Posts Tagged ‘teaching’

Explain Pain and the hunt for better outcomes

June 26, 2013

Some people instantly understand and run with the powerful therapeutic benefits of pain stories – for some, the stories are easy to deliver, gratefully received and a useful knowledge enrichment follows.
But for others, the stories are rejected, the patient looks confused, and angry, saying things like “how dare you suggest it has something to do with my brain” or “yeah, but my pain is different to the one you are telling me about”.  At NOI, we try different metaphors, stories, educational applications and contemplate variables impacting on whether they “get it” from multiple domains – that of the deliverer, the learner, the message and the social context. Prompted by recent work from educational psychologists (Chi, Roscoe et al. 2011), we are increasingly aware that an important variable may be whether the learner and the deliverer have emergent neurosignatures in their brains.

Emergent neurosignatures?
A neurosignature (schema, mental framework) is a body of knowledge in the brain constructed by a pattern of brain cell activity.  Emergence is something which “just happens” or appears to just happen – examples are applause, consciousness, diffusion, traffic jams, ants’ nest activity, bankruptcy, and erosion. Emergence, or emergent patterns are things that occur, often surprisingly, when a collection of objects interact with each other in complex ways.  The ‘objects’ might be water molecules, neurones, insects, animals, humans, cars, or clouds.  The patterns or phenomena that emerge could be a snowflake, a thought, a swarm, a herd, a crowd at a water fountain during a music festival in summer, a traffic jam or weather.

The players or agents (eg cars in traffic jams, neurones in consciousness) in an emergent pattern have reasonably equal status, the overall outcome emerges from the combined and simultaneous activity of the agents and just a small action of one of the agents can have disproportionate effects. For example, the actions of just one car may set off a massive traffic jam, but it still requires all agents (e.g. all cars, road conditions, weather, drivers, time of year etc.)  to make the traffic jam. Take erosion – many factors contribute, but then the whole bank of a river could give way with normal water flow.

Love, fear and movement are emergent. So is pain – sometimes a tiny event, perhaps a thought, can kick off a nasty and chronic pain. Some historical events like the fall of the Berlin Wall are also emergent. To deeply understand emergent patterns, you probably require emergent neurosignatures (schemas, mental frameworks) in your brain.

I would like to suggest a hypothesis that patients might never understand the pain process because they (and maybe you) may not have emergent neurosignatures in their brains. Why is this worrying? And how do we fix it? Read on.

Sequential and linear patterns
Other patterns and processes in our lives are more sequential and linear – moon phases, the circulatory system, tissue healing, mitosis, the digestive system, and most childhood stories. There is often a dominant initiating process and the sequential nature means that something has to happen and perhaps be completed before the next phase. You eat then swallow then digest. You sprain a ligament, it inflames, swells and remodels. Sequential patterns are usually more easily understood than emergent patterns.

Did you “wipe out” in high school science?
Conceptual change theorists and researchers such as Chi (Chi, Roscoe et al. 2011) have studied emergence in high school science students. Such students are known to have problems when they learn about processes that are emergent (diffusion, electricity, natural selection) – sequential patterns are usually less problematic (apparently nearly 10,000 papers exist on this topic!).  It has been suggested that these students may not have emergent neurosignatures/schemas in their brains, or that perhaps their emergent signatures may be dormant. If you try to understand and problem-solve processes that are emergent by using linear/sequential neurosignatures you will have trouble. Now I know why some parts of high school chemistry and physics were disasters for me!

Emergence and “Explain Pain” as therapy
This is likely to have great relevance for our pain education.

Do you ever wonder about patients (and colleagues) who just can’t get it? When a patient is totally fixated on a singular cause (perhaps a single piece of anatomy – “the bloody disc” or blame one person, “the bloody supervisor”) for a complex chronic pain state?

Or those who seem to know a lot about a lot of things, but can’t pull it all together, i.e. can’t ‘see the wood for the trees’?? Maybe they don’t have emergent schemas. When I mark assignments where the question requires some understanding of emergence (e “Describe pain as a brain output rather than an input”) some students are all over the place with piecemeal answers, others can pull it together – maybe they have emergent schemas?  With pain, of course, there will be many agents and contexts which simultaneously merge for the emergent output.

Did you ever think how sometimes you are educating about tissue healing (a linear sequential process) and then jump to a discussion on pain or cognitions (emergent) and as we mentioned earlier, see the patient’s eyes glaze over. Again, think about the patient who insists there is a singular cause/blame for a complex problem and can’t see any other possible contributions?

Maybe we need to teach our patients about emergence? Maybe we need to try to work out if they have emergent schemas first?  Emergence modules are now being trialled in the “Explain Pain” course.

Tim Cocks and I have discussed emergence, pain and education in greater depth in the blog post on

We are very keen to hear your thoughts there.

Chi, M. T. H., R. D. Roscoe, et al. (2011). “Misconceived causal explanations for emergent processes.” Cognitive Science 36: 1-61.