Welcome back to the Healing Pain Podcast with Dr. Kai Karos, PhD
If you follow this show for some time, you know that one of the aims of this show is to help reconceptualize pain from a biomedical perspective and increase the awareness of a biopsychosocial approach to pain care. Chronic pain has long been recognized as an experience that can threaten your need for safety, both physically and psychologically, but what about feeling safe from a social context? Social context can be a powerful mediator and influence how pain is experienced. The social context of pain is such an important topic that there’s even a movement to change the definition of pain from being an unpleasant sensory and an emotional experience to one that emphasizes pain as an experience associated with sensory, emotional, cognitive and social components.
Joining us to talk about the pain in a social context is Dr. Kai Karos. Kai earned a Bachelor’s and a Master’s in Psychology at Maastricht University in the Netherlands. He then went on to complete a PhD where he investigated the effects of threatening social environments on the experience and communication of pain. Kai is working as a postdoctoral researcher investigating in the social learning of pain-related fear and avoidance. You will learn all about pain as a threat to the social self, including how pain interferes with the basic human needs such as the need for autonomy, the need to belong and the need for justice and fairness. Kai is a highly sought-after speaker regarding the social context of pain and one of a small handful of researchers globally who is investigating this important topic. This is a topic that does not receive enough media attention, so I’m excited to share this with you.
Watch the episode here:
Pain In A Social Context with Dr. Kai Karos, PhD
Kai, welcome to the podcast. It’s great to have you.
Joe, thanks for having me.
I’m excited to talk to you about pain in regard to the social context of pain. It’s a great topic. There are not too many people out there studying the social context of pain, so you’re part of a unique, interesting group of researchers that are tackling one part of the biopsychosocial model that we often talk about but we don’t know what to do with it. Tell us how you got involved with thinking about studying this social context and how you said, “I’m going to take this and own this part of the research?”
My main interest is in social psychology and forensic psychology, so health psychology I stumbled into it quite by accident because that was what was available. My promoter was Professor Johan Vlaeyen and some people might be familiar with his work with fear-avoidance and the fear-avoidance model. He offered me a PhD position, but there was not anything social in it. What he offered me was an opportunity to bring my own interests into the project. That was to add some social framework to that. I didn’t know much about pain or chronic pain for that matter. What I was stunned by is that all the work that he did and that most people that in pain to me, that was this big aspect missing. People are talking about the biopsychosocial framework, but the main thing is maybe a little bit of psychology. If you go to a pain congress, you will see that but nothing social. If you look at fear-avoidance as an example, it’s still focused on the individual and separate from the context. What he said is make it your own and try to come with your own projects, and that’s what I did. That was adding the social context and trying to study how social context affects pain experience and pain expression.
I was at the World Congress in Boston. I know you were there too. There’s a lot of psychology at the conference. Some biology in various parts of the biological aspect and no other than probably the one or two lectures that you gave the social context. It’s great that you’re contributing. I know part of your research and your doctor work you have an article in The Journal of Pain in September 2018 called Pain As A Threat to the Social Self: A Motivational Account. It’s a great piece of research that I read through. In there, you have a model which we’ll talk about and go through the social context pain. Can you tell us the three parts of that model? Let’s start with that first because there’s a lot to this model.
Chronologically, this was a project that I tried to do in my PhD to wrap my head around the bigger picture. As an experimental psychologist, you focus on little gaps and this is our attempt to review the literature and see what’s out there in terms of social threat. I’m within the niche of social, but within that niche, I’m focusing on social threats, which is even less researched in social factors in general. You can say it’s all the experiences that people with acute and chronic pain phase that experience is threatening and fortunately, there are a lot of different experiences that you could think of that are common.
What we tried to do with this model is to review the literature specifically in pain and come up with a common theme that seems to be coming back. What we did is we identified three common needs that we think are interpersonal and social that are commonly threatened when someone is in pain, especially chronic pain. The first need is a need for autonomy, which is a bit counter-intuitive because if you think of it as a social thing, it’s job setters. It’s like you try to be independent and people try to be autonomous, they try to be in control of their lives. Our thought was that pain challenges this need because what it does is it puts you in a state of dependency. It puts patients especially in a state where they need to reach out for help.
It’s not just physical, but they also need to reach out to others for understanding, healthcare professionals, family. Others have described the pain as a need state, and often this need is solved by reaching out to others, which is a good thing. It does lead to feelings of helplessness, being a burden to others because all of a sudden, you are not independent anymore because you have to rely on others. The second need that we thought of is the need to belong, which is well-researched, especially within social psychology because as humans, as social species, we seek out social connection. Social isolation has been shown to be detrimental to physical and psychological health. In pain, there’s a lot of research, especially in chronic pain patients who are isolated. One of the biggest costs of chronic pain that is often overlooked is that there is a social disconnect, so people can engage in such activities anymore.
They might feel they’re a burden to their families and friends and might disengage or they’re simply not able to leave the house and stay at home. There’s a lot of experiences of social disconnect, which then challenged this need to belong because in the end you end up feeling lonely and excluded. The third is a need for justice, which is another need that is also well-described in lots of different kinds of literature. Primary economy and evolution. There’s a sense of justice that people adhere to and they have a need for justice. I don’t know if the audience is familiar with the just-world hypothesis, but there’s this need that a lot of people have that they feel they want to live in a just-world where things happen for a reason and are fair.
That’s not always true and pain is another good example, especially chronic pain where there’s a lot of research mainly by Whitney Scott who shows that people with chronic pain have experiences of injustice. They feel that they’re not treated fairly, they feel that pain is not the result of a fair process, especially in cases where the pain is to resolve of someone else’s problem negligence, like a car accident. These perceptions of injustice have real consequences for pain experiences. That’s the same with all those needs. It’s not that they’re common in people with acute and chronic pain, but they have real consequences for the pain experience itself.
You started out in the world of fear-avoidance, but then you dialed into the aspect of a threat, which I don’t hear people talk about that as much. What I like about this framework regarding pain and threat is when you look at this framework, it almost helps a practitioner, whether it’s a psychologist or a physical therapist to try to figure out fear and threat is a problem. This framework that you developed allows you to dial even further deeper and say, “Where is the specific threat?” How can we start to address that in patients or in the larger aspects of society? One of your frameworks there, the need to belong, you talk about exclusion and isolation. Can you talk about that in the context of evolutionary science and how that may inform what has happened with regards to pain?
That’s another interesting aspect because that’s another perspective that is not often discussed in pain research. That’s the evolutionary perspective and that’s something that also informed my PhD research. My PhD research was less about social exclusion because there’s a lot of work done. In terms of social exclusion, the main thing that we learned from evolutionary psychology is that people use others if it’s of benefit to themselves, which sounds selfish, but of course, at social enemies, we can use that as a resource to help us. That’s what most people commonly think of when someone is in pain. They will communicate it to others, which is a social thing to do. The basic assumption is that we do that in order to motivate others, to help us with our pain and to lessen it. That’s certainly true in a clinical context. You go to the doctor in order to help. Another problem is that often patients do not feel supported or helped or understood even. That’s especially in these biomedical contexts in regard to pain. Patients tell us is that they go to different healthcare professionals and what they experience is more invalidation.
Clinicians are basically saying that they don’t believe that the pain is real. That is still a common thing. That they didn’t think even worse that it’s exaggerated because often chronic pain, there is no biomedical cause that a healthcare professional can posit to. What that leads to is that the patient will not feel accepted or understood and will feel isolated and excluded because the person that they turned to for help is not being helpful. From an evolutionary standpoint, there’s this idea that it’s about costs and benefits. Everything that you do, especially in the past, what was important was to weigh the cost and the benefits carefully. There’s the benefit, there’s potential help. That’s why people express vulnerabilities. They tell people what they’re paying for instance and the benefit that they can get us help.
There is a cost and there’s a risk associated with that because you make yourself vulnerable. In an evolutionary context, in terms of survival, if you show vulnerability to the wrong person, it can end in mortality. That’s not as serious, but what still happens is that patients weigh probably the cost and benefits of disclosing their pain experience. If we listen to patients and if you look at the literature often, it has not met with help, it’s not met with understanding. That’s ties nicely into my PhD research because if we looked at what happens for the pain experience and the pain communication, other people are perceived as threatening rather than helpful.
Where does discrimination fall into that? Patients don’t feel they’re being helped necessarily when they go for treatment because there’s not necessarily a biomedical explanation that they can readily cling on to. Does that then lead to they feel discriminated? How does that influence what’s happening in society at large with regards to pain?
There’s surprisingly little work on that, but it’s a nice research line from Lies De Ruddere, which is from Ghent University in Belgium, and she has also written a nice paper on stigmatization. It’s closely related to discrimination. What you see in patients of chronic pain, especially if there’s no biomedical foundation for their pain is their stigmatization. It’s nice research showing that healthcare professionals who take the pain less seriously of someone who doesn’t have any biomedical evidence for their pain. They will have cognitions about the pain is exaggerated, not real, which also nicely ties into the evolutionary idea because we have cheated detection mechanism. We don’t want to help people who don’t deserve to be helped. What happens in the clinic is that pain is underestimated often.
The stigmatization is twofold. One, the feeding of stigmatization is common in chronic pain patients and that has been shown to have real consequences for the pain experience. For disability, it’s increased but there’s also a lot of evidence that it has real consequences in the clinic, how patients are treated. Pain that has no underlying biomedical causes is disbelieved. Patients that report pain without biomedical foundation are often disliked, which again leads to pain underestimation because it’s taken seriously. There’s a lot more research that needs to be done to show what happens with patients that go to a clinician and are not believed because of this much predominant biomedical accounts that are still happening.
It’s definitely a problem that patients experience every day still in the world of pain. I also think it’s a place that practitioners aren’t as sensitive to all the time and they’re not quite sure how to help someone with regard to that one problem, so it’s great information. When you hear the word helplessness, hopelessness is both in social circles when you’re talking to people with pain. You also hear about it from cognitive psychology, traditional cognitive model, but how does that play into someone’s need for autonomy?
Traditionally when you think of helplessness, there’s a lot of research of course, but helplessness and controllability are important factors. People who feel that they’re in control of their pain seemed to better cope with pain than people who feel that it’s uncontrollable and feel helpless. It’s also nicely tied in with the research into depression, learned helplessness, the cause of logical ability between chronic pain and depression. Initially most people will not think of it as a social phenomenon. They will think of it as something that is within the individual. The reason why we thought of it as a social phenomenon is because it is true that chronic pain patients frequently report that they feel helpless, they feel alone, they feel without control. What is unique to pain and in healthcare in general is that when someone is in a state of disease that they need to reach out to others, it is a human thing. We have others to reach out to.
You place the control and you usually have yourself onto others and you’re dependent on their reaction. That makes it a social thing and that makes it also so that all the other factors we talked about are impactful. If you feel helpless, you reach out, you’re vulnerable and you try to go to someone else for understanding and help, and then that help is denied. That of course can be impactful on your experience. That’s why the need for autonomy seems counterintuitive in the beginning, if you think about all those needs that we talked about. What needs to be realized is that in a state of vulnerability, especially with pain, often there’s this shift that as a patient, you have to rely on others for help. That makes it important to see for the other person, do they provide the help that someone’s asking for? Do they fulfill the needs of the patients? I don’t know if we are aware that is such an influential factor when someone goes into therapy for instance.
I got that because there’s so much information and talk amongst practitioners about making patients independent, what they need to do on their own so they can obviously be discharged from treatment and then move on through life, which is important. There’s this delicate balance between helping someone and giving them the care and support that they need is making them independent. I would assume throughout the course of care that you’re moving from one part of that spectrum on to the next part. That’s a great way to look at it.
I would definitely agree with that because you start the societal idea of us, especially in western society of being autonomous, of being self-efficacy to be able to control your life. At a certain time, you will need to rely on others and the ideas that you can rely on others, but hopefully be independent again. They’d be able to do the things you do without being disconnected. That’s the crucial aspect of it.
The third part is the need for justice. The word justice is such an interesting word to use, especially in our political environment. Things that are happening and essential programs are being cut for people who need all sorts of care. Not only chronic pain care, but chronic disease care in general, at least in the US where I am. Can you talk about the need for justice with regard to chronic pain?
The need for justice is an interesting one because first of all, one thing that is important to realize is the social dimension. You talked with Claire Ashton James about that. The social is on many different levels. You can talk about one-on-one interactions that we have, but you can also think about it within a community, within a family, within a therapy group. You can also think of it as higher. That’s something that has little research on but as a culture, as a country on a systemic level, that is still social. The way we talk about pain, it had to do with what we think about pain, the way that we treat pain in the society, all those things trickle down to the individual. If you focus on the individual, it will be easy to miss.
One of the big reasons why the social domain in the biopsychosocial is often ignored is because those big systemic influences are hard to tackle because one therapist will not be able to do this. If you talk about injustice, you can look at it from different levels. There’s a lot of research that asks individual patients if they feel that their pain experience is just. There’s a nice questionnaire. It basically measures perceived injustice. It’s what the perception of the patient if they have some injustice that is the cause for their pain, whether they did anything in order to bring it about. On different levels, other interesting research shows for instance that pain care for minorities is worse than for other groups, so there are real injustices.
It’s not just if you’re talking about procedural justice, that isn’t about patients perceiving this, but it’s about also systemic injustices. Not everybody gets the care that they deserve. If you think about solutions, it’s about not focusing on the individual but also focus on systemic changes, which is one thing that you can learn from focusing on the social factors. In the lab, that’s mainly where I am. I will also not be able to do big changes. What we see is that perceptions of injustice matter. If you feel that your pain is the result that someone else is intentionally causing pain to you. That’s what I did in my experiment, then the pain is experienced as worse. If you talk to patients or even in acute pain, there’s often an element of blame and it might be directed to simply if your pain as a result of a car accident, it’s simple to blame someone else for your pain. It might be directed at God. It might be directed at family members or healthcare professionals who don’t provide the care that you think you deserve.
If you have this perception of justice, it’s tied to anger, aggression and all those processes have been shown in research that they are negatively related to dealing with pain. There’s an example of people about to go back to work or try to rehabilitate to go back to work and then hire perceptions of injustice are associated with staying longer at home. They are not going back to work because some people, for instance, blame the employee and then see this as a way to punish them for what they consider is their fault. it is affecting a lot of different levels and one of them is pain, but there’s a lot of different ways that it affects rehabilitation and a lot of the disability that you see with chronic pain especially.
That’s such an interesting part. The need for justice, as you’re talking, I’m reflecting about society as a whole. My question for you, maybe you’re the right person to ask this too since you were studying this. With regard to prosocial values, let’s say a country’s treatment of pain is potentially a good litmus test for what they’re prosocial values in a society.
It’s not just pain in general but it’s for the care in general, like taking care of someone in need in general, be it pain otherwise, be it mental illness otherwise is probably a good measure of wealth because that’s at the end what you need. You need resources. It’s twofold. On the one hand, you have to be willing to care. On the other hand, that’s the other big one, it’s also a lot about education. It’s a lot about understanding what pain is, how pain is affected and seeing that something that injustice matters. It’s probably a good litmus test. If you see levels of care across the world and I don’t want to say anything about the United States, but you will see differences. It’s this balance between autonomy and catching people that need help and providing that care.
Most practitioners and people who follow this podcast who are Americans probably would say that we need to deepen our values and the way we help people with care. That comes from the government level, societal level and then a healthcare level. A lot of different levels involved in the social aspect, which is why this topic is interesting. Where do you see your field heading with regard to pain care and pain science?
I guess with my field doing these social aspects. I’m a young researcher. I’m getting into it and I’ve seen a lot. I’m quite optimistic. I started off pretty pessimistic because there were not much on social things. Most people, they will even raise an eyebrow if you talk about the psychology of pain. If you think about the social thing, there are several things that have happened that make me think that it’s getting more recognition. One, there’s no special interest group. I don’t know if you talked with Claire Ashton James about it, but she started a special interest group and I asked to bring people together talking about the social aspects specifically.
The interesting thing is it’s a framing issue because a lot of people do social things. They just call it differently. If you go to pediatrics, they do parent-child interactions. That is social. They will not think necessarily of it as a social thing. Bringing those people together will already make a huge difference in terms of reframing what we already know because there’s a lot that we know that has relevance for the social dimension. There are pushes to change the definition of pain. I don’t know if you’re aware of that, but it was a nice paper of Amanda Williams. They proposed a change to the official definition of pain where they basically said if we believe that pain is biopsychosocial and social should be near a definition, which it is not. If you can still have a good discussion about what it means if you say pain is social? That’s a good discussion to have.
Can you recite their definition? Do they have that fully developed yet or are they still working on that?
The definition that they proposed was pain is a distressing experience associated with actual or potential tissue damage, which is much like the old one, with sensory, emotional, cognitive and social components. It originally was sensory and effective, and what they edit is cognitive and social. You can discuss what it means to say that pain has social components. The problem with that’s probably what I would say that everything is social. It becomes a bit non-explanatory if you say it’s social. It’s important that we make it specific about what we mean by saying that pain is social.
The third thing that I would mention is that at least at conferences, I feel that there is no more interest in the social dimension. I was lucky that Springer reached out to us and we published a book that I am one of the editors on and that’s a book where we tried to reach out to everybody in the field who does social research in pain. That book was called Social and Interpersonal Dynamics in Pain. I can see that there are a lot of people doing this and have an interest in this. Hopefully, it’s going to get better in the future but on the other hand, the biomedical model has proven strong and it always has.
We’re chipping away and slowly but surely it is starting to change. When we talk about the social context of pain, I can’t help my brain starts to go towards social media. I’m wondering if you have thought about how your work could help inform social media or potentially help the practitioner who is using social media to educate people about pain or to bring people in pain together. Have you given any thought with regards to those types of topics?
The reason why the social aspect it so developed is that the biomedical idea of pain is still strong, not just in the clinic, but especially in the general population. That’s still our idea that pain has a cause. It’s in the body, there’s an injury and it will go away. Probably with pain, we don’t know what to do. We don’t know how to explain it. If you look at the Body in Mind group for instance, they are amazing in two ways because they develop these great pain education programs, but they also use social media for instance to spread it and to make YouTube videos. You probably have seen the body and mind explaining pain YouTube video where they try to simplify it for anybody to learn and to understand that the biopsychosocial model is what we think of as pain and also what it means.
I remember I had this because I wrote a blog entry for Body in Mind and it was put on Facebook. You can see the comments and as a fundamental experimental researcher, usually the people you talk to are other scientists. It’s like preaching to the choir. They agree with you. Social media is a nice way of seeing how your ideas arrive for instance, patients. I remember that blog entry and it was more or less the same message I’m giving you and there was a patient commenting on it and saying, “That psychologist basically is still saying it’s all in our head.” It was such a wake-up call. How far we are still from reaching the people that we want to reach and to explain what we mean when we talk of biopsychosocial? For a patient, they hear from everybody, “It’s in your head,” and briefly talking about expectations and social context and all those things that they don’t necessarily think influence their pain. For them, it might be translated, “It’s not real. It’s in your head.” That is of course not the message you want to send. There’s a lot to be done in pain education, anything on social media. You will reach the people that you want to reach probably.
It’s interesting because you and I probably travel in circles of people who understand all the nuances about the things we’re talking about. When you sit down and speak to someone who has pain which hasn’t been introduced any of this, they are coming from a completely different place. They don’t have that type of knowledge. That’s one of the reasons why I started this podcast. I talked to both practitioners and the public about pain through this podcast so people would get the message. Still, if I see a patient who’s fresh off the streets so to speak, they don’t know any of this and it’s all new and it takes a long time. Sometimes it takes a while for people to start to change. How has your work changed you as an individual in society at large? You weren’t going to start off in pain. You started off in something totally different and you looked at the pain, there’s not much there. You learned about it and you’re two knees deep in the sand. How has it changed your outlook from someone who was trying to change what’s happening in the world?
I wasn’t interested in social psychology to begin with, but I was interested mainly because I always thought that it was interesting to understand how people affect each other. I would describe myself as a social person. For me, that was always interesting to see how people as individuals function but how they change and how they can change based on important context, that’s one of the main lessons of social psychology. One of the reasons why in the beginning I would’ve never thought of pain or health psychology is because I thought of it as focused on the individual. When you hear pain at the time, I thought of the biomedical idea. I didn’t even know that pain psychology is a thing until you don’t fly and others try to explain what it is about. To realize how much of it is social and how little their standards still is to me absolutely bewildering. All of the things that we talked about, all the different levels especially with something like chronic pain, there are no epidemic proportions. You have the opioid epidemic.
You can only think of it as social. You will only solve it with social solutions. You must have societal change. if anything, it may be more of an activist, which is hard to straighten out with being a fundamental scientist because at the end of the day, you still go into the lab. I don’t even see patients, so it’s not something that gives you an immediate feeling of achieving change. This is something great because you get that message out and hopefully people will still take it and will react to it. They will let me know if those ideas that we developed resonate with patients for instance. It’s twofold. If anything, it convinced me more about how important social factors are. Even in areas where we don’t usually think of social factors like health. It seems to be at the core of everything.
If you were to give a tip to your practitioner on how they could start to look at your framework, the need for autonomy, the need to belong, the need for justice. I’m looking at all the different parts underneath that. If there is a question they can include in there patient intake or maybe a certain type of patient scoring or test they can use, what tip would you give to your practitioner who says, “This is missing from my practice and I’d like to try to include a little part of this into what I’m doing every day.”
There’s a ton of options. To be critical, the first thing every practitioner should do is based on the work that’s out there to ask themselves whether they think that they fulfill the social needs that often are threatened, especially with chronic pain patients. Do they give the feeling to the patient that they are in a safe space? Do they listen to the patient? Are they understanding, are they supportive? Those things on a basic level, it’s something that the practitioner can do. In terms of what I can do for the patient, it’s to make it a topic. One of the problems is that there is little good work done on measurement instruments. For instance, to social needs, there’s not much care but to make it a topic to not just talk about pain but to make it a broader context, and there are different ways you can do it.
You talked with Claire about it as well. You can involve other people in therapy. You can make this a thing. We should do more research on it because we know little group therapy in terms of how that changes the dynamics if we know groups are powerful and you can utilize that. What social network is that patient in? Is it important for that patient? It might not be important, but usually, patients have their social context. They have family, they have partners, friends. Does it somehow affect them and does it affect their pain? This is relevant to them. Is this a need for what they want to be addressed? If it’s not mentioned by a petitioner first, the patient will not necessarily come up with those themselves. They think that this is a topic that matters for someone who they go to ask for help about pain. To make it a topic is already a good start.
What are you working on that you’re excited about?
The new project not much relates to this because the research trend is much about social learning. Learning was always central to research in general, but most of our learning when we focused on it is based on how you learn from experience. Often, our learning depends on others as we watch other people, especially children. They watch their parents. We watch other people living with chronic pain in the therapy context. What we’re looking at is pain-related fear, how afraid you are of pain and avoidance behavior, two central processes in the fear-avoidance model. Can they be socially learned? Without you having pain or avoiding, if you watch someone else doing that, is that something that can transfer? We are confident that it is because that’s usually how you learn about the world. Does it have potential therapy? For instance, if you have an anxious patient, can you use other patients in your group to model certain behaviors to affect how likely it is for your patient for Cognitive Behavioral Therapy to engage in an exposure and do things that they are afraid of, which we know is effective when we’re using pain-related disability. That’s experimental work. We look at social learning of those processes, but hopefully down the line we’ll also have implications for treatment. It is social. It’s about how do you gather information from your social environment, which probably happens a lot more than we think.
It’s been great chatting with you, Kai. Your research is needed and important and not that many resources out there studying the social aspects. We definitely need more information. We’ll look forward to the work you’re developing on. How can people learn more about you? Do you have a website? Where can people find out information about you?
The best way would be Twitter, @KaiKaros. I do have a website but the link is terrible, so probably the easiest would be to just Google my name and click on the second link. It’s the department websites. Those are the two main sources probably.
At the end of every episode, I ask you to share this information out on social media. This is the perfect show to share on social media because we’re talking about the social aspects of pain. Take the link to this show and share it on Facebook, Twitter, LinkedIn, in your favorite Facebook group and whatever group you belong to. It’s important and it directly relates to all the work we’re talking about. I want to thank Kai for joining us. I want to thank you for taking the time and learning about pain, pain science and pain care. We’ll see you next time.
- Dr. Kai Karos
- Professor Johan Vlaeyen
- Pain As A Threat to the Social self: A Motivational Account
- Claire Ashton James – previous episode
- Amanda Williams
- Social and Interpersonal Dynamics in Pain
- Body in Mind
- @KaiKaros – Twitter
- Website link – Kai Karos
About Dr. Kai Karos, PhD
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