# Motivation and emotion/Book/2024/Pain and motivation

* Multimedia presentation (3 min)

## Overview

* Case study - Amanda's chronic back pain
* Figure 2. Pain can interfere with daily activities.
* Amanda deals with chronic back pain from a gym injury she got a year ago. Having worked at a cafe for the last couple of years, she feels a constant ache in her spine. Over-the-counter medication isn't enough to dull the pain and walking around serving customers is becoming something Amanda is starting to dread. She feels that her pain is inescapable, and that there's nothing she can do about this situation.
* She used to serve with a smile, but with each passing day she struggles to muster up the motivation to be cheery towards others. Her boss has noted her newfound lack of enthusiasm at work and has given her an official warning.
* Amanda isn't sure what to do and she feels helpless.
Almost everyone has experienced pain at some point in their life to varying degrees, and for those who have experienced pain, many have experienced the feeling of relief when the pain has gone away or lessened. While most people have experienced pain, what we may not necessarily realise is how many different kinds of pain we may experience, pain's relationship with our motivational drive, and how pain can both positively and negative impact motivation. There are many ways that pain can influence an individual's life, in their daily activities and their overall drive. Pain is intrinsically tied with our motivation via encouraging living beings to return to the painless state of homeostasis and experience relief, causing us to learn to be helpless in situations of constant and inescapable pain, and to motivate us to protect ourselves from danger due to past painful experiences.
* Focus questions:
* What is pain and what is motivation?
* What's the relationship between pain and motivation?
* How does learning involve pain?
* How does pain positively and negatively impact motivation?

## What is pain?

The International Association for the Study of Pain describes pain is described as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage." (Raja et al., 2020). As a subjective sensory-emotional experience, pain is an experience that feels anywhere from uncomfortable to excruciating, processed consciously within the brain, and involves signals sent from various parts of the body (Chen et al., 2023). The experience of pain cannot be separated from the experience of the negative emotions that the sensation brings, as without the strong emotion there wouldn't be a severely aversive reaction (Becker et al., 2018). Pain is not just the cognitive perception of feeling hurt or injured, it is equally the experience of the aversive, discomforting emotions that follow a painful sensation.
Pain is signaled via special sensory neurons within the nervous system called nociceptors, and the job of these specialised cells can detect acute, fast pains as well as slow, widespread pains within the skin, joints, muscles, and visceral organs (Chen et al., 2023). Pain is felt in order to protect the body from being damaged or injured, [grammar?] it is essentially an adaptive survival mechanism that keeps living organisms healthy and as safe as possible (Chen et al., 2023; Navratilova & Porreca, 2014; Raja et al., 2020).

### Types of pain

According to Chen et al., there are several different kinds of pain, including:
* Acute pain: Pain that occurs at the location of an injury.
* Chronic pain: A pain which persists long term, normally beyond the normal healing time or for over several weeks. Often related to conditions or illnesses which cause either inflammation or an alteration to nerves. Can be influenced by external factors such as stress, the environment, one's emotional state, which may increase or decrease the amount of pain felt and it's persistence.
* Somatic pain: Pain which is felt in deep tissues or surface of body with many causes, one of the more common kinds of pain.
* Visceral pain: Pain felt in the visceral organs, such as the stomach.
* Neuropathic: Pain related to nerve damage.
* Allodynia: Pain resulting from something which normally does not cause pain, such as a feather.
* Hyperalgesia: Increased pain sensitivity or an extreme, exaggerated pain response.
* Referred pain: Pain that is felt at a different location on the body than the source of the injury or stimulation.

### Levels of pain

Because pain is a subjective experience, it is important to measure how much pain someone is in. To measure this, medical professionals often use pain scales, such as the one in Figure 3, in order to understand a patient's self-reported pain. The self-reporting of pain via is one of the best ways to describe pain since it is highly accurate and reliable, and self-reporting can be done regardless of age, communication ability, or disabilities. (Karcioglu et al., 2018). Pain scales can vary, some involve words and others only use facial expressions. Pain scales tend to range from a nonexistent or mild scale, to moderate and disruptive, to agonising and debilitating.

## What is motivation?

Motivation is best described as an internal process or state which drives goal-directed behaviour, both initiating the goal directing behaviour and sustaining it over time (Bin Abdulrahman et al., 2023; Morris et al., 2022; Simpson & Balsam, 2016). Essentially, individuals are driven by the feeling of motivation to begin behaviours which will result in achieving a goal, and they are internally encouraged to continue their behaviours. Motivation is both driven by internal states, such as a drive for hydration, hunger satiation, and sexual satisfaction, and influenced by the environment (Morris et al., 2022; Simpson & Balsam, 2016).
Additionally, there are two main kinds of motivation: intrinsic motivation and extrinsic motivation. The former is driven by the activity itself, where the individual is motivated to do an action or behaviour simply because. E.g "I enjoy sewing clothing because it is fun!". The latter is driven by an external reward, such as money. E.g "I enjoy sewing clothing because I can sell them!" (Morris et al., 2022). Intrinsic motivation is associated with better performance and mental health, while extrinsic motivation is associated with poorer mental health (Morris et al., 2022). This is because intrinsic motivation is internally rewarding. Intrinsic motivation comes from within, and is essentially guaranteed to be experienced from intrinsically motivating activities, while extrinsic motivation comes from rewards which are not always guaranteed at the end of an activity.

## The relationship between pain and motivation

* Case study - Amanda's learned helplessness
* Figure 5: Therapy can assist in un-learning maladaptive thinking patterns.
* Amanda was encouraged by her friend to see a psychologist. She was confused by her friend's request, since Amanda thought seeing a physiotherapist would be enough to resolve her back issue, but she entertains her friend's request anyway.
* After discussing her symptoms and experiences, she discovers that being in constant pain and working at a physically straining job has made her depressed. She also learned that she is experiencing something called 'learned helplessness', but her psychologist says she can un-learn her feelings of being trapped. Amanda learns she can 'learn optimism' and that she should begin to treat herself with more compassion.
* After several sessions, Amanda feels empowered and that she doesn't have to live like this anymore. She decides to look for a new job and enquire with a doctor about stronger medication for her injury.
Several theories can help explain the relationship between motivation and the subjective experience of pain including the theory of learned helplessness and the theory of operant conditioning. Both these theories focus on how pain teaches the body and mind about stimuli, situations, and others. Both theories integrate the relationship between motivation, or an absence of motivation referred to as amotivation, and the experience or expectancy of pain.

### Pain and learned helplessness

Pain is almost inherently unpleasant and something that living beings desire to avoid, escape from, fight against, and alleviate. However, individuals who experience frequent, constant, seemingly inescapable pain such as those with mood disorders or high stress (K. R. Scherer, 2022) or chronic pain (Mohamadi et al., 2021) experience a significant decrease in motivation to manage or avoid the pain and stress they're experiencing. Additionally, a study on self-compassion found that self-compassion can be used to reduce severity of stress and mental health conditions (Xue et al., 2023).
The original learned helplessness studies were conducted on dogs, with the use of shocks as a source of pain. (Seligman M.E, 1972). While some of the dogs were either not shocks at all as part of a control group, and other dogs had a lever they were taught to press to stop the shocks, the rest of the dogs quickly learned there was nothing they could do to escape the pain they were experiencing. In the second part of the experiment the dogs simply had to jump a fence to escape the pain, however the dogs who originally had no way to turn the shocks off didn't attempt to escape, and to un-learn this helplessness the experimenters had to physically show the dogs how to escape at least twice before all the dogs were jumping the fence (Seligman M.E, 1972). This experiment demonstrated how the experience on a constant, frequent inescapable pain can cause a living being, such as a dog, to become amotivated towards escaping their stressors or sources of pain.
Several follow up experiments have since been conducted on humans, and the majority have observed similar results in people as with the original dog experiment. A 2021 study involving individuals with chronic musculoskeletal pain found that learned helplessness lead to not [say what?] accepting the pain, and strongly impacted both the relationship with promoting better health and with handling distress (Mohamadi et al., 2021). Additionally, a study focused on mood disorders found that not only did stress affect overall emotional stability and increased the likelihood of developing an emotion disorder, they emphasised the concept of motivated helplessness which they described as a sense of helplessness which can serve as a paradoxical protective measure, keeping people from doing actions or continuing inactions to mentally protect themselves (Marques et al., 2022). Finally, a 2023 study on self compassion found that during the COVID-19 lockdown when mental health was rapidly deteriorating, being compassionate to oneself could improve the perception of control one has against threats and encourages adaptive coping mechanisms (Xue et al., 2023). Essentially, these studies emphasis that prolonged pain can lead to individuals believing they're unable to change the situation they are in or their circumstances, but that this negative viewpoint can be altered by introducing more positive, adaptive coping mechanisms. This implies that therapeutic measures such as cognitive behavioural therapy may be helpful in managing feelings of learned helplessness in regards to pain.

### Pain, operant conditioning, and homeostasis

Pain is a survival mechanism, and the majority of living organisms are motivated to both avoid pain and alleviate themselves when they are in pain. The theory of operant conditioning suggests that individuals learn about which behaviours lead to punishments or rewards, in regards to either the addition or the removal of a pleasant or unpleasant stimuli (Gatzounis et al., 2012). Essentially, a behaviour is a function of what consequence it brings. If a behaviour led to pain then the behaviour is reduced, but if the behaviour leads to pain reduction or to pleasure, then the behaviour is increased. There is an innate motivational desire within us to return to a state of balance and normalcy within the body, a desire to return to homeostasis and to escape, adapt, or avoid pain entirely (Becker et al., 2018; Navratilova & Porreca, 2014). Essentially, pain motivates us to either not experience it when possible or to reduce it as quickly as possible.
In regards to chronic pain, several studies have been conducted. A 2018 study on operant learning and chronic pain found that pain responses can be conditioned to increase both pain perception (hyperalgesia) and change the brain's response to pain and fear (Becker et al., 2018). Additionally, pain that is constant, like chronic pain, is a motivator for pain relieving behaviours which are perceived as being rewarding, since these behaviours take away a negative stimuli. They also stated that chronic pain becomes a disruptor towards previously motivated, goal directed behaviour (Becker et al., 2018), which implies that the enhanced focus on pain takes away focus on other motivational goals by prioritising motivation towards pain relief and control. Additionally, a 2014 study describes pain as 'a call to action, like hunger, thirst, and desire for sleep' (Navratilova & Porreca), and they agreed that chronic pain shifts one's motivations away from other goals or needs towards achieving homeostatic equilibrium via pain relief. This study also suggests that expecting pain or expecting relief from pain can change how pain is perceived, which is supported by previous literature (Becker et al., 2018; Navratilova & Porreca, 2014).
Overall, pain is a major source of learning. With an innate desire to keep an internal balance and to avoid damage, pain draws attention away from other goals. Therefore, the constant experience or expectation of goals alters one's motivations towards avoidance of pain, and increases the extent to which pain is felt. While studies on pain and motivation in operant learning are plentiful, it can be argued that operant conditioning is too simple of a perspective when it comes to understanding the relationship between pain and motivation.
Pop Quiz!
[Tailor this question towards the relationship between pain and motivation]
Which of the following scenarios best describe learned helplessness?
I didn't do well on my exam, but it's just because my teacher is strict! A different teacher would've graded me differently
I have failed my driving test so many times, there's no point in studying for it or trying again
Sometimes I do well at job interviews and other times I freeze up, I won't give up until I am hired :

## How does pain positively and negatively impact motivation?

Pain can positively or negatively impact motivation. Positive influences on motivation involve protection of the self, while negative influences include focusing on pain too much and on encouraging amotivation.

### Pain as a positive influence on motivation

* Pain is protective, telling the body when to withdraw and motivating individuals to protect themselves mentally and physically
* Pain can teach individuals which situations to avoid in the future as a part of learning
* Pain relief can teach individuals what to do in order to help themselves and others when in pain

### Pain as a negative influence on motivation

* Constant, chronic pain can make individuals amotivated
* When fearful of pain, individuals may be motivated to focus intensely pain control and avoidance, neglecting other goals
Pop Quiz!
Which of the following are the positive motivating aspects of pain?
Motivates you to seek out situations which caused pain
Motivates you to avoid experiencing the painful scenario again
Motivates you to continue the action(s) which caused pain
Motivates you to withdraw from the active painful situation :

## Conclusion

* Case study - Amanda's new job
* Figure 6: A change in lifestyle can be beneficial.
* After being prescribed a stronger medication for pain relief, continuing her psychology sessions, and changing to a less physically demanding job in an office, Amanda is feeling like her old self again.
* Her pain has reduced, and even though it can never truly go away it no longer makes her feel the way it used to. Her pain is now manageable, and she feels both mentally and physically relieved.
* She feels she is capable of leaving situations that cause her pain or stress, and she no longer feels trapped in a life that causes her pain. She used to feel like there was no way to escape her pain, but now the smile has returned to her face.
Pain is often perceived as an exclusively negative experience due to its adverse effects, but in reality it is a complex and vital survival mechanism which teaches individuals about which situations to avoid and protects them from present and future dangers. Additionally, [missing something?] drives us towards an internal balance, motivating us to take care of ourselves. While it is key for survival in acute situations, the experience of constant, unavoidable pain has several negative side effects such as obsession over pain management, feeling amotivated due to learned helplessness, and increasing level of pain felt. However, developing adaptive coping mechanisms for chronic pain, whether mental or physical, can be used to counter the negative side effects and promote seeking out healthier behaviour. Overall, pain and motivation are inseparable from one another.