In recent years, the societal and personal impacts of pain, and the fact that we still lack an effective method of treatment, has motivated researchers from diverse disciplines to try to think in new ways about pain and its management. In this paper, we aim to develop an enactive approach to pain and the transition to chronicity. Two aspects are central to this project. First, the paper conceptualizes differences between acute and chronic pain, as well as the dynamic process of pain chronification, in terms of changes in the field of affordances. This is, in terms of the possibilities for action perceived by subjects in pain. As such, we aim to do justice to the lived experience of patients as well as the dynamic role of behavioral learning, neural reorganization, and socio-cultural practices in the generation and maintenance of pain. Second, we aim to show in which manners such an enactive approach may contribute to a comprehensive understanding of pain that avoids conceptual and methodological issues of reductionist and fragmented approaches. It proves particularly beneficial as a heuristic in pain therapy addressing the heterogenous yet dynamically intertwined aspects that may contribute to pain and its chronification.

We propose a new conceptualization of pain by incorporating advancements made by phenomenologists and cognitive scientists. The biomedical understanding of pain is problematic as it inaccurately endorses a linear relationship between noxious stimuli and pain, and is often dualist or reductionist. From a Cartesian dualist perspective, pain occurs in an immaterial mind. From a reductionist perspective, pain is often considered to be “in the brain.” The biopsychosocial conceptualization of pain has been adopted to combat these problematic views. However, when considering pain research advancements, paired with the work of phenomenologists’ and cognitive scientists’ advanced understanding of perception, the biopsychosocial model is inadequate in many ways. The boundaries between the biological, psychological, and social are artificial, and the model is often applied in a fragmented manner. The model has a limited theoretical foundation, resulting in the perpetuation of dualistic and reductionist beliefs. A new framework may serve to better understand and treat pain. In this paper, we conceptualize pain as a 5E process, arguing that it is: Embodied, Embedded, Enacted, Emotive, and Extended. This perspective is applied using back pain as an exemplar and we explore potential clinical applications. With enactivism at the core of this approach, pain does not reside in a mysterious immaterial mind, nor is it an entity to be found in the blood, brain, or other bodily tissues. Instead, pain is a relational and emergent process of sense-making through a lived body that is inseparable from the world that we shape and that shapes us.

Qualitative research approaches under the umbrella of phenomenology are becoming overly prescriptive and dogmatic (e.g., excessive and unnecessary focus on the epoché and reduction). There is a need for phenomenology (as a qualitative research approach) to be renewed and refreshed with opportunities for methodological flexibility. In this process paper, we offer one way this could be achieved. We provide an overview of the emerging paradigm of post-cognitivism and the aligned movement of enactivism which has roots in phenomenology and embodied cognition. We argue that enactivism can be used as a flexible resource by qualitative researchers exploring the unfolding of first-person (subjective) experience and its meanings (i.e., the enactive concept of sense-making). Enactive approaches are commonly tethered to “E-based” theory, such as the idea that sense-making is a 5E process (Embodied, Embedded, Enacted, Emotive, and Extended). We suggest that enactivism and E-based theory can inform phenomenological research in eclectic and non-prescriptive ways, including integration with existing methods such as observation/interviews and thematic analysis with hybrid deductive-inductive coding. Enactivism-informed phenomenological research moves beyond methodological individualism and can inform novel qualitative research exploring the complex, dynamic, and context-sensitive nature of sense-making. We draw from our enactive study that explored the co-construction of pain-related meanings between clinicians and patients, while also offering other ways that enactive theory could be applied. We provide a sample interview guide and codebook, as well as key components of rigor to consider when designing, conducting, and reporting a trustworthy phenomenological study using enactive theory.

Key words: phenomenology, enactivism, enactive approach, embodiment, qualitative research