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Painful metaphors: enactivism and art in qualitative research
  1. Peter Stilwell1,
  2. Christie Stilwell1,
  3. Brenda Sabo2,
  4. Katherine Harman3
  1. 1Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
  2. 2School of Nursing, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
  3. 3School of Physiotherapy, Faculty of Health, Dalhousie University, Halifax, Nova Scotia, Canada
  1. Correspondence to Dr Peter Stilwell, Faculty of Health, Dalhousie University, Halifax, NS B3H 4R2, Canada; peterstilwell{at}


Enactivism is an emerging theory for sense-making (cognition) with increasing applications to research and medicine. Enactivists reject the idea that sense-making is simply in the head or can be reduced to neural processes. Instead, enactivists argue that cognisers (people) are embodied and action-oriented, and that sense-making emerges from relational processes distributed across the brain-body-environment. We start this paper with an overview of a recently proposed enactive approach to pain. With rich theoretical and empirical roots in phenomenology and cognitive science, conceptualising pain as an enactive process is appealing as it overcomes the problematic dualist and reductionist nature of current pain theories and healthcare practices. Second, we discuss metaphor in the context of pain and enactivism, including a pain-related metaphor classification system. Third, we present and discuss five paintings created alongside an enactive study of clinical communication and the co-construction of pain-related meanings. Each painting represents pain-related metaphors delivered by clinicians during audio-recorded clinical appointments or discussed by clinicians and patients during interviews. We classify these metaphors, connecting them to enactive theory and relevant literature. The art, metaphors and associated narratives draw attention to the intertwined nature of language, meaning and pain. Of clinical relevance to primary and allied healthcare, we explore how clinicians’ taken-for-granted pain-related metaphors can act as scaffolding for patients’ pain and agency, for better or worse. We visually depict and give examples of clinical situations where metaphors became enactive, in that they were clinically reinforced and embodied through assessment and treatment. We conclude with research and clinical considerations, suggesting that enactive metaphor is a widely overlooked learning mechanism that clinicians could consider employing and intentionally shape.

  • pain management
  • art and medicine
  • metaphor
  • medical humanities
  • rehabilitation medicine including disability

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  • Contributors PS drafted this manuscript and all authors revised and approved the final version. PS and KH contributed to the acquisition of data and all authors assisted with the analysis and interpretation for this manuscript. CS created the paintings with conceptual guidance from PS.

  • Funding The original qualitative data used in this paper was from a study that received funding from the Faculty of Health Research Development Fund (Dalhousie) and the Canadian Chiropractic Guideline Initiative (CCGI).

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Ethics approval Dalhousie University Health Sciences Research Ethics Board (#2017–4103).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.