“But, I have real pain”: When Ethics Collides with Ontology

No doubt, the words of this title have been uttered countless times by countless people with chronic pain. In my work in chronic pain rehabilitation, someone tends to say it to me most everyday. It often comes when discussing the effectiveness of chronic pain rehabilitation, which focuses on coaching people how to self-manage pain. A patient, say, gets referred to our chronic pain rehabilitation program, but the patient believes that it would be better to seek care elsewhere, such as with a spine surgeon, or an interventional pain clinic where spinal injections get performed, or at a clinic that provides long-term prescriptions of opioid pain medications. In such cases, I might make the recommendation that, as long as one is willing to learn how, self-management is an effective treatment option, even in many cases the most effective option. Nonetheless, the patient responds, “But, I have real pain.” The phrase, “I have real pain,” in these instances tends to justify the use of procedural-based medical care, which becomes opposed to seeking self-management based care, as if real pain could never be self-managed and so requires medical or surgical procedures or narcotic pain medications.

Still other times, the phrase “But, I have real pain” gets expressed when I talk to patients about the role of the nervous system in the cause of chronic pain. In chronic pain rehabilitation, we routinely discuss this role of the nervous system because it provides a scientifically accurate rationale for why self-management is effective: the self-management strategies that patients learn in chronic pain rehabilitation reduce pain and increase coping by targeting the nervous system and making it less and less reactive over time. So, we subsequently review with patients why it’s important to therapeutically target their nervous systems: it’s because pain is the product of a two-way communication between the nerves in the painful area and the spinal cord and brain. It’s not uncommon for patients to react to such discussion by retorting, “But I have real pain.” This response expresses disagreement with the overall conversation and alludes to a different way that they understand the nature of their pain. People often go on at this point to explicitly state their understanding of, say, back pain by emphasizing an orthopedic model of pain – something, like, “My surgeon said it was because my discs are degenerating.”

It’s not just patients who say it too. Providers commonly use the phrase as well. Most often, I suppose, providers say a variation of it to patients as a form of reassurance. “I know you have real pain” is a frequently necessary form of reassurance, letting patients know that they are believed. Countless times in case conferences, too, where the overall plan of care is discussed among a team of different providers, the phrase gets used, particularly when a case is discussed in which the orthopedic basis of pain can’t be found. An all-too-common example might be a patient who presents with chronic low back pain, but the MRI of the lumbar spine shows nothing that might reasonably be the cause of pain. In such cases, providers often profess, “I know he [i.e., the patient] has real pain, but the scans are normal…”

meaning of painWhat, though, does this phrase really mean? When we use the phrase ourselves or when we hear it, we tend to respond in the course of the conversation as if nothing out of the ordinary was just said. That is to say, we understand the phrase and subsequently move on without ever giving it a moment’s notice. But, if we were ever stopped and asked to explain what in fact we mean by the phrase, it gets a little difficult to actually put it into words.

What does it mean?

We might first notice that in the phrase, “But I have real pain,” the use of the word “real” would seem to be drawing a contrast. Specifically, at first blush, it seems to be contrasting the present “real pain” with pain that is… what… not real? Therein lies the problem. What might we ever mean by “unreal pain”? It’s a phrase we never use, not at least at any time I have ever heard or come across, and even if we did it would seem unclear as to what we might mean.

Pain is an experience that we either have or don’t have. Sometimes, we have a little pain and sometimes we have a lot of pain, but in either case, it is something we either have or don’t have. In what circumstances might we ever have a pain that is unreal, which doesn’t mean we have actual pain, but means something other than having no pain? It’s as if “unreal pain” lies somewhere within a never-never land between either having pain and not having pain.

So, on the face of it, it doesn’t seem to make sense to emphasize that one’s pain is “real” if the contrast that we draw by using it doesn’t make any sense. In other words, to contrast “real pain” with something that doesn’t make sense, something that’s really a nothing, is to say that we don’t really need to use the adjective “real” in the first place.

We might thus conclude, all pain is pain and call it a day.

Not the end of the story

Perhaps our analysis thus far is mistaken. Specifically, we may have mistakenly assumed that words have meaning only when they refer to something. In our analysis, we recognized that the adjective “real” in the phrase “real pain” appears to contrast with something, but we can’t find anything that the contrast “unreal pain” refers to. So, we came to the conclusion that the adjective “real” adds no value. Real pain is just pain, we concluded, so we might as well drop the adjective.

This tack would likely make us all uncomfortable for it really does seem like we are Real Painmeaning something important when we say, “I have real pain.” So, to keep looking for what we might mean by the phrase, we might recall Wittgenstein’s famous dictum that the meaning of words lie in their common everyday use (1953). He recognized that language doesn’t have universal referents in all times and places, but rather language can be and is more idiosyncratic than that. Words have particular uses in particular times and places. Language, of course, doesn’t run amok because people are similar enough and live in similar enough ways that we more or less can understand each other, despite the particularities of word uses. So, the meaning of words lie in their use and, sometimes, this use refers to things, but sometimes words have meaning in other ways. Perhaps, the phrase “real pain” is meaningful in one of these other ways.

I think we hit upon this use earlier in the introduction to this essay. The phrase “real pain” doesn’t refer to some special type of pain as much as it’s used to provide reassurance that others believe that one in fact has pain.

No one wants to be called or even considered a faker. There are times when others, such as family members or healthcare providers or employers or defense attorneys might consider whether the person who reports having pain is really faking that they have pain. In such circumstances, patients might assert, “But I have real pain” or still others might come to their defense by asserting that the patients have “real pain.”

Thankfully, such situations are not daily affairs for most people with chronic pain or for most providers in pain clinics. However, the phrase gets used much more commonly, even, as I suggested in the introduction, almost daily. So, there must be other uses – other ways of gaining reassurance by the phrase, “real pain,” even when no one is accusing anyone of faking.

Maybe, the use of the adjective provides a sense of legitimacy to one’s pain. In this way, perhaps it really is drawing a contrast between types of pain: pain that society tends to see as legitimate and pain that society doesn’t. What people defend against, then, when they use the phrase, “But I have real pain,” is stigma.

When stigma raises its ugly head

Patients and providers alike can tend to use the phrase “real pain” when emphasizing the legitimacy of one’s pain and any problems in functioning associated with it. “Real pain” is thus the contrast to the “it’s-all-in-your-head” type of pain. If you have trouble coping or are disabled from “real pain,” you get a pass. People tend to understand and allow you to stay home from work or allow you to be down about it and have a good cry. If, however, you have trouble coping or are disabled from the “it’s-all-in-your-head” type of pain, well, there’s no free pass for you. It’s time to ‘buck up and deal’ instead. No one excuses it when you stay home from work or sees your depressed tears.

Like “real pain,” though, the “it’s-all-in-your-head” type of pain is a bit slippery when attempting to define it. We all know what it means when we say it or hear it, or at least we think we do. Nonetheless, it’s hard to actually put it into words.

We tend to associate the “it’s-all-in-your-head” type of pain with stress-related pain. In chronic pain rehabilitation, we routinely review the importance of stress management when it comes to self-managing pain, but it’s not uncommon for patients to dismiss the relevance of the topic with the assertion, “But I have real pain.” Indeed, at times, we might be tempted to think they are on to something. For, at first blush, pain caused by stress and tension doesn’t seem as real as pain that occurs in relation to clearly identifiable tissue damage. Thus, our initial reaction is that the pain we feel when stepping on a nail seems somehow more real than the gut ache of the child who’s nervous about starting school tomorrow or the headache we might have after a bad day at work. From this light, real pain is pain caused by tissue damage, something that has nothing to do with stress. Stress is involved in the other type of pain, that not-as-real pain, which we refer to as the “it’s-all-in-your-head” type of pain.

An impasse?

But we might then think about what we just said for a minute. In so doing, it might slowly dawn on us that we’ve had a tension headache before, as have most people who have ever been alive on earth. Those tension headaches seem pretty real – that is, pretty painful. The telltale signs of a tension headache are descriptions like “pounding” and “vice-like.” Those descriptions even sound painful… truly painful… or might we say like real pain.

And of course it is. Anyone who has ever had a tension headache knows that it is really painful. You have a long and difficult day and as a result your head is pounding. You reach for the ibuprofen and lay down on the couch or just go to bed outright. You can’t really argue that a tension headache isn’t “real pain.”

Even in cases where pain is associated with identifiable tissue damage, stress makes it worse. When you stub your toe in the course of a lengthy argument with your spouse, the very “real pain” you have hurts worse than when you stub your toe during a really fun party or when watching an exciting football game. It doesn’t take a rocket scientist to tell you that stress makes the “real pain” of chronic conditions worse too. All it takes is the average person with rheumatoid arthritis. Here we have a condition that causes “real pain” and which is associated with clearly defined tissue damage and stress still makes that “real pain” more painful.

pain is painSo, now what do we do? We thought we were on to something. We thought we had found the meaning of the phrase “real pain.” We thought it’s that kind of pain which is associated with tissue damage and which differs from the stress-related “it’s-all-in-your-head” type of pain, but we now see that stress-related pain produces just as real pain as “real pain.”

We thus seem stuck. It seems so obvious that we know what it means when we use the phrase “real pain,” but it seems like we can’t define it. Can we, then, say that we know what it means?

Maybe, we have just come full circle (pun intended) to the tautology that all pain is pain.


Wittgenstein, L. (1953). Philosophical Investigations. New York: MacMillan.


Author: Murray J. McAllister, PsyD

Date of last modification: 9-20-2015

2 thoughts on ““But, I have real pain”: When Ethics Collides with Ontology

  1. Pain vs. Unreal Pain

    I used to think that pain was when you had to try and sew your face back together because you we’re clotheslined by a barb wire fence. Lacerations we’re irrigated with alcohol and when the stitches kept ripping through the skin you had to resort to butterflies to pull the cuts together(still have a perfect cross on the bridge of my nose). Or how about driving a pipe into your arm and the only thing that stopped it was your ulna (scar). Or dislocating your shoulder and having to drive it back in using a wall (Mel Gibson was a life saver).

    My dad was former Army Intelligence so you can imagine the childhood I had growing up in a home where you don’t show pain. You fight it. All of the prior instances I just listed as well as many others didn’t require tears, or yelling, or passing out. They required focus. You take pain by the throat and you swallow it till you get the job done. This state of mind helped me tremendously and as a former Marine, bodybuilder, martial artist & retail store manager I’m sure you can understand that I speak from experience.

    This isn’t about me telling you how tough I was because humility is the backbone of being a good Samaritan as well as a Christian. You see all these things ended for me when I became mysteriously ill several years ago.

    Prior to getting sick I was training 3-4 times a week (free weights, machines, bag work, etc) at an hour a clip. My 6 year old son was playing soccer and I had just started to train him in self-defense. My work week was generally 50-60 hours depending on the work load with my days running in the 10-12 hr range (90% was spent on my feet). My wife also worked so there would be nights when I would cook dinner, do laundry, mow, wash the car, etc (everything a good husband/father should do) My down time was usually spent on the computer gaming at night.

    I started getting sick in March with what I thought was a cold and finally ended up going to the clinic in April. At this point I had to stop working out. The doctors started and kept feeding me ab’s for a couple months while my health rapidly deteriorated until finally I raised a concern that it might be fungal. I was right. Pretty lame when doctors won’t take the time to run the proper tests because if they had I probably wouldn’t be in the mess I am today. The only saving grace I have was the fact that if I hadn’t been in the shape that I was prior to the infection I more than likely would have been dead.

    For nearly 5 months I continued to work 50+ hours a week while all this was going on because the doctors didn’t think it was serious. I started having periods of extreme fatigue where my heart would race and I would experience sensations of vertigo. I was always able to power through in the beginning, but then it started to become harder to make it through a days work on top of being a ft husband/father.

    It all ended with me collapsing in my store with my heart racing to the point of nearly blowing out(file cabinets made a nice landing). I was completely drenched and weaker than a newborn. A week later I blacked out in my car due to extreme vertigo/nausea (fortunately parked). The doctors finally pulled me from work. What ensued afterwards can only be described as a journey into neurological insanity. Heart cath was clear (doctors comment was that I had the heart of a race horse). MRI of the brain showed a lesion on the right frontal lobe (even the doctors at the Mayo couldn’t explain it). Blood test after blood test after spinal tap (Protein level was high, but no one could explain why except possible mycotoxins-remember the mold?) after failed prognosis’s again and again and again. Cardiologists, neurologists, endocrinologists, rheumatologists, chiropractors, etc. and while this was going on my body literally deteriorated before my eyes. The muscles in my body began to jump. Motion sensitivity became so bad I couldn’t even sit on a raft in the pool let alone ride in a car. I began to lose sensation to both touch (numb), taste (ever stick your tongue on a 9volt battery?), feeling (imbalance & unsteady), sight (blurry at times), relate (thought processes are slow), reflexes (loss of use in extremities) and just about everything else but hearing. Sleeping became nonexistent. I began blacking out on a regular, but random basis and what once was strong was replaced with sickening fatigue to the point that I couldn’t even get out of bed at times and to top it all off my body started to burn and swell as if it was on fire starting from the back of my head to the bottom of my feet. There we’re and still are times when electricity seems to course throughout my body in conjunction with the burning. I had to resort to using a cane to try and ease the pressure on the bottom of my feet/joints as well as giving myself balance. There we’re times that the pain coursing from the back of my head (I have a pretty good idea of what it would feel like to get hit by a cattle prod from the inside of the brain) and running throughout my body left me literally curled up on the floor crying out for God to have mercy on me (And yes I was crying). The painkillers that the competent doctors prescribed for me (Lortab/Lyrica) didn’t even come close to touching it and when I called them to relate what happened to me they responded by saying that they couldn’t prescribe anything stronger. Idiots…I wasn’t asking for more meds: I was concerned for my life. Needless to say I contacted a lawyer to have my last will and testament drawn up after that incident. Daily activities became a struggle. I would try and help my wife with laundry, still try to mow the yard (what once took me and hour now took days), etc; but when ever I would do this I ended up in bed sometimes for days fighting a sickening fatigue and a firestorm of pain. In fact the pain began progressing from my extremities and upward into my joints. It became hard to use my hands at times due to the numbing pain. My heart would literally seize up at times just from taking a simple shower to the point that it felt like an EMP went off. (effects from that lasted nearly a month). Pain would literally shoot through my legs and arms to where I began to yell out. My body would literally jerk involuntarily for no reason as well as my extremities. I could go on and on about the metamorphosis that my body underwent and still go’s through today, but I’m sure you get the picture by now. In the 2 years that ensued I learned not to do a lot of things that I used to take for granted every day (like breathing).

    I got bounced from clinics to universities for 2 years even visiting Vanderbilt University until I finally landed at the Mayo in Florida. After several weeks of tests their final diagnosis was CSS. My wife and I looked at each other thinking what the heck is that. The doctors description was almost spot on with what I had been going through and the illness that took my body 2 years ago was the trigger that sent my brain over the edge to a pain that I never knew could exist. He described it as fibromyalgia on crack (I remember a customer that I used to help that had fibromyalgia. You definitely knew when she was having a bad day and I felt so sorry for her and would do what I could for her when she was in that condition). Well after 2 years we finally had a name. Now I needed a cure which the doctor quickly halfheartedly gave. No cure. WHAT? How can there be no cure to an unending, UNREAL PAIN that never stops (not even on holidays). We we’re told that I would basically have to live the rest of my life in a bubble meaning no stress (physical or mental) because even the most minute action could set it off (tell me about it). The only thing they had to offer was a 3 week course teaching you to live with it. All of the doctors, tests, time, miles, research, etc, etc, etc …all for nothing. I appreciated all of the doctors & nurses at Mayo for their time and they did at least give us a diagnosis, but I had already had 2 years of learning to live with it and I simply didn’t want to spend a fortune on how to learn to live with a pain that apparently decided to make best friends with me. That was 4 months ago and unfortunately nothing has changed. I live with a pain. A very UNREAL PAIN that defies logic at times. I spoke with other doctors regarding a cure and they all told me the same thing. I used to get mad when I had to take Excedrin for a headache. I now am on a daily regiment of Gabapentin and Lortab (Ohhhh boy!). Am I happy about that? Absolutely not. I look back at the doctors that would ridicule me in the beginning. Oh he’s just looking for a free ticket, or he just has a headache, what a whiner, etc. I’ve just about heard and seen it all when it comes to this… (It’s bad enough that my wife and son have to see what I’ve become knowing what I once was). I still get discounted today even with the diagnosis from the Mayo when I see doctors however I did have one doctor actually apologize to me once he realized the pain I was experiencing was actually real.

    My life today is a sedentary life. I can’t work, or workout, or play with my 9 year old son, or take my wife on an exciting vacation (I’m afraid that doesn’t work anymore either-humiliating). Oh I still try to do things knowing what’s going to happen afterwards, but I was raised to fight and not back down regardless of what you face in life even if it means risking it.

    I guess what I’m trying to say is that there are thousands of people suffering from REAL pain. All you have to do is read the blogs and do the research to know this and I feel for these individuals who are treading the same path I was and still am. They are literally begging for help (like myself) and getting a cold shoulder in return. Some will never get an answer because their doctors are only interested in making a name for themselves and could care less if their patient is suffering from pain (Have you seen the new Lambo’s? Awesome!!!).

    Anyway…back to my point. For you to categorize pain in your article the way you did makes me wonder what you truly think of your patients. There is pain and there is PAIN. And then…there’s UNREAL PAIN. I know because I live with it everyday of my life and to all of you who are taking the time to read this and are suffering from PAIN you get in your doctors face and demand that they put their Iphone down and do their job. They took an oath right? It’s time they started to live up to it instead of pushing their drugs so they can get kickbacks from the pharmaceutical companies and milk our insurance companies. I’ve got about a 12″ stack of medical files from the last 2 years to prove that doctors rarely know what their talking about (I had one cardiologist trying to convince me I had Brugada’s Syndrome and wanted to do an EP. By the way I’m Caucasian). I would still be in limbo today not knowing if I was going to live or die had I not got in my doctors face and demanded action. We don’t need your empathy, or your smirks, or your thoughts, or your drugs. We want you to help us to deal with our reality (something I hope you or anyone else never experiences). I used to be a very patient, fun loving, caring, outgoing, funny guy. My smile is now often replaced with a grimace and I find myself retreating for the first time in my life to a home that has now become my prison.

    I’m done. Hopefully you will read this with a salt shaker, but anger is quick to rise in me now especially when I read articles such as this. My prayers go out to those who truly suffer from PAIN and also to those who hopefully are there to truly treat this pain we face today, tomorrow, and the rest of our lives. Good Night and God Bless.

    • Hi Eric,

      Thank you for your heartfelt and honest thoughts about the post. I work in chronic pain rehabilitation, which is the branch of chronic pain management that specializes in the treatment of central sensitization syndromes. So, everyday, we see folks like you, good people, who are suffering tremendously. I say this as way to try to show you that I know your pain is real.

      In fact, in the post, I am arguing against people who would take the position that your pain is not real. I know that there are those who divide up people who have pain into two categories, those who have real pain and those who don’t. They often do so on the basis that ‘real pain’ is pain due to tissue damage of some kind. So, for those whose pain is due to the nervous system, and not tissue damage, they get considered as having not real pain. It is this position that I object to with my arguments in the post.

      In other words, what I try to show in the post is that this distinction between ‘real’ and ‘unreal’ pain makes no sense and so all pain is pain, no matter what its source. Thus, we should never consider anyone’s pain as ‘unreal’ — not your pain or anyone else’s pain. I hope that helps to provide some clarification.

Leave a Reply