009). Culture, subjectivity, and the ethics of patient-centred pain care. //Cambridge Quarterly of Healthcare Ethics, 18//, 47-56. doi: 10.1017/S0963180108090087

Lovering, S. (2006). Cultural attitudes and beliefs about pain. //Journal of Transcultural Nursing, 17//(4), 389-395. doi: 10.1177/1043659606291546

McCaffery, M. and Pasero, C (1999). Pain: Clinical manual (2nd ed.). St. Louis, Missouri: Mosby.

Narayan, M. C. (2010). Culture’s effects on pain assessment and management. //American Journal of Nursing, 110//(4), 38-47. doi: 10.1097/01.NAJ.0000370157.33223.6d

Norris, R. S. (2009). The paradox of healing pain. //Religion, 39,// 22-33. doi: 10.1016/j.religion.2008.03.007

Pesek, T. J., Helton, L. R. and Nair, M. (2006). Healing across cultures: Learning from traditions. //EcoHealth Journal, 3//, 114-118. doi: 10.1007/s10393-006-0022-z

Pierre, J., Hutchinson, E. and Abdulraza, H. (2007). The Shi’a remembrance of Muharram: An explanation of the days of Ashura and Arba’een. //Military Review, 87//(2), 61-69. Retrieved from http://usacac.army.mil/cac2/militaryreview/index.asp

Queensland Government, Department of Education, Training and the Arts. (2008). //Queensland’s labour market progress: A 2006 census of population and housing profile//. Retrieved from Queensland Government Department of Education and Training website http://training.qld.gov.au/employers/labour-market-research/census-bulletins.html

Shilling, C. and Mellor, P. A. (2010). Saved from pain or saved through pain? Modernity, instrumentalization and the religious use of pain as a body technique. //European Journal of Social Theory, 13//(4), 521-537. doi: 10.1177/1368431010382763

Sutherland, L. L. (2002). Ethnocentrism in a pluralistic society: A concept analysis. //Journal of Transcultural Nursing, 14//(4), 274-281. doi: 10.1177/104365902236701

<span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">**Reflections** <span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">Page: Chlamydia, MTV and Pornography - Generation Y's Sexual Revolution <span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">Page: Culture and Pain Management, Who Knows What to do <span style="display: block; font-family: Arial,Helvetica,sans-serif; font-size: 110%; text-align: justify;">Page: [|Australians - Unsatisfied with sex in the classroom]