Book Review: All in Your Head: Making Sense of Pediatric Pain

All in Your Head: Making Sense of Pediatric Pain. Mara Buchbinder. Berkeley: University of California Press, 2015, 256 pp.

All in Your Head comes in the wake of an incredible amount of recent scholarly attention to the topic of pain, yet Mara Buchbinder finds a unique anthropological voice that is subtle and distinctive in her exploration of the treatment of pediatric pain. Buchbinder’s approach is not phenomenological––though attention to private experience and internal states are not absent. Crucially, Buchbinder aims to show how “pain transcends the individual body through its treatment in the social arena” (p. 3). She focuses on the social and professional language of pain management and treatment, following how tropes of neurobiological explanation are shaped between family members and clinicians and are taken up by different actors to represent pain: Clinical knowledge builds contours around pain’s lack of thingness (p. 9).

The way pain’s elusive materiality is given biological form is anything but vague: The meetings between multidisciplinary team members, families, and patients are an exercise to “legitimize mysterious symptoms” (p. 89), to locate pain in the brain as well as to perform distance from psychosomatic causes and psychodynamic solutions. Buchbinder deftly identifies the changing character and tenor of these accounts of pain as they travel between domains––and, more importantly, how these explanatory assemblages are stitched together as a rhetorical strategy to justify treatment and compliance.

In contrast to the intricate models she and the families are offered, Buchbinder’s writing is spare. The author resists the temptation to launch into theoretical appraisals of her interlocutors words and actions at every turn. Instead, Buchbinder walks her readers through each encounter, filled with sadness, uncertainty, desperation, and less frequently, hope, to great effect. Buchbinder followed four families for approximately 18 months. In that time, she recorded interactions between children, parents, clinical team members, researchers, and others who these young patients encounter. Her observations expose the ways that discourses of pediatric pain unfold and take shape in a world of competing social and scientific priorities and not-always-transparent clinical deliberations, a heady mix of professional ambition and insecurity.

Buchbinder follows along the grain of her subjects’ lives rather than her own priorities, which makes her voice that much more convincing. From the beginning, readers are drawn into a world of parents and sick children, coupled with the anthropologist’s own struggle to maintain the right comportment. Buchbinder reflects on her apprehension and on her place in the scene (in one moment, forgetting Kleenex when she knows there will be tears); in doing so, her presence highlights for readers the uneasy road to understanding.

Perhaps the most impressive feature of All in Your Head is where it takes place. In what she describes as “the clinic backstage” (p. 116), Buchbinder accesses spaces where pediatric pain is negotiated––where families are summed up by clinicians and staff along the lines of their willingness to participate in treatment, their cooperation and buy-in, and the likelihood of success. She is witness to pediatric pain in the living room, around the kitchen table, at school, in the consultation room, and in the conference room––sites of conversation as much as conversion. Buchbinder shows impressive sensitivity and restraint throughout. She is not seduced by the explicatory prowess of neurobiology, wiles from which even social scientists are not immune, yet she embraces discussion. She clarifies for her readers and for herself, as doctors deliberate and turn private pain into an object of medical work and technical understanding. And just as with pain itself, making visible what is hidden is even harder when it is assumed to be so present and available already.

These clinical encounters are social encounters, and Buchbinder’s “clinic backstage” offers an extraordinary view into the world of pediatric pain treatment as it comes into being through persuasion as much as scientific precision (p. 31). Buchbinder’s All in Your Head extends earlier work in anthropology and sociology on the formation of pain medicine from the laboratory to the clinic through deep empirical attention to patients and families, further exposing the closeness of administrative life (referrals, insurance, access) and therapeutic practice (to codify diagnosis and treatment, to manage, to meet uncertainty with certainty) as rendering pain a social and scientific form.

I end this review with a scene from the conclusion of the book. Michael has had a tough time in middle school: He’s the object of bullying and ridicule and suffers from crippling abdominal pain. After treatment and moving to a new school, his physical symptoms improved but his anxiety landed him in the school’s office almost daily, from which he would be sent home. At some point, the school’s assistant principal said he would no longer make the call for Michael to go home and that he would have to remain at school. Predictably, Michael did not react well. He protested, claimed he was being held hostage, and threatened to call the police. The assistant principal calmly reminded him that truancy was against the law and that if he called the police it would likely result in trouble. But instead of escalating the situation further, the assistant principal shared with Michael his own history of anxiety and told Michael that, while he would not allow him to go home, he was welcome stay in the office as long as he needed. After this encounter, things slowly improved for Michael.

This is the kind of post-treatment story that rarely finds a place within the ethnographic record––nothing earth shattering, but a moment of backsliding, identification, and reparative kindness. Children with pain improve and then what?––what worlds do they continue to navigate? Buchbinder does not make big claims on a “social” that never appears in her writing; instead, she lays out the social and scientific terms of pain, its banalities, and otherwise forgettable moments that make making sense of pediatric pain something negotiated, again and again, every day.

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