Social communication model of pain.

Abstract

Clinicians and researchers are challenged to understand the dynamic interplay among biological, psychological, and social determinants of pain. The social communication model,2,8 (Fig. 1), provides an inclusive framework for organizing and considering these facets and their relationships. Understanding any episode of pain, acute or chronic, requires grasping the broad picture and details at biological, psychological, and social levels of analysis. The social communication model of pain specifies necessary domains to be attended to in the education of researchers and practitioners.1,16 Innovative features (1) A painful event chronology is provided: episodes of pain unfold over time, involving status of the individual before the event, perception of pain, personal expression, and the appraisal and actions of observers, with each phase responsive to preceding events. Reciprocal, recursive, and dynamic influences are acknowledged. Different colors are used to attract attention to the importance of each phase. (2) Social determinants of pain are explicitly acknowledged in human and nonhuman animals.10 (3) A clear distinction is made between historical and current biological and social determinants: (a) Intrapersonal: people bring dispositions to react based on their biological, psychological, and social histories. (b) Current setting: the immediate social and physical environment within which pain is suffered has a powerful impact on both the person in pain and potential caregivers. Timeline with illustrations of research Antecedents People are predisposed to react in variable ways when in pain, for example, through biological priming or adaptation, and trait-like dispositions, including fear of pain and catastrophising.15 Pain prevention or amelioration strategies are possible and important. Pain experience Biological substrates for the perception of pain have been a heavy focus for research and medical interventions. Life history has a potent impact. Socialization in unique familial/ethnic environments determines the meaning and affective understandings of pain.6,11 Pain expression Although pain is inherently private, behavioral activity permits observer inferences.13–15 Some features of pain reactions are spontaneous and reflexive, whereas others reflect conscious deliberation.3 Expressions of pain are often modulated (eg, enhanced or suppressed) with considerable sensitivity to the audience and social milieu.3,12 Decoding pain expression Displays of pain command the attention of observers, leading to spontaneous neurophysiological reactions,4 reflexive distress, reflective appraisal, and the potential for empathy and clinical judgment.7,9 Experience with pain, professional histories, and personal characteristics, including biases, influence dispositions to attend, recognize, and understand the experience of others.3,5 Action The appraisal of pain drives decisions to deliver care. Clinicians with personal commitments, indifferent bystanders, and enemies would be expected to react differently. Professional training and institutional best practices invariably constrain service delivery. Social, economic, and physical ecological contexts of care delivery The contexts of community caring, professional standards of practice, institutional structures and policies, health care delivery systems, the research enterprise, and political systems all have powerful influences on how people care for others in pain.