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"Cultural Components in Responses to Pain" by Mark Zborowski

 The ways that we respond to illness are strongly influenced by
 cultural factors. In this article, Mark Zborowski shows that even
 the physical sensation of pain is often interpreted differently by
 members of different American ethnic groups who tend to respond to
 their discomfort in terms of the meanings that they have learned in
 their own families.

 Some Basic Distinctions

 In human societies biological processes vital for man's survival
 acquire social and cultural significance. Intake of food, sexual
 intercourse or elimination - physiological phenomena which are
 universal for the entire living world - become institutions
 regulated by cultural values and social rules.... Human beings
 experience hunger for food and sexual desire, but culture and
 society dictate to the kind of food people may eat, the social
 setting for eating or the adequate partner for mating.

 Moreover, the role of cultural and social patterns in human
 physiological activities is so great that they may in specific
 situations act against the direct biological needs of the
 individual, even to the point of endangering his survival. Only a
 human being may prefer starvation to the breaking of a religious
 dietary law or may abstain from sexual intercourse because of
 specific incest regulations. Voluntary fasting and celibacy exist
 only where food and sex fulfill more than strictly physiological

 Members of different cultures may assume differing attitudes towards
 these various types of pain. Two of these attitudes may be described
 as pain expectancy and pain acceptance. Pain expectancy is
 anticipation of pain as being avoidable in a given situation, for
 instance, in childbirth, in sports activities or to battle. Pain
 acceptance is characterized by a willingness to o experience pain.
 This attitude is manifested mostly as an inevitable component of
 culturally accepted experiences, for instance, as part of initiation
 rites or part of medical treatment. The following example will help
 to clarify the differences between pain expectancy and pain
 acceptance. Labor pain is expected as part of childbirth, but while
 in one culture, such as in the United States, it is not accepted and
 therefore various means are used to alleviate it, in some other
 cultures, for instance in Poland, it is not only expected but also
 accepted, and consequently nothing or little is done to relieve it.
 Similarly, cultures which emphasize military achievements expect and
 accept battle wounds, while cultures which emphasize pacifistic
 values may expect them but will not accept them.

 In the process of investigating cultural attitudes toward pain it is
 also important to distinguish between pain apprehension and pain
 anxiety. Pain apprehension reflects the tendency to avoid the pain
 sensation as such, regardless of whether the pain is spontaneous or
 inflicted, whether it is accepted or not. Pain anxiety, on the other
 hand, is a state of anxiety provoked by the pain experience, focused
 upon various aspects of the causes of pain, the meaning of pain or
 its significance for the welfare of the individual.

 Moreover, members of various cultures may react differently in terms
 of their manifest behavior toward various pain experiences, and this
 behavior is often dictated by the culture which provides specific
 norms according to the age, sex and social position of the individual.

 The fact that other elements as well as cultural factors are
 involved in the response to a spontaneous pain should be taken into
 consideration. These other factors are the pathological aspect of
 pain, the specific physiological characteristics of the experience,
 such as the intensity, the duration and the quality of the pain
 sensation, and finally, the personality of the individual.
 Nevertheless, it was felt that in the process of a careful
 investigation it would he possible to detect the role of the
 cultural components in the pain experience.

 The Research Setting

 With these aims in mind the project was set up at the Kingsbridge
 Veterans Hospital, Bronx, New York, where four ethno-cultural groups
 were selected for an intensive study. These groups included patients
 for Jewish, Italian, Irish and "Old American" stock. Three groups -
 Jews, Italian, and Irish - were selected because they were described
 by medical people as manifesting striking differences in their
 reaction to pain.

 Italians and Jews were described as tending to "exaggerate" their
 pain, while the Irish were often depicted as stoical individuals who
 were able to take a great deal of pain. The fourth group, the "Old
 Americans," were chosen because the values and attitudes of this
 group dominate in this country and are held by many members of the
 medical profession and by many descendants of the immigrants who, in
 the process of Americanization, tend to adopt American patterns of
 behavior. The members of this group 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

 The Kingsbridge Veterans Hospital was chosen because its population
 represents roughly the ethnic composition of New York City, thus
 offering access to a fair sample of the four selected groups, and
 also because various age groups were represented among the
 hospitalized veterans of World War l, World War ll and the Korean
 War. In one major respect this hospital was not adequate, namely, in
 not offering the opportunity to investigate sex differences in
 altitude toward pain. This aspect of research will be carried out in
 a hospital with a large female population.

 In setting up this project we were mainly interested in discovering
 certain regularities in reactions and attitudes toward pain
 characteristic of the four groups. Therefore, the study has a
 qualitative character, and the efforts of the researchers were not
 directed toward a collection of material suitable for quantitative
 analysis. 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 case
 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, because in
 terms of the original hypothesis those attitudes and reactions which
 are displayed by the patients of the given cultural groups are held
 by all members of the group regardless of whether or not they are in
 pain although in pain these attitudes may come more sharply into
 focus. In certain cases the researchers have interviewed a member of
 the patient's immediate family in order to check the report of the
 patient on his pain experience and in order to find out what are the
 attitudes and reactions of the family toward the patient's experience.

 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 ethno-cultural
 background the respondents are distributed as follows: "Old
 Americans," 26; Italians, 24; Jews, 31; Irish, 11; and 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.

 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
 culture 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 though
 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
 which 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 which
 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 which 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 which may cause the pain. Nurses and doctors have
 reported cases in which patients would hide the pill which 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 though 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 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 lend to describe the behavior of the Italian and
 Jewish patient as exaggerated and overemotional. The material
 suggests that they do tend to minimize the actual pain experience of
 the Italian and Jewish patient regardless of whether they have the
 objective criteria for evaluating the actual amount of pain which
 the patient experiences. It seems that the uninhibited display of
 reaction to pain as manifested by the Jewish and Italian patient
 provokes distrust in American culture instead of provoking sympathy.

 Despite the close similarity between the manifest reactions among
 Jews ad 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 trails 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 within the family. Though 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, asks 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
 the pathological cause 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 reactive patterns of the Jewish
 and Italian patients, the material suggests that on a semi-conscious
 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 towards 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 ethno-cultural 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 among "Old
 American" patients. Their complaints about pain can best be
 described as reporting on pain. In describing 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 an 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. This 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" on the ward. He seems to be, more than any other patient,
 aware of an ideal pattern of behavior which 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 which 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

 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 which 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 wit h 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.

 Though 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 functions and by the
 confidence in the skill of the expert which are so frequent in the
 American, in that the body is often viewed as a machine which has to
 be well taken care of, be periodically checked for dysfunctioning
 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 though 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, X-rays, 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 which 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 Intra-Group Variation

 In the description of the reactive patterns and altitudes 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 which causes the
 pain or to elements of the personality of the patient. However,
 there are also other factors that are instrumental in provoking
 these differences and which can still be traced back to the cultural
 backgrounds of the individual patients. Such variables as the degree
 of Americanization of the patient, his socio-economic 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 further 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 which 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 the 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

 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.