In recent years, the societal and personal impacts of pain, and the fact that we still lack an effective method of treatment, has motivated researchers from diverse disciplines to try to think in new ways about pain and its management. In this paper, we aim to develop an enactive approach to pain and the transition to chronicity. Two aspects are central to this project. First, the paper conceptualizes differences between acute and chronic pain, as well as the dynamic process of pain chronification, in terms of changes in the field of affordances. This is, in terms of the possibilities for action perceived by subjects in pain. As such, we aim to do justice to the lived experience of patients as well as the dynamic role of behavioral learning, neural reorganization, and socio-cultural practices in the generation and maintenance of pain. Second, we aim to show in which manners such an enactive approach may contribute to a comprehensive understanding of pain that avoids conceptual and methodological issues of reductionist and fragmented approaches. It proves particularly beneficial as a heuristic in pain therapy addressing the heterogenous yet dynamically intertwined aspects that may contribute to pain and its chronification.
Enactivism is an emerging theory for sense-making (cognition) with increasing applications to research and medicine. Enactivists reject the idea that sense-making is simply in the head or can be reduced to neural processes. Instead, enactivists argue that cognisers (people) are embodied and action-oriented, and that sense-making emerges from relational processes distributed across the brain-body-environment. We start this paper with an overview of a recently proposed enactive approach to pain. With rich theoretical and empirical roots in phenomenology and cognitive science, conceptualising pain as an enactive process is appealing as it overcomes the problematic dualist and reductionist nature of current pain theories and healthcare practices. Second, we discuss metaphor in the context of pain and enactivism, including a pain-related metaphor classification system. Third, we present and discuss five paintings created alongside an enactive study of clinical communication and the co-construction of pain-related meanings. Each painting represents pain-related metaphors delivered by clinicians during audio-recorded clinical appointments or discussed by clinicians and patients during interviews. We classify these metaphors, connecting them to enactive theory and relevant literature. The art, metaphors and associated narratives draw attention to the intertwined nature of language, meaning and pain. Of clinical relevance to primary and allied healthcare, we explore how clinicians’ taken-for-granted pain-related metaphors can act as scaffolding for patients’ pain and agency, for better or worse. We visually depict and give examples of clinical situations where metaphors became enactive, in that they were clinically reinforced and embodied through assessment and treatment. We conclude with research and clinical considerations, suggesting that enactive metaphor is a widely overlooked learning mechanism that clinicians could consider employing and intentionally shape.
Qualitative research approaches under the umbrella of phenomenology are becoming overly prescriptive and dogmatic (e.g., excessive and unnecessary focus on the epoché and reduction). There is a need for phenomenology (as a qualitative research approach) to be renewed and refreshed with opportunities for methodological flexibility. In this process paper, we offer one way this could be achieved. We provide an overview of the emerging paradigm of post-cognitivism and the aligned movement of enactivism which has roots in phenomenology and embodied cognition. We argue that enactivism can be used as a flexible resource by qualitative researchers exploring the unfolding of first-person (subjective) experience and its meanings (i.e., the enactive concept of sense-making). Enactive approaches are commonly tethered to “E-based” theory, such as the idea that sense-making is a 5E process (Embodied, Embedded, Enacted, Emotive, and Extended). We suggest that enactivism and E-based theory can inform phenomenological research in eclectic and non-prescriptive ways, including integration with existing methods such as observation/interviews and thematic analysis with hybrid deductive-inductive coding. Enactivism-informed phenomenological research moves beyond methodological individualism and can inform novel qualitative research exploring the complex, dynamic, and context-sensitive nature of sense-making. We draw from our enactive study that explored the co-construction of pain-related meanings between clinicians and patients, while also offering other ways that enactive theory could be applied. We provide a sample interview guide and codebook, as well as key components of rigor to consider when designing, conducting, and reporting a trustworthy phenomenological study using enactive theory.
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