Making Sense of Pain: Critical and Interdisciplinary Perspectives

Edited by Jane Fernandez Making Sense of Pain Probing the Boundaries Series Editors Dr Robert Fisher Dr Daniel Rih...

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Edited by

Jane Fernandez

Making Sense of Pain

Probing the Boundaries

Series Editors Dr Robert Fisher Dr Daniel Riha

Advisory Board Dr Alejandro Cervantes-Carson Dr Peter Mario Kreuter Professor Margaret Chatterjee Martin McGoldrick Dr Wayne Cristaudo Revd Stephen Morris Mira Crouch Professor John Parry Dr Phil Fitzsimmons Paul Reynolds Professor Asa Kasher Professor Peter Twohig Owen Kelly Professor S Ram Vemuri Revd Dr Kenneth Wilson, O.B.E

A Probing the Boundaries research and publications project. http://www.inter-disciplinary.net/probing-the-boundaries/ The Making Sense Of: Hub ‘MSO: Pain’

2010

Making Sense of Pain Critical and Interdisciplinary Perspectives

Edited by

Jane Fernandez

Inter-Disciplinary Press Oxford, United Kingdom

© Inter-Disciplinary Press 2010 http://www.inter-disciplinary.net/publishing/id-press/

The Inter-Disciplinary Press is part of Inter-Disciplinary.Net – a global network for research and publishing. The Inter-Disciplinary Press aims to promote and encourage the kind of work which is collaborative, innovative, imaginative, and which provides an exemplar for inter-disciplinary and multi-disciplinary publishing.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means without the prior permission of Inter-Disciplinary Press.

Inter-Disciplinary Press, Priory House, 149B Wroslyn Road, Freeland, Oxfordshire. OX29 8HR, United Kingdom. +44 (0)1993 882087

ISBN: 978-1-84888-36-8 First published in the United Kingdom in eBook format in 2010. First Edition.

TABLE OF CONTENTS Introduction Jane Fernandez

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Section 1: Making Sense of Pain: Breaking the Mould The Ambiguity of Pain Sascha Benjamin Fink

3

Who is Able to Feel Pain? A Cartesian Attack on the Bête-Machine Anik Waldow

13

The Mind/Body Problem in Contemporary Healthcare Gillian Bendelow

21

An Uncertain Anodyne: Making Sense of Pain through Mesmerism in the Nineteenth Century Elizabeth Todd

31

Journeys with Chronic Pain: Acquiring Stigma along the Way Amanda Nielsen

43

Connecting Pain and Drug Use in GLBTQ Communities Ian Flaherty

55

The Trajectory of Chronic Non-Cancer Pain in Six Patients: A Roller Coaster Ride Ruth Ellen Dubin

67

Section 2: Making Sense of Pain: Liminality of Spaces The Clinical Conversation about Pain: Tensions between the Lived Experience and the Biomedical Model Milton Cohen & John Quintner Inflicting Pain Hildur Kalman & Naomi Scheman

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The Audiences of Pain: The Indonesian Audiences’ Response to Human Rights Documentaries Kurniawan Saputro

109

Communication with Emotions: Use of Emotional Intelligence as Pain Relief Yavuz Tuna

117

Pain and Personal Experiences of Cancer: A Complex Intersection Heather McKenzie

133

Revelational Indicators: A Framework for Analysing Pain Shona Hill

141

How to Listen to Chronic Pain Narratives Mary Buchinger Bodwell

153

Section 3: Narrative Textuality and Revolt: Speaking the Body of Pain Eros and Thanatos: The Murderous Struggle of Pain and Desire in Gabriele D’Annunzio’s Triumph of Death and in Lars von Trier’s Antichrist Angela Tumini

165

Gravity’s Rainbow: The Baroque Folds and Contanus Sese Conservandi in Tarsem Singh’s The Fall Yen-Chen Chuang

173

Pain and the Performing Musician: The Interplay of Culture, 185 Cancer and Identity Meghan Neaton, Jean Giebenhain, Sarah Schmalenberger, Lisa Starr & Charles Gessert Dancing in Other’s Shoes: Between Pain and Pleasure Daria Radchenko

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The Erotics of Pain: BDSM Femslash Fan Fiction Malin Isaksson

203

The (Swedish) Zombia and the Welfare State: Politics and Emotion in John Ajvide Lindqvist’s Handling the Undead Katarina Gregersdotter

211

Post-Independence Malaysian Short Stories: A Depiction of Racially Inflicted Pain Nor Hashimah Isa

219

Painstaking Pain: Alice McDermott’s Child of My Heart Hoda Elsayed Khallaf

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The Discourse of Cutting: A Study of Visual Representations 237 of Self-Injury on the Internet Hans T. Sternudd Shooting Pains: Addressing Illness-Related Pain through Video Autobiography Broderick Fox

249

Negotiating Pain: Beyond Nostos to Co Presence in Flanagan’s The Sound of One Hand Clapping Jane Fernandez

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Acknowledgement On behalf of the participants of the Making Sense of Pain Conference, I wish to thank Mira Crouch, Rob Fisher, Nancy Billias and Inter-Disciplinary.Net for providing the forum for the conversations on the theme of pain at this conference. Special thanks to Mira for making the conference collegial, comfortable, structured, stimulating and focused. On a personal note, I wish to thank my husband, Stephen Goldborough, for many hours of support in putting this book together.

Introduction Jane Fernandez Your pain is the breaking of the shell that encloses your understanding. Even as the stone of the fruit must break, that its heart may stand in the sun, so must you know pain. And could you keep your heart in wonder at the daily miracles of your life, your pain would not seem less wondrous than your joy; And you would accept the seasons of your heart, even as you have always accepted the seasons that pass over your fields. And you would watch with serenity through the winters of your grief. Gibran, The Prophet. I begin the introduction to this volume of conference proceedings on Making Sense of Pain held in Sydney in February 2010, by appropriating Gibran’s metaphor of the breaking shell with its connotations of enclosure (spaces), rupture (contours/shifting contexts) and flow (essence/ understanding) for my purpose. Gibran’s metaphor of the breaking shell conveys the metaphysical reality of pain, its intricate and intimate essence located within the secret splits and grooves of our wounding. For Gibran, pain is a season whose memory sleeps till it is renewed in a new season of awakening; an unwelcome guest who promises perhaps a deeper awareness of mystery. For Gibran pain is a discipline inherent in the natural framework of living organisms like ‘the stone of a fruit’ that must submit to the harsh sun, a necessary secret that waits to unfold to us the grander and deeper insights to human existence. Against the heightened awareness of our pained sensibilities, Gibran invites us to focus on ‘the daily miracles of our lives so that our ‘pain would seem less wondrous than joy’. Gibran’s paradox is encapsulated in this absurdity, this kernel of truth that all things are less and more than they seem, that something of the Other lies asleep in our deepest conceptions of Self and Life! We could well ask, how indeed, could pain pierce us with wonder? Can we not know joy or beauty without knowing our wounding? Perhaps this is the transition from pain to knowledge/suffering to understanding/mystery (flow); somewhere in that space between feeling, living and meditating, mystery converts pain to awe. And our attempt in making sense of pain could begin here. Gibran characterizes pain as ‘the breaking’ mystery, a signifier pointing to the sign: the broken body /shell through which ‘understanding’ spills/flows. The poem draws us into the transitions of mourning and acceptance and ‘serenity’ in the face of a phenomenon we cannot change or deny, the inevitable dilemma of pain. Pain strikes a pose with ambivalence, inside/outside, in-between and all the time sliding away from resolution, like a phantom that cannot bear too much light. The meaning of pain is negotiated in the poem through a series of oppositions that are systematically raised and collapsed: shattering and enclosing, pain and joy, and

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__________________________________________________________________ serenity and grief. Conceptually, the poem contests the meanings it methodically evokes and cancels and eventually slides to embody its induced contradictions. If we followed the trajectory the poem positions us within, we could say that pain is elementally, paradoxically and repetitively rupturing its own skin. If pain is the breaking of the body in its ‘enclosed…understanding’, the body itself holds only a residue of the meaning of pain. Its real meaning is the spilled understanding, the intersection of the framework of the political and social and spiritual realms that defines us. In short, most of us work and live and laugh and grieve not as monolithic units but as a symphony of many selves marked by the social and cultural baggage we are bogged in. Taking Gibran’s cue, we could say that pain is, like the actor occluded, a masked persona who waits for someone/something to locate and retrieve the real embodied subject. We could also say that pain is an economy that works and demands something of us; an economy that taxes too often the limits of our strength; an economy reliant on the intersubjective positioning of colluding and competing determinants of the Self in its shifting contextual frames. Accordingly, Gibran tells us that the management of pain can be converted into strength. The poem invites us to search for the trajectories of the meaning of pain; its implicit signs that point inside/outside, within/without the secret, sacred spaces of the Self. This is the secret of pain. It points to the silent, secret wounds of the sacred self, the whole embodied person in both its metaphysical, social, political and contextual framing. It is this qualified slipperiness of meaning and the contradiction embedded in the pain discourse in the poem that I wish to appropriate as a controlling paradigm for this collection. In summary, the catalogue of papers presented attempted to grapple with the terrain of what is without doubt a contestable and increasingly ambiguous term ‘pain’. Linguistically, conceptually, metaphorically and scientifically, the term evades decipherability and its mystique remains largely impenetrable. And this, arguably, some would say, extends the pain of Pain. Scholars who try to coin definitions of pain and moderate emerging attitudes to pain allude consistently to pain’s embedded meanings, its performance and witnessing contexts, its layered phenomena i.e. its ‘deep subterranean fact’1 and its ‘resist[ance] to verbal objectification.’2 The meaning and contextual application of the term ‘pain’ has been stretched and strained over the last several decades by pressures placed upon scientific and medical boundaries of the limited use and application of the term. Traditionally, pain has been assessed on the basis of the ‘the biomedical model’. From this perspective, the body is a clinical unit, a ‘machine […] composed of separate and replaceable parts, controlled by one’s physiology and capable of being ‘worked on’ from the outside’, an automated, ‘dissect[able] specimen ‘isolated from his or her social sphere [...].’3

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__________________________________________________________________ The failure of classical biomedical models is its denial or circumvention of the ‘subterranean’ reality of pain, the embedded layers that wait to speak itself into existence. As early as 1959 Engel notes that ‘pain can never be neutral.’4 By 1967, Merskey and Spear emphasize the need ‘to evaluate both the pain experienced by the patient and the patient experiencing the pain.’5 In 1973 John J. Bonica, noted that ‘Pain is a malefic force which often imposes severe emotional, physical, and economic stresses on the patient, on his family, and on society.’6 By 1980s Scarry tells us that pain is not a single deducible subject but rather determinant of a threein-one positioning of inter-related and complex variables, each embedded in the other: ‘first, the difficulty of expressing physical pain’, second, ‘the political and perceptual complications that arise out of that difficulty’ and third, ‘the nature of both material and verbal expressibility.’7 Wall in 1999 writes that ‘pain is a syndrome that joins together a coincident group of signs and symptoms, rather than a single phenomenon. It could be that we are aware of the combination of events rather than of pain as single, separate event.’8 Even within these parameters, pain continues to confound the attempts of pain therapists/practitioners to understand or manage it, as in the case of ‘[… ]a surprisingly large proportion of people suffering pain’ who do not have identifiable tissue pathology or other evidence of a pathophysiological process […].’9 Given that making sense of pain will continue to accrue progressive controversies as much as qualified consensus, we are indebted to those who over time have added to our understanding of pain. One of the clear strands that emerged from this conference was the need to collaboratively address the limitations of a clinical view of pain. The dialogue throughout this conference merged on the biopsychosocial terrain of the human persona: the emotional, social and psychological framing of the human personality. This conference proceeding provide an attempt to extend the conversation on pain, notwithstanding that the boundaries of the word ‘pain’ are characteristically blurred by connotations of suffering and trauma. The variety of papers in this collection transgress these boundaries knowingly, inviting a more expansive rather than narrow definition of pain. In this context, Wall’s observation is pertinent. Wall observes: because classical theory assigns different parts of the brain to the task of the primary sensory analyses and the task of adding affect, one would expect some disease to separate pain from misery. No such disease is known. […] There has never been a report of pain evoked that was not accompanied by fear, misery or other strong affects.10 The horrors of violence in our times deepen our inability to articulate the nature of our pain and delineate it from grief or misery or indeed fear. It could be argued

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__________________________________________________________________ that all pain is tied inevitably to fear, the fear of the unknown, the absurdity of life and the incomprehensibility of the universe. What is unbearable is not to suffer, but to be afraid of suffering, to endure a precise pain, a definite loss, a hunger for something one knows - this is possible to bear. One can live with this pain. But in fear there is all the suffering in the world; to dread suffering is to suffer an infinite pain since one supposes it unbearable.11 It appears in the 21st century, the capacity to imagine an ‘infini[ty]’ of pain escalates the pain syndrome. The level of information we are privy to in an information- rich age complicates further our attempt to retrieve the real subject of pain. When we speak of pain, we invoke several archetypes: the hero, the beloved, the enemy, the divine, the witch, the victim, the physician, the heretic, the inquisitor, the torturer, the tortured. Perhaps, it would be appropriate to say that like Jung’s archetypes, pain ‘speaks with a thousand tongues.’ The utterance of pain splits and dissolves language, history and positionality. Kenneth Craig argues that the ‘evolution of human capacities for cognitive processing and social adaptation necessitate a model of pain incorporating these capabilities (interpersonal processes).’12 To a considerable extent, basic and clinical science research effort has been committed to establishing the biological bases of the sensory, emotional, and motivational features of this particular system protective of self-interest. But that is a limited perspective on pain in humans.13 Humans evolved and acquired cognitive (language, abstract reasoning, problem solving) and affective capabilities (…) necessary to support remarkably complex social situations and practices.14 Further, Craig argues the ‘[t]he capacity to protect others, reflected in the potential for empathy, altruism and compassionate care giving, appears to be superimposed in more evolved, social species on the ancient self-oriented systems, which in the case of pain supported behavioural escape and avoidance.’15 Against this we must measure our capacity for cruelty, which extends also the story of pain. Accordingly, the dominant narratives of our time impact shape and revise our concepts of pain. It is no surprise to scholars that the 20th century with its twin great wars, its catalogue of civil and global violence intensified the search for answers in relation to the meaning and management of pain. Since the Second World War, attitudes to pain have been influenced by the sheer size and nature of

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__________________________________________________________________ human casualties. The horrors of the holocaust reframed the metaphysical enquiry into questions of life and death in the context of the limits/excesses of human cruelty. Two World Wars, neo-colonial practices, global and civil strife, the realities of torture, genocide, terrorism, remind us that the micro-narratives of pain have a larger political and socio-cultural economy that shapes them. In terms of the holocaust, Primo Levi, writing in the context of Auschwitz remarks: ‘Anyone who has been tortured remains tortured.’16 In the context of more recent conflicts, Hoda Khallaf’s reading of Child of My Heart is poignant in articulating how our narratives could serve as ‘an antidote’ to ‘the useless longings of all of us who get left behind’. Indeed, for those of us who imagine that there is a ‘country’ beyond pain, it would serve well to be reminded that ‘[t]he ‘beyond’ is neither a new horizon, nor a leaving behind of the past [...].’17 To cite Cohen & Quintner’s framework which opens Section 2 of this collection, pain is an aporia, a mystery within which we are locked. In this context, Charon astutely locates this mystery as embedded in the intersection of the lived experience of the social self: ‘By virtue of having dedicated yourself to the mystery of pain, you are on the frontier of mind/body, of definition of self, of the convergence of the physical and the mental and the spiritual […].18 The problem of pain is so pervasive that whatever our frustrations; we continue to look to health and medical practitioners to redeem the suffering body/mind/ psyche. But despite the fact that pain is the single most dominant medical complaint, Wall argues that the medical profession fails to address this in its inability to prioritise pain studies in the training of medical doctors. In the preclinical years, pain can be ‘explained’ in fifteen minutes by mouthing the hundred-year-old myths that there are pain fibres in the peripheral nerves and a pain tract in the spinal cord with a pain centre in the thalamus. A few hours of lecture have been inserted to cover the whole of psychology. The pharmacologist may give a one-hour lecture on analgesics. In the clinical years there may just be a single session on pain. This means the fully qualified doctor usually merges with only three to four hours of tuition on pain.19 To what extent has this limitation been addressed in the last decade? The papers in this catalogue that appeal for a more transcendent understanding of the Self audit this concern and call for more attention to be paid to the psychological, affective and spiritual needs of the patient. Speaking specifically of chronic pain, Charon writes that it is ‘today’s equivalent to other time’s tragedies – widespread epidemics in one age, the crisis of faith in another – a devastation that comes, unannounced to those who have

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__________________________________________________________________ done nothing to deserve it.’20 The sacrificial connotations of Charon’s definition of pain are unmistakable: ‘It probably stands for death or for sacrificial suffering 21 that occurs randomly to some and spares the rest of us – epidemiologically speaking – the need to suffer ourselves.’22 Charon’s sacrificial typology here evokes Rene Girard’s thesis on the relationship between violence and the sacred.23 Girard’s proposes that violence is deflected from a community through the appointment of ritual scapegoats. Whereas in Girard, the scapegoat is deliberately chosen to purge a community, here, in our study of pain, on one level at least, the scapegoat is random. Clearly, the uncertainty/fear of our own election to the sacrificial altar complicates the pain syndrome. But there are other implications for this study of pain? Who indeed are the scapegoats in our community? To what extent are pain complaints, manifestations of deeper levels of scapegoating and displaced or misplaced violence? How do we map pain in the twenty-first century? If the seamlessness of pain, its mystique, its untranslatability has confounded theorists, researchers and practitioners, what leaps must we make against the backdrop of post-modern pressures? The old problem of pain is its apparent defiance of language, its unspeakability that accounts also for its power to induce helplessness in the self in pain. Scarry points out ‘[p]hysical pain does not simply resist language, but actively destroys it.’24 For too long, pain has been treated as a spectre that shatters language; a transgressive phenomena resisting meaning and codification. No sooner do we name one type of pain that we recognize that we have included too much of what is not and excluded too little of what is. The conference theme Making Sense of Pain is an attempt to investigate/locate/retrieve/create a language for pain. Making Sense of Pain calls for collaborative research, the application of interdisciplinary models and intertextual reframing of the meaning of pain as anticipated in the interdisciplinary initiative of this conference. Accordingly, the conference facilitated dialogue between wide-ranging disciplines, which as a rule are regarded as autonomous and self-reliant. The interdisciplinary conference format endorsed the broadening understanding of pain which merited participation from a field as diverse as medicine, literature, film, life writing, history, social studies, psychology and philosophy to address what is arguably one of the most urgent, complex and emergent fields of inquiry. The overall tone of the conference embraced a more ‘holistic’ approach to the field of pain studies. For instance, Gillian Bendelow’s paper audits the necessary shift from a dualistic to ‘a mind/body/society perspective’, in the treatment and management of pain. She calls for a ‘dissolution of the artificial divides between mental and physical health.’ Both Bendelow and Yavuz Tuna emphasize the ‘role of emotions in health and illness.’ In ordering the sequence of papers here, I return to Gibran’s metaphor of the breaking/broken shell/seed as my rationale for the structure of this collection. The shattering, spilling, flowing elements raised by the image of the breaking shell

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__________________________________________________________________ reflect the focus of the majority of papers, breaking the mould of traditional concepts/ treatment/ management of pain and encouraging the flow of new currents and interdisciplinary and multidisciplinary dialogue. The tension between the science and humanities is productive and celebratory in that several papers privilege the role of narrative in the treatment and management of pain. Ethics, empathy, compassion are key words that circulate in one form or another throughout this collection. Of particular note are key ideas raised through Cohen & Quintner’s profiling the ‘third space’, Khalman and Scheman’s ‘inflection’ flow, Han’s Sternudd’s ‘third position’, Broderick Fox’s ‘performing pain’, Mary Bodwell’s logos and Shona Hill’s ‘sacred associations’. This collection of papers is divided into three sections: Section One: Making Sense of Pain: Breaking the Mould explores the limitations of the classical definition of pain as well as moderates the modern definition provided by the IASP in the light of emerging views of pain in the context of the ideals within the ethical and moral parameters for the twenty-first century. The papers in this section speak to, explicitly or implicitly, the limitations of the definition of pain and raise the ethical implications of these gaps. What indeed are the ethical dilemmas in relation to pain-inducing scientific experiments, stigmatisation, chronic pain and education? Sasha Fink’s paper followed by Anik Waldow’s appropriately introduces this collection because it declares centre stage what should be the underlying framework for the study of pain, the prevention and management of pain as an ethical and moral responsibility. Fink’s premise that ‘pathological and nonpathological cases prove evidence that there is no common feature shared in all cases falling under pain’ is the platform shared by several of the papers presented in this book. Accordingly, Fink argues that in the light of the ‘ambiguity of pain’, ‘ethical theorists’ need to clarify ‘exactly what kinds of pain are ethically relevant.’ Further Fink cites more recent findings that ‘lots of nonhuman entities like animals…are able to feel pain in a morally relevant sense’. It is this debate that Waldow extends. Waldow argues that ‘overemphasis on language and conceptual capacities is mistaken when it comes to answering the question of who can feel pain’. The search for distinctions between animals and humans is an old and ongoing debate. Orlans in In the Name of Science qualifies the perception that ‘much original research is for biomedical purposes –’ by pointing out that animals are also used in ‘in weapons development’. ‘In the United States, dolphins have in the past been used as carriers of lethal weapons’.25 Accordingly Orlans observes that debates over the last two centuries have not resolved the issue of animal experimentation: ‘a consensus is yet to be reached on who or what has moral standing and what is the nature of the moral relationship between humans and animals.’26

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__________________________________________________________________ Elizabeth Todd’s discussion of mesmerism qualifies the role of the historian in critiquing the ‘pain of the past’ and in this sense also invites investigation into the ethics of research and study. Further, Todd’s premise that the historian’s understanding of pain ‘involves some imaginative exercise’ in the ‘envisioning of the ‘historical actor suffering pain’ is pertinent to the entire study of pain. It calls for a more imaginative response to investigations within this field of study. Amanda Nielsen’s study of stigmatisation demonstrates how the language of pain, the scepticism of the medical profession can strengthen stereotypes of already burdened patients. Similarly, Ian Flaherty’s study explores how cultural stereotypes advance ‘negative narrations of the self’ and affect the level to which individuals use drugs as coping mechanisms. Ruth Dubin’s paper is the first to ‘graphically depict [chronic pain trajectory] over several decades’. In breaking the mould, Dubin calls for more attention to be paid to ‘psychosocial problems’ that impact and deepen the experience of pain. More significantly, Dubin’s study calls for an overhaul of political, health and financial systems. Dubin endorses the management of pain as a ‘basic human right’ and closes this section by mapping the implications of narrow clinical definitions of pain and the associated ethical dilemmas of institutions that directly impact on the Self in pain. In Section 2 of this collection entitled Making Sense of Pain: Liminality and Spaces, I have positioned papers that argue for a new way of knowing pain, a place of transition or liminality, a space of ambiguity, a space where contesting ideas can exist and collude with the imagination to move us beyond fixed ideas of pain or the Self-in-Pain. I have positioned Milton Cohen & John Quintner’s paper to open this sequence because their paper critiques the limitations of the historical pain models measured against the ‘lived experience of pain.’ More importantly, their privileging empathy and intersubjectivity, through appropriating Winnicott’s concept of the ‘third space’ as the potential site of the intersubjective exploration of the ‘patient and clinician’ speaks pertinently for the opening up and subversion of the traditional binary borders of pain characterization. In this context, Rita Charon affirms that ‘[...] medicine is confirming a growing understanding of the pivotal importance, in the outcome of care, of who the patient is, who the doctor is, and the authentic relation and dialogue between them.27 At this juncture, an investigation of Bhabha’s concept of the Third Space could be of further use to our study of pain, given the directions proposed by several papers in this collection for communicating the language of pain, speaking pain and attending to social and cultural factors in rewriting the discourse of pain. Bhabha writes that ‘interpretation is never simply an act of communication between the I and the You designated in the statement.’28 Rather, ‘[t]he production of meaning requires that these two places be mobilized in the passage through a Third Space, which represents both the general conditions of language and the specific implication of the utterance in a performative and institutional strategy of

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__________________________________________________________________ which it cannot ‘in itself’ be conscious.’29 For Bhabha, the ‘act of interpretation’ produces an ‘ambivalence’ which destroys any ‘hierarchical claims to the inherent originality or ‘purity’ of cultures’30. It is that Third space, though unrepresentable in itself, which constitutes the discursive conditions of enunciation that ensure that meaning and symbols of cultures have no primordial unity or fixity, that even the same signs can be appropriated, rehistoricized and read anew.31 Just as for Bhabha, the ‘burden of the meaning of culture’ lies in the ‘inbetween space,’32 so too can we suggest that the ‘burden of the meaning of’ pain can only be negotiated in the in-between space, the Third Space. In other words, pain performs in a third space, alluding to I and You and Other, constrained by language and a series of miscarried signs, sounds and silences. For those who argue that pain speaks as an alien, foreign, contaminating presence, the third space provides an accommodative space to negotiate this unspeakability. Given that pain’s apparent indecipherability can exact real, temporary, slippery and often catastrophic approximations, our use of Bhabha’s focus on ‘inter’ as the cutting edge of translation and negotiation is useful and reinforces the underlying framework of several papers in this collection in naming the ambiguity of pain. To that end we should remember that it is the ‘inter’ – the cutting edge of translation and negotiation, the in-between space – that carries the burden of the meaning of culture.33 These ‘in-between’ spaces provide the terrain for elaborating strategies of selfhood – singular or communal- that initiate new signs of identity, and innovative sites of collaboration, and contestation, in the act of defining the idea of society itself.34 In this vein, Hildur Kalman and Naomi Scheman call for a marking of the space between ‘the expression and acknowledgement of pain.’ Kalman and Scheman argue that this space is not ‘empty’. It acts and is acted upon. Kalman & Scheman call attention to this ‘social space’ to consider ‘how meaning of pain, even pain itself, inflect that space and is inflected by it. In fact, they challenge that there is such a thing as the pain itself uninflected, pre-social. Similarly, Shona Hill’s bodies-in-pain ideal type framework reminds researches and policy makers that pain is, [....] neither pure biology nor pure culture but merges at the intersection of bodies, minds and cultures. Hill’s model enables language by stabbing at the mystique of pain. Of significance is also Hill’s proposition of the relevance of a sacred register for pain, even in a secular society. Further, Hill’s study of three

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__________________________________________________________________ paintings of Golgotha has implications also for those who desire to break the silence that accompanies not just illness but disfigurement.35 Yavuz Tuna’s study of the role of emotional intelligence has implications also for the value of the affective domain in the study of pain. Saputro’s study of Indonesian audiences’ perceptions in relation to the depiction of pain in two human rights documentaries, measures the space between the production, the viewing and the translation of distinctive responses in relation to empathy, sympathy and pity. Heather McKenzie’s study highlights how cancer survivors live in a liminal space, fearing the recurrence of cancer. This space is contested by both real and imaginary fears based on collective understandings of cancer and by the experience of fear and anxiety that is not socially validated and therefore not able to be expressed. In this regard, McKenzie’s study extends this discussion by implicating social taboos that disallows speech/confession of fears as impacting also on the pain syndrome. Accordingly, Mary Bodwell’s appropriation of logos to profile the management of chronic pain brings together the gaps positioned and articulated by the previous papers by her underscoring the power of narratives/stories as pathways to healing. Bodwell cites Bakhtin and Heidegger in implicating language as historical and social performers. I have positioned Bodwell’s paper strategically at the close of the section on the Third Space and as a means of leading into Section 3 on the textuality of pain. Bodwell’s paper asks us to revisit ideas about the language void in the study of pain and investigate the means to locate and birth the subject of pain in logos, the word made flesh. Section 3 Narrative Textuality and Revolt: Speaking the Body of Pain brings together the rest of this collection by profiling the papers that deal with the discourse of pain. In profiling Section 3, I wish to cite Kristeva’s concept of revolt in relation to anamnesis. Kristeva in explaining anamnesia elaborates that: In anamnesia we have the possibility of entering as afar as possible into the investigation of infantile memory to discover the most distant memories of our childhood. These are so often traumatic memories. In this journey, a strange transmutation occurs in our language. In speaking, in traversing the universe of signs, we arrive at emotions, at sensations, at drives, at affects and even what Freud named the umbilicus of the dream. This is something unnameable, which becomes, none the less, the source of our investigation.36 Perceived through this lens, one could argue that narrative texts reflect and imitate the ambivalent, chaotic and deep structuring of the process/outcome of anamnesis. Speaking the pain narratives of the self is, arguably, a form of

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__________________________________________________________________ encountering anamnesis, seeking the unnameable, nailing it in thought/ reflection/language, a revolt against the regimes of pain and trauma. Kristeva defines revolt ‘in the Proustian sense [as] a search for the past – time, anamnesis, a moment when thought is that language which returns to the past, in order to displace us towards progress. It is the past, which prepares a renaissance, a rebirth.37 Kristeva’s Proustian understanding of revolt is significant to this study of pain in that it enables us to see narratives of pain as a revolt against the phantom of pain. In this light, stories, narrative become the trajectory through which a return to the past is facilitated to enable a renaissance, a rebirth for those in pain. In Written on the Body, Jeanette Winterson writes written on the body is a secret code only visible in certain lights; the accumulations of a lifetime gather there.38 How do we discern and make visible…the accumulations of a lifetime? How do we write and speak the body, decode the secret code, trace the regimes of pain inscribed through our mind and flesh? How do we trace the routes to our wounding even as they split repetitively in the process? This involves skills of learning to live with and in language, risking and forgiving language, reading to retrieve not what the story says but what the story performs. And performance is never neat or linear! As Charon argues in the context of chronic pain, ‘chronic pain has ‘a plot, a past, a present and a future’ 39and ‘telling the story of the pain – is past, present and future – combines memory and bearing witness, enabling the sufferer to behold not only the reality of pain but its meaning’.40 [...] the plot of the pain is contested. What caused it? When did it start? How has it lived in my life? […] And so the means of telling of pain will be contested; the telling might take place in language, in pictures, perhaps in some cases directly through the body in performance or movement of some kind. […].41 This expose of chronic pain elucidates for us the character of pain per se; telling the story of pain involves probing beneath the terrain of the grainy surface of the only text we have access to as pain subjects, the traumatised body that speaks its soliloquy with or without witnesses. If we have learned anything from recent studies, it is that the collaboration of all academic disciplines is necessary to enable us to unravel the paradox of pain. Not surprisingly, Rita Charon upholds that ‘medicine is now in an explicitly narrative moment.’42 Charon affirms the ‘[...] profound and daring recognition that illness calls forth the self-of the patient who suffers and the clinician who wants to help- and the self is knowable only through stories.’43 Narrative medicine is what we call medicine practiced with narrative competence to receive and honour other people’s

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__________________________________________________________________ stories – how to attend to stories, to absorb them, respect them, understand their surface and deep meaning, how to enter them, to let them transform their tellers and listeners44 mobilize the imagination.45 Further Morris sees how narrative analysis can help debunk the myth of the solitary and private nature of suffering: Narrative analysis offers at least one useful response to catastrophe if it allows us to debunk the myth that individual suffering is intrinsically private, unknowable, and incommunicable.46 In recent decades, health care professionals have demonstrated increasingly urgent interest in the language of their interaction with patients.47 This interest in communicating effectively has matured in to a real commitment to enter the narrative worlds of patients. ‘With help from oral historians, writers, chaplains, and those who treat trauma survivors, medicine is learning to honour the critical importance of the telling of illness and the gravity of the responsibility to receive these stories.’48 The story of pain is as elemental as humankind and its political and narrative power is raised through the returning myths of gendered constructions of the self, raised repeatedly in literature through the figure of the Eternal Womanly, Eve. Accordingly, as an archetype of the story of pain, Angela Tumini’s paper opens this section as her study explores the treatment of feminine archetypes, the Eternal Womanly and the mother/whore dichotomy in her comparison of the work of D’Aunnunzio and Lars von Tier. Her study invokes the cultural myths of the source of pain in relation to the Eternal Eve figure, the female fatale. Von Tier’s Antichrist, written in the aftermath of a nervous breakdown and described subsequently as the most misogynistic film of recent times reflects how the text is doubly inscribed pointing to the scripted secret code of the author’s body/ life. Further the characterization of life as a ‘Speziafall of falling’ in Yen Chen’s study evokes connotations of anamnesis in the image of repeated and incessant falling into the archives of memory, unfurling the eternal return of sufferings. While Malin Isaakson’s discussion of textualised representations of sexualised pain’ extends the discussion of pain by locating its political economy within transgressive discourses, Katarina Gregersdotter’s critique of the zombie speaks the pain of the real through the phantom Other. The author intertwines these two sorrows (personal and societal), within the framework of the horror/gothic genre, using genre conventions simultaneously as reconstructing them. It could be argued that this employment of the transgressive which converts to ‘hope’ at the end of the novel is an extension of Kristeva’s definition of Proustian rebellion. Nor Hashima explores the tensions of living in a pluralistic society against the backdrop of racial and religious differences. Both Meghan Neataon et al. and Daria Radchenko argue for pain as a punishing, disciplining and yet redeeming matrix through which the creativity of art is shaped. Hans Sternudd studies the phenomena of cutting and explores the way in which the broken skin speaks and so becomes a site

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__________________________________________________________________ negotiating new possibilities of/for the self in crisis. Sternudd argues that the skin ego is a third position that creates a new location for closure, for making meaning to the world. […] the cuts become, in fact the text, a discursive closure that challenges other discourses on the field. The possibilities of investigating the nexus between Sternudd’s third position and Cohen and Quintner’s ‘third space is worth noting. Broderick Fox explores the use of video diaries as a way of speaking/writing back to the vulnerabilities induced by the medical gaze. As opposed to diaries written for a clinical purpose, personalized video pain diaries, Fox argues, provides confessional and therapeutic value. Patients exercise autonomy and creative expression and become director[s] choosing and ordering their own responses and thereby reducing the trauma of the body’s appropriation as a site of contestation between doctor and patient. Fox argues that the camera functions as a silent, non-judging proxy. In this regard, Fox’s paper anticipates the last paper in this collection, my discussion of proxy and co-presence in Richard Flanagan’s The Sound of One Hand Clapping. I argue that through the function of co-presence, the novel resolves the trauma of maternal abandonment and fills the lacuna, the space haunted by suicide and loss with meaning through Flanagan’s treatment of lace. Finally, Charon cites against the backdrop of respect[ing] the singular, irreducible, unknowable dimension of each patient [...] – movements to increase self-awareness among physicians characterized by ‘the introduction of humanities teaching in medical schools.’49 This final section of this collection honours and authenticates this intervention. It profiles the literary collection of papers to demonstrate how words ‘speak’ the world. These papers trace the dislocated voices of the pain subject embedded in the body of pain. Literature helps us recognize that stories are never finished. We read narratives and Narratives read us and it is this interplay of witnessing that enables us to understand the entangled subjectivities by which we are defined. We inhabit the stories we create which in turn create us. Put differently, stories help us read the body in pain and revolt against the body of pain. In closing, I return to Kristeva’s Proustian revolt to remind us that words/language are the only economy through which we can agitate against pain and hope for a renaissance of the self. The section is devoted to understanding how the oldest surviving tradition of our human history, the use of stories can be employed in making sense of pain. In the telling of our stories, we give of ourselves to life and to each other. And through the giving and receiving of our narratives of pain, we are cherished for another season of Understanding.

Notes 1

E Scarry, The Body in Pain: The Making and Unmaking of the World, Oxford University Press, New York, 1985, p. 3.

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__________________________________________________________________ 2

ibid, p. 12. M Heesacke & R Schwartz, ‘Physical Illness: Social Construction or Biological Imperative?’ Journal of Community Health Nursing, Vol.18, no. 4, 2001, p. 214. 4 N Autton, Pain: An Exploration, Darton Longman and Todd, London, 1986, p. 13. 5 ibid, p. 9. 6 JJ Bonica, cited in TS Jensen, ‘Incoming President’s Address: To Study Pain,’ Proceedings of the 11th World Congress on Pain, IASP Press, Seattle, 2006, p. 10. 7 Scarry, op. cit., p. 3. 8 P Wall, Pain: The Science of Suffering, Weidenfeld & Nicolson, London, 1999, p. 49. 9 ibid., p. 25. 10 Wall, op. cit., p. 149. 11 Autton, op. cit., p. 12. 12 ibid., 22 13 ibid., 14 ibid., 15 Ibid., 16 Wall, op. cit., p. 16. 17 H Bhabha, The Location of Culture, Routledge, London, New York, 1994, p. 1. 18 R Charon, ‘Suffering, Storytelling, and Community: An Approach to Pain Treatment from Columbia’s Program in Narrative Medicine,’ Proceedings of the 11th World Congress on Pain, IASP Press, Seattle, 2006, p. 20. 19 Wall, op. cit., p. 168 20 Charon, op. cit., p. 20. 21 ibid., p. 19. 22 ibid., p.20. 23 R Girard, Violence and the Sacred, P Gregory, trans., John Hopkins University Press, Baltimore, 1972,1979. 24 Scarry, op. cit., p. 4. 25 FB Orlans, In the Name of Science: Issues in Responsible Animal Experimentation, Oxford University Press, Oxford, New York, 1993, p. 39. 26 ibid., p. 61. 27 R Charon, ‘A Medicine for Pain,’ in Narrative, Pain, and Suffering, DB Carr, JD Loeser & DB Morris, (eds), IASP Press, Seattle, 2005, p. 34. 28 Bhabha, op. cit., p. 37. 29 ibid., 30 ibid., 31 ibid., 3

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ibid., ibid., p.38 34 ibid., pp.1-2. 35 J Jackson, ‘How to Narrate Chronic Pain? The Politics of Presentation,’ in Narrative, Pain, and Suffering, IASP Press, Seattle, 2005, p. 236. 36 ibid., p. 9. 37 Griselda Pollock, ‘Dialogue with Julia Kristeva,’ Parallax 4, no 3, 1998, 6. 38 Jeanette Winterson’s Written on the Body, cited in Alison Lee, ‘Angela Carter’s New Eve(lyn): De/En-Gendering Narrative’, Ambiguous Discourses, ed. Kathy Mezei (US: North Carolina UP, 1996) 238. 39 Charon, ‘Suffering, Storytelling, and Community,’ 20. 40 ibid.,21. 41 ibid., 21. 42 Charon, op. cit., p. 32. 43 ibid., p. 34. 44 Charon, op. cit., p. 21. 45 ibid., 26. 46 DB Morris, ‘Success Stories: Narrative, Pain and the Limits of Storytelling,’ Narrative, Pain, and Suffering, IASP Press, Seattle, 2005, p. 282. 47 ibid., 32. 48 Charon, op. cit., p. 33. 49 Charon, op. cit., p. 33. 33

Bibliography Autton, N., Pain: An Exploration. Darton Longman and Todd, London, 1986. . Bhabha, H., The Location of Culture. Routledge, London and New York, 1994. Carr, D., Loser, J.D. & Morris, D.B. (eds), Narrative, Pain, and Suffering. IASP Press, Seattle, 2005. Charon, R., ‘Suffering, Storytelling, and Community: An Approach to Pain Treatment from Columbia’s Program in Narrative Medicine.’ Proceedings of the 11th World Conference on Pain. IASP Press, Seattle, 2006. _______

, ‘A Narrative Medicine for Pain.’ Narrative, Pain, and Suffering. IASP Press, Seattle, 2005. Craig, K.D., ‘The Social Communication Model of Pain.’ Psychology/Psychologie Canadienne, Vol. 50:1, 2009, pp. 22-32.

Canadian

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__________________________________________________________________ Enright, R., Helping Clients Forgive: An Empirical Guide for Resolving Anger and Restoring Hope. American Psychological Association, Washington DC, 2000. Flor, H., Kalso, E. & Dostrovsky, J. (eds), Proceedings of the 11th World Congress on Pain. IASP Press, Seattle, 2006. Gibran, K., The Prophet. Alfred A Knopf, New York, 1923. Girard, R., Violence and the Sacred. Gregory, P. trans., John Hopkins University Press, Baltimore, 1972, 1979. Orlans B., In the Name of Science: Issues in Responsible Animal Experimentation. Oxford University Press, Oxford, New York, 1993. Petersen, S., Heesacker, M. & Schwartz, R., ‘Physical Illness: Social Construction or Biological Imperative?’ Journal of Community Health Nursing. Vol. 18, no. 4 2001, pp. 213-222. Pollock, G., ‘Dialogue with Julia Kristeva.’ Parallax. Vol. 4, no. 3, 1998, pp. 5-16. Scarry, E., The Body in Pain: The Making and Unmaking of the World. Oxford University Press, New York, 1985. Wall, P., Pain: The Science of Suffering. Weidenfeld & Nicolson, London, 1999.

Section 1

Making Sense of Pain: Breaking the Mould

The Ambiguity of Pain Sascha Benjamin Fink Abstract In this paper, it is argued that ‘pain’ is an ambiguous term, given that a term's meaning is determined by its usage. I show that the official definition of the International Association for the Study of Pain does not meet the necessary conditions of definitions in general. Pathological and nonpathological cases provide evidence that there is no common feature shared in all cases falling under ‘pain’. With the ambiguity of ‘pain’ established, I sketch the consequences for a scientific inquiry into pain, and for ethical theories working with pain as a relevant concept. Key Words: Pain, ambiguity, definition, explication, pain asymbolia, phantom limb pain, pain vs. pleasure, first person reports ***** 1. Introduction: Unified in Pain It seems like pain ought to be one of the most clear cut terms, given how much we invest to get rid of it: 34.3 billion $ a year are spent in Australia alone on chronic pain; 80% of all visits to the doctor are pain related. Given the amount of resources we – patients, companies, and governments alike – spend on research, treatment and alleviation, we have to ask ourselves: Is it one thing we are concerned with? This would determine whether we are fighting a war against a common enemy on different fronts, or whether we are locked in a bar brawl without a unifying strategy or common cause on either side. Our intuition surely is that the term ‘pain’ actually refers to a homogeneous family of phenomena, one whose members share a commonality. It is exactly this belief of the unity of pain that will be questioned and denied in this paper. In contrast, I will argue for a strategy of divide and conquer in science and ethics. 2. The Ambiguity of ‘Pain’ in Science and Subjects' Reports It was on their IVth World Congress in 1984 that the IASP phrased a highly influential definition of ‘pain’.1 The IASP's definition (IASPDf) reflects our intuitions from an experiencer's view point quite well: Pain: An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.2

4

The Ambiguity of Pain

__________________________________________________________________ Imagine stubbing your foot on the wardrobe. The sensation felt is unpleasant, and it may anger you to live through it. Surely, this is associated with the damage just inflicted upon your toe. However, we should not be too benevolent with this definition. Defining is a game with high stakes, as definitions express universal equivalents. This entails that one single counterexample negates a definition as fitting: If it is possible that p without q, then it is not universally true that p and q come together. The IASP acknowledges the testability of their definition in a note to their official definition: Note: [...] Many people report pain in the absence of tissue damage or any likely pathophysiological cause [...]. If they regard their experience as pain and if they report it in the same ways as pain caused by tissue damage, it should be accepted as pain.3 If a patient talks about pain, and this pain does not exhibit unpleasantness, being a sensation, being an emotion, being experienced, is associated with, or is described in terms of tissue damage, we know that these are unnecessary features of pain. This is exactly why IASPDf fails: Counterexamples are available, and no single feature mentioned is shared by all things subsumed under ‘pain’ which is not also shared by a number of other things clearly not being pain. If we concentrate on reports by patients, then we need to bracket being an experience: It is entailed by the report that the pain was also experienced. This caveat does not challenge the overall argument. There might be the possibility of unconscious pain.4 Then, being an experience is also not necessary. If on the other hand unconscious pains are indeed impossible, then being an experience does not distinguish pains from other experiences like warmth or blueness, and the IASPDf fails for this reason. (Another remark on the side: IASPDf assumes pain to be composite of sensation and emotion without determining the relation between the both. A way out is to assume a somatic theory of emotions, making emotions sensations;5 but it is a risky manoeuvre to tie the success of a definition of pain to the truth of a specific theory of emotions.) First then, unpleasantness: The majority of pains is unpleasant, but this is not true of all pains. One can refer to masochism, in which something is experienced as being pain and eliciting sexual pleasure. As unclear as the phenomenology of masochistic pain might be, we still have to acknowledge the possibility of experiencing pain as pleasant, and this rejects the necessity of unpleasantness for pain.6 Less juicy but more spicy: the hotness of food is a mild form of pain as the capsaicin triggers pain receptor. In tasting, we sometimes misattribute the pain experience as being a taste experience, yet we enjoy this oral pain and often even ask for more.7 These are two examples of pain being pleasant.

Sascha Benjamin Fink

5

__________________________________________________________________ Yet, Pain can be also neither pleasant nor unpleasant. Patients with pain asymbolia, recognize pain but lack appropriate motor and emotional responses to painful stimuli applied anywhere on the body surface.’9 Pain asymbolics are able to classify noxious stimuli as painful; in their judgements, a sensation falls under the class of ‘pain’. However, they were indifferent to the painful stimulus. Pain asymbolia is, as Nikola Grahek argued, a case of pain without negative evaluation, and therefore, of pain without unpleasantness;10 it is also case of pain without pleasantness. The case of pain asymbolics also raises doubts for the necessity of pain being emotionally charged; but one does not need to refer to pathologies: Being hypnotised during dentistry is a state in which pain is felt as pain, but not as being tied to an emotion. Jesse Prinz, proposing a somatic theory of emotions, points out that pain can be a pain without being accompanied by an emotion. He argues further that the unpleasantness of pain is redundant, as it is accounted for by the accompanying emotions: ‘Pain feels bad because it contains anxiety, not because it is valent.’11 This leaves being a sensation, although, ‘sensation’ can have different meanings: in the case of meaning, being experienced, we have already provided an argument above. Yet, ‘sensation’ might also mean, ‘being felt in a sensual way’. This again can be understood in two ways: As being a perception or as being a merely feeling of the body. The difference is crucial, as perception entails veridicality, i.e. when I perceive a bottle standing on the table, then there is necessarily a bottle on the table. Otherwise, I am having a bottle illusion. This does not hold for mere feelings: A dreamt itch is still itchy. Is pain a perception? Transitive or intransitive? A perception is transitive if and only if a person perceives something other with her body. This entails intersubjective accessibility in the same mode of perception. However, you and I cannot perceive the same tissue damage in the same perceptual modality; only one alone person feels one individual pain. To allow bodily sensations to still be perceptions, Armstrong introduced the notion of intransitive perceptions:1 a person perceives the body with the body. Tickles, itches and orgasms might fall under this category, but does pain? Phantom limb pain is a clear counterexample: the sufferer feels pain in a body where there is no body. If pain is a perception, and perceptions are veridical, then phantom limb pain can only be a pain hallucination. Surely, one does not want to claim that these patients are merely hallucinating pain – they are in real pain. Pain is therefore not necessarily a perception. Is it necessarily bodily? Contrary to our intuitions, there are actual cases in which people talk about pains without it being a bodily sensation. There is pain that is a sensation, but is not embedded into one's own body image: Empathic pain, feeling the pain of others as pain. Empathic pain might lack the incorporation into one's own body image, but shares the negative evaluation and a need to act upon, while still being a sensation. This point

6


__________________________________________________________________ is supported by the studies of Singer et al., in which subjects where asked to rate the painfulness and unpleasantness of merely watched in contrast to actually felt painful stimuli, and did so significantly similar, irrespective of whether the pain was applied to themselves or to the partner.’12 The neural correlate of empathic pain is also part of the neural pain matrix of actual pain; furthermore, it feels painful to the empathic subjects without being phenomenally incorporated into their own body image. What we are left with is associated with tissue damage and described in terms of tissue damage. Association is too arbitrary to count as necessary. Laughing hysterically about somebody who just fell down the stairs – an instance of Schadenfreude – can also be an unpleasant sensation, followed by shame and associated with tissue damage; just with somebody else's. This is definitively not pain, even though it is strictly in accordance with the IASP's definition. We also ought to be reluctant to claim describability as a necessary condition for pain: Think of a newborn baby being slapped. Surely, she screams and feels pain without describing it. Even if left alone, she has pain without anybody ascribing it to her. We should hold on to our intuition that pain is not description-dependant. Pain existed before language, descriptions, theories, linguistic or social communities were around, fulfilling in most cases an important evolutionary function. As we have seen, none of the features deemed necessary by IASPDf is actually necessary: Pain can be a sensation and emotion without being unpleasant, as in the case of masochism or spicy food. Pain can also be an unpleasant emotion without being a bodily sensation, as in the case of phantom limb pain. Pain can be a sensation without being unpleasant or an emotion, as in the case of pain asymbolia. Pain can also be an unpleasant emotion and sensation without being tied to the body or being owned by the experienced. Still, these phenomena can be called ‘pain’ felicitously. In conclusion, ‘pain’ refers not to one class, but a cluster of different phenomena. It is impossible to give a real definition for cluster terms like ‘pain’as they necessarily lack a unifying feature. 4. Consequences for Science If ‘pain’ is an ambiguous term, then pain science cannot be reductive. Reduction is a relation between terms of two theories, and all terms referring to family resemblances are impossible to reduce as the reduction relation cannot hold between the ambiguous usage of normal language and the exact usage of scientific language. However, this does not mean that there can be no science of pain; The claim is merely that ‘pain’ needs to be somehow broken down into a coherent classes of phenomena, which in turn might be reducible. Explication, as Carnap called this process, is not a one-to-one-relation, but a one-to-many-relation.13 The usage of a normal language term is analysed and parts of its usages are rebuilt in the exact language of a given science, namely physics; e.g. ‘Water’ can be explicated as


7

__________________________________________________________________ ‘H2O’ even though ‘H2O’ is not synonymous to water in every case: ‘My old cat can't hold his water any longer.’ But is this picture of explication transferable to pain science? Hardly, as we are dealing with a term referring to a phenomenal experience. At the moment, we are lacking an acceptable theory of the physical basis of consciousness. Given this general epistemic hindrance, it seems impossible to know which explications in physical language are adequate. Given the constraints for space, I can only sketch an alternative: In the critique of the IASPDf, we relied not on physical language, but on phenomenological reports. It therefore seems possible to explicate ‘pain’ a language referring to phenomena. We would aim for structural explications, i.e. naming more fine grained elements and their relation to each other. In the case of „pain’, such elements might be evaluation, personhood, ownership, integration into a body image, etc. The phenomenological explication will get us a class of possible structures of conscious experience that show some family resemblance to paradigmatic cases of pain. They will in turn enable patients to express their own experience in a more adequate way – something Virginia Woolf called for when she wrote that, ‘[t]he merest schoolgirl, when falling in love, has Shakespeare and Keats to speak for her; but let a sufferer try to describe a pain in his head to a doctor and language at once runs dry.’14 This structural taxonomy is expressed in the form of relations of elements to each other. Given a specific relation R(a,x), we might now search for commonalities in the neural basis.15 It might very well be the case that two different groups of neural events elicit mental state x, e.g. p and q; a can stand in a relation with xp or with xq. Given this possible result, it seems worthy to inquire whether there is a felt difference between an R(a,xp)-pain with an R(a, xq)-pain. If there is a felt difference, we have a further taxonomy which was unavailable from the experiencer's viewpoint alone. If there is no felt difference, science will learn something about the minimally sufficient grain level of the supervenience base of conscious R(a,x)-pain. This general sketch illustrates what Ayede and Güzeldere proclaimed: Pain science might be a paradigmatic case for a science of consciousness per se.16 5. Consequences for Ethics The most practical lesson the ambiguity of pain teaches us is in ethics, as pain and pleasure were seen as antipodes by many theorists. Consider Jeremy Bentham: A thing is said to promote the interest, or to be for the interest, of an individual, when it tends to add to the sum total of his pleasures; or, what comes to the same thing, to diminish the sum total of his pains.17

8


__________________________________________________________________ Being able to feel pain or pleasure has thereby constrained the application of ethical theories like Bentham's utilitarianism. A utilitarian holds that the moral value of an action is determined by its manipulation of the ratio of pleasure to pain. Here, a moral object (something we have to act morally towards) can only be an entity that is able to feel pleasure or pain. Therefore, a puppy probably is a moral object, while a table is not. Consider compassionism;18 the driving force behind acting ethically is our ability to feel the pain of others and wanting to prevent it. This entails that our ability to feel empathic pain constitutes the class of moral subjects, (the class of entities able to perform moral acts). In conclusion, the ability to feel certain kinds of pain determines whether a given ethical theory is applicable in a given case. Mind though whether the judgement ‘X is in pain!’ is true depends on which understanding we have of ‘pain’. The ambiguity of ‘pain’ then calls for a revision of such moral theories in at least two ways. First, the case of masochism and pain asymbolia show that pain is not the antipode to pleasure: Pain can be pleasant, or it can be neither pleasant nor unpleasant. In conclusion, not every pain is ethically relevant. Therefore, the first challenge for ethical theorists is clarifying exactly which kinds of pain are ethically relevant. I suggest: Only those pains that incorporate negative emotions like anxiety and whose prolonged having enslaves the ability of shifting one‘s attention away from them. Here, pain is only relevant in virtue of its emotional charge. The implication for treatment is: To teach emotional control. Secondly, as we are becoming more and more aware of the varieties of pain experiences and their affordances to a neural basis, it is more and more evident that lots of non-human entities like animals (but possibly artificial life forms as well) are able to feel pain in a morally relevant sense. However, it is also clear that some individuals are not able to feel such morally relevant pains. This will determine whether e.g. experiments on encephalopods are permissable – a case in which our moral intuitions falter. The elucidation of the application of some ethical theories depends on the one hand on ethicists clarifying which pains are morally relevant, and on the other hand on scientists revealing which neural bases elicit which pain experiences. In conclusion, the ambiguity of ‘pain’ calls strongly for a revision of established ethical theories, and also for a revision of our relation to our closest and most distant non-human relatives and offspring. The simplistic talk of pain and pleasure in ethics cannot go on in the light of this evident conceptual unclarity.

Notes 1

No textbook on pain seems to do without, e.g.: RJ Moore, ‘Preface’, in Biobehavioral Approaches to Pain, R J Moore (ed), Springer, New York, 2009, pp.


9

__________________________________________________________________ vii-viii; AI Basbaum & CM Bushnell, ‘Introduction’, in Science of Pain, AI Basbaum & CM Bushnell (eds), Elsevier, Amsterdam, 2009, pp. ix-x. 2 International Association for the Study of Pain, ‘Pain Terms: A Current List with Definitions and Notes on Usage,’ Pain, Supplement 3, 1986, pp. 345-361. 3 Shortly mentioned in: F Dretske, ‘The Epistemology of Pain,’ Pain: New Essays on Its Nature and the Methodology of Its Study, M Ayede (ed), MIT Press, Cambridge, MA, 2005, pp. 59-73. 4 S Rachels, ‘Is Unpleasantness Intrinsic to Unpleasant Experiences?’ Philosophical Studies, 2000, pp. 187-210. On page 201, Rachels sketches the space of logical possibilities for the pleasure-pain-relation in masochistic experiences. 5 The locus classicus of somatic theories of emotions is: W James, ‘What Is an Emotion?’ Mind, 1884, pp. 188-205. Newer formulations of somatic theories of emotions is also: J Prinz, Gut Reactions: A Perceptual Theory of Emotions, Oxford University Press, Oxford, 2004; A Damasio et al., ‘The Somatic Marker Hypothesis and the Possible Functions of the Prefrontal Cortex,’ Philosophical Transactions: Biological Sciences, 1996, pp. 1413-1420. 6 On different locations of the body, capsaicin (C18H27NO3) is experienced as pain. If you are still not convinced, ask yourself what you would call such an experience were it to happen in your knee after a tennis match. Ask yourself also whether it would be possible to imagine something like a sweetness experience in your knee. 7 M Berthier, et al., ‘Asymbolia for Pain: A Sensory-Limbic Disconnection Syndrome,’ Annals of Neurology, 1988, pp. 41-49. 8 N Grahek, Feeling Pain and Being in Pain, MIT Press, Cambridge, MA, 2007, p. 38. 9 J Prinz, op. cit., p. 117. 10 D Armstrong, Bodily Sensations, Routledge, London, 1962. 11 T Singer, et al., ‘Empathy for Pain Involves the Affective but not Sensory Components of Pain,’ Science, Vol. 303, 2004, pp. 1157-1162. 12 R Carnap, Der logische Aufbau der Welt, Felix Meiner Verlag, Hamburg, 1998; R Carnap, Induktive Logik und Wahrscheinlichkeit, Springer, Vienna, 1959. 13 V Woolf, On Being Ill, Paris Press, 1928/2002. 14 This is a rephrasing of a neurophenomenological approach in analytic terms. For a more phenomenological leaning, see: FJ Varela, ‘Neurophenomenology: A Methodological Remedy for the Hard Problem,’ Journal of Consciousness Studies, Vol. 3 (4), 1996, pp. 330-349; E. Thompson, et al., ‘ Neurophenomenology: An Introduction for Neurophilosophers,’ Cognition and the Brain: The Philosophy and the Neuroscience Movement, A Brook & K Akins (eds), Cambridge University Press, Cambridge, 2005, pp. 40-97. 15 M Ayede & G Güzeldere, ‘Some Foundational Issues in the Scientific Study of Pain,’ Philosophy of Science, Vol. 69 (Supplement), 2005, pp. 265-283.

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__________________________________________________________________ 16

J Bentham, An Introduction to the Principles of Morals and Legislation, Dover, Mineola & New York, 1780/2007, p. 3. 17 Two prolific defenders of compassionism are Albert Schweitzer and Arthur Schopenhauer. See: A Schweitzer, Die Ehrfurcht vor dem Leben – Grundtexte aus fünf Jahrzehnten, Beck, München, 1991; A Schopenhauer, Über das Mitleid, dtv, München, 2005. 18 These points have been made extensively by e.g. Peter Singer. I would like to refer especially to: P Singer, Animal Liberation, Harper, New York, 1975/2009; P Singer, ‘All Animals Are Equal,’ Animal Rights and Human Obligations, T Regan & P Singer (eds), Prentice Hall, Englewood Cliffs, 1989, pp. 73-86.

Bibliography Aristotle, Organon. Felix Meiner Verlag, Hamburg, 1995. Armstrong D., Bodily Sensations. Routledge, London, 1962. Ayede, M. & Güzeldere, G., ‘Some Foundational Issues in the Scientific Study of Pain’. Philosophy of Science. Vol. 69 (Supplement), 2005, pp. 265-283. Basbaum, A.I. & Bushnell, C.M., ‘Introduction.’ Science of Pain. Basbaum, A.I. & Bushnell, C.M. (eds), Elsevier, Amsterdam, 2009, pp. ix-x. Bentham, J., An Introduction to the Principles of Morals and Legislation, Dover, Mineola and New York, 1780/2007. Berthier, M., et al., ‘Asymbolia for Pain: A Sensory-Limbic Disconnection Syndrome’. Annals of Neurology. Vol. 24, 1988, pp. 41-49. Carnap, R., Der logische Aufbau der Welt. Felix Meiner Verlag, Hamburg, 1998. –––, Induktive Logik und Wahrscheinlichkeit. Springer, Vienna, 1959. Damasio, A. et al., ‘The Somatic Marker Hypothesis and the Possible Functions of the Prefrontal Cortex.’ Philosophical Transactions: Biological Sciences. Vol. 351 (1346), 1996, pp. 1413-1420. Dretske, F., ‘The Epistemology of Pain.’ Pain: New Essays on Its Nature and the Methodology of Its Study. Ayede, M. (ed), MIT Press, Cambridge, MA, 2005, pp. 59-73.


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__________________________________________________________________ Grahek, N., Feeling Pain and Being in Pain. MIT Press, Cambridge, MA, 2007. International Association for the Study of Pain, ‘Pain Terms: A Current List with Definitions and Notes on Usage.’ Pain. Supplement 3, 1986, pp. 345-361. James, W., ‘What Is an Emotion?’ Mind. Vol. 9, 1884, pp. 188-205. Moore, R.J., ‘Preface.’ Biobehavioral Approaches to Pain. Moore, R.J. (ed), Springer, New York, 2009. Prinz, J., Gut Reactions: A Perceptual Theory of Emotions. Oxford University Press, Oxford, 2004. Rachels, S., ‘Is Unpleasantness Intrinsic to Unpleasant Philosophical Studies. Vol. 99 (2), 2000, pp. 187-210.

Experiences?’

Schopenhauer, A., Über das Mitleid. dtv, München, 2005. Schweitzer, A., Die Ehrfurcht vor dem Leben – Grundtexte aus fünf Jahrzehnten. Beck, München, 1991. Singer, P., Animal Liberation. Harper, New York, 1975/2009. –––, ‘All Animals Are Equal.’ Animal Rights and Human Obligations. Prentice Hall, Englewood Cliffs, 1989. Singer, T. et al., ‘Empathy for Pain Involves the Affective but not Sensory Components of Pain’. Science, 303, 2004, pp. 1157-1162, at p. 1159. Thompson, E. et al., ‘Neurophenomenology: An Introduction for Neurophilosophers.’ Cognition and the Brain: The Philosophy and the Neuroscience Movement. Cambridge University Press, Cambridge, 2005, pp. 4097. Woolf, V., On Being Ill. Paris Press, 1928/2002. Varela, F.J., ‘Neurophenomenology: A Methodological Remedy for the Hard Problem.’ Journal of Consciousness Studies. Vol. 3 (4), 1996, pp. 330-349.

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__________________________________________________________________ Sascha Benjamin Fink studied philosophy, history of art and japanese studies at the University of Mainz and Nihon University, Tokyo. He is a member of MINDGroup, an interdisciplinary network of scientists and philosophers of mind at the Frankfurt Institute for Advance Studies, and is currently at the Institute for Cognitive Science at the University of Osnabrück.

Who is Able to Feel Pain? A Cartesian Attack on the Bête-Machine Anik Waldow Abstract Many philosophers deny that animals can feel pain, because in order to do so, they argue, animals would need to share our concept of pain, which they obviously do not: someone is understood to share our concept of pain only if she refers to herself and others in the same way as we do. What follows from this is the counterintuitive claim that only competent language speakers can feel pain, excluding animals and small children. The paper intends to challenge this conception of pain by testing it against Descartes’ dream argument. According to this argument, it is impossible to distinguish between dream experiences and real experiences: the dreaming mind is said to be able to have sensations of pain, although the real body is asleep and safe from the fire that causes tremendous pains to the dreaming mind. The question that emerges here is that of how it is possible for us to distinguish real sensations from dream sensations. It will be argued that reference to our ability to conceptualise pain cannot help us here, because, in principle, nothing prevents the dreaming mind from operating with a concept of pain shared by other persons figuring in the alleged dream. And this entails that someone’s ability to use the concept of pain correctly tells us nothing about her ability to feel real pain: after all, the dreamer feels mere dream pains and yet shows sign of operating with a concept of pain appropriate to the dream context. The results of this thought experiment will be used to advocate a concept of pain that pays special attention to the bodily dimension of the experience of pain. On this conception animals and small children are taken to be capable of pain because they have bodies fit for the production of pain. Key Words: Attribution of mind, animal sentience, Descartes, bête machine, mechanism, Cartesian soul, argument from analogy, other minds. ***** 1. Introduction Many philosophers deny that animals can feel pain, because in order to do so, they argue, animals would need to share our concept of pain, which they obviously do not: someone is taken to share our concept of pain only if she refers to her pain experiences and that of others in the same way as we do. On the face of it, this argument looks counterintuitive. Is the capacity for pain not a matter of how our bodies are designed rather than a matter of how we use language? Do we not need to look at a creature’s nervous system instead of its conceptual capacity to determine what it can and cannot sense? In this essay I will defend these intuitions

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Who Can Feel Pain?

__________________________________________________________________ by showing that the need to discriminate real pain from hallucinated pain clearly refers us to the body as the material basis of pain. 2. Cartesian Roots of the Language Argument A challenge to this rather commonsensical understanding of what is needed for a creature to be able to feel pain has been provided by Descartes’ theory of the bête machine. As the standard reading of Descartes goes, an animal is nothing but a very sophisticated machine: it is composed of various mechanisms that more or less automatically lead to a certain behavioural output if stimulated in this or that way. And although Descartes may admit that the animal machine is more complex than, let’s say a clock or even a dishwasher, he nevertheless believes that the animal is a machine that, as it has traditionally been claimed, lacks awareness of what is going on inside of its tubes, pores and fibres. The reason that is usually cited for this interpretation is that, according to Descartes, animals don’t have minds, while conscious awareness of bodily phenomena, such as pain, is taken to require a mind that is attached to the machine in question. We can here see that the question of whether or not someone is able to feel pain is closely related to the question of whether or not someone has a mind, because it is the mind that is claimed to provide the awareness needed for someone to take notice of the fact that harm is being done to the lump of matter that constitutes her body. If our mind were absent, the argument goes, those occurrences we usually experience and interpret as pains would amount to mere dysfunctions within the mechanics of the body. Once we make the move and accept that some sort of mental awareness or, more generally put, a mind is needed for someone to be able to feel pain, we understand why the ability to speak has often been cited as the litmus test for the attribution of mind, and hence for the attribution of the capacity for pain. Descartes is a proponent of this test; in a letter to Henry More he writes: It has never been observed that any brute animal has attained the perfection of using real speech, that is to say, of indicating by word or sign something relating to thought alone and not to natural impulse. Such speech is the only certain sign of thought hidden in a body.1 The point here seems to be that another person’s mind is something we cannot experience the way we experience that someone has large feet. According to Descartes, the mind is hidden and can merely be indicated by certain signs, of which the clearest is someone’s ability to use language in an intelligent way.2 The problem with this approach, of course, is that it is too restrictive. If the ability to feel pain is taken to go hand in hand with the ability to speak, because speech is the sign that proves that the creature in question has a mind, and hence is

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__________________________________________________________________ aware of her bodily phenomena, animals and small children must be denied sentience. To claim this, however, is not only entirely counterintuitive, it also presents our practice of attributing pain to what Crispin Wright calls the ‘conceptually innocent’ as unintelligible: What goes missing on the resultant view is any role for empathy or projection in the range of broadly evaluative responses – sympathy, outrage, sadistic satisfaction, delight, etc. – which we have towards the suffering or pleasure of the conceptually innocent. Events and states whose occurrence makes no conceptual demands on their ‘owner’ cannot be understood on the model of events and states which essentially go with thought. So it seems that such broadly evaluative responses become groundless, or even unintelligible: where do we look for a satisfactory conception of what is bad about the suffering on an animal or an infant per se if its state cannot be conceived by analogy with the awful thing that we sometimes experience, and if what is awful about the latter depends essentially on its being experienced as awful, as falling under that concept?3 Some philosophers have tried to help this problem by claiming, as McDowell does, that the conceptually innocent do feel pain. Their lack of our concept of pain would merely prevent them from feeling pain the way we feel pain when we experience, for instance, headaches as headaches or stomach ache as stomach ache.4 The underlying assumption here seems to be that creatures can experience something as something only to the extent that they possess a concept in virtue of which they can represent the experience they are having. For instance, I cannot experience snow as having a certain shade of white if I lack the concept of this particular shade: it would only look white to me, whereas for those with a more refined concept of white, the experience of the very same patch of snow would present itself in a different light. And the same presumably goes for pain: if we have a certain concept of pain we experience pain as something specific. Those having a different concept of pain (or none) may therefore still experience something, just not the same thing as we do when we conceptualize an experience in accordance with our concept of pain. 3. Back to the Body How convincing is this approach? In the remainder of the paper I will once more refer to Descartes in order to show that the overemphasis on language and conceptual capacities is mistaken when it comes to answering the question of who can feel pain. In order to do so I will draw on Descartes’ famous dream argument. This will put us in a position to see that it is wrong not only to tie the attribution of

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Who Can Feel Pain?

__________________________________________________________________ mind to someone’s ability to speak intelligently, but also to think that sentience cannot be achieved by creatures who lack a Cartesian mind, which is the mind that enables creatures to form rational thoughts.5 I will thus advocate a concept of mind based on a creature’s bodily dispositions to feel rather than on a creature’s putative rationality. If we compare animals to humans and claim that they do not experience pain the way we do, and on the basis of this deny them the ability to feel pain, we make a claim about what counts as real pain as opposed to what does not: we claim that those who do not share our concept of pain may feel something, but that they do not feel pain, at least not what we understand by ‘pain’. Another way of discriminating between real pain and mistaken pain comes into sight if we go along with Descartes and suppose for one moment that everything we take to experience under ordinary conditions is part of an endless dream as long as it cannot be proved that we are not dreaming, but are awake and experiencing reality. Given this setup, it turns out that someone’s ability to use language intelligently tells us little about whether or not she has a mind and can feel pain. This is because all experiences to which speakers in our pretended dream refer with sentences of the sort ‘I am in pain’ are performances that cannot be known to be the performances of real people. It could well be the case that it is only a bad trick of my dreaming mind that I think that there are real people who are capable of using the concept of pain the way I do and that, in fact, there are no real people at all. This possibility, however, needs to be ruled out, because if it cannot be known whether there are real people it cannot be known whether there are real pains as opposed to imagined pains either. At first sight this thought experiment may look farfetched. This impression, however, changes if we consider that the dream argument helps us to understand that pain is something that we tend to identify by looking at the body and its dysfunctions rather than by determining whether the person we perceive as being in pain shows all the signs of being in possession of our concept of pain. So, what comes under scrutiny is not so much the question of whether or not there are real people in a real world as opposed to fictitious characters in an eternal dream. The point rather is that our understanding of what real pain is relates to something other than the use of language: it relates to something that is going on within the body, because in cases where one cannot be sure whether a body exists, and grounds the assumption that someone is in pain, it is hard to speak of real pain experiences. One may here object that hypochondriacs do really feel pain, although there is nothing wrong with their bodies, which seems to show that events happening at a bodily level are less important to the question of who is able to feel pain than it has been suggested. However, if we reflect on the position of the dreamer herself, and not only on the question of how dreamers can know whether those in their social surroundings, that is, other people starring in the supposed dream, are suffering from pain, we can see that the example of the hypochondriac only reinforces the point made. Vivid as dreamt pain experiences can be, they do not qualify as real:

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__________________________________________________________________ they are dream experiences and remain so, if our body, that is, the body that is safely located in our bed, remains intact and does not show the symptoms our dream body exhibits. Descartes writes: Often when we sleep, and sometimes even when we are awake, we imagine certain things so vividly that we think we see them before us, or feel them in our body, although they are not there at all.6 The dream argument thus shows that the mind alone is insufficient for producing real pain. Disembodied minds, such as the Cartesian dreaming mind, cannot feel real pain. They need the body to provide the material basis for this pain. Hypochondriacs are in a somewhat similar position to dreamers. Their bodies are supposedly intact, but they feel pains as if their bodies were affected by the disease in question. They thus possess vivid experiences that, for want of a material basis, do not qualify as real pains. Of course, it may well be that this material basis actually exists (perhaps in places where doctors did not look for it, such as the brain)7 and that it only remains undetected. If this is the case, the hypochondriac’s experience of pain turns into real pain. 4. Conclusion The advantage of this approach is that pain, and not merely some sort of pain, can be attributed to creatures who lack language, such as infants and animals. This is because one grants that our concept of pain refers us to dysfunctions within the body rather than someone’s conceptual capacities. Evidence for such dysfunctions must therefore be treated as evidence for the presence of pain, regardless of whether the creature in question can be taken to have that sort of pain experiences that we have when we are encountering pain. This is not to say that in the human case testimony of experience is irrelevant to the determination of the causes of pain and their cures; on the contrary, reports about one’s experienced pains are invaluable and must be taken into account whenever they become available. The point rather is that someone’s conceptual capacities cannot ground our concept of pain - not merely because this leads to undesirable restrictions when it comes to the attribution of pain; the main reason for resisting the McDowellian conception of pain is that it puts too much emphasis on the human kind of experience, because the human kind of experience, that can be had only by creature that share our concept of pain, is treated as the default case of pain experience. One is here only a small step away from the good old argument from analogy that extrapolates from one’s own case to claims about the way other creatures must be feeling. If pain is conceived as something that relates to features of the body and its microscopic particles, one avoids this trap: one stays away from questions that are impossible to

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Who Can Feel Pain?

__________________________________________________________________ answer, such as the question of how someone other than oneself experiences her body and surrounding world.

Notes 1

R Descartes, The Philosophical Writings of Descartes, trans. J. Cottingham et al, Vol. III, Cambridge University Press, Cambridge, 1991, p. 366. Passages taken from this book are referred to by CSM volume and page number or CMSK and page number. 2 Descartes denies that animals that have been trained to speak are capable of thought. According to him, the capacity for intelligent language presupposes that the creature in question is inventive of language: ‘We must not confuse speech with the natural movements which express passions and which can be imitated by machines as well as by animals. Nor should we think, like someone of the ancients, that the beasts speak, although we do not understand their language.’ (CSM, I, 140) 3 C Wright, ‘Postscript to ‘Human Nature?’ Criticism of McDowell’s Concept of Experience,’ Reading McDowell, N Smith (ed), Routledge, New York, 2002, pp. 164-65. 4 J McDowell, ‘Reply to Commentators,’ Philosophy and Phenomenological Research, Vol 58(2), 1998, p. 429. 5 Descartes writes to More: ‘Please note that I am speaking of thought and not of life or sensation. I do not deny life to animals, since I regard it as consisting simply in the heat of the heart; and I do not even deny sensation, in so far as it depends on a bodily organ.’ (CSMK, 366) 6 CSM, I, 338. 7 Descartes is a proponent of the view that pains are in the brain. See his discussion on phantom limbs in Descartes to Plempius for Fromondus, 3 October 1637 (CMSK 64).

Bibliography Descartes, R., The Philosophical Writings of Descartes. trans. Cottingham, J. et al., Vol. I-III, Cambridge University Press, Cambridge, 1991. McDowell, J., ‘Reply to Commentators.’ Philosophy and Phenomenological Research. Vol. 58(2), 1998, pp. 403-431. Wright, C., ‘Postscript to ‘Human Nature?’ Criticism of McDowell’s Concept of Experience.’ Reading McDowell. Smith, N.H. (ed), Routledge, New York, 2002, pp. 160-173.

Anik Waldow

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__________________________________________________________________ Anik Waldow is lecturer in the Philosophy Department at the University of Sydney. She mainly works in 17th and 18th century philosophy and has a special interest in David Hume, the belief-generating function of sympathy, the problem of other minds, scepticism and personal identity. Her current research focuses on the question of how the emergence of empirically based approaches in early modern natural philosophy gave way to a general shift of interest away from the realm of the metaphysical to the natural world of sentient human beings.

The Mind/Body Problem in Contemporary Healthcare Gillian Bendelow Abstract The rise of scientific or ‘biomedicine’ as a major aspect of the enlightenment process has bestowed enormous benefit such as increased life expectancy and protection from infectious disease, at least in the so-called ‘developed’ world. By the 21st century, diagnostic categories have expanded greatly, not least with the patterning of health and illness associated with longevity and emotional/mental health, demanding multifactorial aetiologies which require traditional categories, formulations and management strategies to be re-evaluated. Critiques of biomedicine and the process of medicalisation have emphasised the limitations of conventional scientific medicine in the separation of mind and body, hence the turn to more holistic or integrated models of health and illness, which are now permeating many areas of medical education and healthcare practice. Conditions with 'medically unexplained symptoms' such as chronic idiopathic pain syndromes; eating, sleeping and anxiety disorders, emphasise the limitations of the divisions between mental and physical health in the intertwining of emotion and embodiment. Although those who suffer such conditions may experience severe and distressing symptoms, traditional biomedicine may be unable to provide appropriate ‘care’ to alleviate them. Using the example of chronic pain, this chapter considers whether developments in the conceptualisation and treatment of pain have resulted in a paradigm shift which in turn address the mind-body dilemma in healthcare. Key Words: Chronic pain, mind/body medicine, Cartesian dualism, biomedical model, biopsychosocial, integrated healthcare. ***** 1. Background Health and illness are multi-faceted concepts, which span a range of disciplines and have varied meanings in different societies. Since the nineteenth century we have witnessed dramatic advances in the understanding and cure of disease with an unprecedented extension of both quality and length of life (albeit confined to socalled ‘western’ or ‘developed’ countries). Yet even as medical science has progressed, there has been a decline of faith in biomedicine and its dominance challenged by litigation, scandal, government regulation, lay expertise and social activism.1 2 Social sciences associated with medicine, particularly medical sociology, philosophy, bioethics and health psychology have made a major contribution to shaping modern ideas about health and illness throughout the

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The Mind/Body Problem in Contemporary Health Care

__________________________________________________________________ twentieth century, subsequently challenging the narrow philosophical grounding of biomedicine. The combined impact of these factors has prompted critical developments in medical education, reflected in the UK in the rise of the ‘new’ medical schools and in radical changes in the medical curriculum including an unprecedented emphasis on the social sciences and ethics.3 Within medicine itself, particularly within general practice, there are competing orientations of models of health4 with the creation of new sub-disciplines such as liaison psychiatry and behavioural medicine. Furthermore health awareness has become a facet of everyday living, and lay perceptions and understandings (including collective enterprises such as politics and the media) play a vital role in defining concepts. The critique of biomedicine, with its emphasis on high-technology, cure and the mind/body divide has developed alongside the decline of high mortality rates from infectious diseases. In the ‘developed’ countries mortality tends to be largely replaced by degenerative illnesses such as cancer and cardio- vascular disease, and morbidity patterns increasingly dominated by conditions closely associated with ‘lifestyle’ such as diabetes, anxiety and eating disorders, and increasingly, with illnesses associated with increased life expectancy such as Parkinsons, Alzheimers and rheumatoid arthritis. Thus, both biomedicine and medical social sciences have been challenged by a host of illnesses with multifactorial aetiologies and complex mind-body relationships which require traditional categories, formulations and management strategies to be re-evaluated. 2. Integrated Models of Health and Illness The divide between physical and mental illness historically reinforces hierarchical divisions within medicine, since anything that is classified as a ‘mental’ or emotionally triggered illness is, and always has been, consistently stigmatised and marginalised. Nevertheless, epidemiological patterns reveal increasing prevalences and recent estimates claim that at least 25% of GP consultations in the UK are prompted by psychological symptoms and that 20% or more of UK adults have a recognisable medically defined mental disorder.5 These mainly comprise of anxiety and depressive disorders, of which estimates as high as 80-90% are managed in primary care rather than by the mental health services.6 Moreover, behaviours which are perceived as being major health risks, such as smoking, over-eating, alcohol and substance abuse, the transmission of sexually transmitted diseases, as well as violent, accident-inducing and suicidal behaviour, have complex emotional substrates and cannot be modified by rational choice interventions alone. Since the 1980’s the biopsychosocial model gained popularity amongst physicians as its multicausal definition allowed for the variety of perspectives to be taken into account in diagnosis and treatment, implying an inherently multidisciplinary approach. However, this model has also been criticised for not fully

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__________________________________________________________________ addressing mind/body dualism as the patient can still be compartmentalised by the physician addressing biomedical symptoms and the psychosocial element by the psychologist or psychiatrist. More recently, the combined shift towards both holism and interdisciplinarity in healthcare practice has resulted in integrated models becoming the preferred consensual term for both practitioners and theorists.7 Figure 1 charts the paradigm shift in models of health which renders the labels of physical and mental illnesses as outdated and redundant. Biomedical Model Mechanistic

Integrative Model Holistic

Body-mind dualism/reductionism

Interaction between body/mind

Single fundamental cause of illness Isolated individual Treatment = Curative ‘magic bullet’ approach

Multicausality Socially connected individual Treatment= Appropriate interventions ( may be biological/psychosocial) Management Preventive- health maintenance

Pharmaceutical/technological interventions Focus on acute illness

Focus on long term health Allows for chronic illness

Table 1. A Paradigm Shift in Models of Health and Illness.8 3. Medically Unexplained Symptoms Medically unexplained symptoms or MUS, an acronym in popular usage in the medical and social science literature is perhaps more neutral and less stigmatising than ‘psychosomatic symptoms’, but still identify illnesses or syndromes which cannot be defined in terms of organic pathology and are thus seen as abnormal and low in ‘illness hierarchy’. The term ‘contested conditions’ is used to signify illnesses of controversial scientific status (e.g., ME, CFS, RSI, chronic low back pain) in which the patient experiences distressing physical symptoms such as impaired mobility or coordination, intermittent paralysis, fitting, pain, fatigue, or visual disturbance, but there is usually an absence of physical signs, clinical explanation or medical diagnosis, and estimates vary that between 25-50% of GP consultations in the UK are prompted by emotional or psychological issues.9 Traditionally biomedicine has been unable to deal effectively with people who present in this way, creating a ‘diagnostic limbo…which widens the gap between clinical reductions and lost metaphysics’10 but may be more accessible by integrative, holistic approaches. As we have seen, physical complaints do often

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__________________________________________________________________ point to physical disorders, but pain and fatigue can also be clues to psychological disturbance which manifest in distressing symptoms which also require help or intervention. The acute/ chronic distinction within the biomedical model can also potentially place limitations on understanding the illness experience. A primary role of medicine is often perceived as treating or alleviating pain, but what actually constitutes pain is subjective, value laden, and difficult to define objectively and empirically, relying as it does on expressivity of both bodily signs and language which are culturally embedded, subject to multiple interpretation, and the phenomena of chronic pain in particular provides us with one of the clearest examples of the need to adopt integrative models of healthcare which understand the relationship, not only between mind and body, but mind/body/society. 4. Chronic Pain Medical theories of pain have traditionally concentrated upon its neurophysiological aspects, both in diagnosis and treatment and scientific medicine reduces the experience of pain to an elaborate broadcasting system of signals, rather than seeing it as moulded and shaped both by the individual and their particular sociocultural context. A major impediment to a more adequate conceptualisation of pain is due to the manner in which it has been medicalised, resulting in the inevitable Cartesian split between body and mind. Consequently, the dominant conceptualisation of pain has focused upon sensation, with the subsequent inference that it is able to be rationally and objectively measured. Medical practice has concentrates on the nociceptive or sensory aspects of pain, employing the acute/chronic differentiation which does not necessarily take emotional aspects of pain in to account. It is universally acknowledged that one of the most complex and difficult types of pain to treat is idiopathic pain - that is, pain for which there is no established physical pathology11 - often termed chronic pain syndrome. Yet as well as being a medical problem pain is an everyday experience, and not the sole creation of our anatomy and physiology. Rather, as David Morris suggests, it emerges only at 'the intersection of bodies, minds and cultures.12 Moreover, defining pain is a semantic problem; in any language there may be wide variations in interpretation and meanings. For example, according to the Oxford Reference Dictionary pain refers to any or all of the following:

1. 2. 3.

PAIN [from the Latin poena, meaning penalty or punishment] An unpleasant feeling caused by injury or disease of the body. Mental suffering. [old use] punishment e.g. on pain of death.

Greek language uses algos for physical pain which derives from roots indicating neglect of love. Another Greek word akos signifies 'psychic pain' from which we

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__________________________________________________________________ derive the English ache.13 Implicit in these meanings is a broader definition of pain than the narrowly defined Cartesian proposition, which inevitably acts to divorce mental from physical states and tends to attribute single symptoms to single causes. Indeed, the notion of pain having a substantial emotional component, literally the obverse of pleasure is much older than that of pain being a physiological sensation and can be traced back to Plato's deliberations of extremes and opposites in the World of Forms. He declares pleasure and pain to be the twin passions of the soul, the results of the interactions between earth, air, fire and water. Aristotle developed the pain/pleasure principles further, describing them as basic moral drives guiding human action, and believed the pain experience to be negative passion which had to conquered by reason. He believed that pain was conveyed by the blood to the heart, yet excluded it from his classification of the five senses, instead preferring to describe it as 'a quale ( emotional quality) of the soul; a state of feeling and the epitome of unpleasantness'. 14 Literature, theology and philosophy abound with considerations of the nature and purpose of pain (amongst many others, see Systematic Theology vols. 1-3 1950-63, by Tillich; or Works of Love 1847 by Kierkegaard) and the pleasure/pain dichotomy is constantly evoked and reinforced, as in this early example from de Montaigne: Our well being is only freedom from pain, That is why the philosophical school which has given the greatest importance to pleasure has also reduced it to mere absence of pain. Not to suffer is the greatest good man can hope for.15 5. Treatment of Chronic Pain The critique of the limitations of biomedicine has developed within medicine, by those working in the area of pain, most notably in the pioneering work of Melzack and Wall 16 17 and Bonica.18 Developments such as the widespread acceptance of Melzack and Wall's Gate-control theory of pain and the influence of the hospice movement have shifted the pain paradigm, increasing the emphasis upon cultural and psychological components and the need for a multi-disciplinary approach. Social science, in particular the sociological literature on chronic illness offers a framework for understanding the experience of chronic pain by focusing on the person rather than the pain. Here, concepts such as biographical disruption, narrative reconstruction and illness adjustment 19 20 21 have been particularly valuable. In relation to adjustment to chronic pain, Kotarba, a pain physician charted the process of becoming a pain-afflicted person, in order to trace the continuity of personal identity. Using pain biographies he identified three stages in this process. First, there is the onset stage, which is perceived to be transitory, and able to be dealt with by diagnosis and treatment. Here, pain is diagnosed as real by physicians, in other words having a physiological basis. The second stage concerns

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__________________________________________________________________ what Kotarba terms the emergence of doubt. At this stage, treatment may not work, there is an increase in specialist consultations but patients still feel in control in seeking the best care available. Finally, the third stage is the chronic pain experience. Following the shortcomings of treatment, the patient, at this stage, may return to the lay frame of reference, and seek help within the chronic pain subculture.22 Using a focus on the person, rather than measuring so-called objective symptoms, allows us to encompass more easily the notion of total pain, which includes psychological, spiritual, interpersonal and even financial aspects of chronic pain, as well as its physical aspects, as was advocated by Dame Cicely Saunders,23 one of the founders of the hospice movement. Additionally, beliefs about pain have been shown to have an important effect on compliance with physical therapy interventions.24 However, whilst at a theoretical level, medicine may acknowledge the holistic, multi-faceted nature of pain, it is nonetheless debatable how much the attempt to transcend the mind/body dualism extends to treatments or therapy. Pain clinics or pain centres are institutions which have been developed specifically for the treatment of chronic pain conditions (pain with no demonstrable cause was rarely treated before the 1970's). The concept of having special institutions for treating pain originated with John Bonica, an anaesthetist in the US, who recommended25 that the treatment and understanding of pain would be best achieved through the co-operation of different disciplines. The first pain clinic was set up in the USA in 1961 with specialists from thirteen different disciplines, aiming to collaborate in a non-hierarchical manner. The subsequent development of pain centres vary in provision and resources, but are characterised by diversity in the organisation of work, medical specialities, working principles and therapies. They can be private organizations, or affiliated to medical schools, university departments or hospitals, and may incorporate a variety of treatment methods, or adopt one approach. A cross-sectional survey of 25 pain centres in a single urban community in the U.S. found that there were wide variations in the treatment modalities offered, the types of pain conditions treated, the populations served, the patient selections criteria and the diagnostic and aetiologic frames of reference. The research also examined pain centres and clinics across the whole of the U.S. and identified three different types. First, they found multidisciplinary, comprehensive pain centres, which are dedicated to all kinds of pain problems and offer a wide range of treatment modalities. Secondly, there were syndrome-orientated centres, which only treat one kind of pain problem (e.g. headache or back pain). Finally, there were modality-orientated treatment centres, which offered only one type of treatment modality (e.g. analgesic nerve blocks).26 A review of the theory and practice of pain in eight academic pain centres in the Netherlands, and identified five broad approaches to both theoretical and practical aspects of pain, namely

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__________________________________________________________________ Somatico-Technical, Dualistic Body-Orientated, Behaviourist, Phenomenological and Consciousness, of which the latter two in particular represent a rejection of the dualistic framework.27 Thus, illness narratives and phenomenological accounts have become intrinsic components of pain treatment in many pain clinics, which have been at the forefront in challenging the mind/body divide. Nevertheless it remains the case that many chronic pain sufferers do not have access to these highly specialised treatment centres and, in the absence of any aetiological or pathological evidence, continue to experience stigma and marginalisation by health care professionals. A seminal study of patients consulting with chronic back pain maintains that the acknowledgement of pain as ‘real’ by a physician is still the most important aspect in both understanding and ‘treating’ chronic pain.28 6. Conclusion Integrated models of health and illness are increasingly permeating contemporary healthcare, and are gaining popularity and credibility within the mainstream medical literature and research, as the limits of biomedicine become increasingly evident in contemporary time. Integrated models also challenge traditional sociological assumptions that doctors are only concerned with biological (disease) and that the social (illness) is of concern outside medicine as ‘in everyday clinical practice doctors constantly faced with issues relating to social causes of ill-health and the social contexts of ill-health and lifestyle provide doctors with a framework to talk about the social.29 Certainly, the concept of balance, which is intrinsically holistic and based on the Hippocratic view of the body as a microcosm of Nature is crucial to the process of intellectual and conceptual thinking, as it is in understanding and constructing models of health care which encapsulate the social in a meaningful way. The dissolution of the artificial divides between mental and physical health is an essential part of this rapprochement, and an understanding the role of emotions in health and illness is crucial to developing a mind/body/society perspective, as well as more enlightened healthcare.

Notes 1

R Fox, ‘Medical Uncertainty Revisited,’ Gender, Health and Healing: The Public/Private Divide, Routledge, London, 2002, pp. 236-253. 2 G Scambler, Health and Social Change: A Critical Theory, Open University Press, Buckingham, 2004. 3 T Greenhalgh & B Hurwitz (eds), Narrative Based Medicine: Dialogue and Discourse in Clinical Practice, BMJ Books, London, 1998. 4 D Wade & W Halligan, ‘Do Biomedical Models of Illness Make for Good Healthcare Systems?’ BMJ, Vol. 329, 2004, pp. 1398-1401.

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Mental Health Foundation http://www.mentalhealth.org.uk retrieved 2009. G Bendelow, Health Emotion and the Body, Polity Press, Oxford, 2009. 7 Wade & Halligan, op. cit., p.1400. 8 G Bendelow, op. cit., p. 3 9 S Nettleton et al., ‘Enigmatic Illness: Narratives of Patients who Live with Medically Unexplained Symptoms,’ Social Theory and Health, Vol. 2:1, 2004, pp. 4 7-67. 10 G Williams, ‘The Genesis of Chronic Illness: Narrative Reconstruction,’ Sociology of Health and Illness, Vol. 6:2, 1984, pp. 175-200. 11 R Melzack & P Wall, The Challenge of Pain, Penguin, London, 1988. 12 D Morris, The Culture of Pain, University of California Press, Berkeley CA and London, 1991, p. 1. 13 E Procacci & P Maresca, ‘A Philological Study on Some Words Concerning Pain,’ Pain, Vol. 22, 1985, p.201.. 14 G Bendelow, Pain and Gender, Pearson Education, Harlow, 2000, p. 34. 15 ibid., p. 35 16 R Melzack & P Wall, ‘Pain Mechanisms: A New Theory’, Science, Vol. 150, 1965, pp. 971-979.. 17 ibid. 18 J Bonica, The Management of Pain, Lea and Feibiger, Philadelphia, 1953. 19 G Williams, op. cit., p.191. 20 M Bury, ‘The Sociology of Chronic Illness: A Review of Research and Prospects,’ Sociology of Health and Illness, Vol. 13:4, 1991, pp. 451-68. 21 ibid. 22 J Kotarba, Chronic Pain: its Social Dimensions, Sage, Beverly Hills CA, 1983, p. 27. 23 C Saunders, ‘Care of the Dying,’ Nursing Times, 72, 1976, pp. 3-24. 24 D Williams & B Thorn, ‘An Empirical Assessment of Pain Beliefs,’ Pain, Vol. 36, 1999, pp. 351-358. 25 J Bonica 26 J Csordas & T Clark, ‘Ends of the Line: Diversity among Chronic Pain Centers,’ Social Science and Medicine, Vol. 34, 1992, p 385. 27 M Vrancken, ‘Schools of Thought on Pain,’ Social Science and Medicine, Vol. 29:3, 1989, pp 436-440. 28 C Glenton, ‘Chronic Back Sufferers: Striving for the Sick Role,’ Social Science and Medicine, Vol. 57, 2003, pp 2243-2252.. 29 E Hansen & G Easthope, Health and Lifestyle, Routledge, London, 2006 6

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__________________________________________________________________

Bibliography Bendelow G., Pain and Gender. Pearson Education, Harlow, 2000. _______

, Health Emotion and the Body. Polity Press, Oxford, 2009

Blaxter M., Health. Polity Press, Oxford, 2004. Bonica J., The Management of Pain. Lea and Feibiger, Philadelphia, 1953. Bury M., ‘The Sociology of Chronic Illness: A Review of Research and Prospects.’ Sociology of Health and Illness. Vol.13:4, 1991, pp. 451-68, 1991. Csordas T. & Clark, J., ‘Ends of the Line: Diversity among Chronic Pain Centers.’ Social Science and Medicine. Vol. 34, 1992, pp.383-393. Fox, R.C, ‘Medical Uncertainty Revisited.’ Gender, Health and Healing: The Public / Private Divide. Routledge, London, 2002. Glenton C., ‘Chronic Back Sufferers: Striving for the Sick Role.’ Social Science and Medicine. Vol. 57, 2003, pp. 2243-2252. Greenhalgh T. & Hurwitz, B. (eds), Narrative Based Medicine: Dialogue and Discourse in Clinical Practice. BMJ Books, London, 1998. Good, M.J.D., et. al., Pain as Human Experience: An Anthropological Perspective. Berkeley, CA, 1992. Hansen E. & Easthope, G., Health and Lifestyle. Routledge, London, 2006. Helman C., Culture, Health and Illness. Oxford University Press, Oxford, 2001. Kotarba J., Chronic Pain: Its Social Dimensions. Sage, Beverly Hills, CA, 1983. Melzack R. & Wall, P., ‘Pain Mechanisms: A New Theory’. Science. Vol. 150, 1965, pp. 971-979. . , The Challenge of Pain. Penguin, London, 1988. Morris D., The Culture of Pain. University of California Press, Berkeley, CA, and London, 1991.

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__________________________________________________________________ Nettleton S. et. al., ‘Enigmatic Illness: Narratives of Patients who Live with Medically Unexplained Symptoms.’ Social Theory and Health. Vol. 2:1, 2004, pp. 47-67. Procacci E. & Maresca, P., ‘A Philological Study on some Words Concerning Pain.’ Pain. Vol. 22, 1985 pp 201-203. Saunders C., ‘Care of the Dying’. Nursing Times. Vol. 72, 1976, pp.3-24. Scambler G., Health and Social Change: A Critical Theory. Open University Press, Buckingham, 2004 . Vrancken M., ‘Schools of Thought on Pain.’ Social Science and Medicine. Vol. 29, 1989, pp. 435-444.. Wade D. & Halligan, P., ‘Do Biomedical Models of Illness Make for Good Healthcare Systems?’ BMJ. Vol. 329, 2004, pp.1398-1404. Wall P., Pain: The Science of Suffering. Weidenfeld and Nicolson, London, 1999. Williams G., ‘The Genesis of Chronic Illness: Narrative Reconstruction.’ Sociology of Health and Illness. Vol. 6, 1984, pp. 175-200. Williams D. & Thorn, B., ‘An Empirical Assessment of Pain Beliefs.’ Pain. Vol. 36, 1999, pp. 351-358. Gillian Bendelow is a professor of Sociology in the School of Law Politics and Sociology, University of Sussex.

An Uncertain Anodyne: Making Sense of Pain through Mesmerism in the Nineteenth Century Elizabeth Todd Abstract Mesmerism is often examined as a therapeutic or mystical agent, but in the nineteenth century mesmerism also enjoyed significant popularity as a surgical anaesthetic agent. In the mid-nineteenth century the application of mesmerism for pain relief in surgical procedures problematised understandings of the mechanism, function and meaning of pain. These questions were confronted even more aggressively with the introduction of inhalation anaesthetics, such as ether in 1846 and chloroform in 1847. Such questions included: Was it acceptable or desirable to remove pain in a medical procedure? What functions did pain serve? Did some patients suffer pain more acutely than others? Was mesmerism an effective anodyne? The new inhalation anaesthetics for surgical pain-relief did not immediately supersede mesmerism. James Esdaile in India and John Elliotson in London practiced and published widely on the subject into the 1850s. However, there was considerable disbelief from both the medical and lay communities regarding the efficacy of mesmerism as an anodyne. There were accusations of practitioners colluding with patients in public demonstrations to make it appear that the patient felt no pain from the surgeon’s knife. There was further debate among the medical community as to whether mesmerism could be regarded as a medical technique, or should be relegated to the realm of quackery. This paper will examine mesmerism as a means of relieving pain, and then explore the nature of disagreements as to its efficacy. It will also explore some of the questions mesmerism raised about the concept of ‘pain’ in nineteenth century Britain, before assessing some of the questions these issues raise for historians studying pain of the past. Key Words: Mesmerism, anaesthesia, pain, John Elliotson, James Esdaile, surgery, nineteenth-century, Britain. ***** Mesmerism has been a topic of much interest to historians and other scholars studying the eighteenth and nineteenth centuries. Scholars have explored the use of mesmerism using a variety of frameworks: they have looked at its use as a tool for uncovering the unconscious; at its application as a therapeutic treatment; or they have focused on mesmerism’s later use in the realms of clairvoyance and mysticism towards the end of the nineteenth century.1 However, those scholars who study mesmerism generally do not devote much of their analysis to its role as an agent of surgical anaesthesia.2 Similarly, historians of anaesthesia and surgery

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__________________________________________________________________ do not seem to regard mesmerism as a serious attempt by nineteenth century society to produce an effective anaesthetic agent. In anaesthetic history, mesmerism is often mentioned in passing as one of the many failures in the search for an effective agent to relieve the pain of surgery before the (apparently) ‘perfect’ solution was found with inhalation anaesthesia in 1846.3 In this field of scholarship, mesmerism, if it is mentioned at all, is considered, at best, an undignified chapter in the technological advancement that led to modern anaesthesia. In fact, mesmerism enjoyed significant popularity as a surgical and dental anaesthetic agent, both before and after the introduction of inhalation anaesthesia. In this paper I will examine mesmerism as a means of relieving pain, and then explore the nature of disagreements as to its efficacy. I will also explore some of the questions mesmerism raised about the concept of pain in nineteenth century Britain, before assessing some of the questions these issues raise for historians studying pain of the past. The pain of surgery is a horrifically unpleasant sensation and has been a struggle for both doctors and patients for millennia. In the West, the ancient societies of Egypt, Babylon, Greece and Rome tried various herbal remedies. In the East, herbal remedies were also employed from ancient times, as was acupuncture. Soporifics such as opium and alcohol have been employed in different ways, usually ingested orally either before or after the medical procedure. Often, these soporifics were not administered exclusively for their ability to relieve pain, but to stimulate the bodily systems or to give the patient some Dutch courage for the impending procedure. Throughout the medieval and early modern periods in Europe various plants, chemical substances, and supernatural practices were tested for their capacity to relieve pain. Of course, surgery was not a common practice, but was resorted to in cases where it was necessary for the preservation of life. However, because of the limited success of any of these substances or practices to reduce the sensation of pain, pain itself had to be rationalised into human existence. Thus, different groups in different societies at different times regarded pain as: a punishment, a divine test, or a necessary part of the healing process. But however pain was rationalized, it was still unpleasant! By the late eighteenth century in Europe, individuals with interests in science and medicine focused their attention on the properties and possible applications of gaseous substances for pain-relief, particularly with the discoveries of oxygen, nitrous oxide and carbon dioxide.4 Such experiments eventually led to the discovery of the narcotic powers of volatile substances (such as ether and chloroform) used in inhalation anaesthesia, which was first publicly demonstrated in surgery in Boston in 1846. However, other pioneers such as Friedrich Anton Mesmer looked to other forces to relieve pain.

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__________________________________________________________________ 1. Mesmer and Mesmerism Friedrich Anton Mesmer was born in a small village on the shores of Lake Constance in present-day Germany in 1734, and commenced his medical studies at the University of Vienna in 1759.5 After completing his doctorate in 1766 on the effects of the phases of the moon on the human state of health, Mesmer began to formulate his theories on what he called animal magnetism, the practice that would later come to bear his name - mesmerism.6 Mesmer believed that something called animal magnetism flowed through all living things, and that a proficient practitioner could manipulate this force or fluid to make an ill person well. This was done either by using magnets or by simply passing his hands over a patient’s body. This practice would thus restore balance to the four humours of which every human being consisted, the imbalance of which caused symptoms of illness.7 When applied to surgery, Mesmer’s followers believed that the mesmeric practitioner could manipulate the magnetic field in such a way that the patient would become insensible to pain. Mesmer’s theories did not receive a warm reception in Austria, so he travelled to Paris hoping to attract a more sympathetic audience. He attracted enough followers to set up a mesmerism practice in Paris, and he acquired a following of students to whom he taught his techniques. He gained some powerful patrons including the French Queen, Marie-Antoinette. However, Mesmer also attracted several powerful enemies who ridiculed his ideas and accused him of quackery. The French King called a Royal Commission in 1784 to inquire into the validity of Mesmer’s claims and practices. The Commission, headed by Benjamin Franklin who was living in France at this time, found that there was no scientific basis to Mesmer’s claims or practices.8 But this was not the end for mesmerism. 2. Mesmerism and Surgery The dreadful pain that human beings suffered at the hands of their health was no longer acceptable at the beginning of the nineteenth century. Mesmerism might have been discounted at the end of the eighteenth century, but, as historian Alison Winter has shown, by the late 1830s in Britain, mesmerism was being reinvestigated for its possible value as a means of relieving the agony of surgery.9 The first surgical procedure in Britain to be performed with the assistance of mesmerism took place in 1842, when 42-year-old J. Wombell, a labourer from Nottingham, underwent an amputation of the leg at the thigh whilst in a mesmerized state. A prominent London practitioner, John Elliotson, Professor of Clinical Surgery at University College Hospital described Wombell’s state during the procedure: Mr Ward slowly plunged his knife into the centre of the outside of the thigh, directly to the bone, and then made a clear incision round the bone, to the opposite point on the inside of the thigh.

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__________________________________________________________________ The stillness at this moment was something awful; the calm respiration of the sleeping man (Wombell) alone was heard, for all other seemed suspended...10 There were complications in detaching the leg and creating a flap of skin for the stump, making the operation far more tedious and painful than the ordinary...Yet notwithstanding all this, the patient's sleep continued as profound as ever. The PLACID look of his countenance never changed for AN INSTANT; his whole frame rested, uncontrolled in perfect stillness and repose; not a muscle was seen to twitch. To the end of the operation, including the sawing of the bone, securing the arteries, and applying the bandages, occupying a period of upwards of twenty minutes, he lay like a statue.11 Afterwards, Wombell professed to have felt no pain during the amputation, and went on to live for another 30 years, dodging the fatal surgical threats of haemorrhage and infection.12 3. Mesmerism, Questions and Doubt When the news of Wombell’s amputation was reported in the medical and popular press, some disbelieving members of the medical profession and the lay public accused Wombell of being in cahoots with his surgeons and pretending his insensibility to his surroundings and to the excruciating proceedings.13 The mechanisms of mesmerism were not agreed or understood (by the public or the medical profession) so many assumed there must be trickery or subterfuge involved. There was further debate among the medical community as to whether mesmerism could be regarded as a medical technique, or should be relegated to the realm of quackery. Others argued that there was simply no need for it, that pain had a necessary function in the surgical process, that it assisted healing, constricted the blood vessels to prevent fatal haemorrhage and was a sign of the presence of life - when pain and sensibility began to fade away, it was taken as an indication that life was fading. Doctor John Elliotson, who described Wombell’s operation, became the most prominent advocate of mesmerism in Britain and spent much energy refuting these accusations. In an open letter published in his journal of mesmerism, The Zoist Elliotson criticised the medical community for questioning the integrity of Wombell and the surgeons who had performed the procedure.14 He gave detailed descriptions of his own successful administrations of mesmerism on patients at

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__________________________________________________________________ University College Hospital, providing multiple examples of the efficacy of mesmerism as a means for relieving pain. Despite Elliotson’s protestations, the considerable disbelief regarding the efficacy of mesmerism as an anodyne persisted. Elliotson and others undertook dozens of mesmeric experiments and large crowds often gathered to witness these public displays of mesmerism. However, the veracity and legitimacy of the experiments were regarded as questionable given the subjectivity of pain, and therefore the subjectivity of mesmerism’s success in relieving pain. No one who witnessed the application of mesmerism could verify that the mesmerised subject was not experiencing pain whilst in the mesmeric state - the only evidence was the patient’s own testimony, and their reactions during the painful procedure. Medicine was becoming increasingly scientific in the mid-nineteenth century, and this inability to scientifically legitimise the practice of mesmerism meant that it had trouble gaining acceptance into mainstream medical practice.15 One British doctor who did believe in the efficacy of mesmerism for painrelief, and who eventually surpassed Elliotson in the number of mesmeric procedures he performed, was Doctor James Esdaile. Esdaile, practicing in Calcutta as an Assistant Surgeon for the East India Company, was convinced by Elliotson’s ideas about the medical applications of mesmerism. He was given permission and funding by the British Government in India to establish a Mesmeric Hospital, which opened its doors in 1846 with the aim of treating both Indians and Europeans with this controversial technique. Esdaile’s official reports describe countless operations performed under mesmerism, serious procedures such as mastectomies, amputations and excisions of tumours. Most of Esdaile’s descriptions of his patients during these painful procedures mirror the one given by Elliotson of Wombell’s surgery. Again and again the patient, upon the commencement of the surgery, is described as being absolutely un-disturbed by any pain: ‘He bore the knife like a corpse;’ ‘The boy lay like a log;’ ‘He remained perfectly passive under the knife, making no movement whatever;’ ‘No dead body could be more perfectly passive.’ 16171819 To Esdaile, his administration of mesmerism made his patients absolutely insensible to the pain he was inflicting upon them during surgery, and the patients’ lack of reaction or response was evidence of this. 4. Mesmerism, Pain and History So, how does looking at the use of mesmerism in the nineteenth century help us study pain in the past? In his Theory of Moral Sentiments Adam Smith noted that As we have no immediate experience of what other men feel, we can form no idea of the manner in which they are affected, but conceiving what we ourselves should feel in the like situation.

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__________________________________________________________________ Though our brother is upon the rack, as long as we ourselves are at our ease, our sense will never inform us of what he suffers. They never did, and never can, carry us beyond our own person, and it is by the imagination only that we can form any conception of what are his sensations.20 To situate pain historically, a historian must be careful not to place current understandings and explanations of pain on the past. But they must to some extent use their imagination to come to an understanding of the experiences of the historical actor suffering pain. This is a contested aspect of pain history. Some scholars have argued that pains are so different in kind and meaning, that any experience of pain is fundamentally different in different historical contexts, and so cannot be fully understood or compared.21 However, as others have argued, there is an innate biological foundation of pain that allows for some, if not total, understanding of historical pain.22 Historicizing the medical body is a dilemma often faced by historians of medicine, as the body, as a biological entity, can in some ways be regarded as a historical constant, even though our understandings of its forms and functions have changed over time. Scholars who aim to historicize pain, are thus confronted by such questions as: Can pain be felt in the past the same as in the present it if it is simply a biological process? If we accept that there are cultural aspects to the experience of pain, can you assume that there are innate, unchanged biological aspects to pain that are unaffected by culture or context? Is the mediation of culture so strong that that a comparable biological phenomenon becomes impossible? For every doctor like Elliotson or Esdaile who swore by the efficacy of mesmerism, there were crowds of others who declared it to be quackery or, worse, a conspiracy. A historian can simply present these arguments, analysing both sides within their context and as part of the contested space of medical practice in the nineteenth century. But if the historical actors were trying to work out what effect mesmerism actually had on the experience of pain, is there not some value in the historian speculating also? Mesmerism raises questions about pain in the past because historians are forced to contemplate whether or not it actually succeeded in relieving pain. If the historian accepts that mesmerism did work, then the sources will be analysed in a particular way. However, if the historian does not accept that mesmerism relieved the pain of surgery, then a whole different set of questions

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__________________________________________________________________ need to be asked of the sources, particularly those that relate to the state of the patient. To a modern-day reader, who may not believe in the existence of a magnetic fluid flowing through all living beings, the reports of Elliotson and Esdaile seem to indicate remarkable feats of endurance on the part of mesmerised patients. But Elliotson, and particularly Esdaile, performed hundreds of real, painful surgical procedures. Assuming that the surgery being performed was real (and not some sort of carnival-esque sleight-of-hand) how did the patients endure the pain involved in these procedures? If we assume that mesmerism had no effect at all, I find it difficult to reconcile Esdaile and Elliotson’s accounts with other accounts of surgery in the period. Compare, for example, the earlier descriptions from Elliotson and Esdaile of stoic, passive patients, to this description from English author Fanny Burney describing the pain of her mastectomy in 1811: …when the dreadful steel was plunged into the breast - cutting through veins – arteries – flesh – nerves - I needed no injunctions not to restrain my cries. I began a scream that lasted unintermittingly during the whole time of the incision - and I almost marvel that it rings not in my Ears still! so excruciating was the agony. When the wound was made, and the instrument was withdrawn, the pain seemed undiminished, for the air that suddenly rushed into those delicate parts felt like a mass of minute but sharp and forked poniards, that were tearing the edges of the wound - but when again I felt the instrument - describing a curve - cutting against the grain, if I may so say, while the flesh resisted in a manner so forcible as to oppose and tire the hand of the operator, who was forced to change from the right to the left then, indeed, I thought I must have expired.23 Several factors could explain the differences in these experiences of surgical pain: the procedures were different; the constitutions, personalities and medical conditions of the patients were different. However, for Elliotson, Esdaile and other supporters of mesmerism, the single explanation for the differences in these accounts was that mesmerism was not applied in Fanny Burney’s case. It could perhaps be argued that a comparison between Burney’s account and Elliotson’s and Esdaile’s accounts provides a fairly clear indication that mesmerism was having some effect on these patient’s experiences of pain. But historians in the twenty-first century are confronted with the same problem as the British medical community in the nineteenth century - the pain-relieving capacity of mesmerism is not verifiable. We could venture other explanations for the apparent painlessness of the operation: a psychological ‘placebo’ effect where the

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__________________________________________________________________ patient believed that mesmerism was being effective, or perhaps the flesh that was being incised was necrotised and dead or the nerves damaged. The possibilities are endless and probably say more about a twenty-first century understanding of pain than a nineteenth century understanding. Alternatively, we could simply treat the people of the past as ‘other’ who experienced and expressed their pain differently in a way we cannot comprehend, believing that a modern historian’s imaginary rendering of the pain involved may be far more excruciating that the actual sensation. These are questions I hope we can explore through discussion in this panel session. 5. Conclusions The properties of mesmerism led practitioners and patients to question the nature of pain in the nineteenth century. They questioned the purpose of pain, the physiological mechanisms of pain, and how human-kind could work to alleviate pain with the tools available in the mid-nineteenth century. For modern historians studying the phenomena, mesmerism raises questions. Questions about the subjectivity of the painful experience. Questions about the role of the physiological experience of pain. Questions about the mediation of pain by society and culture. And questions about whether there is value in speculating on the expressions and sensations of the painful experiences of the past.

Notes 1

See in particular A Winter, Mesmerized: Powers of Mind in Victorian Britain, University of Chicago Press, Chicago, 1998; A Crabtree, From Mesmer to Freud: Magnetic Sleep and the Roots of Psychological Healing, Yale University Press, New Haven, Connecticut, 1993; F Kaplan, ‘The Mesmeric Mania: The Early Victorians and Animal Magnetism’, Journal of the History of Ideas, Vol. 35, no. 4, 1974, pp. 691-702; and for a different perspective of mesmerism in history, see R Darnton, Mesmerism and the End of the Enlightenment in France, Harvard University Press, Cambridge, Massachusetts, 1968. 2 An exception is A Winter’s work ‘Ethereal Epidemic: Mesmerism and the Introduction of Inhalation Anaesthesia to early Victorian London,’ Social History of Medicine, Vol. 4, 1991, pp. 1-27, and Mesmerized, pp. 163-186. 3 See, for example, SJ Snow, Blessed Days of Anaesthesia: How Anaesthetics Changed the World, Oxford University Press, Oxford, 2008; SJ Snow, Operations Without Pain:The Practice and Science of Anaesthesia in Victorian Britain, Palgrave Macmillan, Houndsmills, Basingstoke, Hampshire, 2006; K Sykes, Anaesthesia and the Practice of Medicine: Historical Perspectives, Royal Society of Medicine Press, London, 2007. 4 Joseph Priestley and Antoine Lavoisier independently conducted extensive and influential experiments on oxygen and on nitrous oxide. Humphrey Davy

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__________________________________________________________________ conducted several years of experiments on nitrous oxide, publishing his results in Researches, Chemical and Philosophical, Chiefly Concerning Nitrous Oxide or Dephlogisticated Nitrous Air and its Respiration in 1800. He noted in this work that nitrous oxide had anaesthetic properties that could prove useful if applied to surgery. English surgeon Henry Hill Hickman conducted several experiments into the anaesthetic properties of carbon dioxide in 1823. None of these methods caught the wider medical imagination at this time and were not implemented in more than a few cases. 5 Mesmer is also known in some contemporary literature as Franz Anton Mesmer. 6 The label ‘animal magnetism’ was devised to differentiate it from ‘mineral magnetism,’ the force that eighteenth century scholars understood existed in certain types of rocks. 7 A Mesmer, Mesmerism: A Translation of the Original Scientific and Medical Writings of F. A. Mesmer, trans. by G Bloch, William Kaufmann, Los Altos, California, 1980. 8 B Franklin, Report of Dr. Benjamin Franklin, and Other Commissioners, Charged by the King of France with the Examination of Animal Magnetism as now Practiced at Paris, Printed for J Johnson, St Paul’s Church Yard, London, 1785. 9 Winter, op. cit., p. 5. 10 J Elliotson, ‘False Accusation of the Royal Medical and Chirurgical Society against a Poor Man because He Suffered no Pain while his Leg was Amputated in the Mesmeric Coma and Cruel Refusal of the Society to Receive his Solemn Denial of the Truth of the False Accusation,’ London, 1851 (taken from Zoist, April, 1851, pp. 1-19), p. 2. 11 ibid., p. 2. Elliotson’s emphasis. 12 The details of Wombell’s procedure and the ensuing controversy are described in detail in Winter, Mesmerized, pp. 165-9. 13 ibid., pp. 1, 4. 14 ibid., p 4. 15 Though, as Alison Winter has argued, mesmerism did still maintained a presence in medical circles, it cannot be completely relegated to the realm of quackery and alternative medicine as medical historians often do. 16 J Esdaile, Record of Cases Treated in the Mesmeric Hospital, from June to December, 1847: With Reports of the Official Visitors, Military Orphan Press, Calcutta, 1848, p. 8. 17 ibid, p. 11. 18 ibid., p. 12. 19 ibid., p. 12. 20 A Smith, Theory of Moral Sentiments, J.J. Tourneisen, Basil, 1793 (first published, 1752), p. 2.

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J Croissant, ‘Pain and Culture,’ Oxford Reference Online, Oxford University Press, Oxford, 2005, pp. 1-6. http://www.oxfordreference.com/views/ENTRY .html?subview=Main&entry=t210.e74, Accessed 13 September 2007, p. 1. 22 C Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine, Cambridge University Press, Cambridge, 1992, p. 5; L Manger, A History of Medicine, Informa Healthcare, New York, 2007, p. vi. 23 F Burney, Selected Letters and Journals, Oxford University Press, Oxford, 1986, pp. 127-41.

Bibliography Burney, F., Selected Letters and Journals. Oxford University Press, Oxford, 1986. Crabtree, A., From Mesmer to Freud: Magnetic Sleep and the Roots of Psychological Healing. Yale University Press, New Haven, Connecticut, 1993. Croissant, J., ‘Pain and Culture.’ Oxford Reference Online. Oxford University Press, 2005 http://www.oxfordreference.com/views/ENTRY.html?subview=Main &entry=t210.e74, Accessed 13 September 2007. Darnton, R., Mesmerism and the End of the Enlightenment in France. Harvard University Press, Cambridge, Massachusetts, 1968. Davy, H., Researches, Chemical and Philosophical: Chiefly Concerning Nitrous Oxide, or Dephlogisticated Nitrous Air and its Respiration. Butterworths, London, 1972, first published 1800. Esdaile, J., Record of Cases Treated in the Mesmeric Hospital from June to December, 1847: With Reports of the Official Visitors. Military Orphan Press, Calcutta, 1848. Kaplan, F., ‘The Mesmeric Mania: The Early Victorians and Animal Magnetism.’ Journal of the History of Ideas. Vol. 35, no. 4, 1974, pp. 691-702. Manger, L., A History of Medicine. Informa Healthcare, New York, 2007. Mesmer, A., Mesmerism: A Translation of the Original Scientific and Medical Writings of F. A. Mesmer. Los Altos, California, 1980. Rosenberg, C., Explaining Epidemics and Other Studies in the History of Medicine. Cambridge University Press, Cambridge, 1992.

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__________________________________________________________________ Snow, S. J., Blessed Days of Anaesthesia: How Anaesthetics Changed the World. Oxford University Press, Oxford, 2008. _______

, Operations Without Pain: The Practice and Science of Anaesthesia in Victorian Britain. Palgrave Macmillan, Houndsmills, Basingstoke, Hampshire, 2006. Smith, A., Theory of Moral Sentiments. J. J. Tourneisen, Basil, 1793. (First published, 1752). Sykes, K., Anaesthesia and the Practice of Medicine: Historical Perspectives. Royal Society of Medicine Press, London, 2007. Winter, A., Mesmerized: Powers of Mind in Victorian Britain. University of Chicago Press, Chicago, 1998. - --, ‘Ethereal Epidemic: Mesmerism and the Introduction of Inhalation Anaesthesia to early Victorian London.’ Social History of Medicine. Vol. 4, 1991, pp. 1-27. Elizabeth Todd is a PhD candidate in the Department of History at the University of Sydney. She is currently completing her thesis, ‘Primum non nocere? Anaesthesia and medical harm in British and colonial medicine, 1846-1891: How doctors and patients reconciled pain, anaesthesia and the medical obligation to ‘first, do no harm.’

Journeys with Chronic Pain: Acquiring Stigma along the Way Amanda Nielsen Abstract Chronic pain has been identified as a major and underestimated health care problem, with extensive individual, social and economic ramifications. Recognition of pain as a multidimensional experience has contributed to the biopsychosocial model of health gaining substantial recognition in the pain management domain. There is evidence, however, that the ‘promise’ of the multidimensional approach has not been realised in the daily lives of people with chronic pain. A relationship between stigma and chronic pain has recently begun to emerge in the qualitative literature concerning the lived experience of chronic pain. Drawing on a narrative study with twenty people with chronic pain, this paper will use the conceptual framework outlined by Link and Phelan to illustrate the social processes involved in the stigma acquired by people in their journey with chronic pain. Stigmatisation has significant consequences for people living with chronic pain which cannot be addressed at an individual cognitive level. This adds salience to the author’s contention that the social dimension of chronic pain needs to be further articulated and addressed at a policy and practice level, not only to ensure a more comprehensive response to chronic pain, but also to ameliorate the social suffering experienced by people living with chronic pain in our community. Key Words: Chronic pain, stigma, social environment. ***** 1. Introduction Chronic pain has been identified as a major and underestimated health care problem, with extensive individual, social and economic ramifications. Recognition of pain as a multidimensional experience has contributed to the biopsychosocial model of health gaining substantial recognition in the pain management field.1 2 This in turn has facilitated the development of new approaches to chronic pain treatment, ostensibly aimed at integrating the biological, psychological and social domains of individual experience. There is evidence, however, that the ‘promise’ of the multidimensional approach has not been realised in the daily lives of people with chronic pain . In particular, it has been argued that the application of the biopsychosocial model continues to direct attention to the biological and psychological aspects of the pain experience, while minimising or ignoring factors located in the social domain which may also be significant.

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__________________________________________________________________ It has been proposed that in order to more comprehensively respond to the complex phenomenon of chronic pain, the social dimension of the experience needs to be further articulated and addressed at a policy and practice level.3 In this paper, this contention is illustrated through an exploration of the relationship between stigma and chronic pain. Drawing on a narrative study with twenty people with chronic pain,4 stigmatisation is shown to be a social process that has significant consequences for the stigmatised which cannot be addressed at the individual cognitive level. The paper highlights the critical importance of focusing not only on the individual with pain, but also on the social environment within which the individual lives, and the ways in which these domains intersect and influence each other. 2. Defining Chronic Pain Chronic pain is a complex phenomenon which is not easily or neatly defined. A number of definitions and classification systems exist. Most simply, pain can be considered chronic when it persists longer than expected; a period of six months or longer was used for the study reported on in this paper. 3. Study Participants The narratives referred to in this paper were part of the author’s doctoral study. 5 In this study, narrative interviews were conducted with a convenience sample of 20 adults with chronic pain, predominantly residing in the state of Queensland, Australia. Participants were required to have ongoing pain which had persisted for at least six months, with little or no identifiable pathology. There is evidence that people with chronic pain without obvious physical pathology are a particular ‘pain’ sub-group that may be subject to social disadvantage.6 7 8 9 Consequently, this subgroup were the focus of this study. Transcripts of participants’ narratives were analysed using a qualitative interpretive method,10 resulting in three principal themes and seven sub-themes. This paper is concerned with the sub-theme ‘Acquiring stigma’. 4. Defining Stigma A relationship between stigma and chronic pain has recently begun to emerge in the qualitative literature concerning the experience of living with chronic pain.11 12 13 14 15 Contemporary discussions of stigma continue to acknowledge Goffman’s classic explication of the concept.16 However, literature concerning stigma demonstrates variability in definition and application. In this paper, the concept of stigma as developed by Link and Phelan will be applied; that is, that ‘stigma exists when the elements of labelling, stereotyping, separating, status loss, and discrimination co-occur in a power situation that allows these processes to unfold’.17 The advantage of this definition in the current context is that it focuses attention on the social environmental factors that create and sustain stigma, rather

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__________________________________________________________________ than the predominantly individualistic or interpersonal focus of other literature on stigma . The components of stigma, as conceptualised by Link and Phelan, are discussed with reference to the narratives which formed the basis of the author’s doctoral study. 5. The Interrelated Components of Stigma and Chronic Pain 5.1 Labelling The term ‘labelling’ in this context refers to the taken-for-granted culturally created categories that are used to identify differences that matter socially. These categories are part of the cultural system of the social environment in which people live, and as such are incorporated into the individual’s ‘ways of seeing’ themselves and others. The process of being labelled is not necessarily problematic; the majority of differences between people are minimally, if at all, socially relevant. It is only when the attributed label identifies a difference that is socially salient that labelling may become significant. For participants in the study reported on in this paper, the process of labelling was grounded in a problematic and unsuccessful search for diagnosis and cure of their pain. Hilbert appropriately described living with chronic pain as an atypical and acultural experience: atypical as chronic pain does not conform to the trajectory of ‘normal’ pain and acultural because: The cultural resources usually summoned to render pain meaningful are inadequate when pain persists. Chronic pain sufferers are afflicted with a ‘condition’ which from their vantage point makes no sense and defies every attempt to stabilise it.18 Lack of diagnosis and a clear treatment path, combined with the open-ended nature of chronic pain, also meant participants could not perform the roles of the socially acceptable sick person; that is, actively participate in the recommended treatment regime and then return to normal duties.19 Thus, the lack of a culturally condoned, straightforward label for their condition, as is available for many other health states, contributed to participants being alternatively, if not explicitly, labelled as somehow different or difficult. 5.2 Stereotyping In the Link and Phelan schema, the process of labelling is not inherently stigmatising. A label only becomes problematic when it is linked to a set of undesirable characteristics that become a stereotype. The stereotype of ‘malingerer’ was one that the majority of participants in the study felt had been applied to them to varying degrees. Most participants believed health professionals, and society more generally, questioned the reality of their pain in the

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__________________________________________________________________ absence of an identifiable cause or an observable manifestation of disability. As one participant stated: ‘if it’s not explained by a blood test or an x-ray or whatever, it doesn’t exist’. As a result, the possibility of being a malingerer was, even if not overtly stated, a status participants felt was implied by some health professionals and by others more generally in society. Stereotyping of the chronic pain patient may indeed result in more than stigmatisation; Chibnall and Tait’s body of work suggests that biomedical evidence has an ‘inordinate amount of influence’ on physician pain judgements, and may contribute to under-treatment of pain.20 21 22 23 24

Psychologically, the majority of study participants wrestled with the same cultural stereotypes they believed others were applying to them. This was reflected in the search undertaken for some form of physical pathology that would explain their pain. For many, not only did this search fail to find a diagnosis or cure, but they had in fact suffered unexpected side-effects of treatment or iatrogenic harm. Study participants generally resisted the malingerer stereotype, as they knew they were living with very real pain. Simultaneously, however, they found it difficult not to apply the culturally-acquired model of mind-body dualism to their own situation, thus revealing the threat that if a bodily reason could not be found, the pain must be ‘in their head’ or in some way psychosomatic. The implicit implication of this was that they might be suffering from some form of mental illness, with all the additional cultural stereotypes that this implied. Labelling and stereotyping had clearly affected the lives of the study participants, both in terms of their relationships and interactions with others, and in their view of themselves. They were confronted with what Archer25 termed a ‘constraining contradiction’; that is, the interaction between two irreconcilable but inter-related elements: ongoing pain in the absence of biomedical evidence. However, as individuals, they lacked the transformational power to change the circumstances in which they found themselves. 5.3 Separation The third component of the Links and Phelan stigma schema is separation; that is, when social labelling and stereotyping implies a separation of ‘us’ and ‘them’. In other words, the reactions of others produce a sense of being devalued or disrespected, or in some way different in a negative way to others in society. 26 Stigma can therefore be seen to be a cumulative process mediated through sociocultural interaction. The majority of study participants described a process of separation through the gradual recognition that their pain was atypical and acultural. The ever-present nature of chronic pain meant that participants were constantly aware that they were different; they had what Hilbert described as ‘an extreme personal idiosyncrasy’ which although invisible, was constant, preoccupying, and could not be left at home for a good night out.27 The omnipresent nature of chronic pain created and

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__________________________________________________________________ continually reinforced a sense of isolation and estrangement from society, with participants describing varying processes of social withdrawal. Participants’ narratives also demonstrated what could be termed a more ‘active’ process of separation in regard to the way they were treated by some health professionals. The invisibility and subsequent lack of legitimacy of their chronic pain would appear to be at the core of this phenomenon. For example, one participant deliberately structured his narrative to include a section on what he introduced as ‘how the medical profession has dealt with me’. He described being treated with cynicism and suspicion, particularly when requesting pain relieving medication. Another participant said she believed she was considered ‘a liar and a cheat’, while another woman said she felt that others were always judging the veracity of her pain story. Without a culturally assigned role or status in our society, chronic pain sufferers are positioned in a negative stereotype which separates them not only from society as a whole, but also from more ‘deserving’ people with legitimate health problems.28 This can be related to what Holloway and colleagues29 have termed ‘moral stigma’; that is, chronic pain sufferers are labelled as ‘morally weak’ when there is a lack of congruity between pain behaviours and biomedical findings. In this way the plight of the person with chronic pain can be individualised, and therefore not a threat to those of ‘us’ who are not like ‘them’. 5.4 Status Loss and Discrimination The process of labelling, stereotyping and separation constructs a rationale for devaluing and excluding people within society. Link and Phelan referred to this process as culminating in status loss and discrimination, the fourth component of their stigma schema. Link and Phelan further categorised discrimination into individual and structural discrimination. They suggested that, within the stigma literature, the most common way of conceptualising connections between labelling, stereotyping and discrimination falls within the individual category. For the purposes of this paper, however, the concept of structural discrimination is more pertinent, due to the focus on the social dimension of living with chronic pain. The concept of structural discrimination ‘sensitises us to the fact that all manner of disadvantage can result outside of a model in which one person does something bad to another’.30 In this study, participants’ stories of struggling to maintain employment illustrated the impact of disabling environments, rather than inherent limitations of the individual. One participant, for example, spoke of the requirement of being ‘100% fit’ before she would be allowed to re-commence her nursing duties. From her perspective, lack of support and harassment from her employer eventually made her position untenable, and she resigned. Although her arm pain may have eventually meant she was unable to work in the nursing role, she felt she was never provided with a supportive work environment to explore her

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__________________________________________________________________ remaining abilities, or to develop an alternative role which would have retained her knowledge and experience within the workplace. Other participants said they believed they had little choice but to leave their employment when it became clear they could no longer physically fulfil duties the position required, and there appeared to be little in the way of alternative employment options available. Of additional relevance to participants in this study is the discriminatory potential of status loss. While labelling and stereotyping may initially have led to lower status, over time the lower status itself can become the basis of both individual and structural discrimination; they may become ‘the recipient of structural discrimination whether or not anyone happens to treat him or her in a discriminatory way because of some stereotype’.31 For example, loss of status as a result of unemployment and subsequent financial dependence on government welfare benefits can have an impact on many aspects of an individual’s life, such as being unable to participate in social and recreational activities, regardless of the reason for the person being unemployed. Cultural stereotypes can also affect the labelled person in ways that do not involve obvious forms of discrimination. Participants themselves had internalised cultural stereotypes such as the previously mentioned mind/body dualism. In consequence, some went to extreme lengths to locate a bodily cause for their pain so they would not become one of the ‘them’ implied through labelling and stereotyping. For example, one participant expressed her disdain of people who ‘whinged’ about their pain, identifying them as ‘totally negative’ and ‘miserable’, and emphasised through an anecdote of working through extreme pain to accomplish a physical task, that she was not that sort of person. This concern about becoming a member of a devalued group in society was also evident in aspects of other participants’ stories, such as expressed shame at receiving the disability support pension, inferring the strength of the welfare dependent or ‘bludger’ stereotype in our society. Similarly, the extent to which some participants went to retain their employment is indicative of the social value placed on being employed. Thus the discrimination experienced by the stigmatised does not necessarily directly relate to the initial cause of the stigma, in this case biomedically unexplained pain, but can be widespread and have an impact on multiple life domains and life chances. 5.5 Power The discussion concerning stigma to this point has illustrated that the interrelated components of labelling, stereotyping, separation, status loss and discrimination were experienced by study participants. However, Link and Phelan have suggested that even with these components co-occurring, power differences need to be present for stigma to occur. Use of only the cognitive components of the concept; that is, labelling and stereotyping, to define stigma could result in high social status groups such as lawyers and medical practitioners being considered

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__________________________________________________________________ stigmatised groups. Stigma, according to Link and Phelan, is ‘entirely dependent on social, economic, and political power – it takes power to stigmatise’: Groups both with and without power label and form stereotypes about the other groups…But what matters is whose cognitions prevail – whose cognitions carry sufficient clout in social, cultural, economic and political spheres to lead to important consequences for the group that has been labelled as different.32 Due to the importance of power in stigmatisation, Link and Phelan proposed a set of questions concerning the ability of potential stigmatisers to have an impact on a stigmatised group . Central to these questions is whether those who might stigmatise have the power to significantly control access to major life domains like employment and health care . Consideration of the study participants’ narratives illustrated that this is indeed the case for people with chronic pain. Limited or no flexibility in workplace expectations and demands; difficulty in obtaining timely and adequate pain relief; loss of income and subsequent financial difficulties; barriers to obtaining income support and therapeutic services - these are just some of the examples of the disadvantages experienced by study participants which could only occur where there is a power imbalance between the stigmatised and the stigmatisers.33 While the impact of stigma varied in degree amongst the participants, it can be concluded that stigma is a valid concept to apply to chronic pain. Stigmatisation is a social process that has significant consequences for the stigmatised which cannot be addressed at an individual cognitive level. 6. Conclusion This paper has applied a multi-component conceptual framework to the narratives of people living with chronic pain to explicate the development of stigma as part of the social dimension of the chronic pain experience. If the stigmatisation of people with chronic pain is a multi-level and flexible social process, removing stigma becomes more complex than adopting one specific intervention, such as changing the way health care practitioners communicate with their patients. Rather, a multifaceted approach is required, aimed at addressing the fundamental causes of stigma. Additionally, the conceptualisation of stigma as a social process directs practitioners and policy makers to consider not only the person with chronic pain, but also other strata of society, such as the health care system, work places, and cultural beliefs and folklore concerning what is ‘normal’ pain and how we make sense of other forms of pain. Failure to adopt this extended view will not only deny individuals with chronic pain improved health services and social legitimacy for their condition, but will continue to entrench a social form of stigma which unnecessarily adds to the suffering of people living with chronic pain.

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Notes 1

Prior to the development and application of the biopsychosocial model of health to chronic pain, the biomedical model, underpinned by the Cartesian concept of mind-body dualism, was the dominant theoretical perspective used to understand pain. When applied to chronic pain, the biomedical model predominantly focuses on bodily malfunction, with the logical progression that treatment should also focus on the body. In the absence of an identifiable pathology to account for ongoing pain, the ‘default’ position of the biomedical model is that the problem must be psychological, rather than physical. 2 WR Nielson & R Weir, ‘Biopsychosocial Approaches to the Treatment of Chronic Pain,’ The Clinical Journal of Pain, 17/4, Supplement 2001, S114-S27. 3 A Nielsen, ‘It's a Whole Lot More than Just about My Pain’: Understanding and Responding to the Social Dimension of Living with Chronic Pain,’ University of Queensland, 2009. 4 ibid. 5 ibid 6 JT Chibnall & RC Tait, ‘Social and Medical Influences on Attributions and Evaluations of Chronic Pain,’ Psychology and Health, 14 1999, 719-2 7 L Haugli, E Strand & A Finset, ‘How do Ppatients with Rheumatic Disease Experience their Relationship with Their Doctors? A Qualitative Study of Experiences of Stress and Support in the Doctor-Patient Relationship,’ Patient Education and Counselling, 52 2004, 169-74. 8 K Kouyanou, et al., ‘A Comparative Study of Iatrogenesis, Medication Abuse, and Psychiatric Morbidity in Chronic Pain Patients With and Without Medically Explained Symptoms,’ Pain, 76 1998, 417-26. 9 JJ Marbach, et al., ‘Losing Face: Sources of Stigma as Perceived by Chronic Facial Pain Patients,’ Journal of Behavioural Medicine, 13/6 1990, 583-603. 10 Interpretive Phenomenological Analysis (IPA) JA. Smith & M Osborn, 'Interpretive Phenomenological Analysis,' Qualitative Psychology a Practical Guide to Research Methods London: Sage Publications, 2003. 11 P Asbring & A Narvanen, ‘Women’s Experiences of Stigma in Relation to Chronic Fatigue Syndrome and Fibromyalgia,’ Qualitative Health Research, 12/2 2002, 148-60. 12 I Holloway, B Sofaer-Bennett, &J Walker, ‘The Stigmatisation of People with Chronic Back Pain,’ Disability and Rehabilitation, 2007, 1-9. 13 JE Jackson, ‘Stigma, Liminality, and Chronic Pain: Mind-Body Borderlands,’ American Ethnologist, 32/3 2005, 332-53. 14 DT Kenny, ‘Constructions of Chronic Pain in Doctor-Patient Relationships: Bridging the Communication Chasm,’ Patient Education and Counselling, 52 2004, 297-305.

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__________________________________________________________________ 15

JC Richardson, ‘Establishing the (Extra)Ordinary in Chronic Widespread Pain,’ Health, 9/1 2005, 31-48. 16 E Goffman, Stigma: Notes on the Management of Spoiled Identity; Harmondsworth: Penguin, 1968. 17 BG Link & JC Phelan, ‘Conceptualizing Stigma,’ Annual Review of Sociology, 27 2001, 363-85. 18 RA Hilbert, ‘The Acultural Dimensions of Chronic Pain: Flawed Reality Construction and the Problem of Meaning,’ Social Problems, 31/4 1984, p. 368. 19 T Parsons, ‘Definitions of Health and Illness in the Light of American Values and Social Structure,’ Patients, Physicians and Illness; Free Press, Glencoe, IL, 1958. 20 JT Chibnall, RC Tait & LR Ross, ‘The Effects of Medical Evidence and Pain Intensity on Medical Student Judgements of Chronic Pain Patients,’ Journal of Behavioral Medicine, 20 1997, 257-71. 21 JT Chibnall & RC Tait, ‘Social and Medical Influences on Attributions and Evaluations of Chronic Pain,’ Psychology and Health, 14 1999, 719-29. 22 JT Chibnall, A Dabney & RC Tait, ‘Internist Judgements of Chronic Low Back Pain,’ Pain Medicine, 1/3 2000, 231-37 23 RC Tait & JT Chibnall, ‘Physician Judgments of Chronic Pain Patients,’ Social Science & Medicine, 45/8 1997, 1199-205. 24 RC Tait & JT Chibnall, ‘Racial and Ethnic Disparities in the Evaluation and Treatment of Pain: Psychological Perspectives,’ Professional Psychology, 36/6 2005, 595-601. 25 M Archer, Realist Social Theory: The Morphogenic Approach, Cambridge University Press, 1995. 26 S Green, et al., ‘Living Stigma: The Impact of Labeling, Stereotyping, Separation, Status Loss, and Discrimination in the Lives of Individuals with Disabilities and Their Families,’ Sociological Inquiry, 75/2 2005, 197-215. 27 RA Hilbert, ‘The Acultural Dimensions of Chronic Pain: Flawed Reality Construction and the Problem of Meaning,’ Social Problems, 31/4 1984. 28 JE Jackson, ‘Stigma, Liminality, and Chronic Pain: Mind-Body Borderlands,’ American Ethnologist, 32/3 2005, 332-53. 29 I Holloway, B Sofaer-Bennett & J Walker, ‘The Stigmatisation of People with Chronic Back Pain,’ Disability and Rehabilitation, 2007, p.3. 30 BG Link & JC Phelan, ‘Conceptualizing Stigma,’ Annual Review of Sociology, 27 2001, 363-85. 31 ibid. 32 ibid. 33 A Nielsen, ‘‘It's a whole lot more than just about my pain’: Understanding and Responding to the Social Dimension of Living with Chronic Pain,’ University of Queensland, 2009.

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Bibliography Archer, M., Realist Social Theory: The Morphogenic Approach. Cambridge University Press, 1995.

Asbring, P. & Narvanen, A, 'Women's Experiences of Stigma in Relation to Chronic Fatigue Syndrome and Fibromyalgia.' Qualitative Health Research, vol. 12/2, 2002, 148-60. Chibnall, J.T., Tait, R.C. & Ross, L.R., 'The Effects of Medical Evidence and Pain Intensity on Medical Student Judgements of Chronic Pain Patients.' Journal of Behavioral Medicine, Vol. 20, 1997, 257-71. Chibnall, J.T. & Tait, R.C., 'Social and Medical Influences on Attributions and Evaluations of Chronic Pain.' Psychology and Health, Vol. 14, 1999, 719-29. Chibnall, J.T., Dabney, A. & Tait, R.C., 'Internist Judgements of Chronic Low Back Pain.' Pain Medicine, 1/3 2000, 231-37. Goffman, E., Stigma: Notes on the Management of Spoiled Identity. Penguin, Harmondsworth, Penguin, 1968. Green, S., et al., 'Living Stigma: The Impact of Labelling, Stereotyping, Separation, Status Loss, and Discrimination in the Lives of Individuals with Disabilities and Their Families.' Sociological Inquiry, 75/2 2005, 197-215. Haugli, L., Strand, E. & Finset, A., 'How do Patients with Rheumatic Disease Experience their Relationship with Their Doctors? A Qualitative Study of Experiences of Stress and Support in the Doctor-Patient Relationship.' Patient Education and Counselling, Vol. 52, 2004, 169-74. Hilbert, R.A., 'The Acultural Dimensions of Chronic Pain: Flawed Reality Construction and the Problem of Meaning.' Social Problems, Vol. 31/4, 1984, 36578. Holloway, I., Sofaer-Bennett, B., & Walker, J., 'The Stigmatisation of People with Chronic Back Pain'. Disability and Rehabilitation, 2007, 1-9. Jackson, J. E., 'Stigma, Liminality, and Chronic Pain: Mind-Body Borderlands.' American Ethnologist, vol. 32/3, 2005, 332-53.

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__________________________________________________________________ Kenny, D.T., 'Constructions of Chronic Pain in Doctor-Patient Relationships: Bridging the Communication Chasm.' Patient Education and Counselling, Vol. 52, 2004, 297-305. Kouyanou, K, et al., 'A Comparative Study of Iatrogenesis, Medication Abuse, and Psychiatric Morbidity in Chronic Pain Patients With and Without Medically Explained Symptoms.' Pain, Vol. 76, 1998, 417-26. Link, B.G. & Phelan, J.C, 'Conceptualizing Stigma'. Annual Review of Sociology, vol. 27, 2001, 363-85. Marbach, J.J., et al., 'Losing Face: Sources of Stigma as Perceived by Chronic Facial Pain Patients.' Journal of Behavioral Medicine, Vol. 13/6, 1990, 583-603. Merskey, H. & Bogduk, N. (eds), Classification of Chronic Pain: Description of Chronic Pain Syndromes and Definition of Pain Terms. IASP Press, Seattle,1994. Nielsen, A, ‘It's a whole lot more than just about my pain’: Understanding and Responding to the Social Dimension of Living with Chronic Pain.' University of Queensland, 2009. Nielson, W.R. & Weir, R., 'Biopsychosocial Approaches to the Treatment of Chronic Pain.' The Clinical Journal of Pain, Vol. 17/4, Supplement 2001, S114S27. Parsons, T, 'Definitions of Health and Illness in the Light of American Values and Social Structure.' Patients, Physicians and Illness. Free Press, Glencoe, IL, 1958. Richardson, J.C., 'Establishing the (Extra)Ordinary in Chronic Widespread Pain.' Health, Vol. 9/1, 2005, 31-48. Scambler, G., 'Re-Framing Stigma: Felt and Enacted Stigma and Challenges to the Sociology of Chronic and Disabling Conditions.' Social Theory & Health, vol. 2, 2004, 29-46. Smith, J.A. & Osborn, M., 'Interpretive Phenomenological Analysis.' Qualitative Psychology - A Practical Guide to Research Methods. Sage Publications, London, 2003. Tait, R.C. & Chibnall, J.T., 'Physician Judgments of Chronic Pain Patients.' Social Science & Medicine. Vol. 45/8, 1997, 1199-205.

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__________________________________________________________________ , 'Racial and Ehnic Dsparities in the Ealuation and Teatment of Pain: Psychological Pperspectives.' Professional Psychology. Vol. 36/6, 2005, 595-601. Amanda Nielsen has lived with chronic pain since 1995. She is a Research Officer in the School of Health and Rehabilitation Sciences, The University of Queensland, Australia. She completed her doctoral thesis on the social dimension of living with chronic pain in 2009.

Connecting Pain and Drug Use in GLBTQ Communities Ian Flaherty Abstract The literature suggests that the prevalence of use of both licit and illicit intoxicating substances is much higher among the gay, lesbian, bisexual, transgender, queer (GLBTQ) community when compared with the non-GLBTQ community. Additionally, in qualitative studies of the GLBTQ community, incidences of trauma associated with sexual encounters figure more prominently in many ways when compared with the non-GLBTQ community. In many of these qualitative studies, the ‘self-help’ approach is presented as a mechanism through which people from GLBTQ communities might achieve both a resolution to the pain associated with traumatic sexual encounters, as well as a sense of a new identity – an identity associated with strength, resistance to pain and autonomy. This paper seeks to unravel these interconnected narratives. I seek here to connect with the paradox that has beleaguered the GLBTQ community since the events of Stonewall. Why does a favourite Sydney establishment for the GLBTQ community align itself so closely with the assuagement of pain of belonging to a minority group through the use of licit, and probably illicit, intoxicating substances? Why is it so widely reported in the GLBTQ community that people ‘truly find themselves’ once they have had apocryphal experiences with illicit substances? At least some of the answers lie, in my paper, in the interactions between experienced pain, of both a physical and psycho-emotional nature, the urgency to ‘discover oneself’, and the mechanisms commonly prescribed to accomplish this process. In this paper, an attempt is made to connect the narratives of a group of gay men in highly-modernised societies with more-widely accepted understandings of pain, and how the narratives of ‘self-help’ have influenced their decisions to use licit and illicit intoxicating substances. My hope is that an enriched understanding of the connections between the use of both licit and illicit intoxicating substances for pain, of varying sorts, for the GLBTQ community will be yielded. Key Words: Drugs, GLBTQ, pain, self-help, identity. ***** 1. Introduction There is an abundance of literature, albeit from developed countries, of the disproportionate consumption of both licit and illicit drugs by GLBTQ communities when compared with non-GLBTQ communities. A study in the US found for example that, ‘Sexual orientation is an important risk marker for growth in adolescent substance use, and the disparity between LGB and heterosexual

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__________________________________________________________________ adolescents increases as they transition into young adulthood.’1 Another study goes further to suggest that there is ‘heightened risk of substance use and substance dependence among some sexual minority groups.’2 This study by McCabe is the more recent and reports to support findings from previous studies. A study with college students in the US found that GLBTQ students were more likely to have used illicit substances in the past year, were more likely to have experienced negative consequences as a result of their alcohol and other drug use and were more likely to have thought about or attempted suicide in the past year than their non-GLBTQ fellow students.3 In sum then, GLBTQ people are more likely to use illicit and licit substances, more likely to demonstrate dependence and more likely to experience adverse effects from their substance use when compared with the non-GLBTQ population. Again, this needs to be qualified by acknowledging that this evidence almost in its entirety stems from studies in the developed world. When discussing the trauma associated with sexual encounters among the GLBTQ community, several salient features must be noted. In this paper, the focus is upon men who have sex with men (MSM), and in particular, gayidentifying men who have sex with men. Many studies suggest that the prevalence of child hood sexual abuse is significantly higher among this population than among other populations. One study for example, reported that 39.7% of the participants who were HIV-positive MSM had experienced childhood sexual abuse.4 Another study, quoted in a qualitative study of adult male survivors of child hood sexual abuse, reported that the prevalence of child hood sexual abuse among the general adult male population was at least 7.9%.5 The difference here is startling. For many gay-identifying men who have sex with men, trauma associated with sexual encounters is not delimited to the act of sex. Violence based on perceived or actual homosexuality is widely reported, so much so that here in Sydney, for example, large and visible campaigns such as ACON’s antiviolence project ‘Speak Up’, are dedicated to its eradication.6 Significantly too, are the ways in which gay men narrate their homosexuality to themselves. What has been describes as internalised homophobia7 can have serious deleterious effects on gay male intimate relationships. Similarly, internalised homonegativity can produce painful social effects such as peer socialisation and comfort with sexual orientation.8 For some gay men, in order to overcome this negative narration of self, drugs and alcohol are used in the context of the physical encounter in order generate a positive sexual script about themselves and the act of sex. In one study, for example, alcohol contributed significantly to the script some men told themselves when engaging in sex acts which they traditionally considered taboo.9 In the context of intimate relationships too, often the larger focus is upon ‘forcing gay relationships into heterosexual models [which] leads to the ignoring or pathologizing of those non-heterosexual aspects of gay relationships (Coyle and Kitzinger, 1995; Phillips, 2000)’.10 The trauma experienced by GLBTQ communities, and in the focus of this paper, gay-

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__________________________________________________________________ identifying men who have sex with men, when thinking about and enacting their sexuality, comes therefore in multiplicity of forms. 2. Method The research design of the larger study was built around interviews of five same-sex attracted males and a form of narrative analysis that included literary and cultural texts. The transcripts of the interviews were analysed and comparisons were drawn between the narratives produced in the interviews with the narratives found in English fictional literature, contemporary popular media and the theoretical narratives found in the work of Susan Sontag,11 Lynn Jamieson,12 Anthony Giddens13 and Ulrich Beck.14 This comparison aimed to demonstrate that works of fiction and popular media strongly influence the way in which the interviewees develop their own personal narratives, and that the narratives of the democratisation of personal life and love relationships are seen in the ways in which the interviewees consider their own personal narratives, particularly in relation to pain experiences, drug use and sense of identity. Interactive interviews were used in the larger study to draw personal narratives, or autobiographies, from five same-sex attracted men. These autobiographical constructions were compared with the broader theoretical constructions of Sontag,15 Jamieson,16 Giddens17 and Beck.18 Literary and cultural texts were used to encourage the interviewees to think about their own personal narratives and the ways in which they have been influenced by such texts. It was possible to show that both the literary and cultural texts, as well as the broader theoretical narratives, have in many ways shaped the development of the personal narratives of these men. In order to do this in this paper, two case studies of the narratives of same-sex attracted men are presented. In particular in this paper, the narratives of these participants in relation to pain and self-help are examined. The participants’ names have been changed. 3. Case Studies Dave grew up in what has traditionally been a financially and educationally disadvantaged community in Sydney’s outer suburbs. The housing estate in which Dave had his early life-experiences was often characterised by relatively highlevels of unemployment and generalised social disadvantage. Dave still shares a somewhat fraught relationship with his parents and some of the many siblings with whom he grew up. A key theme that emerged from the interviews was the ongoing relationship Dave has with the abuse he experienced as a child. Dave’s narrative regarding this experience is often contextualised within the narratives of ‘selfhelp’, and is often problematised by his adolescent experiences of his emerging sexuality. Dave often spoke of needing to, and having done, ‘work on himself’. He located this in a homework framework, homework which had been provided by a therapist. Dave characterised his thoughts about the abuse he endured as a child

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__________________________________________________________________ as if he were able to look at the ‘whole picture from outside’. The inference was that he was able, after the ‘work’ he had done, to place the emotions associated with the childhood abuse in a discreet location to which only he had privilege. This inference lies in tension however with the ways in which he narrated his experiences of his late, former partner, who himself had also been abusive but in an emotional way. In this narration, Dave often overlaid his adult experiences with those of his childhood, relating many of the emotions he had felt toward his childhood abuser to his former partner. Dave spoke too of his initiation into drug use, mainly the use of cannabis, ecstasy and cocaine. Much of this narrative centred around the feeling of needing to make sense of his experiences, both as a child and as an adult, in an environment in which he felt safe and in which he express who he ‘truly was’. The physical contexts here were gay clubs and dance parties where the consumption of illicit substances is a given. Phillip by contrast, grew up in a financially and educationally advantaged social place in the relatively affluent inner suburbs of Sydney. At quite an early age, Phillip was sent to boarding school outside of Sydney, a boarding school of considerable prestige. It was here Phillip recalls, that he first felt a feeling of love develop between he and another student, the son of a diplomat. When the relationship was discovered by the school and parents, the other young man was promptly returned to school in the United Kingdom. Phillip contextualises this with some resignation, within an inflexible schooling system more specifically, and within a more inflexible society more broadly. The love narrative within is obfuscated by Phillip’s resignation, but attention needs to be give also to the legal framework within which these inflexible systems are operating. Phillip spoke of experiencing no abuse as a child, and although fraught by the complication of his emerging sexuality, reported to have a stable and amicable relationship with his family. Phillip contextualised his feelings and thought about his life at present within his successes at work and the maintenance of a loving intimate relationship. Phillip, by most measures, initiated illicit drug use later in life, and this use was mainly restricted to cocaine and ecstasy. He too used illicit substances in the contexts of clubs and dance parties, and at house parties. Phillip did not refer in any way to the discourse which formed such a large part of Dave’s narrative. Rather, Phillip presented his identity in many ways fixed and not susceptible to the many possible assailments of being gay. 4. Discussion: Therapeutic Discourse - Admission, Recovery, Identity In many ways, the riots at the Stonewall Inn in New York in 1969 and the Stonewall Hotel in Sydney’s Oxford Street in the present day are connected by themes of resistance and the fight for equality. Part of the aim of the larger paper was to examine though, how these two establishments have diverged so completely in purpose. In looking at the two case studies in the current paper, it is possible to see where the answer to this question might lie. Dave thoroughly engages with a

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__________________________________________________________________ therapeutic discourse, characterised by language around intellectualisation, transference and trauma,19 in accounting for the pain he feels associated with childhood, and indeed adulthood, abuse. In many ways too, Dave connects the capacity to express these feelings of pain with the disinhibiting effects of illicit substances such as cocaine and ecstasy. Phillip, by contrast, distances his narrative of identity from childhood experiences, and rather locates them within his current successes in professional and personal life. He also describes his drug use as a way to enhance a party experience rather than as a disinhibiting factor in his narration of painful experiences. This analysis may at first seem highly critical and lacking in compassion, for Dave’s and Phillip’s narratives of childhood and adulthood are patently on the one hand full of pathos and on the other resonant of hope and certainty. The two case studies may however point to two processes that occur in the lives of those experience pain associated with the emotional impact of abuse: the engagement of a therapeutic discourse in the narration of self to self, and the use of licit and illicit intoxicating substances to enhance this. Such an adoption of therapeutic discourse should perhaps not be so surprising because: ...patterns of meaning [ways of speaking that we draw upon whenever we try to communicate information about the social world or ourselves] and shapes of subjectivity [certain notions of what it is to be a self] are constructed in a culture saturated with psychoanalytic concepts (Parker, 1993).20 Within this culture too, resolution of pain associated with and mediated by emotions is key to an understanding of self and identity: A number of cultural discursive factors—such as the western construction of persons as self-contained and ‘interiorized’ individuals (Rose, 1998; Sampson, 1993), the conflation of common-sense and therapeutic discourse (Parker, 1999), the elevated cultural status of ‘truthtelling’ professionals, and therapy’s privileged standing as a way of knowing about persons and resolving their problems...21 ...are evident in this narration of self to self. The question remains: is it possible to overcome the pain of the negative narration of self to self without engaging the therapeutic discourse aided by the use of intoxicating substances? 5. Conclusion The answer is as multifaceted as the experiences of gay men themselves. One possibility lies in the ‘wholesale democratisation of personal life’22 characterised by relationships built on mutual trust and disclosure that continue for as long as

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__________________________________________________________________ both participants are wholly devoted to the continuation of the relationship. The difficulty lies in the disentanglement of illicit drugs and the assuagement of emotional pain that has come to be represented so often in gay men’s negative narration of self to self.

Notes 1

MP Marshal, MS Friedman, R Stall & AL Thompson, ‘Individual Trajectories of Substance Use in Gay, Lesbian and Bisexual Youth and Heterosexual Youth,’ Addiction, 104, 2009, p. 975. 2 SE McCabe, TL Hughes, WB Bostwick, BT West & CJ Boyd, ‘Sexual Orientation, Substance Use Behaviors and Substance Dependence in the United States,’ Addiction, 104, 2009, p. 1333. 3 E Reed, G Prado, A Matsumoto & H Amaro, ‘Alcohol and Drug Use and Related Consequences among Gay, Lesbian and Bisexual College Students: Role of Experiencing Violence, Feeling Safe on Campus and Perceived Stress,’ Addictive Behaviors, 35, 2010, p. 168-171. 4 MT Fullilove, ‘Toxic Sequelae of Childhood Sexual Abuse,’ The American Journal of Psychiatry, 166 (10), 2003. 5 F Putnam, ‘Ten-Year Research Update: Child Sexual Abuse,’ Journal of the American Academy of Child and Adolescent Psychiatry, 42, 2003, p. 269-278. 6 ACON, 2010, Sydney, New South Wales. 7 LG Nungesser, Homosexual Acts, Actors and Identities, Praeger, New York, 1983. 8 BRS Rosser, WO Bockting, MW Ross, MH Miner & E Coleman, ‘The Relationship between Homosexuality, Internalized Homo-Negativity and Mental Health in Men Who Have Sex with Men,’ Journal of Homosexuality, 55 (2), 2008, p. 185-203. 9 JT Parsons, KJ Vicioso, JC Punzalan & PN Halkitis, ‘The Impact of Alcohol Use on the Sexual Scripts of HIV-Positive Men Who Have Sex with Men,’ The Journal of Sex Research, 41 (2), 2004, p. 160-172. 10 K Bonello & MC Cross, ‘Gay Monogamy: I Love You but I Can’t have Sex with You Only,’ Journal of Homosexuality, 57, 2010, p. 117-139. 11 S Sontag, AIDS and Its Metaphors, Penguin, London, 1988. 12 L Jamieson, Intimacy: Personal Relationships in Modern Societies, Polity Press, Cambridge, 1998; L Jamieson, ‘Intimacy Transformed: A Critical Look at the ‘Pure Relationship’’, Sociology, 33 (3), 1999, p. 477-94. 13 A Giddens, Modernity and Self-Identity, Stanford University Press, Stanford, CA, 1991. 14 U Beck, ‘Living Your Own Life in a Runaway World: Individualism, Globalisation and Politics,’ Global Capitalism, The New Press, New York, 2000, p. 164-174.

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__________________________________________________________________ 15

S Sontag, op. cit. L Jamieson, op. cit. 17 A Giddens, op. cit. 18 U Beck, op. cit. 19 I Parker, ‘Postmodernism and Its Discontents: Therapeutic Discourse,’ British Journal of Psychotherapy, 12 (4), 1996, p. 447-460. 20 ibid., 459. 21 M Guilfoyle, ‘From Therapeutic Power to Resistance?: Therapy and Cultural Hegemony,’ Theory and Psychology, 15 (1), 2005, p. 101-124. 22 A Giddens, op. cit., p. 4. 16

Bibliography Banks, A. & Banks, S.P., ‘The Struggle Over Facts And Fictions. Fiction and Social Research: By Ice or Fire. Altamira, Walnut Creek, CA, 1998. Bauman, Z., Postmodern Ethics. Blackwell, Cambridge, MA, 1993. Beck, U., ‘The Reinvention of Politics: Towards a Theory of Reflexive Modernization.’ Reflexive Modernization: Politics, Tradition and Aesthetics in the Modern Social Order. Polity Press, Cambridge, 1994, pp. 1-55. Beck, U., ‘Living Your Own Life in a Runaway World: Individualism, Globalisation and Politics.’ Global Capitalism. The New Press, New York, 2000, pp. 164-174. Bell, A.P. & Weinberg, M.S., Homosexualities: A Study of Diversity Among Men and Women. Touchstone, New York, 1978. Bersani, L., ‘Is the Rectum a Grave?’ AIDS: Cultural Analysis, Cultural Activism. Massachusetts Institute of Technology Magazine, October 1989, pp. 197-222. Bertaux, D. (ed), Biography and Society: The Life History Approach in the Social Sciences. Sage Publications, Beverly Hills, CA, 1981. Blumstein, P. & Schwartz, P., American Couples: Money, Work, Sex. William Morrow, New York, NY, 1983. Boling, P., Privacy and the Politics of Intimate Life. Cornell University Press, USA, 1996.

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__________________________________________________________________ Brenneis, D., ‘Telling Troubles: Narrative, Conflict and Experience.’ Disorderly Discourse: Narrative, Conflict and Inequality. Oxford University Press, New York, NY, 1996. Butler, J., Bodies That Matter: On the Discursive Limits of ‘Sex’. Routledge, New York, NY, 1993. Clark, D., ‘Commodity Lesbianism.’ The Lesbian and Gay Studies Reader. Routledge, New York, NY, 1991. . Coffey, A., The Ethnographic Self: Fieldwork and the Representation of Identity. Sage, London, 1999. Conigrave, T., Holding the Man. Penguin, Melbourne, 1995. Cook, J. & Fonow, M.M., ‘Knowledge and Women’s Interests: Issues of Epistemology and Methodology in Feminist Sociological Research.’ Sociological Inquiry, Vol. 56, 1986, pp. 2-27. Coyle, A. & Kitzinger, C., ‘Lesbian and Gay Couples: Speaking of Difference.’ Psychologist. 8, 1995, pp. 64–69. Denzin, N.K., Interpretive Biography. Sage Publications, Inc., Newbury Park, CA, 1993. Derrida, J., Positions. University of Chicago Press, Chicago, 1972/1981. de Vaus, D.D., Surveys in Social Research. George Allen and Unwin, Sydney, 1986. Ellis, C., Kiesinger, C. & Tillman-Healy, L.M., ‘Interactive Interviewing: Talking About Emotional Experience.’ Reflexivity and Voice. R. Hertz, Sage, Thousand Oaks, CA, 1997. Drummond, M., ‘Men’s Bodies: Listening to the Voices of Young Gay Men.’ Men and Masculinities. Vol.7(3), January, 2005, pp. 270-290. Edwards, T., Erotics and Politics: Gay Male Sexuality, Masculinity and Feminism. Routledge, London, 1994.

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__________________________________________________________________ Fielding, N. & Thomas, H., ‘Qualitative Interviewing.’ Researching Social Life (second edition). Sage, London, 2001. Fontana, A. & Frey, J., ‘The Interview: From Structured Questions to Negotiated Text.’ Handbook of Qualitative Research. Sage, Thousand Oaks, CA, 2000. Fraser, N., ‘Sex, Lies, and the Public Sphere: Reflections on the Confirmation of Clarence Thomas.’ Feminism: The Public and the Private. Oxford University Press, Oxford, 1998. Giddens, A., Modernity and Self-Identity. Stanford University Press, Stanford, CA, 1991. Glassner, B. & Loughlin. J., Drugs in Adolescent Worlds: Burnout to Straights. St.Martin’s Press, New York, NY, 1987. Goffman, E., Stigma. Prentice Hall Inc., Englewood Cliffs, NJ, 1963. Haasager, S.L,. ‘Stories that Tell It Like It Is? Fiction Techniques and PrizeWinning Journalism.’ Fiction and Social Research: By Ice or Fire. Altamira, Walnut Creek, CA, 1998. Habermas, J., Legitimation Crisis. trans. T. McCarthy, Beacon Press, Boston, MA, 1975. , Theorie des kommunikativen Handelns. Suhrkamp, Frankfurt, 1981. Hammersley, M. & Atkinson, P., Ethnography: Principles in Practice. Routledge, London, 1997. Hertz, R., ‘Separate but Simultaneous Interviewing of Husbands and Wives: Making Sense of Their Stories.’ Qualitative Inquiry 1, 1995, pp. 429-51. Jamieson, L., Intimacy: Personal Relationships in Modern Societies. Polity Press, Cambridge, 1998. , ‘Intimacy Transformed: A Critical Look at the Pure Relationship.’ Sociology 33(3), 1999, pp. 477-94. Jorgenson, J., ‘Co-Constructing the Interviewer/Co-Constructing Research and Reflexivity. Sage, London, 1991.

Family.’

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__________________________________________________________________ , ‘Relationalising Rapport in Interpersonal Settings.’ Social Approaches to Communication. Guilford, New York, NY, 1995. Krieger, S., Social Science and the Self: Personal Essays on an Art Form. Rutgers University Press, New Brunswick, 1991. Lesser, W., ‘Autobiography and the ‘I’ of the Beholder.’ The New York Times Book Review. 27 November, 1988, 1, pp. 26-28. Laslett, B. & Rapoport, R., ‘Collaborative Interviewing and Interactive Research.’ Journal of Marriage and the Family. Vol. 20, 1975, pp. 968-77. Miller, M. ‘Ethics and Understanding through Interrelationship: I and Thou in Dialogue.’ Ethics and Process in the Narrative Study of Lives. Sage, Thousand Oaks, CA, 1996. Mumby, D., ‘Modernism, Postmodernism and Communication Studies: A Rereading of an Ongoing Debate.’ Communication Theory. 7, 1997, pp.1-29. Paine, R., ‘Friendship: The Hazards of an Ideal Relationship.’ The Anthropology of Friendship. Berg, Oxford, 1999. Parker, I., ‘Social Constructionist Psychoanalysis and the Real.’ Recent Trends in Theoretical Psychology. Vol. III, Springer-Verlag, New York, 1993. Parker, I., ‘Postmodernism and Its Discontents: Therapeutic Discourse.’ British Journal of Psychotherapy. Vol. 12 (4), 1996, pp. 447-460. , ‘Critical Reflexive Humanism and Critical Constructionist Psychology.’ Social Constructionist Psychology: A Critical Analysis of Theory and Practice. Open University Press, Buckingham, 1999. Patton, M., Qualitative Research and Evaluation Methods. 3rd ed., Sage, Thousand Oaks, CA, 2002. Phillips, J.C., ‘Training Issues and Considerations.’ Handbook of Counseling and Psychotherapy with Lesbian, Gay, and Bisexual Clients. American Psychological Association, Washington, DC, 2000, pp. 337–358. Plummer, K., Documents of Life. Allen and Unwin, London, 1983.

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__________________________________________________________________ Proulx, A., Close Range: Brokeback Mountain and Other Stories. Harper Perennial, London, 2006. Punch, K., Developing Effective Research Proposals. Sage, London, 2000. Quan, A., Calendar Boy. New Star Books, Vancouver, 2001. Reinharz, S., Feminist Methods in Social Research. Oxford University Press, New York, NY, 1992. Reinharz, S., ‘Who am I? The Need for a Variety of Selves in the Field.’ Reflexivity and Voice. Sage, Thousand Oaks, CA, 1997. Roberts, H., Doing Feminist Research. Routledge and Kegan Paul, London, 1981. Rose, N., Inventing Our Selves: Psychology, Power, and Personhood. Cambridge University Press, Cambridge, 1998. Roth, P., The Facts. Knopf, New York, NY, 1988. Sampson, E.E., Celebrating the Other: A Dialogic Account of Human Nature. Westview, San Francisco, CA, 1993. Scheper-Hughs, N., ‘Ire in Ireland.’ Ethnography. 1(1), 2000, pp. 117-140. Sedgwick, E.K., Between Men: English Literature and Male Homosocial Desire. Columbia University Press, New York, NY, 1985. Sedgwick, E.K., ‘Epistemology of the Closet.’ The Lesbian and Gay Studies Reader. Routledge, New York, 1993, pp. 45-61. Silverman, D., Interpreting Qualitative Data. Sage, London, 1993. Sontag, S., AIDS and Its Metaphors. Penguin, London, 1988. Weeks, J. Invented Moralities: Sexual Values in an Age of Uncertainty. Columbia University Press, New York, NY, 1995. Weston, K., Families We Choose: Lesbians, Gays, Kinship. Columbia University Press, New York, NY, 1991.

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__________________________________________________________________ Wodak, R., Disorders of Discourse. Addison Wesley Longman Ltd., Essex, UK, 1996. Worth, H., Reid, A. & McMillan, K., ‘Somewhere over the Rainbow: Love, Trust and Monogamy in Gay Relationships.’ Journal of Sociology. Vol. 38(3), 2002, pp.237-253. Yip, A. ‘Gay Male Christian Couples and Sexual Exclusivity.’ Sociology. 31(2), 1997, pp. 289-306. Ian Flaherty is a PhD candidate in the Department of Sociology and Social Policy at the University of Sydney. His special interest is in the relationships between the narratives of fiction and the sociology of auto/biography, in particular how this applies to same-sex attracted men across the life course. Email: [email protected]

The Trajectory of Chronic Non-Cancer Pain in Six Patients: A Roller-Coaster Ride Ruth Ellen Dubin Abstract The diagnosis of chronic non-cancer pain (CNCP) is based entirely on patient selfreport unlike conditions such as diabetes or multiple sclerosis. Objective tests, the sine qua non of the medical model, are not widely known outside of specialty clinics. Canadian family physicians are poorly trained to deal with this common and debilitating condition. Using a novel graphic representation of the major themes raised during primary care visits, Dubin and Van Vlack (Pain Res. Manage., in press) discussed factors including mood disorders, financial concerns, conflicts with employers and insurers, and independent life events which affected healthcare utilization in six pain patients followed in Dr. Dubin’s general practice for 6 to 22 years. A locally-developed education/exercise CNCP self-management program seemed to improve patient function and reduce healthcare utilization in those whose major conflicts were behind them. Physicians, insurers, lawyers and employers may be contributing to patients’ pain and disability by adopting a disbelieving and confrontational approach to CNCP sufferers. Terms such as ‘functional’, ‘malinger’, ‘drug-seeking’, and ‘sickness or pain behaviours’ allow professionals to separate themselves from and ‘blame’ their clients. At the same time, patients may be forced to use ever-more exaggerated verbal and non-verbal cues to communicate their distress to others. This paper will present the chronic pain trajectory as a roller-coaster ride which engulfs the patient, family, employers, insurers and medical care-givers alike. Avoiding this destructive path requires a shift from the medico-legal models (purely scientific, allowing only objective findings) to ones that incorporate both patient empowerment and an expanded understanding of the pain experience. Professional training in chronic pain should be multi-disciplinary, and should include input from the Humanities and Social Sciences. Key Words: Chronic pain, healthcare utilization, self-management, exercise, conflict, pain behaviours, stress. ***** The past, being more or less imagined, or more or less organized after the event, acts on the future with a power comparable to that of the present itself. Paul Valery.1

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The Trajectory of Chronic Non-Cancer Pain in Six Patients

__________________________________________________________________ But if the only external sign of the felt-experience of pain (for which there is no alteration in the blood count, no shadow on the X-ray, no pattern on the CAT scan) is the patient's verbal report (however itself inadequate), then to bypass the voice is to bypass the bodily event, to bypass the patient, to bypass the person in pain. Thus the reality of a patient's X-rayable cancer may be believed in but the accompanying pain disbelieved and the pain medication underprescribed.....to have great pain is to have certainty, to hear that another person has pain is to have doubt. Ellen Scarry.2 Introduction Twenty percent of Canadian adults live with chronic non cancer pain (CNCP). Access to specialty pain clinics is limited both by geography and wait lists that exceed one to two years. While veterinary students receive 87 hours of lectures on pain during their 4 years, medical students get only 16 hours! Though family physicians are poorly trained in chronic pain treatment, they manage the majority of chronic pain sufferers. 3, 4, 5 Pain arising from the back, neck and joints is the most common reason that patients visit their doctors. These patients require more time per visit and suffer more mood disruption than other patients. It is little wonder that family physicians find them challenging to manage. 6, 7, 8 Evidenced-based medicine is the current mantra. Yet in chronic pain, the only ‘evidence’ is the patient’s self-report, or history. The absence of recognizable organic pathology may lead healthcare providers, employers, insurers, and even family members, to disbelieve or downplay the pain patient’s suffering. Lacking a clear understanding of the cause of their symptoms, patients themselves may develop increased disease-related anxiety with subsequent increased healthcare visits.9, 10, 11, 12 As a family physician, I struggled ineffectually to prevent my patients from entering the maelstrom of chronic pain. The treatments that others and I were recommending: physiotherapy, medications, MRI’s, consultants and rehabilitation professionals failed to improve their lives. When a patient with a 10-year history of chronic back pain, wept in my office because he could no longer be intimate with his wife, I realized that my medical model had failed. With the help of physiotherapists, an occupational therapist, fitness consultants, pain physicians, and a pain psychologist, I spear-headed the development of a local exercise/education self-management program for chronic pain patients, named YPEP (for YMCA Pain Exercise/Education Program).13 On reviewing my Y-PEP patients’ files, I recognized that the major correlate of their healthcare utilization was stress: from depression, from financial losses, from insurance or legal claim conflicts, and independent life events. My graphic exposition of their 6-22 years in

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__________________________________________________________________ my clinic is neither randomized, nor controlled, but contains the richness of longitudinal information from a primary care practice. 14 The purpose of this paper is to illustrate through these case histories both the roller-coaster trajectory of chronic pain and those factors that, in my opinion, make patients sicker. My hope is that, by reviewing the past (i.e. these case histories), I can find a future path that will allow everyone: patients, families, healthcare providers and insurers, to avoid stepping aboard the chronic pain roller-coaster. 1. Case Histories I reviewed patients’ complete medical files, recording the number of healthcare visits made annually for reasons either relating to pain or other conditions. Visit themes of depression, conflict with employers/insurers/ lawyers or others, and financial concerns were also graphed. All patients agreed to share their stories with the public.

Figure 1: The Pain Trajectory for ‘M’ from 1990 to 2007. M’s pain visits in 2003 and 2004 were very high because he was receiving trigger point injections. Painrelated visits (dark blue bars) and unrelated visits (light blue bars), ( ) depression, ($ ) financial concerns, ( ) conflict with employers and/or insurance providers. The size of the symbols reflects the proportion of visits where these themes were discussed. The blue ‘back pain’ figure indicates times when back injuries occurred.

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__________________________________________________________________ A. ‘M’. (Figure 1) ‘M’ came to Canada from a war-torn county in 1990, learned English, and worked in a restaurant, successfully achieving a managerial position. Despite mild lower back pain and recurrent prostatitis, he functioned normally and was happily married. An occupational injury in 1998 led to 4 years of intensive rehabilitation efforts while he attempted to keep working. He developed hypertension and morbid obesity. On seeing him take pain killers, his boss fired him. A severe depression ensued with a brief psychiatric admission when his home burned down! His pain visits rose dramatically until his home was rebuilt, a WSIB pension was granted, and he abandoned his dream of working. After attending Y-PEP, ‘M’s’ pain was well controlled until mid 2009 when his sister was diagnosed with metastatic cancer. Since her successful therapy, his pain and distress have improved, though he isolates himself from others, spending much time in prayer.

Figure 2: The Pain Trajectory for ‘L’ from 1989 to 2007. This patient had three work-related back injuries and tried to re-train three times before receiving a WSIB pension. (Legend same as in Figure 1.)

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__________________________________________________________________ B. ‘L’ (Figure 2) ‘L’ emigrated from the same country as ‘M’ after receiving death threats for his work in human rights. In Canada he worked in patient care but suffered a back injury in 1994. He worked hard to recover but became severely depressed in 1997 due to lack of progress. Then his dog attacked a neighbour and he was admitted briefly to a psychiatric ward. Other diagnoses included hypertension, non-cardiac chest pain, diabetes and post-traumatic stress syndrome. ‘L’ retrained as an addictions counsellor but re-injured his back while attempting to stop a client’s fall. Intensive rehabilitation therapy followed and a minor car accident in 2001. In 2004 he failed a course at school and accepted a pension from the Workmen’s Safety and Insurance Board (WSIB), after which his pain visits fell. In 2009, ‘L’ spear-headed a chronic pain patient’s support group and is currently doing very well.

Figure 3: Pain trajectory in ‘D’ from 1988 to 2007. After Y-PEP, this patient had reduced opioid analgesics and returned to full-time work. Unfortunately, shortly until early 2010 (not shown) when her lawsuit settled. Legend as in Figure 1. C. ‘D’ (Figure 3) ‘D’ became my patient in 1988 as a ward of the Children’s Aid Society (parental abuse). In her teens she had back, pelvic, wrist, and abdominal pain and

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__________________________________________________________________ fibromyalgia, and a post-partum depression in 1992. ‘D’ worked at a manual job. In 1999, a back injury led to WSIB rehabilitation treatments but she refused their return-to-work demands. Denied benefits, she depended on her spouse’s income. After Y-PEP, she exercised regularly, reduced her medication, took a full-time job and decided to leave her partner. Unfortunately a minor car accident in 2007 completely reversed her functional gains. Involved in a lawsuit regarding her car accident, her pain levels and medication doses escalated and she became dependent again on her ex-husband. Her lawsuit settled in 2010: her office visits have fallen and she has again left her spouse.

Figure 4: The Pain Trajectory for ‘P’ from 1989 to 2007. ‘P’ suffered from low back pain and also abdominal and joint pains due to hepatitis C. He battled addiction and legal issues in his early years, but was able to achieve abstinence and returned to part time work after completing Y-PEP which is very rare after longterm disability. He remains well to this day. Legend as in Figure 1. D. ‘P’ (Figure 4) ‘P’ was referred in 1989 after a lengthy admission for severe depression. He suffered childhood abuse, was illiterate, and abused alcohol and intravenous drugs.

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__________________________________________________________________ He had lower back pain and chronic abdominal pain (due to hepatitis). From 1998 to 2002 his pain increased when he was fired from work, and had marital and legal conflicts. ‘P’ attained abstinence in 2003, and his healthcare visits declined. After Y-PEP, he returned to part-time work (despite 8 years of complete disability). Figure 5 – ‘Dn’

Figure 5: ‘Dn’s’ trajectory. His entire family was traumatized by his accident, they lost their home before their claim was settled, and ‘Dn’ had a stroke two days later. After buying a new home, ‘Dn’s’ pain visits fell in 2009 until late in the year when a minor legal action began. Legend as in Figure 1. E. ‘Dn’ (Figure 5) ‘Dn’ was referred to me 3 years after a disabling car accident. In 2004, he was rear-ended while turning into his driveway. His wife and son saw his vehicle fly across the lawn! A vertebral fracture and severe shoulder pain at the site of an earlier injury ensued.

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__________________________________________________________________ ‘Dn’ had no previous psychosocial problems. A typical Canadian, he enjoyed all-terrain-vehicles, snowmobiles, hunting and fishing, and puttering around the garage. During and after Y-PEP he remained completely disabled, with severe depression and pain, both unresponsive to medication. Nerve blocks by a pain specialist provided only partial pain relief. Litigation involved multiple lawyers and consultations by professionals from the ‘other side’ attempting to prove that ‘Dn’ was exaggerating his disability. His wife and child also experienced anxiety. Insurance benefits were withheld and the family lost their home to creditors. At the end of 2008 the lawsuit settled in ‘Dn’s’ favour. Three days later he suffered a stroke from which he has mostly recovered! His pain visits fell dramatically and the family was able to purchase a new home. In late 2009, with another legal hearing for further damages pending, ‘Dn’ has again developed severe pain. F. ‘A’, (no Figure) ‘A’ had a 30-year history of depression and back and pelvic pain. Abused as a child, she had misused drugs and alcohol, and still smokes marijuana daily for pain relief. Since attending Y-PEP her visits have fallen to regular preventive care, and she expresses much more life satisfaction. 2.

Discussion The chronic pain trajectory is like a roller-coaster with increases in medical visits at the time of injuries and later during ‘crises’ (pressure from insurers, legal battles, failed return-to-work attempts or other personal troubles). ‘Pain’ was the ‘presenting problem’: the symptom that I attempted to treat. Socio-economic and employment problems or mood and sleep disruption did not appear important until I carried out this retrospective review. These themes did not recede until conflicts were resolved. Doctors are trained to rule out ‘red flags’ such as tumours and infections and may not recognize the life stressors that could be causing increased pain. We order more tests, consultations, and stronger medications (with an inevitable increase in side-effects). By failing to provide accurate explanations to patients about the nature and course of chronic pain, we may contribute to patient anxiety and increased healthcare visits. By ignoring the psychosocial conflicts we may perpetuate patient suffering and disability. Qualitative interviews with injured workers and their family physicians in a study of occupational injuries revealed that doctors resented the administrative time, felt pressure from insurers to return patients to work whether ready or not, and were uncomfortable speaking to employers due to confidentiality concerns. Patients described their experience with WSIB as cumbersome, intimidating, frustrating, demeaning, causing feelings of powerlessness and anger. Delays in

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__________________________________________________________________ claim processing caused inability to pay for medication for severe acute pain. Patients found the compensation process confusing; felt disempowered, and expressed feelings of ‘not being heard’ by the insurer. Two reactions occurred: antagonism and anger, or passive ‘uncaring’ withdrawal. 15 Patients with compensation and litigation issues are more functionally impaired and suffer more pain and depression. 17, 18 Frustration, disempowerment, anger, and stress may increase pain and depression (a well-known correlate of chronic pain).16 Insurers, who withhold benefits, thus creating financial crises, also increase clients’ disability. Litigation can invalidate the applicant’s lived experience. Traditionally, doctors interpret non-dermatomal sensory loss as ‘functional’ (non-organic, indicating ‘somatization’). Workers identified as ‘management problems’ by WSIB had a higher prevalence of non-dermatomal sensory loss which was associated with altered functional MRI brain activation.19 Chronic pain pathophysiology may one day include the stress of insurance and legal claims that increase pain perception through inflammation or other mechanisms of maladaptive ‘neuroplasticity.’20 A study using PET scans of patients who (like mine) had been exposed to serious emotional trauma, revealed metabolic changes in emotion and pain processing areas of the brain. Perhaps at last, the terms ‘somatization’, ‘psychogenic’, ‘functional’ and ‘hysterical’, now have a physiological explanation.21, 22, 23 Many believe that ‘catastrophizers’ (patients who magnify pain threat, worry excessively about pain or are unduly pessimistic), are predisposed to poorer outcomes. However, Walker et al.’s chronic back pain interviews exposed themes of loss (of physical and mental abilities, occupational and social activities), financial hardship and changes in interpersonal relationships, all eventually leading to diminished self-worth, future and hope. The authors stated that: [T]he stories told by our participants suggest that the negative material and social consequences of back pain may be sufficient to generate feelings of worthlessness and hopelessness even where no latent personal vulnerability existed prior to the onset of pain.24 Labels such as ‘catastrophizer’, ‘functional’, ‘drug-seeking’, ‘malinger’, and ‘sickness or pain behaviours’ can be useful clinical concepts, but can also separate the professional from the patient and could be interpreted as blaming. Family physicians often know their patients before misfortune befalls them. Despite having experienced catastrophic events (childhood abuse: ‘D’, ‘P’ and ‘A’; civil war and emigration: ‘L’ and ‘M’, an accident witnessed by wife and child, home repossession, stroke: ‘Dn’), my patients had behaved quite normally before their injuries. ‘L’ and ‘M’ repeatedly attempted to resume working; their optimism

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__________________________________________________________________ faded only as they had to abandon their dreams of productive employment. ‘P’ and ‘A’ had conquered addiction and lived on disability pensions for many years. Yet ‘P’ chose to return to part-time work. ‘D’ adopted an independent fitness-oriented life but a car accident reawakened her pain and dependence on others. ‘Dn’ was a normal Canadian man before his roller-coaster ride began. My patients’ pain experiences involved losses in many spheres combined with powerlessness at the hands of insurers and lawyers. Grieving their former lives was complicated by financial constraints, mood disruption and independent life misfortunes. Reaching acceptance25 could really only occur once material security was achieved, and major conflicts were resolved. The concept of a ‘chronic pain trajectory’ is not new, 9, 26 but this is the first study to graphically depict this journey over several decades. Doctors should recognize ‘pain behaviours’27 as manifestations of neurobiological phenomena and explore the underlying psychosocial problems that drive worsening pain and function. Family practice care that involved listening, understanding and shared management was the greatest factor in reducing global disability in occupationally injured patients.15 Physicians may improve patient outcomes by remaining supportive and open-minded when symptoms arise that lack current pathophysiological explanations. Factitious illness is uncommon. 28 That legal and insurance claims worsen pain is widely known. Many multidisciplinary pain programs refuse to accept patients who are involved in ongoing claims (which begs the question: is it ethical to refuse care to those clients with the greatest suffering?) However, the insurance and legal industries should also recognize their role in causing pain and disability. Major changes to these systems are needed so that pain patients receive financial support while claims are settled. Strong-arm tactics, like withholding benefits or imputing malingering despite medical opinions to the contrary, can damage the sufferer’s well-being. Health professionals require more education in pain medicine, but so do lawyers and claim managers. The treatment of chronic pain is a basic human right,29 and institutions that prolong or worsen peoples’ suffering should be revamped and their members re-educated. In 2003, Blyth et al, from Sydney, suggested that ‘there is a need to establish to what extent the compensation process per se contributes to these outcomes [painrelated disability]’.30 In 2010, in Sydney, I would like to suggest that this is an idea whose time has come.

Notes 1

P Valery, ‘Historical Fact,’ The Outlook for Intelligence, Harper Torchbooks, The Bollingen Library, New York, 1962. 2 E Scarry, The Body in Pain, Oxford University Press, Oxford, 1985, pp. 6-7.

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__________________________________________________________________ 3

R Jovey, ‘The Canadian Pain Survey 2007-2008,’ Canadian Pain Society Annual General Meeting, Nanos Research Group, Toronto, Canada. Quebec. 4 PK Morley-Forster, ‘Primary Care for Chronic Pain Sufferers,’ Canadian Family Physician, 51, 2005, pp. 1073. 5 J Watt-Watson, et. al., ‘A Survey of Prelicensure Curricula in Health Science Faculties in Canadian Universities,’ Pain Research Management, Vol.14, no.6, 2009, pp. 439-444. 6 EM Badkey, et. al., ‘Relative Importance of Musculoskeletal Disorders as a Cause of Chronic Health Problems, Disability and Health Care Utilization: Findings from the 1990 Ontario Health Survey,’ J. Rheumatology, Vol. 21, 1994, pp. 505-14. 7 J Rapoport, et. al., Refining the Measurement of the Economic Burden of Chronic Diseases in Canada,’ Chronic Disease Canada, Vol. 25, 2004, pp. 3-21. 8 PK Morley-Forster, et. al., ‘Attitudes toward Opioid Use for Chronic Pain: A Canadian Physician Survey,’ Pain Research Management, Vol. 8, 2003; pp. 18994. 9 JC Richardson, BN Ong & J Sim, ‘Remaking the Future: Contemplating a Life with Chronic Widespread Pain,’ Chronic Illness, Vol. 2, 2006, pp. 206-218. 10 M Von Korff & KM Dunn, ‘Chronic Pain Reconsidered,’ Pain, Vol. 138, 2008, pp. 267-276. 11 M Von Korff, EHB Lin, JJ Fenton & K Saunders, ‘Frequency and Priority of Pain Patients’ Health Care Use,’ Clinical Pain, Vol. 23, 2007, pp. 400-408. 12 JA Faucett & JD Levine, ‘The Contributions of Interpersonal Conflict to Chronic Pain in the Presence or Absence of Organic Pathology,’ Pain, Vol. 44, 1991, pp.35-43. 13 C King Van Vlack, et. al., ‘Education and Exercise Program for Chronic Pain Patients,’ Practical Pain Management, Vol. 7, 2007, pp.17-27. 14 R Dubin & CK van Vlack, ‘The Trajectory of Chronic Pain: Can a CommunityBased Exercise/Education Program Soften the Ride?’ Pain Research Management, 2010, in press. 15 G Russell, The Family Practice Care of Patients with Occupational Injuries, Unpublished Doctoral Dissertation, University of Western Australia, Australia, 2005. 16 JW Carson, et. al., ‘Conflict about Expressing Emotions and Chronic Low Back Pain: Associations with Pain and Anger,’ Journal of Pain, Vol. 8, No. 5, 2007, pp 405-411. 17 MR Landers, et. al., ‘Workers’ Compensation and Litigation Status Influence the Functional Outcome of Patients with Neck Pain,’ Clinical Pain, Vol. 23, 2007, pp. 676-682. 18 PB Suter, ‘Employment and Litigation: Improved by Work, Assisted by Verdict,’ Pain, Vol. 100, 2001, pp. 249-557.

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A Arvantaj, et. al., ‘Characteristics of Injured Chronic Pain Workers Identified by Workers Safety and Insurance Board (WSIB) Staff as Management Problems,’ Pain Research Management, Vol. 13, 2008, pp. 31 (Abst). 20 JA DeLeo & RP Yesierski, ‘The Role of Neuroinflammation and Neuroimmune Activation in Persistent Pain,’ Pain, Vol. 90, 2001, pp. 1-6. 21 N Egloff, et. al., ‘Nondermatomal Somatosensory Deficits in Patients with Chronic Pain Disorder: Clinical Findings and Hypometabolic Pattern in FDGPET,’ Pain, Vol. 145, 2009, pp. 252-258. 22 A Mailis-Gagnon &. Nicholson, ‘Nondermatomal Sensory Deficits (NDSNs): A Neuropsychobiological Phenomenon?’ Pain, Vol. 145, 2009, pp. 12-13. 23 H Merskey, ‘Somatization or another God that Failed,’ Pain, Vol. 145, 2009, pp. 4-5. 24 J Walker, B Sofaer & I Holloway, ‘The Experience of Chronic Back Pain: Accounts of Loss in Those Seeking Help from Pain Clinics,’ European Journal of Pain, Vol. 10, 2006, pp. 199-207. 25 D Lachapelle, S Lavoie & A Boudreau, ‘The Meaning and Process of Pain Acceptance: Perceptions of Women Living with Arthritis and Fibromyalgia,’ Pain Research Management, Vol. 13, 2008, pp. 201-210. 26 H Skuladottir & S Halldorsdottir, ‘Women in Chronic Pain: Sense of Control and Encounters with Health Professionals,’ Qualitative Health Research, Vol. 18, 2008, pp. 891-901. 27 A Mailis-Gagnon, et. al., ‘Pain Characteristics of Adults 65 Years of Age and Older Referred to a Tertiary Care Pain Clinic,’ Pain Research Management, Vol. 13, 2008, pp. 389-394. 28 Fishbain et al, 1999, suggested that 1.25% to 10.4 % of chronic pain patients may be malingering. I discount the 20% to 50% figure put forth by Greve et al, 2009, because along with the only really definite evidence of malingering: an inconsistency in behaviour during examination versus when patients believe they are not being observed, these authors used criteria such as the presence of ‘nonorganic findings’ and submaximal effort on psychological testing, or having a lawyer, all of which can be normally present in chronic pain patients.21,22,23 See also Ross et al, 2005. DA Fishbain, et. al., ‘Chronic Pain Disability Exaggeration/Malingering and Submaximal Effort Research,’ Clinical Pain, Vol. 15, 1999, pp. 244-274. 29 ‘Please, Do not Make us Suffer any More: Access to Pain Treatment as a Human Right,’ Human Rights Watch, March 2009. ISBN 1-56432-449-4, 30 FM Blyth, et. al., ‘Chronic Pain, Work Performance and Litigation,’ Pain, Vol. 103, 2003, pp. 41-47.

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Bibliography Arvantaj, A., et. al., ‘Characteristics of Injured Chronic Pain Workers Identified by Workers Safety and Insurance Board (WSIB) Staff as Management Problems.’ Pain Research Management. Vol. 13, 2008, pp. 31 (Abst). Badkey, E.M., Rasooly, I. & Webster, G.K, ‘Relative Importance of Musculoskeletal Disorders as a Cause of Chronic Health Problems, Disability and Health Care Utilization: Findings from the 1990 Ontario Health Survey.’ J. Rheumatology. Vol. 21, 1994, pp. 505-14. Blyth, F.M., et. al., ‘Chronic Pain, Work Performance and Litigation.’ Pain. Vol. 103, 2003, pp. 41-47. Carson, J.W., et. al., ‘Conflict about Expressing Emotions and Chronic Low Back Pain: Associations with Pain and Anger.’ Journal of Pain. Vol. 8, No. 5, 2007, pp 405-411. DeLeo, J.A. & Yesierski. R.P., ‘The Role of Neuroinflammation and Neuroimmune Activation in Persistent Pain.’ Pain. Vol. 90, 2001, pp. 1-6. Dubin, R. & Van Vlack, C.K., The Trajectory of Chronic Pain: Can a CommunityBased Exercise/Education Program Soften the Ride? Pain Research Management, 2010, in press. Egloff, N., et. al., ‘Nondermatomal Somatosensory Deficits in Patients with Chronic Pain Disorder: Clinical Findings and Hypometabolic Pattern in FDGPET.’ Pain. Vol. 145, 2009, pp. 252-258. Faucett, J.A. & Levine, J.D., ‘The Contributions of Interpersonal Conflict to Chronic Pain in the Presence or Absence of Organic Pathology.’ Pain. Vol. 44, 1991, pp.35-43. Fishbain, D.A., et. al., ‘Chronic Pain Disability Exaggeration/Malingering and Submaximal Effort Research.’ Clinical J. Pain. Vol. 15, 1999, pp. 244-274. Greve, K.W., et. al., ‘Prevalence of Malingering in Patients with Chronic Pain Referred for Psychological Evaluation in a Medico-Legal Ccontext.’ Arch Phys Med Rehab. Vol. 90, 2009, pp.1117-1126.

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__________________________________________________________________ King Van Vlack, C., et. al., ‘Education and Exercise Program for Chronic Pain Patients.. Practical Pain Management. Vol. 7, 2007, pp.17-27. Lachapelle, D., Lavoie, S. & Boudreau, A., ‘The Meaning and Process of Pain Acceptance: Perceptions of Women Living with Arthritis and Fibromyalgia.’ Pain Research Management. Vol. 13, 2008, pp. 201-210. Landers, M.R., et. al., ‘Workers’ Compensation and Litigation Status Influence the Functional Outcome of Patients with Neck Pain.’ Clin J Pain. Vol. 23, 2007, pp. 676-682. Mailis-Gagnon, A., et. al., ‘Pain Characteristics of Adults 65 Years of Age and Older Referred to a Tertiary Care Pain Clinic.’ Pain Research Management. Vol. 13, 2008, pp. 389-394. Mailis-Gagnon, A. & Nicholson, K., ‘Nondermatomal Sensory Deficits (NDSNs): A Neuropsychobiological Phenomenon?’ Pain. Vol. 145, 2009, pp. 12-13. Merskey, H., ‘Somatization or Another God that Failed.’ Pain. Vol. 145, 2009, pp. 4-5. Morley-Forster, P.K., ‘Primary Care for Chronic Pain Sufferers.’ Canadian Family Physician. Vol. 51, 2005, p. 1073. Morley-Forster, P.K., et. al., ‘Attitudes toward Opioid Use for Chronic Pain: A Canadian Physician Survey.’ Pain Research Management. Vol. 8, 2003; pp. 18994. Rapoport, J., et.al., ‘Refining the Measurement of the Economic Burden of Chronic Diseases in Canada.’ Chronic Disease Canada. Vol. 25, 2004, pp. 3-21. Richardson, C., et. al., ‘Remaking the Future: Contemplating a Life with Chronic Widespread Pain.’ Chronic Illness. Vol. 2, 2006, pp. 206-218. Ross, R.S., et. al., ‘Cognitive Complaints are Associated with Depression, Fatigue, Female Sex and Pain Catastrophizing in Patients with Chronic Pain.’ Arch Phys Med Rehab. Vol. 86, 2005, pp. 1147-1154. Russell. G., ‘The Family Practice Care of Patients with Occupational Injuries.’ Unpublished doctoral dissertation, University of Western Australia, Australia, 2005.

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__________________________________________________________________ Scarry, E., The Body in Pain. Oxford University Press, Oxford, 1985. Skuladottir, H. & Halldorsdottir, S., ‘Women in Chronic Pain: Sense of Control and Encounters with Health Professionals.’ Qualitative Health Research. Vol. 18, 2008, pp. 891-901. Suter, P.B., ‘Employment and Litigation: Improved by Work, Assisted by Verdict.’ Pain. Vol. 100, 2001, pp. 249-557. Valery P., ‘Historical Fact.’ The Outlook for Intelligence. Harper Torchbooks, The Bollingen Library, New York, 1962. Von Korff, M., et. al., ‘Frequency and Priority of Pain Patients’ Health Care Use.’ Clinical J Pain. Vol. 23, 2007, pp. 400-408. Von Korff, M. & Dunn, K.M., ‘Chronic Pain Reconsidered.’ Pain. Vol. 138, 2008, pp. 267-276. Walker, J., Sofaer, B. & Holloway, I., ‘The Experience of Chronic Back Pain: Accounts of Loss in Those Seeking Help from Pain Clinics.’ European Journal of Pain. Vol. 10, 2006, pp. 199-207. Watt-Watson, J.et. al., ‘A Survey of Prelicensure Curricula in Health Science Faculties in Canadian Universities.’ Pain Research Management. Vol.14, no.6, 2009, pp. 439-444. Ruth Ellen Dubin has practiced family medicine in Kingston, Ontario, Canada since 1987. She has been a member of the Canadian Pain Society since 2005, and teaches medical students and family medicine residents at Queen’s University.

Section 2

Making Sense of Pain: Liminality and Spaces

The Clinical Conversation about Pain: Tensions between the Lived Experience and the Biomedical Model Milton Cohen & John Quintner Abstract Despite the application to pain of the biopsychosocial model of illness, the clinical path of the person in pain presenting to a health professional still leads to frustration for both. The biopsychosocial model generated the ‘official’ definition of pain, two major conceptual frameworks in pain medicine, and three putative explanatory models for pain. However, in the absence of a theory that explains the lived experience of pain as an emergent and unpredictable phenomenon, these progeny of the biopsychosocial model have been unable to displace biomedical reductionism or to transcend body-mind dualism. In particular, the implication that pain can be an object divorced from the body bears little relationship to the lived experience of pain. This traditional observer-dependent stance of the clinician results in marginalisation of the ‘patient’, compromises effectiveness of therapy and leads to reluctance of the clinician to engage with a potential clinical nemesis.The lived experience of pain defies lineal reduction. Metaphysically it constitutes an aporia that denies us access to its secrets. However application of principles underlying the self-referentiality of living systems, such as autonomy and autopoiesis, opens a path to integrating the traditional somatic dimension of biomedical analysis with the dimensions of beliefs, emotions, behaviour and environment.In the clinical encounter, pain may be grasped anew through the engagement of two autonomous self-referential beings in the intersubjective or ‘third space’ with each influenced by similar sets of humanist factors but excluded from the same aporia. This framework supplants the current biopsychosocial approach by linking the different domains of analysis of pain, by not resorting to reductionism and dualism and by ‘leveling’ the clinical ‘playing field’ in order to generate new therapeutic possibilities. Key Words: Biopsychosocial, reductionism, dualism, aporia, self-referentiality, intersubjective, third space. ***** Introduction This paper seeks to understand why what should be a basic function of the health professions - the management of pain - is not only unsatisfactory but frustrating for both the person in pain and the health professional. How is it, we ask, that there is such a poor fit between the conventional medical approach to pain and the lived experience of pain?

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The Clinical Conversation About Pain

__________________________________________________________________ 1. The Biomedical Model In Western culture, body and mind are conceptualised as different and distinct entities; moreover the physical (‘objective’ and therefore measurable) tends to be prioritised over the mental (‘subjective’ and therefore immeasurable).1 This ascendancy of the physical over the mental characterises contemporary biomedicine, which assumes that knowledge about the properties of parts of a system is sufficient to understand the global behaviour of the whole system. At the core of the biomedical explanatory model is the assumption that all symptoms – including pain – are expressions of a discoverable disease process and that there is a predictable and reliable connection between pathological changes and clinical features. This primacy of structural pathology has been the major criterion for discovering disease in Western societies, eclipsing functional pathology and relegating to the background behavioural, psychological and social factors. When applied to the problem of clinical pain, the biomedical model posits a predictable hard-wired neurobiological relationship between identifiable tissue damage, the brain and the report of pain. The implications of the biomedical model are profound. Firstly, the experience of illness is demoted to the depersonalised expression of a disease process. Secondly, the process of diagnosis becomes exclusively reductionist, the only phenomena of interest being discrete causal chains. Thirdly, the relationships between such chains are assumed to behave predictably and to apply universally.2 In effect this model privileges the ostensibly ‘objective’ view of the clinician over the sufferer’s lived experience of pain. Thus if there is no nociception, there can be no ‘real’ pain: the clinical encounter defaults to either dismissal of the patient’s complaint or to an inference of ‘psychogenesis’ by the clinician.3 This reversion to culturally entrenched body-mind dualism defies and confronts the lived experience of pain, which, to quote is ‘simultaneously and interactively both physical and mental.’4 2. The Biopsychosocial Model of Illness In an attempt to breach this rampart of misinterpretation, psychiatrist George Engel (1913-1999) formulated the biopsychosocial model of illness, which retains the assumptions of biomedicine but invites consideration that patients’ self-reports of illness could be influenced and sometimes even determined by psychological, social, and cultural factors.5 6 7 Engel’s model was derived from General Systems Theory (GST) as formulated in the early 20th century by Viennese theoretical biologists, Ludwig von Bertalanffy and Paul Weiss.8 GST considers that organisms are highly organised hierarchical systems, embedded in their respective environments. Any perturbation sufficient to cause changes in any one system might produce changes in any or all of the other systems. The organism itself produces these changes ‘in an effort to stay constant with regard to its outside.’9

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__________________________________________________________________ Engel intended that clinicians would collect qualitative and quantitative data in each of these domains and incorporate them into diagnostic and therapeutic processes, thereby arriving at a better understanding of the ‘human experience’ of disease or, more correctly, of illness. Importantly, these transactions were to take place at the ‘two-person’ system level, that is, the doctor-patient relationship.10 3. Pain Medicine Embraces the Biopsychosocial Framework Theoreticians in pain medicine were quick to adapt the biopsychosocial framework, as it seemed to fit the growing recognition of pain as an expression of complex interactions between biological, psychological, social and cultural factors.11 12 13 The important contribution of such interactions to the lived experience of pain had already been predicted by the gate control theory of Melzack and Wall (1965), based on the plasticity and modifiability of events at all levels within the central nervous system.14 15 Whether or not a person will perceive a particular stimulus as painful is determined not only by the nature of that stimulus but also by the context within which it is experienced, together with associated memories, emotions and beliefs.16 The biopsychosocial approach generated the ‘official’ definition of pain, two major conceptual frameworks and at least three putative explanatory models for pain, each of which will be briefly examined. A. IASP Definition Pain has been defined, for clinical practice and research purposes, as ‘an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage’.17 This definition was an advance on the biomedical approach to pain as it had the potential for breaking the nexus between actual tissue damage and the subjective experience and thus accord legitimacy to the experience of the person in pain. However the explanatory notes that accompany the IASP definition, contain the rider that ‘[M]any people report pain in the absence of tissue damage or any likely pathological cause; usually this happens for psychological reasons.’18 [italics added] Thus, even this potentially enlightening definition fell back into the circular trap of body-mind dualism, and has inadvertently sanctioned the efforts of clinicians to seek explanations for a variety of pain syndromes solely from psychosocial factors, from which arises the untestable construct of somatisation.19 B. Hierarchical ‘Models’ In 1980, neurosurgeon John Loeser proposed a framework consisting of four nested hierarchical domains: nociception, pain, suffering, and pain behaviour. Of these, only the last is observable - the interaction between the person in pain and the surrounding world. The clinician’s task was to determine which of these four factors might be ‘playing significant roles in the genesis of the person’s problem,

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__________________________________________________________________ and then to direct therapies at the appropriate aetiological factors’.20 This approach posed two major theoretical and practical problems. Firstly, the framework suggests that pain, suffering, and pain behaviour are somehow discrete phenomena, whereas in fact the clinician-observer is unable to make such a distinction. Secondly, although nociception may be understood as a quantitative physiological process involving specific neuronal signals and pathways, the other domains resist such a reductionist approach. The connection between them is undefinable and arbitrary. The Glasgow Illness Model was formulated similarly, postulating four domains of interest: physical problem, psychological distress, illness behaviour, and social interactions. The clinician must not only differentiate illness behaviour from physical disease, but also must detect any mismatch between the amount of demonstrable disease causing pain and the level of disability allegedly caused by the pain. How these crucial decisions are to be made is left entirely to the clinician’s discretion, guided by the same arbitrary constructions constrained by dualism. Of major influence in pain medicine, each of these models fails to postulate how their domains are connected. Thus they are conceptual frameworks, not explanatory models. They imply that there are non-nociceptive influences on pain and behaviour but they neither escape dualism nor solve the unacknowledged ‘puzzle of pain’.21 C. A Psychobiological Model Jumping forward about twenty years, a new trend has emerged, focussing on trying to infer overarching neurobiological mechanisms. Flor and Hermann formulated a psychobiological model of pain, viewing it as a multi-component behavioural response to aversive stimuli. Through prior learning, operant and respondent conditioning, powerful pain memories are formed at all levels of the nervous system. The individual components (physiological, behavioural-motor, and subjective-verbal) of this response are said to reflect the dynamic and continuous interplay between various physiological and psychological factors.22 Once established, such pain memories are said to be capable of maintaining pain even in the absence of peripheral nociceptive input. That is, pain transmutes from being an emergent aversive response into a learned memory that may cause profound reorganisational changes within the nervous system, thus perpetuating itself. D. Pain as a ‘Homeostatic Emotion’ Craig pursued the theme of grounding pain in disturbed bodily function by reconceptualising it as one of many possible emotions through which the integrity of the body (self) can be maintained in the face of conditions that threaten to disturb its homeostasis. He suggested that pain is not part of the exteroceptive


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__________________________________________________________________ somatosensory system but rather ‘is represented in an unforeseen, novel pathway in humans that is part of a hierarchical system of interoception subserving homeostasis, the sense of the physiological condition of the body (interoception) and the subjective awareness of feelings and emotion.’23 This was based on the known relationship in humans between activated Cfibres and the conscious perception of pain, and a proposal that functions to monitor the physiological condition of the entire body and could be responsible for an individual’s subjective awareness of inner body feelings, including emotionality.24 The activity in this interoceptive pathway is represented in a part of the brain called the insular cortex:25 an ‘interoceptive image’ of activity in ‘homeostatic afferents’ responsible for a myriad of bodily feelings, and, importantly, for their associated emotions. Pain is hereby reconceptualised as but one of many possible responses to disturbed homeostasis.26 This claim raises two important issues. Firstly, the particular disturbance of homeostasis that gives rise to pain is quite specific, being signalled only through the summated activation of nociceptors, that is, by tissue damage. This is an attempt to unify (old) specificity theory with (new) convergence theory, favouring the former. The second, and more profound, issue is that Craig’s hypothesis depends on representationism (objectivism) whereby the nervous system is held to mirror an independent world, which includes a ‘thing’ called pain and a sensory image of the physiological condition of the body. Not only is this claim untestable, it requires that the organism step outside itself in order to observe its own condition, which seems to be an impossibility unless one postulates the existence of an homunculus to read this information. As pointed out by Edelman, such a proposition requires a similar entity to read the resulting messages, and so on, endlessly.27 Furthermore, it would also require what the philosopher Daniel Dennett calls a Cartesian Theater, an obscure place in the mind/brain ‘where it all comes together.’28 E. Persistent Pain as a Disease Another example of pain as a ‘thing’ is the attempt of Siddall and Cousins to assign disease status to the clinical problem of persistent pain. These authors cited ‘secondary pathology’29 within the nervous system, induced by altered sensory inputs from the periphery, including anatomical reorganisation in nociceptive pathways and the alterations in patterns of brain activation and cortical topography found in persistent pain states. In the light of recent knowledge this proposition is, in itself, unexceptional. However, to then state ‘persistent pain does give rise to its own secondary pathology’30 again elevates pain to the status of a causative ‘thing’ and thus constitutes the circular argument that pain causes itself.

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__________________________________________________________________ These authors then went further by adducing environmental factors as the ‘tertiary pathology’ of pain and thus assert that pain is ‘an environmental disease’. Such tertiary pathology was said to include ‘factors such as genetic makeup, level of spinal inhibition, psychological status and the societal litigation system.’31 In effect, this proposition is no different from identifying that non-nociceptive factors may be relevant to the pain experience. To label this as ‘tertiary pathology’ carries the implication that these factors can in some -unspecified- ways contribute to an altered nervous system. At the same time, by including ‘psychological status’ as part of this tertiary pathology, and therefore external to the body, the argument defaults to the familiar circle of body-mind dualism. Furthermore, what is the pathological basis of the influence, for example, of the ‘societal litigation system’? In effect, this proposition appears to be concordant with the biopsychosocial framework but the attempt to portray pain itself as a causative ‘thing’ represents a dramatic return to the linear causality of the biomedical model. Moreover, Siddall and Cousins fail to distinguish between their ‘discovery’ of the ‘pathology’ of pain and any process that might lead to justification of its validity.32 4. Critiques of the Biopsychosocial Framework of Pain The application of the biopsychosocial framework to the discipline of pain medicine has been useful in facilitating the evaluation of clinical pain, in generating putative explanatory models and to some extent influencing modes of therapy. The framework also promised to provide useful insights into enigmatic situations such as pain in the absence of nociception, the absence of pain in the presence of tissue damage, the variability and unpredictability of individual responsiveness to identical treatments, and the lack of a predictable relationship between pain, impairment and disability. However, in the absence of a theory that seeks to understand how the different domains interact with each other, these attempts have been caught in circular argument and have been unable to transcend biomedical reductionism or the perpetuation of body-mind dualism. In particular, the implication that pain is a ‘thing’ separate and distinct from the body not only bears little relationship to the lived experience of pain but also emphasises the inherent problem that arises when an observer attempts to reduce the experience of the pain of ‘the other’ to predictable parameters. In this initiative, pain theorists have continued to adopt the traditional observerdependent stance of the clinician, which not only marginalises the patient but also ignores the important role the observer plays in the clinical encounter and its outcome. Pain cannot be reduced to its neurophysiological correlates, nor can it be conceptualised as a disease, an emotion, or a memory. Thus the biopsychosocial initiative is better seen as another reductionistic and dualistic framework for analysis rather than as an explanatory model for the complex phenomenology of pain states.33


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__________________________________________________________________ 5. A New Theoretical Framework for Pain Medicine Why are pain and its ethical treatment so elusive of theory? To address this question we identify the clinical encounter as the central transaction in pain medicine: the presentation of a person distressed because of a profound threat to their bodily integrity to another person reputed to be learned in the art (if not also the sciences) of healing. In searching for a new theoretical perspective to understand this encounter, we will draw on three vantage points:  



The central idea of pain as an aporia that cannot be accounted for adequately on the biomedical model or in a biopsychosocial framework; The nature of humans (and indeed other biological systems) as (autonomous) autopoietic units which have different perspectives and needs based on the demands of their particular circumstances (which includes the societies in which they are embedded); Inter-subjectivity or empathy as the natural ground for rapprochement between the world of the clinician and the world of the person in pain in the clinical setting.

A. Pain as an Aporia The lived experience of being human is not linear and indeed is beyond bodymind monism or dualism.34 Pain is difficult to express in language but ultimately not communicable: too complex to be apprehended from linear determinism or from a desire to make sense of it. Our attempts to develop explanatory models bounce off a metaphysical brick wall, which constitutes the aporia of pain. An aporia is a mystery, a space to which an observer is denied access but paradoxically from which we cannot escape. That is, it is unlikely that pain can ever be known objectively. B. Self-Referential Biological Systems A critical insight from GST is the capacity of a living organism to change itself in response to perturbations in its environment. Chilean biologists Maturana and Varela argued that the unique property possessed by living organisms is a particular circular mechanism of spontaneous autonomous activity contained within a semipermeable boundary, a process which they called autopoiesis, from the Greek, meaning ‘self-producing’. They defined an ‘autopoietic unit’ as a particular type of homeostatic system capable of being self-sustaining by virtue of an inner network of reactions (i.e. its organisation) that regenerate all the system’s components (i.e. its structure). Autopoiesis is the continual production by a network of the very components that comprise and sustain the network and its processes of production..35 In other words, such a system is said to be self-

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__________________________________________________________________ referential (capable of examining itself) and self-organising (capable of changing and ordering its internal structure according to local rules). 37 38 39 The critical variable of a living system is its own organisation. This is highly negentropic (far from thermodynamic equilibrium): loss of the system’s organisation results in its death. By contrast its structure (its components) changes constantly as the system continues to adapt itself to unpredictable disturbances caused by environmental changes. When the organism’s environment includes another living organism, each triggers changes in the other’s structure; such a congruent reciprocal relationship continues for as long as they remain engaged. During that time, the lived body-environment of each becomes a unique unitary domain of communication.40 Importantly, during such interaction each organism conserves its own autopoiesis and compatibility with its environment. However the result of that interaction is not determined by a stimulus external to the organism but only by the aggregate state of the organism itself at a given moment.41 The nervous system – including most importantly the brain – forms part of an autonomous unity in which every state of activity leads to another state of activity in the same unity because its operation is circular or in operational closure. Being an embedded system in continuous structural change, the nervous system has the property of plasticity, which makes it possible for it to participate in the process by which the organism and its environment remain in a continuous inseparable relationship. The brain is not simply a hard-wired computer-like machine that only processes an externally referenced environment. Rather the brain is both the object of interpretation and the interpreter: its own self-organising reference.42 We argue that the key to understanding pain is found in the role of the selfreferential brain embedded in an autopoietic living system. When that living system is a human reporting the experience of pain, we – as observers - must infer that something has changed in that person’s nervous system arising out of an attempt to maintain its autopoietic organisation. C. Empathy Although clinician and patient are both excluded from the same aporia (the pain of the other), they interact as two autopoietic entities, simultaneously observer and observed. The domain of this ‘level playing-field’ interaction allows the emergence of the phenomena of intersubjectivity and empathy. Using a neurosemiotic approach, Favareau argues that such a relationship might be built upon the primary involuntary activity of deeply embedded cortical sensorimotor ‘mirror’ neurons in clinician and patient.43 44 For at the mirror neuron level of organization, the distinction between seer and doer, action and reaction, identity and alterity


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__________________________________________________________________ is – like the ‘reflection’ one finds oneself presented with in front of a full length mirror – a distinction which is impossible to maintain.45 The mere knowledge that someone else is currently in pain is enough to elicit activity in brain regions associated with the experience of pain. 46 Clearly that is not a sufficient explanation but it shows what might happen when neuroscientific findings are interpreted from the point of view of the subject rather than as an object. The realisation of intersubjectivity takes place within what Winnicott termed the ‘third space’.47 In relation to play, the ‘third space’ is that in which children are able construct a relevant culture. In the empathetic clinical encounter, clinician and patient seek to carve out a communal public space of signs created by their respective actions.48 6. Conclusion As clinicians it is necessary to engage the aporia of pain because of our ethical obligation to the person in pain. The clinician and the person in pain share two outstanding characteristics: they are simultaneously observer and observed, locked in a dance that defines the impossibility of objectivity, and haunted by the spectre of self-reference.49 Thus the clinical encounter of the other in pain is the engagement of two self-referential organisms engaged in a unique narrative. This framework has the advantage of escaping dualism by linking the selfreferential autopoietic brains of both clinician and patient through underlying neurobiological processes without privileging either participant in the clinical engagement. It allows the clinician to infer a change in the autopoietic organisation of the patient and the patient to come to appreciate that such a change has occurred. In overcoming the linear reductionist thinking of the biomedical model, which has been perpetuated in biopsychosocial iterations to date, this framework does not supplant the quest for clinical identification of ‘mechanisms’ or ‘causes’ or ‘factors’ but rather invites integration of that approach with a biologically informed substrate that recognises the elusive neurophenomenology of pain. New therapeutic possibilities that may emerge from the arena of this intersubjective engagement include developing unique narrative (especially but not only verbal language, as there are other creative modes of expression), reframing ‘cognitive-behavioural’ approaches and more limited but targeted use of agents that might modify nervous system function. To give Dennett the last word:

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__________________________________________________________________ … I recommend giving up … all ‘essential’ features of pain, and letting pain states be whatever ‘natural kind’ states the brain scientists find (if they ever do find any) that normally produce all the normal effects. … These will be discoveries based on a somewhat arbitrary decision about what pain is, and calling something pain does not make it pain … whether or not one is in pain is a brute fact, not a matter of decision to serve the convenience of the theorist.50 Acknowledgement: The authors are grateful to Dr Pamela Lyon for her helpful suggestions.

Notes 1

M Crowley-Matoka, et. al., ‘Problems of Quality and Equity in Pain Management: Exploring the Role of Biomedical Culture,’ Pain Medicine, Vol. 10, 2009, pp. 1312-1324. 2 W Gray, ‘Ludwig von Bertalanffy and the Development of Modern Psychiatric Thought,’ Unity Through Diversity: A Festschrift for Ludwig von Bertalanffy, Part 1, Gordon and Breach Science Publisher, New York, 1973,pp.169-83. 3 JL Quintner, ML Cohen, D Buchanan, J Katz & O Williamson, ‘Pain Medicine and Its Models: Helping or Hindering?’ Pain Medicine, Vol. 9, 2008, pp. 824-834. 4 M. Crowley-Matoka et al., op. cit. 5 GL Engel, ‘The Need for a New Medical Model: A Challenge for Biomedicine. Science, Vol. 196, 1977a, pp. 129-136. 6 GL Engel, ‘The Care of the Patient: Art or Science? Johns Hopkins Medical Journal, vol.140: 1977b, pp. 222-32. 7 D Greaves, Reflections on a New Medical Cosmology, Journal of Medical Ethics, vol. 28, 2002, pp. 81-85. 8 M Drack & W Apfalter, ‘Is Paul Weiss’ and Ludwig von Bertalanffy’s System Thinking Still Valid Today? Systems Research and Behavioral Science, Vol. 24, 2007, pp. 537-546. 9 Weiss, PA, Tierisches Verhalten als ‘Systemreaktion,’ Die Orienterung der Ruhstellungen von Schmetterlingen (Vanessa) gegen Licht und Schwerkraft. Biologica Generalis, vol. 1, 1925, p.125. 10 GL Engel, 1977b. 11 GM Aronoff, RM Gallagher & JB Feldman. ‘Biopsychosocial Evaluation and Treatment of Chronic Pain,’ Practical Management of Pain, 3rd edn, Mosby, St Louis, 2000, pp. 156-65. 12 H Flor & C Hermann, ‘Biopsychosocial Models of Pain,’ Psychosocial Aspects of Pain, Progress in Pain Research and Management, Vol 27, IASP Press, Seattle, 2004, pp. 47-75.


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F Andrasik, H Flor H & DC Turk, ‘An Expanded View of Psychological Aspects in Head Pain: The Biopsychosocial Model. Neurological Science, vol 26, 2005, pp. S87-S91. 14 R Melzack & PD Wall, ‘Pain Mechanisms: A New Theory,’ Science, Vvol. 150, 1965, pp. 971-979. 15 R Melzack, ‘From the Gate to the Neuromatrix,’ Pain, Suppl 6: 1999, pp. S121126. 16 A Basbaum, MC Bushnell & M Devor, ‘Pain: Basic Mechanisms,’ Pain 2005 an Updated Review: Refresher Course Syllabus, IASP Press, Seattle, 2005, pp. 3-9. 17 H Merskey & N Bogduk, Classification of Chronic Pain, IASP Press, Seattle, 1994, p. 210. 18 Ibid. 19 AJ Barsky & JF Borus, ‘Somatization and Medicalization in the Era of Managed Care,’ Journal of the American Medical Association, Vol. 274, 1995, pp.19311934. 20 JD Loeser, ‘Perspectives on Pain,’ Proceedings of the First World Congress on Clinical Pharmacology and Therapeutics, Macmillan, London, 1980, pp. 313-16. 21 R Melzack & PD Wall, The Puzzle of Pain, Penguin Books, Harmondsworth, 1973. 23 Flor & Herman, 2004. op. cit. 24 AD Craig, ‘How do you Feel? Interoception: The Sense of the Physiological Condition of the Body,’ Nature Reviews Neuroscience, Vol 8, 2002, pp. 655-66. 25 AD Craig, ‘Human Feelings: Why are Some more Aware than Others?’ Trends in Cognitive Sciences, Vol 8, 2004, pp. 239-41. 26 AD Craig, ‘Pain Mechanisms: Labelled Lines versus Convergence in Central Processing, Annual Reviews of Neuroscience, Vol 26, 2003, pp. 1-30. 27 AD Craig, ‘Forebrain Emotional Asymmetry: A Neuroanatomical Basis?’ Trends in Cognitive Sciences, Vol.12, 2005, pp. 566-71. 28 G Edelman, Bright Air, Brilliant Fire, Penguin Books Ltd., London, 1992, pp. 73-80. 29 D Dennett, Consciousness Explained, Penguin Books Ltd., London, 1993, pp. 21-42. 30 ibid. 31 ibid. 32 ibid. 33 P Medawar, Induction and Intuition in Scientific Thought, Methuen, London, 1969. 34 CC Butler, M Evans, D Greaves & S Simpson. ‘Medically Unexplained Symptoms: The Biopsychosocial Model Found Wanting,’ Journal of the Royal Society of Medicine, Vol 97, 2004, pp. 219-212.

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OD Williamson, DA Buchanan, JL Quintner & ML Cohen, ‘Pain beyond Monism and Dualism,’ Pain, Vol.116, 2005, pp. 169-170. 36 HR Maturana & FJ Varela, Autopoiesis and Cognition: The Realization of the Living, Reidel Publishing Co., Dordrecht, 1980, pp. 5-58 37 H von Foerster, ‘On Self-Organizing Systems and their Environments,’ SelfOrganizing Systems, Pergamon Press, London,1960, pp. 31-50. 38 N Luhmann, Social Systems, Stanford University Press, Stanford, 1995. 39 PL Luisi, ‘Autopoiesis: A Review and a Reappraisal,’ Naturwissenschaften, Vol. 90, 2003, pp. 49-59. 40 Maturana & Varela, op. cit. 41 P Lyon, ‘Autopoiesis and Knowing: Reflections on Maturana’s Biogenic Explanation of Cognition,’ Cybernetics and Human Knowing, Vol. 11, 2004, pp. 21-46. 42 M Arbib, P Erdi & J Szentagothai J, Structure, Function and Dynamics: An Integrated Approach to Neural Organisation, MIT Press, New York, 1988 43 Favareau, D, ‘Beyond Self and Other: On the Neurosemiotic Emergence of Intersubjectivity,’ Sign System Studies, Vol. 30, 2002, pp. 57-100. 44 For a fuller discussion of mirror neurons, see Rizzolatti et al., 1999; Rizzolatti & Sinigalgli, 2007; Catanio & Rizzolatti, 2009. 45 Favareau 2003, op cit. 46 T Singer & C Lamm, ‘The Social Neuroscience of Empathy,’ Annals of the New York Academy of Sciences, Vol. 1156, 2009, pp. 81-96. 47 DW Winnicott, Playing and Reality. Tavistock Publications, London, 1971. 48 Favareau 2003, op. cit. 49 Quintner et al, 2008, op. cit.

Bibliography Andrasik, F., Flor H.H. & Turk, D.C., ‘An Expanded View of Psychological Aspects in Head Pain: The Biopsychosocial Model.’ Neurological Science. Vol 26, 2005, pp. S87-S91. Arbib, M., Erdi, P. & Szentagothai J., Structure, Function and Dynamics: An Integrated Approach to Neural Organisation. MIT Press, New York, 1988 Aronoff, G.M., Gallagher, R.M. & Feldman, J.B., ‘Biopsychosocial Evaluation and Treatment of Chronic Pain.’ Practical Management of Pain. 3rd edn, Mosby, St Louis, 2000, pp. 156-65.


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__________________________________________________________________ Barsky, A.J. & Borus, J.F., ‘Somatization and Medicalization in the Era of Managed Care.’ Journal of the American Medical Association. Vol. 274, 1995, pp. 1931-1934. Basbaum A., Bushnell, M.C. & Devor, M., ‘Pain: Basic Mechanisms.’ Pain 2005 an Updated Review: Refresher Course Syllabus. IASP Press, Seattle, 2005. Butler, C.C., Evans, M., Greaves, D., & Simpson, S., ‘Medically Unexplained Symptoms: The Biopsychosocial Model Found Wanting.’ Journal of the Royal Society of Medicine. Vol. 97, 2004, pp. 219-212. Cattaneo, L. & Rizzolatti, G., ‘The Mirror Neuron System.’ Archives of Neurology. Vol. 66, 2009, pp. 557-560. Craig, A.D., ‘How do you Feel Interoception: The Sense of the Physiological Condition of the Body.’ Nature Reviews Neuroscience. Vol. 8, 2002, pp. 655-66. _______

, Pain Mechanisms: Labelled Lines versus Convergence in Central Processing.’ Annual Reviews of Neuroscience. Vol. 26, 2003, pp. 1-30. _______

, ‘Human Feelings: Why are Some More Aware than Others?’ Trends in Cognitive Sciences. Vol. 8, 2004, pp. 239-41. _______

, ‘Forebrain Emotional Asymmetry: A Neuroanatomical Basis?’ Trends in Cognitive Sciences, vol.12, 2005, pp. 566-71. Crowley-Matoka, M., Saha, S., Dobschka, S.K. & Burgess, D.J., ‘Problems of Quality and Equity in Pain Management: Exploring the Role of Biomedical Culture.’ Pain Medicine. Vol. 10, 2009, pp. 1312-1324. Dennett, D., Brainstorms: Philosophical Essays on Mind and Psychology. Penguin Books, London, 1997. _______

, Consciousness Explained. Penguin Books Ltd., London, 1993.

Drack, M. & Apfalter, W., ‘Is Paul Weiss’ and Ludwig von Bertalanffy’s System Thinking Still Valid Today?’ Systems Research and Behavioral Science. Vol. 24, 2007, pp. 537-546. Edelman, G., Bright Air, Brilliant Fire. Penguin Books Ltd., London, 1992, pp. 7380.

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__________________________________________________________________ Engel, G.L., The need for a new medical model: a challenge for biomedicine. Science, vol. 196, 1977, pp. 129-136. _______

, ‘The Care of the Patient: Art or Science?’ Johns Hopkins Medical Journal,. Vol.140: 1977, pp. 222-32. Favareau, D., ‘Beyond Self and Other: On the Neurosemiotic Emergence of Intersubjectivity.’ Sign System Studies. Vol. 30, 2002, pp. 57-100. Flor, H. & Hermann, C., ‘Biopsychosocial Models of Pain.’ Psychosocial Aspects of Pain, Progress in Pain Research and Management. Vol 27, IASP Press, Seattle, 2004, pp. 47-75. Foerster, H. von, ‘On Self-Organizing Systems and Their Environments.’ SelfOrganizing Systems. Pergamon Press, London, 1960. Gray, W., ‘Ludwig von Bertalanffy and the Development of Modern Psychiatric Thought.’ Unity Through Diversity: A Festschrift for Ludwig von Bertalanffy, Part 1. Gordon and Breach Science Publisher, New York, 1973,pp.169-83. Greaves, D., ‘Reflections on a New Medical Cosmology.’ Journal of Medical Ethics. Vol. 28, 2002, pp. 81-85. Loeser, J.D., ‘Perspectives on Pain.’ Proceedings of the First World Congress on Clinical Pharmacology and Therapeutics. Macmillan, London, 1980, pp. 313-16. Luhmann, N., Social System. Stanford University Press, Stanford, 1995. Luisi, P.L., ‘Autopoiesis: A Review and a Reappraisal.’ Naturwissenschaften. Vol. 90, 2003, pp. 49-59. Lyon, P., ‘Autopoiesis and Knowing: Reflections on Maturana’s Biogenic Explanation of Cognition.’ Cybernetics and Human Knowing. Vol. 11, 2004, pp. 21-46. Maturana, H.R. & Varela, F.J., Autopoiesis and Cognition: The Realization of the Living. Reidel Publishing Co., Dordrecht, 1980, pp. 5-58. Medawar, P., Induction and Intuition in Scientific Thought. Methuen, London, 1969.


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__________________________________________________________________ Melzack, R. & Wall, P.D., ‘Pain Mechanisms: A New Theory.’ Science. Vol. 150, 1965, pp. 971-979. _______

, The Puzzle of Pain. Penguin Books, Harmondsworth, 1973.

Melzack, R., ‘From the Gate to the Neuromatrix. Pain. Suppl 6: 1999, pp. S121126. Merskey, H. & Bogduk, N., Classification of Chronic Pain. IASP Press, Seattle, 1994, p. 210. Quintner, J.L., Cohen, M.L., Buchanan, D., Katz, J. & Williamson, O., ‘Pain Medicine and Its Models: Helping or Hindering?’ Pain Medicine. Vol. 9, 2008, pp. 824-834. Rizzolatti, G., Fadiga, L., Fogassi, L. & Gallese, V., ‘Resonance Behaviors and Mirror Neurons.’ Archives of Italian Biology. Vol. 137, 1999, pp. 85-100. Rizzolatti, G. & Sinigaglia, C., ‘Mirror Neurons and Intentionality.’ Functional Neurology. Vol. 22, 2007, pp. 205-210. Siddall, P.J. & Cousins, M.J., ‘Persistent Pain as a Disease Entity: Implications for Clinical Management.’ Anaesthesia Analgesia. Vol.99, 2004, pp. 510-20. Singer, T. & Lamm, C., ‘The Social Neuroscience of Empathy.’ Annals of the New York Academy of Sciences. Vol. 1156, 2009, pp. 81-96. Waddell, G., Bircher, M., Finlayson, D. & Main, C.J., ‘Symptoms and Signs: Physical Disease or Illness?’ British Medical Journal. Vol. 289, 1984, pp. 739-741. Weiss, P.A., ‘Tierisches Verhalten als ‘Systemreaktion’. Die Orienterung der Ruhstellungen von Schmetterlingen (Vanessa) gegen Licht und Schwerkraft. Biologica Generalis. Vol. 1, 1925, 165-248. Williamson, O.D., Buchanan, D.A., Quintner, J.L. & Cohen, M.L., ‘Pain beyond Monism and Dualism.’ Pain. Vol.116, 2005, pp. 169-170. Winnicott, D.W., Playing and Reality. Tavistock Publications, London, 1971. Milton Cohen is a consultant physician in pain medicine and rheumatology on the St Vincent’s Health Care Campus in Sydney, Australia. He is a past Dean of the

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__________________________________________________________________ Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists. His major interests are in medical epistemology including pain theory, rational management of people with chronic pain and implications of pain policy. John Quintner is a consultant physician in pain medicine and rheumatology, currently attached to the pain unit at Fremantle Hospital, Western Australia. His major interests lie in the theoretical and epistemological aspects of pain medicine, as well as in improved health service delivery to people in pain.

Inflecting Pain Hildur Kalman & Naomi Scheman Abstract Starting from the connection and tension between the expression and the acknowledgement of pain, we explore the interpersonal space between the two: how it is that pain’s expression and acknowledgement are always inflected by the space between the one in pain and the other, and how, in turn, pain’s expression and acknowledgement inflect that space. To inflect, grammatically, is to mark words - by gender, number, tense, mood, indicating a constitutive difference: our words are always inflected somehow or other. In this sense, the expression or suppression of pain, its being acknowledged or ignored, marks interpersonal space and is marked by it. Through some examples, we raise questions about what we learn about interpersonal space - when that space inflects and is inflected by pain. We are especially interested in the absence of expression and/or acknowledgement, in the ignoring of pain and the constraints on acknowledgement. Examples that will be discussed are: Ignoring pain, love-making, and intimate space: We want to think about minor, incidental (non-eroticised) pain - that typically carries with it a determination not to express the pain, in order to avoid the distraction of its being acknowledged-the disruption of the space of intimacy. Inflicting pain, professional caring, and professional space: Again, we focus on the (relatively) mundane and morally unproblematic-the pain inflicted, e.g., by a doctor’s cleaning a wound or by a physiotherapist initiating motion in an injured limb. The interpersonal space is one of professional engagement, and both pain’s expression and its acknowledgement are and should be contextualised by expectations of appropriate care. Witnessing pain, face-to-face: Either professionally or by chance, one may become a witness to the newly bereaved. A risk here is an acknowledgement that collapses the interpersonal space where the pain calls for presence at a distance, respecting the aura of emptiness. Key Words: Pain, emotion, expression, acknowledgement, interpersonal space, metaphysically private, meaning-making. ***** 1. Introduction Thinking about pain, we want to suggest, is a useful way of trying to make sense of interpersonal space and to break the grip of dualism, in part because of its obvious claims to both mentality and physicality. Pain’s claim to physicality rests most obviously on its tie to bodily damage - to wounds and injuries. Its claims to mentality are equally obvious - it is, in fact, philosophers’ favourite example of the inscrutably inner; the realm of presumptively private subjective experience. In

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__________________________________________________________________ arguing against metaphysical privacy - the inside of my mind that only I can directly know - Wittgenstein discusses pain, arguing for a conceptual connection between the experience and the expression.1 He expects to be misunderstood here, as though he could mark no difference between real and feigned pain, between the genuine and the counterfeit expression, a difference he insists he has no intention of undermining. Rather, it is through expressing our own pain and having it acknowledged and learning to acknowledge the pain of others that we learn what pain is, which includes learning how to fake it.2 Expression marks the middle ground: an expression of pain is linked inwardly to the experiencing and outwardly to its acknowledgement. Pain is naturally expressive, it is in its nature to be expressed, but the form of that expression is shaped by its context - just like it is natural to eat, but the way one eats or fasts is shaped by context, and we thus turn to the pairing of expression and acknowledgement - expression in the first person, the self, and the acknowledgement in the second person, that is the other. We think of this in spatial terms: with the expression of pain being met by acknowledgement. The acknowledgement traverses the space between the self and the other - and that space is not empty - what is in that space can/should change the kind of acknowledgement there is. Acknowledgement is naturally responsive - just as pain cries out for expression, witnessing pain cries out for acknowledgement. So - starting from the connection and tension between the expression and the acknowledgement of pain, we aim to explore the interpersonal space between the two: how it is that pain’s expression and acknowledgement are always inflected by the space between the one in pain and the other, and how, in turn, pain’s expression and acknowledgement inflect that space. Inflection has two meanings: -

-

the first connects to the way words change their forms. To inflect, grammatically, is to mark words (by gender, number, tense, mood, etc) the second meaning refers to the tonal differences in one’s voice.

There is no such thing as a voice without a tone or a word without a form. Hence inflection is a constitutive difference - a difference that cannot be subtracted out. In this sense, the expression or suppression of pain, its being acknowledged or ignored, marks interpersonal space and is marked by it. The original naturalness of pain’s expression is always inflected by what goes on in the interpersonal space. Through a series of examples, we raise questions about what we learn about interpersonal space - the space between the self and the other - when that space inflects, and is inflected by pain. We are especially interested in the absence of expression and/or acknowledgement, in the ignoring of pain and the constraints on acknowledgement.

Hildur Kalman & Naomi Scheman

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__________________________________________________________________ 2. Pain and/in Intimate Space To begin with we have chosen an example of pain and intimate space; that of ignoring pain when love-making, and how this is inflected by and inflects intimate space: We are here thinking about minor, incidental (non-eroticised) pain - the pain, for example, from being awkwardly positioned or from pressure on a minor bruise. The one feeling the pain might well choose to (try to) ignore it, a choice that typically carries with it a determination not to express the pain, in order to avoid the distraction of its being acknowledged - the disruption of the space of intimacy. If the pain is expressed it threatens to break the mood of love-making. If it is expressed, and acknowledged, this acknowledgement breaks the mood, and if the pain is ignored, the other is being callous - which inflects and disrupts the space of intimacy and nearness. For oneself to ignore the pain is, of course, quite another thing - but the question is: at what point does the ignoring of one’s own pain turn into self-estrangement? If you never let on how you feel it is more than possible that the habit of this creates a distance from your own feelings and further: the interpersonal space of intimacy is changed to be more distanced as it is inflected by the ignoring of one’s own pain. But we also want to point out that there are times when not letting a minor discomfort get in the way of love-making is what makes intimate space possible…. But where the irony is that the intimacy may gets shrouded from the failure to disclose one’s feeling. There is no clear line here: a little shrouding now and then may make for intimacy in the interpersonal space, but if it becomes habitual real intimacy gets shrouded. This is of course an example where gendered expectations and habituation would matter to who heeds and who ignores their own pain, as such choices - to not express pain or discomfort - are not made in a social void.3 Just like fake orgasms such choices are more likely to be made by women striving to ‘lay the table’ for the interpersonal encounter.4 3. Pain and/in Professional Space Next we have chosen an example representing the inflection of pain in a context of professional caring and where interpersonal space is inflected by its being a professional’s encounter with a patient - that is: a professional space. This is also a space where a pain can be inflicted. Again, we want to focus on the (relatively) mundane and morally unproblematic - the pain inflicted, for example, by a doctor’s cleaning a wound or by a physiotherapist initiating motion in an injured limb. While it is certainly appropriate for the one inflicting the pain to acknowledge it in some fashion, such acknowledgement needs to be quite different from what would be expected under other circumstances: typically, for example, it should not call for stopping doing whatever is causing the pain. The interpersonal space is one of professional engagement, and both pain’s expression and its acknowledgement are and should be contextualised by expectations of appropriate care.

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__________________________________________________________________ Acknowledgement can mean a lot of things - acknowledgement in circumstances such as cleaning the wound might be said to encompass that one ignores the pain to a certain extent - where one’s acknowledgement is not one of being a participant in the experience of that pain, but rather that of an engaged beholder. Paediatricians and veterinarians in such circumstances are faced with an especially difficult task, because to fill the interpersonal space in the right way requires the right cooperation between both parties. An adult may become complicit - and give acceptance - and so the space is filled with a shared understanding of the regrettable necessity of this pain. With small children or animals such verbal communication and agreement, where both compassion and regret can be expressed - and subsequently shared - is hardly the case. 4. Witnessing Pain: Face-to-Face Sometimes pain is not a presence but an absence - the pain of loss, of bereavement - and either professionally or by chance, one may become a witness to the newly bereaved. Much as nature abhors a vacuum, witnessing such grief can prompt a rush to fill the void, to comfort, to reassure. But understanding the nature of that particular interpersonal space - the space between the newly bereaved and everyone else - ought often, in certain cultural contexts, to lead one not to fill but to respect it. It is not simply empty - it is filled with emptiness. In an account on the radio, a woman who serves as a chaplain for the U.S. National Park Service, described part of her job which is to deliver terrible news: someone’s family member has, for example, drowned or fallen to their death in the park; or to be present as people deal with terrible uncertainty: a family member has, perhaps, vanished while on a hike. She spoke movingly about how she had to learn to respond, in particular about blocking what might feel like the natural acknowledgement of their pain, acknowledgement that can collapse the interpersonal space. What she learned was that, for most of the people she encountered, entering too fully into the pain of bereavement can impinge on the space of bereftness, crowding out the sudden, horrible void. In the cultural context in which she works, acknowledgement of the pain of bereavement calls for presence at a distance, respecting the aura of emptiness, not attempting to fill it. Her presence, silent, not touching, keeps the grief from engulfing the world, even as it holds the world at a distance. Her experience is that after some time, the newly bereaved person will say something (that is, use language as communication) or reach out to be touched or held, allowing acknowledgement of the pain, beginning to give both the grief and the griever a place in the social world. Until such a sign, the role of the witness is to guard the perimeter of the space of bereavement: helping to ensure that the world will not rush in, nor will it be obliterated.


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__________________________________________________________________ 5. Interpersonal Space and the (in)Expressability of the Pain as Being Part of the Pain Our finding it difficult or impossible to successfully communicate pain verbally is often taken to support claims of the utter privacy of such emotions. Elaine Scarry e.g. writes about the inexpressibility of pain, and how this inexpressibility can trap the sufferer in an inaccessible space.5 When Wittgenstein denies the possibility of essentially incommunicable experience - of metaphysical privacy - , he can seem to be denying this phenomenon. Sue Campbell argues for another way to theoretically approach this matter - to account for our often not having words to name our feelings without characterizing them as metaphysically private.6 Even though feelings may well be difficult to communicate, their expressiveness does not hinge on their being nameable. She discusses the various resources we have - in stories, poems, music - for expressing what we cannot give a name to. In line with this Minae Inahara argues that pain may well be resistant to ready communication - one can, as Scarry describes, feel trapped and alone in one’s pain. But, she argues, this inability to describe is not just an inability to describe to others: in such cases, one is equally unable to describe the pain to oneself: one lacks the words. Inahara turns to Kristeva’s account of the semiotic realm (vs the symbolic realm of words) to suggest how, in particular through art, one can find ways of expressing one’s pain to oneself and to others, that do not require naming and categorizing it.7 We would argue that experiences of the tension between the obviously felt realness of pain and the simultaneous difficulty of articulating, explaining and communicating that pain, are what drive us towards the mistaken conclusion that pain, and other feelings and emotions, are metaphysically private. And further, we see the difficulties of communicating pain as pointing toward the need for a responsive other in order for us to be able to express and/or communicate pain and where the space between us is the site of meaning. Pain that cannot find expression in social space will be confused and incoherent even to the sufferer herself. The features provided by interpersonal space are what make for the ability or inability to express and communicate feelings such as pain. This does not merely add up to interpersonal space being a medium for communication. Rather, we would claim that the very (in)expressability is part of the pain itself - as a defining feature. So, if we focus on such feelings that may prove difficult to communicate, what can interpersonal space provide? First of all a responsive other, for whatever means by which one tries to communicate it - by analogy, by metaphor, in pictures, by setting it in a frame, a context, a tale, in which the pain may be diminished or enlarged. Interpersonal space’s ability to mediate varies, as communication rests on the availability of shared representations, stories, etc, that may serve the traversing and meaning-making of pain in interpersonal space. One may, of course, be in pain when one is alone, or may choose to block the expression of pain when one is with others. But the possibility and practice of expression - and its counterpart, acknowledgement - give shape even to pain that

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__________________________________________________________________ we suffer alone or in silence.8 Even the sort of isolation that Scarry writes about requires another - the isolation is an extreme inflection of interpersonal space: it is the fact that the other is there, uncomprehending, that frames the isolation. So too when we intentionally withhold an expression of pain, not wanting the other’s acknowledgement, for whatever reason, the withholding is something we actively do, and the space between us is shaped by it. 6. Conclusion Attending to the social space between pain and its acknowledgement can help us see how the meaning of pain, even the pain itself, inflects that space and is inflected by it. In particular, it can help wean us from the idea that there is such a thing as ‘the pain itself,’ uninflected, pre-social, in the body - or the mind - of the one in pain.

Notes 1

L Wittgenstein, Philosophical Investigations, trans. Anscombe, G.E.M., Blackwell Publishers, Oxford, 1967. 2 Cf. N Scheman, ‘Forms of Life: Mapping the Rough Ground,’ Cambridge Companion to Wittgenstein, Cambridge University Press, 1996. 3 Cf. H Kalman, ‘Njutning eller fejk – en filosofisk betraktelse,’ Fejkad Orgasm (Fake Orgasm), Ordfront förlag, Stockholm, 2008, p. 51 ff. 4 E Elmerstig, B Wijma & C Berterö, ‘Why do Young Women Continue to have Sexual Intercourse Despite Pain?’ Journal of Adolescent Health, Vol. 43, Issue 4, October 2008, pp. 357-363. 5 E Scarry, The Body in Pain: The Making and Unmaking of the World, Oxford University Press, Oxford, 1985. 6 S Campbell, Interpreting the Personal: Expression and the Formation of Feelings, Cornell University Press, Ithaca, 1997. 7 M Inahara, ‘The Voice of Pain: The Semiotic and Embodied Subjectivity,’ Gender, Body, and Health, Paper presented at the conference ‘Dimensions of Pain’, The Nordic Network, Helsinki, Finland, September 17-18, 2009. 8 Cf. N Scheman, ‘Forms of Life: Mapping the Rough Ground,’ Cambridge Companion to Wittgenstein, Cambridge University Press, 1996, p.399 ff.

Bibliography Campbell, S., Interpreting the Personal: Expression and the Formation of Feelings. Cornell University Press, Ithaca, 1997.


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__________________________________________________________________ Elmerstig, E., Wijma, B. & Berterö, C., ‘Why do Young Women Continue to have Sexual Intercourse Despite Pain?’ Journal of Adolescent Health. Vol. 43, Issue 4, October 2008, pp. 357-363. Inahara, M., ‘The Voice of Pain: The Semiotic and Embodied Subjectivity.’ Gender, Body, and Health. Paper presented at the conference ‘Dimensions of Pain’ arranged by The Nordic Network. Helsinki, Finland, September 17-18, 2009. (forthcoming in the edited volume Dimensions of Pain). Kalman, H., ‘Njutning eller fejk – en filosofisk betraktelse’ (‘Pleasure or Fake – A Philosophical Reflection’). Fejkad Orgasm (Fake Orgasm). Ordfront Förlag, Stockholm, 2008. Scheman, N., ‘Forms of Life: Mapping the Rough Ground.’ Cambridge Companion to Wittgenstein. Cambridge University Press, 1996. Scarry, E., The Body in Pain: The Making and Unmaking of the World. Oxford University Press, Oxford, 1985. Wittgenstein, L., Philosophical Investigations. trans. Anscombe, G.E.M., Blackwell Publishers, Oxford, 1967 [1953]. Hildur Kalman is an Associate Professor in Philosophy of Science, and works as Senior lecturer at the Department of Social Work and as coordinator of the Graduate School for Gender Studies at the Umeå Centre for Gender Studies at Umeå University, Sweden. Naomi Scheman is Professor of Philosophy and of Gender, Women's, & Sexuality Studies at the Philosophy Department, University of Minnesota, and Guest professor at the Umeå Centre for Gender Studies at Umeå University, Sweden.

The Audiences of Pain: The Indonesian Audiences’ Response to Human Rights Documentaries Kurniawan Saputro Abstract This article presents an examination of the Indonesian audiences’ reception of the depiction of pain in two human rights documentaries. The documentaries are: Operation Fine Girl (about rape used as war weapon in Sierra Leone) and Listen to Our Voice (presents testimonies of torture victims in Papua, Indonesia). I will argue in the article that in the process of reception, Indonesian audiences position themselves to forge an imagined commonality and difference between themselves and the victims, and, also, among themselves. The use of subjective perspective in showing the pain of Sierra Leonean rape victims was received almost viscerally by female audiences, in contrast with their detached comments to the formal-verbal testimonies of torture victims from Indonesia. Furthermore, the audiences forge solidarity with rape victims based on their gender, whereas with torture victims they build solidarity based on their citizenship. Drawing their knowledge from media, the audiences reproduced paternalistic relationship with inferior Papuans, whereas they pitied the Sierra Leonean women’s unfortunate lives as equal human for lack of knowledge of them. Knowledge of the victim’s life, then, shaped how the Indonesian audiences felt their sympathy toward the victims. Key Words: Audiences, human rights documentary, reception, sympathy, Papua, Sierra Leone. ***** 1. Pain in Human Rights Documentary Since the beginning of the twentieth century visual images, including moving pictures, have played an essential role in campaigns for human rights. One of the main forms of visual strategies used by human rights activists is documentary. A human rights documentary has several distinctive characteristics that distinguish it from other subgenres of political documentary. Of those characteristics, two are relevant to our discussion. First, the human rights subgenre of political documentary focuses, among others, on the depiction of bodily suffering of others.1 In addition to its function as evidence, the depiction of human bodily pain symbolically unifies otherwise different individuals, based on the premise that pain is universal.2 Second, human rights documentary often uses victims’ testimony as its core narrative.3 This study uses two human rights documentaries. One is Operation Fine Girl, or OFG, which is about rape used as war weapon in Sierra Leone. And two is Listen to Our Voice, or LtOV, which presents testimonies of torture victims in

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__________________________________________________________________ Papua, the eastern and less developed part of Indonesia. The documentaries were shown to 14 Indonesians, who were divided into group A and group B, and then discussed the documentaries with the researcher acting as moderator. 2. Pain and Solidarity Meg McLagan and Luc Boltanski claim that bodily suffering is essential to human rights rhetoric.4 McLagan argues that ‘individual bodily suffering is the indivisible unit of symbolic currency in human rights media.’5 The bodily suffering itself does not have to be represented visually, but can also be portrayed in a specific form of narrative, namely testimony. In fact, in both of the documentaries in this study the suffering was related verbally through testimonies, not visually. My analysis on the visual and verbal aspects of the documentaries shows that LtOV presents the suffering as an impersonal fact, whereas OFG presents it as a personal experience. Receiving the documentaries, group A’s initial reaction to LtOV was divided into ‘surprised’ (kaget, terkejut) and ‘unsurprised’ (tidak kaget, tidak terkejut). The Indonesian word kaget or terkejut is usually used to express a state of mind and, less likely, state of the body when a person learns of unexpected information, or experiences a sudden change of circumstance. In this context, the participants used the word kaget or tidak kaget to refer to their state of mind having, or not having, learned of new information about torture in Papua. They adopted the position offered by LtOV, namely to learn about suffering as an impersonal fact. The participants’ reservation note concerning the factuality of the case, also supports this conclusion. Differing from their responses to LtOV, some of the participants’ responses to OFG were anger and speechlessness. Their bodily gestures showed that they did not only learn new facts, but also ‘experienced’ the suffering. There is no equivalent word in Indonesian to express the bodily response to an unexpected change of events. Sometimes Indonesians borrow the English word to express their reaction, namely shocked. The quality lies not in a person’s knowledge of the new information, but in how she experiences it. Therefore, whether a person has or does not have knowledge about the fact is irrelevant here. Although a few of the participants in both groups had known about the incidents from news media, popular feature films, and the internet about rape in war, they were still shocked. The display of pain in human rights documentary is essential, but it is not an end in itself. Based on the premise that ‘pain is universal,’ the display of pain is intended to ‘create solidarity out of difference.’6 The solidarity is achieved through the construction of a discursive space where similar identities can be manifested. But, the similar identities can only be understood if they are simultaneously defined against what is not included, or against what differs from them. This is what Jukka Törrönen calls the spatial aspect of subject position.7 The documentaries construct subject positions for the audiences by categorizing reality into ‘us’ and ‘them.’

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__________________________________________________________________ Table 1. The images of ‘us’ and ‘them’ in the documentaries. Us

Them

LtOV

Civilians, citizens, Indonesians (not Military and police forces, Papuans), human rights defender state, human rights abuser

OFG

Female, civilians

rape

victims/survivors, Male, rapist, rebel soldiers

My analysis of LtOV shows that the space of us, what our value is as a society, is defined against what is not. The space of us is the space of the civilians whose human rights have been abused by the state. All of the survivors were characterized by their identity as Indonesians, citizens, who have the rights to be protected, not to be tortured, by the state. They are not, in any way, represented as Papuan; they are Indonesians in Papua. In OFG the survivors are clearly shown as female civilians who were raped by male rebel soldiers. In the words of one participant, But the similar condition can be found in every part of Indonesia. Not only in Papua. I mean, the despotism seems to be universal for military personnel. I don’t know if it’s because of their lack of education so that they can only use … [violence]. This participant surveyed the whole country of Indonesia in her mind and concluded that the incident can be found not only in Papua, but in every part of country as well. In so doing, she drew the line that delineated us, civilians, from them, the military. The spatial aspect of subject position lays the basis for attaching values that separate civilians from the military. The participants considered military personnel to be more prone to frustration, to the use of inhuman and violent techniques, to obeying the hierarchical chain of commands, and not well educated. With regard to torture, the military personnel’s actions were seen as a question of organizational misconduct. It is in the nature of military and police force to use violence in their operation. However, it has to be justified and carefully monitored. In the participant’s opinion, due to their lack of education and high levels of stress, individual soldier might have conducted maltreatment. Nonetheless, the root of the problem was still attributed to the organization. Differing from the perpetrators in LtOV, the perpetrators of rape in OFG were in the militia. Although they were equipped with military weapons, uniforms, and conducted military operations, they were not recruited by the legal government. Therefore, they did not have the exclusive right to exert force in their duty. Violence is not the nature of their job. The root of their violence, then, must be attributed not to their organization, but to their motives. Despite their same status as

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__________________________________________________________________ civilians, the participants drew the boundary between themselves and the rebel soldier based on their internal tendency to commit crimes, susceptibility to the machination of the elites, and their irrational and animalistic instincts. This supports the argument that the value of us is defined against what is not us, namely the rebel’s characteristics. 3. Sympathy How do the audiences develop the feeling toward the suffering distant others? Drawing from Adam Smith’s work The Theory of Moral Sentiment, Boltanski argues that the distance between the spectator and the suffering other can be linked by deliberately imagine the feeling of the suffering others, who is otherwise unconnected to us.8 The state of ‘feeling’ the other’s suffering is called sympathy. Nevertheless, sympathy is not born of a magic capacity with which we can feel what the other feels. It is an act of imagination to ‘represent to himself the sentiments and sensations of the sufferer.’9 It is clear that the definition still maintain the distinction between us the seer and them the sufferer. In fact, there has to be a distance, a difference, between the audiences and the sufferers. However, the difference only lays the foundation for the audiences’ response. Because the suffering others are strangers to the audiences and live in a distant place, the audiences need to generalize their feeling. And in order to generalize, ‘[It] becomes eloquent, recognizing and discovering itself as emotion and feeling.’10 This ‘emotion and feeling’ is what I call sympathy here. The term sympathy was expressed fairly often by participants. In the focus groups discussion setting, two categorizations can be identified. The first pair of categories is the category of ‘us’ and ‘them’ that is constructed by the documentary’s narrative. The second pair of categories is the category of ‘us’ and ‘them’ that is brought about by the group’s dynamics. The ‘us’ in the first category is further divided into another ‘us’ and ‘them.’ James T. Siegel sees that the other of the Indonesian identity has been seen as intolerable and in need of taught to be a real Indonesian.11 Along this line of argument, Dave McRae also argues that the separatists in Indonesia are seen as ‘less developed,’ ‘inferior,’ and needing ‘guidance.’12 And Peter King sees, too, that Indonesians in Papua regard the native Papuans as backwards and as aliens.13 These existing discourses in Indonesian academic work, media, and daily life conversations provide resources from which the audiences draw to express how they receive the survivors in LtOV. Although nowhere in the video are the survivors pictured as Papuans, but as Indonesians who live Papua, the audiences draw the difference between themselves and the Papuans based on their previous knowledge of Papuans. They are the same as Indonesians, but at the same time different. In the categories constructed by LtOV, the ‘us’ is Indonesian. But in order to feel sympathy towards them, in order to overcome the distance, and in order to generalize their feelings towards all the actual and potential survivors, the

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__________________________________________________________________ audiences adopted further categorizations. Accordingly, the new pair of categories is ‘us’ the ‘modern’ Indonesians, as opposed to ‘them,’ the ‘backward’ Indonesians. Or, in McRae’s analysis, the ‘genuine’ and the ‘inferior’ Indonesians. By adopting the categories, the audiences created a space to imagine and express their feelings toward Papuans, the other of themselves. Table 2. The images of ‘us’ and ‘them’ in the discussion.

Social motives Social relationships Social institutions

Us - Modern/ genuine Indonesian

Them - Backward/ inferior Indonesian

autonomic suspicious/cautious rule-regulated

dependent trusting, innocent somewhat arbitrary

It is useful to employ the three dimensions of the categories as postulated by Törrönen, namely social motives, relationships, and institutions, to further analyze how sympathy was developed by the audiences.14 The participants differentiate themselves, and thus ascribing values to their identity, from the Papuans who are dependent on the superiors, trusting toward strangers, and less regulated. The participants thought that Papuans cannot control themselves, let alone develop and educate themselves. They need a central effort from the national government to intervene in their development. They are uneducated and, therefore, easily believe in strangers as well. Their tribalism greatly hampers the enforcement of law. Therefore, for example, it made sense to one participant to argue that the incidents were local/tribal in nature and could not be generalized to the other tribes. The same argument about Papuan’s tribalism was even stretched further to make a case about their inability to educate themselves. And the other participants agreed on this point. With regard to LtOV’s claim that torture was wide-spread, the participant refuted the claim and argued that this torture must be local in nature. This argument was not based on competing evidence, but on a general assumption of the structure of Papuan society. That is, the localized and isolated nature of the society makes every incident independent of other incidents. Again, although nowhere in the documentaries are the survivors pictured as primitive, the participants readily supplied their own imagination of them as such. In the participants’ imagination, many of Papuans were still using natural resources just to survive, depending on their stone-age technology, dressing naturally, and were subjected to the will of a promiscuous leader. Therefore, when one participant pitied the Papuans for the torture and for being a Papuan, it was not a senseless statement. Nor was the juxtaposition incidental. On the contrary, it was essential. To empathize with the Papuans, for whatever reasons, it is essential for the Indonesians to invoke their existing discourse about Papuans. The dominant

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__________________________________________________________________ discourse of Papuan constructs them as the underdeveloped and, thus, the ideal object of pity. The distance between us and them is essential for the capacity of sympathy. The capacity to impart sympathy will be hampered if us cannot recognize our difference from them. One participant who had a similar experience, being arbitrarily searched and mistreated by the military in Aceh, accepted the incidents as ‘unsurprising’ because they were like his experience. He drew parallels between his circumstance and the Papuan’s. Both of them were mistreated, both of them still had ‘primitive’ sections of society, and they demanded independence to get the central government’s attention. It was not that he did not have the capacity for empathy, he claimed, but it was hard. In short, the distance was too close. How do the Indonesian audiences sympathize with survivors of OFG? It is true that the male participants did not feel the same pain, and in so doing failed to adopt the category of ‘us,’ for the female-rape-survivor. But, their failure to feel the same pain did not mean that they could not impart their sympathy. Quite the contrary, they were perfectly able to sympathize with the survivors. Since sympathy does not require similarity of experience, the male participants can fully imagine the survivor’s suffering. The male participants’ categories largely converged with the female participants’ categories. The male participants’ constructed simple categories of the fortunate and the unfortunate, the principal element of pity. On the other hand, the female participants did not articulate ‘backwardness’ and the ‘pitifulness’ as they did with the Papuans. In other words, they disarticulated, or decoupled, the two discourses when they imagined the Sierra Leonean women. What causes the decoupling is open to discussion. But in my opinion the answer is to do with the availability of the discourse of Sierra Leonean, be it because of their lack of knowledge of them or of simple inattention to the issue. 4. Conclusion I argue in this chapter that pain, an essential element of human rights documentary, plays an important role in the forging of audiences’ affinity with the survivors. However, the reception of pain is not a natural and spontaneous process. The Indonesian audiences used discursive resources, such as elements of narrative and mass media’s discourse, to build commonalities that lay foundations for their ability to ‘feel for’ the survivors. The audiences forge solidarity with rape victims based on their gender, whereas with torture victims they build solidarity based on their citizenship. With regard to sympathy, as a general feeling for the distant others, the audiences draw further the line that distinguishes them from the survivors. Drawing their knowledge from media, the audiences reproduced paternalistic relationship with inferior Papuans, whereas they pitied the Sierra Leonean women’s unfortunate lives as equal human for lack of knowledge of them.

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__________________________________________________________________ Knowledge of the victim’s life, then, shaped how the Indonesian audiences felt their sympathy toward the victims.

Notes 1

M McLagan, ‘Principles, Publicity, and Politics: Notes on Human Rights Media,’ American Anthropologist, Vol. 105, 2003, pp. 605-612. 2 ibid., p. 608. 3 ibid., p. 606-608. M McLagan, ‘Introduction: Making Human Rights Claim Public,’ American Anthropologist, Vol. 108, 2006, p. 191. 4 ibid., p. 607. L Boltanski, Distant Suffering: Morality, Media and Politics, Cambridge University Press, Cambridge, 1999, pp. 3-17. 5 McLagan, p. 607. 6 ibid. 7 J Törrönen, ‘The Concept of Subject Position in Empirical Social Research,’ Journal for the Theory of Social Behaviour, Vol. 31, 2001, pp. 313-329. 8 Boltanski, p. 38. 9 ibid. 10 Boltanski, p. 6. 11 J Siegel, ‘Early Thoughts on the Violence of May 13 and 14, 1998, in Jakarta,’ Indonesia, Vol. 66, 1998, pp. 75-108. 12 D McRae, ‘A Discourse on Separatists,’ Indonesia, Vol 74, 2002, pp. 37-58. 13 P King, ‘Morning Star Rising? Indonesia Raya and the New Papuan Nationalism,’ Indonesia, Vol. 73, 2002, pp. 89-127. 14 Törrönen, pp. 320-321.

Bibliography Boltanski, L., Distant Suffering: Morality, Media and Politics. Cambridge University Press, Cambridge, 1999. King, P., ‘Morning Star Rising? Indonesia Raya and the New Papuan Nationalism.’ Indonesia. Vol. 73, 2002, pp. 89-127. McLagan, M., ‘Principles, Publicity, and Politics: Notes on Human Rights Media.’ American Anthropologist. Vol. 105, 2003, pp. 605-612. _______

, ‘Introduction: Making Human Rights Anthropologist. Vol. 108, 2006, pp. 191-195.

Claim

Public.’

American

McRae, D., ‘A Discourse on Separatists.’ Indonesia. Vol. 74, 2002, pp. 37-58.

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__________________________________________________________________ Siegel, J., ‘Early Thoughts on the Violence of May 13 and 14, 1998, in Jakarta.’ Indonesia. Vol. 66, 1998, pp. 75-108. Törrönen, J., ‘The Concept of Subject Position in Empirical Social Research.’ Journal for the Theory of Social Behaviour. Vol. 31, 2001, pp. 313-329. Kurniawan Saputro is a lecturer of department of photography, Indonesia Institute of the Arts at Yogyakarta, Indonesia. His interests range from visual media, activism, to media literacy.

Communication with Emotions: Use of Emotional Intelligence as Pain Relief Yavuz Tuna Abstract Emotional intelligence is the capacity for recognizing our own feelings for motivating ourselves and for managing emotions effectively in ourselves and others. Emotional intelligence is related to four clusters that are self-awareness (the ability to read one’s emotions and recognize their impact), self-management (involves controlling one’s emotions and impulses and adapting to changing circumstances), social awareness (the ability to sense, understand and react to others’ emotions) and relationship management (the ability to inspire, influence, and develop others while managing others). The emotional competencies are not genetic and they can be developed. Emotional intelligence consists of specific skills behaviours and attitudes that can be learned, applied and modelled by patients to improve personal satisfaction and effectiveness. Emotional intelligence is also very important ability to exercise healthy self-control and self management. As a fact that pain is a source of intensive emotions and every patient handle the situation concerning the pain in different way. Patients have different feelings concerning the same type of pain based on their experiences or their psychological condition. Some patients can perceive their emotions and manage them easily. Some of the patients as a result of the intensive emotions can be very aggressive in their relationships. In other words this study will reflect the pain-patient communication from the perspective of emotional intelligence competencies. Consequently the purpose of the study is to establish a pain relief method based on the interviews of cancer patients. Therefore, this study will be conducted with the participation of cancer patients so as to determine the effects of the emotional intelligence competencies on quality of communication with self and others as a method of pain management. Key Words: Emotional intelligence, cancer, emotions, emotional awareness, emotional management, relationship management ***** 1. Introduction In recent years patterns of illness have been changed and biological, psychological, and social factors have become complex outcome of illness with the role of emotions in these processes.1 Accordingly, within this framework, the key areas of interest concern the direct physiological links between emotions, stress, and disease and the moderating role of individual differences in the way people perceive, experience, and cope with distressing experiences.2

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__________________________________________________________________ The style of coping with illness and invasive medical procedures constitutes another special case where emotional intelligence may have an additional bearing on the health-related quality of life. It has been proposed that suppressed negative emotional states can intensify pain and slow down the process of healing and recovery.3 Some medical evidence shows that emotional intelligence moderates the impact of traumatic diagnoses and treatments on the degree of pain and emotional distress experienced by patients. Emotional intelligence concerns facilitation of cognitive activities. Emotions are complex organizations of the various psychological subsystems-physiological, experiential, cognitive and motivational. For that reason they have impact on how the person feels the intensity of the pain. According to researches individuals high capacity in emotional intelligence are capable of withstanding pressure and regulating stress generated by pain.4 Several studies have found that emotional intelligence can have a significant impact on various elements of everyday living. Conceptually, emotional intelligence is defined as a set of abilities and competencies essential for adaptive stress management and successful coping with life demands.5 Positive emotions help sustain an individual’s attempts to cope with a stressful situation.6 Empirically, multiple studies have founded reliable moderate correlations between higher emotional intelligence, lower emotional distress, and better somatic health. EI was a positive predictor of happiness.7 The higher levels of emotional intelligence are associated with an increased likelihood of attending to health and appearance, positive interactions with friends and family.8 The researchers found that high scores in emotional intelligence are correlated to increased positive interpersonal relationships among children, adolescents, and adults.9 2. The Competencies of Emotional Intelligence With the idea of emotional intelligence, Goleman's model outlines four 18 main emotional intelligence constructs. The first, self-awareness, is the ability to read one's emotions and recognize their impact while using gut feelings to guide decisions. The second construct, self-management involves controlling one's emotions and impulses and adapting to changing circumstances. The third one, social awareness includes the ability to sense, understand, and react to other's emotions while comprehending social networks. Finally, relationship management, entails the ability to inspire, influence, and develop others while managing conflict.10 A set of emotional competencies within each construct of emotional intelligence are learned capabilities that must be worked on and developed to achieve outstanding performance.11 The competencies fall under one of four categories: the awareness of emotions in oneself or others and the management of emotion in oneself or others that are listed and defined as below:12

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__________________________________________________________________ Self-Awareness concerns knowing one's internal states, preferences, resources, and intuitions. The Self-Awareness cluster contains three competencies: Emotional Awareness: Recognizing one's emotions and their effects Accurate Self-Assessment: Knowing one's strengths and limits Self-Confidence: A strong sense of one's self-worth and capabilities Self-Management refers to managing ones' internal states, impulses, and resources. The Self-Management cluster contains six competencies: Emotional Self-Control: Keeping disruptive emotions and impulses in check Transparency: Maintaining integrity, acting congruently with one’s values Adaptability: Flexibility in handling change Achievement: Striving to improve or meeting a standard of excellence Initiative: Readiness to act on opportunities Optimism: Persistence in pursuing goals despite obstacles and setbacks Social Awareness refers to how people handle relationships and awareness of others’ feelings, needs, and concerns. The Social Awareness cluster contains three competencies: Empathy: Sensing others' feelings and perspectives, and taking an active interest in their concerns Organizational Awareness: Reading a group's emotional currents and power relationships Service Orientation: Anticipating, recognizing, and meeting customers' needs Relationship Management concerns the skill or adeptness at inducing desirable responses in others. The Relationship Management cluster contains six competencies: Developing Others: Sensing others' development needs and bolstering their abilities Inspirational Leadership: Inspiring and guiding individuals and groups

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__________________________________________________________________ Change Catalyst: Initiating or managing change Influence: Wielding effective tactics for persuasion Conflict Management: Negotiating and resolving disagreements Teamwork & Collaboration: Working with others toward shared goals. The physical pain brings with intensive emotions can be transformed into uncontrollable situations for the people. The experienced pain can lead to negative emotions and as vicious circle the negative emotions can increase the intensity of the pain perceived. Accordingly, awareness concerning the emotions and the affective management of them are very significant for people to overcome the hazardous effects of negative emotions. The people have opportunity to recognizing their emotions and their effects, to managing their internal states, impulses, and resources can handle relationships and awareness of others’ feelings, needs, and concerns successfully. The focus of the study is the people have experienced physically and psychologically pain in the process of cancer treatment. In the framework of the study, the divergent types of pain, destructive emotions followed by the pain, overcoming the difficulties caused by emotions and the effects of the devastating emotions affecting relationships will be discussed. In generally, the aim of the study is personally and socially to put forward the effects of the emotional intelligence competencies on awareness and management of destructive emotions originated by pain. In the preparation of the interview outline, the researcher used the basic emotional intelligence competencies and related research literatures to construct a semi model interview. During the formal interview process, High definition camera was used to collect the raw data. All details and the reflections of the emotions on body and face were recorded by the camera. Before the interview, the researcher after getting permission from the management of Ege University Faculty of Medicine contacted the participants by personally and telling them about the objectives of the interview, as well as the probable direction and contents of the interview questions. After asking for their volunteer participation in the research and respecting the participants by assuring them that they could stop or leave the interview at anytime and by giving them the authority to correct or delete the interview content after the interview process. 3. Analysis of Interview Data Coding In view of qualitative research, reliability relates to replication, stability, and consistency. Validity relates to dependability, predictability, and accuracy. In order to increase the reliability and validity of this research, the recorded interview data were arranged and the information was generalized based on topic analysis. After

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__________________________________________________________________ continuous comparison and interpretation, triangulation was used to explain the meaning of the data. After two experts discussed and corrected the encoding work, and then the researcher make efforts to classification with them. Next step involved establishing the validity of data coding. In order to be able to handle the interview data impersonally and precisely, two encoders were invited to assist with impersonal data analysis of the interview context. They assisted in establishing a framework for a written script, and in interpreting the analysis of the script. During the coding process, the researcher and the two encoders discussed first the determination of the sentences, coding and differentiation concepts, and after solving differences between the concepts, a common consensus was achieved. Finally, coding of the script data of every individual interview was carried out to increase the validity of the coding of the script. In this study interviews were conducted with the cancer patients in the Oncology Department of Ege University Medical Faculty located in Izmir. In the content of the research 10 people have experienced throat, lung, breast cancer successfully were participated to interviews. The profiles of the participants are listed below with the codes: P1= Participant 1 (male, age 64, throat cancer) P2= Participant 1 (male, age 52, throat cancer) P3= Participant 1 (male, age 59, colon cancer) P4= Participant 1 (male, age 63, lung cancer) P5= Participant 1 (male, age 29, throat cancer) P6= Participant 1 (male, age 85, prostate cancer) P7= Participant 1 (male, age 63, throat cancer) P8= Participant 1 (female, age 68, breast cancer) P9= Participant 1 (female, age 46, breast cancer) P10= Participant 1 (male, age 56, lung cancer) Cancer could be conceived of as a terrifying and terminal tragedy both in the past and the present. The standpoints on cancer and the experiences during this process of the cancer patients may range to a great extent. Some patients successfully overcome this process, and manage well the pain and the accompanying feelings during this process. The semi-structured interviews with the participants, whose profiles are presented above, were designed as to realize, share and to cope with the feelings, to reveal information about the painful process experienced and relationships with other people during this process. The following questions were posed to the participants during the interviews: 1.

What feelings did you have when you first learnt that you were a cancer patient?

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__________________________________________________________________ 2. 3. 4.

5.

6.

7.

8.

With whom and how did you share these feelings? What did you do in order to cope with these feelings? What ways did you undertake? What processes were painful during this process? In what ways was this experienced pain reflected to your feelings? (In case chemotherapy or similar treatments are accentuated as painful experiences, which other feelings did this pain cause?) What did you do in order to cope with and manage the feelings that arouse during chemotherapy or painful processes? Were there any methods of managing that you developed? Were there any changes or differences in your relationships with the outer world and your environment and in your communication with other people after you were diagnosed with cancer? How? (e.g. What differences did other people recognize in you?) Do you think that you can manage well your feelings and therefore your communication with the environment by realizing the feelings related to what you experienced and your pain (if exists) during this process? Do you have any methods (or suggestions) that you can advise to other people diagnosed with cancer on coping with the painful process and the feelings that this process imposed on you?

Descriptive analysis was used in order to analyse the responses to the interview questions. The responses of the participants were recorded, and the interview texts were investigated under specific themes in line with the aims of the project and the conceptual framework. The codes that support these themes were developed, and the data belonging to these codes were examined by an expert to control the reliability of the coding. Moreover, the excerpts from the responses of the participants were included in order to render the researchers’ interpretations more comprehensive and clearer. The researchers state the importance of including excerpts from the participants’ responses and explaining the results utilizing these excerpts in the studies that employ a descriptive analysis method in terms of validity13. Therefore, the excerpts from the responses of the participants are quoted in order to support the research findings. At this point; The findings from qualitative studies have quality of ‘undeniability’. Words especially organized into incidents or stories, have a concrete, vivid, meaningful, flavour that often proves for more convincing to a reader – another researcher, a policy maker, a practitioner than pages of summarized numbers14.

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__________________________________________________________________ According to findings, the distribution of the participants in terms of gender and education level was listed in the table 1. Table 1. The distribution of the participants in terms of demographic characteristics n= GENDER Male

8

Female

2

EDUCATION LEVEL Compulsory education

2

High school

3

University

4

According to findings are presented in Table 1., 8 people of the total respondents are male. According to Education levels of the participants, 2 of them graduated from compulsory level (the first 8 year in school, elementary and middle school) of education, 3 of them graduated from high school and 4 of them graduated from university. The evaluations of the participants about the painful period they experienced include psychological and physiological pain. In order to reflect the level of the pain they experienced, the participants used the following expressions. ‘I stayed in the hospital for two months, it was as if my stomach was drilled, I couldn’t eat. But I believed that one day I’d eat’ (P4) ‘The four-year treatment and the pain took away 70% of my life’ - (P10) ‘Chemotherapy was so painful. Not being able to eat, nausea, weeping, cries’ - (P9) ‘After chemotherapy it’s continuous pain and vomiting. That is the most difficult. You’re trembling all over. Your feet hurt. As if they’re nailing you. My mother used to massage my knees until the morning. You can’t eat because of pain’ - (P5) ‘You can’t eat. You can’t even swallow water. You spit the water’ - (P3)


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__________________________________________________________________ ‘It’s as if being in the middle of the sea and a huge wave is approaching you. It throws you upwards in the middle of the sea, you can’t break loose’ -(P6) ‘In the end it’s poison what they give to you. They go into your lungs during the treatment; as if you die’ - (P9) ‘Rather than physical pain, the only painful part for me was my daughter’s future, to make her stand on her feet. I’m here as I didn’t lose this energy. I’m here even though my other friends died’ - (P2) ‘During the operation I felt pain, emotional breakdown, I felt myself as half a person. But I wasn’t afraid of dying’ - (P4) Researcher and other two coders have compromised on some emotional competencies of participants observed in the interviews listed below in the Table 2. Table 2. The Distribution of the Codes in terms of Emotional Competencies EMOTIONAL COMPETENCIES

P1

P2

P3

Emotional Awareness Accurate Self-Assessment Self-Confidence Emotional Self-Control Transparency Adaptability Achievement Initiative Optimism Empathy Organizational Awareness Service Orientation Developing Others Inspirational Leadership Change Catalyst Influence Conflict Management Teamwork & Collaboration

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

P4

X

P5

P6

P7

P8

P9

P10

TOTAL

X

X

X

X

X

X

X

X

X

10 8 10 9 8 7 5 5 10 1 1

X

X

X X X

X

X X X

X X

X

X

X

X

X

X X X

X

X

X X

X

X X X

X

X

X

X X X

6

X X X

6 4 2

According to coders represented in Table 2, emotional competencies related to emotional awareness, self confidence, optimism have been observed in all participants’ interviews. Additionally, accurate self assessments, emotional self control, transparency, adaptability competencies have been seen in most of the

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__________________________________________________________________ participant’s statements. The emotional competencies concerning the service orientation, teamwork and collaboration haven’t been found in the expressions of the participants. The participants express different standpoints on what they felt when they were diagnosed with cancer. The four participants out of ten have responded to the question ‘What feelings did you have when you first learnt that you were a cancer patient?’ with ‘surprise’ and they furthered that they did not know what to do under those conditions. As the participants pointed out, after first impression they assumed to control related to feelings that they are a cancer patient. The other patients have described their feelings as ‘coolness’ when they first learnt that they were a cancer patient and they expressed their feelings concerning the question as follows. ‘I didn’t think I’d die, I’m at peace with myself. I know what this disease is. I’ll get rid of it, eradicate it. I told myself the whole thing was that easy’ (P2) and ‘I thought about my 3-year-old daughter. I motivated myself thinking that I needed to live and fight regardless of everything and I trusted in the doctors’ (P4). ‘After getting bad news, I didn’t see this disease as a problem. I clung to life’ (P3). The statements reflected by the participants in order to respond to that question consist of the cues related to emotional awareness and accurate self assessment competencies. All participants have pointed out the significance of the ‘self confidence’ and one of the participants have explained the importance of the self confidence as follows ‘There are those shepherd dogs, big, full of self-esteem; they keep their tails upright. Nothing would happen if you keep the tail upright. If you keep the tail between your legs and run, you can’t win’ (P2). The other participant has added ‘I never lost my hope. We know that everyone will die one day. It’s better to live our life as much as we can’ (P5). The researcher have asked each of the participants if they had further comments about that they can manage well their feelings and therefore their communication with the environment by realizing the feelings related to what they experienced and their pain (if exists) during cancer treatment process, all the participants believe that they managed their emotions well. They also believe that they handled massive change in their lives and relationships successfully in that process. In the process of cancer treatment, the participants interviewed offered also similar in their responses concerning the emotional self-control. These are ‘I’ve got strict feelings, no panic, it’s necessary to be coldblooded; you need to view it from a different standpoint. This situation resolves in mind, the brain and the heart should become one’ (P10). ‘There was not much of a change. I did control everything. Others say that I’m a carefree and cheerful person after cancer. I cheered up my friends with cancer. We have to struggle’ (P6). Their statements also have elements about the ‘adaptability’ competency means flexibility in handling change. ‘I didn’t worry; I accepted everything to the most possible extent. I didn’t bother myself for what is broken, collapsed. Honestly if my house is on fire, I’ll just watch it from a

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__________________________________________________________________ distance. I always react positively. I became carefree. I’m happy to be like this’ (P9). If people fell that they have the power to control even to a minimum extent against any situation that might arise, they are better off compared to those who feel desperate. What makes a situation insuperable in personal terms is the element of desperation’(Goleman, 1995). Participants have indicated optimistic feelings about their cancer and future. They believe that these kinds of feelings have advantage to struggle with the hazardous effects of the cancer. They expressed their optimistic feelings with sense of humour by the statements like that ‘I don’t have my right lung, the heart slid downwards; the intern couldn’t find my heart’ (P1). ‘A friend of mine was diagnosed with colon cancer, he was operated one day before mine, and we buried him one month ago. We used to have another friend, we buried him too (laughing)’ (P4). ‘There is no such thing as all cancer patients would die’ (P7). The responses of the participants to question ‘Do you have any methods (or suggestions) that you can advice to other people diagnosed with cancer on coping with the painful process and the feelings that this process imposed on you?’ had different characteristics. They have emphasized the importance of the positive people, self therapy, inventing reasons to live, living today colorfully, travelling, fighting mentally and thinking egocentrically so as to win a war with cancer and they explained their feelings as follows. ‘I gave up meeting with negative people – I told I don’t receive positive energy from you, we suspend our friendship now. They considered it normal’-(P10). ‘I did self-counseling as if there was someone in front of me’(P9). ‘I didn’t give up on life. I put it as an aim to work. Not everything depends on medicine and treatment; if they are combined with high spirits some medication would be more effective’- (P7). ‘Everything depends on them. The distress is yours; you should accordingly struggle against it mentally and at heart’- (P3). ‘Let bygones be bygones. It’s necessary to look forward to tomorrow’- (P8). ‘I invented reasons to live. The pictures of my grandsons and hugging them keep me clinging to life’- (P6).

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__________________________________________________________________ ‘I traveled; I went to cheerful places, not to sad places. I went around places with fresh air’- (P9). ‘You should forget, think about only yourself and you’ll succeed. You shouldn’t worry about anything. Not even about the family; it’s you first. If you start worrying about your family, you lose. First you, then the family. Because if you lose there won’t be such thing as family. Me first....’- (P5). ‘I don’t worry; I accept everything to the most possible extent. I don’t bother myself for what is broken, collapsed. Honestly if my house is on fire, I’ll just watch it from a distance. I always react positively. I became carefree. I’m happy to be like this’- (P2) ‘Don’t get demoralized, you should renew yourselves constantly in order to fight against the feelings that cause pain. You should think about the things that cling you to life. You cling to life as if every day is a new day’- (P8) Participants have exhibited feelings in their statements under the cluster of Relationship Management related to sensing others' development needs and bolstering their abilities correspond to ‘developing others’ competency. They have appeared to see themselves as supporter of the other cancer patients. They have presented their feelings about that situation like that: ‘I told him ‘you are a warrior, I won this war before, don’t let yourself go, it used to get so horrible after the chemotherapy, you’re a warrior… didn’t let it go and now he’s as large as life’- (P5). ‘People become more sensitive, they get sad. They call me to cheer up the other patients. They should overcome and trust in themselves’- (P10). In addition to these statements represented above in terms of the response to question ‘Were there any changes or differences in your relationships with the outer world and your environment and in your communication with other people after you were diagnosed with cancer? How? (e.g. What differences did other people recognize in you?)’, the six participants think that the after diagnosing cancer, there were not any differences in their relationships with the outer world and with other people. They have exhibited their feelings under the cluster of ‘relationship

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__________________________________________________________________ management’ as it follows ‘If you feel bad about it, the others will do the same. Anxiety could cause an adverse reaction. You need to be relaxed otherwise the ones around you wouldn’t be relaxed either’- (P7). The other participant has represented to emotions in his relationship as it follows. ‘There was no difference in the relationships and in the attitude to life, I am always optimistic’(P8). 4. Conclusion Cancer and the treatment process are the source of physically and psychologically pain. The intensity of the pain in that process leads to negative emotions sometimes that cannot be controlled by the patients. In the process of interviews, it is possible to see the impressions on the faces of the patients related to pain originated by cancer. Participants sometimes cried and exhibited nonverbal cues when they remembered the pain related memories. This data represents the intensity of the emotions generated by pain. Several studies show that that emotional intelligence can have a significant impact on various elements of everyday living. In order to control pain properly in patients with cancer, perception, assessment, recognition and management of emotions is very important for being alive. In this study participants appeared to use emotional competencies related to emotional awareness, self confidence, optimism, accurate self assessments, emotional self control, transparency, adaptability to eliminate negative effects of the cancer based pain. These emotional intelligence competencies are naturally found in the participants. All participants believe that they perceived and managed their emotions well. They also believe that they handled massive change in their lives and relationships successfully in that process. Another reality should be taken into consideration is that emotional competencies are not genetic or inborn characteristics. Accordingly, they are learned capabilities that must be worked on and developed to achieve outstanding performance. For that purpose in the process of cancer treatment and coping with the hazardous effect of cancer related pain, the programs based on emotional intelligence competencies can be developed.

Notes 1

T Mayne, ‘Emotions and Health,’ Emotions: Current Issues and Future Directions, Guilford Press, New York, 2001, pp. 361–397.

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__________________________________________________________________ 2

A Baum, & D Posluszny, ‘Health Psychology: Mapping Biobehavioral Contributions to Health and Illness,’ Annual Review of Psychology, 50, 1999, APP. 137–163. 3 SJ Lepore & JM Smyth, Writing Cure: How Expressive Writing Promotes Health and Emotional Well-Being, American Psychological Association, Washington, DC, 2002; JW Pennebaker & CK Chung, ‘Expressive Writing, Emotional Upheavals, and Health,’ Handbook of Health Psychology, Oxford University Press, New York, 2007, pp. 263–284. 4 A Furnham & KV Petrides, ‘Trait Emotional Intelligence and Happiness,’ Social Behaviour and Personality, Vol. 31, 2003, pp. 815-824. 5 R Bar-On, The Emotional Quotient Inventory (EQ-i): Technical Manual, MultiHealth Systems, Inc., Toronto, 1997; D Goleman, Emotional intelligence, Bloomsbury, London, 1995. 6 CA Smith, ‘The Self, Appraisal, and Coping,’ Handbook of Social and Clinical Psychology: The Health Perspective, Pergamon, New York, 1991, pp. 116–137. 7 A Furnham, & KV Petrides, ‘Trait Emotional Intelligence and Happiness,’ Social Behaviour and Personality, 2003, pp. 815-824. 8 MA Brackett & JD Mayer, ‘Convergent, Discriminant, and Incremental Validity of Competing Measures of Emotional Intelligence,’ Personality and Social Psychology Bulletin, 2003, pp. 1147-1158. 9 CLRice, A Quantitative Study of Emotional Intelligence and Its Impact on Team Performance, Unpublished master's thesis, Pepperdine University,1999; MM Rubin, Emotional Intelligence and Its Role in Mitigating Aggression: A Correlational Study of the Relationship between Emotional Intelligence and Aggression in Urban Adolescents, Unpublished dissertation, Immaculata College, Pennsylvania, 1999. 10 D Goleman, Working with Emotional Intelligence, Bantam Books, New York, 1998. 11 D Goleman, Emotional Intelligence, Bloomsbury, London, 1995. 12 RE Boyatzis, D Goleman & K Rhee, ‘Clustering Competence in Emotional Intelligence: Insights from the Emotional Competence Inventory (ECI),’ Handbook of Emotional Intelligence, Jossey-Bass, San Francisco, 1999. 13 A Yıldırım & H Şimşek, Sosyal Bilimlerde Araştıma Yöntemleri Seçkin Yayınları, Ankara, 2006. 14 MB Miles & AM Huberman, Qualitative Data Analysis: An Expanded Sourcebook, 2nd ed. Sage, Thousand Oaks, CA, 1994.

Bibliography Bar-On, R., The Emotional Quotient Inventory (EQ-i): Technical Manual. MultiHealth Systems, Inc., Toronto, 1997.

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__________________________________________________________________ Baum, A. & Posluszny, D., ‘Health Psychology: Mapping Biobehavioral Contributions to Health and Illness.’ Annual Review of Psychology. Vol.50, 1999, pp. 137–163. Brackett, M.A. & Mayer, J.D., ‘Convergent, Discriminant, and Incremental Validity of Competing Measures of Emotional Intelligence.’ Personality and Social Psychology Bulletin. Vol. 29 (9), 2003, pp. 1147-1158. Boyatzis, R.E., Goleman, D. & Rhee, K., ‘Clustering Competence in Emotional Intelligence: Insights from the Emotional Competence Inventory (ECI).’ Handbook of Emotional Intelligence. Jossey-Bass, San Francisco, 1999. Furnham, A. & Petrides, K.V., ‘Trait Emotional Intelligence and Happiness.’ Social Behaviour and Personality. Vol. 31., 2003, pp. 815-824. Goleman, D., Working with Emotional Intelligence. Bantam Books, New York, 1998. Lepore, S.J. & Smyth, J.M., Writing Cure: How Expressive Writing Promotes Health and Emotional Well-Being. American Psychological Association, Washington, DC, 2002. Mayne, T.J., ‘Emotions and Health.’ Emotions: Current Issues and Future Directions, Guilford Press, New York, 2001. Miles, M.B. & Huberman, A.M., Qualitative Data Analysis: An Expanded Sourcebook. 2nd ed., Sage, Thousand Oaks, CA, 1994. Pennebaker, J.W. & Chung, C.K., ‘Expressive Writing, Emotional Upheavals, and Health.’ Handbook of Health Psychology, Oxford University Press, New York, 2007. Rice, C.L., A Quantitative Study of Emotional Intelligence and Its Impact on Team Performance. Unpublished master's thesis, Pepperdine University,1999. Rubin, M.M., Emotional Intelligence and Its Role in Mitigating Aggression: A Correlational Sudy of the Relationship between Emotional Intelligence and Aggression in Urban Adolescents. Unpublished dissertation, Immaculata College, Pennsylvania. 1999.

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__________________________________________________________________ Smith, C.A., ‘The Self, Appraisal, and Coping.’ Handbook of Social and Clinical Psychology: The Health Perspective. Pergamon, New York, 1991. Smith, T.W., ‘Personality as Risk and Resilience in Physical Health.’ Current Directions in Psychological Science. Vol. 15, 2006. Yıldırım, A. & Şimşek, H., Sosyal Bilimlerde Araştıma Yöntemleri Seçkin Yayınları, Ankara, 2006 . Yavuz Tuna, Ph.D, is Assistant Professor in Anadolu University Communication Sciences Faculty.

Pain and Personal Experiences of Cancer: A Complex Intersection Heather McKenzie Abstract Personal experiences of cancer are inevitably affected by shared social understandings of the meanings attributed to cancer in any given society. In western societies, cancer is strongly associated with physical pain and disability, both of which are seen as part and parcel of most cancer illness experiences. Social attitudes in western societies to physical limitations mean that cancer experiences are inherently social experiences, for instance they can lead to the individual sufferer withdrawing from many social roles, responsibilities and commitments. Such effects can underpin a range of emotional pains, some of which may ultimately be more enduring than the physical effects of disease and/or associated treatments. Drawing on two studies of personal experiences of cancer, this paper explores the meanings of pain in this context for individuals and their families. It is argued here that it is emotional pain that tends to dominate in personal narratives of living with cancer and emotional pain that lives on long after the experience of physical pain has receded. The paper elaborates on a range of different experiences of emotional pain, and, where relevant, the relationship between these feelings and physical pain. Key Words: Cancer survivorship, emotional pain, fear, isolation. ***** Personal experiences of cancer are inevitably affected by shared social understandings of the meanings attributed to cancer in any given society. In western societies, cancer is strongly associated with physical pain and disability, both of which are seen as part and parcel of most cancer illness experiences, and it is also the case that emotional pain may ultimately be more enduring than the physical effects of disease and/or associated treatments. Drawing on two studies that have examined a range of personal experiences of cancer, this paper explores the meanings of pain in this context for individuals and their families. It is argued here that, although physical pain is frequently a significant dimension of cancer illness experiences, it is emotional pain that tends to dominate in personal narratives of living with cancer and emotional pain that lives on long after the experience of physical pain has receded. The paper elaborates on a range of different experiences of emotional pain, and, where relevant, the relationship between these feelings and physical pain. Modern medical science has achieved considerable success in relation to the control, or at

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Pain and Personal Experiences of Cancer

__________________________________________________________________ least the management, of physical pain for cancer sufferers. The management of emotional pain does seem to be more intractable and less well understood. 1. Fear and Uncertainty One of the most profoundly unsettling experiences for cancer survivors is the fear that, in spite of very aggressive treatments, one’s body may still harbour cancer cells. As one of the study respondents, Ralph, puts it: ‘You had this thing, now would it come back? … Is it sitting there in a dark corner? … Really, you’re flying in the face of death’. Quite simply, cancer survivors fear that their ordeal may not be over, that time will reveal any claim to survival to have been an illusion. Even many years after the cancer episode, people can continue to be intensely concerned about issues related to identity and continuity which flow from this deep-seated fear that the disease will recur. Because she travels to the city by train for her annual mammogram checks, Nancy finds any train journey painfully evocative: ‘It’s really weird ... whenever I catch a train … it all comes back, floods back’. Grief and sorrow about her past predicament are at the heart of these memories, but they also reflect the haunting fear of recurrence which is her frequent companion, and which is especially intrusive at the time of medical checks: I always feel depressed. ... Are they going to tell me this time it’s in the right breast? ... It’s an awful feeling. I think it’s the fear, the fear that they are going to turn around one day and say to you, ‘Well, yes, it is in the other breast, or, yes, it is somewhere else’. You can push it out as much as you want, but it always sits in the back of your mind. Many people experience feelings of fear & dread when unusual pain or discomfort is felt. Nancy sometimes has pains in her chest: ‘I think to myself, oh, it’s gone into the heart muscle. ... I think, oh my God, is it going to go there? Am I going to get it in my heart? There’ll be no saving me then’. Felicity explains that she sometimes feels anxious about her own reflection in the mirror: ‘You see dark circles under your eyes and you think, gee, do I look very well? Maybe I don’t look a very good colour. What colour did I look before I got sick?’ She also worries about intermittent back pain: They say the symptoms are any unusual pain, specially bone pain or back pain. Now the problem is with people my age, a lot of people have got bad backs anyway, so every time you think, I’ve got a backache today ... should I go and get it checked? That sort of thing is with you all the time.

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__________________________________________________________________ Barbara has similar misgivings. ‘When you’re in pain, when you’ve got a physiological thing happening, it stimulates your feelings of dread as well.’ On several occasions since her initial diagnosis and treatment, Carol has had physical symptoms which have necessitated further intrusive tests, at which point her ‘anxiety would just skyrocket’. Her immediate fear would be of cancer recurrence: ‘I’d be starting to think, oh my God, I can’t bear it if I’ve got cancer again. I can’t bear to go through it again, it’s a nightmare. I would just freak out’. Towards the end of our first interview Gary explained that, because of a family history of bowel cancer, he had been contacted by a genetic counsellor and told of the availability of genetic testing for predisposition to bowel cancer. By the time we met again Gary had been for an interview with the counsellor and his initial fear that the issue would become extremely complex for him was certainly realised. The interview brought to his attention many factors that Gary had not previously considered: ‘What we’re talking about here is a predisposition to cancer. ... I thought, OK that’s fine, I wouldn’t have any worries about that, or fear ... but now that I’ve had to think about it a bit I’m not so sure’. The availability of genetic testing altered Gary’s feelings in relation to his cancer experience. Before he became aware of the test Gary believed that he had some control over his own health prospects. He was reasonably confident that his response to the initial diagnosis – taking quite drastic life-changing measures – would protect him from any recurrence of the disease. The possibility of predisposition threatened to undermine the security he felt as a result of the changes he had made in his life: ‘I thought I was pretty confident about not getting a recurrence and when something like this comes along which almost gives you like you’re carrying … an extra handicap. ... it brings to the surface there is always that fear there’. 2. Social Attitudes to Cancer This very personal fear of cancer recurrence is intensified and complicated by the collective fear of cancer – a widely shared emotional response to systemic features and social arrangements of cancer as a social phenomenon. It is argued here that, for a number of reasons, the social experience of cancer is enveloped in a ‘climate of fear.’1 Cancer has always been a frightening disease, but it does seem that the collective fear has become more widespread and intense in recent times.2 Perhaps this reflects a general feeling that, despite the money, time and effort expended on the ‘war against cancer’, the overall picture remains grim.3,4 Instead of collective hopes of success being realised, the disease seems still as aggressive and threatening as ever, perhaps even more so, given the constant flow of information about screening, ‘anti-cancer’ diets and other such measures. Arguably, there are still deeper sources for our collective fear of cancer. Radley has identified the notion of ‘abhorrence’ as crucial to an understanding of the general response of the ‘putatively healthy’ to those who are less fortunate.5 In

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__________________________________________________________________ line with Sontag, 6,7 Radley argues that abhorrence is aroused when an illness ‘evokes a psychological (if not physical) shudder’, especially where ‘the prospect of future mutations and a difficult death are envisaged.’8 In that it subsumes fear, loathing and disgust, all of which are implicated in widespread feelings about cancer, the concept of abhorrence encompasses the range of feelings involved in the emotional climate referred to here. The disease is feared because it appears uncontrollable, but the fear is intensified by feelings of disgust and loathing evoked by images of malignant decay, and inevitable and painful death. 3. Isolation & Loss Some participants explained that they noticed reticence on the part of those around them when it comes to discussing their feelings about cancer. Andy explains: ‘I’m very aware that most people are uncomfortable about the subject. The closer they are to you the less they’ll talk about it’. Nancy found that her mother was so upset about her illness that she wanted to avoid the subject: Her way of coping was: ‘Come on … don’t think about it and get on with your life’. So … there was always this barrier ... so I felt lonely in that respect. Because a lot of people are very scared to talk about it. ... they can’t cope with the fact that in the back of their mind they think, well you’ve had cancer, you’re going to die from it eventually. ... Or will it happen to me? People don’t like to talk about it. ... You have to put this brave front on for people. Rachel explained that, because they want to feel that everything has now returned to ‘normal’, she tries to shield her family and friends from her distressing feelings: ‘You sort of juggle it ... ‘cause you certainly don’t want to be dragging people down with you. ... The whole time you feel like you’ve got to keep lifting everything up’. For Gary, the isolation of his experience was compounded by the fact that he was not able to talk about his fear of death, even with the person closest to him. ‘I wanted to talk about what’s going to happen if I die ... [but] I understood that it was beyond this person’s capability to be able to talk about it. ... So there’s no one you can turn to ... you’re very, very alone’. Max was inclined to tell the people he meets that he has had cancer, but he finds that, in response, ‘some people are very stand-offish and don’t want to know’. Andy also explains that ‘because of the taboo on ... the name and the emotions and the feelings that cancer brings up, people just sort of stay away from you. ... Some people can’t cope, even if they like you a lot’. Carol suspects that

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__________________________________________________________________ ‘everybody out there is totally freaked out about cancer’. She found that several good friends ‘went totally weird and ... wouldn’t talk about it at all’ when she was being treated for cancer, but when she was feeling better ‘they started being normal again’ – though being ‘normal’ did also involve the expectation that Carol, too, would be ‘as before’ the cancer episode. Cancer survivors are thus thrown on their own resources to cope with deepseated fears that the disease will recur. Even cancer support groups are not necessarily helpful at this stage. Most respondents for this study were no longer involved with these groups. Although, for some, these had been helpful in the first year or two after diagnosis, beyond that the benefits tend to be seen as very limited. In fact, several respondents pointed out that the presence of newly diagnosed people at support group meetings can be confronting for those who strive to put the experience behind them. As Carol points out: ‘It’s very hard with new people coming all the time … because they’re always really needy and also really freaked out. … I think my needs are very different from the needs of somebody who’s just been diagnosed’. And Nancy: I went to a group but it was women a lot older than I was and they were very negative and a lot of them were complaining of cancer that had gone somewhere else … I don’t think there’s enough support for women with breast cancer, specially young women.… you can’t really talk to people about it. You can’t talk to your girlfriends because they don’t want to hear about it. They want to pretend that it didn’t happen to you. You can’t talk to your family either because they want you to be strong and get on with it. Nancy now prefers to be with people who have not been affected by cancer, and for the most part she does not tell them about her illness. The respondents’ comments reveal the sense of isolation that cancer survivors feel. For many years they live in a state of uncertainty somewhere between the well and the unwell, burdened by their liminal status.9,10 They are unable, yet, to feel confident that the future will be cancer-free, and, unlike other people, they are, therefore, transfixed – immobilised – in the (dangerous) present. Many are surprised that even five years after diagnosis they do not feel confident about their future prospects, although, as Andy’s comment – ‘everyone says you’ve got to wait five years’ – reveals, prior to this there is a general expectation that five years is some sort of transition marker. Barbara also comments: ‘Today I pass into that five year period where I now go statistically back to where everyone else is in terms of getting breast cancer again. ... They keep you on the roller coaster for five years’. But for many it actually takes much longer than this – perhaps ten years or

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__________________________________________________________________ so – before they feel a real sense of self-confidence in the future, and therefore a legitimate participant in the shared reality of the everyday world. Nevertheless, cancer survivors continually yearn to feel, once again, the enveloping comfort of that shared sense of practical consciousness. But this remains impossible as long as existential equilibrium is persistently disturbed by fear and anxiety that is not socially validated and therefore not able to be expressed. This study reveals that cancer survivors respond to this fear and anxiety by attempting – privately – to dissolve, transform or transcend these feelings, whatever the personal and social constraints of their lives may be. 4. Conclusion Cancer survivors, then, are very preoccupied by their efforts to control or transcend emotions which seem to them either psychologically too painful to endure or socially inappropriate – and in many instances, both. In private, they are deeply involved in ‘managing’ their fears of cancer recurrence, longing for the time when they will no longer be troubled by such feelings, and will, therefore, be able to freely and joyously participate in the ordinary everyday world of ‘healthy’ others. In the meantime, constrained by the reticent responses of others to their suffering, their emotion management efforts produce and maintain an ‘emotional false consciousness’ which will convince others, and perhaps also themselves, that all is well.11,12

Notes 1

J Barbalet, Emotion, Social Theory and Social Structure: A Macrosociologica Approach, Cambridge University Press, Cambridge, 1998. 2 R McGrew, Encyclopaedia of Medical History, Macmillan Press, London, 1985. 3 J Bailar & H. Gornick, ‘Cancer Undefeated,’ The New England Journal of Medicine, Vol. 336, no. 22, 1997, pp. 1569-74. 4 T Beardsley, ‘A War Not Won,’ Scientific American, January 1994, pp. 118-26. 5 A Radley, ‘Abhorrence, Compassion and the Social Response to Suffering,’ Health, Vol. 3, no. 2, 1999, pp. 167-87. 6 S Sontag, Illness as Metaphor, Allen Lane, London, 1979. 7 S Sontag, Aids and Its Metaphors, Farrar, Straus and Giroux, New York, 1989. 8 A Radley, ‘Abhorrence, Compassion and the Social Response to Suffering,’ Health, Vol. 3, no. 2, 1999, pp. 167-87. 9 M Little, C Jordens, K Paul, K Montgomery & B Philipson, ‘Liminality: A Major Category of the Experience of Cancer Illness,’ Social Science and Medicine, Vol. 47, no. 10, 1998, pp. 1485-94. 10 M Little, C Jordens, K Paul & E Sayers, Surviving Survival: Life after Cancer, Choice, Sydney, 2001.

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P Freund, ‘The Expressive Body: A Common Ground for the Sociology of Emotions and Health and Illness,’ Sociology of Health and Illness, Vol. 12, no. 4, 1990, pp. 453-77. 12 P Freund, Social Performances and their Discontents: The Biopsychosocial Aspects of Dramaturgical Stress, Routledge, London, 1998.

Bibliography Barbalet, J., Emotion, Social Theory and Social Structure: A Macrosociological Approach. Cambridge University Press, Cambridge, 1998. Bailar, J. & Gornick, H., ‘Cancer Undefeated.’ The New England Journal of Medicine. Vol. 336, no. 22, 1997, pp. 1569-74. Beardsley, T., ‘A War Not Won.’ Scientific American. January 1994, pp. 118-26. Freund, P., ‘The Expressive Body: A Common Ground for the Sociology of Emotions and Health and Illness.’ Sociology of Health and Illness. Vol. 12, no. 4, 1990, pp. 453-77. Freund, P., Social Performances and their Discontents: The Biopsychosocial Aspects of Dramaturgical Stress. Routledge, London, 1998. Little, M., Jordens, C., Paul, K., Montgomery, K. & Philipson, B., ‘Liminality: A Major Category of the Experience of Cancer Illness.’ Social Science and Medicine. Vol. 47, no. 10, 1998, pp. 1485-94. Little, M., Jordens, C., Paul K. & Sayers, E., Surviving Survival: Life After Cancer. Choice, Sydney, 2001. McGrew, R., Encyclopaedia of Medical History. Macmillan Press, London, 1985. Radley, A., ‘Abhorrence, Compassion and the Social Response to Suffering.’ Health. Vol. 3, no. 2, 1999, pp. 167-87. Sontag, S., Illness as Metaphor. Allen Lane, London, 1979. , Aids and Its Metaphors. Farrar, Straus and Giroux, New York, 1989.

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__________________________________________________________________ Heather McKenzie is a Senior Lecturer at the Sydney Nursing School, University of Sydney, Australia.

Revelational Indicators: A Framework for Analysing Pain Shona Hill Abstract In the West we exist in a culture where it is possible to detect weariness with both history and tradition. Despite this, Mellor and Shilling, exploring differing processes of reading and writing the re-forming Christian body, base their concepts in the understanding that every historical moment (its developing texts and traditions) has a dynamic all its own. In their book, ‘Re-forming the Body: Religion, Community and Modernity’ (1997), they suggest that history signifies the past allowing the future to come into being. They also suggest that tradition is the handing on and over of an historical narrative so that it may be told freely and creatively by each generation. From this understanding they develop ideal-type bodies consistent with Medieval, Reformation and contemporary epochs. Utilising these ideal-type bodies within Latour’s perspective that ‘the body is an interface that becomes more and more describable when it learns to be effected by many elements’ I create an heuristic model for analysing the competing contemporary collective representations of pain. Specifically in this paper I focus on locating pain in three paintings that depict the killing fields of Golgotha and explore how these scenes of Christ’s crucifixion not only change over time but also shed light on the contemporary management of pain in everyday life. Key Words: Christianity, bodies-in-pain, crucifixion paintings, ideal types. ***** Imagine yourself travelling across vast stretches of geographical space and back along time co-ordinates until you reach 1515. Arriving lost and confused, you find yourself in the graveness of a gothic monastery hospital where the air reeks with the stench of rotting flesh. It is a place where an order of monks administer medicinal and sacramental comfort to the sick, the suffering and the dying. Before you, twice the height of man, towers the Isenheim Altarpiece and the medieval painter Grunewald’s depiction of pain, suffering, charity and hope found in Christian narratives.1 Within this altarpiece Grunewald’s Catholic sensibility merges context into text, secular into sacred and makes visible the violence of Christ’s violated human body. Out of this brutality and pain, we see gnarled fingers reaching up and beyond the temporal plane, drawing the viewer into the Passion’s painful narrative of death, redemption and salvation.2 In contemporary times, Dury has claimed that ‘we can only be distressed, even appalled [by this crucified body] hanging on a cross.’3 He argues that this ‘atrocious form of public death by ignominious torture [can only be seen] with

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__________________________________________________________________ feelings of horror.’4 However because ‘feelings of horror’ are not particularly helpful to those living in pain today, the purpose of this paper is to develop a framework which will give context to both Dury’s appalled reaction to pain and to Grunewald’s determination to make every painful wound undeniably visible. My aim is to produce a conceptual framework in which bodies in pain can be meaningfully explored and discussed. To do this I will investigate the Christian underpinnings of contemporary society which are frequently ‘unacknowledged and often expressly denied’ in order to produce three ideal type models of bodies-inpain.5 These ideal type models will highlight continuity within, and between, the particular Western cultural motivators that either restrict or mobilise depictions of, and responses to, the pained and wounded body within contemporary Western society. To begin I draw from Mellor and Shilling’s ideal typical study of Medieval Catholicism and the Protestant Reformation in order to systemise - in relation to pain - the three re-forming ideal types that their study produces.6 1. The Framework There are criticisms of an ideal type approach and a more in-depth discussion can be sourced in an article by Susan Hekman.7 In this paper it is suffice to say that although in everyday life ideal types will overlap and do recur in different forms, they should be understood as an heuristic model. More specifically ideal types should be seen as dominant tendencies within particular time periods rather than definitive facts. Mellor and Shilling liken these dominant tendencies - what they have termed re-forming bodies - to Marxian modes of production. Thus as modes of production each of Mellor and Shilling’s sensory ideal type bodies reveal a perceived shift in the location of the sacred. This shift altered the ‘underlying structures which provided, [rather than determined the dominant] parameters’ for acquiring knowledge and organising society.8 Accordingly their first re-formed sensory body is the Medieval Catholic restructure of the Pagan/Christian Body which they call ‘Volatile Bodies, Sacred Communities’.9 The second is the Protestant Reformers’ re-structure of Volatile Bodies which they call ‘Sinful Bodies, Profane Associations’.10 The third is the Catholic Counter-Reformation’s use of Baroque culture combined with the Modern attempt to restructure Sinful Bodies which they call ‘Ambivalent Bodies’.11 To explain these re-formations in relation to pain, I begin within the enchanted social world of Volatile bodies where Crucifixion paintings make clear signs of blood, pain, gore and injury.12 2. The Volatile Body Simplistically within the world of the Volatile Body, God and the supernatural were perceived to dwell in ‘this world’ and in the body. God was the absolute source of legitimate authority and His messages came through both the close and the distant contact bodily senses. For example knowing God through the close-

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__________________________________________________________________ contact sense of taste within the sacramental ritual of communion was not symbolic but a literal ingestion of God to better understand His will. This required a focus not only on the divinity and physicality of Christ’s pain but also meant that an event such as pain, which confronted all the senses so intensely, played a significant role in the action and interpretation of everyday life. As such pain as a form of ‘carnal knowing’ became a pedagogical technique used by individuals and the State alike.13 For example techniques for ascertaining social justice included torture, hanging, flogging, the breaking of bones, the public display of dismembered body parts and the trial by ordeal which could include grasping a red hot iron. Pain in ‘this world’ was understood within sacred associations and also as transformative. In this way pain played two roles.14 Pain was a deterrent against evil and pain was considered merciful because it corrected evil. In cases of extreme evil such as treachery against the State (and by implication God), a painful death was a purifying act of mercy that guided sinners towards redemption and salvation. For lesser sins ‘the penitent, who flayed his skin to the point of intense pain removed shame ... humiliation ... and isolation’ that came from evil-doing.15 Although I have simplified the description of the roles of pain for this paper, by and large these two roles - deterrence and mercy - meant pain remained visible and was persuasive when shared by both suffers and spectators. As Merback notes ‘pain ... though ugly to behold ... revealed the inner beauty of the soul that had made peace with God.’16 For example while the glorious abjection of the martyrs might be seen as particularly pious, pain that marked the body was not ‘world destroying’ but accepted as a legitimate part of knowing the body, the world and God.17 I have labelled this ideal typical way of experiencing pain Volatile Bodies: Valued Embodied Pain (hereafter VEP). Its key characteristic is that it gave a positive transformative role to the body-in-pain. Hence it needed to be made visible, experienced and shared. Pain when viewed from this ideal type was not believed to be as horrifying as Dury has claimed. However when viewed from a contemporary perspective Dury’s horrified response to graphic displays of pain and suffering raises the question: is this model for living with pain a relic of history? One may think so when in 1954 Salvador Dali set out to paint Christ’s crucified body which he claimed would be ‘the absolute antithesis of the materialist and savagely anti-mystical Christ of Grunewald.’18 3. The Sinful Body In this painting Christ’s body is seen from below - a perfect incarnation, unblemished by wounds or bodily hair. This monumentalised, rational mathematical structure isolates Christ from his and our humanity and our pain and suffering. According to Frank, this kind of isolating and marginalising treatment of bodily suffering contributes towards a society unable to deal with the lived body

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__________________________________________________________________ in pain.19 Mellor and Shilling claim that distancing and isolation is a key element found in the disenchanted world of Sinful Bodies and is due, in part, to the Protestant Reformers’ perceived relocation of the sacred from ‘this world’ to an ‘other worldly’ location.20 This new sense of transcendence created an inspirational, but almost impossible, concept of perfection, which prioritised the distant-contact sense of sight, ‘cognitive apprehension’ and ‘profane associations’ within ‘imagined communities of faith’.21 The reason sight and ‘imagined communities’ were prioritised is because it was believed that sight was uncontaminated by the fallen sinful flesh. As a result fleshy pain lost its meaningful messages, and eventually became a sign of susceptibility to the Devil. Indeed, the physical body was understood as a pathway through which the Devil was able to seduce sinners. Pain, deformity and disability could even be interpreted as a sign of evil itself. Thus managing bodily signs became, as DelVecchio has argued, an obsession and the lived body-in-pain became an impediment to the rational pursuit of god’s will.22 Simplistically, within the world of Sinful Bodies, Protestant principles became dominant. Overtime however, as, God lost His place as a source of self-evident truth, Protestant thought merged with aspects of Enlightenment thought. Life became mundane, the body profane and the body-in-pain reformed into a mysterious, individual bodily issue which was alleviated through mindful rational control. Immersed in this view Descartes, for example, could argue that the ‘the living body is not fundamentally different from the lifeless; it is a kind of animated corpse, a functioning mechanism.’23 Eventually this mechanistic approach came to dominate intellectual thought and ‘the dead body [was] taken as model for the living.’24 In cases where it was not possible to control bodily sensation, drugs were used to numb, that is deaden, the body. I have labelled this way of marginalising and silencing the body-in-pain Sinful Bodies: Anesthetised Pain (hereafter AP). AP’s key characteristic is that it silences pain and as a result it became meaningless and useless to the emerging modern elites. Yet, given that embodied forms of ‘carnal knowing’ and ‘cognitive apprehension’ of stubborn living bodies could not be silenced as easily as Descartes corpses, resistance to AP emerged and converges within Mellor and Shilling’s third re-formed ideal type - Ambivalent Bodies. An example of this ideal type can be seen in Sutherland’s Crucifixion.25 4. The Ambivalent Body Sutherland’s narrative of pain retains Grunewald’s gnarled fingers reaching up and out of the temporal plane and he retains the torturous crown of thorns. He also exposes viewers to the pain of his time, the emaciated figures of Auschwitz, the gas chambers of World War 2 and by implication the sign of human starvation. He connects our bodies to the bodies of sufferers by returning to the frontal display of Christ. Yet, Sutherland is not back in Grunewald’s volatile world. He isolates

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__________________________________________________________________ Christ’s bruised and beaten crucified body from the community by placing Christ not only outside the city wall but also distancing and marginalising him behind a barrier. Christ suffers in silence, and alone. This retains Frank’s concern at the isolating way of treating those in pain.26 While, as a model, Ambivalent Bodies marks the Catholic Counter-Reformer’s simulation of aspects of the Protestant Body it is not merely a revival of either Volatile or the Sinful Bodies. What is unique to Ambivalent Bodies is the Catholic Counter Reformation’s use and combination of emotion, illusion and melancholic nostalgia found within Baroque Culture. As a result Ambivalent Bodies is a mode of production in which Volatile and Sinful Bodies collide, merge and oscillate altering the way in which the body, and I argue pain, is perceived.27 Mellor and Shilling make it clear that the fragmentation of re-forming Ambivalent Bodies stabilises in a common terrain where sight, isolation and the ‘rational organisation [of] banal associations’ often dominate but ‘sensual solidarities (an increasing visibility of the sacred)’, indulgence, nostalgia and I argue graphic painful representation (amongst other things) also coexist in the ebbs and flows of a ‘janus faced modernity’.28 In turn this accommodated and hybridised binary opposites forming new bodies and giving the appearance of choice. Although this appearance of choice underpins the belief that modernity is secular, nevertheless these choices are bound within, or between, the two Christian options of VEP and AP. I have labelled this way of experiencing pain Ambivalent Bodies: Torn Pain (hereafter TP). These ideal type bodies-in-pain can be seen in the following Venn diagram where VEP indicates the medieval Catholic view that pain is carnally shared for its positive messages of transformation and AP indicates the Protestant need to remove bodily signs of evil such as pain, deformity and disability.29 Contemporary Bodily Choices of Orientation and their Christian Boundaries

Catholic

Protestant Common Terrain

Volatile Baroque TP: Bodies VEP: Bodies

AP: Bodies

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__________________________________________________________________ In the centre of the diagram both the multiple and overlapping choices which make up the common terrain of TP become clear. The diagram also highlights the boundaries which enclose these choices and can be found in a variety of contemporary pain-related research. For example, Lawton examines how bodiesin-pain are hidden away from public view and concealed in hospice care.30 Seltzer notes an increase in the representation of open, pained and wounded bodies in what he describes as pathological public spaces.31 Carr notes an increase in slasher films where pained victims scream, cower, are often dismembered and eventually killed and Wilkinson & Kitzinger note how patients in pain are not encouraged to dwell on pain, fear, or any so-called negative thoughts.32 This bodies-in-pain ideal type framework highlights two aspects. The first is that within the common terrain of TP the different ways of knowing, associating and dealing with pain encompasses concepts of; integration and disintegration, awesomeness and awfulness, hope and horror. More specifically TP highlights that there are alternatives to AP and its isolating and marginalising responses to pain management. For example VEP confronts pain that challenges medical solutions revealing that pain need not be treated as if it is a temporary, or an inconvenient, problem as it often is. Rather when manifested in the common terrain of TP – VEP not only reinvigorates the ‘carnal knowing’ of sensory flesh as a legitimate source of understanding and dealing positively with pain but also resurrects the normalisation of pain and its attendant violence. This in turn highlights that in order to address different responses to pain we need to better understand society’s impulses to violence and how we overtly manage this, rather than control it in a Protestant or Enlightenment removal of human sensation. The second aspect which this framework highlights is that even if VEP is a marginalised technique, confined to ‘pathological spaces’ or representations, it is nevertheless available. As circulating in TP, VEP not only draws attention to the dominant choices available to those in pain today but also gives the appearance of variety, competition and choice, which in our contemporary world, often claims to be free of Christian framing. As Latour argues this supports the self-belief that modernity supports ‘anything and its opposite.’33 However many people in pain do not report such freedom to either re-form, or re-invent their lives in ways that accommodate and address their pain. For example, one pain patient expresses her frustration at being told she is progressing toward so-called ‘normality’ without pain, because she has learnt to accept her pain. She states that she would rather other people accepted that she is living in pain.34 To assist people like this the body-in-pain framework which I have overviewed in this paper opens our culture to review so that people are not necessarily trapped by notions that have different sources of legitimate authority, unless they so choose. To bring this paper to its conclusion, I suggest that to better understand some of the cultural motivators for pain responses, the body-in-pain framework reminds researchers and policy makers that pain is, as Morris suggests, neither pure biology

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__________________________________________________________________ nor pure culture but merges ‘at the intersection of bodies, minds and cultures’.35 This is because experiential difference in perceiving pain involves a nexus of cultural variables, such as, economics, language, medicine, politics and religion. All variables play a part in how we make sense of pain, how we verbally or nonverbally articulate it and ultimately how it comes to signify meaningfulness or meaninglessness. In this way the body-in-pain becomes a question of semiotics. It is a perspective we arrive at only as it plays out, in and against, culture and the body. As a result the body-in-pain ideal types identify what is often a missing picture - those unseen barriers which make people in pain feel trapped, angry, misunderstood or even hopeless, because society claims they are free to choose ways of managing pain. My overall argument is that the body-in-pain ideal type models make it clear that an integrated approach to the study of pain’s basis in thinking sensory bodies and its connection with the sacred is necessary, even if society considers itself to be secular. Without doing this, we run the risk of never adequately addressing those living in pain, dying within disintegrating bodies, living with phantom limb pain and even those that choose to inflict pain upon themselves.

Notes 1

Throughout this paper crucifixion paintings were used to illustrate the re-forming ideal type models discussed. Accordingly I will provide an internet link to different paintings beginning with Matthias Grunewald, The Crucifixion from the Isenheim Altarpiece, ca. 1515, Musee Unterlin, Colmar, France. http://commons.wikimedia.org/wiki/File:Grunewald_Isenheim1.jpg. 2 For insightful and illustrated studies of the Isenheim Altarpiece examples include: R Melinkoff, The Devil at Isenheim: Reflections of Popular Belief in Grunewald’s Altarpiece, University of California Press, Berkeley, 1988; A Hayum, The Isenheim Altarpiece: God’s Medicine and the Painter’s Vision, Princeton University Press, Princeton, 1989. 3 J Dury, Painting the Word: Christian Pictures and Their Meanings, Yale University Press, New Haven, 1999, p. ix. 4 ibid., p. ix. 5 P Mellor, Religion, Realism and Social Theory: Making Sense of Society, Sage Publications, London, 2004, p 5. 6 P Mellor & C Shilling, Re-Forming the Body: Religion, Community and Modernity, Sage Publications, London, 1997. 7 S Hekman, ‘Weber’s Ideal Types: A Contemporary Reassessment,’ Polity, Vol. 16(1) 1983, pp. 119-137. 8 Mellor & Shilling, op. cit., p. 5. 9 Mellor & Shilling, op. cit., pp. 64-97. 10 Mellor & Shilling, op. cit., pp. 99-130.

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Mellor & Shilling, op. cit., pp. 161-189. M Grunewald. The Small Crucifixion, ca. 1511-1520. http://www.artun framed.com, Search site: The Small Crucifixion. 13 Mellor & Shilling , p. 23 14 Mellor & Shilling, p. 23 15 A Glucklich, Sacred Pain: Hurting the Body for the Sake of the Soul, Oxford University Press, Oxford, 2001, p. 178. 16 M Merback, The Thief, the Cross and the Wheel: Pain and the Spectacle of Punishment in Medieval and Renaissance Europe, Reaktion Books, London, 1999, p. 157. 17 In her study of torture Elaine Scarry argues that intense pain is world and language destroying rather than world making. See E Scarry, The Body in Pain: The Making and Unmaking of the World, Oxford University Press, New York, 1985, p. 49. 18 S Dali, Corpus Hypercubicus. 1954. Metropolitan Museum of Art, New York http://www.theartistsalvadordali.com/salvador-dali-painting-poster-print-corpushypercubus.htm Moorhouse, Dali. London: PRC Publishing, 2002, p. 102. 19 A Frank, The Wounded Storyteller, University of Chicago Press, Chicago, 1995, p. 180. 20 Mellor & Shilling, p. 161. 21 Mellor and Shilling, p. 23, p.16. For an overview of B Anderson concept of ‘imagined communities’ as it relates to Protestantism and this paper see Mellor & Shilling, p. 111. 22 S DelVecchio, Bodily Saints: The New England Puritan Obsession with the Body. Unpublished PhD. Brandeis University, 1996. 23 D Leder, ‘A Tale of Two Bodies: The Cartesian Corpse and the Lived Body,’ Body and Flesh: A Philosophical Reader, Wiley-Blackwell, London, 1998, p. 119. 24 D Leder, The Absent Body, University of Chicago Press, Chicago, 1990, p. 147. 25 G Sutherland, Crucifixion. 1946. St. Matthew’s Northampton, England htt://www.jwaller.co.uk/stmatthews/crucifixion.asp. 26 A Frank, The Wounded Storyteller, University of Chicago Press. Chicago, 1995, p180. 27 For examples of different crucifixion paintings see R Crumlin, Beyond Belief: Modern Art and the Religious Imagination, National Gallery of Victoria, Melbourne, 1998; J Hasting, Crucifixion, Phaidon Press, Hong Kong, 2000. 28 Mellor & Shilling, p. 166, p. 173, pp. 131-160. 29 S Hill, Torn Between Boundaries: Bodies-in-Pain, Christianity and Feature Films, Unpublished PhD. Victoria University of Wellington, 2009. 30 J Lawton, ‘Contemporary Hospice Care: The Sequestration and the Unbounded Body and ‘Dirty Dying,’’ Sociology of Health and Illness, Vol. 20(2) 1998, pp. 121-143. 12

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M Seltzer, Serial Killers: Death and Life in America's Wound Culture, Routledge, New York, 1998; M Seltzer, ‘Wound Culture: Trauma in the Pathological Public Sphere’. October, Vol. 22, Spring 1997, pp. 3-26. 32 D Carr, ‘23 Days of Cannibalistic Joy: How Jeepers Creepers Sets Itself Apart from the Conventional Slasher Film,’ There Be Dragons Out There: Confronting Fear, Horror and Terror, Inter-Disciplinary Press, Oxford, 2008; S Wilkinson & C Kitzinger, ‘Thinking Differently about Thinking Positive: A Discursive Approach to Cancer Patients’ Talk,’ Social Science and Medicine, Vol. 50(6) 2002, pp. 797811. 33 B Latour, We have Never been Modern. Harvard University Press, Cambridge, 1993, p. 38. 34 R Pritchard, Tidy Theories and Untidy Human Beings, Paper presented at: Annual Conference of New Zealand Association of Counsellors, Waitangi, New Zealand, March, 1998. http://www.rhondapritchard.co.nz. 35 D Morris, The Culture of Pain, University of California Press, Berkeley, 1993, p. 3.

Bibliography Carr, D., ‘23 Days of Cannibalistic Joy: How Jeepers Creepers Sets Itself Apart from the Conventional Slasher Film.’ There Be Dragons Out There: Confronting Fear, Horror and Terror. Inter-Disciplinary Press, Oxford, 2008. Crumlin, R., Beyond Belief: Modern Art and the Religious Imagination. National Gallery of Victoria, Melbourne, 1998. DelVecchio, S., Bodily Saints: The New England Puritan Obsession with the Body. Unpublished Ph.D. Brandeis University, 1996. Dury, J., Painting the Word: Christian Pictures and Their Meanings. New Haven, Yale University Press, 1999. Frank, A., The Wounded Storyteller. University of Chicago Press, Chicago, 1995. Glucklich, A., Sacred Pain: Hurting the Body for the Sake of the Soul. Oxford University Press, Oxford, 2001. Hasting, J., Crucifixion. Phaidon Press, Hong Kong, 2000. Hayes, J., The Art of Graham Sutherland. Phaidon, Oxford, 1980.

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__________________________________________________________________ Hayum, The Isenheim Altarpiece: God’s Medicine and the Painter’s Vision. Princeton University Press, Princeton, 1989. Hekman, S., ‘Weber’s Ideal Types: A Contemporary Reassessment.’ Polity. Vol 16(1), 1983, pp. 119-137. Hill, S., Torn Between Boundaries: Bodies-in-Pain, Christianity and Feature Films, Unpublished PhD. Victoria University of Wellington, 2009. Latour, B., We have Never been Modern. Harvard University Press, Cambridge, 1993. Lawton, J., ‘Contemporary Hospice Care: The Sequestration and the Unbounded Body and ‘Dirty Dying.’’ Sociology of Health and Illness. 20(2), 1998, pp. 121143. Leder, D., ‘A Tale of Two Bodies: The Cartesian Corpse and the Lived Body.’ Body and Flesh: A Philosophical Reader. Wiley-Blackwell, London, 1998. Leder, D., The Absent Body. University of Chicago Press, Chicago, 1990. Melinkoff, R., The Devil at Isenheim: Reflections of Popular Belief in Grunewald’s Altarpiece. University of California Press, Berkeley,1988. Mellor, P., Religion, Realism and Social Theory: Making Sense of Society. Sage Publications, London, 2004. Mellor P & Shilling, C., Re-Forming the Body: Religion, Community and Modernity. Sage Publications, London, 1997. Merback, M., The Thief, the Cross and the Wheel: Pain and the Spectacle of Punishment in Medieval and Renaissance Europe. Reaktion Books, London, 1999. Moorhouse. P., Dali. PRC Publishing, London, 2002. Morris, D., The Culture of Pain. University of California Press, Berkeley, 1993. Pritchard, R., Tidy Theories and Untidy Human Beings. Paper presented at: Annual Conference of New Zealand Association of Counsellors, Waitangi, New Zealand. March, 1998. http://www.rhondapritchard.co.nz.

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__________________________________________________________________ Scarry, E., The Body in Pain: The Making and Unmaking of the World. Oxford University Press, New York, 1985. Seltzer, M., Serial Killers: Death and Life in America's Wound Culture. Routledge, New York, 1998. Seltzer, M., ‘Wound Culture: Trauma in the Pathological Public Sphere.’ October. vol. 22 Spring, 1997, pp. 3-26. Wilkinson, S. & Kitzinger, C., ‘Thinking Differently about Thinking Positive: A Discursive Approach to Cancer Patients’ Talk.’ Social Science and Medicine. 50(6), 2002, pp. 797-811. Shona Hill is a Tutor in Sociology and Religious Studies at Victoria University of Wellington, New Zealand. Her primary research interests merge at the intersection of Visual Sociology and Social Justice.

How to Listen to Chronic Pain Narratives Mary Buchinger Bodwell Abstract Chronic pain-pain that does not respond to treatment-is problematic not only for the patient but also for the health care provider. Patients with chronic pain represent, to some extent, a health care system’s failure and, as a result, they can become both resented and stigmatised by providers; empathy wears out. In medicine, the restitution story, the patient is sick, treated, and gets better-is privileged. It is the story every listener prefers-a story of triumph and success, a story of progress, of restoration, of redemption. But patients with chronic pain cannot tell a restitution story-despite the pressures from their audience, which includes family, friends, health care providers. Yet patients must and will tell their stories, and it is in the careful and empathic listening to those stories that care providers can prevent chronic pain from becoming true suffering. Health care providers are trained and poised to take action, to intervene, to do things. In the biomedical sphere, health care providers supply answers to needy patients. However, patients outside a restitution narrative pull providers into a different kind of relationship, one that is non-hierarchical, thus placing the provider in a less controlling and less guarded position. How to recognize and then honor this shift in the patient-provider relationship is not generally included in the medical professional curriculum. I discuss the role narrative plays as a coping tool for patients with chronic pain as well as the kind of empathic listening these narratives require from health care providers. Specifically, I address this topic from the perspective of one who teaches communication skills to future health care professionals, including nurses, physician assistants, and radiographers. Key Words: Chronic pain, narrative, empathy, health care. ***** According to the Book of John in the New Testament, ‘in the beginning, was the word.’ Freud amended this to, ‘in the beginning, was the deed.’ Linguistic philosophers propose that the word is the deed. For my part, I agree with everyone, adding that, also in the beginning, was the story. The story consists of words as deeds. The story, or the implication of a word, ensures that the word/deed will not be neutral—neither neutral in its formation nor neutral in its reception. I am using the term ‘story’ broadly to refer to that which gives meaning to a word—the net of significance in which a word is caught, heard, and responded to. My understanding of word as story is informed by Bakhtin’s return of logos or discourse to the concept of ‘word’.1 That is, words have histories, are socially embedded, and imbued with intention. Words are responsive as much as they are assertive.

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__________________________________________________________________ Heidegger said that we not only speak the language, we speak out of the language. Words are entangled in meanings—if words are not of themselves a story, they emerge from story, they imply a story. We tell stories to make sense of what happens to us. Stories provide glue— coherence—in what the anthropologist Malinowski calls the ‘imponderabilia of life.’2 Here in Australia, the Aboriginals have Dreamtime, which operates as an explanatory framework, a way to make sense of and establish a spiritual connection to the fantastic landscape. As physician and psychiatrist Mehl-Madrona writes, ‘[w]e interpret our sensory experiences of the world by creating stories that simulate an unbroken chain of experience, connecting past events to the present— as well as to an imagined or desired future.’3 He points out that we have stories at every level of organization—individual, family, culture, society. These stories give us our identity; they provide us with a way of understanding ourselves and others. They are both explanatory and constructive of experience and relationships. As he notes: ‘[s]tories give us a fluidity of expression, an opportunity for improvisation, and a way to design alternatives.’4 That is, we can argue with and through stories; as constructions of reality, stories can be challenged and changed. Doctors, such as Anton Chekov and William Carlos Williams, tell stories, and patients do, too. Anatole Broyard, a literary critic and essayist diagnosed with metastatic prostate cancer, writes: [m]y initial experience of illness was as a series of disconnected shocks, and my first instinct was to try to bring it under control by turning it into a narrative. Always in emergencies we invent narratives. We describe what is happening, as if to confine the illness…Stories are antibodies against illness and pain. 5 What is the meaning of these stories and how should we attend to them? Meaning depends, in large part, on a shared understanding. If I start speaking gibberish that no one understands, then I will fail to mean. Pain is a subjective experience; we can describe our pain, but we cannot make someone else feel it. Pain is, to some extent, gibberish. The closest we can get to help someone understand what we’re feeling is through description, stories, metaphor. Richard Hilbert, a sociologist, writes about the need for social feedback: ...notions of pain as a private reality undermine the very possibility of [sufferers] ever ‘knowing’ that reality. There can be none of the interpretive work, linguistic use, or social negotiation essential to a knowable reality, that is, a reality with parts, features and organization…if pain is private and unavailable to others, nothing counts as verification or as a correct description of ‘how’ the pain feels. 6

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__________________________________________________________________ Pain takes shape through a patient’s words and acquires significance within the story of a person’s life. The meaning of the pain is derived from the role it plays in the lifeworld of the patient. To understand the pain, one must understand the meaning of the pain to the patient. And to understand that, one must understand the patient’s personal narrative beyond the presentation of pain. Illness is itself a story, one that challenges the narrative of the self. Illness erodes the coherence one has constructed around the events of his or her life and this erosion can lead to suffering. Eric Cassell, a physician and clinical professor who has written extensively about the nature of suffering and role of caring in medicine, offers a topography of personhood, including family, culture, social networks, past experiences. A person has roles and can do things; a person has a body, both a secret and a spiritual life, a perceived future.7 Ignoring the meaning of the illness for the patient, that is, failing to attend to the ways in which the patient’s personhood is affected by the illness, can cause suffering. Cassell points out that suffering is not a necessary corollary of pain, however, in treating pain, doctors often cause suffering. Cassell suggests this can happen when doctors focus on the disease instead of the person with the disease. He explains that medical stories have at least two characters: ‘a person and that person’s body.’ 8 A given disease manifests itself differently, depending on the patient’s personality, social networks, age, education, economic status, etc. As Cassell notes, in any narrative, change the protagonist and everything changes. Unless the patient is treated within the sensemaking frame of his or her personal narrative, the treatment itself may cause suffering. Chronic pain begins like ‘regular’ pain, that is, pain that is expected to end. No one anticipates pain to continue and when it does, it is bewildering. The chronicity itself becomes a source of pain. The past becomes a place of what used to be possible, while the present and future hold impossibility.9 Chronic pain is a story stalled. Psychiatrist Kleinman calls ‘Chronicity’ ‘the dangerous crossing of borders, the interminable waiting to exit and reenter everyday life, the perpetual uncertainty of whether one can return at all.’ 10 Chronic pain thrusts one’s life into a holding pattern, yet it is an inhospitable dwelling place. As Kugelmann, a psychologist, found in interviews with sufferers of chronic pain, metaphors for living with pain include ‘living in a prison’ and ‘being homeless’—in both, he notes, the ‘person is cut off from the possibility of dwelling, of being at home.’ 11 He writes, ‘[p]ain presents itself as more a non-place, because the place of pain cannot be abided.’12 In essence, chronic pain isolates the individual from the self, as well as from others who are, by turns, frightened and exhausted by the continued presence of pain in another. Chronic pain threatens to drain a life’s narrative of direction and meaning. How can a health care provider help to alleviate suffering? Broyard writes: ‘I’d like my doctor to scan me, to grope for my spirit as well as my prostate. Without some such recognition, I am nothing but my illness...While he inevitably feels superior to me because he is the doctor and I am the patient, I’d

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__________________________________________________________________ like him to know that I feel superior to him too, that he is my patient also and I have my diagnosis of him. There should be a place where our respective superiorities could meet and frolic together.’13 Broyard is asking his doctor to become involved with his personal story, not just the story of his illness. Why is this so important? What makes a doctor a doctor is medical expertise, not interpersonal skills. However, a patient with a serious illness or chronic pain is already suffering some loss of personhood. If the doctor only attends to the story of the illness, then the patient is reduced to being just the illness. To attend to the story of the person of the patient, the doctor, according to Broyard, must bring his or her own self to the table—be more than a doctor so that the patient can be more than a patient. In this broadened space of the stories of two human beings coming together, lies potential for the alleviation of suffering. Yet, in the age of managed care, who could possibly be the doctor Broyard longed for? Studies of students in medical school document the plummeting of empathy as stress rises. Doctors, watching the clock, are cautious about opening up what they fear will be a floodgate of emotions when talking with a patient about serious illness. In a recent study of interactions between patients with lung cancer and their doctors, it was found that doctors missed opportunities to respond empathically over 90% of the time. However, when doctors did acknowledge and respond with empathy to their patients’ emotions, the patients’ subsequent turns were brief. In fact, failure to communicate empathy throughout interactions with patients generally results in longer sessions because patients keep trying to elicit what they need from the doctor.14 In addition to reducing patient anxiety, responding empathically may help alleviate burnout on the part of doctors and other healthcare providers. Almost half of all third-year medical students report burnout; among practicing physicians, one in three experiences burnout at any one time. 15 Burnout entails not only poorer quality of life for physicians, including increased depression, substance abuse, accidents and stress-related illnesses, but also increased medical errors, patient dissatisfaction, and malpractice suits. 16 Burnout is not inevitable. Recent studies have shown the value of engaging physicians in practices that encourage selfreflection and mindful communication. Mindfulness includes ‘the ability to notice, observe, and experience bodily sensations, thoughts, and feelings even though they may be unpleasant; acting with awareness and attention (not being on autopilot); and focusing on experience, not on…labels or judgments.’17 As Shanafelt, a physician and researcher, notes, finding meaning in doctoring can save both doctors and patients.18 Broyard argues this as well: A doctor’s job would be so much more interesting and satisfying if he simply let himself plunge into the patient, if he could lose his own fear of falling...[The doctor] doesn’t have to lie to the sick man or give him false assurances: He himself, his presence,


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__________________________________________________________________ and his will to reach the patient are the assurance the sick man needs.’19 In my communication classes, I invite students to tell a story about an important experience in their lives that took place in a medical setting. The students are all future health care professionals and many tell the story of how they came to decide their career path, focusing on positive encounters with health care providers—a doctor who was especially kind, a nurse who showed concern, etc. These encounters inspired the students to imagine themselves likewise acting in the role of a health care professional and helping someone in need. What is the importance of these stories? What happens to them in the course of further medical training and in these individuals’ subsequent careers? One of my colleagues related an incident with an oncologist when his mother was dying from cancer in a hospital in Boston. She was in pain and he asked the doctor to do something to alleviate her pain. The doctor looked at the chart and reported that according to the chart, she was not in pain. What had happened to that doctor that the chart held more meaning for him than the patient’s voice? Roger Schank, in his work on artificial intelligence, studied how we hear others’ stories and concludes that we only hear what we are able to relate to our own experiences; that is, we listen for connections to our own funds of stories. 20 This research perhaps helps to explain why health care professionals who deliberately reflect on their practice find their work more meaningful—they are actively adding stories to their repertoire. It may also explain why doctors who are more open to their patients’ personal narratives have a greater potential for connection with the patient and are able to communicate understanding and empathy more effectively. Schank’s work suggests, however, that we can never fully empathize with another, that is, put ourselves in another’s place and feel what he or she feels. We are limited by our experiences; yet, according to Broyard, ‘the will to reach the patient’ is enough. In the end, there are differing views on how to listen to patient narratives. Rita Charon, director of Columbia University’s Program of Narrative Medicine, advocates the use of narrative to optimize doctor/patient interactions. She suggests doctors use narrative competence to: ‘[wring] all possible medical knowledge from what a patient conveys about the experiences of illness and how he or she conveys it.’21 However, Arthur Frank, a sociologist writing out of his own experience as a patient, cautions doctors against listening to a patient’s narrative as a therapeutic technique, which narrows the interaction. Instead, he suggests the listener be an empathic witness, honor the suffering, and hear exactly the story that is being told.22 Schank’s work suggests we cannot do this—everyone hears each story differently; yet, the point remains that the patient is a person with a story and the doctor needs to be attentive to that story and its relation to his or her own.

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__________________________________________________________________ It is the case that patients who are chronically ill challenge the dominant biomedical narrative of diagnosis, treatment, recovery. Patients who do not get well may pull providers into a different kind of relationship—one that is less hierarchical. When the doctor can no longer rely on expertise and medical technology to treat the patient, when all options for helping the patient get well are exhausted, it is the person of the doctor who must face and be with the person of the patient. This is what the doctor must understand and ought not to fear. A doctor not only helps patients get well, a doctor can help patients live with pain. As Broyard writes: [N]ot every patient can be saved, but his illness may be eased by the way the doctor responds to him—and in responding to him the doctor may save himself. But first he must become a student again; he has to dissect the cadaver of his professional persona; he must see that his silence and neutrality are unnatural...In learning to talk to his patients, the doctor may talk himself back into loving his work. He has little to lose and everything to gain by letting the sick man into his heart. If he does, they can share, as few others can, the wonder, terror, and exaltation of being on the edge of being. 23 Health care providers are privileged in their access to some of the most dramatic moments in a person’s life. The more open they are to patients’ stories and the more richly textured their understanding of human nature, the greater their flexibility and resources for caring for their patients and the more meaningful the work. There is vast mystery in ‘being on the edge of being’ but health care providers need not be afraid of it. True stories are generally inconclusive, untidy, open to interpretation. Patients and health care providers are true stories.

Notes 1

D Patterson, ‘Mikhail Bakhtin and the Dialogical Dimensions of the Novel,’ The Journal of Aesthetics and Art Criticism, Vol. 44(2), 1985, p. 131. 2 B Malinowski, Argonauts of the Western Pacific: An Account of Native Enterprise and Adventure in the Archipelagoes of Melanesian New Guinea, Routledge, London, p. 18. 3 L Mehl-Madrona, Narrative Medicine, Bear & Co, Rochester, VT, 2007, p. 52. 4 L Mehl-Madrona, op. cit., p. 53. 5 A Broyard, Intoxicated By My Illness, Ballantine Books, New York, 1992, pp. 20-21.


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RA Hilbert, ‘The Acultural Dimensions of Chronic Pain: Flawed Reality Construction and the Problem of Meaning,’ Social Problems, Vol. 31(4), 1984, p. 374. 7 E J Cassell, The Nature of Suffering, Oxford University Press, New York, 1991, pp. 30-47. 8 E J Cassell, op. cit., p. 112. 9 RA Hilbert, op. cit., p. 373. 10 A. Kleinman, The Illness Narratives: Suffering, Healing, and the Human Condition, Basic Books, New York, 1988, p. 181. 11 R Kugelmann, ‘Complaining About Chronic Pain,’ Social Science and Medicine, Vol. 49, 1999, p. 1671. 12 R Kugelmann, op. cit., p. 1671. 13 A Broyard, op. cit., pp. 45. 14 DS Morse, MD; EA Edwardsen, MD; HS Gordon, MD, ‘Missed Opportunities for Interval Empathy in Lung Cancer Communication,’ Arch Intern Med, Vol. 168(17), 2008, pp. 1853-1858. 15 LN Dyrbye, et al. ‘A Multicenter Study of Burnout, Depression, and Quality of Life in Minority and Nonminority US Medical Students,’ Mayo Clin Proc., Vol. 81(11), 2006, pp. 1435-1442. 16 T Shanafelt, ‘Enhancing Meaning in Work: A Prescription for Preventing Physician Burnout and Promoting Patient-Centered Care’. JAMA, vol. 302(12), 2009, pp. 1338-1340. 17 MS Krasner, RM Epstein, H Beckman, AL Suchman, B Chapman, CJ Mooney & TE Quill. ‘Association of an Educational Program in Mindful Communication with Burnout, Empathy, and Attitudes Among Primary Care Physicians,’ JAMA, Vol. 302(12), 2009, pp. 1284-1293. 18 T Shanafelt, op. cit., p. 1340. 19 A Broyard, op. cit., pp. 55. 20 R Schank, Tell Me A Story: A New Look at Real and Artificial Memory, Northwestern University Press, Evanston, IL, 1990. 21 R Charon, ‘Narrative and Medicine,’ New England Journal of Medicine, Vol. 350(9), 2004, p. 862. 22 A Frank, op. cit., pp. 201-02. 23 A Broyard, op. cit., pp. 57.

Bibliography Broyard, A., Intoxicated By My Illness. Ballantine Books, New York, 1992. Cassell, E.J., The Nature of Suffering. Oxford University Press, New York, 1991.

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__________________________________________________________________ Charon, R., ‘Narrative and Medicine.’ New England Journal of Medicine. Vol. 350(9), 2004, pp. 862-864. Dyrbye, L.N., et. al., ‘A Multicenter Study of Burnout, Depression, and Quality of Life in Minority and Nonminority US Medical Students.’ Mayo Clin Proc. Vol. 81(11), 2006, pp. 1435-1442. Frank, A., ‘Just Listening: Narrative and Deep Illness.’ Families, Systems & Health. Vol. 16.3, 1998, pp. 197-212. Hilbert, R.A., ‘The Acultural Dimensions of Chronic Pain: Flawed Reality Construction and the Problem of Meaning.’ Social Problems. Vol. 31(4), 1984, pp. 365-378. Kleinman, A., The Illness Narratives: Suffering, Healing, and the Human Condition. New York: Basic Books, 1988. Krasner, M.S., et. al., ‘Association of an Educational Program in Mindful Communication with Burnout, Empathy, and Attitudes Among Primary Care Physicians.’ Vol. 302(12), JAMA. pp. 1284-1293. Kugelmann, R., ‘Complaining about Chronic Pain.’ Social Science and Medicine. vol. 49(12), 1999, pp. 1663-1676. Malinowski, B., Argonauts of the Western Pacific: An Account of Native Enterprise and Adventure in the Archipelagoes of Melanesian New Guinea. Routledge, London, 2001. Mehl-Madrona, L., Narrative Medicine. Bear & Co, Rochester, VT, 2007. Morse, D.S., et. al., ‘Missed Opportunities for Interval Empathy in Lung Cancer Communication.’ Arch Intern Med. Vol. 168(17), 2008, pp. 1853-1858. Patterson, D., ‘Mikhail Bakhtin and the Dialogical Dimensions of the Novel.’ The Journal of Aesthetics and Art Criticism. Vol. 44(2), 1985, pp.131-138. Schank, R., Tell Me A Story: A New Look at Real and Artificial Memory. Northwestern University Press, Evanston, IL, 1990.


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__________________________________________________________________ Shanafelt, T., ‘Enhancing Meaning in Work: A Prescription for Preventing Physician Burnout and Promoting Patient-Centred Care.’ JAMA. Vol. 302(12), 2009, pp. 1338-1340. Mary Buchinger Bodwell is Associate Professor of English and Communication Studies at the Massachusetts College of Pharmacy and Health Sciences, Boston, Massachusetts, U.S.A.

Section 3

Narrative Textuality and Revolt: Speaking the Body of Pain

Eros and Thanatos: The Murderous Struggle of Pain and Desire in Gabriele D’Annunzio’s Triumph of Death and in Lars von Trier’s Antichrist Angela Tumini Abstract What can Gabriele D’Annunzio, Italy’s most controversial poet, novelist and playright, possibly have in common with a contemporary Danish filmmaker such as Lars von Trier? The answer could be that they both developed a lifelong delight in breaking conventions and rules. D’Annunzio’s novels and poems riddled with sensuality, and his unruly lifestyle and political ideas earned him much scorn and despise by the public and by the Catholic Church. Von Trier’s films have been marked by unusual manipulations of sound and image, by hand-held cameras and improvised dialogue, and by real sex and art stills inserted into the narrative, which have proved to be disturbing for some of the viewers. A lot of the analogies between these two artists, however, spring from their search for spiritual or heroic transcendence, and from the way in which they underline the fact that evil is inherent to human nature simply because it is a pre-existing condition. This paper will analyse the way in which Gabriele D’Annunzio and Lars von Trier utilize their own pain as a stimulus to their works and repeatedly discover that it is impossible to address evil without perpetuating it. For this reason, human nature is revealed as dark, broody and often utterly perverted, especially when dealing with the question of relationship between the two sexes. As an example, I will be using Trionfo della morte/Triumph of Death, one of D’Annunzio’s best known novels which is part of the Trilogia della rosa/Trilogy of the Rose, and Antichrist, von Trier latest and much criticized movie. Key Words: Eden, misogyny, Triumph of Death, Antichrist, D’Annunzio, von Trier, self-torment, sexuality, death, pain. ***** 1. Eden and Eve In The Virgin Mary’s Cult and Re-emergence of the Goddess, Geoffrey Ashe discusses at length the question of the Eternal-Womanly, or, to put it in Goethe’s words, the Ewig-Weibliche; that is the question of how in the world, before the rise of any verified gods, human beings worshipped goddesses. He points out that, in passing from pre-history to the oldest recoverable rituals and myths, the EternalWomanly is one at her apogee. This imagery flowered without dispute into a goddess-centred religion.1 Thus, when the myth and folktale of Eve in the Old Testament and of Mary the Virgin in the New, are discussed, it becomes apparent that these stories were not there put on record for the first time. Christian thinkers

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__________________________________________________________________ imposed their own theological structure upon these subjects. The subjects reflect the contrast between the age of sorrow and distress (the age of Eve) and the age of the holy life-giving Mother (the age of Mary). Eve, once called ‘ the mother of all living’ after the fashion of the great mother-goddesses, eventually became the ‘woman of death’ as compared with Mary, ‘woman of life’.2 The onus placed upon the Eve figure forms a narrative thread which gathers weight throughout Gabriele D’Annunzio’s Triumph of Death and Lars von Trier’s Antichrist, presenting, nevertheless, some complex and twisted angles in the adaptation of the story. Ippolita, the heroine in Triumph of Death, is an independent, defiant and earth-bound woman who takes no part in any life-process, she is in fact sterile. Ippolita is more than just D’Annunzio’s fictional creation: in her we find echoes of Francesca da Rimini in Canto V of Dante’s Inferno, and could be seen flying at the side of the devil with Bulgakov’s Margarita. She represents, in other words, the traditional model of femme fatale. Ippolita drives Giorgio, the male protagonist, to psychological dysfunction by usurping his masculine authority which makes him ‘inept’ for his traditional patriarchal role in society. For this reason D’Annunzio has often been accused of misogyny. 2. Misogyny, Death and Desire Greek literature considered misogyny to be an anti-social condition, in that it ran contrary to the perception of the value of women as wives. Some feminist theory suggests that misogynists think in terms of mother/whore dichotomy, where they hold that women can only be ‘mothers’ or ‘whores.’ In D’Annunzio’s Triumph of Death, there is a clear distinction between the mother being the consolatrix unica, and the lover/whore who is the source of disruption. Ippolita represents also the incarnation of the sexual desires of her lover who yields to her disarming allure and destructing power. At the last Cannes festival, Lars von Trier’s Antichrist was awarded an ad-hoc prize for ‘most misogynist movie’ by the Jury. In this film, a couple known as She and He journey to their remote cabin in a forest in search of Eden. The couple is attempting to get over the loss of their toddler son who fell out of a window to his death while they were having sex. One may add that She, in this movie, resembles in some ways von Trier’s Medea and the story of the brutal hanging of her children, highlighting a key autobiographical theme, namely that children are being sacrificed for the selfish desires of adults. Moreover, autobiographical traces arises if we consider that, according to Freudian psychology, the mother/whore complex often develops when the sufferer is raised by a cold and distant mother, something that happens to be the case for this film director. ‘My mother didn't give me a childhood. If I were to say, will I die tonight, she would say ‘Perhaps’3, stated Lars von Trier in one of his interviews. In Antichrist, the mother/whore dichotomy is marked by a bloody denouement involving both male and female castrations and physical torture. The cabin where the couple retreats, in the forest/ Eden, is where the wife/Eve descends into

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__________________________________________________________________ gruesome violence and self-mutilation. Nevertheless, to say that Antichrist is merely a screed against womankind is quite a simplistic a conclusion. Von Trier creates an atmosphere of brooding malaise through a visualization of the dark heart of human nature. In the woods things get very strange very fast and remain unexplained the whole time. The couple fall asleep to an ominous rain of acorns on the roof and constantly find themselves confronted with animals eating their own young. Like Giorgio in Triumph of Death, He, in the Antichrist, tries to master the mystery of female’s psyche; moreover, he endeavours to pit reason against the irrational with cognitive therapy. Von Trier made the film after experiencing a nervous breakdown that debilitated him for about six months. Therefore, it is imbued with his disdain for cognitive therapy as a way to alleviate the angst of existence. Von Trier unveils throughout the movie his profound distrust for therapists who claim that they can establish a connection between thoughts and psychological pain, and for those who believe that they can appraise the accuracy of those thoughts creating anxiety. In Antichrist, He convinces She to become his patient, but her resentment towards his therapeutic exercises materializes in their natural surroundings. Eve’s Garden of Eden is overwhelmed by darkness resembling some of the circles of Dante’s Inferno. In Triumph of Death, D’Annunzio combines in Ippolita an image of the serpent of Genesis by conceiving her as ‘snella e lunga piena di serpentine eleganze /thin and tall and elegant like a snake’4, with that image of the biblical Eve, the temptress. There is a conjunction of Eros and Thanatos forces in this novel as life and death seem to be in continuous dialogue. In Dannunzio’s case, the influence of his background culture should not be under estimated, since much of his works was coloured by the folklore of his native Abruzzo. This is a region in Italy where the death rituals are alive to this day. His obsession with the love/death dichotomy may have been influenced by a ‘popular’ genre known in Abruzzo with the name of Verbumcaro. This was a form of tenzone: a fictional debate that took place between the living and the dead. This tradition, according to the folklorist Giovanni Pansa, was in existence in several places in the region and was performed on its streets until recent times: Due cantastorie, per lo più ciechi, siedono a conveniente distanza sul limitare di due case; uno rappresenta il morto, l’altro il vivo; ovvero, l’uno l’anima e l’altro il corpo. L’anima rim provera al corpo i suoi trascorsi peccaminosi, gli rinfaccia i piaceri della carne.5/.Two story tellers, often blind, sit facing each other between two houses; one represents the dead, the other represent the living; that is to say that one man symbolizes the body, the other symbolizes the soul. The soul reproaches the body for his past sins, for the pleasure of the flesh, for his lust for carnal life.

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__________________________________________________________________ Since Ippolita, in Giorgio’s eyes, desires to attain full knowledge of sexual life and of all the feminine power that she can gain from it at his expense, the Verbumcaro is reflected in Giorgio’s spiritual struggle against Ippolita’ sensuous predominance. Giorgio’s discomfort stems from knowing that his love offers him no possibility of escaping moral decadence: In questi due anni d’amore, ella è giunta a poco a poco a limitare la mia attività materiale nelle cose dei sensi; è giunta ad acquistare quasi il privilegio delle carezze.6./ In these past two years of loving, she has managed to limit my material abilities to the purely sensual ones; she has managed to gain the exclusiveness of all my caresses. Giorgio recognizes the supremacy of his lover and his physical and emotional experience of her is transformed into a piercing pain, which is redolent of a falling victim for the allure of a predator. Indeed, Ippolita like other Dannunzian fictional women, appear to be, to use Charles Klopp’s words, ‘the product of D’Annunzio’s sexual fantasies rather than the depictions of autonomous feminine personalities.’7 Like Eve who seizes the fruit that will endow her with potency, Ippolita seeks to get the better out of her lover by grasping emotional control from his hands. With that corrupting, but overwhelming passion, the woman debilitates her lover, making him dependent and turning him into an object. The psychological pain is exacerbated by the male protagonist’s awareness of the impossibility of fully possessing the ‘other’ in the relationship, and by the realization that there cannot be real communication between the two sexes. Giorgio grows increasingly aware of the illusory side of human relationships; for this reason, he begins to responds to the demands of his inner self which seeks eternal tranquillity of the spirit: Egli disse: ‘Beati i morti perchè non dubitano più.8 He said: ‘Lucky is the dead since he doubts no more’. This psychological and spiritual isolation propelled by self-torment and selfinflicted pain leads Giorgio to resolve to the idea of annihilation as the only possible solution. Giorgio renounces his ties with other entities beyond the limits of his own ego and plunges off a cliff towering above the Adriatic, dragging with him his imploring lover. After a brief season of passion and hope, Giorgio and Ippolita are fated to disappear and re-emerge in more legendary light, transfixed into the eternity of memory which has defeated reason 3. Male and Female In Antichrist, it is indeed reason which is annihilated while a criminal folly takes place and an unchecked nature of human bestiality comes alive. Unlike

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__________________________________________________________________ D’Annunzio’s Triumph of Death, the gender confrontation between man and woman that takes place is not intended as a confrontation between two separate entities. Von Trier sees the nature of man as dualistic. The female force of nature is within the man himself and can stir up some devastating forces resembling the one of a mythological and blood-thirsty harpy. The ‘She’ that ‘He’ confronts lives within him, and in order to return to his oneness he must kill his ego. The women we see walking past the male protagonist in the last scene are not outside of him but within him, and they are made into the symbol of redemption through the sacrifice of the female protagonist. Like D’Annunzio, however, von Trier sees sexuality as a corrupting force, which drags mankind into insanity, sadism, and bestiality that inhabits human nature as a result of an ancestral chaos which condemns us at birth; thus castration in the film is used as a means of spiritual purification. It is obvious that symbols are deeply woven into the fabric of Antichrist and Triumph of Death, and in both works nature takes on a major role. In the film, nature is taken as a locus of pain and its evil precedes man before history, reason and civilization. The three names: despair, grief and pain, appearing in the initial scenes of the film are present in the child's room before he falls out of the window. These three emotional conditions are conceived as the three angry beasts which force Dante to turn back as he attempts to climb toward the light on the hill. In Triumph of Death, the natural element is associated with the sea and it is contemplated as a tableau of death and the transience of life itself by Giorgio. The male figure is depicted as tending towards order, in search of the logic and the rational elements of life. On the opposite end we find the woman figure that symbolizes chaos, nature, the irrational, the primitive. The waters, in Triumph of Death, are to wash away Giorgio’s exacerbated anguish caused by his inadequacy and by the ephemeral character of love; that is to say that eternal anguish springing from man’s unquenched desires. 4. Conclusion Here we have two artists born one hundred years apart who are brought together by the universal language of pain. The pain inflicted on us by the angst that springs directly from unanswered existential questions. Gabriele D’Annunzio and Lars von Trier took literary and cinematic allegory to their logical conclusion and reminded us that they can be complex, subtle, dialectical, real and open to multiple readings. In all their extremes the stories they chose to tell us have parallels in that of others and in the story of human existence. One may even argue that Arthur Symons’ s review of the Triumph of Death, written in 1898, can be adequately applied to Antichrist in spite of its time: Here are a man and a woman: I can scarcely remember their Christian names, I am not even sure if we were ever told their

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__________________________________________________________________ surnames; and in this man and woman I see myself, you, everyone who has ever desired the infinity of emotion, the infinity of surrender, the finality of possession […]. The lovers of the Triumph of Death might well be ourselves, evoked in some clouded crystal, because they have only so much of humanity as to have the desires, and the dangers, and the possible ecstasies, and possible disasters, which are common to all lovers who have loved without limitation and without wisdom.9

Notes 1

G Ashe, The Virgin Mary’s Cult and Re-emergence of the Goddess, Arkana, New York, 1976. 2 For this comparison see: M Brackenbury Crook, Women and Religion, Beacon Press, Boston, 1964, p.152. 3 See: K Badt, ‘Most Hated Director at Cannes: Lars von Trier as Antichrist or Shaman?’ The Huffintgon Post, Posted May 29, 2009. 4 G D’Annunzio, Prose di romanzi, Mondadori, Milano, 1988, p.808. 5 G Pansa, Miti, leggende e superstizioni dell’Abruzzo, Arnaldo Forni Editore, Bologna, 1978, p. 353. 6 G D’Annunzio, Prose di romanzi, Mondadori, Milano, 1988, p.807. 7 C Klopp, Gabriele D’Annunzio, Ohio State University, Twayne, 1988, p.122. 8 G D’Annunzio, Prose di romanzi, Mondadori, Milano, 1988, p.646. 9 A Symons, ‘D’Annunzio in English,’ Saturday Review, Vol. 1, 1898, pp.18-24.

Bibliography Ashe, G., The Virgin Mary’s Cult and Re-emergence of the Goddess. Arkana, New York, 1976. Badt, K., ‘Most Hated Director at Cannes: Lars von Trier as Antichrist or Shaman?’ The Huffintgon Post. May 29, 2009. http://www.huffingtonpost. com/karin-badt/most-hated-director-at-ca_b_208880.html. Brackenbury Crook, M., Women and Religion. Beacon Press, Boston, 1964. Björkman, S., Trier on von Trier. Faber and Faber, London, 2003. D’Annunzio, G., Prose di romanzi. Mondadori, Milano, 1988.

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__________________________________________________________________ Hjort, M. & Bondebjerg, I., The Danish Directors Dialogues on Contemporary National Cinema. Intellect Books, Bristol, 2003. Klopp, C., Gabriele D’Annunzio. Ohio State University, Twayne, 1988. Nestingen, A. & Elkington, T.G., Transnational Cinema in a Global North Nordic Cinema in Transition. Wayne State University, Detroit, 2005. Pansa, G., Miti, leggende e superstizioni dell’Abruzzo. Arnaldo Forni Editore, Bologna, 1978. Symons, A., ‘D’Annunzio in English.’ Saturday Review, Vol. 1, 1898, pp.18-24. Angela Tumini is an Assistant Professor of Italian Studies at Chapman University in California. Her research interests span 19th & 20th century Italian Literature, Italian Cinema and comparative European cinema. She is currently working on a project in which she analyzes the connection between Italian literature, cultural movements such as Futurism and Neo-realistic cinema with contemporary Danish cinema and the works of Lars von Trier in particular.

Gravity’s Rainbow: The Baroque Folds and Contanus Sese Conservandi in Tarsem Singh’s The Fall Yen-Chen Chuang ‘If, in all that you will you begin by asking yourself: is it certain that I will do it an infinite number of times? This should be your solid centre of gravity.’ - Nietzsche Abstract Following the philosophical notion of conatus (endeavour), this paper discusses the relationship between motion, emotion, and pain in Tarsem Singh’s 2006 film The Fall. In the Newtonian physics, conatus refers to a state of inertia, a force that keeps planets moving along their orbits. Such force that occurs at a distance, so to speak, is a force of gravity. Later, Spinoza associates conatus with a motion governed by emotions. The principle of conatus is based on a passion or endeavour to avoid pains. As gravity makes possible the dynamics of attractive and repulsive forces, conatus conditions two emotions opposing each other, pleasure and pain. Spinoza uses the term conatus sese conservandi (the striving for self-preservation) and insists on the being’s will to live. At some level, the experience of living is considered choreography of pleasure and pain. In Singh’s film, whirls, rotations, dances, and fans are essential to create tensions in which the hero strives to live. Despite his death wish, the movie’s Baroque folds have produced a stunt that defies gravity. The hero’s attempt to commit suicide, a fall condemned because of loss, finally leads to levitation of pains. However, it is not simply a victory in which weightlessness overcomes gravity. A will to live is somehow akin to a will to suffer. Suffering repeats itself like a musical note in a consonant counterpoint. For Singh, life is a Spezialfall of gravity—it not only owns the power to drag down but also heaves the objects to a certain kind of glory. The Bacchanalian dance can be profoundly noble. In the film, the protagonist features a monadic conatus, and manages to take action of his own accord. The monad, though situated in a static windowless room, is able to move like a fluid vortex. The hamstrung patient, in the cinematic imagination, performs a dazzling ballet out of suffering. Further, I argue that the director’s Baroque style is predicated on a sense that the characters are always on the verge of falling. As Deleuze sums up, ‘[t]he Baroque itself already marks a crisis in theological reasoning—a final attempt to reconstruct a world that’s falling down’ (N, 161). This vertigo, the danger of tumbling down, envisions the law of gravitation nothing but various curvatures or recurrent patterns unfurling the eternal return of sufferings. Key Words: Tarsem Singh, Deleuze, Baroque *****

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__________________________________________________________________ 1. The Rainbow of Baroque Folds Johann Wolfgang von Geothe once observes that all colour is a phenomenon bordering between light and darkness. Pigmentation is an infinite chiaroscuro (dark-light) in which black and white shimmers fluid iridescence. At centre of the prismatic circus is the gravity of lightness. How does the human fall immerse itself into the force of light and nebulosity? Confronting Mephistopheles, the doctor advances and falls, emitting an ever-creasing and increasing radiance deflected under gravity. The first edition of Faust contains an etching by Rembrandt, which depicts the study of a scholar. In Rembrandt’s portrait, the light emerges from the dark background (See figure 1). The scholar’s gaze is directed toward a disk inscribed with a mysterious text.1 The light here, seeping through the window, seems to be absorbed into obscurity. Looming behind the light are the silhouetted apparitions confusing illumination with a larger regime of darkness. From this perspective, we might as well make an analogy between the doctor’s study room and the Baroque chamber, an enclosure corresponding to the Leibnizian monad. Deleuze characterizes the Baroque architecture as having two levels constituting the cryptic construction. The upper level has the tendency to weightlessness and belongs to interiority, while the lower level is charged with heaviness and figured as the façade. It wouldn’t be a stretch to say that light and reason are sealed inside whereas scream and pains remain the walls—what a cinematic screen/scream manifests is an explosive inside. The walls of the house are the multi-layered expression of the world. This expressivity of the monad embraces reason that has its own gravity—reason in the face of collapse, reason that screams. Such a struggle is a swirling movement often seen in Baroque architecture (eg. the Solomonic columns of Bernini’s Baldacchino or the spire of Vor Frelsers Kirke). The irregular pearls exist only with a liquid exterior. The wavy façade paves a gradient, a gradation, a gravisphere that either defies its own law or pushes the envelope of deceleration. Beyond its historical limits, Baroque signifies a crisis of living and reasoning. In Van Gogh’s starry night or Frank Lloyd Wright’s ceiling, we discern the patterns of curves purling throughout the firmament. The so-called ‘moment of union between inner self and outside world’ (Purce, qtd. Hargittai, 19) is rather a maelstrom of madness. A spiral, even in the form of a closed loop, is open to the world and full of an immediate tension of emotions. Tarsem Singh’s The Fall, set in a hospital in Los Angeles during the 1920’s, begins with a stuntman telling a story to a little girl. The director, who has previously taken his cue from Caravaggio in his musical video (R.E.M.’s ‘Losing My Religion’), dramatically parallels light with darkness to create a revved-up space. The visual style of the film, with its Baroque legacy, presents a kaleidoscopic fantasy exemplified in the scene where the girl sees the light filtered through a keyhole—a device of camera obscura—a monadic point of view perceived from a dark room shut inside. Deleuze’s black marble room has an

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__________________________________________________________________ aperture, and so does Tarsem Singh’s hospital ward. If the walls of a Baroque house are adorned with trompe l’oeil, it is in a similar way that Singh’s film is set into motion via visual tricks. The cinematic illusion seems to lure the audience to an abyssal, vertiginous weightiness. At the outset of the movie the hero’s suicide already foreshadows a series of falling movements. The ostentatious theatricality performed by our heartbroken stuntman is impossible were it not for the motion of free fall. After he jumps into the river with a horse, a rope is thrown from the high bridge like a glissando. This is a Baroque line that folds and enfolds itself ad infinitum, a parabola that introduces differential vectors and speeds. In a way, the director’s parabolic trajectory describes a spatialized emotion pertain to the suffering state of Leibniz’s monad. Open to an emotive vulnerability, one can feel painful to the extent that he or she faints: ‘when one turns around and around in the same direction, a dizziness comes in, which makes him swoon and makes him able to distinguish nothing. Among animals, death can occasion this state for quite a period’.2 Unable to come to rest, the monad faces the danger of losing consciousness as it moves along an orbit. In other words, it is through endless activities that a monad gives rise to suffering or an animal-like death. Each monad is a Humpty-Dumpty whose great tumble causes actions and passions in relation to each other. To put the broken pieces together is impossible since everything is falling apart. With regard to this deconstructive nature of monadology, Gregg Lambert states, ‘the principle characteristic of the monad is an extreme vertigo, or dizziness, brought on by extreme heights even though it lives in a room located on the second floor.’3 In Singh’s film, whirls, rotations, dances, and fans are essential to create tensions in which the hero strives to live/die. Roy Walker, the paralysed patient who cannot walk at all, fulfils his actions with a discrete body—the broken limbs of Orpheus or Dionysus. His passion toward the princess is predicated upon an act of descending, followed by the appearance of a fan-mask. Indeed, one cannot fall in love without a fall. The lush costume of the princess, in Eiko Ishioko’s design, brings into play Japanese fans reminiscent of lotus petals and butterflies (Darwin’s remark). The fan functions as a veil oscillating and generating veil after veil. Recall Deleuze’s figuration of the fan: ‘At times the open fan makes all particles of matter, ashes, and fog rise and fall,4 the process of folding is a stairway up-anddown that causes the masked bandit’s giddiness. In the later wedding scene, the bride again wears a beaded veil, and our bandit is obviously under the influence of ubiquitous spirals, surrounded by a group of dancing dervishes. The priest’s trick turns out nothing but a trick of trompe l’oeil, an apparatus leading to a series of errors. Folds, pleats, fringes and creases are at core of dramaturgy through which a monad expresses itself and projects the world onto the walls. For any critic who complains of Tarsem Singh’s lack of depth, it is noteworthy that the depth of suffering is already manifested on surface as a scar. The façade is not made of materials of heaviness strictly stratified and layered but a kind of flowing fabric

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__________________________________________________________________ with mobility. In vestmentary terms, textures are products of spinning during which motions and emotions are weaved together. 2. Possessing Lucretia Upon seeing the veiled princess, Roy makes a declaration: ‘Boys, she’s mine.’ This passion is accompanied by his attempt to free the slaves as if freedom, whatever it means, is the by-product of an action of taking possession. As free as the air, but be that as it may, what exactly is the autonomy of a gale? Is it possible for air to be free of ghosts, that is, a spirit without a spirit? What is at stake here is not the object of possession, but the site of possession, a haunting place that sets a motion of the wind. Nurse Evelyn is also a mountain (Everest) and a heart (Everhardt); this ventricle placed in the highest, stolen by Roy, has become a topographical abstraction, a space filled with breath of life, an Eve that is a creature of air. Irigaray, in her discussion of dwelling, postulates that air is ‘a universal matter of living.’5 Air makes possible to transform a falling into a flight. The Indian’s wife, the most beautiful squaw/squall in the world, throws herself from the labyrinth to fly like a bird. She is, like Evelyn, a bottomfly, who seeks to dwell in another place. The wind nourishes, and yet chops, changes, and provides a choppability or cuttability of essence. Alexandria witnesses a boy to be chopped when she steals the drug. The birds are flying from the mystic’s mouth when he’s been chopped. The breath taken away from me, the breath I take for granted, the breath I steal: all these would be pointless if it is not on the ground that we do possess air. The air is the fundamental ground of being. One cannot dwell or walk except in the air. Grounded, encompassed by the warm air, beings are thus able to swing into actions. Alexandria keeps all her treasures in a box. From the outset, her possessions have haunted Roy’s epic tale: the photo, the elephant, and the gap in the teeth. The possessor is the possessed. She begins to be possessed by her enchanter as he himself later realizes that he has fallen in love with his foe. This, I should say, is the fall-etics of possession. The sense of possession, in effect, reminds us of the Hamletian question as to the essence of being. The kid-napped princess, no longer a captive, conditions an affirmation of existence. Roy cannot live without her, or rather, without his fantasy of love, and he certainly won’t convalesce but for another fantasy of having the little girl. Does the ability ‘to have or not to have’ call into question the fundamental existence of being (the issue here is considered à la Deleuze rather than Lacan)? The monad has to possess a body in order to perceive pains or pleasure. All possession, at some level, only reflects the necessity of selfpossession. For Deleuze, possession is a form of folding: ‘To have or to possess is to fold’.6 The act of fold seems to render possession a positive attribute. However, a full possession is hardly possible inasmuch as passion is at work. Etymologically related to suffering, a passion without an adequate reason is conceptualised as passivity. Driven by the force of the wind, the obscure object I must possess is ever

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__________________________________________________________________ elusive as there would be no object/subject at all in pure passivity. I must kill myself—but this object for me to kill has already vanished. To give up the ghost; to give up nothing. In a death-like state, dark dusts agglomerate and dance together. The spirit who lingers in the graveyard strangely clings to the principle of possessing. Such free air loaded with heavy matters denotes not only ‘an excess of air’7 but also an excess of desire or perceptions. Roy has indicated that for Evelyn to follow her heart she has to follow the wind. Through the pneumatic folding that gives breath, the aerial soul soars over the abyss and gains the power of motion. Striving to come into possession of the power to act, numerous micromonads constitute an affective network already decomposed and disseminated in the lawless, wild, wild wind. In the Being’s throwness into the air, pleasure and pain are mixed; life and death are converged. A pain in dispersion is a sylph, a spirit, and hence cannot be dispirited. Deleuze writes thus: ‘How could a pain follow a pleasure if a thousand tiny pains or, rather, half-pains were not already dispersed in pleasure, which will then be united in conscious pain?’8 At this point, suffering is not derived from pain. It is suffocation caused by the lack of air. With regard to the logic of having, Deleuze notes that ‘all monads possess an infinity of compossible minute perceptions.’9 Elsewhere, he further makes explicit the link of mini perceptions as a crowd to the effect of harmony: ‘reciprocal determination of differentials does not refer to a divine understanding, but to tiny perceptions as representatives of the world in the finite self…The infinite present in the finite self is exactly the position of Baroque equilibrium and disequilibrium.’10 The tiny pains and tiny pleasure together contour an area of penumbra that is neither light nor darkness. The infinity of shadows, emerging from the dynamic between two floors, therefore sings a harmonious hymn out of discordant differences. Reason and imagination/unreasonable emotions achieve a contradictory harmony. This economy of resonance based on polyphony should not be accounted a suppression of dissonance. Rather, it is full of indistinct noises and obscure murmuring. As Deleuze discerns in Kant a cleft between the faculties of reason and imagination, what Roy’s imaginative fantasy engenders is an intrusion into reality, an effect akin to ‘harmony in pain.’11 To consider Deleuze’s statement that ‘the resolution of dissonance is tantamount to displacing pain,’12 we might as well assume that the space of suffering is a kind of discordant-accord, an accord that introduces dissension. In ‘Putting the Virtual back into VR,’ Andrew Murphie points out that ‘[p]leasure and pain are intrinsically related in testing…harmony’s limits.’13 In their harmonious accord, pain and pleasure are predicated upon each other. The two sensations produce a tune of double stop typical of Bach’s counterpoint that reminds us so often of the flying angels’ praise of God, the glorified hymn performed before they perish. Since, in Leibniz, angels do have a body, it might not be far-fetched to assume that no angels are exempt from falling. After all, all celestial bodies are under the influence of gravity, according to the eighteenth-century philosophy.

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__________________________________________________________________ Although the film opens with Beethoven’s Seventh Symphony instead of traditional Baroque music, it is noteworthy that the allegretto itself provides a dizzy example evoking the sense of tumbling down. Beckett once describes the piece as ‘nothing but a path of sounds suspended in giddy heights, linking unfathomable abysses of silence.’14 The ghostly pauses, expressive of a certain joyful feeling, nonetheless orchestrate a harmony that suppresses neither pain nor dissonance. With a sublime atmosphere, the second movement plays a melancholic theme verged on heaviness. It reveals, as the premiere of the composition may suggest, the pain of a war. In the director’s own words, the musical score creates ‘a lot of chaos, but not much energy.’15 How does falling, a sensation often associated with negative feelings or experiences such as pain, activate a movement that is under the governance of inertia? 3. Falling and Self-Preservation In Newton’s physics, conatus (literally meaning ‘endeavour,’ or a ‘force’) refers to a state of inertia. Such force that occurs at a distance is a force of gravity. In Mathematical Principles of Natural Philosophy, Newton evokes the principle of inertia: ‘every body perseveres in its state of rest, or of uniform motion in a right line, unless it is compelled to change that state by forces impressed thereon.’16 On one hand, inertia is a phenomenon of inactivity. On the other, it presupposes an absolute motion, a duration of the existence that strives to persevere. Inertia, as an inherent force within matters, creates a tension even when moving in a monotonous, straight line. And duration, we might say, stores a great deal of passion and infinite productivity. To endure in one’s existence, so to speak, is to maintain a state of continuous variation. To a great level, the endeavour to remain is not tantamount to an endeavour to be not affected. Instead, conatus makes an effort to effect a change, to effect an affect. Later, in Spinoza’s reformulation of conatus, it becomes a principle of life, and thus the criterion for good and evil. What defines the good is the will to live, the desire to continue. The conatus constitutes one body’s relation to others’. A good encounter between bodies generates affects of joy, whereas in a bad encounter we experience sadness or pain. The fall of Adam, according to Spinoza, is not a result of God’s punishment. It is not a moral judgment. God simply indicates a natural consequence of a poisonous fruit—’you shall die if you eat the fruit’. Adam ignores or misinterprets the warning and hence encounters a body that does not agree with his own. A bad encounter brings about the human fall, accompanied with sorrow and loss. Adam’s decision, under the influence of another body, may not be a free will, but it expresses his desire—a will to desire, a will to give birth to all kinds of possibility. In the same vein, a free fall should not be understood as free at all, it is indeterminate, like a pendulum oscillating under the force of gravity. Seen this way, falling is no longer merely a descending movement. It consists of ups and downs, rise and decline, levitation and sedimentation.

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__________________________________________________________________ In a way, motion is governed by emotions that push human beings to a greater or lesser perfection. In the face of passive affections, conatus initiates a motion strives to live. For Spinoza, the Freudian death instinct is impossible. All we have is a self-preservative instinct. Even in suicide, there is still a hope to change, a hope regarding our after-life. A hope, however deferred, to reach the bottom. The feeling of pain, therefore, does not aim for annihilation. On the contrary, it aims for something un-annihilable. Deleuze discusses sadness in a Spinozean context: ‘In sadness there is something irreducible, something…neither negative nor extrinsic: a passage that is experienced and is real. A duration.’17 Duration as a passage of continuing existence is the attribute of a living thing. It has its infinite mode that plays between sadness, joy, and desire. A body that endures is a body capable of the power of conatus. A nod to the Not (hardship). That is essential to all negativity. The weight is invisible and only leaves traces on durable surfaces. Alexandria’s licking the ice recalls a recurrent image in the movie. It names another form of falling—licking the ground—but it also denotes a speedy motion, to dance at a full lick. Despite the hero’s death wish, the movie’s Baroque folds have produced a stunt that suspends gravity. Singh’s astonishing aesthetics of grace, in contrast to Kleist’s marionette without a soul and affects, augments the emotions of a soul waiting to be saved. Roy, more like a boy with thorn, makes himself a laughingstock by trying to relieve pain out of his foot. In order to regain his bodily grace, the boy simply has to fall again. The mystic’s swallow of a poisonous map, suggestive of the Adamic fall, leads the group to a verdant meadow— ‘It is greener down there.’ The geodesic lines he draws are multi-directional—the pyramids, the Great Wall, the Colosseum, the Eiffel Tower, windmills of Consuegra. At the center of the gravational montage is a graceful jump among various quick cuttings. This speediness, interwoven with immobility and drowsiness, gives the foreground of gravity and impetus of dreams. Roy longs for morphine—the god of dreams. His dream content is full of grandiose dynamism of Baroque. Such hyperbole takes on a double curve, a hyperbola approaching its asymptote (not falling together) without touching together. Morphin3—a drug that ‘combines both ‘word’ and number’ (logos+arithmos)18—has become a logarithm, a disarticulation of language and disruption of mathematical discipline. Alexandria’s gibberish thus puts a joke on gravity. With her message falling down the window, she exemplifies what Paul de Man calls antigrav (anti-gravity), a step away from the grave. As De Man notes, the word ‘Falle’ in German means ‘trap’ or ‘decoy’. Roy’s inveiglement of Alexandria into stealing morphine for him, the serpent’s seduction, turns out to be a fall-acy, an anamorphosis or metamorphosis of their surrounding environment. Each character has a fallen counterpart in Roy’s story. Distortion, deformation, and perspectivism thus constitute a decisive moment of falling into grace.

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__________________________________________________________________ The hero’s attempt to commit suicide, a fall condemned because of loss, finally leads to levitation of pains. However, it is not simply a victory in which weightlessness overcomes gravity. A will to live is somehow akin to a will to suffer, a will to mourn. Suffering repeats itself like a musical note in a consonant counterpoint. ‘He is not the first guy to lose a girl’—Roy performs a cliché of despair. All those repetitive gags, stunts, and smacks at the end, in Sinclair’s sneering, are nothing new. However, it is exactly through infinite repetitions that conatus keeps its momentum. It does not suffice to say that motion is impelled over and over again; the motion is necessarily over-the-top even in descending. Dancing with pain, dancing with vain: nothing can be weightier than grace. Heidegger observes that weightiness (Gewichtigkeit) is at once risks (Wagnisse) and balance (Waage)—an ongoing wagon constantly on the move.19 The center of gravity is losing its ground due to the difficulty and danger it faces. Nonetheless, the being is endangered only when it ceases to engender, when it takes risks of not falling. Alexandria ridicules Alexander’s adventure (Wagnis) for his determination to show all soldiers are equal. A genuine adventure is not to be determined. Squandering water leads to exhaustion, not pure duration—but perhaps Alexander’s case (Fall) simply shows an impotency of determination. His reckless act is a plunge into stupidity, inexplicable because it is deprived of value. This stubbornness, this ‘will to stupidity’20 is unthinkable as it is beyond worthiness. Both Alexandria, the orange-flinger, and Alexander, the king surrounded by an orange desert, are pushing reasoning to the point of miscalculation, misunderstanding, and mischief; one by obduracy, and the other by gibberish and orange-tricks. Here the director evokes the trope of the orange, an orange that turns. The orangey sand, first introduced by Alexander’s spinning movement, reminds us of Rilke’s orange-girl: ‘Dance the orange. Throw its warmer landscape / away from you, until the ripenes shines / amind these native breezes.’21 The orange, peeled, sliced, disseminated, emptied, transformed into a special tree, creates a vertiginous horizon, layers and folds of horizon. It takes over the aptitude from which the horse is galloping down. The flowing latitudinal lines, capable of the force of falling, are revealed from a height, shadowed and nearly traversed by a messenger-rider. In Singh’s movie, a fall is a pall more often than not, but in the hastiest precipitation there is still a lively space, a gust within a dancing body, a seed buried deep, deep down.

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Rembrandt, Van Rijn. ‘Faust.’ Ca. 1652, Rijksmuseum Amsterdam, Amsterdam. 15 February. 2010. http://en.wikipedia.org/wiki/File:Rembrandt,_Faust.jpg.

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__________________________________________________________________ 4. Conclusion As the location of the hospital suggests, dancers do follow the path of lawless angels (Los Angeles). Moreover, angels are partakers of life and striving. At some level, the experience of living is considered choreography of pleasure and pain. The moving bodies become affects of striving, and those bodies are defined through their movements. For Singh, life is a Spezialfall of falling—it not only owns the power to drag down but also heaves the objects to a certain kind of glory. The Bacchanalian dance can be profoundly noble. In the film, the protagonist features a monadic conatus, and manages to take action of his own accord. The monad, though situated in a static windowless room, is able to move like a fluid vortex. The hamstrung patient, in the cinematic imagination, performs a dazzling ballet out of suffering. Further, I argue that the director’s Baroque style is predicated on a sense that the characters are always on the verge of falling. As Deleuze sums up, ‘[t]he Baroque itself already marks a crisis in theological reasoning—a final attempt to reconstruct a world that’s falling down.’22 This vertigo, the danger of tumbling down, envisions the law of gravitation nothing but various curvatures or recurrent patterns unfurling the eternal return of sufferings.

Notes 1

Within the circle there is an anagram that evokes God’s name. See S Perlove & L Silver, Rembrandt’s Faith: Church and Temple in the Dutch Golden Age, Pennsylvania State University Press, 2009, p. 63. 2 GW Leibniz, Discourse on Metaphysics and the Monadology, Prometheus, 1992, p. 71. 3 G Lambert, The Non-Philosophy of Gilles Deleuze, Athlone Press, 2002, p. 66. 4 G Deleuze, The Fold: Leibniz and the Baroque, University of Minnesota Press, 1993, p. 30. 5 L Irigaray, I Love to You: Sketch of a Possible Felicity in History, Routledge, London, 1996, p. 148. 6 G Deleuze, The Fold: Leibniz and the Baroque, University of Minnesota Press, 1993, p. 110. 7 The term comes from Irigaray’s discussion of Heidegger. See L Irigaray, The Forgetting of Air in Martin Heidegger, Athlone Press, London, 1999, p. 40. 8 G Deleuze, The Fold: Leibniz and the Baroque, University of Minnesota Press, 1993, pp. 86-87. 9 Ibid, p. 90. 10 Ibid, p. 89. 11 G Deleuze, ‘The Idea of Genesis in Kant’s Aesthetics,’ Angelaki: Journal of the Theoretical. Vol. 5, no. 3, 2000, p. 63. 12 G Deleuze, The Fold: Leibniz and the Baroque, University of Minnesota Press, 1993, p. 151.

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A Murphie, ‘Putting the Virtual back into VR,’ A Shock to Thought: Expression After Deleuze and Guattari, Routledge, 2002, p. 208. 14 S Beckett, Disjecta: Miscellaneous Writings and a Dramatic Fragment, Grove Press, New York, 1984, p. 172. 15 T Singh, ‘Commentary with Writer/Director,’ The Fall, DVD, 2008. 16 I Newton, ‘Mathematical Principles of Natural Philosophy,’ Principia, Prometheus Books, Amherst, New York, 1995, p. 19. 17 G Deleuze, Spinoza: Practical Philosophy. City Lights Books, San Francisco, 1988, p. 39. 18 P de Man, ‘Aesthetic Formalization in Kleist,’ The Rhetoric of Romanticism, Columbia UP, New York, 1984, p. 266. 19 M Heidegger, Off the Beaten Track, p. 210. Also see, JM Rabaté, ‘The Mujic of the Footure,’ Futures: Of Jacques Derrida, Stanford UP, 2001, pp. 190-3. 20 G Lambert, The Non-philosophy of Gilles Deleuze, Athlone Press, 2002, p. 5. 21 RM Rilke, Sonnets to Orpheus, University of Scranton Press, Scranton and London, 2007, p. 47. 22 G Deleuze, Negotiations, 1972-1990, Columbia UP, 1997, p. 161

Bibliography Beckett, S., Disjecta: Miscellaneous Writings and a Dramatic Fragment. Grove Press, New York, 1984. Deleuze, G., Negotiations, 1972-1990. Columbia UP, 1997. –––, Spinoza: Practical Philosophy. City Lights Books, San Francisco, 1988. –––, ‘The Idea of Genesis in Kant’s Aesthetics.’ Angelaki: Journal of the Theoretical. Vol. 5, no. 3, 2000, pp. 57-70. –––, The Fold: Leibniz and the Baroque. University of Minnesota Press, 1993. Hargittai, I. & Pickover, C., Spiral Symmetry. World Scientific Company, 1992. Irigaray, L., I Love to You: Sketch of a Possible Felicity in History. Routledge, London, 1996. Lambert, G., The Non-Philosophy of Gilles Deleuze. Athlone Press, 2002. Leibniz, G.W., Discourse on Metaphysics and the Monadology. Prometheus, 1992.

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__________________________________________________________________ Murphie, A., ‘Putting the Virtual back into VR.’ A Shock to Thought: Expression After Deleuze and Guattari. Routledge, 2002. Newton, I., ‘Mathematical Principles of Natural Philosophy.’ Principia. Prometheus Books, Amherst, New York, 1995. Rilke, R.M., Sonnets to Orpheus. University of Scranton Press, Scranton and London, 2007.

Media Resources The Fall. Dir. Tarsem Singh. DVD. Sony Pictures, 2008. Losing My Religion. Dir. Tarsem Singh. 1991. Online video clip. Spike.com. Accessed on 1 March 2010. http://www.spike.com/video/losing-myreligion/247857. Yen-Chen Chuang is currently a language teacher at Soochow University. Her research interest includes critical theory, Renaissance, and film studies.

Pain and the Performing Musician: The Interplay of Culture, Cancer and Identity Meghan Neaton, Jean Giebenhain, Sarah Schmalenberger, Lisa Starr, & Charles Gessert Abstract The burgeoning field of performing arts medicine has formally validated what professional musicians have known for years-playing hurts. However, this specialty branch of medicine has yet to examine the role of pain and performance as a result of severe illness. The present study identified female musicians throughout the United States who had recently survived breast cancer. Extensive telephone interviews of 38 respondents revealed a complex interaction among pain, the culture of the professional music world, and the musician’s own concept of self-identity. The fiercely competitive realms within the professional often encourage a ‘play unless you are dead’ mentality. Moreover, many of the women stated that much of their own self-image and identity is derived from being a musician. Thus, the specter of pain to the performing artist represents a threat not only to the physical, corporeal body, but also to the cultural expectations and social world that a musician inhabits, along with her sense of self and psychological wellbeing. The act of denying or ignoring pain, then, becomes a powerful mechanism in achieving a sense of normalcy Key Words: Pain, performing artist, culture, identity, musician, cancer. ***** Every disease is a musical problem, every cure a musical solution.- Novalis1 Pain, as any performing musician can attest, often accompanies the demands and rigors of the professional world. Like their athletic counterparts, performing artists are required to continuously rehearse their craft, training and fine-tuning their bodies to achieve a degree of musical perfection. Whether moving a bow across the strings of a violin or inhaling and pressurizing the air in the diaphragm to produce sound in woodwind and brass instruments, performing musicians are in a constant state of kinaesthetic awareness.2 When a serious illness such as breast cancer threatens the life and livelihood of performing artists, potential consequences include not only drastic bodily invasions in the form of lumpectomies or mastectomies, but long-term side effects from adjuvant therapies including lymphedema, neuropathy, chronic fatigue, shoulder morbidity, and postradiation contracture.3

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__________________________________________________________________ Recent data from the National Cancer Institute (NCI) suggest that nearly 200,000 American women were diagnosed with breast cancer in 2009. Fortunately, the rate of survival following a breast cancer diagnosis continues to increase—the current five-year survival rate for breast cancer is approximately 89.1 per cent.4 These high survival rates, coupled with the fact that nearly 1 in 8 American women will develop breast cancer in a lifetime, create a significant area of research regarding quality of life problems arising from the diagnosis and survivorship. Theoretical approaches in the field of anthropology can serve to expand upon current medical knowledge and understanding of experiences of health, illness, the self, and the body. Sickness and illness cannot be interpreted as the sole products of biological disorder. A critical understanding of the social and cultural components of health and illness is necessary to provide an integrated approach to medical care. 1. The Anthropological Discourse on Cancer and Pain It has long been established in the social sciences that the modern biomedical model of Western medicine and technology often fails to capture the entirety of experiences of both health and illness. The Western tradition, deeply rooted in the Cartesian duality of mind versus body, tends to view illness and disease as entities separate from the body and the self. That is, illness can be found in the mind or the body, but said illness cannot be attributed to or contribute to one’s sense of self. Moreover, illness and disease are seen as removed from any social or cultural context.5 By contrast, many non-Western ethnomedical models emphasize the relationship between mind, body, and self in the etiology and treatment of disease. In addition, these systems emphasize the role of social and cultural traditions in the experience of health and illness.6 Similarly, the current Western medical understanding of pain is thought of as a series of neurochemical signals travelling throughout the central nervous system.7 Alleviating or reducing pain, then, becomes a task in identifying these pain signals, and primarily these signals. An individual’s life experience and their socio-cultural context become irrelevant.8 Yet pain, as described by Melzack and Wall: represents a category of experiences, signifying a multitude of different, unique experiences having different causes, and characterized by different qualities varying along a number of sensory, affective and evaluative dimensions.9 In other words, pain and its counterpart, suffering, unlike the sensory experiences of sight or smell, present as a product of an individual’s beliefs and values systems, which are, of course, uniquely social and cultural experiences.10 In the 1950s and 60s, Cicely Saunders, a nurse in Britain’s newly formed hospices, sought to expand upon the then-current notion of pain. She developed the

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__________________________________________________________________ concept of ‘total pain,’ which, she argued, must be understood not only as physiological, but psychological, emotional, social, and spiritual as well.11 The experience of pain, when viewed as interconnected and inseparable from an individual’s biographical, social, and cultural context, not only expands upon the biomedical understanding of pain, but can then be used to provide fuller and more appropriate care.12 The rise of the incidence of cancer throughout the 20th century provides an additional interpretative model of health and illness. Weiss, in a recent study examining cancer metaphors in an Israeli setting, explains: Cancer makes cells proliferate…Cancer is depicted as a domestic subversion, in which rogue cells inside the body mutate, moving out from an original site or organ to overrun other organs or systems.13 Cancer is seen as separate from one’s self and identity, as an entity which has originated in the body, yet remains foreign and alien, a form of pollution.14 Underlying this notion of pollution, Weiss concludes that cancer is ‘framed by the metaphor of transformation.’15 Cancer, far from existing solely as a mass of mutated cells within the body, may also prove to be a catalyst for personal growth and change, or physical and psychological devastation. 2. The Culture of the Performing Musician Contemporary definitions of culture regard it as a set of: community specific ideas about what is true, good, beautiful, and efficient. To be cultural, those ideas about truth, goodness, beauty, and efficiency must be socially inherited and customary. To be cultural, those socially inherited and customary ideas must be embodied or enacted meanings; they must be constitutive of (and thereby revealed in) a way of life.16 In sum, culture is understood as beliefs, values, and ideals within a community that are learned, transmitted, and lived from one generation to another. Moreover, the anthropological subfield of cultural psychology posits that culture and psyche are inextricably intertwined. That is, culture and psyche ‘make each other up.’17 Contrary to standard psychological practice, which is arguably concerned with seemingly universal psychological norms and standards, cultural psychology holds that multiple psychologies can and do exist. It is the purpose of cultural psychology to examine the myriad cultural and ethnic origins of emotional and somatic functioning.18 In order to do so, one cannot focus solely on culture or psychology; a critical understanding of the interconnectedness of the two domains is necessary.

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__________________________________________________________________ The world of the American performing musician, then, qualifies as a uniquely cultural experience (and, following cultural psychological theory, a uniquely psychological one as well), often with sub-cultural systems working together simultaneously. Of these sub-cultural models, perhaps the most well known is that of the virtuoso and orchestral musician. The culture of the virtuoso places high emphasis on technical expertise and interpretation, along with attention to fine details of execution.19 Technical mastery is reached through countless hours of practice and rehearsal, in which mental memories are transformed into physical memories and holistic understanding.20 As Mead notes, ‘music, is indeed something we do [emphasis added].21 Physical dexterity and flexibility, stamina, and endurance are imperative for successful musical performance. This standard of perfection can only be achieved by extraordinary efforts of rehearsal of the mind, body, and will.22 Compounding the physical demands of the musical world, musicians also inhabit a culture of fierce competition, with little room for error or weakness. There will always be more talented musicians than openings in an orchestra or symphony. Indeed, it has been noted that the ‘symphony orchestra world is one of the most complex, competitive, and stratified organizational sets in existence.’23 Not unlike the hierarchy of athletic starters and backups, orchestral musicians are assigned positions of principal, assistant principal and section players.24 Yet behind this ideology of rank and expertise lies the implicit understanding that weakness of will or physicality translates to an individual’s lack of talent. Open admission of pain, whether related to musical injury or not, physical or psychological in origin, is often penalized, as the image of the virtuoso often entails a vision of perfection, free from physical challenges or pain. Performing musicians may prefer to suffer in silence than risk endangering their career.25 3. Breast Cancer and the Female Musician The present study began with a quantitative web-based survey (musiciansurvivor.org) detailing the physical symptoms of breast cancer treatment and its impact on female musicians. The results and analysis of the data collected through this survey are forthcoming. The second phase of the study included telephone interviews with survey respondents who met the criteria (female, primary livelihood as a musician or music educator, successfully completed breast cancer treatment in the past one to five years) and agreed to be interviewed. Participation in the study was voluntary and anonymous. The multidisciplinary research team consisted of a professional musician, clinical psychologist, two medical professionals, and two research assistants. One or two team members conducted lengthy telephone interviews with the participants, asking detailed questions regarding their breast cancer diagnosis, treatment, its impact on music-making, social support, and the like. The interviews were then transcribed and coded by four members of the research team for major


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__________________________________________________________________ themes including (1) breast cancer, medical care, and physical change; (2) music, change in music, and role of music; (3) support, interaction with others, coping, and surviving; (4) personal reaction, personal growth, and transformation; and (5) miscellaneous. A complete analysis of the coded transcripts is currently in progress. The following represents one team member’s preliminary anthropological interpretation. 4. The Interplay of Culture, Cancer and Identity As previously stated, the culture of the performing musician can often be tremendously cutthroat and competitive. Artists who have committed a lifetime of energy and commitment to their craft may not be able to openly acknowledge pain and weakness for fear of negative consequences, including loss of employment.26 Not surprisingly, after being diagnosed with breast cancer several respondents expressed concerns confirming these fears: I was not going to become a professional patient, because I was afraid of how it would affect my employment. I really believe there is a perception by people sitting out there in the audience by looking at you and if they think something is the matter with you, it changes their whole attitude of the experience. I didn’t want to tell people that I had cancer because in (large Midwestern city), the minute you tell somebody you’re sick, they say, ‘Oh, she’s sick, don’t call her’ [for gigs, employment, etc.] To allay these fears, a number of respondents adopted a ‘tough it out’ mentality, opting to continue to work and perform throughout treatment and pain, which may have included surgery, chemotherapy, and radiation. One respondent, a high school band director, recalled that throughout her treatment, which included a lumpectomy and radiation, she ‘didn’t miss a single day of school.’ Even after developing a hematoma at the site of the lumpectomy, she said: ‘It was so painful. I had to go in every week and get it [the hematoma] drained…I had to be creative because it was so painful…seven to eight weeks of radiation, and I never missed a day. I kept right on working.’ When asked how she conducted her band in such pain, she responded: ‘You just do it. It was uncomfortable, but I was determined that it wasn’t going to interfere with my life, with my job, with my responsibilities at work.’ Performing one’s regular duties, even to the point of denying or ignoring pain, may also serve as a means of reasserting normality and reaffirming one’s sense of self. As Alford and Szanto noted, the performing artist will likely endure physical

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__________________________________________________________________ pain not only to protect his or her career, but also to preserve one’s ego identity.27 Unlike other professions, the performing musician begins the study of their craft at a very young age, investing tremendous amounts of both time and resources. It is not surprising, then, that a majority of respondents simply could not separate their sense of self from music; the self did not exist without music: I thought if this [treatment-induced neuropathy] is going to happen to me, I may as well jump off a roof right now because I won’t be able to make a living, either as a writer or as a musician. I am a pianist, and I’m not gonna (laughing) not play the piano. It’s that mystery of the combinations of tone, of pitch, of being a part of creating beauty. I really believe that when we make music we are participating in the divine creation of the thing…so it’s kind of like a bit of the divine working through me to create something new…that resonates in your soul. I think with all musicians, it’s kind of part of your identity…if you have to give that up, you’re giving up a huge percentage of your own identity. I’ve done that all my life and that’s all I ever wanted to do. I don’t know how to do anything else. Furthermore, cancer, as Weiss noted, may prove to be a catalyst for personal growth and transformation.28 Many respondents reported significant change not only in their musical abilities (for better and worse), but also in the meaning and value of music in their lives. In other words, cancer, ego identity, and the unique musical culture interacted to promote transformation, including attitudes towards music and performance: I don’t play as well as I used to, but that’s okay because I can work with that…so there’s both the achy joints and the swelling from the lymphedema, and so I can’t play individual notes on the guitar as well as I used to, but when I do they are much more soulful and more focused and directed than they used to be. I did a lot more research into traditional music, into old Scottish ballads and things…the old traditional ballads are a continuum. They’re part of a very long history of people, largely women, who have just passed these songs down from one person to the next...I wouldn’t say it’s a kind of immortality but it’s kind of a


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__________________________________________________________________ continual family line…I like to feel like part of that continuum, part of the riverbed…There just seems to be this huge massive fire that goes through and burns through you and you’re left with something very different. I found that whatever music I chose to work on, whether it was to conduct or to direct or to actually sing, I wasn’t satisfied unless it was deeply meaningful to me personally. It is important to note that this personal transformation did not always come readily or easily. Suffering, despair, and depression were common in the respondent’s experiences. Ultimately, however, the majority of women did report experiences of personal growth and change. An individual’s culture and psyche act as powerful modifiers on ht expression and acknowledgment of pain. The experience of health and illness cannot be viewed separate from one’s social and cultural world. The medicalization of cancer reduces the individual to a mass of malignant cells to be eradicated, transforming the social and cultural into the biological.29 As the experiences of these respondents affirm, the social and cultural worlds one inhabits are inextricably linked to the experience of illness. To ignore these worlds is detrimental to the wellbeing of patients and their overall quality of life. Future research may include further investigations regarding the physical consequences of medical treatment for lifethreatening illnesses such as cancer and HIV/AIDS, and their social and cultural repercussions.

Notes 1

O Sacks, A Leg to Stand On, Simon & Schuster, Inc., New York, 1984, p. 110. S Schmalenberger, ‘Life and Livelihood: Musicians Surviving Breast Cancer,’ Review of Disability Studies: An International Journal, Vol. 4(1), 2008, pp. 43-55. 3 ibid. 4 MJ Horner, LAG. Ries, M Krapcho, N Neyman, R Aminou, N Howlader, SF Altekruse, EJ Feuer, L Huang, A Mariotta, BA Miller, DR Lewis, MP Eisner, D.G. Stinchcomb & BK Edwards (eds), SEER Cancer Statistics Review, 1975-2006. National Cancer Institute, updated November 2008, viewed January 2010. http://seer.cancer.gov/statfacts/html/breast.html 5 N Scheper-Hughes & M. Lock, ‘The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology,’ Medical Anthropology Quarterly, Vol. 1, 1987, pp. 6-41. 6 ibid. 7 GA Bendelow, ‘Pain, Suffering and Risk,’ Health, Risk & Society, Vol. 8, 2006, pp. 59-70. 2

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ibid. Melzack & Wall (1988) as cited in ibid, p. 61. 10 op. cit. Bendelow, 2006. 11 D Clark, ‘Total Pain, Disciplinary Power and the Body in the Work of Cicely Saunders, 1958-1967,’ Social Science & Medicine, Vol. 49, 1999, pp. 727-736. 12 ibid. 13 M Weiss, ‘Signifying the Pandemics: Metaphors of AIDS, Cancer, and Heart Disease,’ Medical Anthropology Quarterly, Vol. 11, 1997, p. 456. 14 op. cit. Weiss, 1997, pp. 456-476. 15 op. cit. Weiss, 1997, p. 460. 16 R Shweder, Why Do Men Barbecue: Recipes for Cultural Psychology, Harvard University Press, Cambridge, MA, 2003, p. 11. 17 op. cit. Shweder, 2003, p. 33. 18 op. cit. Shweder, 2003, p. 30. 19 R Alford & A Szanto, ‘Orpheus Wounded: The Experience of Pain in the Professional Worlds of the Piano,’ Theory and Society, 25, 1996, pp. 1-44. 20 N Kogan, ‘Careers in the Performing Arts: A Psychological Perspective,’ Creativity Research Journal, Vol. 14, 2002, pp. 1-16. 21 A Mead, ‘Bodily Hearing: Physiological Metaphors and Musical Understanding,’ Journal of Music Theory, Vol. 43, 1999, pp. 1-19. 22 op. cit. Alford & Szanto, 1996. 23 RR Faulkner, ‘Career Concerns and Mobility Motivations of Orchestra Musicians,’ The Sociological Quarterly, Vol. 14, pp. 323-346. 24 ibid. 25 op. cit. Alford & Szanto, 1996. 26 op. cit. Alford & Szanto, 1996. 27 op. cit. Alford & Szanto, 1996. 28 op. cit. Weiss, 1997. 29 op. cit. Sheper-Hughes & Lock, 1987. 9

Bibliography Alford, R.R. & Szantzo, A., ‘Orpheus Wounded: The Experience of Pain in the Professional Worlds of the Piano.’ Theory and Society. Vol. 25, 1996, pp. 1-44. Bendelow, G.A., ‘Pain, Suffering and Risk.’ Health, Risk & Society. Vol. 8, 2006, pp. 59-70. Clark, D., ‘Total Pain, Disciplinary Power and the Body in the Work of Cicely Saunders, 1958-1967.’ Social Science & Medicine. Vol. 49, 1999, pp. 727-736.


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__________________________________________________________________ Faulkner, R.R., ‘Career Concerns and Mobility Motivations of Orchestra Musicians.’ The Sociological Quarterly. Vol. 14, 1973, pp. 334-349. Horner, M.G., et. al., (eds). SEER Cancer Statistics Review, 1975-2006. National Cancer Institute. updated November 2008, viewed January 2010. http://seer.cancer.gov/statfacts/html/breast.html Kirmayer, L.J., ‘The Body’s Insistence on Meaning: Metaphor as Presentation and Representation in Illness Experience.’ Medical Anthropology Quarterly. Vol. 6, 1992, pp. 323-346. Kogan, N., ‘Careers in the Performing Arts: A Psychological Perspective.’ Creativity Research Journal. Vol. 14, 2002, pp. 1-16. Lock, M., ‘Cultivating the Body: Anthropology and Epistemologies of Bodily Practice and Knowledge.’ Annual Review of Anthropology. Vol. 22, 1993, pp. 133155. Manderson, L. & Sterling, L., ‘The Absent Breast: Speaking of the Mastectomied Body.’ Feminism & Psychology. Vol. 17, 2007, pp. 75-92. Mattingly, C. & Lawlor, M., ‘The Fragility of Healing.’ Ethos, Vol. 29, 2001, pp. 30-57. Mead, A., ‘Bodily hHearing: Physiological Metaphors and Understanding.’ Journal of Music Theory. Vol. 43, 1999, pp. 1-19.

Musical

Persson, R.S., ‘Surival of the Fittest or the Most Talented?’ Journal of Secondary Gifted Education. 2000, pp. 25-39. Sacks, O., A Leg to Stand On. Simon & Schuster, Inc., New York, 1984. Scheper-Hughes, N. & Lock, M.M., ‘The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology.’ Medical Anthropology Quarterly. Vol. 1, 1987, pp.6-41. Schmalenberger, S., ‘Life and Livelihood: Musicians Surviving Breast Cancer,’ Review of Disability Studies: An International Journal, vol. 4, 2008, pp. 43-55. Shweder, R., Why Do Men Barbecue: Recipes for Cultural Psychology. Harvard University Press, Cambridge, Mass., 2003.

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__________________________________________________________________ Tierney, W.M. & McKinley, E., ‘When the Physician-Researcher gets Cancer: Understanding Cancer, Its Treatment, and Quality of Life from the Patient’s Perspective.’ Medical Care. Vol. 40, 2002, pp. 20-27. Weiss, M., ‘Signifying the Pandemics: Metaphors of AIDS, Cancer, and Heart Disease.’ Medical Anthropology Quarterly. Vol. 11, 1997, pp. 456-476. Young, A., ‘The Anthropologies of Illness and Sickness.’ Annual Review of Anthropology. Vol. 11, 1982, 257-285. Meghan Neaton is a research assistant at the University of St. Thomas, St. Paul, Minnesota, USA. She is currently studying anthropology and psychology. Jean Giebenhain is a professor of psychology at the University of St. Thomas and a practicing clinical psychologist. Sarah Schmalenberger is a professor of music at the University of St. Thomas and a professional musician. Lisa Starr is a certified nurse practitioner at St. Mary’s Duluth Clinic, Duluth, Minnesota, USA. Charles Gessert is a medical doctor and researcher at St. Mary’s Duluth Clinic.

Dancing in Other’s Shoes: Between Pain and Pleasure Daria Radchenko Abstract Practicing dances of foreign cultures leads to the need of transforming one's body for corresponding to the physical demands of a foreign bodily practice. This process may be painful; yet pain is often seen as a value in its own and as a virtue of the dancer. Some groups, however, see their dancing as a way to relieve pain. The paper investigates the process of disciplining one’s body for dancing in the Other’s way, finding compromises between one’s own culture and the Other’s body techniques, forms and functions of pain in amateur ‘ethnographic’ dancing, perception and representation of painful/painless dancing within groups which practice Irish dance, belly dance, swing dance, etc. Key Words: Dance, subculture, ethnicity, pain. ***** Practicing dances of foreign cultures has become a popular hobby in Russia in last decade. Belly dance, Irish dance, Indian dance, flamenco and swing dances gather the largest number of followers. These dance practices are not, though, ‘ethnic’ in a traditional sense. Years of their development and re-enactment in alien cultural milieu has transformed them into a kind of super-ethnic constructs, synthetic complexes and mixes of ethnic dances, reconstructions made to the demands of the society to dance something ‘authentic’, a product of collaboration of strikingly different cultural traditions. Still, the process of involvement of a beginner into an alien dance practice is twofold. On one hand, it is rarely considered as a way of understanding the Other’s culture. The goals of participants of dance rehearsals are far from that: most of them describe their dancing activities in terms of socializing, recreation, looking for something new, relaxation or fitness. On the other hand, this bodily perspective of dancing for fitness plays a perfidious trick. However adapted and transformed, these dances retain significant traces of foreign cultures. As such, they were developed for and by the people with peculiar bodily habits and the structure of the body. The motions which are ‘natural’ or at least understandable for a native dancer may puzzle a foreigner . This leads to the articulated need of transforming the body. As a lindy-hopper told in an interview, dancing is about ‘feeling oneself a black man’. In Russia as in many Western countries the post-colonial stereotype of some idealized ‘natives’ who move in a ‘natural’ way, being free from the bodily restrictions of the Western society is central to the idea of alien dance practices.

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__________________________________________________________________ This process of transformation of the body may be painful. Generally, pain is a normal element of learning new body practices, be it sport or dance, and a valuable instrument in it. As Susan L. Foster describes, Working to correct bad habits, to modify the body’s aberrations and to increase its capabilities, the dancer frequently incurs pain and learns quickly to distinguish between several kinds: constructive pain that will lead to greater strength or flexibility; destructive pain caused by the incorrect positioning or use of a part of the body; chronic pain, the cumulative result of bad habit; pain resulting from too much tension, too little strength, activities other than dance, overambition, inattentiveness, and so on.1 Yet the perception of this pain may differ significantly. There is a common cultural cliché of pain as the method of evaluation of one’s diligence in training. Then, Russian culture has developed a settled stereotype of the value of overcoming of pain. If a person continues his/her progress paying no attention to pain, it strengthens self-esteem and social status. At the crossroads of these two presuppositions there lies a common stereotype of the Russian culture than nothing valuable can be achieved through pleasure. Skills and results can only be deserved by constant effort, through violating mind and body and the general willingness and ability to suffer throughout the process of learning and performing. This understanding of bodily pain as a precondition and result of any serious achievement gets a dancer in another trap. The majority of the practitioners of foreign dances are amateurs who see them as a form of recreation. Moreover, their social milieu also sees these practices as a hobby and estimate it as something of little value in comparison with classic dance or sports. Practicing alien dances, however, requires as much resources as any of the practices which are seen as ‘normal’ and ‘serious’ by the general society, including time, effort, and funds. As the majority of dancers in Russia are young people (14-30 y.o.) and particularly young women, many of them are financially dependent on their parents or spouses. To get money for their hobby they have to justify it in their social group and even in their own eyes. Pain comes here as a means of putting a practice into the group of socially encouraged activities: it is painful, hence, it is serious. Pain, thus, becomes a cultural instrument of evaluating bodily practices and a person’s result in them; it is not a surprise, therefore, that it becomes desired. The other side of understanding of pain in dance practices is its relation to recreation itself. Though recreation is generally understood as leisure and pleasure there are two aspects which seem to be an important part of any bodily practices, especially dances. First, pain is a part of the complex of sensory deprivation compensation. Like re-enactment activities, a dance practice allows to experience a past culture through physical activity, which was shown by a number of

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__________________________________________________________________ researchers.2 The postmodern culture is visualized to a large extent; virtual pseudoimages and pseudo-artifacts are dominating the cultural space. The majority of activities of the middle-class (who forms the core of the researched group) lies within the field of intellectual work deprived of any physical sensations. Thus, the need to experience one’s own reality through creation of tangible objects or feeling physical sensations leads to the introduction of a number of practices which fill the gap between the ‘real’ and the ‘virtual’. ‘Pain’ in this dimension of the cultural space becomes a synonym of ‘the real’ and ‘the authentic’, meaning both the correspondence of practice with the original ethnic dances re-enacted in a rehearsal studio, and, more important, the physical existence of the practitioner. Second, pain, paradoxically, can become the means of the escape from the daily reality. As an Irish dancer confesses, … after the first class everything aches, everything which was trained before, EVERYTHING, even the toes… but it is an absolutely indispensable relax for the brains, for 2 hours all problems remain behind the door of the dancing studio, all thoughts and sorrows wait outside and I am alone with my body for these two hours.3 Pain does not allow concentrating on anything except the class and one’s own body and therefore provides some break of the daily routine. Dance, being itself a captivating practice, is supported by pain in the process of escape from the pressure of modern society. Through it, a person liberates from the conventions of the society and allows oneself to move like an idealized free and close-to-nature Other, as a result getting to know one’s own body and learning to master it in the way which is not common for the Western post-modernity. Then, the ‘exotic’ practices, social relations and costumes are included into the system. And, finally, he/she simultaneously puts a barrier between dancing self and the everyday reality, and legitimises this practice in the eyes of the reference group by experiencing the pain, and, still more important, talking about it. Dance, and specifically an alien dance is thus a complex system of creating an alternate reality. We can see now how pain in the amateur dance scenes receives certain cultural meaning, becomes an instrument of locating oneself in the alternate reality of dance, and a value of its own. Still, in general, pain is less a physical sensation than a representation of a number of stereotypes, which stimulate the exaggeration of it in communications both inside and outside the group. Various dancing scenes differ greatly in their understanding and appreciation of this phenomenon. One of the most rigid dance practices is the Irish dance, which demands serious physical activity with stress on the spine, legs, development of specific posture and almost as advance stretching ability and turnout as in classical ballet. Though it emerged in an ethnic community constitutionally close to the Russians, its

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__________________________________________________________________ formalization and institutionalisation led to development of high demands to a dancer. Learning Irish dance is thus bound together with painful sensations, which are in this group understood as an integral and positive part of the process of involvement into this bodily practice. Though the dancers generally find some humorous aspect in constant talking of pain, they continue to articulate the topics of pain, traumas, overcoming the pain, and, most interesting, the rigid fixation of the body during the dance. Irish dance body discipline combines the rapid and very precise leg movement with absolute stiffness of the upper body. This fixation shows even on the level of the self-presentation on official dance occasions: securely attached red curly wig, thick material of the dress, socks glued to legs for safety, and even formally prohibited corsets and sleeves sewn to the dress not to allow hand movement4. On the level of communications, this ‘stiffness’ and discipline of Irish dance can be presented as in the following testimony: …we have a a new catchphrase here - ‘the epic Irish dowel’… the one which keeps the torso motionless… at least has to.5 M. Seaver suggests that the reason for such regulative treatment of the dancer’s body lies within the nature of the Irish dance itself. The national dance was seen by the activists of celtic renaissance as a means to ‘mold bodies to reflect the body politics of the new state.’6 Dance, in fact, was used to form the controlled, guided body of a subject with a clear understanding of the national idea and morality; as Thomas M. Wilson and Hastings Donnan put it, it was a part of the ‘colonial state’s efforts to pacify, civilize, modernize and discipline the Irish body.’7 There is no surprise, then, in the fact that this disciplining attitude keeps shaping the dance practice through decades. The perception of pain and body transformation is absolutely opposite on belly dance scene. Though this practice also constructs the body of a dancer to a certain extent, the goal is different. The majority of amateur dancers regard belly dance not even as a fitness, but as a slimming practice and, more important, as a way to improve the quality of life by compensating consequences of a number of diseases. In Russia, belly dance is promoted as a complex of exercises which can cure gynecological diseases and improve reproductivity in general, which is supported by the myth of belly dance’s ‘harem’ origin. The participants of belly dance groups also seek relief of spine and leg pain. This idea of dance relieving pain is in a sense a manifestation of post-colonial myth of harmony between the ‘native’ and natural environment. There is a general understanding that a ‘native’, led by ‘instincts’, unconsciously creates practices which at first glance can seem connected rather with art, religion or other type of social communication, but are aimed at maintenance of health and hygiene. On the

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__________________________________________________________________ other hand lies the popular myth of ‘eastern wisdom’, which shows itself in such practices. Belly dance is seen as an instrument of body shaping – but at the same time it is also seen as a way of getting in terms with one’s own body as it is. Belly dance allows to compensate psychological problems which are linked with a body status different from mass cultural norms.8 The feeling of one’s own disparity from the common beauty standard forces women to find practices and groups which will appreciate their shortcomings and make use of them. Opposite to many other foreign dance practices, belly dance allows not to re-shape the body. Transformation here concerns more mind than body; attitude to oneself rather than bodily attitudes. Asked about the reasons for choosing belly dance, women often say something like: ‘I have large bottom and I wanted to make use of it.’9 Belly dance is thus a practice, which aims at avoiding pain and transformation, having pure pleasure of one’s collaboration with one’s own body. While Irish and, in some cases, Indian dances are putting pain as a value in itself and a sign of progress, belly dance sees it as something harmful, unhealthy and a sign that something has gone wrong. Between these two extremes lies the subculture of swing dances. It is characterized by total absence of the pain concept, which is rather uncommon for dance practices. Being a very intense body activity and involving a developed rank structure, swing dances however demonstrate a very special understanding of body shaping. The core of the practice lies in the idea of ‘inspiration’ and gradual rooting into the new body techniques. That is no coincidence that the practitioners usually speak of their training in terms of ‘getting involved in music’ or even meditation-like ‘opening the chakras’. In this it has much in common with Latin social dances (e.g. salsa), where ‘almost mystical experience that can be created by dancing with the right partner to the right music at the right time: the ‘flow’, a feeling of absolute harmony and correspondence.’10 As a female dancer exclaims in her blog, I’ve got it! I’ve got how to dance lindy-hop! First year has passed and I am receiving dance enlightenments. I have got bounce finally… for a minute, for a very-very short while, but I’ve got hold of this sensation, and everything has changed!11 The reason for this difference of concepts of body, training, transformation and pain is, perhaps, ideological. Irish dance is aimed at achievement. Of all foreign dances it is most close sport and sport dance with its ranking system, conventions, formality, lack of individual creativity and improvisation – a regulating and disciplining dance. Most of the Indian dances practiced in Russia (e.g. the most popular Bharata Natyam, Kathakali, Odissi, Kuchipudi) aim at maintenance of tradition, and require much devotion and self-denial, but are as much adapted to

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__________________________________________________________________ the host culture by the practitioners, putting more stress at health value and beauty of performance than on the conservation of the dance, often at the cost of pain and serious body reconstruction. Belly dance is understood as a purely recreational practice, a relief rather than strain, which makes it deny pain. Swing dances are totally different from all the before mentioned practices. In their dance, lindyhoppers seek socializing, play, free improvisation, humour and ‘being oneself’. The process of learning might be demanding physically, but this finds no reflections in the group’s communication, because pain is neither goal nor means of progress evaluation. Thus we can draw an imaginary axis, on which the foreign dance practices will be located on the basis of their attitude to pain. Though all the practices have much in common, this characteristic differs significantly, and reflects the ideological background of the dances. It can be even suggested that changing interest to a dance practice with a certain ideology shows the transformation of values, myths and stereotypes in certain social groups.

Notes 1

SL Foster, ‘Dancing Bodies,’ Meaning in Motion: New Cultural Studies of Dance (Post-Contemporary Interventions), Duke University Press, 1997, p.240. 2 See, e.g., V Agnew, ‘Introduction: What is Reenactment?’ Criticism, Vol. 46, #3, Summer, 2004. p. 330; D Radchenko ‘Simulating the Past: Reenactment and the Quest for Truth in Russia,’ Rethinking History, Vol.10, #1, March 2006. 3 viewed on 25 May 2009, http://www.liveinternet.ru/users/kutek/post86659304. 4 7 April 2008, viewed on 25 May 2009, http://bukashk0.livejournal. com/73293.html. 5 11 January 2009, viewed on 25 May 2009, http://strori.livejournal.com/ 214852.html. 6 M Seaver, ‘Stepping into Footprints: Tradition and the Globalization of Irish Dance,’ Dance in a World of Change: Reflections on Globalisation and Cultural Difference, SB Shapiro (ed), Human Kinetics Publishers, 2008, p. 5. 7 T Wilson, H Donnan, The Anthropology of Ireland, Berg, 2006, p. 49. 8 Maira, op.cit., p. 333. 9 31 March 2005, viewed on 25 May 2009, http://www.beledi.ru/forum/ viewtopic.php?t=214. 10 H Wieschiolek, ‘Ladies, Just Follow His Lead! Salsa, Gender and Identity,’ Sport, Dance and Embodied Identities, Berg, New York, 2003, p. 129. 11 11 March 2009, viewed on 25 May 2009, http://catluin.livejournal. com/52882.html.

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Bibliography Agnew, V., ‘Introduction: What is Reenactment?’ Criticism. Vol. 46, #3, Summer, 2004, p. 330. Foster, S.L., ‘Dancing Bodies.’ Meaning in Motion: New Cultural Studies of Dance (Post-Contemporary Interventions. Duke University Press, 1997, p.240. Seaver, M., ‘Stepping into Footprints: Tradition and the Globalization of Irish Dance.’ Dance in a World of Change: Reflections on Globalisation and Cultural Difference, Human Kinetics Publishers, 2008. Wilson, T. & Donnan, H., The Anthropology of Ireland. Berg, 2006. Wieschiolek, H., ‘Ladies, Just Follow His Lead! Salsa, Gender and Identity.’ Sport, Dance and Embodied Identities. Berg, New York, 2003, p. 129. Daria Radchenko is an independent researcher from Moscow.

The Erotics of Pain: BDSM Femslash Fan Fiction Malin Isaksson Abstract Fan fiction writers use an existing fictional universe (film, novel, etc) to develop scenarios and characters in creative ways within the logic of the original universe. In this paper, I examine the representations of the erotics of pain in two fanproduced, so-called femslash texts describing romantic and sexual BDSM-oriented relationships between the two super powered slayers Buffy and Faith from Joss Whedon’s TV series Buffy the Vampire Slayer. I argue that the fan-produced graphic, hard-core descriptions of safe, sane and consensual BDSM involving Buffy and Faith are transgressive in that they break the rules of how sexualities can be represented in the prime-time TV series that the two female characters are borrowed from. Furthermore, they challenge stereotypical ideas about female sexual behaviour as ‘vanilla’. The potential for transgression may explain fan writers’ attraction to Buffy/Faith femslash centring on BDSM relations and the resulting depicted transgressions may account for and readers’ interest in these stories. Key Words: Sexualized pain, pornography, intertextuality, Buffy/Faith femslash, fan fiction, Buffy the Vampire Slayer. ***** 1. Buffy, Faith and Fan Fiction Joss Whedon’s cult TV series Buffy the Vampire Slayer was first aired in the US between 1997 and 2003 and continues to fascinate fans around the world. Buffy’s universe, the Buffyverse, is the subject of numerous fan fictions (fanfics) posted on the internet. In fan fiction texts, writers elaborate various aspects of Buffy the Vampire Slayer and its spin-off series Angel, such as alternative plot developments and relationships between characters. Homoerotic fan fictions about male characters are called ‘slash’ and its female equivalent is called ‘femslash’. In Buffyverse fan fiction, the most popular female pairing consists of the two vampire slayers Buffy and Faith, two super-powered girls. The pairing of two extremely tough and strong girls in fan fiction, where a general rule is to stay true to the original characters’ ‘personalities,’ gives the opportunity to create nonstereotypical or transgressive representations of female characters involved in a love story where BDSM plays an important part.1 The pain I will try to make sense of, from my socio-literary perspective, is the sexualized pain described in graphic detail in two fan fiction texts: Faith’s Fantasies, by Rebelrsr, and New Desires, by Naughti (both accessible on internet sites). It is important to note that my study concerns textual representations of

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__________________________________________________________________ sexualized pain in scenes involving two fictional characters. These representations are more likely to say something about the fanfic authors’ perceptions of BDSM, and about their fantasies concerning two female superheroes engaging in such sexual activities, than about real-life BDSM. 2. Kinky Sex in Buffy the Vampire Slayer The Buffyverse lends itself especially well to so-called kink-fic, not only of the male slash version analyzed by several scholars,2 but also of the femslash variety pairing Buffy and Faith. As media scholar Esther Saxey points out, in Buffy fandom, there is an added interest in the sexualization of emotional suffering, which is that suffering is already so much part of the series and the slash. Writers combine these two ejected themes – suffering and kinky sex – and play them against each other.3 Saxey’s observation on male slash about characters in the Buffyverse is valid for Buffy/Faith femslash as well. Buffy and Faith are women with Slayer powers, which means that they are both preternaturally strong and capable of suffering extreme amounts of pain, not least because they have extraordinary healing capacities. Furthermore, they are the female heroes of a TV show that frequently alludes to, and even to some degree depicts, kinky sex although in a veiled manner (since Buffy is a prime-time show, it is restricted by a number of regulations concerning the ways in which sexuality may be represented). Buffy the Vampire Slayer abounds with ‘moments of kink’,4 as Saxey calls them: sexy leather clothes are common in the series, as are half-naked, injured or tortured characters. There are chains next to beds, sexual scenes in cages, and both Buffy and Faith are seen chained up in erotically charged scenes. There is no doubt, then, that kinky sex is present in the TV series, even if it is presented as morally wrong on an explicit level. Its many allusions to non-normative sexual practices form a base for Buffyverse fan fiction containing kinky sex. The ‘moments of kink’ in the show which femslash authors draw on can be specific scenes from the series, as well as more general, recurring allusions to kinky sex, but also the characterizations of the two Slayers. Faith is undisputedly familiar with BDSM practices; not only does she overtly state that she prefers to be the ‘top,’ but she also displays sexually violent behaviour towards Buffy’s friend Xander, as she initiates a kind of foreplay so rough that she nearly strangles him. Her behaviour in this scene is explicitly connected to BDSM, since Buffy’s boyfriend Angel asks Faith, as he saves Xander, if she forgot about the ‘safety word’. Her reply suggests that such mutual agreements matter little to her: ‘Safety words are for wusses.’5 Buffy is depicted as more conventional and less expressive when it comes to sexuality, especially in the first three seasons of the series during

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__________________________________________________________________ which she is still in high school. However, she is not always portrayed as ‘vanilla.’6 In season six, Buffy is the one who initiates sex with the no longer evil vampire Spike in what will become a clearly BDSM-influenced relationship. Buffy scholar Jenny Alexander notes that Their relationship is depicted as ‘unhealthy’ by the story arc. Buffy is portrayed as continually ashamed and disgusted with herself for enjoying these assignations. However, the camera tells a different story. It continually lingers on the unzipping and re-buckling of black leather.7 This ambiguity between overt moral messages and visually pleasurable and/or eroticised scenes reflects the way kinky sex is represented in Buffy the Vampire Slayer: ‘morally wrong yet illicitly delicious’, to quote Jenny Alexander.8 3. Kinky Sex in Buffy/Faith Fan Fiction The fan fiction Faith’s Fantasies takes place in a so-called alternate universe set after the seventh and last season of the series. In this text, Buffy and Faith no longer function as vampire slayers, but live in ‘domestic bliss’. Faith’s Fantasies is written as Faith’s story about how BDSM enters into her and Buffy’s relationship, with Buffy as the ‘top.’ Initially, this kind of sexual power play starts as Buffy’s Valentine’s gift to her lover, but ‘the Game’, as she and Faith call it, becomes an integrated part of their love life. In the beginning of this fanfic, kinky sex is presented as deviant in the sense that it is a practice that turns away from the norm. This echoes Buffy the Vampire Slayer since non-normative sexual practices are marked as unhealthy in the series. In the opening lines of the fanfic, Faith recounts how she had to explain ‘about leatherdykes, femme tops, and Daddies’, as she declared her feelings to Buffy. 9 Those practices are thus unusual enough to require explanation. Furthermore, they are perceived as shameful: ‘I thought my face was going to burst into flames I was blushing so hard’, Faith thinks. But the most difficult part is admitting that she dreams of a partner who ‘[l]ikes to be called Sir or Ma’am’. The fact that Buffy doesn’t ‘get it’, but rather laughs at such a wish, stresses its non-normative character. The inflicting of sexualised pain is the main obstacle to the erotic scenarios that Faith dreams of in Faith’s Fantasies: ‘You never could get passed [sic] the idea that I really wanted you to hurt me’, she thinks.10 However, once Buffy passes the initially rather high threshold to BDSM games, she does not hesitate to let the blows fall on Faith’s body. The sexual role play is Buffy’s surprise gift to Faith who is described as astonished, and even frightened, at the beginning of the role play because she is uncertain of what is going on. As Buffy without warning or explanation grabs Faith from behind and blindfolds her, Faith feels ‘creeped out’, until Buffy grabs her

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__________________________________________________________________ breasts and whispers in her ear, which makes clear that the situation is erotic. Faith responds to these moves in a very physical manner: ‘I nearly moaned at the deep, husky sound of your voice, and moisture gathered between my legs’. The mix of insecurity and sexual excitement that characterizes the beginning of the sex scene turns into a blend of excitement and pain as Faith receives a series of blows: ‘I lost count of the times you painted my ass with fire. […] Each time the paddle landed, I could feel my wetness increase and my nipples ached under my shirt’. The countless blows is an intertextual reference to the supernatural resilience of the Slayers’ bodies. Faith’s physical reactions to this treatment make clear that pain is linked to arousal in this fan fiction. The representation of kinky sex in the fan fiction New Desires turns away from the TV series since ‘kink’ is something that Buffy here is more than comfortable with, even if the title of the fan fiction stresses the novelty of the various kinky sexual practices performed by Buffy and Faith in 24 short chapters with descriptive titles like: ‘Spanking’, ‘Handcuffs’ and ‘Clamps.’ In this text, Faith takes for granted that Buffy is not ‘vanilla’ in bed: ‘[…] couldn’t be, she had dated a vampire after all’.11 4. Therapeutic Pain The fan fiction authors describe sexualised pain not only as arousing, but also as psychologically satisfying. This mirrors the TV series, where both Buffy and Faith are seen needing physical ‘punishment’ in order to deal with their personal problems. This need is however presented as unsound, psychologically unstable behaviour. The fanfic authors, on the other hand, thematize the therapeutic gains of pain in a positive manner. In New Desires, Naughti describes how a spanking session based on mutual love and care releases both sexual and psychological tension for the partner who receives the punishment. Moreover, it enhances the emotional intimacy between the two lovers. In this fan fiction, it is Buffy who is struggling with problems that she is unable to verbalize. This characterization alludes to the traumatized Buffy depicted in season six of the series, where she is depressed but chooses to keep her problems to herself; the only – temporary – release she finds is through rough sex with Spike. Whereas their violent sexual encounters in the TV series are presented as unhealthy, especially since they do not lead to healing but only to self-hatred, the blows distributed in New Desires are based on love and care. In a chapter appropriately titled ‘Spanking’, Buffy and Faith argue about Buffy’s reluctance to share her problems with Faith. Naughti describes how Buffy needs a spanking to let her feelings out and emphasizes Faith’s concern with Buffy’s unhealthy silence: Faith […] wanted her lover to be able to confide in her. She didn’t mind the fights; they happened. What she did mind was that there was clearly something on Buffy’s mind and she wasn’t

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__________________________________________________________________ sharing it with her. Faith had worked hard to provide them both with a safe environment since they began dabbling in BDSM. She didn’t want it all to come crumbling down because Buffy refused to share with her.12 Buffy’s tendency to keep her problems to herself is described as unhealthy in this fan fiction, as it is in the TV show. However, in the fanfic text, the rough sex results in Buffy ‘allowing herself to cry and let it all out’ in her lovers’ arms, which then enhances their intimacy. The importance of verbally ‘sharing’ psychological problems is explicitly linked to the ‘safe environment’ that is required in BDSM, according to the standpoint Faith expresses in New Desires. The concern about safety reflects what BDSM scholars and practitioners refer to as the ‘ethics of care’, which implies a ‘safe, sane and consensual’ basis for sexual power play.13 Faith’s line underscores that it is important for the dominating partner to make sure the sexual games stay within the limits of what her lover enjoys. Buffy’s response to the spanking shows that the scene is both ‘sane’ and ‘consensual’: ‘She enjoyed the control Faith had over her and she knew everything the other girl did to her was out of love and respect’. Sexualised pain is both sexually gratifying and psychologically healing, then, because it is based on love and respect, and also because both partners know the limits of their games. Focus in the consecutive sex scenes which constitute both fanfic texts is on the sexually pleasurable aspects of pain, especially from the submissive partner’s point of view. The characters’ moans, gasps, husky voices, bodily fluids, orgasmic cramps and other physical reactions that bear witness to sexual excitement and satisfaction are represented in graphic detail – as is the pain that causes the pleasure. Even when the pain is extreme, it provokes sexual arousal. In Faith’s Fantasies, Faith ‘screamed and jerked at the bonds holding [her] arms’ when Buffy puts clamps on her nipples; ‘everything exploded in a haze of pain’ and Faith ‘swallowed hard against a surge of nausea’.14 Alongside the details about this excruciating pain, a couple of brief notes regarding Faith’s arousal are inserted, such as the following sentence which describes Faith’s feelings at the end of the clamp session: ‘My world narrowed to the burning in my chest and the desire dripping from my body’. Such sparseness of details about the submissive character’s pleasure give the impression that the sexually gratifying aspects of pain literally go without saying. Considering that the text is a pornographic account of consensual BDSM,15 it is reasonable to suppose that pain is inextricably linked to sexual pleasure, rather than to suffering. In other words, the detailed descriptions of painful sensations may appear as pornographic as the portrayal of sexual arousal and release.

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__________________________________________________________________ 5. Contextualized and Transgressive BDSM The ‘adult’ femslash texts discussed here provide explicit, graphic representations of kinky sex between familiar female characters. The fact that the characters’ background and previous relationship are known to the readers is important. In relation to Buffy/Faith femslash, knowledge of their strength, their healing capacities and the erotic tension that exists between them in the TV show makes a BDSM-influenced relationship seem like a natural development. Furthermore, the sexualised pain described in fan fiction can be extreme and yet remain ‘safe and sane’. Given the emphasis on the ‘ethics of care’ in the fanfic texts analysed, the authors apparently consider it important to show that Buffy and Faith’s rough sex is based on mutual consent, love and respect. Another possible explanation to the interest of the fan fiction texts discussed here,16 is their transgressive nature. Creating BDSM femslash about the two Slayers may seem logical, considering Buffy and Faith’s ‘personalities’ and relationship in the TV series. However, it also entails a transgression of the rules that govern Buffy the Vampire Slayer, a heteronormative prime-time show. Here, sex scenes are never explicit, lesbian love is clearly ‘different’, and kinky sex is presented as unhealthy. The fanfic texts, on their part, abound with graphic and explicit BDSM (or other kinky) sex scenes, which may be labelled hard-core pornography. With their focus on kinky and rough sex, the fanfic depictions of Buffy and Faith furthermore transgress stereotypical ideas about female desire and sexual behaviour as ‘vanilla’. These ideas are still wide-spread in our culture, Clarissa Smith states in her recent reader-response study of women’s pornography,17 even as representations of strong women as well as of ‘alternative’ sexualities are no longer unusual. What is titillating about pornography, according to Laura Kipnis, is ‘its theatrics of transgression, its dedication to crossing boundaries and violating social strictures’.18 Perhaps the mix of the preexisting/restricted – two powerful Slayers from a ‘tamed’ TV series – and the new/challenging stories about these two female superheroes inflicting sexually gratifying pain on each other is a key to making sense of the pain in BDSM femslash about Buffy and Faith.

Notes 1

The shortened acronym stands for ‘Bondage and Discipline, Dominance and Submission, Sadism and Masochism.’ 2 For instance V Keft-Kennedy, ‘Fantasising Masculinity in Buffyverse Slash Fiction: Sexuality, Violence, and the Vampire,’ Nordic Journal of English Studies 7:1, 2008. 3 E Saxey, ‘Staking a Claim: The Series and Its Slash Fan-fiction,’ Reading the Vampire Slayer: An Unofficial Critical Companion to Buffy and Angel, Roz Kaveney (ed), Tauris Park, New York, 2001, p. 206.

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Saxey, p. 203. ‘The Zeppo’, Buffy 3.13. 6 When used in a sexual context, ‘vanilla’ refers to standard and conventional sexual practices, which exclude BDSM. ‘Vanilla’ is often used as the opposite of ‘kink’. 7 J Alexander, ‘A Vampire Is Being Beaten: De Sade through the Looking Glass in Buffy and Angel,’ Slayage 15, December 2004, par. 20. 8 J Alexander, par. 8. 9 Faith’s Fantasies, ‘Valentine’s Surprise’. 10 Faith’s Fantasies, ‘Valentine’s Surprise’. 11 New Desires, ‘Virgins’. 12 New Desires, ‘Spanking’. 13 See for example G Taylor & JM Ussher, N Rambukkana and P Califia. 14 Faith’s Fantasies, ‘Let’s Start at the Beginning’. 15 ‘Non-Con’ Fanfic, about non consensual sex, is another fan fiction variety. 16 Both texts have received positive reviews from readers, and New Desires is mentioned as one of the most read texts on AdultFanfiction.net. 17 C Smith, One for the Girls: The Pleasures and Practices of Reading Women’s Porn, Intellect Books, Bristol & Chicago, 2007, p. 47. 18 L Kipnis, ‘How to Look at Pornography,’ Pornography: Film and Culture, Peter Lehman (ed.), Rutgers U P, New Brunswick, New Jersey and London, 2006, p. 119. 5

Bibliography Alexander, J., ‘A Vampire Is Being Beaten: De Sade through the Looking Glass in Buffy and Angel.’ Slayage: The Online International Journal of Buffystudies 15. December 2004. http://www.slayageonline.com/essays/slayage15/Alexander. htm. 7 January 2010. Califia, P., Public Sex: The Culture of Radical Sex. Cleis Press, San Francisco, 2000. Keft-Kennedy, V., ‘Fantasising Masculinity in Buffyverse Slash Fiction: Sexuality, Violence, and the Vampire.’ Nordic Journal of English Studies. 7:1, 2008, pp. 4980. http://guoa.ub.gu.se/dspace/handle/2077/10206. Accessed 7 January 2010. Kipnis, L., ‘How to Look at Pornography.’ Peter Lehman (ed.), Pornography: Film and Culture. Rutgers U P, New Brunswick, New Jersey and London, 2006.

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__________________________________________________________________ Naughti. New Desires. http://buffy.adultfanfiction.net/story.php?no=600030282. Accessed 8 December 2009. Rambukkana, N., ‘Taking the Leather Out of Leathersex: The Internet, Identity, and the Sadomasochistic Public Sphere.’ Queer Online. Peter Lang, 2007, New York, pp. 67-80. Rebelrsr. Faith’s Fantasies. http://buffynfaith.net/fanfictions/index.php?act=vie& id=199. Accessed 8 December 2009. Saxey, E., ‘Staking a Claim: The Series and Its Slash Fanfiction.’ Reading the Vampire Slayer: An Unofficial Critical Companion to Buffy and Angel. Tauris Park, New York, 2001. Smith, C., One for the Girls! The Pleasures and Practices of Reading Women’s Porn. Intellect Books, Bristol & Chicago, 2007. Taylor, G.W. & Ussher, J.M., ‘Making Sense of S&M: A Discourse Analytic Account.’ Sexualities. 4.3, 2001, pp. 293-314. Malin Isaksson is Research Fellow of French at Umeå University, Sweden. Her research interests span contemporary French literature, fan fiction, reception studies, gender and queer theory. In an on-going project, ‘Tough Girls’ Love’, she analyses femslash about strong female characters from TV series. Together with Dr. Maria Lindgren Leavenworth, she is working on the book FAN(G)S: Queer Sexualities in Vampire Fan Fiction.

The (Swedish) Zombie and the Welfare State: Politics and Emotion in John Ajvide Lindqvist’s Handling the Undead Katarina Gregersdotter Abstract John Ajvide Lindqvist’s novel Handling the Undead (2005) has a zombie theme. In this article I argue that the Swedish zombie is very much formed by — or part of— a typically Scandinavian literary context. This entails, among other things, that an implied or explicit discussion about the welfare state helps shape the narrative. Lindqvist describes a contemporary Stockholm where thousands of dead people suddenly wake up. In the novel the zombie is used as a metaphor for and a means to discuss the state of the welfare state. On the other hand, the zombie is also used as a way to handle pain and grief. Key Words: The welfare state, pain, love, hope, Swedish crime fiction, zombies, consumerism. ***** 1. Introduction The opening sentences of the novel frame the subsequent narrative. A drunk and possibly homeless man is standing in the exact spot where former Swedish Prime Minister Olof Palme was assassinated in 1986. Olof Palme had for 17 years been the leader of the Social Democratic Party. This political party had introduced the welfare state system, which after the end of the Second World War, basically was to become synonymous with Swedish politics and the Swedish way of life. The man says: ‘It’s all going to hell, Olof. Down, down and further down’.1 After these words, the man nods ‘goodbye to the Prime Minister and trace[s] his assassin’s steps toward Tunnelgatan.’2 By using these words, and then choosing for the character the assassin’s way to leave the crime scene, Lindqvist emphasizes the fact that the murderer was never captured and it is often suggested that Sweden lost her innocence with the death of Palme and the unsuccessful attempts at closing the case. It was unfathomable that this type of crime could have happened in Sweden. Similarly, Lindqvist ascribes the same sense of incomprehensiveness to characters in the novel when the dead wake up in Stockholm, Sweden: ‘Sweden, he thought, Sweden. That sort of thing doesn’t happen here.’3 The welfare state plays a significant part in Handling the Undead. Despite the many elements in this novel which apparently place it in the horror/gothic genre, Lindqvist also places himself within a Scandinavian literary tradition, employing thematic elements and social commentary that are often found in crime fiction. This furthermore means that a surrounding – implied or explicit – discussion about the welfare state is present in the narrative. This paper maintains that the zombie is

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__________________________________________________________________ used as a means to discuss, and a metaphor for, the (dying) welfare state. The zombie reveals the social structures and ambitions which are failing people, causing them pain, leaving them desolate and without hope. The zombie is proven to be a useful tool; in comparison to other monstrous figures it is ‘embodied and material, walks and bleeds and sweats.’4 The author intertwines these two sorrows (personal and societal), within the framework of the horror/gothic genre, using genre conventions simultaneously as reconstructing them. In order to achieve this reading I will regard this text in relation to the zombie genre per se. Zombies are most commonly portrayed in the movies, so references will be made to a few examples of classic zombie movies, and critique regarding these.5 Furthermore I will place the novel in the context of Swedish crime writing, and briefly discuss that as well. 2. What Is a Zombie? The zombie has been discussed by many, and the most intriguing aspect is its contradictory nature. It is a ‘boundary figure.’6 However, the zombies depicted in the novel are remarkably different from most other illustrations of zombies, visual or textual. Generally, ‘the zombie [is the] body without mind or soul that nevertheless impersonates the human.’7 The image in Handling the Undead is not of the brain dead, flesh eating, rabid creature which is a danger to everybody and everything. The zombies in the novel are called ‘reliving’ and not ‘living dead’ or ‘zombie,’ thus emphasising life instead of death. Many critics write about the inherent duality of zombies: they are, for example, both dead and alive, both human and not, both slave and rebel.8 Lindqvist’s zombies are also sites of ambiguity, but their duality is of a different kind: here they are symbolic of the dual opposition hope and pain, which is reflected in the emotional reactions of the other characters. Discussing more positive illustrations of the monstrous, Fred Botting writes that present textual examples of monsters are less often described as evil and terrifying but instead they are sites of identification, sympathy, and self-recognition. Excluded figures once represented a malevolent, disturbed, or deviant monsters are rendered more humane while the systems that exclude them assume terrifying, persecutory, and inhuman shapes.9 The monsters Botting refers to do not include zombies however; they seem to largely prevail as characters of either dystopian narratives or pure splatter/gore, and sometimes a combination of both. Yet, in Handling the Undead the zombies, which I will hereafter refer to as the reliving, are used as sites for emotions such as

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__________________________________________________________________ love, grief, pain and hope. The system around them is however, in accordance with Botting’s thesis, depicted as actively opposing these emotions. Handling the Undead is far from the first narrative of this kind to use social commentary. Romero’s Dead-series deals with racism and consumerism, for example.10 The beating of the reliving by young men with baseball bats in Handling the Undead is an obvious intertextual reference to Night of the Living Dead, where a violent posse of humans kills whoever they believe is a zombie. This, in turn, is part of Romero’s social commentary: the posse can be likened to a lynch mob out to kill blacks. In Lindqvist’s case, the mob is made up of young men who are all dressed the same way, and resemble ‘a social club from The Business School’11 and can thus been seen as representatives of the capital. Still, with the clear references to the horror and gothic genre, Lindqvist’s social commentary also situates him within the traditions of Swedish crime writing, though the crimes here are neither solved by the police, nor attempted to be solved. 3. A Swedish (and Emotional) Context When Maj Sjöwall and Per Wahlöö published the first novel in the series about inspector Martin Beck in 1968, Roseanna, the crime novel in Sweden changed. Politics became an important part of plot; the so-called reality and the social environment were issues crucial to the description of characters on both sides of the law. Since Sjöwall and Wahlöö entered the scene, many crime writers have followed in their footsteps. Swedish crime fiction is sometimes referred to as the ‘Ulcer School,’ where the protagonists are not simply doing their job—solving crimes—but also are permitted to be affected by the society surrounding them. They are allowed to ‘have an opinion’ about society, and that is when the ulcer enters the scene.12 Lindqvist writes in this tradition, and this is seen in the fact that the setting is of high importance, not just for ‘colour’, but ‘on socially defining comments on the characters.’13 The before mentioned homeless man is an illustration of such socially defining comments. One of the characters, Flora, whose grandfather is a reliving, goes to meet her outcast friend living in what is called ‘The Heath.’ The Heath is described to be ‘a blot of shame on the city; a failed and slightly dodgy construction project, now a gathering place for those displaced from the rest of the city.14 The Heath is carefully depicted. ‘Broken glass crunched underfoot and the sound was magnified, bouncing back and forth between the bare concrete walls.15 The place has a clear hardness to it, a place evidencing governmental amnesia or ignorance, and this is also fittingly where the authorities will place (or rather store) the reliving. Flora is the character which most openly comments on her society. For her, society has collapsed already, and when the news of the reliving has reached her she says: ‘Everything is different now. …Everything they’ve based all their shit on…’.16 Flora talks about ‘they’ here, without being specific, but it is obvious she

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__________________________________________________________________ has the social and governmental authorities in mind. She predicts chaos, of course, but adds that at least it ‘is something else, and damn if I don’t think that’s good.17 Flora wants change, and the change she longs for is on a societal level. She has a vision of Stockholm and its inhabitants wrapped in plastic, and it is an image of artificiality and of emotional and physical stagnancy. 4. Consumerism, Gender and the Welfare State One aspect of society which stands out as being a major factor in the deconstruction of the welfare state concerns consumption and the ideals of consumerism. One of the characters is a stand up comedian and when his son asks him why the audience laughs he replies ‘’I think that people laugh because they want to laugh. They have paid to come and laugh, and so they laugh’.18 This conversation illustrates the idea that people can buy happiness, or at least that they have decided, or have been told, that they can buy it. The same character uses a picture ‘every time his ideas dried up, when he felt hesitant,’ and the picture ‘was death; the thing you struggle against’ (HTU 7). The picture of ‘death’ is a photo of a sculpture called ‘Supermarket Lady.’19 A woman, obese, in a pink top and turquoise skirt, pushing a loaded shopping trolley. […] Her gaze is empty. […]. But the trolley is full. Filled to bursting. […]. Her body is a lump of flesh forced inside her skin, which in turn has been crammed into the tight skirt, the tight top. The gaze is empty […]. 20 In line with Jean Baudrillard’s theories, consumption rather than production is stressed. Since the zombie ‘has becomes an existential term, about mental and physical enslavement’21 the woman can be seen to resemble a traditional zombie rather than a woman. The empty gaze should be seen in comparison to her outfit, shopping trolley and her obesity. She is symbolically trapped in the supermarket and her own body. The sharp colors emphasize the surface, and her body size and the filled shopping trolley show the never-ending appetite, and could be an illustration of Steven Shaviro’s words about the zombie: ‘We all know those shuffling idiot bodies, wandering obliviously […], wailing with a hunger that can never be sated […].’22 Another example of the attitudes to consumption is detected in the description of when Flora’s parents return home from a trip, bearing gifts. ‘There it was. The rustle that always announced her parents’ return from a trip. The shopping bags’.23 Flora says that she does not need a new iPod, and ‘[s]ilence fell. A plastic bag crumpled up with a sound like a sigh. Flora savoured it. Not everything can be bought, no, not everything can be bought’.24 (Baudrillard writes: ‘The fundamental, unconscious, and automatic choice of the consumer is to accept the life-style of a particular society,’25 and throughout this narrative, Flora links this attitude to the


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__________________________________________________________________ values of the middle-class. She feels ‘contempt for the middle-class world she had been born into’.26 Emotions have been replaced with goods, and when she was younger, Flora used to react by cutting herself. It is a perhaps natural consequence since, as Baudrillard states: ‘Conformity and satisfaction are interrelated.’27 Flora does not accept the middle-class values; she does not ‘conform’ to them and therefore can receive no satisfaction, only pain. On the topic of conformity David Punter and Glennis Byron state: ‘Conformity is central to one of the earliest of Gothic monsters established in the twentieth century: the zombie.’28 This is evidence of the fact that conformity is part of the critical discussion on both consumerism and the zombie as a symbol. Flora shares the physical and emotional pain with her grandmother and it is a pain that has no place in the welfare society due to its gendered nature. The female characters belong to different generations but both have been labelled by society. As a comment on the strict, brutal gender structures, Flora has hidden her razor blade in the Pretty Woman DVD case, and in the 1950s, Elvy was diagnosed ‘hysterical.’ In the fifties, as the welfare state flowered and the final victory of rationality seemed imminent, it was not a nice thing to be hysterical. […] No one had the right to be unhappy.29 Thus, emotions have no real place in a rational society. 5. Love and Pain When the reliving have woken up they try to go home. Despite the fact that the reliving are medically speaking dead they act as if they have memories of life and of emotions, quite the opposite to most other descriptions of zombies. When they died, their family members stopped living as well, in a sense. The pain of those still alive is shown in various ways: one character contemplates suicide every day, for example. It is possible to claim that the reliving are created this way so that they can respond to the unbearable pain and grief of their loved ones. The reliving are described by authorities to be a logistical problem, and all human emotions connected to them are initially ignored. The reliving are handled by and shuffled between various authorities to eventually be placed in The Heath. The relatives to the reliving end up going through the same pain all over again, and as one character says: ‘As an old Social Democrat I am very disappointed in the government’s actions […]. [T]his will have an impact when I go to vote next month’.30 Yet, the reliving are not just logistically problematic. What is ironic is that all characters in the novel, when they are in close proximity to the reliving become exposed to other characters’ thoughts, and thus also emotions:

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__________________________________________________________________ Large numbers of dead people were having an effect on the minds of the living, but the large numbers of the living were also affecting the dead. As if through a system of prisms, emotions were being enlarged, reflected in each other, reinforced, and this went on until the force field was unbearable. 31 In the presence of the reliving, the metaphorical plastic wrapping of Stockholm bursts, and there is no way to escape emotion. The end of the novel is tragic and in line with the general inability to deal with so much emotions. Yet, the author describes hope as well. A few of the characters have a new chance to say a proper goodbye to their loved ones: ‘I believe. There is a place where happiness exists. A place, and a time’.32 Above all, the link between the reliving and hope that the author provides —despite the many instances of various sorts of violence performed by authorities and private citizens33—is not dystopic. This link forms the horror narrative in new ways, and the zombie is neither a symbol for end of the world nor gore, but rather love and ways to overcome pain.

Notes 1

Handling the Undead 1 ibid. 2 3 ibid. 274 4 M Warner, Phantasmagoria, Oxford University Press, Oxford, p 358. 5 G Punter and D Byron write: ‘One the whole zombies proliferate more in film than in printed fiction […],’ The Gothic, Blackwell Publishing, Malden, MA,2004, p. 265. Marina Warner also talks about this (361). 6 SJ Lauro and K Embry, ‘A Zombie Manifesto: The Nonhuman Condition in the Era of Advanced Capitalism,’ Boundary, 2: 35: 1, 2008, p. 90. 7 Punter and Byron, p. 285 8 See for example J Lauro and K Embry. Jacques Derrida writes that ‘zombies infect the oppositions grouped around them.’ J Collins and B Mayblin, Introducing Derrida. Icon, 2005, Cambridge: p. 21. 9 F Botting quoted in D Punter and G Byron, p. 265. 10 See for example, J Webb and S Bynard’s ‘Some Kind of Virus: The Zombie as Body and as Trope,’ Body & Society, 14: 83, 2008, S Harper’s ‘Zombies, Malls, and the Consumerism Debate: George Romero’s Dawn of the Dead,’ Americana: The Journal of American Popular Culture 1900 to Present, Fall 2002, Vol. 1, Issue 2, and A Loudermilk’s ‘Eating ‘Dawn’ in the Dark: Zombie Desire and commodified Identity in George A. Romero’s Dawn of the Dead,’ Journal of Consumer Culture, 3: 83, 2003. 11 HTU op-cit., p.326 12 B Lundin, The Swedish Crime Story. Jury, Bromma, 1981, p 10. 2


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Lundin, p 10. HTU p.116 15 Ibid., 16 Ibid., p. 92 17 Ibid., p.93 18 Ibid., p.10 19 This is a photo of Duane Hanson’s plastic sculpture called ‘Supermarket Lady.’ 20 P.7 21 Warner 359. 22 Shaviro, p. 171. 23 HTU p.197 24 Ibid., p.199 25 J Baudrillard, ‘Consumer Society,’ Selected Writings, Polity, Cambridge, 2001, p. 40. 26 TU p.214 27 Baudrillard, p. 40 28 Punter and Byron 264 29 HTU p.38 30 Ibid.. p.225 31 Ibid., p.296 32 Ibid., p. 356 33 Flora thinks: ‘That evening in Elvy’s garden she had wishes…she had known…that something was going to happen. Something that would change Sweden forever. Now it had happened, and what was the change? Nothing. Terror gave birth to terror, hatred begat hate and all that was left in the end was a pile of burnt bodies. As everywhere; as always’ (HTU 348). 14

Bibliography Lindqvist, J., Handling the Undead. 2005. Quercus, London, 2009. Baudrillard, J., ‘Consumer Society.’ Jean Baudrillard: Selected Writings, Polity, Cambridge, 2001. Brodén, D., Folkhemmets Skuggbilder. Ekholm och Tegebjer, Stockholm, 2008. Byron, G. & Punter, D., The Gothic. Blackwell Publishing, Malden, MA, 2004. Harper, S., ‘Zombies, Malls, and the Consumerism Deabte: George Romero’s Dawn of the Dead. Americana: The Journal of American Popular Culture (1900present). Vol 1, issue 2, Fall 2002. http://www.americanpopularculture.com.

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__________________________________________________________________ Lauro, S.J. & Embry, K., ‘A Zombie Manifesto: The Nonhuman Condition in the Era of Advanced Capitalism.’ Boundary. 2 35:1. 2008. Loudermilk, A., ‘Eating ’Dawn’ in the Dark: Zombie Desire and Commodified Identity in George A. Romero’s Dawn of the Dead.’ Journal of Consumer Culture. 3: 1, 2003, pp. 83-108. Lundin, B., The Swedish Crime Story. Jury, Bromma, 1981 Mighall, R., ‘Gothic Cities.’ Routledge Companion to the Gothic. Routledge, London and New York, 2007. Poster, M., Jean Baudrillard: Selected Writings. Polity. Cambridge, 2001. Shaviro, S., Connected, Or What it Means to Live in the Network Society. University of Minnesota Press, Minneapolis, 2003. Spooner, C. & McEvoy, E., The Routledge Companion to the Gothic. Routledge, London and New York, 2007. Webb, J. & Byrnand, S., ‘Some Kind of Virus: The Zombie as Body and as Trope.’ Body Society. 14: 83, 2008, pp. 83-98. Katarina Gregersdotter is senior lecturer in English literature at Umeå University, Sweden. She is a member of the nationally awarded research group Challenging Gender at Umeå University. Her research areas include among others gender studies, popular culture, crime fiction and fan fiction. She is currently involved in two book projects, one on representations of rape in crime narratives, and the other on emotions.

Post-Independence Malaysian Short Stories: A Depiction of Racially Inflicted Pain Nor Hashimah Isa Abstract This paper addresses the theme of pain and endurance as portrayed in two short stories in relation to post-independence Malaysia. Pengabdian [Submission] by Awang Had Salleh (1966) and Gadis Tionghua di Daerah Pendalaman [The Chinese maiden from the remote district] by Zaid Ahmad (1969) deal with themes of poverty and inter-racial conflicts. This paper is interested in the personal and social challenges faced by the different race groups as they come to terms with living in a newly independent multi-racial nation. Key Words: Inter-racial conflicts, instances of conflicts, nation building. ***** 1. Introduction The aim of this paper is to examine racially inflicted pain endured by the characters as portrayed in two post-independence Malaysian stories Pengbadian [Submission] by Awang Had Salleh (1966) and Gadis Tionghua di Daerah Pendalaman [The Chinese maiden from the remote district] by Zaid Ahmad (1969). These stories published in 1966 and 1969 respectively focus on conflicts in relation to inter-racial love and Malay poverty. The Malaysian writers reveal the continuous hardship of forbidden inter-racial love and the challenges of economic instability experienced by the races as they struggled to live in the new nation. The story Pengabdian (1966) is about Fee Fong, a rich Chinese university student, who has a Malay driver who drives her to campus in a Mercedes. Fee Fong is attracted to Kamal, a Malay student she meets at the University. Kamal’s family is very poor and his father works in the paddy fields. His mother makes and sells cakes helped by his nine siblings. Kamal tells Fee Fong that the Malay driver is a status symbol for Fee Fong’s father. As a student leader Kamal wants the Malays to be neither impoverished nor exploited and accuses the Chinese of being opportunistic. Fee Fong becomes angry and defensive and this causes a strain in their relationship. The story Gadis Tionghua di Daerah Pendalaman (1969) is about Hairi, a Malay man who is posted to a remote rural estate as an officer. The majority of workers on the estate are Malays while the owner, Mr Lee, is Chinese. Hairi becomes friends with Mr Lee’s daughter, Nancy. At first Hairi is welcome in Nancy’s house and is respected by her father, Mr Lee. They even discuss the notion of Malays and Chinese living together in peace. But when Hairi and Nancy fall in love, Mr Lee strictly forbids Hairi from visiting Nancy at the house. He even

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__________________________________________________________________ gives Nancy a beating. Later, Hairi asks for a transfer out of the place and that ends their relationship. 2. Racially Inflicted Pain Racially inflicted pain is emotional pain that is felt by a race arising from another race’s act. Skevington says that a schema integrates information about pain, which may be elaborated as a person continues to experience pain. 1The change can be physical or emotional. Health Psychology describes the experience of pain as the end result of a number of physiological, psychological, social and cultural factors.2 McCall and Simmons’s view of identity theory as when emotions emerge when a prominent identity is challenged in interaction, as when others do not support one’s identity performance.3 Racially inflicted pain is emotional pain. This is evident in the post-independence scenario of the very diverse Malaysian population where one race is affected by another race’s pursuit of economic stability. One race is challenged by another that is trying to mark its existence in the new nation. Hence, pain is endured as a result of disjunctions and dissatisfactions felt by the races in the sixties. 3. Portrayal of Racially Inflicted Pain in the Post-Independence Short Stories The stories are analysed using Turk’s Pluralistic Conflict Theory 1969.4 Pain is depicted in the short stories when instances of conflict 1 and conflict 3 occur. The conflict indicators are: Conflict 1 - Ongoing struggle in a heterogeneous society Conflict 2 - Inter-group struggle for dominance in politics Conflict 3 - Negative reaction from one group as a result of being provoked by another group’s behaviour, cultural meaning, and significance. A. Conflict 1: Ongoing Struggle in a Heterogeneous Society In Pengabdian (1966), Fee Fong and Kamal exhibit the conflict of an ongoing struggle in a heterogeneous society. A conflict is exemplified and the racially inflicted pain is felt when Fee Fong supports Kamal’s convictions to eradicate poverty amongst the Malays. ‘[By] doing that, I feel I devote myself to his race, the Malay race. But, this does not mean I am a traitor to mine, because I hope this devotion will lessen the tension between the two races.’5 Fee Fong experiences this conflict as she loves a man out of her own race and simultaneously she conforms to her Chinese value system of communal and clan allegiance. Undeniably, she supports Kamal’s convictions of eradicating poverty amongst the Malays and she must stay loyal to her Chinese people. Kamal and Fee Fong endure the pain as the issue of race and economic dissatisfaction heighten contributing to their break up. Fee Fong experiences the pain because Kamal, a Malay accuses the Chinese of

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__________________________________________________________________ being opportunists in the new nation. He recklessly utters, ‘[The] Chinese really make use of the opportunities given to them. The Malays are not utilizing the opportunities to develop, because the opportunities are not given to them.’6 Irrefutably, there exists deep discontent in Kamal when he compares the economic success of the Chinese compared with his poor Malay people. This hurts Fee Fong deeply as Kamal is her boyfriend and yet he accuses her people. Kamal too experiences the pain resulting from the conflict when he sees his race deprived of the opportunity to develop. In the sixties, the Malays were poor and uneducated. Some blame the British for the `Divide and Rule’ policy that restricted the Malays to the villages, the Chinese to the towns and the Indians to the rubber estates. The Malays were thrown into the vicious cycle of poverty and deprivation of good education. The diverse populace was required to live together amidst their racial baggage and discontent. Another example of this conflict is when Fee Fong feels very upset and concerned with Kamal’s speeches that are intentionally trying to evoke the Malays’ anger and prejudice at the other races. She says, ‘[They] become angry at others, who all along have profited more than them.’7 Kamal, a student leader at the university uses his speeches to evoke awareness amongst the Malays but instead they are hurtful to Fee Fong. An instance of the conflict is evident in the second story Gadis Tionghua di Daerah Pendalaman (1969). Here, Tuan Lee, the estate manager tells Hairi, a Malay man who teaches English to his daughter, Nancy, that he supports the Malays and Chinese living peacefully together, ‘[Isn’t] it nice if the Chinese live peacefully with the Malays like us now.’8 Tuan Lee, Nancy’s father appears to have positive thoughts about the Malays and Chinese living peacefully. Ironically, he does not condone his daughter’s love for Hairi. Tuan Lee endures the conflict of an ongoing struggle in a heterogeneous society as he witnesses his daughter loving Hairi, a Malay man. He seems almost hypocritical as he tells Hairi of his desire to see the Malays and Chinese living harmoniously together despite the difference in religion and foods, ‘[You] just think. Why must we fight with the Malays? The Malays don’t eat pork. But, why worry? We live together peacefully as we work.’9 With such positive thoughts it is unquestionably sad that Tuan Lee gave Nancy beatings and sent her far away from Hairi. It seems that the elders want the races to live in peace but that deal does not include being in love or intermarriage. In the sixties, racial gap existed amongst the races as they strive to live in the young nation. Inter-racial love is forbidden as the races adhere to their cultures and religions. However, the story extends the ideas of values and beliefs amongst the young Chinese. This is highlighted by Nancy’s daring confession of love for Hairi, ‘[You] mustn’t hide anymore! You mustn’t hide anymore!’10 While Nancy sees Hairi’s concealment and denial of his feelings for her as unnecessary, we can also read his intentions as one of being cautious in an inter-racial love. Nancy endures the racially inflicted pain when Hairi is discreet about his feelings for her.

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__________________________________________________________________ The stories reveal no instance of conflict 2 - Inter-group struggle for dominance in politics. This is comprehensible because in the sixties, the races were more adamant in their pursuit of economic success in the young country. B. Conflict 3: Negative reaction from One Group as a Result of being Provoked by Another Group’s Behaviour, Cultural Meaning, and Significance In Pengabdian (1966) an instance of this conflict is evident when Fee Fong justifies her breakup with Kamal, ‘[Now] I have to leave Kamal. If I continue to be with him I am with the person who speaks badly of my own race.’11Fee Fong endures the pain and conflict as she pledges allegiance to her race and decides to leave the man she loves. She feels the negative reaction from Kamal who is provoked by the Chinese’s success. There is prejudice and bigotry as the races strive to live together. Subsequently, Kamal tells Fee Fong that the Malay driver is her father’s status symbol, ‘[I] feel that the Malay driver is your father’s status symbol.’12 In the sixties, the Malays began to compare their poverty to the other races’ and felt challenged and embarrassed when their people worked as drivers to rich Chinese people. Malays then were very proud of their status as Bumiputera. This also signifies socio-economic issues amongst the races. Another example is when Fee Fong becomes even more hurt by Kamal’s accusatory speeches, ‘[I] resent this. I am so hurt. It seems that my Malay friends scold and hate other people who are more fortunate and use this as escapism.’13 She is subjected to intense racially inflicted pain. Another portrayal of this conflict is when Fee Fong expresses her regret and sadness to Kamal via a letter, ‘[But], you are using another track now: you spark the fire of anger between our two races. Obviously, I cannot follow that track.’14 Here, Fee Fong feels the negative reaction and is provoked by Kamal’s behaviour. Kamal feels the pain too as he watched his people’s living in poverty, [They] are made poor. Abandoned! Suppressed!’15 Kamal’s utterance is a negative reaction of being provoked by the Chinese’s accumulation of wealth. In the sixties, the poor Malays aspired after better living and eradication of their prolonged poverty. 4. Discussion The issues in the stories are not merely consequences of inter-racial forbidden love. Socio-economic deprivation and uncertainties are also portrayed that led to racial prejudice, intolerance and unattainable love. The educated young Malays feel the pain as they watch their uneducated people deprived of a better life and they are determined to see their people pull through the poverty. They felt the conflict watching other races benefit living in this country while they continue to suffer in hardship. In matters of the heart, the elders are not in support of interracial love as they hold fast to their cultures, religions and identity. Racial

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__________________________________________________________________ dissatisfaction and suspicion blur any effort to unite the different races in matrimony and these young innocent people suffer immensely. Malaysia is a new nation with a plural society comprising Malays, Chinese, Indians and other ethnic minorities. The country achieved independence from the British in 1957 after having experienced colonialism. From 1957 to 1969, the new country with its diverse ethnic groups was striving to forge itself into a nation. On 13 May 1969, a bloody racial clash occurred that shook the country and left scars in race relations. The conflicts experienced by the ethnic groups during the early years of independence blew out of proportion when there was a lot of suspicion and economic aspirations were constantly not met. Experts speculated that these led to the racial riot of 1969. In contemporary Malaysia, there is harmony but issues of religion and identity constantly cause uproars of dissatisfactions amongst the races. In 1998, there was a racial clash at Kampung Rawa in Penang. The issue was the proximity of a Hindu temple to the Kampung Rawa mosque. In 2001, the country was shaken by the Kampung Medan racial riot in Jalan Klang Lama, Kuala Lumpur between the Malays and the Indians. This was mainly due to the socioeconomic dissatisfaction of the lower income community. The country is tested again. This time the issue is the usage of the Kalimah ‘Allah’ by the Herald in its Catholic weekly publications. The Muslims protested to the usage of ‘Allah’ as the Malaysian Christians’ God when the Malaysian high court declared that the Herald can use the word `Allah’ in its publications. Hence, a few churches were attacked in the country. Adding salt to the wound, a mosque was attacked with bricks causing the glass doors to break. The issue of religion is undeniably very sensitive in a country like Malaysia. Values and norms are adhered to although they stand to the test of time and modernization. When racial riots or conflicts broke out, the government quickly introduced efforts to foster better unity amongst the races. Mahathir Mohammad in his speech `Building a Malaysian Nation’ at the Launching of the Programme on Socialisation, at Putra World Trade Centre, Kuala Lumpur, on 1 August 1988, said: ‘The authorities have no intention of wiping out the identity of any race. All races are free to perpetuate their own identity in their language, religion and culture’.16 5. Conclusion The conflicts are cyclical and they continue to exist in contemporary Malaysia although they are under control. There are ways to address the conflicts such as 1Malaysia. It is an on-going campaign announced by Prime Minister Najib Tun Razak on September 16, 2008, calling for the cabinet, government agencies, and civil servants to more strongly emphasize ethnic harmony, national unity, and efficient governance. Najib says, ‘The government is committed to carrying out a transformation programme as its main agenda based on approaches and philosophy of 1Malaysia-

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__________________________________________________________________ people first, performance now’17. 1Malaysia can be the ultimate prescription for unity and tolerance amongst the different ethnic groups if its eight values are materialized. The values are perseverance, acceptance, education, integrity, meritocracy, humility, loyalty and culture of excellence. These are very significant values for unity and nation building yet irrefutably challenging to materialize. The government also introduced the New Economic Policy (DEB) – to restructure the communities and to decrease the gap between the races’ income and social economic status (SES). Another way of addressing the conflicts is to create the Bangsa Malaysia (Malaysian nation), a policy introduced by Mahathir Mohamad to create an inclusive national identity for all inhabitants of Malaysia. He said it means ‘people being able to identify themselves with the country, speak Bahasa Malaysia (the Malay language) and accept the Constitution.’18 This received various responses from the ministers. Abdul Ghani Othman Johor says, ‘Even if the term Bangsa Malaysia is to be used, it must only be applied in the context of all the peoples of Malaysia with the Malays as the pivotal race’.19 Lim Keng Yaik says it should be used as a government policy. Najib Tun Razak then says it has nothing to do with the skin or colour of the races.20 The Bangsa Malaysia concept is a good promising step towards tolerance and nationhood although it is challenging when it concerns the rights and privileges of the Malays as Bumiputera.

Notes 1

SM Skevington, Psychology of Pain, John Wiley & Sons, New York, 1995, p. 109. 2 S Horn & M Munafo, Health Psychology: Pain, Theory, Research and Intervention, Open University Press, Buckingham. 1997, p.68 3 McCall and Simmons’s 1978 in Handbook of the Sociology of Emotions, Springer, New York 2006, view identity theory as when emotions emerge when a prominent identity is challenged in interaction, as when others do not support one’s identity performance. This is evident in the post-independence scenario of the very diverse Malaysian population where one race is affected by another race’s pursuit of identity. One race is challenged by another that is trying to mark its existence in the new nation. 4 Keel 1997, p. 1–3. Turk’s Pluralistic Conflict Theory 1969. This paper discusses the emotional pain as instances of conflicts felt by the characters in the stories. See also J Hamlin, (2005). Conflict Theory: Sociological Theories of Deviance http://www.d.umn.edu/~jhamlin/conflict/html, R Keel, 1997, Sociology of Deviant Behavior in Culture Conflict Theory, http://www.umsl.edu/~rkeel/200/culflic.html, and R Keel, 2005, Conflict Theory: Issue of Institutional vs Individual Behaviour http://www.umsl.edu/~rkeel/200/conflict.html.

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HS Awang, Pengbadian: An Ongoing Struggle in a Heterogeneous Society,1966. p. 99. A portrayal of Conflict 1 6 ibid., p. 98 7 ibid., p. 100 8 M Sikana 1987, p. 65. Gadis Tionghua di daerah Pendalaman The Chinese maiden from the remote district . A portrayal of Conflict 1- an ongoing struggle in a heterogeneous society. 9 ibid., p. 65. A portrayal of Conflict 1 10 ibid., p. 65 A portrayal of Conflict 1 11 Awang op. cit., p. 101. A portrayal of Conflict 3 - negative reaction from one group as a result of being provoked by another group’s behaviour, cultural meaning, and significance. 12 ibid, p.97.. A portrayal of Conflict 3 13 ibid, p.100-101. A portrayal of Conflict 3 14 ibid, p. 101 A portrayal of Conflict 3 15 ibid, p. 98. A portrayal of Conflict 3 16 M Mohamad, ‘Building a Malaysian Nation. Prime Minister, Malaysia,’ Ceremony for Launching of the Programme on Socialisation, Putra World Trade Centre, Kuala Lumpur. 1st August, 1988, 10.30am. 17 The Prime Minister, Najib Razak’s Speech on 1Malaysia http://www.1Malaysia.com.my/index.php?=content&view=articles&ibid=358&Ite mid=70&lang=en. 18 The Prime Minister’s 1Malaysia 19 http://www.1Malaysia.com.my/index.php?=content&view=articles&ibid=358&It emid=70&lang=en 20 NT Razak, the deputy Prime Minister then defended the Bangsa Malaysia saying ‘it has nothing to do with the skin or colour of the races.’ Bangsa Malaysia (Malaysian nation) was a policy introduced by Mahathir Mohamad - ‘people being able to identify themselves with the country, speak Bahasa Malaysia (the Malay language) and accept the Constitution.’ Also see http://en.wikipedia.org/wiki/ Bangsa_Malaysia.

Bibliography Ahmad, T.T., The Hindraf Issue: An Analysis within the Malaysian SocioReligious Tolerance Context. Paper presented at the Malaysian seminar on Malaysian Study of Islam on June 28-29 at the University of Wales Lampeter, United Kingdom, 2008. Asma, A. & Pedersen, P.B., ‘Understanding multicultural Malaysia.’ Delights, Puzzles and Irritations. Prentice Hall, Kuala Lumpur, 2003.

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__________________________________________________________________ Asmah, H.O., Language and Society in Malaysia. Dewan Bahasa dan Pustaka, Kuala Lumpur, 1993. Awang, H.S., Merah kuning biru. Penerbitan Federal Berhad, Kuala Lumpur, 1966. Bangsa Malaysia http:/en.wikipedia.org/wiki/Bangsa-Malaysia. Viewed on 30 March 2010. Chai H.C., ‘Education and Nation-Building in Plural Societies: The West Malaysia Experience.’ Development Studies Centre Monograph Series; no.6. The Australia National University. National Library of Australia. 1977. Keel, R., Sociology of Deviant Behavior in Culture Conflict Theory. http://www.umsl.edu/~rkeel/200/culflic.html Viewed on 20 July 2003. Keel, R., Conflict Theory: Issue of Institutional vs Individual Behavior. http://www.umsl.edu/~rkeel/200/conflict.html Viewed on 16 September 2005. Mana, S., Cerpen sepanjang zaman.: Siri Sastera PEP. Penerbit Pan Earth Sdn. Bhd, Petaling Jaya 1987. Mahathir, M., Prime Minister, Malaysia. Ceremony for Launching of the Programme on Socialisation. Putra World Trade Center, Kuala Lumpur, 1st August, 1988, 10.30am. Husin, S.A., The Malays: Their Problems and Future. Heinemann Educational Books (Asia) Ltd, Malaysia, 1981. Nor Hashimah Isa is a senior lecturer of the English Language Department, Faculty of Languages, Universiti Pendidikan Sultan Idris (Sultan Idris Education University), Malaysia. She holds a PhD in English Literature. Her current research is on literary selection of the Malaysian Secondary Schools. It is FRGS or Fundamental Research Grant Scheme, fully sponsored by the Malaysian Ministry of Education. She teaches English literature and literatures in English to Bachelor and Masters Students.

Painstaking Pain: Alice McDermott’s Child of My Heart Hoda Elsayed Khallaf Abstract In a Powell’s Author interview, Alice McDermott stated that her novel, Child of My Heart (2002), is the story of a teenage girl’s coming of age, a kind of response to the attacks of 9/11, a way of remaking the world through art, and a lament. Reviewers have often puzzled over the book’s ‘meaning’; and the character of Theresa, the teenage heroine, raises more questions than answers. To me, the novel is mainly about pain: the pains of searching for cultural identity, of adolescence, of illness, of growing old, of loss, of death. Yet the theme of pain as such is not a clear-cut one. A set of undercurrent dualisms adds to the ambiguity of the novel: Adolescence/ Maturity, Life/ Death, Conformism/ Non-conformism, and Traditional/ Untraditional. However, through a deconstructive reading of the text, and an analysis based on psychological theories of Defense Mechanisms, this paper will attempt to resolve the novel’s thematic ambiguity. Key Words: Adolescence, Deconstruction, Defense Mechanisms, Art, Pain. ***** Shortly after the publication of her fifth novel, Alice McDermott, in an interview, stated that ‘I’m finding that Child of My Heart is a difficult book for me to talk about, and from what I’m hearing it’s a very difficult book for other people to talk about too.’1 Indeed, reviewers varied in their response to the text. Cheryl Dellasega saw the book as ‘an odd ‘coming of age’ novel with an unusual fifteen year old girl as narrator.’2 Margaret O’Brien Steinfels believes the novel to be about the theme of loss, though she accords with other reviewers in their fear that the text appears to lack form, and therefore, the projection of its theme is flawed – ‘a mess of emotional pottage.’3 McDermott herself told Alice Cary that ‘in the aftermath of 9/11, it’s a book about mothering and nurturing, as well as the absence of those things.’4 Dave Weich, interviewing McDermott, remarks that ‘a lot has been made of what doesn’t get drawn out in the story. One reviewer basically said, ‘She skipped the most important parts!’’; and then he wonders what the book meant for the author herself. McDermott replies that ‘it’s a book about art, why we need it, and what the impulse to make it involves: incredible selfishness and incredible generosity.’5 Complicating the matter further, a close reading of the novel would reveal that a number of dualisms permeate the text. The first one is Adolescence/Maturity. Teenage heroine Theresa displays an interest, a kind of discovered awareness of the physicality of her body, and of other people’s bodies.

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__________________________________________________________________ Babysitting the twins at the Kaufman’s, and baby Flora at her elderly father’s house, Theresa notices Dr. Kaufman’s and Flora’s father’s awareness of her physical beauty, vaguely but gradually picks up an understanding of the marital relationship between these men and their wives, and eventually loses her virginity in exploring that understanding with Flora’s seventy-year-old father. As an adolescent, Theresa still retains childish characteristics. Walking with her eight-year-old cousin, Daisy, in the snow, they ‘threw back [their] heads and opened [their] mouths and stuck out [their] tongues and felt the snowflakes in [their] eyes and on [their] bare throats.’6 However, unlike an adolescent, Theresa has neither boyfriends nor girlfriends. Instead, most of her summer time is spent in efficiently taking care of other people’s children and pets. Also unlike rebellious adolescents, Theresa does not seek escape from her dwelling place; rather, she ‘loved every corner of that house, even then,’7 at fifteen. She does not display reluctance in any of her actions. In fact, most of the time she seems to ‘always know what [she] was doing.’8 Another dual theme is that of Life/Death. The very first sentence of the book introduces a crowd of budding creatures in an implied care-free world: ‘I had in my care that summer four dogs, three cats, the Moran kids, Daisy, my eight-year-old cousin, and Flora, the toddler child of a local artist.’9 And the novel is ripe with their lively anecdotes. But then the baby rabbits die; little Debbie’s cat, Curley, is hit by a car, and gruesome details of its bleeding, crushed scalp are given; the details of Uncle Fred’s death and funeral are remembered; the filmy, decaying skin and toothache of Flora’s father are keenly noted by Theresa, as much as she alarmingly notes the mysterious fever and dark bruises on Daisy’s skin; and then there’s Daisy’s death, as sad and inexplicable, as it is. The third binary opposition is that of Conformism/Non-conformism. Theresa’s parents and uncles are children of Irish migrants who have settled in Manhattan, New York; the time-long doorway into the U.S., and symbol for cultural diversity and intermingled cultural dialogue. Yet Theresa’s family members, and their friends, the Clarks, cling on to their inherited heritage. On Sundays, when the Clarks would be having dinner with Theresa’s parents, ‘as usual’, ‘all their interest and enthusiasm were reserved for the places they had left.’10 Theresa, on the other hand, thinks their reminiscing ‘odd’ and ‘even then [she] thought there was something medieval about it.’11 Singing a song that her father used to sing, about a ship that never returned; Theresa incongruously deforms the words as ‘Daisy, face red, her hands flying to her mouth,..doubled over in shame and delight.’12 Finally, there is the dual nature of the novel’s form. McDermott stated that she intended the novel to be a traditional one,13 and traditional elements are there all right. The text seems to be following the classic unities of Time (summer), Place (Long Island, NY), and Action (Daisy’s visit). Consequently, the characters are flat

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__________________________________________________________________ – even supposedly evolving teenage Theresa’s character does not undergo a change. On the other hand, The novel lacks the traditional chapter divisions. Instead, the text is divided into thirteen (significant number?) uneven sections. Moreover, the novel’s temporal representation is not exactly linear, as past and future shifts in time frequently interrupt chronological narrative portions. A New Criticism reading of the novel would rest on trying to discern which of the above-mentioned binary oppositions is privileged over the other, in order to define the text’s ideological framework.14 The first person narration, Theresa’s point of view; the fact that Theresa’s childish indulgences far outstretch her mature actions; the too colourful, playful, merry mood in which the summer days and activities are presented; the implicit complicity in the ‘shame and delight’ Theresa and Daisy share in defying their inherited tradition; and the fact that seven out of the novel’s thirteen narrative sections run chronologically without temporal interruptions – All these might imply favouring the first member of the binary pair; that is, Adolescence, Life, Conformism, and Traditional fictional elements. But such a favouring is not exactly true, nor does it solve the novel’s thematic ambiguity. A Deconstructive reading of the text can. One in which the binary oppositions would be proved not to be contrary at all; but rather overlapping, blended.15 Yet, with Child of my Heart, this cannot be accomplished on the sole basis of literary textual analysis. This is where psychological theories of Defence Mechanisms come in. But first, one observation must be pointed out: Symbolically speaking, the first three thematic dualisms can be viewed as projecting one apparently conflicting binary opposition; that is, Youthfulness/Decay; where the first member of the pair is apparently being favoured. Consider the first one, Adolescence/maturity. Theresa does not want to grow up; she said that she ‘liked children,’16 but how does that fit in with her sexual experience with Flora’s father? With the second one, Life/Death; Flora’s father advises Theresa ‘never to get old,’17 while he fights the pain of his decaying teeth with aspirins. But why would he, at seventy, father a baby girl? And as for the third dualism, Conformism/Non-conformism, why does McDermott devote almost an entire section of the narrative to the sought-for connections and young memories of Theresa’s parents and the Clarks? It seems, then, that the first three dualisms share a yearning for what is young, healthy, and new. The questions raised above, however, still demand answers; which brings us back to Defense Mechanisms, in search for ones. According to the Encyclopedia of Childhood and Adolescence, The concept of defence mechanism originated with Sigmund Freud (1856-1939) and was later elaborated by other psychodynamically oriented theorists, notably his daughter Anna

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__________________________________________________________________ Freud (1895-1982). Defence mechanisms allow negative feelings to be lessened without an alteration of the situation producing them, often by distorting the reality of that situation in some way…Defence mechanisms include denial, repression, suppression, projection, displacement, reaction formation, regression, fixation, identification, introjections, rationalization, isolation, sublimation, compensation, and humor.18 In the case of denial, ‘ an unpleasant reality is ignored, and a realistic interpretation of potentially threatening events is replaced by a benign but inaccurate one.’19 This is most true of the Clarks and Theresa’s parents, as they ignore the unpleasant reality of their self-imposed exile, their fear of losing their inherited identity; and instead seek to replace it with far-fetched connections among the members of their migrant community. Suppression means that ‘unpleasant feelings are suppressed through a conscious decision not to think about them.’20 Like her Uncle Tommy, ‘determined to be happy,’21 Theresa deliberately brushes away any unpleasant or painful feelings, whether experienced directly by herself, or in sympathy for one of the members of her kingdom of children. In this, her creativity is her sharpest means. Like Uncle Tommy’s imaginary mournful ghost who ceased to mourn once given a chair and a child to hold;22 Theresa’s charges, through her conscious will to defy pain, are led to forget about their immediate painful reality and to believe in the fairy-tale world she constructs for them. Petting the Swansons’ two other cats, after the brutal death of Curly; Theresa remembers the blooded skull: ‘it was not Curly anymore...not in my recollection of it. It was the worst thing. It was what I was up against.’23 In this, being consciously against death, sickness, and decay, Theresa is not alone. Flora’s father, wincing with pain caused by his bad tooth, and looking at Flora, Daisy, and Theresa, he wonders how many years it would earn him if he swallowed each one of them whole.24 To explain this vampire-like yearning for youth on behalf of Flora’s father, we need to define identification. According to the Encyclopedia of Childhood and Adolescence, ‘taking on the characteristics of someone else can enable a person to engage in impulses or behavior that she sees as forbidden to her but acceptable for the person with whom she is identifying.’25 Denied health and fresh creativity on account of his senility, Flora’s father can only try to imaginatively absorb these qualities by infusing his world with young women, to the extreme extent of having a baby at the age of seventy. If Flora’s father, in this light, can be viewed as symbolic of illness, decay, and death—what Theresa is ‘up against’—then two other forms of identification, would go a long way in explaining Theresa’s sexual incident with Flora’s father: The first one, identification with the aggressor means that ‘someone who is


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__________________________________________________________________ victimized in some way takes on the traits of the victimizer to combat feelings of powerlessness.’26 Theresa already identifies herself with Flora’s father in terms of creativity, pointing out her superior capacity: ‘I knew what he was trying to do— and I was better at it.’27 The second form of identification is one based on ‘fear of losing the person with whom one identifies.’28 Theresa is afraid of losing Daisy, ‘Child of [her] heart.’29 During her sexual experience with Flora’s father, she ‘put [her] fingertips to his wrists in what was Daisy’s gesture of affection and sympathy.’30 Theresa’s wilful sexual experience, then, does not contradict her desire not to grow up. On the contrary, it is her subconscious means of defying illness and death; as if by offering up her virginity to the person symbolizing these, she might stay young, wildly creative and save Daisy from the clutches of death: What had happened this afternoon, in that pale, enchanted light of the studio where he painted, suddenly struck me as imaginary, a place and time and series of events that were only conjured, recited, wished for, dreamt about, a fanciful antidote to what was real and solid and inevitable.31 One more question still remains unasked, and unanswered. Why does Theresa tell her story, now, evidently years after it happened? In one of the very few instances in which Theresa turns to address the reader, she points out that the death of ‘poor Daisy, while it may well be the end point of this particular story it is not, after all, the reason I tell it.’32 The goal of telling this story then, is not to remember the fact of Daisy’s suffering and consequent death. Theresa has omitted that particular fact from her memory for a long time. This process of omission is known as repression, another defense mechanism, in which ‘painful feelings are conscious initially and then forgotten. However, they are stored in the unconscious, from which, under certain circumstances, they can be retrieved,’33 mostly, deliberately, through therapy. Noting how Theresa has often fought pain with creativity and art, it would be safe to assume that her narration of the events that led to Daisy’s death is a therapeutic attempt at healing the long-time buried pain caused by it. She vehemently exclaims: I wanted them banished, the stories, the songs, the foolish tales of children’s tragic premonitions. I wanted them scribbled over, torn up. Start over again. Draw a world where it simply doesn’t happen, a world of only color, no form. Out of my head and more to my liking: a kingdom by the sea, eternal summer, a brush of fairy wings and all dark things banished, age, cruelty, pain, poor dogs, dead cats, harried parents, lonely children, all

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__________________________________________________________________ the coming griefs, all the sentimental, maudlin tales fashioned out of the death of children.34 This is supported by the novel’s form. Within the fourth dualism, Traditional/Untraditional, the first four narrative sections have complicated temporal patterns; with continuous shifts back and forth in time to introduce new characters, explain character behaviour, or to give foreboding hints about the future. From the fifth narrative section to the eleventh (again, significant number?), chronological narration runs smoothly, uninterrupted, relating the minutest delightful details of Daisy’s visit. Section twelve is a temporal chaos, starting with the afternoon Daisy got bitten by Rags, the wild dog, and accelerating the pace without much detail till her death. The final narrative section brings back the novel full circle to where it started, to the August after Daisy’s death, with Theresa still stubbornly trying to fight inevitable decay, death, and misery as she feeds baby rabbits that she knows will shortly die. The novel, indeed, leans towards the traditional; but while the insertion of back flashes adds to the sense of nostalgia the novel seems to project by its end, the chronological sections determine the story’s focal point. If this is Theresa’s motive for recounting the story, to heal her painful memory through art, then what is McDermott’s motive for writing it? As already noted above, McDermott linked writing Child to post 9/11 painful feelings, saying that the novel is a kind of lament.35 Child of My Heart’s main theme, then, is about pain; the pain of growing up, of getting old, of being neglected, of defining cultural identity, of sickness, of decaying, of loss. The novel is McDermott’s creatively painstaking attempt to heal the indefinite, immeasurable pain after 9/11; a tale of ‘shame and delight’, ‘an antidote’ to ‘ the useless longings of all of us who get left behind.’36

Notes 1

D Weich interviewing Alice McDermott, ‘Child at Heart’, Powell’s Author Interviews, December 2002, viewed on 13/12/2008. 2 http://www.powells.com/authors/mcdermott.html. 3 C Dellasega interviewing Alice McDermott, ‘Mothers Who Write: Alice McDermott’, Writers Write Internet Journal, September 2002, viewed on 3/12/2008. 4 http://www.writerswrite.com/journal/sep02/mcdermott.htm. 5 MO Steinfels, ‘The Age of Innocence – Child of My Heart, a novel – Book Review’, Find Articles, January 2003, viewed on 13/12/2008. 6 http://findarticles.com/p/articles/mi_m1252/is_2_130/ai_985723961?tag=conte nt;col1


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A Cary, ‘The Heart of the Matter: Alice McDermott’s post 9/11 look at innocence and change’, Book Page, December 2002, viewed on 3/12/2008. 8 http://www.bookpage.com/0212bp/alice_mcdermott.html. 9 Weich. 10 A McDermott, Child of My Heart, Farrar, Straus and Giroux, New York, 2002, p. 9. 11 ibid., p. 26. 12 ibid., p. 94. 13 ibid., p. 3. 14 ibid, p.144. 15 ibid. 16 ibid., p. 56. 17 Weich interviewing McDermott. 18 L Tyson, Critical Theory Today: A User-Friendly Guide, Garland Publishing Inc., New York, 1999, p. 255. 19 ibid, pp. 256-257. 20 McDermott, p. 21. 21 Ibid., p. 68. 22 Gale Encyclopedia of Childhood and Adolescence, ‘Defense Mechanisms,’ Gale Research, 1998, Find Articles, viewed on 29/12/2008. http://findarticles.com/p/articles/mi_g2602/is_0001/ai_2602000181/?tag=content;c ol1 23 ibid. 24 ibid., p.1. 25 McDermott, p. 129. 26 ibid., p. 97. 27 ibid., p. 169. 28 ibid., p. 140. 29 Gale Encyclopedia, p. 2. 30 ibid. 31 McDermott, p. 74. 32 Gale Encyclopedia, p. 2. 33 McDermott, p. 11. 34 ibid., p. 225. 35 ibid., p. 231. 36 Ibid., p. 38. 37 Gale Encyclopedia, p. 1. 38 McDermott, p. 180. 39 Weich interviewing McDermott. 40 McDermott, p. 56.

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Bibliography Books Collier, P. & Geyer-Ryan, H. (eds.), Literary Theory Today. Cornell University Press, New York, 1990. McDermott, A., Child of My Heart. Farrar, Straus and Giroux, New York, 2002. Tyson, L., Critical Theory Today: A User-Friendly Guide. Garland Publishing Inc., New York, 1999. Online Sources Interviews & Book Reviews Cary, A., ‘The Heart of the Matter: Alice McDermott’s Post 9/11 Look at Innocence and Change.’ Book Page. December 2002, viewed on 3/12/2008. http://www.bookpage.com/0212bp/alice_mcdermott.html. Steinfels, M.O., ‘The Age of Innocence – Child of My Heart.’ Find Articles. January 2003, viewed on 24/9/2007. http://findarticles.com/p/articles/mi_m1252/ is_2_130/ai_985723961?tag=content;col1. Weich, D., ‘Child at Heart.’ Powell’s Author Interviews. December 2002, viewed on 24/9/2007. http://www.powells.com/authors/mcdermott.html. Psychological Theories of Adolescence ‘Adolescence, Overview, History, Theories.’ King’s Psychology Network. Viewed on 3/10/2007. http://www.psyking.net/id183.htm ‘Defense Mechanism.’ Wikipedia. Viewed on 29/12/2008. http://en.wikipedia. org/wiki/Defense_mechanism. ‘Defense Mechanisms.’ Gale Encyclopedia of Childhood and Adolescence. Gale Research, 1998, Find Articles, viewed on 29/12/2008. http://findarticles.com /p/articles/mi_g2602/is_0001/ai_2602000181/?tag=content;col1. ‘Anxiety and Ego – Defense Mechanisms’, Rensselaer Polytechnic Institute, viewed on 9/1/2009. http://www.rpi.edu/~verwyc/defmech.htm.


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__________________________________________________________________ Hoda Elsayed Khallaf is an Assistant Professor of English Literature, Faculty of Arts, Menofia University, Egypt.

The Discourse of Cutting: A Study of Visual Representations of Self-Injury on the Internet Hans T. Sternudd Abstract In this paper some results from a study of over 6000 photographs of self-inflicted injuries is presented. The typical image is taken by somebody that presents themselves as females; it depicts a body part: an arm which has been cut. Seldom contextualised content is represented. Analyses from a traditional feminists perspective is likely to produce an interpretation that these images shows feminine bodies victimized under a patriarchal oppression. But here an alternative interpretation that focus on the fact that the few contextualised features makes identifications possible for many people regardless of sex, culture, class, race etc. The images emphasize the body and the wound, entities that ‘everybody’ can relate to. We should also consider the aggressive character of the act of cutting. Therefore an alternative interpretation is suggested that emphasize cutting as an act of resistance from a position that’s not necessary based on traditional gender formations. The place for this struggle is the skin and the paper concludes with a suggestion that skin is not only the place for cutting but also the actual place for discursive closure and establishing of identity. Key Words: Self-injury, cutting, skin, skin ego, Internet, gender, discourse. ***** In this paper I argue for the notion that skin cutting is a way of making sense to pain.1 The line of argumentation is based on the understanding of self-injury, especially the practice of cutting, as a language that talks about an inner pain that’s obscured. I propose that the visual aspect is crucial for many self-injurers as it transforms something unspeakable to something concrete and visual (as a bleeding wound or a scar). If that’s true analyses of images of cutting can give us knowledge of the mechanism behind self-injury that we can’t derive from other sources. Cutting alludes to a practice that’s deployed by a group of people, mostly young who commonly are referred to as self-injurers or self-harmers. A self-injurer is usually defined, after the American psychiatrist Armando R Favazza, as someone who repeatedly has inflicted superficial injuries or mutilations to herself without suicidal intentions.2 A self-injurer is also said to have difficulties to resist the impulse to harm her. The act is often understood as a response to an increasing feeling of inner tension which is brought to an end by the injury.3 In this presentation I won’t make an excessive use of terminology utilized in discursive theory. But for the record I use discourse in two different ways. Discourse is used on one hand as meaning production produced in a field, a

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__________________________________________________________________ discourse order, that’s created with and around the practice of cutting; and on the other hand, in a more symbolic way, as the way meaning is produced by the cutting itself. In the latter definition cutting becomes a speech act produced on the skin by penetration. Images of self-injury have to my knowledge not been the subject for any academic studies. In studies on for instance Internet communities or other forums for self-injurers, you’ll find commentaries which express concerns about the spreading of material, like photo, video and artwork with representations of selfinjury.4 This kind of material is commonly understood as triggering, a notion that’s, at least officially, shared by most sites and communities devoted to questions about self-injury. Visitors are warned before they are exposed to images and it is often forbidden to publish or link to images on forums. Scholars never seem to feel the need to base there assumptions of the danger of images of selfinjuries on any studies, it seem to be so obvious that it’s unquestionable. One of the purposes of my research has been to problematise these presumptions by taking a closer look on the images of self-injury, the production and consumption of them.5 I focus on the type of self-injury that manifests itself as skin cutting. There are two reasons for this: Cutting is, according to studies, the most common technique of injuring6 and that it is a visual practice, both during the activity and afterwards when scars has become an index of something that has happened. The images in this study are taken from a website, an Internet community dedicated to information about self-injury and support to self-injurers. Member of the community describe themselves, almost without exceptions, as having personal experience of self-injury. On this site it is possible contribute with autobiographical material like personal stories, poems and pictures/photos which are public accessible. More then 6000 photos has been uploaded. I have analysed the photos regarding their representational and formal aspects. Not surprisingly were producers that could be referred to as female dominating. This is in line with prevalence in most studies of self-injury, and when also considering the fact that girls are more active in social communities on Internet and more often contribute with material like images, this result could be expected.7 Images of bodies or more precise body parts are dominating in the material; most common is arms, followed by legs. Close ups, only showing skin, is one of the largest categories. The method of inflicting the injury that’s dominating the material is cutting, more then nine out of ten of the wounds seem to be done with razor blades, knifes or other sharp objects. Let’s take a look at some typical, representative images in my study. The first image we consider (fig 1) is an example of the statistical most frequent representation of cutting.8 It is taken by a female, it shows an arm with scars and it’s lacking contextualized features. In the discourse constituted of self-injurers you’ll often find expressions of a wish to be for real, to be authentic.9 These images could be understood as way of

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__________________________________________________________________ expressing something true, as documentations of something real. How is then truth constructed in these images? Photography that is produced as indexical traces of light has in it self a capacity to produce contextualised truth. Formal qualities can also be part of production of texts that’s perceived as truthfully. According to a theory on how truth is made in images the Dutch socio semioticians Kress & van Leeuwen suggests that we should consider both formal aspects like; colour saturation, differentiations and modulations; illumination and light, as well as representative aspects like contextualisation or not, if the image is abstract or have richness in details etc. Configurations of these create coding orientations that are producing truth in different discourses.10 Returning to fig. 1 and applying Kress & van Leeuwens model we see that although the colour saturation is quite rich (it’s far from being black and white) the differentiation is quite low; and that goes for the contrast and the variation of light as well. The image is blurry and without many details, it’s lacking contextualisation. Taken together we see an image that’s quite abstract, reduced on details and modulations. Kress & van Leeuwen suggest that this modality could be labelled as an abstract coding orientation which has ‘reduced the individual to the general and the concrete to its essential qualities’.11 They argue that this kind of images is typical for high art, and academic or scientific discourses. Hardly the ones you associate with self-injury. It can also be seen as a paradox that an activity understood as very private and egocentric is communicating with a visual expression that’s reducing the individual. Bodies inscribed in a visual field without contextualisation and with no depicting of depth or perspective are bodies without the possibility to act, which requires a third dimension. Laura Mulvey, professor in film and media studies, has suggested that representations like this are objectifying the depicted.12 The Swedish semiotician Anders Marner proposes that a reason to isolate an element in an image from its environment, like this, could be to give it a more generalized meaning.13 In the images of cutting these two characteristics is often present - they are objectifying and generalizing. Further more they show fragmentised bodies like in a symbolic cut-up. This way of representing bodies, and especially female bodies, is according to feminist art historians common in art practices (especially in modernist art), in advertising and fashion photographs. A body in parts is becoming an object, without the power of an organic whole body (which represents a subject with the possibility to act). The English art historian Griselda Pollock states that we are so used to view representations of cut-upped female bodies that the cut-up itself has become a sign for femininity and therefore of subordination.14 Extreme close-ups, in which skin tissue is filling up the whole picture, are a special category of image in the collection (fig. 2). These images are lacking information not only of a room that surrounds the body, but also which part of the body the skin belongs to. The body becomes totally decontextualized in the closeups, the lack of markers of context like gender, class or culture creates a body

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__________________________________________________________________ that’s wiped out all other intersectional positions apart from being a body that has been cut, that belongs to a cutter. This lack of context gives in the close-ups rich opportunities of identification - everybody has a body, and has been wounded sometimes. In the history of the western world men and women have been associated with formal qualities: woman has been characterized as shapeless and chaotic, unlike men that represent form and structure. The gender order is clear in conceptions of straight and sharp geometrical forms as more masculine than the feminine rounded and organic forms. If we apply this notion on fig. 1 we see how the arm, with its soft roundness represent something feminine, while the carved sharp lines creates a masculine structure. This interpretation could be verified by the understanding that cutting is a strategy to re-establish control.15 From a gender perspective the interpretation could be formulated like this: In the image we see how the feminine flesh is disciplined by the sharp instrument of masculinity. Even clearer seems this to us when we consider the images where blood is pouring out of the wounds (fig. 3). Through the more or less straight cut blood, an organic chaotic form element pours out. The bad blood is let out, leaving a structured entity on the skin. The scars become a sign for the re-establishing of order. The interpretation that has been suggested so far is very much based on ‘classical’ feminist theories derived from the academic fields of art history and film theory. The problem with this approach is that it seems to recreate the female position as a victim. From a discursive perspective we know that the way we talk about the world is creating it and therefore we could ask for alternative ways of interpretations. The amount of scars varies a lot between the images. When the number of cuts/scars becomes big enough a criss-cross pattern sometimes is created (fig. 4). This pattern could resemble the structure of a woven textile. When cutting has been going on for a long time scars tissues can create a thicker skin (so called keloid, fig. 5.). Symbolically this skin re-figuration could be seen as the creation of ‘another layer to the body - a ‘second skin’’.16 This can help us to see the cutting as an act of protection or resistance. An act directed against the interventions of the world. Cutting is separating the body from the body of others. Self-destructive act is often seen as repulsive and it pushes people away - they produce thereby a social isolation.17 This deviant character of the act of cutting is one important feature to consider. Cutting isn’t accepted in most discourses and the activity is by the executor often regarded as something shameful, and can therefore be a strategy to withdraw from situations that’s unbearable. Too deliberately cut and thereby often permanently disfigure the skin is also a very strong rejection of the hegemonic ideals of beauty (especially for young women). With these examples I suggest a reinterpretation of cutting along the line of understanding cutting as an act of resistance instead of

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__________________________________________________________________ victimization. By giving actorship to the cutter we instead of a passive object create an active subject in I understand cutting as a communicative act, not at least a communication with the acting subject as recipient. Understood as an act of formulating and thereby making sense of a indescribable ‘inner’ emotion the cutting could be regarded as a text that concretise feelings which makes them more bearable. If so, what is then the message that cutting communicates? This is a question that’s not so easy to answer, and can often be puzzling to cutters themselves. But if we look at cutting that takes the form of words, a category of cutting in which the communicative aspect is specially manifest, we see that anger is the feeling most frequent. In the material we find FUCK OFF, I HATE U/ME and other expressions of anger cut into the skin in 25% of all of the images with words, followed by disgust often directed against them selves (16%). Anger is not the expression of a passive victim; it comes from somebody that is putting up a fight. Saying FTW! Elaine Scarry has said that pain is something encapsulated and introvert - not just hard to speak about, but actually destroying language and replacing it with unarticulated groans and screams.18 I see cutting as an act that contradicts Scarry’s notion. Skin becomes there a surface for inscription in wounds and blood that gives pain a shape and makes it possible to handle (at least for a moment). The fact that the substance, the ground of the text is based on a basic, humanly shared experience - being in a body that feels pain and are wounded, cutting has maybe a possibility to bridge over other differences. On the internet the network of cutters is based on this conception of a shared experience. In the material for my study there’s no difference between images produced by females or males, and there’s few contextualizing elements in them. We can say that they only communicate through and with the skin. The skin becomes the arena on which discourse is formulated. Inspired by psychoanalytic theories by Anzieu and Rösing19 I propose that the skin actually is the place where identity (at least symbolically) is constituted. Identity is here understood as a discursive formation in/on the skin where understanding of experiences from under it, from the inside, and from the outside is made sense of. This challenges notions that identity is something that comes from inside as well as the notions that identity is wrote upon the skin from outside. As a consequence of this gender differences isn’t important any longer; men, women and other gender formations all has the possession of skin in common. That’s why we could see the skin ego as a third position that unites people and creates a new location for closure, for making meaning to the world. By cutting in the skin a connection between the two identity shaping ‘worlds’ is established and the cuts becomes in fact the text, a discursive closure that challenges other discourses on the field. I call this The discourse of cutting.

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The paper is based on results and interpretations that grown out the research project The Semiotics of Pain - self inflicted pain as communication. The project is financed by the Swedish Research Council and is placed at Gender studies, a section of Global Political Studies, Malmö University in Sweden. 2 AR Favazza, Bodies under Siege, Self-mutilation and Body Modification in Culture and Psychiatry, The Johns Hopkins University Press, Baltimore and London, 1987/1996. 3 Favazza study on self-mutilation and body-modification has become a standard work and his definition of self-injury as an act that doesn’t express suicidal tendencies (which was earlier formulated by Menninger 1938) has been commonly accepted. An extensive body of academic work has been published on self-injury during the last decades. The main part of these has its origins in psychological, medical and sociological disciplines. Rarely, to my knowledge, you’ll find research concerning cultural expressions connected to self-injury. There are of course some examples for instance Barbara Brickman’s study on the construction of a prototypical, female self-injurer or the Swedish ethnologist Anna Johansson with her coming doctorial dissertation concerning web based biographical narratives from self-injurers. 4 Whitlock et. al., ‘The Internet and Self-Injury: What Psychotherapists Should Know,’ Journal of Clinical Psychology: In Session, Vol. 63 (11) 2007, p.1139. 5 These parts of the study aren’t presented in this paper. 6 See e. g. AR Favazzas & K Conterio, ‘Female Habitual Self-Mutilators,’ Acta Psychiatric Scandinavia, Vol. 79, 1989, p 286 or Socialstyrelsen [The National Board of Health and Welfare], Flickor som skadar sig själva, En kartläggning av problemets omfattning och karaktär. Article no. 2004-107-1, p. 14. 7 O Findahl & S Zimic, Unga svenskar och Internet 2008. World Internet Institute, Hudiksvall, 2008, p. 7. 8 The images are published with permission from the photographers (DC, Katie and MyLastKiss) if the anonymity could be guaranteed. Some of them were published on the website in question and others in different ways given to me. They are used here as typical examples of the images discussed in the text. 9 A Johansson, ‘Rakbladsflikkor: Om kvinnlig självskada som identitet och symbolspråk’. Nätverket, no. 14, 2004(a), pp. 100-114. http://publications.uu.se/journals/1651-0593/natverket.htm, pp. 107-110. 10 G Kress & T van Leeuwen, Reading Images, The Grammar of Visual Design, Second edition. Routledge, London & New York, 1996/2006, pp.:160-163, 165166. 11 Kress & van Leeuwen, p. 165.

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L Mulvey, ‘Visual Pleasure and Narrative Cinema,’ Visual and Other Pleasures, Indiana University Press, Bloomington and Indianapolis, 1989, pp. 19-20. 13 A Marner, Burkkänslan, surrealism i Christer Strömholms fotografi, en undersökning med semiotisk metod, diss. Institutionen för konstvetenskap; Institutionen för estetiska ämnen, Umeå universitet, 1999, p. 74. 14 G Pollock, ‘Saknade kvinnor, Omprövning av de första tankarna om kvinnobilder’, in Att tolka bilder, Bildtolkningens teori och praktik med exempel på tolkningar av bilder från 1850 till i dag. Ed., Jan-Gunnar Sjölin, Studentlitteratur, Lund, 1993, p. 439. 15 See e. g. Favazza, p. 278. 16 D Milia, Self-Mutilation and Art Therapy, Violent Creation. Jessica Kingsley Publishers, London and Philadelphia, 2000, p. 61. 17 Ibid., p. 74. 18 E Scarry, The Body in Pain, The Making and Unmaking of the World, Oxford University Press, New York & Oxford, 1985, p. 4. 19 In search of approaches that conquer the phallocentric ground for the formation of identity the literature historian Lilian Munk Rösing is suggesting that the skin should be the metaphor for sexual relations. Sexuality becomes more about the meeting of two persons through the skin then something centered on penetration, see LM Rösing, ‘Hudens kön’. Divan No.1-2, 2001, pp. 20-34. She’s deriving her approach from the French psychoanalyst Didier Anzieu’s notion of The skin ego (1985).

Bibliography Brickman, B., ‘‘Delicate’ Cutters: Gendered Self-Mutilation and Attractive Flesh in Medical Discourse.’ Body & Society. Vol. 10, no. 4, 2004, pp. 87-111. Favazza, A.R., Bodies under Siege, Self-mutilation and Body Modification in Culture and Psychiatry. The Johns Hopkins University Press, Baltimore and London, 1987/1996. Favazzas, A R. & Conterio K., ‘Female Habitual Self-Mutilators.’ Acta Psychiatric Scandinavia. Vol. 79, 1989, pp. 283-289. Findahl, O. & Zimic, S., Unga svenskar och Internet 2008 [Young Swedes and Internet 2008]. World Internet Institute, Hudiksvall, 2008.

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__________________________________________________________________ Johansson, A., ‘Rakbladsflikkor: Om kvinnlig självskada som identitet och symbolspråk’ [Razorblade Girls: About Female Self-injury as Identity and Symbolic Language]. Nätverket, no. 14, 2004(a), pp. 100-114. http://publications.uu.se/journals/1651-0593/natverket.htm. Johansson, A., ‘Ett vackert lidande’ [A Beautiful Suffering]. Kulturella perspektiv. no. 4, 2004, pp. 33-41. Kress, G & van Leeuwen, T., Reading Images, The Grammar of Visual Design. Second edition. Routledge, London & New York, 1996/2006. Marner, A., Burkkänslan, surrealism i Christer Strömholms fotografi, en undersökning med semiotisk metod [Canned Feeling-Surrealism in the Photography of Crister Strömholm-A Semiotic Inquiry]. diss. Institutionen för konstvetenskap; Institutionen för estetiska ämnen, Umeå universitet, 1999. Menninger, K.A., Man Against Himself. Harcourt, Brace & Co., New York, 1938. Milia, D., Self-Mutilation and Art Therapy, Violent Creation. Jessica Kingsley Publishers, London and Philadelphia, 2000. Mulvey, L., ‘Visual Pleasure and Narrative Cinema.’ Visual and Other Pleasures. Indiana University Press, Bloomington and Indianapolis, 1989, pp. 14-26. First published 1973. Pollock, G., ‘Saknade kvinnor, Omprövning av de första tankarna om kvinnobilder’ [Missing Images: Rethinking Early Thoughts on Images of Women].’ Att tolka bilder, Bildtolkningens teori och praktik med exempel på tolkningar av bilder från 1850 till i dag. Ed., Jan-Gunnar Sjölin, Studentlitteratur, Lund, 1993, First published 1990. Rösing, L.M., ‘Hudens kön [The Sex of the Skin].’ Divan. No.1-2, 2001, pp. 2034. Scarry, E., The Body in Pain, The Making and Unmaking of the World. Oxford University Press, New York & Oxford, 1985. Socialstyrelsen, [The National Board of Health and Welfare], Flickor som skadar sig själva, En kartläggning av problemets omfattning och karaktär [Girls that Hurt Themselves: A Mapping of the Extent and Character of the Problem]. Article no. 2004-107-1.

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__________________________________________________________________ Whitlock, et. al., ‘The Internet and Self-Injury: What Psychotherapists should Know.’ Journal of Clinical Psychology: In Session, Vol. 63 (11) 2007, pp. 11351143. Hans T. Sternudd PhD, Swedish Art Historian working at Malmö and Växjö university, with research addresses performance/action art, gender, semiotics and visual culture.

Shooting Pains: Addressing Illness-Related Pain through Video Autobiography Broderick Fox Abstract This paper will look to autobiographical videos and emergent uses of social software sites such as YouTube to explore the possibilities of first-person media as a pain management tool. Beyond the therapeutic possibilities, the paper will also explore the potential of such personal media acts as a means of breaking down taboos around pain and illness – offering up models for managing, discussing, and even ‘performing’ pain in the public sphere. Key Words: Video diary, autobiography, performativity, social media, vlog, pain diary, pain management, illness, digital democracy, public sphere. ***** 1. Taboo Despite a proliferation of new media technologies and interfaces for communication and exchange, Western society still places strong social proscriptions on the candid discussion of pain, illness, and natural death. Mediations of illness have been superseded by discourses of wellness and antiaging, which seem to equate acknowledging pain with weakness and illness or body failure as personal failures. In this paper, I will profile a range of video makers and vloggers (video bloggers) who have turned consumer-grade cameras onto themselves as a means of engaging and managing illness-related pain. Pain videos are not a digital phenomenon. Many of the most indelible examples of pain media are decidedly analog, predating the Internet or the ubiquity of digital cameras. We can all recognize how the Web has revolutionized opportunities for exhibition, distribution, and community formation heretofore impossible. But is technology perhaps outpacing taboo and cultural ideology? Digital democracy may still not be ready for certain subject matters. In Home Movies and Other Necessary Fictions, filmmaker and scholar Michelle Citron offers a contemplative history of home movie images in American culture: We film the Christmas dinner with family and not the meal eaten alone; birthday parties, not the emergency room visits; baby's first step, not fighting with the adolescent; vacation, not work; wedding parties, not divorce proceedings; births, not funerals.1

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__________________________________________________________________ While amateur motion picture technologies’ evolution from Super 8 film, to analog video, to digital video camcorder, and now to Web and Flip cams has been dramatic (along with unprecedented access to the means of prost-production capacities via nonlinear editing software packages), the strict code of ‘appropriate’ home movie recording situations has experienced little change. Such bio-power (a term coined by Michel Foucault to describe the ways in which we all self-regulate and self-censor our thoughts, actions, and appearances in relation to perceived social norms2) can occasionally be seen posted in the user comment streams on YouTube, in response to autobiographical pain video logs or vlogs uploaded there. YouTube vlogger 1938Superman posted a vlog in November, 2006 recounting his bout with testicular cancer. Amongst the specific and productive responses from fellow cancer patients, medical professionals, and the occasional general well-wisher, his video also received this response in the chain from a 25-year-old male user: I wish YouTube administration would ban stupid people from posting videos like this. It’s totally unobjective […] You shouldn’t tell your problems to everyone on YouTube. Nobody cares. People don’t want to hear about tragedies.3 In the face of such potential self-exposure and excoriation, why would someone point the camera onto their pain and then choose share it with a public, often emboldened by the Web’s anonymity to produce lazy language and hate speech? The remainder of this paper will explore some of these motivations, along with some of the personally and culturally transformative potentials of pain diaries. 2. Beyond the Medical Gaze Physicians often instruct patients and caretakers to keep pain diaries, but like the medical file, these autobiographies are coded in medical terms and authored not for self or peers, but for medical professionals. Speaking on this peculiar tension in relation to the medical file in her article ‘Medical Identity: My DNA/Myself,’ scholar Kay Cook writes: I have my file, which is always placed outside the office door while I am inside, usually cold and shivering under a paper garment. The folder is both secret and public; so is my body. The information sheathed in the folder outside has an eerie correspondence to the coarse paper garment that hides my body momentarily from the medical gaze.4 Medically prescribed pain diaries are similar in their tension between author and audience. Patients’ experiences of pain are reduced to a number scale,

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__________________________________________________________________ accompanied by time of day, time since last medication, other concomitant symptoms, and level of activity at the time. There is certainly medical value to such pain diaries, but the video diaries under investigation here are far more personal and confessional in nature. Documentary scholars such as Michael Renov have written at length on the ‘confessional’ nature of video, linking such acts to the three other historical realms of confession in Western society – the church, the courtroom, and the analyst’s chair.5 Each of these contexts is rooted in a form of personal divulgence in the pursuit of relief or absolution, but like the medical gaze, each also is fraught with an inherent power imbalance, where the words spoken fall on privileged ears with the power to grant mercy or judgment. Personalized video pain diaries are therefore an incredibly powerful alternate mode of expression and confession, as the camera functions as a silent, nonjudging proxy for an implied listener or audience, who depending on the desires of the patient may never actually be publicly screened. In Silverlake Life: the View From Here (1991), the illness is AIDS, and the video camera begins autobiographically in the hands of filmmaker Tom Joslin as he documents his daily battle with the disease. With the exception of several clips from earlier Joslin works, the finished piece is culled solely from thirty-five hours of home video. As such, the groundbreaking video represents both a reinvigoration and expansion of the medical form of the pain diary and a subversion of home movie ideology, not only in filming illness but also in the constituency of the American ‘family’ transcribed therein: Joslin and his lover, of twenty-two years Mark Massi, documenting their battle with AIDS at the height of American cultural panic and stigmatisation of those with the disease. Joslin takes a camera everywhere with him and even has a tripod set up next to his bed, which permits him to record diary entries on sleepless nights when pain and worry set in. Tom videos one particularly emotional entry from the passenger seat of the car as he waits for Mark to finish running just one more errand than promised. Emaciated and exhausted, Tom rails about the afternoon and his physical and emotional pain: Went to Dr. Matt's and went through our usual thing this morning – the pain – which was fine, and I got too tired to film towards the end and went and slept in the car while Mark had lunch. I didn’t have lunch because we were going to go right home. […] And then we’re on the way home and he says, ‘Look we’re almost done. I’m going to go to the health food store,’ which is not on the way home […] Meanwhile I haven’t had fucking dinner. I haven’t had any…Jesus! You try to be helpful, getting screwed time and time again! I hate being a nice guy!6

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__________________________________________________________________ Such confessional moments on video are visceral and distinctly in the present tense, capturing an immediacy and a time-based audiovisual presence unattainable by even the most effusive of written diary entries. Transcribed here, one misses the cracks in Tom’s voice as he comes close to tears, the pauses and hesitations between sentences to catch his breath, the varying volume and pace of his voice, his emphasis on certain words, his ravaged physical appearance, and the realities of his surroundings. The video preserves these details in a perpetual liveness, providing a compelling and three-dimensional portrait of Tom’s experience. Joslin’s entry does not provide all the information requested by physicians in a pain diary designed for the medical gaze, but one can imagine a range of benefits to caregivers, patients, and physicians alike, who are able to see the effects of illness-related pain and fatigue in real time. So many fictional and documentary mediations of illness perpetuate the same tropes – patients are either passive objects or upbeat, active models of positivity in the face of adversity. In contrast, seeing the normally mild-mannered and genteel Tom despair and rage in the parking lot, railing against his ‘nice guy’ status is both arresting and potentially refreshing for patients who feel alone in or ashamed of their own private rage rarely validated or modelled by mainstream media or the wellness industry. 3. Performing Pain As such, video diaries could be said to constitute a form of bodily performance, bringing people out of their minds, doses, diagnoses, and passive states as patients, and into a physical, active form of self exploration and self-expression, subverting the traditionally incapacitating and paralysing effects of pain. The act of performance most often leads to the innate desire to apply a sense of structure, trajectory, or significance onto the episode. Such moments are evidenced in Gerry Rogers’ My Left Breast (2000), a video in which the Canadian Rogers chronicles her post-mastectomy bouts with chemotherapy and radiation therapy. In an early morning video diary segment shot in front of a mirror, Rogers, bald and in her flannel pajamas, turns not to her partner and caregiver Peggy, but to the camera to perform her pain and discomfort: It’s um, Saturday December 4th? 5th? Something like that. And I feel probably the sickest I’ve felt, so this is not bad. I’m pretty nauseous. I was up a few times last night throwing up a bit. It’s like my whole body goes flutter, flutter, flutter, flutter, flutter, and the thought of even water, I can’t…I haven’t been able to drink anything yet today. And I’ve got to take those three little pills that I have to bless. Not quite sure yet how I’m going to get them down. Just even the thought of it makes me nauseous […] People ask me if I have any feelings about…or any new thoughts

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__________________________________________________________________ on suffering or life and death, and I don’t. [She blinks back tears.] Only that love and tenderness are so important to me right now. If anybody shows me any love and tenderness it melts me, but it gives me pleasure or peace or something. And I love to be touched. I love to be touched gently. I love to be touched with love, because I feel like I’m a little bit untouchable these days. And not, uh, definitely not the most…desirable. But I guess thinking about it, it’s realizing how radicalizing love, and compassion, and tenderness is. [She holds back tears once again.] And that that seems to brush away everything else.7 Gerry’s video diary entry, spurred by pain, sleeplessness, and nausea, in fact serves to translate such negative physical sensations into an articulation about the restorative, palliative power of touch and expressions of love. As Eve Sedgwick, Thomas Waugh, Judith Butler and others have explored, notions of performativity so prevalent in gender, queer, and now documentary studies derive from speech act linguistics, which to quote Waugh, ‘define a category of utterance that executes, enacts, or performs the action that is uttered.’8 Hence just as gender realities are created through ‘sustained social performances,’9 so too are notions of illness and wellness. Performances of pain on video have the potential to go beyond constantive descriptions of pain to become performative translations and transformations of seemingly senseless physical and emotional suffering into acts of personal pain management and larger humanistic understanding. 4. Pain in the Public Sphere When video diarists such as Tom and Gerry press record and speak, they are not simply talking to the camera or to themselves, but to us: an assumed future audience. Though not physically present in the moment, we are so by proxy, providing a form of witness, support, and alliance. When YouTube vlogger phaedress, a 40-year-old Canadian breast cancer patient, returns for a post-chemo, post-radiation mammogram, she brings her camera along. While she nervously waits, trying to rationalize why the doctors have re-scanned her breast three times and then left her waiting for an hour with no update, she turns her camera onto herself: OK, so positive thoughts. You know what’s really cool, is I know I’m not alone. For one thing my sweetheart is waiting for me in the other room. For another, the nurses here are all very sweet and personable, and they make me feel comfortable […] And then there’s you. I can’t help myself. I’m always thinking about that no matter what I do, in a way it could be just material

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__________________________________________________________________ for a video. And I suppose it’s a form of disassociation – you know, I’m not terrified; I’m just interested and wanting to feed your curiosity in the process. Ok, I take it back. I’m terrified but it’s less terrifying when you get to share it with other people.10 Making sense of pain through video is in many respects a process of mirroring in the psychodynamic sense of the term as detailed by the likes of Heinz Kohut.11 For those excised from mainstream media and popular discourse – minorities and the marginalized existing outside of heteronormative models of health and propriety – there really have been no opportunities for healthy narcissism and cultural mirroring around issues of pain, illness, and mortality. Ironically, this lack of representation perpetuates fear, taboo, and difference around what are perhaps the most universal and shared of inevitable human experiences. Autobiographical pain videos therefore have potential therapeutic and informational value not simply for the recording patient, but for us all, whether we are ill, a caregiver, a physician, or simply someone now healthy inevitably poised to perform at least one of these roles ourselves in the future. Yet even with all these technological advances, fear and taboo still stand to curtail possibilities for a productive digital public sphere in which consumer technologies can be purposed towards making sense of illness, pain, and mortality. Negative responses and YouTube user flagging of her cancer diaries has led phaedress to preface each of her vlogs with the same fourteen-second disclaimer sequence: ‘I am phaedress. Warning! Attention! Achtung! This video contains details about cancer. Still here? Last chance to click off!’12 Such vestiges of bio-power are no doubt in part what has led to the proliferation of closed online niche communities like i2y.com (an acronym for, ‘I’m too young for this!’), a site that caters exclusively to young adult cancer patients and survivors under forty. Member-only Websites and closed support groups are important safe spaces where like can converse with and relate to like in ways that others of us might never be able to fully comprehend without such experiential knowledge. But making pain diaries solely for other cancer patients and survivors is in some respects analogous to making pain diaries solely for the medical gaze. The act of sharing such works with others outside of one’s particular experience in a public sphere, whether that be via DVD or an online social networking site may lead to isolated incidents of viewer discomfort and unproductive comments, but it can also function as a bridge across the longstanding currents of taboo and silence surrounding illness, pain, and mortality in Western culture. Editing, contextualizing, and distributing video diaries, even if done only in the simplest and most rudimentary ways – reviewing, cutting out or together bits with a program like iMovie, uploading to YouTube or another such social networking site, and providing a title, description, and keywords for a search engine – are

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__________________________________________________________________ reflexive acts, demanding retrospection and processing. By juxtaposing or assimilating different moments of footage and by providing context, patients are in fact making sense of pain through narrative. A singular bout with pain becomes but one moment in a larger reality rather than the defining characteristic of an individual, as in the traditional medical pain diary template. In short, patients may not be able to stop their pain, but through video, they can become its director. Patients can choose what forms of performing pain are important and valid for them, rather than following a prescribed template. The presence of an implied you, manifested by the camera’s gaze (be that a future larger audience or simply the ‘other self’) permits a sense of someone bearing witness/seeing and hearing one’s pain. Patients have the power to keep such videos to themselves or to delete them altogether, freeing the process from predetermined outcome or significance. Hopefully through the sharing of pain video diaries in the public sphere, patients can feel a sense of purpose, becoming part of community and turning video monologue into dialogue. By watching such videos, each of us has an opportunity to learn and grow – as physicians, caretakers or simply as fellow humans – cultivating tools with which we can make sense of our own inevitable pains and mortality.

Notes 1

M Citron, Home Movies and Other Necessary Fictions, University of Minnesota, Minneapolis, 1999, p. 19. 2 M Foucault, The History of Sexuality: An Introduction, Vol.1, 1976, R Hurley (trans), Vintage Books, New York, 1990, p. 140. 3 1938 Superman, My Inevitable Cancer Video, Nov. 24, 2006: http://www.youtube.com/watch?v=8yB_6PT4Cho. 4 K Cook, ‘Medical ldentity: My DNA/Myself,’ Getting a Life: Everyday Uses of Autobiography, S Smith & J Watson (ed), University of Minnesota, Minneapolis, 1996, p. 71. 5 M Renov, ‘Video Confessions,’ Resolutions: Contemporary Video Practices, M Renov & E Suderberg (ed), University of Minnesota, Minneapolis, 1996, pp. 78101. 6 P Friedman, T Joslin & M Massi, Silverlake Life: The View From Here, Docurama, 1991, 99 min. 7 G Rogers, My Left Breast, Women Make Movies, 2000, 57min. 8 T Waugh, ‘Walking on Tippy Toes: Lesbian and Gay Liberation. Documentary of the Post-Stonewall Period 1969-86,’ Between the Sheets, In the Streets: Queer, Lesbian, Gay Documentary, C Holmlund & C Fuchs (ed), University of Minnesota, Minneapolis, 1997, p. 110.

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__________________________________________________________________ 9

J Butler, Gender Trouble: Feminism and the Subversion of Identity, Routledge, New York, 1990, p. 141. 10 Phaedress, Cancer Reflections, Part Two, Nov. 24, 2006: http://www.youtube. com/watch?v=ydirSD8J6Eo. 11 H Kohut, The Analysis of the Self: A Systematic Approach to the Psychoanalytic Treatment of Narcissistic Personality Disorders, University of Chicago, Chicago, 1979. 12 Phaedress, Cancer Reflections, Part Two.

Bibliography 1938Superman, My Inevitable Cancer Video. YouTube. United States, Nov. 24, 2006, http://www.youtube.com/watch?v=8yB_6PT4Cho. Butler, J., Gender Trouble: Feminism and the Subversion of Identity. Routledge, New York, 1990. Citron, M., Home Movies and Other Necessary Fictions. University of Minnesota, Minneapolis, 1999. Cook, K., ‘Medical ldentity: My DNA/Myself.’ Getting a Life: Everyday Uses of Autobiography. University of Minnesota, Minneapolis, 1996. Friedman, P., Joslin T. & Massi, M., Silverlake Life: The View From Here. Docurama. United States, 1991, 99 min. Foucault, M., The History of Sexuality: An Introduction. Vol.1. (1976). R Hurley (trans), Vintage Books, New York, 1990. Kohut, H., The Analysis of the Self: A Systematic Approach to the Psychoanalytic Treatment of Narcissistic Personality Disorders. University of Chicago, Chicago, 1979. Phaedress, Cancer Reflections, Part Two. YouTube. Canada, Nov. 24, 2006, http://www.youtube.com/watch?v=ydirSD8J6Eo. Renov, M., ‘Video Confessions.’ Resolutions: Contemporary Video Practices. University of Minnesota, Minneapolis, 1996, pp. 78-101. Rogers, G., My Left Breast. Women Make Movies, Canada, 2000, 57 min.

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__________________________________________________________________ Sedgwick, E., Epistemology of the Closet. University of California, Berkeley, 1990. Waugh, T., ‘Walking on Tippy Toes: Lesbian and Gay Liberation. Documentary of the Post-Stonewall Period 1969-86.’ Between the Sheets, In the Streets: Queer, Lesbian, Gay Documentary. University of Minnesota, Minneapolis, 1997, pp. 107126. Broderick Fox is a media theorist and practitioner residing in Los Angeles, California. He is Assistant Professor of Film & Media Studies in the Art History and Visual Arts Department of Occidental College.

Negotiating Pain: Beyond Nostos to Co-Presence in Flanagan’s The Sound of One Hand Clapping Jane Fernandez Abstract Loretta Baldessar argues that ‘the emotions of missing and longing motivate kin to construct four types of shared (co)presence: virtual, proxy, physical and imagined, which reinforce the sense of family closeness that characterises [...] conceptions of health and well-being’. I appropriate this concept of (co)presence to explore Flanagan’s treatment of loss/absence in the context of maternal dispossession. My interest lies in the way in which the motif of lace is treated in the text to trace the trauma of this dispossession and finally enable the protagonist to overcome feelings of rejection and abandonment. The lace acts as ‘proxy’ for the absent mother and enables the child Sonja to both articulate and overcome this loss. Key Words: Co-presence, Flanagan, Sound of One Hand Clapping, suicide. ***** The central and arresting symbol in Richard Flanagan’s The Sound of One Hand Clapping is the suicidal death of Mariah Buloh. The mystery surrounding Maria’s death acts like a ‘lacuna’, a space waiting writing, defining, explaining; a space we cannot enter nor ignore. The gaps in Maria’s own history are raised but not filled out by Flanagan and the effect is that the ‘trauma’ reflected in her manner of dying is a ‘testimony’ we are asked to seek out and investigate through exploring the secret folds of the text. Isabel Moore speaking of the poems of Paul Celan cites ‘the (im)possibility of speaking or writing poetry after Auschwitz’: There is no answer, only a constant circling of language and time around the ‘essential lacuna’ of trauma and its testimony :1 imperfect, fractured, folding infinitely on itself, turning and returning, because ‘[a]ll we have to do is ‘mark repeatedly the trauma as such.2 In Flanagan’s The Sound of One Hand Clapping, this sense of the wordless ‘circling of language and time’ is echoed in the Slovenian utterance ‘aja’, ‘aja’, Maria’s last words to her child; reassurance that is no reassurance, an utterance for home, that fills the lacuna with the nostalgia for home/homeland. My interest is in Flanagan’s treatment of ‘cultural trauma’ through the Buloh family.3 The novel enables an exploration of questions that deal with the trauma of a child’s survival of ‘separation distress’?4 How does a child, like Sonja Buloh, come to terms with her mother’s suicide? As Isabel Moore asks: ‘What is the place of suicide in the

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__________________________________________________________________ context of trauma and betrayal? Is it too a betrayal (redoubled again), another breaking of faith, a giving up or giving away life that breaks trust because it is chosen after survival itself, because it leaves survivors in those who remain?’5 These are questions the novel raises and leaves us with. The puzzle the text never resolves for us is Maria’s violent death against the backdrop of her daughter’s anxiety. Gerisch writes in exploring the suicide of Sylvia Plath that ‘[t]he wish to fail and to die in order to be liberated from […] various identifications […], justifies suicide/attempted suicide - a paradoxical survival performance in which the alien in the self is destroyed in order to enable a continuation of life’6. This predicament appears to explain Maria Buloh’s encounter with the trauma of her life, her suicide and its effect explored through the pain-filled experiences of her daughter, Sonja Buloh. My interest lies in the way in which the pain of maternal loss is treated and overcome by ‘proxy’ through the articulation and redefinition of the meaning of significant objects in relation to Sonja Buloh. These objects mediate to enable the protagonists to overcome the sense of loss and ultimately close the gap between absence/and presence. In this sense, these objects perform a ‘co-presence’7 function, negotiating the pain of nostalgia and loss and mapping through memory and the imagination a route beyond pain Flanagan’s The Sound of One Hand Clapping is laced with a array of postmemory narratives of pain-filled experiences and nostalgic tensions. These memories have a random and trance-like quality, jostling for space, agitating for meaning and closure through Flanagan’s non-linear narrative treatment. I use the term laced instructively in that lace is one of the novel’s recurring motifs. Flanagan evokes the image of lace through the solitary lace-clad figure of Maria Buloh who through her suicide becomes the novel’s pivotal absent centre. Indeed it can be argued that Maria Buloh is the novel’s structural co-presence and this copresence is treated through Maria’s affinity to lace. While the novel shifts from the treatment of Maria Buloh’s death to the associated trauma-filled lives of her husband Bojan and daughter Sonja, the novel is defined by the ghostly and spectral allusions to the lace-clad figure of Maria Buloh through Bojan and Sonja’s muted grief, Sonja’s dreams of lace and her envisioning of her last memories of her mother. The lace motif, in its connotations of beauty and dignity, appeal for some form of restraint in a text that throbs with pulsating memories of grief and loss. Arguably, the lace frame holds in check the acute trauma underlying the fabric of the text in a tight but semi-pliable model, checking the excesses of grief and pain, by injecting an awareness of beauty and soulful meditation at crucial and critical points of the novel. Lace with its intricate networkings and its hollowed spaces project and foreshadow the deep etchings of grief threaded through the body of the text and absorbed into the lives of the characters.

Jane Fernandez 261 __________________________________________________________________ In this sense, the lace motif quickly and effectively conveys the soft, beautiful, malleable and delicate threads of human connectivity in as much as it transcribes the vulnerabilities that are homed in the threading of our connections to the past and present, to loss and absence, to love and guilt, to home and exile. Like the intricate patterns of lace that hold and spill more than they reveal, the novel moves always towards an acceptance of the incongruent, the mysterious, the transcendent. In this sense the novel is poised in a poetic appraisal of life in its absurdity, compelling towards the very power and energy of life even at the most acute and critical textual encounters with death and human trials. The best example of this is treated ironically at the beginning of the novel in Maria Buloh’s assessment of life just moments before her death. Contrary to stereotypes of suicidal victims, Maria is presented as a poetphilosopher endowed with a dignified, thoughtful, intelligent presence. This is suggested through her soulful contemplation, her poignant and artistic appraisal of the earth’s intimate yet detached relationship to human agency/desire. From the moment Maria steps out of the hut, the novel appropriates a double lens, one poised on Maria treading snow and the other on her abandoned baby daughter crying out to her vanishing lace-clad mother. While the novel positions both mother and daughter as both literally and symbolically out in the cold, it clearly sets them up in an unequal relationship of power and without doubt, we as readers are drawn to the plight of the three-year old abandoned child. Yet, our judgment of Maria is tempered through Flanagan’s treatment of the lace motif, which cautions us against dismissing Maria as a simple, weak or sentimental victim of circumstance or uncaring tyrant mother. Instead the novel’s appeal to the lace motif is a visual sign mapping out the webbed contours of overt and covert networkings and contextual landscapes which complicate Maria’s predicament even as lace crystallizes in the text as a motif of mourning and lament. The latter is treated in the narrative through the emotional landscape of the novel which is haunted by the threat of disintegration evoked repeatedly through Sonja’s dreams of ‘Maria …stepping outside into a snow-swept blackness … and it [being] always the same …: the lace was disappearing’.8 By abandoning her child Maria ‘[violates] the [customary and fundamental] features of motherhood’. Indeed, the Slovenian maternal reassurance ‘aja’ ‘aja’ which she throws back to her child along the track of her exit is meant as much to weigh down the guilt of her own maternal dysfunctionality as it is meant to placate her baby daughter’s fears. This bad mother principle is raised against the backdrop of Maria’s troubled history, a history which robs her of a voice and displaces her sense of being. Indeed, at no point in the text does Maria adopt or is allowed a confessional mode of speaking. Her status as child rape-victim, orphan witness of her parents’ murder, war victim and exile is never articulated through her own voice or mind. The stoic and silent acceptance of her feminine victimization is culturally appropriate and seals off all routes to articulate and bring to the surface the wounding she had absorbed into her mind and body through her harrowing

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__________________________________________________________________ history as a child and woman. ‘[…],only the female body finally remains as an arena for the humiliations,insults, and mutilations suffered, and it must be annihilated’9 Indeed, her husband Bojan Buloh relates with pride how Maria’s never once spoke of the rape she had endured as a 12 year old child even though the facts of her personal history were open source knowledge to the entire village. Against her erasure of self and loss of voice, Maria’s suicide and maternal dysfunctionality is a re-routed voice, articulating the hollowed out self she has suffered, and pointing towards her own entangled subjectivities, out of which she acknowledges her inability to extricate the resource, method or meaning of her mothering role. If Maria refuses to be defined by the functions of motherhood alone, she points also, through it to the limits beyond motherhood, to her alienation and essential solitariness stretching from the dark corridors of her childhood to her troubled and suppressed womanhood. Accordingly, we could well ask if through this rebellion as daughter/wife/mother, she tests and eventually breaches the limits of her domestic/social spaces. Her rebellion against life itself, registered through her act of suicide, is a form of writing back to her own pain through the only avenue she has access to, her vulnerable body, and thereby naming and silencing her many persecutors, even as she chooses to die. Inadvertently, the cost of this is measured through her abandoned child Sonja who inherits the cycle of displacement and cruelty and to whom it is left to break the sequence. Our witness of Maria’s measured movements of self-reflection indicates the potential birth of a personality which regrettably cancels itself out at the frontiers of its own possibilities. It is this tension that is brought home to us through the tableau Maria enacts in the final sequence before her death. Indeed, if the function of narrative testimony is to ‘seek to provide a story worth telling’ the tableau becomes Maria’s best story and her worst story. Through this tableau Flanagan demonstrates the sharp contours of the mind poised between life and death, its heightened powers of observation, its attention to detail and its deepening self-reflexivity. Maria ‘looked at the beautiful impression’ her burgundy ‘shoes made in new snow,’ watched ‘her footprints beginning to disappear in a fresh flurry of snow and wondered at the nature of beauty, wondered at the small time allowed anything good before it was obliterated. Aja aja .10 Flanagan’s artistic sequencing of Maria’s eye movements, from ‘looking back’ to her home then ‘down’ at the impression her burgundy shoes on the snow covered earth and finally looking up, to the circling snow raining on the earth is like a choreographed dance, a prayer vigil for someone’s god, anybody’s god and nobody’s god. Through this eye ballet tableau, Maria draws deep into her senses

Jane Fernandez 263 __________________________________________________________________ the stories she creates intimately with the earth for the very last time. The divergent colors suggested through the burgundy and white, strike a paradoxical pose, wedding opposing images of heat against cold, passion against frigidity, corruption against purity, blood against a bleeding white lace world. Maria’s reflections upon each minute movement converts the drama into a spot of time, a tranquil, solitary, romantic engagement of the mind with nature, poised in its awareness of both the beauty and cruelty of life, assuredly courageous in that knowing and disturbingly cowardly, in her choosing to die in that fullness of her connecting deeply, even momentarily to the mystique of life. In this sense, the novel prepares us for a kind of tragic sublime mode carrying us through to its closing scenes weighed by feeling of sadness. In Maria’s stepping out and directing a symphony of sights, she draws our attention to the overpowering scents of the earth, the snow and the forest and the pervasive power of nature against her own human frailty. The snow’s ability to reveal and conceal the marks/traces of human life and its drizzling beauty ‘circling earthwards … as if they were time passing not constantly but erratically.. … show[ing] that the air was never still, but held endless circling complexities, held infinite possibilities for graceful inexplicable movements’.11 The cadences here move us through the colour scheme of blood, to the overpowering realities of death, treated through the avenging snowfall and finally to the air submitting its invisible body to the onslaught of the circling snow. Through Maria’s close and critical observations we are given a glimpse of the latent power, energy and promise that life holds. This focus on the visual and dramatic appeal provides and anticipates the relief the remainder of the novel agitates for. It comes as a rude surprise then when at the end of this profound and artistic narrative sequence Maria chooses to die, like a soldier who has lost the war; indeed we could not have imagined that suicide was one of the ‘infinite possibilities for ‘the ‘graceful inexplicable movements’ that Maria had described just moments before. The terrible irony of these lines are splattered for us over two pages, seventy-eight chapters later, in graphic detail; the supposedly ‘graceful, inexplicable movement’ of death that Maria chooses converts into parody in the details of Maria’s suicide: her ‘garroted neck like a snake-coil of steel.’12 How then do we come to terms with the disquiet at the heart of this text, Maria’s seeming callousness against maternal and ethical boundaries. What are we to make of Maria’s maternal denial? Indeed, for a good section of the novel we are unclear about Maria’s fate. Did she leave to begin life somewhere else? When the details of her suicidal death are finally confirmed, we are returned again to the colours of burgundy and white she had evoked before her death, only now as somber signs of a woman’s despair emphasized graphically through the descriptions of her transgressive death symbolized in the image of her ‘snakecoil[ed] neck’ returning us this time not to the soft contours of lace but to its macabre double, the rope by which Maria dies. The lace and rope become a labyrinth, a proxy, through which Sonja negotiates a route through her absent/co-

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__________________________________________________________________ present mother to a path where she unlike her mother will choose life. Sonja’s last view of her mother is as a woman dressed in black with a ‘white lace yoke.’13 ‘She wore lace and it was beautiful and Sonja pressed her face against the lace and knew her mother was leaving and that her mother was held within the power of something …, a terrible spell she could not break’.14 While lace signifies by proxy Sonja’s lost mother, it converts also through Sonja’s dreams and fears of disintegration, into a punishing and threatening mediator. In this sense, it both preserves and contravenes its co-presence functions. Whereas the co-present object is supposed to soothe and comfort the bereaved, in this instance, the lace is a trace of pain that threads and unthreads its way through the lives of Sonja and Bojan Buloh. Through Sonja the novel negotiates this co-presence through forcing and enabling Sonja to come to terms with her attachment to and diassociaton from her mother/father, through the motif of lace. The memory of her mother’s last movements convey the spell-bound nature of the various encounters Sonja returns to sporadically and runs from instinctively as she struggles to come to terms with her mother’s abandoning her to the vulnerabilities of childhood, to self-erasure and chronic doubts. Sonja believed herself to be neither a good person nor a strong person nor a kind person. She would wonder if, had she known her mother, and if her mother had been there when she was growing up, whether she would be otherwise: be better, kinder, stronger, and not forever punished.15 The ambivalence of Maria’s role as maternal and malignant presence, cosmic, altering, instrument of destiny is characterized also in Sonja’s overpowering sense of the latent stormy strains of power coiled asleep in the lace through which she identifies with her mother. But more importantly to the child Maria, lace defined her mother as much as her mother was defined by it. This is suggested through the personification of lace, its transubstantiation through communion with the wind and song into human form in the person of Maria Buloh. Mama wore lace and it was beautiful and she had left, but before she left she had sung softly to Sonja, had sung a lullaby soft and wondrous, the words of which she did not understand but the singing of which was both exotic and deeply sad. / […] The lace rode the strange song until it blew beyond the snow … and shaped itself into Sonja’s Mama […]. 16 The incongruent image of lace riding the wind, connotes Maria’s latent lifeforce and converts the lace motif customarily associated with gentleness and

Jane Fernandez 265 __________________________________________________________________ submission to one of willpower and excessive force. In this sequence, it reverses also the positioning of subject and object and explains how in the process of trauma, Maria Buloh had become objectified. Sonja’s mother, Maria Buloh had disintegrated, been swallowed into a vortex of lace. This association suggests how to the child Sonja, her mother had disappeared into the intricate patterns and hollowed out spaces of the lace world. She had become part of the mystery of lace, delicate and elusive at one moment, hollowed out and chillingly detached at another, invoking all that could not be fathomed, all that was lost to the naked eye, blown like a ghoul by the wind into another land, forsaking her child, forsaking her husband. Accordingly, to Sonja, the imprints of the past were embedded in one word: ‘the single, strange, inexplicable word’ Sonja tells us was ‘lace’,17 lace that to a three year old had the power to enthral, enclose, exclude. Sonja’s imputes to the lace a power to seduce the wearer, to determine the wearer’s destiny, to hold within its intricate design the paradoxes of beauty, mystique, song and sadness. But in her developing years, as Sonja comes to understand the manner of her mother’s death, she learns also how the delicate threads of lace fattened on guilt, regret and fear can convert into a rope that can choke and bleed life. Accordingly, the magic and terror of the lace motif is draw out through the novel by Maria’s attempts to patch the traces of her past through chasing the shifting patterns of the lace motif. ‘She would chase it. The chase was always different, but the end was inevitably the same: the lace disappeared in the wind.’18 Accordingly Sonja’s identification with lace is transference of trauma from mother to child and explains Sonja’s imminent fear of disintegration. This fear is finally resolved by the end of the novel through Sonja overcoming her fear of lace and finally adorning her body in lace-edged blouse. Sonja’s choice of cream instead of white revokes the connotations of death and frigidity symbolized through white lace and snow. In this sense, the resolution of the novel is sought through the way in which Sonja overcomes her fear of lace and heals the broken world of her childhood.

Notes 1

G Agamben, Remnants of Auschwitz: The Witness and the Archive,1999a, p. 13; ‘Speak, You Also’: Encircling Trauma,’ Journal for Cultural Research, 9: 1, 2005, p. 99. 2 S Zizek, ‘Speak, You Also: Encircling Trauma,’ Journal for Cultural Research, 9: 1, 2005, p.88 3 Thompson, ‘The Tenco Effect: Suicide, San Remo, and the Social Construction of the Canzone d'Autore,’ Journal of Modern Italian Studies, 11: 3, 2006, p. 343. 4 M Armour, ‘Violent Death,’ Journal of Human Behaviour in the Social Environment, 14: 4, 2007.

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__________________________________________________________________ 5

I Moore., op-cit, p.94. B Gerisch, ‘This Is Not Death, It Is Something Safer: A Psychodynamic Approach To Sylvia Plath,’ Death Studies, 22: 8, 1998, pp.735 – 761. 7 L Baldassar, ‘Missing Kin and Longing to be Together: Emotions and the Construction of Co-Presence in Transnational Relationships’, Journal of Intercultural Studies, 29:3, 2008, pp. 247. 8 R Flanagan, The Sound of One Hand Clapping, Macmillan, Pan Macmillan Australia; 1997, Picador1998, Sydney, Rep 2007, p.32. 9 M Santoro, ‘The Tenco Effect: Suicide, San Remo, and the Social Construction of the Canzone d’Autore,’ Journal of Modern Italian Studies, 11: 3, 342 — 366 10 Flanagan, op.cit, p.2 11 ibid, p.3 12 ibid, p.396 13 ibid, p.380. 14 ibid, p.380 15 ibid, p.175 16 ibid, p.260 17 ibid, p.260 18 ibid, p. 260. 6

Bibliography Armour, M., ‘Violent Death’. Journal of Human Behaviour in the Social Environment. 14: 4, 2007, pp. 53-90. Baldassar, L., ‘Missing Kin and Longing to be Together: Emotions and the Construction of Co-presence in Transnational Relationships.’ Journal of Intercultural Studies. 29:3, 2008, pp 247 – 266. Flanagan, R., The Sound of One Hand Clapping. Macmillan, Pan Macmillan Australia; 1997, Picador1998, Sydney, Rep 2007. Gerisch, B., ‘This Is Not Death, It Is Something Safer: A Psychodynamic Approach To Sylvia Plath.’ Death Studies. 22: 8, 1998, pp.735 – 761. Moore, Isabel A., ‘Speak, You Also: Encircling Trauma.’ Journal for Cultural Research. 9: 1, 2005, pp.87 – 99. Santoro, M., ‘The Tenco Effect: Suicide, San Remo, and the Social Construction of the Canzone d’Autore.’ Journal of Modern Italian Studies. 11: 3, 2006, pp. 342 366

Jane Fernandez 267 __________________________________________________________________ Jane Fernandez is a senior lecturer in the Faculty of Arts, Avondale College, Australia. Jane’s research interests include postcolonial literature, peace studies and diaspora criticism.

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