The Intersection of Pain and Culture ____________________________________________________________
food, their siblings, or banana stalk [196]. Native Americans were also more likely to view pain within the larger holistic context of the mind, body, emotions, and spirit [63]. As such, pain treatment should address each of these dimensions. In one study, individuals in rural Nepal reported the belief that pain is part of the aging process and is endured without the need to seek help [170]. In a study of Black Caribbean and White patients being treated for cancer, the Black Caribbean patients were more likely to attribute their cancer (and related pain) to a testing of their faith (i.e., loyalty to God) and to consider the diagnosis to be an opportunity to strengthen and confirm their religious beliefs [64]. Because the meanings of pain are interwoven with religion and spirituality, it is not surprising that pain is linked to past sins and immoral behaviors in many cultural groups. Similarly, some cultural groups attribute the cause of pain to mysticism or “the evil eye” [144]. Some patients may feel that their pain is a result of wrongdoing—a justifiable retribution [64; 193]. In some religions, prayer and other religious ritu- als may be done as a means to cope and atone for sins [65]. Similarly, some cultures believe pain symptoms are the result of an imbalance or a lack of harmony and may seek tradi- tional healers to restore order (e.g., by performing a ritual or ceremony) [66; 194]. Overall, patients from Western societies tend to attribute pain to biological factors; other cultures are more likely to give a metaphysical explanation, including karma, evil, family wrongdoing, sin, and/or weakness. In these cultures, pain does not automatically mean that one should seek medical treatment. Instead, it may signify hardship and the need to build character and resilience [180]. EXPRESSING/COMMUNICATING PAIN Communication consists of verbal and nonverbal components, both of which are embedded within the culture of the parties disseminating and receiving the information. In the context of pain, the term “pain response” is used to refer to the verbal (e.g., wailing, verbal complaints about pain symptoms) and nonverbal (e.g., facial expressions, body gestures) expressions of pain [67]. In order to understand how culture influences the communication of and coping with pain, it is first important to understand the role of high- and low-context cultures within the larger perspective of communication styles. Styles of communication can be classified on a continuum from high to low context [68]. High-context cultures rely on shared experience, implicit messages, nonverbal cues, and the relationship between the two parties to disseminate information [69]. Members of these cultural groups tend to listen with their eyes and focus on how something was said or conveyed [68; 70]. On the other hand, low-context cultures rely on verbal communication, or what is explicitly stated in the conversation [69]. Consequently, low-context communicators listen with their ears and focus on what is being said [68; 70]. Western culture, including the United States, can be classified as a low-context culture. On the other hand, groups from col- lectivistic cultures, such as Asian/Pacific Islanders, Hispanics,
Native Americans, and African Americans, are considered high context [68]. Clearly, adherence to cultural values influences communication styles. Cross-cultural communication is by no means simple, and there is no set of rules by which to abide. Instead, promoting culturally sensitive communication is an art that requires practitioners to self-reflect, be self-aware, and be willing to learn. Therefore, as practitioners become skilled in noticing nonverbal behaviors and how they relate to their own behaviors and emotions, they will be more able to understand their own level of discomfort and comprehend behavior from a cultural perspective [70]. In-depth interviews with Somalian women living in Sweden revealed that their pain is often communicated through body language as opposed to explicit verbal expression [52]. Most of the women indicated that they had experienced pain symptoms for a long time before communicating them to others. To be extremely expressive with one’s pain (e.g., loud crying, wailing) was also viewed as unacceptable [52]. Similarly, in a qualita- tive study with Chinese women, the participants believed that pain should be dealt with stoically [71]. A separate study found that Asian Indian students were less likely to find overt expressions of pain acceptable compared with their American- born Indian counterparts [67]. Native Americans prefer to “block” all discussion and thoughts of pain [72]. A key theme that emerged in a focus group study about the expression of pain among patients and families in Ethiopia was perceived bravehood for stoic responses [39]. Focus group participants discussed how hiding one’s pain is a sign of strength; tolerating pain was considered brave [39]. In many indigenous groups, endurance of pain is seen as a rite of passage to maturity and signifies courage [199]. Conversely, some cultural groups may be more likely to directly express pain. Studies have observed greater willingness to overtly express pain in American society, with a greater ten- dency to seek help from pain professionals and prescribed analgesics [67; 73]. COPING WITH PAIN Coping is defined as the use of behavioral and cognitive strate- gies to relieve the internal or external environmental stressors that stretch an individual’s strengths and resources [74]. These strategies have been categorized as active or passive. Active coping strategies are characterized by directive problem-solving techniques, actively seeking social support, and employing reappraisal methods to reassess the situation. In a quantitative survey with 90 Filipino migrant workers, the use of diversion and cognitive coping skills helped control pain better than reinterpreting and catastrophizing [200]. Meanwhile, passive coping strategies emphasize avoidance and utilizing techniques such as distancing, escaping, wishful thinking, and self-control [75]. In terms of coping or managing pain, individuals employ- ing active coping strategies would attempt to stay busy, focus less on the pain, place their energies on another activity, and continue with normal activities of daily living [76]. Meanwhile, those in pain employing passive coping strategies may escape
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