IS PAIN SUFFERING? A CASE STUDY

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1 INT L. J. AGING AND HUMAN DEVELOPMENT, Vol. 64(1) 33-45, 2007 IS PAIN SUFFERING? A CASE STUDY HELEN K. BLACK Thomas Jefferson University ABSTRACT In this article, the case study of an elderly woman shows how bodily pain and suffering meld in her narrative, not as the subjective and objective sides of the same event, but as distinct experiences in which both constructs emerge separately or come together based on the meaning she imputes to the event. The case study shows the clear methodological fit of qualitative narrative research with the lived experiences of pain and suffering. The narrator recalled the tremendous pain she experienced almost 60 years previously as both suffering and not-suffering, depending on the outcome of the circumstances that surrounded her pain. This case shows how a significant aspect of the aging experience suffering is medicalized, yet remains resistant to both categorization and medicine. INTRODUCTION A significant aspect of the aging experience that is infrequently discussed is that of suffering. Although suffering is an experience that often attends illness, it resists both categorization and medicine (Black, 2001; Frank, 2001; Kleinman, 1988). In research on suffering, elders note that the enduring nature of suffering might overwhelm [their] aging bodies and minds ; they worry that they will die before suffering ends (Black & Rubinstein, 2004, p. S17). Perhaps because suffering cannot be operationalized, objectified or placed under rubrics of meaning established by the medical model, it is important for those who experience or witness suffering in old age to hear the expert s description of suffering the elder herself (Black, 2002). 2007, Baywood Publishing Co., Inc. 33

2 34 / BLACK In this article, a case study shows how bodily pain and suffering meld in the narrative of an elderly woman, not as the subjective and objective sides of the same events, but as distinct experiences, both of which are addressed by the medical model. Within the research interview, the respondent discusses the terrible pain she endured over 60 years previously, her body s memory of the pain, the life circumstances that caused her to define bodily pain as suffering, and the medical resolution that ended her pain, though not her suffering. This article focuses on the personal meaning of pain and suffering to an elderly woman. We provide a background for the major concept of this article, which is the use of narrative as an organizing tool for the disruptive experiences of pain and suffering (Sarbin, 1986). A narrative approach places the respondent s description and interpretation of suffering against a tapestry of personal background and cohort history. We show the research methods used, and present the respondent s case through the principal themes of her life story and story of suffering. Finally we offer a brief discussion. THE NARRATIVE Events, incidents and time periods of life are given meaning, perspective and a moral significance through the stories told about them. The experience of suffering interrogates the sufferer about a perspective of life before and after suffering, and requires an evaluative stance toward the experience (Charmaz, 1999). The self at the time of the suffering event is also evaluated, making the narrator both subject and object of her story. This evaluation, called by Reissman (1997) the soul of the narrative, requires the narrator to stand back, assess, and interpret the suffering event, both as an insider and outsider. In the forum of the qualitative research interview, a particular form of narrative is elicited. It includes the life story, open-ended and in-depth questions, probes, and in this case, a story of suffering. In creating a life narrative or a narrative of suffering, an individual creates a narrative self. What she decides to relate or leave out of the story reveals how she wants to be known by her listener. Thus, a respondent performs an interview with aspects of drama, such as tragedy and intention, because no one wants a story to lack meaning or purpose. To say a person performs her story does not suggest it is untrue; it implies that the body is integral in processing the event of suffering in order to assimilate the suffering experience to the life lived (Brodwin, 1992). In this research, the topic of discussion is suffering. As a lived experience, suffering is informed by personal and shared systems of meaning, and takes personal biography, cohort history and context into account. Researching experiences of suffering elicits rich descriptive and analytical accounts of the content and quality of the experience. Although an experience of suffering usually disrupts a life, the story of suffering attempts to organize it through the form of the narrative,

3 IS PAIN SUFFERING? / 35 clarifying it through language, and interpreting it with images and metaphors. In the case of physical suffering, both body and narrative may be ruptured by pain; both seek the unity that ultimately resolves suffering (Frank, 1995). In this sense, narrative and the body come together at the points of pain and suffering, and communicate those lived experiences that are difficult to describe without symbols and signs. Data Collection RESEARCH METHODS The data were collected through formal ethnographic interviews and informal conversation (Straus & Corbin, 1990). Data were processed through audiotaping and transcription for analysis and detailed in analyzable field notes; the case study we present was culled from both processes. Private interviews were conducted in respondents homes for intimacy and comfort and lasted approximately two hours in three sessions for a total of approximately six hours. The main tool of this study was the interview schedule, which includes open-ended questions that span three sessions. The first interview session began with a request to hear the life-story. One of the important functions of the life story question in interviews is that it provides, for both interviewer and informant, an interpretive context in which to better situate questions that follow (Bruner, 1990; Reismann, 1997) The second interview session asked specific questions about suffering, for example, a request to hear about an incident, event, or time in your life when you felt you were suffering. Other questions queried respondents about suffering related to physical pain, suffering and old age, and the normativeness of suffering during the life course. Further questions teased out subtler forms of suffering, such as guilt or regret, and the meaning, purpose and value of suffering. The third interview session centered on issues of pain, suffering and health; suffering and spirituality, and thoughts about the future. The third interview summed up the place of suffering within the life as a whole. All interviews were conversational in nature and interactive, that is, the interviewer asked the initial question and obtained a response. Responses were then reframed as an additional line of questioning. Answers to most questions were probed with tailor-made, follow up questions. The interview also probed for elders use of metaphor to formulate or elaborate concepts of suffering. Data Analysis The general approach to data analysis in the project was as follows: Once the data were transcribed, they were analyzed using standard methods of qualitative data, including data review, gross level sorting, coding for thematic and other

4 36 / BLACK topics, team discussion, and fine grained analysis (Glaser & Strauss, 1967). The approach to narrative analysis here was a step-by-step analysis of a segmented paragraph. All responses made by the respondent were included in this method of analysis even if the respondent appeared not to answer a particular question. Nonanswers or circuitous answers are important to the narrative that the respondent creates as a whole (Mischleev, 1986; Sarbin, 1986). FINDINGS Case study is an element of our research design as well as the form in which we present our findings. Case studies are a form of empirical and narrative inquiry (Reissman, 1997) that investigates a contemporary phenomenon within its real life context (Yin, 1989, as cited in DePoy & Gitlin, 1998); a case study informs by its particularity. Here, the contemporary phenomenon is an elder s particularized experience of suffering; the real life context is the research interview. As a form of narrative inquiry, a case study offers the quality and texture of an experience through the perspective of the experiencer. A case study also shows the aesthetics of real life, that is, the ambiguity and unpredictability of an actual situation (Freccero, 1992). The elder described in our case study, Mrs. S., discussed intimate, negative events in her life within the framework of a research interview concerning experiences of pain and suffering. Within the three-session interview, she defines suffering, tells a story about it, imputes meaning to it, and resolves it (Carson, 1986). THE CASE OF MRS. S. Mrs. S. is an 85 year old African-American woman who lives in a subsidized apartment building for seniors and disabled persons of all ages. For each of our three interviews she dressed in an African style caftan, a headdress that matched the caftan, large hoop earrings and gold ballet slippers. She sat in a chair that was placed in front of the only window in the dining/living room of her small apartment. Mrs. S. used at least three means to reveal herself to me. First was her dress. She told me that she began to wear African garb recently. For her, it symbolized both an inner and outer authenticity. She had been, she reported, somewhat dishonest with herself and the world in the recent past. She attended a church she didn t believe in and joined so-called friends in activities [she] didn t really like the friends or the activities. She wore an African dress and headdress when her grandson recently married a white woman. She wanted him to see how proud she was of their African heritage. Mrs. S., through her clothing, gave a message to her grandson and the new world he was entering.

5 IS PAIN SUFFERING? / 37 Mrs. S. also disclosed herself through her body. When I rang the doorbell for each of our three sessions, she would call out, Just a minute. It actually took her several minutes to come to the door with her walker from the chair where she sat for most of the day. As an instrument for revelation, the aged and pained body uses a language that is disquieting; it communicates not only its own contingency, but also the contingency of life itself (May, 1991). It may be difficult to look squarely at the aged or pained body because of what it foretells to the observer. In age and in pain, the body is no longer predictable or controllable. It heralds vulnerability to disease and ultimately to death. Although Mrs. S. could no longer walk easily, she used her upper body as a performing tool; hand gestures, facial expressions and long looks out the tiny window next to the chair in which she sat embodied her experiences. For the most part, Mrs. S. refuted cultural values about the aged body, along with those concerning class status and ethnicity. Still, those values had shaped her experiences of pain and suffering (Belsky, 1997; Huyck, 1990). Mrs. S. narrative was her third means of revelation. Just as her clothing became the language through which her cultural identity was expressed, her narrative was the language through which her suffering identity was brought to light. The rationality, emotion, imagination, and insight she used to create her story were grounded in her bodily experiences (Johnson, 1987). She began her life story this way: I often said I got the best that my mother had to offer because my siblings had problems and I m the only one left and I m the oldest. Up until I was in my mid-70s I got along very well. I ve been using a walker since last fall. Although only two years previously she was an active member of a local theater group, she is now unable to step onto a bus, take a walk, or even clean [her] own apartment due to arthritis. Although her inability to get around has diminished her world, she explained why she is not presently suffering. I do not let myself. I DO NOT LET MYSELF. I force myself to face my fears. I do not allow myself to feel sorry for myself. I look at some of the young people here in the building who have never walked a step in their life. I can walk and dance. I spent the night on a beach in Hawaii. (Mrs. S. emphasis). Mrs. S. recalled memories of her childhood home in North Carolina with her parents, grandparents and siblings. She described their eventual move to Philadelphia while she was still a youngster, and mentioned a turning point in her early life. Mrs. S.: In high school, I expanded my horizons; I met more people. I got involved in more things, and I learned some things that I would just as soon not have learned. But we were coming into a new era. Interviewer: What do you mean? Mrs. S.: Well, Hitler was rattling his saber in Europe and there was a feeling of antagonism and a feeling of fear that I have not had before. There was something in the atmosphere that I had not felt before. We became aware of our blackness in a different way. And it wasn t a good feeling.

6 38 / BLACK Interviewer: Can you tell me a little more about that? Mrs. S.: The only word I can use is a sort of ugliness. In high school I noticed a difference in the attitude of some of the white kids I had gone through school with. I knew I d been black all my life, but then in high school one of the white kids said to me, You know, you re a very pretty colored girl, but you d be one damned ugly white girl. And with my teachers, some of them were openly racist. I worked so hard, but a couple of teachers failed me. And it seemed that the failure had nothing to do with my work, it was a personal thing. The cruelty of prejudice is an overarching theme in Mrs. S. narrative. She described her high school years as a time of no accomplishment. Just an unpleasant experience altogether. Her youthful anxiety foreshadowed local and world events of fanatic racism. She was forced to ride in the Jim Crow car on a train trip to her relatives home in North Carolina and was denied jobs in city department stores because of her color. Although she described these incidents as not surprising they were painful to remember. After relating some of the jobs she held after high school, such as waitress and salesgirl in a five and ten, she then introduced the principal character in her narrative. This character s thoughts and actions, and her reaction to him are major themes in her life story and story of suffering. I met my first husband at the wedding reception of friends. He was still in college so we decided to get married and not tell anybody we were married, which was stupid. And I became pregnant; in fact my son was born on my first anniversary. But my husband decided that he did not want the responsibility of a wife and family; he wanted to complete his education. So we separated and then the war came and I went to work at the Army Base. We were married a short time (2 years). I enjoyed my work at the Base. Mrs. S. bypassed further discussion of her marriage and discussed how much she enjoyed doing men s work during the war. She also admitted, with a smile, that she is good at telling a story, and that her work in the theater allowed her to find expression for [her] wealth of experience. She imputed her story with drama, foreshadowing, and emotional tension. When I asked her to tell me one of the best times of her life, she replied: To me, the best time is the most beautiful. And the most beautiful time in my life was when my baby was born. I felt as if nobody ever had a baby but me. They allowed my husband to come into the delivery room which was not done then. But it was our first wedding anniversary. And he sat there and said, If I could only help you bear the pain. Ours was such a beautiful relationship that it was very difficult to understand why things changed so drastically. It was just a beautiful thing, the two of us there together, with our baby being born. And it almost seemed, it did seem, to be a very spiritual thing the mother, the father, and the child. But then things went to pieces not too long after this.

7 THE LIVED EXPERIENCE OF SUFFERING IS PAIN SUFFERING? / 39 When I asked Mrs. S. if she had ever experienced an event, incident or time period of life when she felt she was suffering, she replied: A time in my life when I was suffering? My husband and I had separated after he told me he wanted to continue his education, but I loved him so much, we still saw each other. We had separated, not divorced. He was still my husband. And suddenly I became very ill, and they took me to the hospital. In fact, he took me. It turns out I had gonorrhea that I caught from him. And they put me in a ward with prostitutes. Mrs. S. reported that the highest and lowest points in her marriage were the best and worst times in her life. She married the love of [her] life and had a child with him. He also infected her with a venereal disease. Despite his reprehensible actions, she did not seek a divorce. She hoped instead that they would reconcile. She described an incident that occurred in the hospital. There was a young doctor there and he said, We re going to move her somewhere else; she shouldn t be here (in the ward with prostitutes). And they moved me into another ward where there were women who had miscarriages and things of that sort. It was assumed by hospital admissions that Mrs. S. disease was a reflection of her self. A woman with gonorrhea must be a prostitute. The stigma of her disease was a moral one; she was physically sequestered with those who, through their own fault had brought upon their illness. Her doctor announced to the hospital community that Mrs. S. was a special case. As a still-married woman who caught the disease from her husband, she was more worthy of sympathy than shame. Her status was raised by her move to the miscarriage ward where other patients were impressed by her husband s devotion. I was in the hospital for over a month. But he came to see me every day. He would bring ice cream, he would sit and feed me, he brought me flowers, he made a big fuss over me. And I thought, this will bring us back together again. If this will bring us back together again I m willing to go through it. PAIN WITHOUT MEANING IS SUFFERING Mrs. S. describes her physical pain during this time as tremendous. The pain resulted from the disease as well as from the pre-antibiotic drugs that were used to treat her. She quickly explained that her pain was not suffering because she believed that this dark period was drawing her husband closer to her. Mrs. S.: While I was in the hospital I had reason to hope (for reconciliation) because he was so devoted to me. All the other patients thought it was so beautiful.

8 40 / BLACK Interviewer: Was this period suffering? Mrs. S.: No, that didn t start until after I was well. Interviewer: What do you mean? Mrs. S.: While I was in the hospital he had actually filed for divorce. Coming to see me everyday was to keep me from being aware of what was going on behind my back. I was in the hospital flat on my back with a fever they could not bring down. The drugs that I took left me with a condition where all of my organs were fused with scar tissue. I could never have another child. While I was in the hospital he established residence in another city. A letter came to my parent s home advising them that divorce proceedings had begun. The letter said you must appear on such and such a date to contest the divorce or it will be granted. My father and his father wanted to send a legal representative to halt the proceedings. My mother and his mother said if he would treat me like this, I m better off without him, let it go through. Her husband s application for divorce and move to another city, the letter from his lawyer, and her parents ultimate decision to let it (the divorce) go through occurred without Mrs. S. knowledge and while she was flat on [her] back. Although her husband created an elaborate ruse to hide his deception, her doctor, family and friends also conspired to protect her from the truth. I learned later that the doctor said, I will not be responsible if you tell this woman the truth (about the divorce). I was still in the hospital when the divorce was granted and he was still coming to the hospital acting as if everything was beautiful. And the day that I found out the truth I think I came closer to losing my mind than I ve ever come before or since. After all that I had gone through! And I had gone through it with my hopes high. That (hope) had enabled me to get through it. And to find out that there was nothing, there was nothing. (Mrs. S. emphasis). Mrs. S. recalled her despair as she whispered the word nothing. The physical pain that she was once willing to go through was now suffering. SUFFERING AND THE MEDICALIZED BODY The picture that Mrs. S. painted of her marriage was a union between the ideal and the real man, woman and child taking on necessary and distinct roles in the fulfillment of emotional, physical and spiritual love. Just as her sense of beauty was created from the experience of giving birth, her response to pain and suffering was gendered. Her perception was that the appearance and usefulness of the body are all of a piece. That is, her body is inscribed with personal experiences as well as those of a cultural community; it is a metaphor, symbol, text and narrative of her ethnicity and gender. Her body holds the memory of love, childbirth, rejection, suffering, and resistance to suffering. It speaks of a corporeal history where a cultural background is written, values are stamped, self-and worldview

9 IS PAIN SUFFERING? / 41 are grounded, pain does battle, and the meaning of life is played out (Scheper-Hughes & Locke, 1987, 1991). Mrs. S. reported that she remembered little about the first year after leaving the hospital, except that she drank a lot, had thoughts about killing [her] husband, and that her parents insisted that she live with them for a while. Her husband remarried someone he met while [they] were still married. Raising her son became her first priority; her ex-husband had no interest in maintaining a relationship with him. Although she was eventually healed of the disease, suffering became a part of her life for the next ten years. The very next year at the very same time that I became ill the first time, I became ill again. Pain in the lower abdomen and bleeding profuse bleeding, a temperature. Yet they could find nothing wrong. And I became pitifully thin during this time. I was being eaten away with bitterness and anger. And every year like clock work it happened. All sorts of tests were taken, nothing showed what would cause this pain, the same pain that I had the first time. I ll never forget. Ah... I had a doctor whose office was near where I lived. He said, I have never seen anything like this, there s nothing to indicate that this should be happening. But it did. So (long pause) my doctor recommended a hysterectomy. Mrs. S. body replayed the original symptoms of gonorrhea on the anniversary of its onset. Her doctors noted, similar to the doctor who moved her from the prostitute ward to the miscarriage ward, that she was a special case; there was nothing organically or physically wrong with her. Long after her body was healed of the disease, it commemorated the start of her suffering and kept it alive in at least two ways: 1) she became pitifully thin after her divorce, admitting that anger and bitterness against her husband were eating her away and 2) his betrayal was inscribed in her organs. The help she sought and found was medical; her doctors returned to the root of her pain and excised the remembering parts of her body. Mrs. S.: And I felt so much better afterwards. I never had any trouble in that area. Interviewer: Why do you think that was? Mrs. S.: (Pause) It was a sort of closure. That s the only way that I can describe or explain it closure. As if it were (pause) my body was saying well, now this is it and ah, never any problems. (Author s emphasis). Mrs. S. and her doctors chose an operation that would remove aberrant body parts and expunge memories. A hysterectomy played out the tragedy of her marriage, illness, divorce, her husband s betrayal and her body s memory of him. Closure came through the expulsion of her reproductive organs.

10 42 / BLACK AFTERWARD When Mrs. S. son was thirteen years old, she met a man who was active in the community and in children s groups, and eventually married him. She described her life after her second marriage as comfortable. As an elder in the church, her husband was liked and respected, and she in turn became a church mother, which was a position of status and influence. Although she described her second marriage as not all romance she believed that, with him, she came to know what love is all about. When both her mother and father became ill, Mr. S. took them into our home and cared for them like they were his own. BENEFITS OF SHARING THE SUFFERING STORY Toward the end of the interview, I asked Mrs. S. about some of the lessons life had taught her. She considered. The major lesson that I learned in life is to be honest to myself and others. Even though it might be hard to swallow at first, it s better. This goes back to the dishonesty that was used by my husband. I know the hurt, the pain, the suffering that I felt because of his dishonesty. I know that it s better to, to, ah, hit hard right away. Be honest; hit hard. Because in the long run, it s better. As I was ready to turn off the tape recorder after our last session, Mrs. S. told me that a few days after our second interview, she approached her grandson for the first time in order to talk about his grandfather. She had put him off when he asked about his grandfather after his death several years previously. She was afraid, she admitted, that painful emotions would be summoned by any discussion of her first husband. I realized that I, I have felt things that I had sort of submerged. Since we talked I do realize ah, this has awakened a lot of things that ah, I had put aside. But that s not bad. Saturday when my grandson was here I talked to him about things he had wondered about. Ah, his grandfather, who was my husband ah, he wanted to know about his family. He wondered, Why did he not want to know us? What was it all about? And I was able to talk freely to him about it. I ve often thought how he should know who his grandfather was, who his grandfather s people were, what sort of people they were. He has a right to know. (Pause) It s come full circle now. If there is a psychological and spiritual imperative for elders to tell a story about personal suffering, then there is a moral imperative for someone to be an audience to such experiences (Schweizer, 1994). The lack of such a listener and despairing awareness of that lack is an important element in suffering at any age (Bregman, 1999). In old age suffering may be compounded by the belief that one s story is no longer interesting or that there are few or no persons left to understand

11 IS PAIN SUFFERING? / 43 the history of the story. Fortunately, Mrs. S. wanted her grandson to be that listener, and he had been awaiting her story. INTEGRATION OF THE SELF AFTER SUFFERING Although body and self are sometimes used interchangeably, pain may separate body and self into discrete entities as a subject (self) who laments the disruption of the object (body). As Mrs. S. reveals in her narrative, the experience of suffering is more than the sum of its parts anguish, despair, pain, regret. The body in unbearable pain was linked to memories of betrayal and a sense of hopelessness, showing the unity of body, mind and spirit in her experience of suffering. For Mrs. S., suffering was the assault against self-integration, as well as the herald to re-integrate the self in order to alleviate suffering. One way that Mrs. S. attempted to re-integrate herself was by undergoing a hysterectomy. Yet, her narrative showed that re-integration of the self was a process that took place over decades. Only when she told her grandson about his grandfather did her story of suffering come full circle the phrase itself indicative of integration. Mrs. S. s narrative shows that issues of suffering are ultimately issues of identity, personhood and relationship in the face of assault. I asked Mrs. S. at the end of our third and final session if she had experienced discomfort or upset because of the deep and painful issues that were raised by our discussions. I have felt things that I had submerged since I talked about them. But that s not a bad thing. Some of what has surfaced in my mind are things that I had tucked away neatly, you know. But they did exist, they did happen and tucking them away neatly doesn t change anything. Since we ve had these discussions I ve had dreams. In one dream I turned around and confronted whatever it was that was ah, it was frightening me, yet I didn t know why I was frightened. And once I turned around and faced it and said, Get away from me, leave me alone, I don t think I ever had the dream again. DISCUSSION A key finding in our research on suffering, and in the case example presented in this article is that the self strives by various means to regain the unity that suffering threatens. Integration of the self after suffering is often accomplished by viewing suffering as having meaning, purpose and value to the life lived. There are routes by which meaning can be created or discovered, such as through religious beliefs, life review, or a sense of generativity, that is, someone else may learn from my experience. Meaning also may be found through the narrative constructed in the forum of the interview. The narrative adheres the suffering experience to the life lived.

12 44 / BLACK As we see in Mrs. S. narrative, her questions (both past and present) about suffering are ultimately not clinical but are questions of meaning. Whether Mrs. S. tremendous pain was or was not suffering depended on both internal and external matters, such as the despair she experienced following her husband s betrayal. In other words, the experiential content of suffering is often ambiguous, complex and paradoxical. Although Mrs. S. defined suffering as pain, her story of suffering revealed unique components hope and betrayal that either ameliorated the pain or exacerbated it until it became suffering. The intensity of her suffering brought attention to the bodily site her reproductive organs of her husband s betrayal. Because no particular organ could be blamed, the medical response was to perform a full hysterectomy on Mrs. S, which was the usual remedy, in the 1960s, for chronic pelvic pain in the bodies of women who could not bear children (Northrup, 2002). Unfortunately, although Mrs. S. said that her pain ended with the operation, her suffering continued. Mrs. S. story of suffering could not stand outside of her life story. The fact that she had a story of suffering to tell is significant; it meant that her suffering experience had been processed in some measure. She wanted important others, such as her grandson, to know that her life was shaped and continues to be shaped by the long-ago, traumatic events illness and divorce that emerged through a relationship of love, yet engendered suffering. In this, some resolution to her suffering seemed to occur during our interview. Mrs. S. had been waiting to tell her story, and her grandson had been longing to hear it. Mrs. S. story of suffering also revealed a sense of hope. That is, suffering may be that which pushes individuals to the edge of life the site of liminality due to intense experiences and enables them to find meaning in those experiences. For Mrs. S., an important activity of suffering is not only to find meaning for it, but also to share that meaning with someone. She had reached suffering s periphery, assessed the landscape, and turned back with story in hand. REFERENCES Belsky, J. (1997). The adult experience. St. Paul, MN: West Publishing Company. Black, H. K. (2001). Jake s story: A middle aged, working class man s physical and spiritual journey toward death. Qualitative Health Research, 11(3), Black, H. K. (2002). Different ways to hurt: An elderly woman s narrative of suffering. Journal of Aging and Identity, 7(1) Black, H., & Rubinstein, R. (2004). Themes of suffering in later life. Journal of Gerontology, 59B(1), S17-S24. Bregman, L. (1999). Beyond silence and denial. Louisville, KY: Westminster John Knox Press. Brodwin, P. (1992). Symptoms and social performances: The case of Diane Reden. In M-J. DelVecchio Good, P. E. Brodwin, B. J. Good, & A. Kleinman (Eds.), Pain as human experience: An anthropological perspective (pp ). Berkeley, CA: University of California Press.

13 IS PAIN SUFFERING? / 45 Bruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard University Press. Carson, R. (1986). Case method. Journal of Medical Ethics, 12, Charmaz, K. (1999). Stories of suffering: Subjective tales and research narratives, Qualitative Health Research, 9, DePoy, E., & Gitlin, L. (Eds.). (1998). Introduction to research: Understanding and applying multiple strategies (2nd ed.). Philadelphia: Mosby. Frank, A. (2001). Can we research suffering? Qualitative Health Research, 11(3), Frank, A. (1995). The wounded storyteller. Chicago, IL: University of Chicago Press. Freccero, J. (1992). Autobiography and narrative. Chicago, IL: The University of Chicago Press. Glaser, B., & Strauss, A. L. (1967). The discovery of grounded theory: Strategies for qualitative research. Chicago, IL: Aldine Publishing Company. Huyck, M. (1990). Gender differences in aging. In J. E. Birren & K. W. Schaie (Eds), Handbook of the psychology of aging, third edition (pp ). San Diego, CA: Academic Press. Johnson, M. (1987). The body in the mind. Chicago, IL: University of Chicago Press. Kleinman, A. (1988). The illness narratives. New York: Basic Books, Inc. May, W. (1991). The patient s ordeal. Bloomington, IN: Indiana University Press. Mischleev, E. (1986). Research interviewing: Context and narrative. Cambridge, MA: Harvard University Press. Northrup, C. (2002). Women s bodies, women s wisdom. NY: Bantam. Reissman, C. (1997). Narrative analysis. Newbury Park, CA: Sage Publications. Sarbin, T. (1986). Narrative psychology: The storied nature of human conduct. New York: Praeger. Scheper-Hughes, N., & Locke, M. (1991). The message in the bottle: Illness and the micropolitics of resistance. The Journal of Psychohistory, 18(4), Scheper-Hughes, N., & Locke, M. (1987). The mindful body: A prolegomenon to future work in medical anthropology. Medical Anthropology Quarterly, 1, Schweizer, H. (1994). To give suffering a language. Literature and Medicine, 14(2), Strauss, A.L., & Corbin, J. (1990). Basics of qualitative research. Newbury Park, CA: Sage. Direct reprint requests to: Helen K. Black, Ph.D. Thomas Jefferson University Center for Applied Research on Aging and Health Suite South 9th Street Philadelphia, PA

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