Rating Pain and The Pain Scale

Lately, I’ve been reading a lot of creative nonfiction essays during the process of designing an upper-level Creative Nonfiction writing course at the University where I teach and work. The process is grueling but exciting, as I sift through some of my longtime favorite essays and seek out new work that piques my interest. Often what I’m looking for is writing that says something old, something we’ve all heard before. I’m looking for essays that express what many of us have thought before, but express this old thing in a new, unique way.

I look for essays that can teach my students, but can also teach myself something. But I never expected to find an essay that would teach me something about my own experience with chronic pain.

“The Pain Scale” by Eula Biss

If you’ve ever wondered how you could possibly quantify your chronic pain on any given day, than this essay is for you. First published in the Seneca Review in 2005, I’m surprised it has taken me nearly two decades to discover this essay that puts into words everything I’ve been struggling to express about chronic pain…and then some.

In “The Pain Scale”, Biss contemplates life with chronic pain and the monumental task of describing and rating that pain (along with the utter inadequacy of rating scales in general) in a series of segmented thoughts that are organized around the 0-10 pain scale (you know the one–it hangs in most doctor’s offices and emergency rooms). Blunt, absurd, thoughtful, and sometimes humorous, this essay helped me comprehend the complex and indescribable nature of pain. Here are some of my take-aways.

1. A zero on the pain scale?

“I am sitting in the exam room of a hospital entertaining the idea that absolutely no pain is not possible. Despite the commercials, I suspect that pain cannot be eliminated. And this may be the fallacy on which we have based all our calculations and all our excesses.”¹

Pain is complex. Pain contains an array of nuances. I think pain is more complicated than we and the medical field understand it to be. I can’t remember the last time I felt “absolutely no pain.” In this way, my experience proves Biss’s statement, but I also live with a chronic disease. But sometimes a shift in perspective leads to a shift in understanding. If pain cannot be eliminated completely–if there is no zero on the pain scale–than pain is the norm and not the exception.

Maybe this shift can help us all have more meaningful conversations about pain (especially pain in women) with our healthcare providers.

2. Assessments and expectations

“The physical therapist raises my arm above my head. “Any pain with this?” she asks. Does she mean any pain in addition to the pain I already feel, or does she mean any pain at all? She is annoyed by my question.”¹

This I relate to 100%. If I am always in pain, of course I’m going to feel pain when a doctor is poking and prodding me. One thing that makes rating pain so difficult is unclear expectations from healthcare providers. Then again, since pain is subjective, how can it be rated using a scale that healthcare providers read objectively?

I’ve experienced varying degrees of pain in my life, from the intense pain of surgical wounds to the radiating, full-body pain of a bad AS flare. And since I’m in pain all the time, I rate my pain on good days as a one. Would my good day pain be a one if I didn’t suffer from chronic pain? Is the doctor looking for me to describe unusual pain or usual pain, or both?

3. My pain in comparison to…?

“Assigning a value to my own pain has never ceased to feel like a political act.” …and…“The problem with scales from zero to ten,” my father tells me, “is the tyranny of the mean.”...I understand the desire to be average only when I am in pain. (1)

Biss makes this point over and over again in her essay–that pain does not exist in a vacuum, that as social beings, we’re rating our pain in comparison to the pain of others. Her constant circling back to this point makes me think it’s one of the most difficult aspects of the pain scale to grapple with.

I feel that too, as I sit in a doctor’s office trying to determine if a three is too high on the pain scale for this incessant back pain. Is a five too high of a rating for the costochondritis that makes me jump with even the slightest touch? Would someone with a more advanced disease rate this pain lower on the scale, or higher?

While we’re supposed to rate our own pain on its own merit, the medical field always compares experience to arrive at conclusions. It’s all so confusing.

4. Believing declarations of pain

“I walked out of a lecture on chronic pain after too many repetitions of the phrase, ‘We have reason to believe that you are in pain, even if there is no physical evidence of your pain.’ I had not realized that the fact that I believed myself to be in pain was not reason enough.”¹

And here it is…that moment when something I’ve thought about tirelessly is put into words in a way that helps me see the issue differently: “I had not realized that the fact that I believed myself to be in pain was not reason enough.”¹ I don’t know where or when it became difficult to believe expressions of pain. Is this a gender problem, signifying a cultural reluctance to believe pain in women? Is this an empirical problem dating back to the scientific revolution, where voiced pain is less credible than pain associated with a bleeding wound?

Whatever the root cause of the unbelievability of pain sufferers, it’s undeniable how something gets lost in the translation of pain from experience to a quantifiable, objective language. Our pain is ours, and no one else can feel it to understand it. But treatment depends on putting our pain into a language that others comprehend. That seems to me the impossible task of the writer or any other doer of language. And still, I cannot figure out how.