Curiosity in the Context of Pain: Part 1 #BTCP

For some time now I’ve been reading a lot about curiosity. I’ve been exploring curiosity from various fields such as philosophy, medical science, psychology, social sciences, education, art and communication; not an exhaustive list at all! Curiosity really is a fascinating area of study. Commonly defined as an eager desire to learn or know about something (https://dictionary.cambridge.org/dictionary/english/curiosity), throughout my reading, I’ve found that there is so much more to curiosity than serving a single purpose, that is to acquire knowledge.

Now it won’t surprise you that physiotherapists undoubtedly use curiosity in their day-to-day practice. Examples of where curiosity crops up to assist us in our clinical work include the initial interview, communicating with our patients, clinical reasoning, conducting a physical exam, formulating a treatment plan, and during treatment and rehabilitation. What might spark your interest though is the style of curiosity that is used. That’s right, curiosity has style!

It literally is everywhere, in everyday speech, on websites, in books, in songs, or roaming the red planet 57 million miles away!

This style of curiosity largely serves the acquisition of knowledge, and it can be fleeting and shallow, serving the individual(s) who have a clear goal in mind. Curiosity in this context is “defanged and commodified” (Zurn & Shankar, 2020, pg xi) as if it literally has no teeth, unable to penetrate the flesh of minds.

Let’s look at an example that is closer to our professional home. Historically, physiotherapy has been built upon a practice of viewing the body as a physical object, a collection of structures and how those structures relate to function, both of which are underpinned by the biomedical/biomechanical model (Fox, 2012; Nicholls, 2017). In these models, the view of the body is reduced to individual parts and static physical objects (Gibson, 2016; Mehta, 2011). This view is mirrored and perpetuated by the way the body is investigated and understood i.e. anatomical models, anatomical posters and books, medical imaging, and the process of clinical reasoning.

Historically, the biomedical/biomechanical model (ergo the scientific method) was built upon the notion that the acquisition of knowledge was derived from observational information. Through observation, theories could be developed to explain the reasons why things were the way they were. That an understanding of structure and function, and the determination between normal and abnormal, hypotheses could be proposed to determine the causal reasons for pain, suffering and disability (Fox, 2012; Kerry, 2018). In the context of the biomedical/biomechanical model, abnormal structures or faulty movements represented, or the potential for, pathology or physical disease within the body. A “privileging the pathological or aberrant case over the typical or normal” (Fox, 2012, pg.22).  

Naturally then, the diseased body is a curious object to the healthcare professional. To the individual living with pain, curiosity occupies a void between what they know (they are in pain) and what they want to know (will the pain go away? How can I get rid of it?).

Yet, a deviance looms as the curiosity that dominates is one that serves the healthcare professional, and that of the effects of the treatment to address the abnormal structure. This professional etiquette has been referred to as “parasitic” (Swain et al., 2003), and continues to perseverate in healthcare. A neurotic rumination. It is a curiosity that is initially possessed by the sufferer but overpowered and manipulated by the healthcare professional. Another way to describe this is through the psychological terms internal and external locus of control, and individual self-efficacy. The removal of faith in a person’s body leads to fear, hypervigilance, and distress (Eccleston & Crombez, 2007; McCracken, 2011). It could be argued then that curiosity in the healthcare context is commodified and defanged to serve the process of the reasoning method that is driven by the underpinning model. Foucault, (1973) spoke of the “medical gaze” in his book The Birth of the Clinic, a concept describing the subtle art of focusing on information that fits into a biomedical paradigm.

However, in recent years, physiotherapy has gone through various changes such as paradigmatic shifts from the biomedical model to the biopsychosocial model, abandonment of ideologies and treatment interventions, shifts in reasoning models and adoption of alternative forms of practice, expansion of scope of practice, and embracing of new technologies. One such shift is the attention given to the pursuit of certainty. More specifically one of the things about biomedicine and Western science more broadly is that they are built to distrust ambiguity and uncertainty. So much medical science is directed at collapsing the unknown and replacing curiosity with certainty. Think of it as, if biomedicine fixes my pain, that’s a thumbs up, if it doesn’t, that’s a thumbs down.

In musculoskeletal medicine, and in physiotherapy, certainty is expressed in many ways. The prevailing roots of the body as a biomechanical machine go deep within society and healthcare. In physiotherapy, we assess and treat signs and symptoms in order to find a resolution. A notion of clarity to offer a reason for patients’ ails and complaints. Patients want the certainty of a diagnosis, certainty of recovery, and certainty that treatment will help to resolve their problem. Paradoxically, the push-pull desire for certainty leads to a pre-contemplative incurious attitude(Darlow, 2016; Darlow et al., 2013, 2018). Interestingly, the pursuit of certainty has received much critique philosophically – Frederich Nietzsche (1844 – 1900) once said, “Not doubt, it is certainty that drives one mad” and similarly Voltaire (1694 – 1778) said, “Doubt is not a pleasant condition, but certainty is an absurd one.”

When it comes to pain and certainty, I once had a client say to me, “the only thing that I am certain about is that I have pain!” This struck me as rather ironic because in a paradoxical kind of way the hunt for certainty leads to pain and the emotional experience of suffering. Interestingly, it bears a resemblance to what Scarry (1985), wrote in her book The Body in Pain, “to have pain is to have certainty; to hear about pain is to have doubt” (pg.13).

What is the answer to this neuroticism for certainty? Should we embrace uncertainty? How can we approach certainty and uncertainty through transgressive reciprocity? Where does curiosity play a role?

That’ll come in part two.

Thanks for having a read.

TNP

References

Darlow, B. (2016). Beliefs about back pain: The confluence of client, clinician and community. International Journal of Osteopathic Medicine, 20, 53–61. https://doi.org/10.1016/j.ijosm.2016.01.005

Darlow, B., Brown, M., Thompson, B., Hudson, B., Grainger, R., McKinlay, E., & Abbott, J. H. (2018). Living with osteoarthritis is a balancing act: an exploration of patients’ beliefs about knee pain. BMC Rheumatology, 2(1), 15. https://doi.org/10.1186/s41927-018-0023-x

Darlow, B., Dowell, A., Baxter, G. D., Perry, M., Mathieson, F., Perry, M., & Dean, S. (2013). The Enduring Impact of What Clinicians Say to People With Low Back Pain. Annals of Family Medicine, 11(6), 527–534. https://doi.org/10.1370/afm.1518.INTRODUCTION

Eccleston, C., & Crombez, G. (2007). Worry and chronic pain : A misdirected problem solving model. Pain, 132(3), 233–236. https://doi.org/10.1016/j.pain.2007.09.014

Foucault, M. (1973). The Birth of the Clinic: An Archaeology of Medical Perception. Tavistock Publications Limited.

Fox, N. J. (2012). The Body: Key Themes in Health and Social Care. Polity Press.

Gibson, B. E. (2016). Rehabilitation: A Post-Critical Approach. CRC Press.

Kerry, R. (2018). Reconceptualising causation in evidence- based physiotherapy. In B. E. Gibson, D. A. Nicholls, J. Setchell, & K. S. Groven (Eds.), Manipulating practices: A critical physiotherapy reader (1st Editio). Cappelen Damm Akademisk.

McCracken, L. M. (2011). Mindfulness and Acceptance in Behavioural Medicine: Current Theory and Practice. New Harbinger Publications.

Mehta, N. (2011). Mind-body dualism: A critique from a health perspective. Mens Sana Monographs, 9(1), 202–209. https://doi.org/10.4103/0973-1229.77436

Nicholls, D. A. (2017). The end of physiotherapy. In The End of Physiotherapy. https://doi.org/10.4324/9781315561868

Scarry, E. (1985). The Body in Pain: The Making and Unmaking of the world. In The Body in Pain (1st editio). Oxford University Press. https://doi.org/10.2110/jsr.60.160

Simpkin, A. L., & Schwartzstein, R. M. (2016). Tolerating Uncertainty — The Next Medical Revolution ? New England Journal of Medicine, 375(18), 1713–1715.

Swain, J., French, S., & Cameron, C. (2003). Controversial Issues in a Disabling Society. Open University Press.

Wray, C. M., & Loo, L. K. (2015). The Diagnosis, Prognosis, and Treatment of Medical Uncertainty. Journal of Graduate Medical Education, 7(4), 523–527. https://doi.org/10.4300/JGME-D-14-00638.1

Zurn, P., & Shankar, A. (2020). Curiosity Studies: A New Ecology of Knowledge (P. Zurn & A. Shankar, Eds.). University of Minnesota Press.