Pain, Intercultural Communication, and Narrative Medicine

  • James HallenbeckEmail author


This chapter examines communication about chronic pain through the lenses of intercultural communication and narrative medicine. Intercultural communication as an anthropologic field offers a perspective that may heighten awareness of common pitfalls in communicating with people with pain. Narrative medicine offers a complementary approach to understanding contextual and relational issues among patients, providers, and significant others. Also discussed are common relational subtexts in communication around pain, such as trust, power dynamics, legitimacy, and specialness and how these may apply to challenging discussions, such as the use of opioids. General strategies for dealing with these subtexts are presented in keeping with principles of intercultural communication and narrative medicine.


  1. Beach, M. C., Roter, D. L., et al. (2006). Are physicians’ attitudes of respect accurately perceived by patients and associated with more positive communication behaviors? Patient Education and Counseling, 62(3), 347–354.PubMedPubMedCentralCrossRefGoogle Scholar
  2. Becker, G. (1997). Disrupted lives, how people create meaning in a chaotic world. Berkeley: University of California Press.Google Scholar
  3. Beckman, H. B., et al. (2012). The impact of a program in mindful communication on primary care physicians. Academic Medicine, 87(6), 815–819.PubMedCrossRefGoogle Scholar
  4. Bergman, A. A., et al. (2013). Contrasting tensions between patients and PCPs in chronic pain management: A qualitative study. Pain Medicine, 14(11), 1689–1697.PubMedCrossRefGoogle Scholar
  5. Biro, D. (2010). The language of pain. New York: Norton.Google Scholar
  6. Botvinick, M., Jha, A. P., et al. (2005). Viewing facial expressions of pain engages cortical areas involved in the direct experience of pain. NeuroImage, 25(1), 312–319.PubMedCrossRefGoogle Scholar
  7. Branch, W. T., Jr. (2006). Viewpoint: Teaching respect for patients. Academic Medicine, 81(5), 463–467.PubMedCrossRefGoogle Scholar
  8. Brennan, F., et al. (2007). Pain management: A fundamental human right. Anesthesia and Analgesia, 105(1), 205–221.PubMedCrossRefGoogle Scholar
  9. Charon, R. (2001). The patient-physician relationship. Narrative medicine: A model for empathy, reflection, profession, and trust. JAMA, 286(15), 1897–1902.PubMedCrossRefGoogle Scholar
  10. Chaudakshetrin, P., Prateepavanich, P., et al. (2007). Cross-cultural adaptation to the Thai language of the neuropathic pain diagnostic questionnaire (DN4). Journal of the Medical Association of Thailand, 90(9), 1860–1865.PubMedGoogle Scholar
  11. Cleeland, C. S., & Ryan, K. M. (1994). Pain assessment: Global use of the brief pain inventory. Annals of the Academy of Medicine, Singapore, 23(2), 129–138.PubMedGoogle Scholar
  12. de Williams, A. C., Davies, H. T., & Chadury, Y. (2000). Simple pain rating scales hide complex idiosyncratic meanings. Pain, 85(3), 457–463.CrossRefGoogle Scholar
  13. Detmar, S. B., Muller, M. J., et al. (2001). The patient-physician relationship. Patient-physician communication during outpatient palliative treatment visits: An observational study. The Journal of American Medical Association, 285(10), 1351–1357.CrossRefGoogle Scholar
  14. Esquibel, A. Y., & Borkan, J. (2014). Doctors and patients in pain: Conflict and collaboration in opioid prescription in primary care. Pain, 155(12), 2575–2582.PubMedCrossRefGoogle Scholar
  15. Fabrega, H. (1997). Evolution of sickness and healing. Berkeley: University of California Press.Google Scholar
  16. Frith, C. (2009). Role of facial expressions in social interactions. Philosophical Transactions of the Royal Society of London. Series B, Biological Sciences, 364(1535), 3453–3458.PubMedPubMedCentralCrossRefGoogle Scholar
  17. Gaston-Johansson, F., Albert, M., et al. (1990). Similarities in pain descriptions of four different ethnic-culture groups. Journal of Pain and Symptom Management, 5(2), 94–100.PubMedCrossRefGoogle Scholar
  18. Grossman, S. A., Shedler, V. R., et al. (1991). Correlation of patient and caregiver ratings of cancer pain. Journal of Pain and Symptom Management, 6(2), 53–57.PubMedCrossRefGoogle Scholar
  19. Goubert, L., Craig, K. D., et al. (2005). Facing others in pain: The effects of empathy. Pain, 118(3), 285–288.PubMedCrossRefGoogle Scholar
  20. Hadjistavropoulos, H. D., & Craig, K. D. (1994). Acute and chronic low back pain: Cognitive, affective, and behavioral dimensions. Journal of Consulting and Clinical Psychology, 62(2), 341–349.PubMedCrossRefGoogle Scholar
  21. Hahn, R. (1995). Sickness and healing. New Haven: Yale University Press.Google Scholar
  22. Hall, E. (1976). Beyond culture. Garden City: Anchor.Google Scholar
  23. Hall, E. (1983). The dance of life. Garden City: Anchor.Google Scholar
  24. Hall, E. (1990). The silent language. New York: Anchor.Google Scholar
  25. Hall, E. (1997). Context and meaning. In L. Samovar & R. Porter (Eds.), Intercultural communication (pp. 45–54). Belmont: Wadsworth.Google Scholar
  26. Hallenbeck, J. (2000). A dying patient, like me? American Family Physician, 62(4), 888–890.PubMedGoogle Scholar
  27. Hallenbeck, J. (2006). High context illness and dying in a low context medical world. The American Journal of Hospice & Palliative Care, 23(2), 113–118.CrossRefGoogle Scholar
  28. Hallenbeck, J. (2007). Cross-cultural issues. In A. Berger, J. Shuster, & J. Von Roenn (Eds.), Palliative care and supportive oncology (pp. 515–525). Philadelphia: Lippincott Williams & Wilkins.Google Scholar
  29. Hallenbeck, J., & Periyakoil, V. (2009). Intercultural communication in palliative care. In C. D. Kissane, B. Bulz, & P. Butow (Eds.), Handbook of communication in oncology and palliative (pp. 389–398). New York: Oxford University Press.Google Scholar
  30. Haugli, L., Strand, E., et al. (2004). How do patients with rheumatic disease experience their relationship with their doctors? A qualitative study of experiences of stress and support in the doctor-patient relationship. Patient Education and Counseling, 52(2), 169–174.PubMedCrossRefGoogle Scholar
  31. Helft, P. R., et al. (2014). Opiate written behavioral agreements: A case for abandonment. Perspectives in Biology and Medicine, 57(3), 415–423.PubMedCrossRefGoogle Scholar
  32. Holen, J. C., Hjermstad, M. J., et al. (2006). Pain assessment tools: Is the content appropriate for use in palliative care? Journal of Pain and Symptom Management, 32(6), 567–580.PubMedCrossRefGoogle Scholar
  33. Houry, D., & Baldwin, G. (2016). Announcing the CDC guideline for prescribing opioids for chronic pain. Journal of Safety Research, 57, 83–84.PubMedCrossRefGoogle Scholar
  34. Hughes, H. K., et al. (2015). A mixed methods study of patient-provider communication about opioid analgesics. Patient Education and Counseling, 98(4), 453–461.PubMedPubMedCentralCrossRefGoogle Scholar
  35. Im, E. O., Lee, S. H., et al. (2009). A national online forum on ethnic differences in cancer pain experience. Nursing Research, 58(2), 86–94.PubMedPubMedCentralCrossRefGoogle Scholar
  36. International Association for the Study of Pain Website. (2010).
  37. Kenny, D. T. (2004). Constructions of chronic pain in doctor-patient relationships: Bridging the communication chasm. Patient Education and Counseling, 52(3), 297–305.CrossRefGoogle Scholar
  38. Kleinman, A. (1994). Pain and resistance – The delegitimation and relegitimation of local worlds. In M. G. Delvechio, P. Browdwin, B. Good, & A. Kleinman (Eds.), Pain as human experience – An anthropological perspective (pp. 169–197). Berkeley: University of California Press.Google Scholar
  39. Kleinman, A. (1995). Writing in the margin: Discourse between anthropology and medicine. Berkeley: University of California Press.Google Scholar
  40. Knotkova, H., Crawford Clark, W., et al. (2004). What do ratings on unidimensional pain and emotion scales really mean? A multidimensional affect and pain survey (MAPS) analysis of cancer patient responses. Journal of Pain and Symptom Management, 28(1), 19–27.PubMedCrossRefGoogle Scholar
  41. Kristiansson, M. H., et al. (2011). Pain, power and patience–a narrative study of general practitioners’ relations with chronic pain patients. BMC Family Practice, 12, 31.PubMedPubMedCentralCrossRefGoogle Scholar
  42. Levinson, W., Gorawara-Bhat, R., et al. (2000). A study of patient clues and physician responses in primary care and surgical settings. The Journal of American Medical Association, 284(8), 1021–1027.CrossRefGoogle Scholar
  43. Lillrank, A. (2003). Back pain and the resolution of diagnostic uncertainty in illness narratives. Social Science & Medicine, 57(6), 1045–1054.CrossRefGoogle Scholar
  44. Lorenz, K. A., Lynn, J., et al. (2006). Quality measures for symptoms and advance care planning in cancer: A systematic review. Journal of Clinical Oncology, 24(30), 4933–4938.PubMedCrossRefGoogle Scholar
  45. Matthias, M. S., et al. (2010). The patient-provider relationship in chronic pain care: providers’ perspectives. Pain Medicine, 11(11), 1688–1697.PubMedCrossRefGoogle Scholar
  46. Matthias, M. S., et al. (2013). “I’m not abusing or anything”: Patient-physician communication about opioid treatment in chronic pain. Patient Education and Counseling, 93(2), 197–202.PubMedCrossRefGoogle Scholar
  47. Matthias, M. S., et al. (2014). Communicating about opioids for chronic pain: A qualitative study of patient attributions and the influence of the patient-physician relationship. European Journal of Pain, 18(6), 835–843.PubMedCrossRefGoogle Scholar
  48. Mattingly, C., & Garro, L. (2000). Narrative and the cultural construction of illness and healing. Berkeley: University of California Press.Google Scholar
  49. McDowell, I. (2006). Pain measurements. In Measuring health (pp. 470–519). New York: Oxford University Press.CrossRefGoogle Scholar
  50. Moore, R. J., & Hallenbeck, J. (2010). Narrative empathy and how dealing with stories helps: Creating a space for empathy in culturally diverse care settings. Journal of Pain and Symptom Management, 40(3), 471–476.PubMedCrossRefGoogle Scholar
  51. Morris, D. B. (2012). Narrative and pain: Towards an integrative model. In Moore (Ed.), Handbook of pain and palliative care (pp. 737–751). New York: Springer.Google Scholar
  52. Moya-Albiol, L., et al. (2010). The neural bases of empathy. Revista de Neurologia, 50(2), 89–100.PubMedCrossRefGoogle Scholar
  53. Nampiaparampil, D., Nampiaparampil, J. X., & Harden, R. N. (2009). Pain and prejudice. Pain Medicine, 10(4), 716–721.PubMedCrossRefGoogle Scholar
  54. Otti, A., Guendel, H., et al. (2010). I know the pain you feel-how the human brain’s default mode predicts our resonance to another’s suffering. Neuroscience, 169(1), 143–148.PubMedCrossRefGoogle Scholar
  55. Palermo, Y. (2013). In R. J. Moore (Ed.)., Handbook of pain and palliative care The art of pain: The patient’s perspective of chronic pain. New York: Springer.Google Scholar
  56. Parle, M., Maguire, P., et al. (1997). The development of a training model to improve health professionals’ skills, self-efficacy and outcome expectancies when communicating with cancer patients. Social Science & Medicine, 44(2), 231–240.CrossRefGoogle Scholar
  57. Parsons, S., Harding, G., et al. (2007). The influence of patients’ and primary care practitioners’ beliefs and expectations about chronic musculoskeletal pain on the process of care: A systematic review of qualitative studies. The Clinical Journal of Pain, 23(1), 91–98.PubMedCrossRefGoogle Scholar
  58. Prkachin, K. M. (1992). The consistency of facial expressions of pain: A comparison across modalities. Pain, 51(3), 297–306.PubMedCrossRefGoogle Scholar
  59. Pugh, J. F. (1991). The semantics of pain in Indian culture and medicine. Culture, Medicine and Psychiatry, 15(1), 19–43.PubMedCrossRefGoogle Scholar
  60. Rager, J. B., & Schwartz, P. H. (2017). Defending opioid treatment agreements: Disclosure, not promises. Hastings Center Report, 47(3), 24–33.PubMedCrossRefGoogle Scholar
  61. Reynolds Losin, E. A., Anderson, S. R., & Wager, T. D. (2017). Feelings of clinician-patient similarity and trust influence pain: Evidence from simulated clinical interactions. Journal of Pain., 18(7), 787–799.CrossRefGoogle Scholar
  62. Samovar, L., & Porter, R. (Eds.). (1997). Intercultural communication. Wadsworth: Belmont.Google Scholar
  63. Scarry, E. (1985). The body in pain. New York: Oxford University Press.Google Scholar
  64. Schiavenato, M., & Craig, K. D. (2010). Pain assessment as a social transaction: Beyond the “gold standard”. The Clinical Journal of Pain, 26(8), 667–676.PubMedGoogle Scholar
  65. Schott, G. D. (2015). Pictures of pain: Their contribution to the neuroscience of empathy. Brain, 138(Pt 3), 812–820.PubMedPubMedCentralCrossRefGoogle Scholar
  66. Sontag, S. (1978). Illness as metaphor. New York: Farrar, Straus & Giroux.Google Scholar
  67. Suchman, A. L., Markakis, K., et al. (1997). A model of empathic communication in the medical interview. The Journal of American Medical Association, 277(8), 678–682.CrossRefGoogle Scholar
  68. Thomas, V. J., & Rose, F. D. (1991). Ethnic differences in the experience of pain. Social Science & Medicine, 32(9), 1063–1066.CrossRefGoogle Scholar
  69. Tishelman, C., Taube, A., et al. (1991). Self-reported symptom distress in cancer patients: Reflections of disease,illness or sickness? Social Science & Medicine, 33(11), 1229–1240.CrossRefGoogle Scholar
  70. Trnka, S. (2007). Languages of labor: Negotiating the “real” and the relational in Indo-Fijian women’s expressions of physical pain. Medical Anthropology Quarterly, 21(4), 388–408.PubMedCrossRefGoogle Scholar
  71. Volkow, N. D., & McLellan, T. A. (2011). Curtailing diversion and abuse of opioid analgesics without jeopardizing pain treatment. JAMA, 305(13), 1346–1347.PubMedCrossRefGoogle Scholar
  72. Volkow, N. D., & McLellan, A. T. (2016). Opioid abuse in chronic pain–misconceptions and mitigation strategies. The New England Journal of Medicine, 374(13), 1253–1263.PubMedCrossRefGoogle Scholar
  73. Weissman, D. E. (1994). Understanding pseudoaddiction. Journal of Pain and Symptom Management, 9(2), 74.PubMedCrossRefGoogle Scholar
  74. Weissman, D. E., & Haddox, J. D. (1989). Opioid pseudoaddiction – An iatrogenic syndrome. Pain, 36(3), 363–366.PubMedCrossRefGoogle Scholar
  75. Williams, A. C. (2002). Facial expression of pain: An evolutionary account. The Behavioral and Brain Sciences, 25(4), 439–455 discussion 455–488.PubMedGoogle Scholar
  76. Young, J. L., & Davidhizar, R. (2008). Attitude: Impact on pain assessment. Journal of Practical Nursing, 58(2), 6–10.PubMedGoogle Scholar
  77. Zatzick, D. F., & Dimsdale, J. E. (1990). Cultural variations in response to painful stimuli. Psychosomatic Medicine, 52(5), 544–557.PubMedCrossRefGoogle Scholar
  78. Zheng, Z., et al. (2013). Chaos to hope: A narrative of healing. Pain Medicine, 14(12), 1826–1838.PubMedCrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Primary Care and Population Health, Department of MedicineStanford University School of MedicineStanfordUSA
  2. 2.VA Palo Alto Health Care ServicesPalo AltoUSA

Personalised recommendations