"The Cultural Components of Pain", , pgs. 38-47 in Down to Earth Sociology, ed. James M. Henslin, The Free Press, New York, 1988.
How do you experience pain? "You either have pain, or you don't," one might reply. "And if you have pain, you feel it in the same way everyone else feels pain."
With its focus on the objective, biophysical aspects of pain there is much truth to such a viewpoint. What it overlooks, however, are the cultural components of pain. For example, why do two individuals sometimes react so differently to similar pain from similar injuries? Their contrasting reactions, says Zborowski, are due not to the pain but to their differing cultural experiences first, to their interpretations of the meaning of the pain (that is the cultural context within which they place pain and from which they derive the meaning of the pain they are experiencing) and second, to the expectations they have learned concerning the "correct" way to express pain. Zborowski develops these principles by contrasting the interpretations and expressions of pain by Italian and Jewish immigrants and by "Old Americans."
THIS PAPER REPORTS ON ONE ASPECT of a larger study: that concerned with discovering the role of cultural patterns in attitudes toward, and reactions to, pain that is caused by disease and injury-in other words, responses to spontaneous pain. .
In setting up the research, we were interested not only in the purely theoretical aspects of the findings in terms of possible contributions to the understanding of the pain experience in general; we also had in mind the practical goal of a contribution to the field of medicine. In the relationship between the doctor and his patient, the respective attitudes toward pain may play a crucial role, especially when the doctor feels that the patient exaggerates his pain, while the patient feels that the doctor minimizes his suffering. The same may be true, for instance, in a hospital where the members of the medical and nursing staff may have attitudes toward pain that are different from those held by the patient, or when they expect a certain pattern of behavior according to their cultural background, while the patient may manifest a behavior pattern that is acceptable in his culture.
With these aims in mind, the project was set up at the Kingsbridge Veterans Hospital, Bronx, New York, where [three] ethnocultural groups were selected for an intensive study. These groups included patients of Jewish, Italian ... and "Old American" stock. "Old Americans" can be defined as White, native-born individuals, usually Protestant, whose grandparents, at least, were born in the United States, and who do not identify themselves with any foreign group, either nationally, socially, or culturally.
The main techniques used in the collection of the material were interviews with patients of the selected groups, observation of their behavior when in pain, and discussion of the individual cases with doctors, nurses, and other people directly or indirectly involved in the pain experience of the individual. In addition to the interviews with patients, "healthy" members of the respective groups were interviewed on their attitudes toward pain. .
The discussion of the material presented in this paper is based on interviews with 103 respondents, including 87 hospital patients in pain and 16 healthy subjects. According to their ethnocultural background, the respondents are distributed as follows: "Old Americans," 26; Italians, 24; Jews, 31, [also Irish, 11; others, 11]. In addition, there were the collateral interviews and conversations noted above with family members, doctors, nurses, and other members of the hospital staff.
With regard to the pathological causes of pain, the majority of the interviewees fall into the group of patients suffering from neurological diseases, mainly herniated discs and spired1 lesions. The focusing upon a group of patients suffering from a similar pathology offered the opportunity to investigate reactions and attitudes toward spontaneous pain that is symptomatic of one group of diseases. Nevertheless, a number of patients suffering from other diseases were also interviewed.
Pain Among Patients of Jewish and Italian Origin
The Jews and Italians were selected mainly because interviews with medical experts suggested that they display similar reactions to pain. The investigation of this similarity provided the opportunity to check a rather popular assumption that similar reactions reflect similar attitudes. The differences between the Italian and Jewish cultures are great enough to suggest that, if the attitudes are related to cultural pattern, they will also be different, despite the apparent similarity in manifest behavior.
Members of both groups were described as being very emotional in their responses to pain. They were described as tending to exaggerate their pain experience and being very sensitive to pain. Some of the doctors stated that, in their opinion, Jews and Italians have a lower threshold of pain than members of other ethnic groups, especially members of the so-called Nordic group. This statement seems to indicate a certain confusion as to the concept of the threshold of pain. According to people who have studied the problem of the threshold of pain-for instance, Harold Wolff and his associates, the threshold of pain is more or less the same for all human beings regardless of nationality, sex, or age.
In the course of the investigation, the general impressions of doctors were confirmed to a great extent by the interview material and by the observation of the patients' behavior. However, even a superficial study of the interviews has revealed that, although reactions to pain appear to be similar, the underlying attitudes toward pain are different in the two groups. While the Italian patients seemed to be mainly concerned with the immediacy of the pain experience and were disturbed by the actual pain sensation that they experienced in a given situation, the concern of patients of Jewish origin was focused mainly upon the symptomatic meaning of pain and upon the significance of pain in relation to their health, welfare, and, eventually, for the welfare of the families. The Italian patient expressed, in his behavior and in his complaints, the discomfort caused by pain as such, and he manifested his emotions with regard to the effects of this pain experience upon his immediate situation in terms of occupation, economic situation, and so on; the Jewish patient expressed primarily his worries and anxieties as to the extent to which the pain indicated a threat to his health. In this connection, it is worth mentioning that one of the Jewish words to describe strong pain is yessurim, a word that is also used to describe worries and anxieties.
Attitudes of Italian and Jewish patients toward pain-relieving drugs can serve as an indication of their attitude toward pain. When in pain the Italian calls for pain relief and is mainly concerned with the analgesic effects of the drugs that are administered to him. Once the pain is relieved the Italian patient easily forgets his sufferings and manifests a happy and joyful disposition. The Jewish patient, however, often is reluctant to accept the drug, and he explains this reluctance in terms of concern about the effects of the drug upon his health in general. He is apprehensive about the habit-forming aspects of the analgesic. Moreover, he feels that the drug relieves his pain only temporarily and does not cure him of the disease that may cause the pain. Nurses and doctors have reported cases in which patients would hide the pill that was given to them to relieve their pain and would prefer to suffer. These reports were confirmed in the interviews with the patients. It was also observed that many Jewish patients, after being relieved from pain, often continued to display the same depressed and worried behavior, because they felt that, although the pain was currently absent, it may recur as long as the disease was not cured completely. From these observations, it appears that, when one deals with a Jewish and an Italian patient in pain, in the first case it is more important to relieve the anxieties with regard to the sources of pain, while in the second it is more important to relieve the actual pain.
Another indication as to the significance of pain for Jewish and Italian patients is their respective attitudes toward the doctor. The Italian patient seems to display a most confident attitude toward the doctor, which is usually reinforced after the doctor has succeeded in relieving pain; whereas the Jewish patient manifests a skeptical attitude, feeling that the fact that the doctor has relieved his pain by some drug does not mean at all that he is skillful enough to take care of the basic illness. Consequently, even when the pain is relieved, he tends to check the diagnosis and the treatment of one doctor against the opinions of other specialists in the field. Summarizing the difference between the Italian and Jewish attitudes, one can say that the Italian attitude is characterized by a present-oriented apprehension with regard to the actual sensation of pain, and the Jew tends to manifest a future-oriented anxiety as to the symptomatic and general meaning of the pain experience.
It has been stated that the Italians and Jews tend to manifest similar behavior in terms of their reactions to pain. As both cultures allow for free expression of feelings and emotions by words, sounds, and gestures, both the Italians and Jews feel free to talk about their pain, complain about it, and manifest their sufferings by groaning, moaning, crying, etc. They are not ashamed of this expression. They admit willingly that, when they are in pain, they do complain a great deal, call for help, and expect sympathy and assistance from other members of their immediate social environment, especially from members of their family. When in pain, they are reluctant to be alone and prefer the presence and attention of other people. This behavior, which is expected, accepted, and approved by the Italian and Jewish cultures, often conflicts with the patterns of behavior expected from a patient by American or Americanized medical people. Thus, they tend to describe the behavior of the Italian and Jewish patients as exaggerated and overemotional. The material suggests that they do tend to minimize the actual pain experiences of the Italian and Jewish patients, regardless of whether they have the objective criteria for evaluating the actual amount of pain that the patient experiences. It seems that the uninhibited display of reaction to pain as manifested by the Jewish and Italian patients provokes distrust in American culture instead of provoking sympathy.
Despite the close similarity between the manifest reactions among Jews and Italians, there seem to be differences in emphasis, especially with regard to what the patient achieves by these reactions and as to the specific manifestations of these reactions in the various social settings. For instance, they differ in their behavior at home and in the hospital. The Italian husband, who is aware of his role as an adult male, tends to avoid verbal complaining at home, leaving this type of behavior to the women. In the hospital, where he is less concerned with his role as a male, he tends to be more verbal and more emotional. The Jewish patient, on the contrary seems to be more calm in the hospital than at home. Traditionally, the Jewish male does not emphasize his masculinity through such traits as stoicism, and he does not equate verbal complaints with weakness. Moreover, the Jewish culture allows the patient to be demanding and complaining. Therefore, he tends more to use his pain in order to control interpersonal relationships within the family. Although similar use of pain to manipulate the relationships between members of the family may be present also in some other cultures, it seems that, in the Jewish culture, this is not disapproved, while in others it is.
In the hospital, one can also distinguish variations in the reactive patterns among Jews and Italians. Upon his admission to the hospital, and in the presence of the doctor, the Jewish patient tends to complain, ask for help, be emotional even to the point of crying. However as soon as he feels that adequate care is given to him, he becomes more restrained. This suggests that the display of pain reaction serves less as an indication of the amount of pain experienced than as a means to create an atmosphere and setting in which the pathological causes of pain will be best taken care of. The Italian patient, on the other hand, seems to be less concerned with setting up a favorable situation for treatment. He takes for granted that adequate care will be given to him, and, in the presence of the doctor, he seems to be somewhat calmer than the Jewish patient. The mere presence of the doctor reassures the Italian-patient, while the skepticism of the Jewish patient limits the reassuring role of the physician.
To summarize the description of the reaction patterns of the Jewish and Italian patients, the material suggests that, on a semiconscious level, the Jewish patient tends to provoke worry and concern in his social environment as to the state of his health and the symptomatic character of his pain, while the Italian tends to provoke sympathy toward his suffering. In one case, the function of the pain reaction will be the mobilization of the efforts of the family and the doctors toward a complete cure, while, in the second case, the function of the reaction will be focused upon the mobilization of effort toward relieving the pain sensation.
On the basis of the discussion of the Jewish and Italian material, two generalizations can be made: (1) Similar reactions to pain manifested by members of different ethnocultural groups do not necessarily reflect similar attitudes to pain. (2) Reactive patterns similar in terms of their manifestations may have different functions and serve different purposes in various cultures.
Pain Among Patients of "Old American" Origin
There is little emphasis on emotional complaining about pain among "Old American" patients. Their complaints about pain can best be described as reporting on pain. In describing his pain, the "Old American" patient tries to find the most appropriate ways of defining the quality of pain, its localization, duration, etc. When examined by the doctor, he gives the impression of trying to assume the detached role of an unemotional observer who gives the most efficient description of his state for a correct diagnosis and treatment. The interviewees repeatedly state that there is no point in complaining and groaning and moaning, etc., because "it won't help anybody." However, they readily admit that, when pain is unbearable, they may react strongly, even to the point of crying, but they tend to do it when they are alone. Withdrawal from society seems to be a frequent reaction to strong pain.
There seem to be different patterns in reacting to pain, depending on the situation. One pattern, manifested in the presence of members of the family, friends, etc., consists of attempts to minimize pain, to avoid complaining and provoking pity; when pain becomes too strong, there is a tendency to withdraw and express freely such reactions as groaning, moaning, etc. A different pattern is manifested in the presence of people who, on account of their profession, should know the character of the pain experience, because they are expected to make the appropriate diagnosis, advise the proper cure, and give the adequate help. The tendency to avoid deviation from certain expected patterns of behavior plays an important role in the reaction to pain. This is also controlled by the desire to seek approval on the part of the social environment, especially in the hospital, where the "Old American" patient tries to avoid being a "nuisance" in the ward. He seems to be, more than any other patient, aware of an ideal pattern of behavior that is identified as "American," and he tends to conform to it. This was characteristically expressed by a patient who answered the question how he reacts to pain by saying, "I react like a good American."
An important element in controlling the pain reaction is the wish of the patient to cooperate with those who are expected to take care of him. The situation is often viewed as a team composed of the patient, the doctor, the nurse, the attendant, etc., and in this team, everybody has a function and is supposed to do his share in order to achieve the most successful result. Emotionality is seen as a purposeless and hindering factor in a situation that calls for knowledge, skill, training, and efficiency. It is important to note that this behavior is also expected by American or Americanized members of the medical or nursing staff, and the patients who do not fall into this pattern are viewed as deviants, hypochondriacs, and neurotics.
As in the case of the Jewish patients, the American attitude toward pain can be best defined as a future-oriented anxiety. The "Old American" patient is also concerned with the symptomatic significance of pain, which is correlated with a pronounced health-consciousness. It seems that the "Old American" is conscious of various threats to his health that are present in his environment and therefore feels vulnerable and is prone to interpret his pain sensation as a warning signal indicating that something is wrong with his health and therefore must be reported to the physician. With some exceptions, pain is considered bad and unnecessary and therefore must be immediately taken care of. In those situations where pain is expected and accepted, such as in the process of medical treatment or as a result of sports activities, there is less concern with the pain sensation. In general, however, there is a feeling that suffering pain is unnecessary when there are means of relieving it.
Although the attitudes of the Jewish and "Old American" patients can be defined as pain anxiety, they differ greatly. The future-oriented anxiety of the Jewish interviewee is characterized by pessimism or, at best, by skepticism, while the "Old American" patient is rather optimistic in his future orientation. This attitude is fostered by the mechanistic approach to the body and its function and by the confidence in the skill of the experts, which are so frequent in the American culture. The body is often viewed as a machine that has to be well taken care of, be periodically checked for disfunctioning, and, eventually, when out of order, be taken to an expert who will "fix" the defect. In the case of pain, the expert is the medical man who has the "know-how" because of his training and experience and therefore is entitled to full confidence. An important element in the optimistic outlook is faith in the progress of science. Patients with intractable pain often stated that, although at the present moment the doctors do not have the "drug," they will eventually discover it, and they will give the examples of sulfa, penicillin, etc.
The anxieties of a pain-experiencing "Old American" patient are greatly relieved when he feels that something is being done about it in terms of specific activities involved in the treatment. It seems that his security and confidence increase in direct proportion to the number of tests, Xrays, examinations, injections, etc., that are given to him. Accordingly "Old American" patients seem to have a positive attitude toward hospitalization, because the hospital is the adequate institution that is equipped for the necessary treatment. While a Jewish and an Italian patient seem to be disturbed by the impersonal character of the hospital and by the necessity of being treated there instead of at home, the "Old American" patient, on the contrary, prefers the hospital treatment to the home treatment, and neither he nor his family seems to be disturbed by hospitalization.
To summarize the attitude of the "Old American" toward pain, he is disturbed by the symptomatic aspect of pain and is concerned with its incapacitating aspects, but he tends to view the future in rather optimistic colors, having confidence in the science and skill of the professional people who treat his condition.
Some Sources of Intragroup Variation
In the description of the reactive patterns and attitudes toward pain among patients of Jewish and "Old American" origin, certain regularities have been observed for each particular group, regardless of individual differences and variations. This does not mean that each individual in each group manifests the same reactions and attitudes. Individual variations are often due to specific aspects of pain experience, to the character of the disease that causes the pain, or to elements in the personality of the patient. However, there are also other factors that are instrumental in provoking these differences, and that can still be traced back to the cultural backgrounds of the individual patients. Such variables as the degree of Americanization of the patient, his socioeconomic background, education, and religiosity may play an important role in shaping individual variations in the reactive patterns. For instance, it was found that the patterns described are manifested most consistently among immigrants, while their descendants tend to differ in terms of adopting American forms of behavior and American attitudes toward the role of the medical expert, medical institutions, and equipment in controlling pain. It is safe to say that the farther the individual is from the immigrant generation, the more American is his behavior. This is less true for the attitudes toward pain, which seem to persist to a great extent even among members of the third generation, and even though the reactive patterns are radically changed. A Jewish or Italian patient born in this country of American-born parents tends to behave like an "Old American" but often expresses attitudes similar to those that are expressed by the Jewish or Italian people. They try to appear unemotional and efficient in situations where the immigrant would be excited and disturbed. However, in the process of the interview, if a patient is of Jewish origin, he is likely to express attitudes of anxiety as to the meaning of his pain, and, if he is an Italian, he is likely to be rather unconcerned about the significance of his pain for his future.
The occupational factor plays an important role when pain affects a specific area of the body. For instance, manual workers with herniated discs are more disturbed by their pain than are professional or business people with a similar disease because of the immediate significance of this particular pain for their respective abilities to earn a living. It was also observed that headaches cause more concern among intellectuals than among manual workers.
The educational background of the patient also plays an important role in his attitude with regard to the symptomatic meaning of a pain sensation. The more educated patients are more health-conscious and more aware of pain as a possible symptom of a dangerous disease. However, this factor plays a less important role than might be expected. The less educated "Old American" or Jewish patient is still more health-conscious than the more educated Italian. On the other hand, the less educated Jew is as much worried about the significance of pain as the more educated one. The education of the patient seems to be an important factor in fostering specific reactive patterns. The more educated patient, who may have more anxiety with regard to illness, may be more reserved in specific reactions to pain than an unsophisticated individual, who feels free to express his feelings and emotions.
The Transmission of Cultural Attitudes Toward Pain
These attitudes toward pain and the expected reactive patterns are acquired by the individual members of the society from the earliest childhood, along with other cultural attitudes and values that are learned from the parents, parent- substitutes, siblings, peer groups, etc. Each culture offers to its members an ideal pattern of attitudes and reactions, which may differ for various subcultures in a given society, and each individual is expected to conform to this ideal pattern. Here, the role of the family seems to be of primary importance. Directly and indirectly, the family environment affects the individual's ultimate response to pain. In each culture, the parents teach the child how to react to pain, and, by approval or disapproval, they promote specific forms of behavior. This conclusion is amply supported by the interviews. Thus, the Jewish and Italian respondents are unanimous in relating how their parents, especially mothers, manifested overprotective and overconcerned attitudes toward the child's health, participation in sports, games, fights, etc. In these families, the child is constantly reminded of the advisability of avoiding colds, injuries, fights, and other threatening situations. Crying in complaint is responded to by the parents with sympathy, concern, and help. By their overprotective and worried attitude, they foster complaining and tears. The child learns to pay attention to each painful experience and to look for help and sympathy, which are readily given to him. In Jewish families, where not only a slight sensation of pain but also each deviation from the child's normal behavior is looked upon as a sign of illness, the child is prone to acquire anxieties with regard to the meaning and significance of these manifestations. The Italian parents do not seem to be concerned with the symptomatic meaning of the child's pains and aches, but, instead, there is a great deal of verbal expression of emotions and feelings of sympathy toward the "poor child" who happens to be in discomfort because of illness or because of an injury in play. In these families, a child is praised when he avoids physical injuries and is scolded when he does not pay enough attention to bad weather, to drafts, or when he takes part in rough games and fights. The injury and pain are often interpreted to the child as punishment for the wrong behavior, and physical punishment is the usual consequence of misbehavior.
In the "Old American" family, the parental attitude is quite different. The child is told not to "run to mother with every little thing." He is told to take pain "like a man," not to be a "sissy," not to cry. The child's participation in physical sports and games is not only approved but is also strongly stimulated. Moreover, the child is taught to expect to be hurt in sports and games and is taught to fight back if he happens to be attacked by other boys. However, it seems that the American parents are conscious of the threats to the child's health, and they teach the child to take immediate care of any injury. When hurt, the right thing to do is not to cry and get emotional but to avoid unnecessary pain and prevent unpleasant consequences by applying the proper first-aid medicine and by calling a doctor.
Often, attitudes and behavior fostered in a family conflict with those patterns that are accepted by the larger social environment. This is especially true in the case of children of immigrants. The Italian or Jewish immigrant parents promote patterns that they consider correct, while the peer groups in the street and in the school criticize this behavior and foster a different one. In consequence, the child may acquire the attitudes that are part of his home-life but may also adopt behavior patterns that conform to those of his friends.