Intercultural communication is a field of anthropology, first developed by Edward Hall (1976, 1983, 1990, 1997). Hall noted that human interactions and related communication can be broadly classified as being high or low in their cultural context. High context communication embeds large amounts of meaning within the situation or context within which communication occurs. Where people are when they are communicating, who is present, and how they position themselves relative to one another are all parts of the context in which a message is delivered, interpreted, and received. High context communication is thus relational. That is, a major goal of such communication is to affect in some way the relationship of those participating in it. Relational goals may include establishment or clarification of the relationship. They may also relate to a request for some change in behavior or assistance. In everyday life, courtship behavior such as dating is an example of an inherently high context encounter. Low context communication, in contrast, is concrete, situation specific, and task-oriented and involves minimal relational work. Such communication is usually straightforward and relatively unambiguous. Asking for street directions is an example of low context communication.

Hall noted that serious cross-cultural misunderstandings can occur when people using low context communication styles interact with others using high context communication styles (or where people using very different high context styles interact with one another). Different ethnic groups may prefer relatively higher or lower contextual communication styles. Certain groups, most notably those of Northern European descent, are believed to be relatively lower in contextual style than others, such as Southern Europeans or Asians (Samovar and Porter 1997). Clashes can occur among individuals from different ethnic groups, based in part on their differing communication styles in this regard. However, cross-cultural clashes can also occur within relatively homogenous ethnic groups. A case in point can be seen commonly in encounters between clinicians, acculturated to the low context world of biomedicine and the lay public, who tend to experience sickness as relational, high context events, regardless of ethnicity (Hallenbeck 2006; Hallenbeck and Periyakoil 2009). Both high and low context approaches to sickness make sense within their particular cultural framings. A scientific, physiology-driven understanding of disease allows for a very precise and often effective optimization of medical therapies. Low context communication includes math, computer, code, and scientific and medical language. It often works better across linguistic groups and cultures precisely because it avoids complex and confounding meanings associated with ordinary language. For instance, the use of pain scores as a means of communicating pain severity via mathematical symbols (1–10) is a low context means of communication, which offers a real advantage in this regard. A Likert scale between 1 and 10 means pretty much the same thing in all languages and cultural groups. In contrast, high context communication about sickness also makes sense in that illness (as opposed to a disease) almost always affects more than one person. Serious illness usually involves an alteration in the relations among closely linked individuals. The sick person becomes dependent upon others, clinicians, family members, and caregivers, for a wide range of needs. High and low context approaches to sickness make sense in their own realms; and ideally these two approaches are complementary and synergistic. However, at worst, what is risked is people talking past another and serious miscommunication.

In terms of intercultural communication, pain is a particularly interesting topic. Like all symptoms pain is by definition a subjective phenomenon. The definition of pain according to International Association for the Study of Pain (IASP) suggests the nature of the problem:

Pain has been defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. Note: The inability to communicate verbally does not negate the possibility that an individual is experiencing pain and is in need of appropriate pain-relieving treatment. Pain is always subjective (2010).

As this quote states, pain is a subjective biopsychosocial experience, which may or may not be associated with tissue damage. As a symptom, pain is unusual in its variable correlation with objective reality (tissue damage). By contrast, patients with nausea or dyspnea usually have clear objective markers associated with their symptoms. The cautionary note regarding communication points to difficulties linking subjective experiences with objective reality. One could also add that when pain has been communicated, it does not necessarily mean that tissue damage has occurred. When no association with tissue damage is found, what does this mean? Does it mean that such an association is present, but clinicians have missed it? Is the “unpleasant experience” being described properly in terms of pain but with no tissue damage? In this instance is the usage of the word pain takes on metaphoric implications. Or, is the person claiming pain not having an unpleasant experience and is in effect lying?

Tissue damage suggests the need for a low context approach to healing. The machine is broken and repairs are in order. Where repair is not possible, a “system override” is needed, where the brain is told to ignore the blinking red panic light. The subjective and often emotional experience of pain in contrast cries out for connection with others in hopes of finding assistance and relief or, where relief is inadequate, at least some degree of empathy and understanding and is thus high context (Biro 2010). Pain, then, is both a high and low context event, requiring both technical and relational expertise for optimal treatment.

In some conditions, common experience leaves little question as to whether tissue damage has occurred. Patients with acute and obvious wounds, burns, and broken bones rarely need to convince others of the severity or veracity of their pain. Cries of anguish and grimacing erupt spontaneously in such severe pain, even in the absence of another person. The objective reality of trauma and the subjective cry for help present as one coherent message. However, in many pain states often classified as chronic pains, there may be little correlation between objective markers of tissue damage and subjective experience of pain and suffering, even where the associated suffering is every bit as real and great (Hadjistavropoulos and Craig 1994). Curiously, one would think that it is precisely in such cases that individuals would want to communicate verbally their distress to others, if for no other reason than to compensate for the lack of physical stigmata validating their complaints. And yet, clinicians often see the exact opposite. Patients with chronic pain tend to withdraw. They do not cry out.

Pain is obviously a fundamental biological property of evolved species that is replete with significant information regarding the need states of an organism and its capacity for adaptive behavior. It constitutes a hallmark of sickness and can elicit caring and nurturing. Fabrega (1997, p. 62).

Let us consider more closely the puzzle presented by the nature of pain. Why is it that when pain is most obvious, people scream the loudest and when pain is least obvious, they are often silent? Such a communication strategy makes sense in evolutionary terms, as highlighted by the experience of nonhuman, social animals. In calling out with acute injury, a social animal alerts other members of the herd of an immediate and urgent need for defense and support. Other members of the group may not only provide defense (e.g., against an attacking animal), but may be able to provide immediate pain relief (as in taking a thorn out of a foot). Both the vocal and nonverbal communication of pain and the social response of “sympathetic pain” (feeling pain or discomfort in seeing another wounded and in pain) appear instinctual and transcultural in their prevalence (Prkachin 1992; Otti et al. 2010; Williams 2002; Goubert et al. 2005; Frith 2009). By way of example, Botvinick and colleagues demonstrated through magnetic resonance imaging similar patterns of cortical stimulation in volunteers viewing facial expressions of pain as occurred in them during thermally induced pain (Botvinick et al. 2005). How then to explain the withdrawal and silence so common in many chronic pains?

Many pains characterized as “chronic” are in fact better characterized by their representing in fact or metaphorically certain types of deep tissue pain. Temporal longevity of a pain episode (acute versus chronic) is variably correlated with this type of pain for which we lack a commonly accepted word in English. Headaches offer a very good case in point. Most headaches, while temporally of a short (acute) duration, do not give rise to vocal outbursts, but rather often result in withdrawal and relative quiet typical of “chronic pain.” Withdrawal in evolutionary terms would be an appropriate response to bodily damage involving certain deep tissues. In animals and in ancient times for people the best chance for survival would have been hiding out and waiting for internal healing, if possible, to occur. Others would be less likely to be of immediate assistance. Indeed, there may have been some survival benefit attached to keeping a low profile. In such situations, communication between the sick individual and other members of the herd or tribe would be less urgent. Such communication to the extent it existed would likely transmit the importance of keeping quiet and being less, rather than more visible.

While primitive people often had little to offer medically to treat conditions giving rise to such chronic [sic] pains, they were generally able to provide support, such as food, water, and shelter, to the sick individual, while they waited to heal. Following traumatic injury, after the initial, spontaneous crying out of acute pain, tissue damage is often so obvious that further evocation or communication would seen unnecessary for the purpose of enlisting ongoing support and exemption from one’s usual social duties. However, for chronic pain, the opposite is the case. Precisely because there is no obvious stigmata of tissue damage, language offers a means for communicating the internal experience of pain, eliciting needed support, and justifying exemptions from social duties. Thus, while chronic pain may not provoke as immediate and guttural a cry as acute pain tends to do, if anything the need for verbal communication is far greater.

One could make the argument, based on the above, that we are “hard-wired” in our responses to acute pain. That is, we are programmed to respond viscerally to images and vocalizations of acute pain. The more horrific the image, the louder the vocalization, the more immediate and intense our instinctual response. Put simply, we are pretty good at “seeing” and empathetically responding to acute pain. In contrast, for equally valid reasons in evolutionary terms we are “color-blind” to certain “chronic” pains. We cannot “see” them and our empathetic responses to such pains are blunted.

A small study highlights the above point. In a study of “gold standard” (thought to be truthful in their pain complaints), cancer patients’ clinicians and caregivers (mostly family members) spent time talking with patients in varying degrees of pain (Grossman 1991). They were not allowed to speak specifically about the pain. Patients, clinicians, and caregivers were then asked to rate the pain using a 0–10 scale. Concordance between patient-reported pain and other’s assessment was then noted. The results are included in a table below.

What can be seen is that when patients had little or no pain, concordance by clinicians (nurse, house officer, oncology fellow) and caregivers (people who knew the patient well) was fairly good. However, these observers were unable to recognize more severe states of pain. These results are rather the opposite of what we might imagine were the study to be replicated with acute, traumatic pain. In acute pain we can easily imagine great concordance between subjects and observers. The study is also interesting because it dispels two common myths; that if a person just “knew” the patient better, they would be better at recognizing severe pain. Caregivers were in fact less accurate than the physicians. Another myth is that people in more sensitive, empathetic positions (nurses, caregivers) should do better than “less sensitive” task-oriented people, like physicians. In fact, nobody was very good at “seeing” the severe, chronic pain of the patient.

The problem is actually worse than this. In many cases we are not only color-blind to chronic pain, we are blind to our blindness. Because we are so good at recognizing and responding to acute pain, we come to believe we are able to recognize pain in all forms. The common resistance by clinicians to efforts to get them to repeatedly inquire about pain using pain scores, for example, can be understood not so much as objection to the notion that pain is bad and ought to be treated but rather as a deeper resistance to the apparently absurd notion that we need to ask about what should be so obvious (Biro 2010, p. 13; Young and Davidhizar 2008).¹

Communication regarding acute pain is relatively low in context, even when help is requested from others. The guttural cry of acute pain is straightforward, task-oriented, and works well across very divergent cultures and language groups. As noted earlier, biomedicine, as a subculture, tends to favor low context communication. Numbers, data, and images are valued over words and meaning. Fabrega, who has written extensively on the evolution of sickness and healing, notes that modern medicine has become quite skilled at alleviating most acute symptoms such as pain, but less skilled in alleviating the distress and suffering associated with chronic illness (Fabrega 1997). Chronic pain would be included among such distress. In part this undoubtedly reflects physiologically based difficulties in alleviating certain chronic conditions such as neuropathic pain. However, in part it may also be that low context, biomedical clinicians are more comfortable responding to the low context communication of those in acute pain and conversely less comfortable responding to more complex, high context communication typical of chronic pain. One could argue that greater comfort in response to acute pain communication reflects not only relatively greater efficacy of treatment and certainty of diagnosis, but also a more favorable reimbursement structures, at least in fee-for-services healthcare systems. However, such reimbursement systems are themselves a product of a society that values low context certainty and unambiguous results over high context relationships. The common aversion to patients with chronic pain goes beyond such practicalities. The inherently high context nature of interactions with individuals suffering chronic pain may be threatening for clinicians, who understandably seek clear boundaries between person and professional personae. Given current limitations in our ability to “cure” chronic pain and the common public perception that such cure is a reasonable expectation of care, clinicians may fear getting caught up in a sticky web of protracted interactions.

Let us then consider such high context communications in more detail. As has been stressed earlier, high context communication is primarily relational. However, the nature of such relationships varies from ones of the provision of basic aid or simple defense to extremely complex relationships based on empathy, mutual understanding, and even politics, enacted through mutually constructed narratives.

In discrete encounters, relational work is often interwoven with task-oriented work. Such relational work often manifests as a set of subtexts to the “text” of verbal communication, which often revolves around concrete, low context medical tasks. Common relational/high context subtexts include (among others):

While these subtexts are presented as discrete categories, considerable overlap exists among them. Trust, respect, and empathy, for example, overlap. Let us consider these categories in more detail and highlight them with relevant examples in pain management. For illustrative purposes we will consider here relationships between providers and patients, although these subtexts also exist in other relationships (e.g., among family members).

Trust: Trust exists relative to distrust. Trust relates to truthfulness or veracity of the pain complaint, but also to the ability of participants to abide by social contracts. Such contracts may be formally codified in written form as may be done with opioid agreements (Heit). However, the use of such agreements does not mean that true trust exists. It is often quite the opposite. Where such contracts are thought necessary almost by definition trust is questionable, at best. Indeed, where the use of such agreements is mandated by the clinician, this is more a display of differential power than a marker of trust. Still, as Heit notes, “Opioid agreements have the potential to improve the therapeutic relationship.” (p. 376) While much writing, especially as relates to pain management in substance abuse, addresses the issue of trust and truthfulness of patients, trust or lack thereof is by definition a two-way street. Patients need to trust that they are respected, that clinicians have adequate competency to address their problems, and that clinicians will do so with due diligence. The “therapeutic relationship” Heit writes about to a large degree reflects an evolving, iterative, process in which trust is either built or damaged through interactions among participants. While trust/mistrust as an issue may be relatively overt, as in drug screening, more often, where mistrust exists it works as an unspoken subtext, played out as participants try to demonstrate their relative trustworthiness or question the trustworthiness of the other (Parsons et al. 2007).

Respect: Respect overlaps with trust, empathy, and an appreciation of specialness (Branch 2006). It differs somewhat from trust in that it is less tightly linked to truthfulness. Respect requires an appreciation for the other, which may exist even if and where the other is quite foreign, even though evidence suggests respect tends to grow with familiarity (Beach et al. 2006). Disrespect, conversely, may be driven either by a negative past history with an individual or a negative experience or stereotype regarding a group or class the other person is perceived as representing. Disrespect or frank prejudice may be felt and displayed toward others based on race, religion, ethnicity, gender, sexual orientation, social or professional role – or any number of factors. While mistrust and distrust may reflect stereotyping or prejudice, they may also be rooted in the personal histories of individual clinicians and patients. Evidence suggests, for example, that African-Americans may receive substandard pain management, relative to other ethnic groups (Nampiaparampil et al. 2009). The reasons for this are likely very complex. Some clinicians may associate drug-seeking behavior with certain ethnic groups such as African-Americans, based both on stereotyping and perhaps past interactions with individuals that may have suggested a link between ethnicity and drug abuse. Conversely, some African-Americans may be all too aware of a history of substandard treatment and care for African-Americans and may have experienced discrimination in seeking medical care. Such experiences on both sides can sow the seeds of distrust, which can readily manifest in shows of disrespect, which insidiously can confirm underlying distrust. Conversely, respect can be demonstrated and expressed even in initial encounters, prior to any evolution of a trusting relationship, which takes time. Indeed, in most initial clinical encounters, the demonstration of mutual respect is the cornerstone upon which strong, trusting relationships are built.

Obligation: What is a “therapeutic relationship?” A therapeutic relationship is defined as a relationship that maximizes the possibility of healing of body, mind, and spirit. In the process of creating such a relationship some sense of personal closeness or bonding between clinician and patient is inevitable, even within their professional relationship. Obligation is a term rarely used in low context cultures, but is of great importance in high context encounters. It refers to an internal drive to respond to a need in another person by doing something positive or helpful. Obligation may exist as simply relative to an ascribed role. Thus, clinicians may speak of a professional obligation to treat patients beneficently and to do as little harm as possible. However, obligation is also very personal, based on prior interactions among people. If previously a person responds positively and does some good for another, then the other may feel a sense of indebtedness to this person. In “returning the favor” to this person, mutual obligation is built. Such mutual obligation acts rather like a social glue binding people together. In professional relationships, obligation may or may not be engendered simply by doing one’s job. Relieving a patient’s pain (and in turn being thanked and paid for this service) may foster some sense of mutual obligation – or not – if such work is viewed merely as an equal trade or barter transaction. Personal obligation is more reliably fostered if and when something outside the expected role is done. Thus, for example if a clinician “goes out of the way” (beyond formal role expectations) to do something good for a patient (get a blanket, e.g., for a cold inpatient or gives a patient their personal cell phone number), then a sense of obligation is likely to be fostered.