2. Pain

Pain is undoubtedly a very complex phenomenon, a fact reflected in the philosophical and medical debates concerning its nature and definition. Central to this complexity is that the experience of pain has clearly two aspects. On the one hand, given the analogy between pain and perception, one may claim that pain is a form of perceptual awareness, a sensory-discriminative state with its appropriate representational content, or more broadly, intentional object. In this sense, the claim ‘I have a pain in my hand’, like the claim ‘I have an apple in my hand’, reports an objective state of affairs. This state can be plausibly construed as some disturbance or damage localised in a specific part of my body, as registered through the activity of appropriate neurons, and represented in my perceptual experience as having a certain quality and intensity. On the other hand, there is a phenomenal quality of pain, a negative affective or evaluative (and eventually behavioural) component in the overall experience (‘it hurts’) that goes beyond the representational content of the perceptual experience and resembles more an act of introspection than an act of perception, since it does not seem to be about anything outside the experience itself.Footnote ¹

The various positions articulated in the philosophical debate on the nature of pain can be considered as responses to this duality, trying to combine these two aspects in various ways or to prioritise one over the other. However, this is not an easy task to the extent that the perceptive and the phenomenal aspects of pain can also exist independently and are thus not necessarily connected. There are well-known conditions in which the appropriate representational content is there, but the painfulness of pain is missing (pain asymbolia or various forms of analgesia), as well as conditions in which the painfulness of pain is there, but in the absence of the bodily damage that could be represented by the appropriate perceptual experience (phantom limb syndrome). Uniquely, pain is a form of perception for which no hallucination or delusion is possible, and this is reflected in the definition offered by the International Association for the Study of Pain, according to which pain is defined in an objectivist manner as ‘unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage’, but under the subjectivist qualification that, ‘[p]ain and nociception are different phenomena. Pain cannot be inferred solely from activity in sensory neurons. […] A person's report of an experience as pain should be respected’.Footnote ²

For the purposes of the present discussion, I shall adopt a broad and subjectivist understanding of pain, where the emphasis is on the ‘painfulness’ of pain and not on its specific perceptual or causal aspect. While by no means intended as an assessment of the debate presented above, I believe that this approach is particularly helpful for elucidating the lived experience of pain and our ways of dealing with it. The importance of drawing clear distinctions between different aspects or components of the experience of pain, as well as, say, between physical and psychological pain, or between pain and other forms of physical or mental unpleasantness or suffering, is evident. However, any significant lived experience of pain does not merely contain distinct episodes of physical pain (of the kind, say, that we may experience after a minor accident or before a visit to the dentist), but is shaped by all kinds of physical, mental, or even social conditions. To understand, for example, how a terminally ill person may try to deal – through art or otherwise – with an experience of persistent pain, while in fearsome anticipation of the future and mourning recollection of the past, in a situation of physical incapacitation and social isolation, we need an expansive definition of pain, in which ‘the boundaries of the word “pain” are characteristically blurred by connotations of suffering and trauma’ (Fernandez, Reference Fernandez2010, p. xiii).Footnote ³

The various aspects of the subjective nature of the experience of pain have been frequently noted in the philosophical reflection on pain. At the core of this subjective understanding of pain lies the claim, expressed here in Hannah Arendt's words, that ‘only pain is completely independent of any [external] object, that only one who is in pain really senses nothing but himself’ (Arendt, Reference Arendt1958, pp. 309–10).Footnote ⁴ A first implication of the lack of an external intentional object in the experience of pain is the radical isolation of the subject of pain. If the pain is intense enough, its experience absorbs the subject as the body is thrown back upon itself. When one withdraws into oneself, the normal function of one's senses is disrupted and so the subject loses touch with the reality of the external world. At the same time, one establishes an intentional relation with oneself in a state of negative and dissociative affection, sensing oneself in opposition to oneself.Footnote ⁵ A second implication is that this experience is radically private, since there is no obvious way to objectify it in order to express and communicate it publicly through linguistic or material signs: ‘the experience of great bodily pain, is at the same time the most private and least communicable of all. […] it [is] perhaps the only experience which we are unable to transform into a shape fit for public appearance’ (Arendt, Reference Arendt1958, pp. 50–1; see also Scarry, Reference Scarry1985, p. 162). In fact, one could go even further and claim that, in its radical lack of an intentional object that could guide the process of signifying, ‘physical pain does not simply resist language but actively destroys it, bringing about an immediate reversion to a state anterior to language, to the sounds and cries a human being makes before language is learned’ (Scarry, Reference Scarry1985, p. 4).

I have already noted above the unusual status of pain as a form of perception for which no hallucination or delusion is possible. This paradox can now be intensified by noticing that, given the objectless nature of the experience of pain, ‘for the person in pain, so incontestably and unnegotiably present is it that “having pain” may come to be thought of as the most vibrant example of what it is to “have certainty,” while for the other person it is so elusive that “hearing about pain” may exist as the primary model of what it is “to have doubt”’ (Scarry, Reference Scarry1985, p. 4).Footnote ⁶ Bridging the gap between private certainty and public doubt cannot be easily accomplished, but is imperative in both directions: the person in pain cannot make sense of their experience without making it public in some way, while the person who is not experiencing this pain cannot remain deaf to the disclosure of a fundamental aspect of human existence. It is thus necessary to come up with ways to ‘reverse the de-objectifying work of pain by forcing pain itself into avenues of objectification’ (Scarry, Reference Scarry1985, p. 6). In what follows, the task is precisely to examine how works of art of a certain kind can help us achieve this aim.

3. Art

Creating works of art is one of the most prominent ways to transform experiences, thoughts, or feelings ‘into a shape fit for public appearance’ (Arendt, Reference Arendt1958, p. 51). The nature of pain entails, of course, that, in a variety of ways, pain is not a particularly appropriate subject for aesthetic or artistic representation, especially if we identify the objective of our engagement with art as a kind of pleasure or delight. Nevertheless, there are many fictional representations of pain in art and literature, shaped by purely artistic exigencies and creative aims against the background of diverse lived experiences of pain that each one of us (and, presumably, the relevant artists) inevitably accumulates through life.Footnote ⁷ Sophocles’ Philoctetes and the statue of Laocoon and his sons, are classical examples where the depiction of the experience of pain is the primary aim of the work.Footnote ⁸ However, artistically informed explorations of pain need not be purely fictional. There are also documentary or quasi-documentary representations of human pain or suffering, ranging across the entire spectrum from journalism to ‘high’ art, usually associated with political or social agendas against injustice, oppression, or exploitation.Footnote ⁹ What brings these two different ways of dealing with pain through art together is their ‘third-person’ perspective: typically, neither the artist nor the audience claim a ‘first-person’ experience of the pain or suffering depicted: the pain is that of ‘others’. The ‘first-person’ experience of pain is however crucial in the way art is used to deal with pain in health care practice, as evidenced in various forms of art therapy.Footnote ¹⁰ What typically happens in art therapy is that under the guidance of the therapist patients are involved in art-making and in reflecting on both the process and the artistic objects they produce, in order to deal with their own pain or suffering. The artistic or aesthetic project is thus fully subordinated to the therapeutic aim and the purpose of art is to transform directly in some desired way the immediate lived experience of pain, to heal those who participate in the therapeutic practice.

However, there is a third possibility, which is what I am interested in pursuing here, namely works of art, which may or may not have been produced in the context of therapeutic practice, but are published or presented in a gallery space, i.e., they become candidates for public aesthetic or artistic appreciation. Such works, rather than being fictional representations of pain, act as (autobiographical) records of a specific lived experience of pain or suffering that their creators had, either in dealing with their own pain or with the pain of individuals close to them.Footnote ¹¹ This direct access to lived experience largely determines the response of the audience. It also generates the main question: what is the significance and the distinctive contribution of these works and their aesthetic appreciation to dealing with the lived experience of pain?

Much of the art included in Phantom Limb is precisely about articulating what pain was for those that experienced it, what it was to be in pain for them, and in that sense, it seems to go beyond an understanding of aesthetic experience as a form of universal pleasure generated by a beautiful representation. This is, then, a case in which art goes against the reticence associated with experiences of pain in many social contexts and directly attempts to make public that pain which is so private that ‘it cannot assume any appearance at all’ (Arendt, Reference Arendt1958, p. 51). So, what is it that we are presented with?

4. Aesthetic Experience

In the previous section, I identified several ways in which the particular artworks discussed contribute to our dealing with the lived experience of pain. This contribution, whether from the point of view of the individual, the artist/sufferer, or the audience who engages with the work, is both cognitive and practical, descriptive and transformative. These works capture and elucidate aspects of our experience of pain, but also articulate active responses to this experience. They try to make sense of the experience of pain by exploring the self-transformations initiated and suffered because of pain. But the leading question of my discussion remains and requires a more systematic elucidation: what is the specificity and significance of art and aesthetic appreciation in this context?

The issue can be broken down in a series of related questions. First, building on a question raised by Ian Williams (Williams, Reference Williams2011, p. 361), ‘is art made as therapy still art?’, we may ask: does it make sense to show such works in a public space, consider them as art, and enjoy them aesthetically? Second, could the fact that a work of art is created on the basis of a specific lived experience contribute something special to its artistic or aesthetic value? And finally, assuming the broad cognitive and practical interest underlying our desire to make sense of our experience of pain and respond to it, how and what does art allow us to learn about pain or suffering that would be difficult to learn in other ways?

In response to the first question, neither every artistic product of therapeutic activity or practice will necessarily be a publicly appreciable work of art, nor does the fact that a work was initially conceived or realised in a therapeutic context prevent it from being art and become a candidate for public appreciation, especially if its creator already has relevant qualifications or experience as an artist. In this sense, it seems that the issue cannot be decided as a matter of principle but should be evaluated on a case-by-case basis. What is clear as a matter of principle is that the criteria of appreciation of the work are different in the two contexts, and one should be careful in applying them appropriately in order to avoid misapprehending the significance of the work, which could be either therapeutic or aesthetic, or both.

The response to the second question seems more complex. Generally, artistic activity is considered as a matter of the imaginative and reflective (re)creation of experience, while the work of art is granted relative autonomy from the circumstances of its creation, such as the conditions or the immediate intention of the artist. So, in that sense, it could be argued that the aesthetic value of the work would be the same regardless of the particular circumstances of its creation. However, from the perspective of the artists, that these works are records of an intense and immediate lived experience, aiming directly to make sense of and respond to this experience, presumably sets them apart from works just conceived in an ordinary manner against the background of the overall experience or empathetic imagination of the artist. Moreover, it is undoubtedly the case that the audience's appreciation of and response to the works in the Phantom Limb exhibition were crucially shaped by their authenticity as vouched for by the actual, specific experience behind them – which, more generally, is also the case with much performance and feminist art. What is worthy of special admiration in the work of Hannah Wilke, for example, may not be that she managed through her art to make sense of pain in a novel or insightful way (she may have done this, but other artists not necessarily having this experience may do so too), but rather that she managed to do so in her condition, hindered, so to speak, instead of being assisted by the immediacy of her experience. In this sense, the special appeal or significance of this kind of art may be that it stands as a testament to the human ability to make sense of any lived experience and respond to it in an admirable way, however horrible and however horribly it affects us.

The final question touches upon a broader issue that has been discussed extensively in aesthetic literature, starting from Aristotle's Poetics, namely the so–called paradox of tragedy or paradox of negative emotions: we seek out and value works of art that depict distressing or horrifying situations which we would normally avoid in real life in order to spare ourselves from the negative emotions generated by the experience.Footnote ¹⁷ One way of dealing with this paradox is the position developed by the early Nietzsche under the influence of Schopenhauer. In the Birth of Tragedy, Nietzsche asserted that suffering is a fundamental and inevitable element of human existence and attributed to art the task to help us deal with it in the most effective way. The superiority of art in this respect is not, of course, practical in the ordinary sense: art is not in competition with medicine for providing more effective pain relief treatments. Rather, according to Nietzsche, the cognitive superiority of art is grounded on the refusal to evade the inevitability of suffering in human life – metaphysically grounded in the philosophy of Schopenhauer but also supported through empirical evidence – by articulating a prospect of a human life free of pain. Its practical superiority rests on its capacity to present that insight in a way that does not affect negatively the will of human beings to live. Depending on how strong one takes Nietzsche's claims to be, art can either provide some kind of justification for suffering, i.e., show how it contributes to the value of human existence, or, more modestly, help us discover or construct the significance and meaning of our experience of suffering in a way that enhances the capacity of the subject to pursue their fundamental interests.Footnote ¹⁸

It may be argued that the suffering of a patient undergoing chemotherapy or heart surgery in a present-day hospital is quite different, say, from the tragic pain of Prometheus or Philoctetes. In this sense, the Phantom Limb exhibition is a difficult case, if not for the substance of Nietzsche's views, at least for his excessive rhetoric. I propose an alternative yet so far underappreciated way of approaching this issue, arguing that the specific contribution of these works lies in affording us the possibility of dealing with the reality of pain or suffering through aesthetic experience.

The notion of aesthetic experience can be traced back to the beginning of modern aesthetics, especially to Kant's work, but it also informs the work of many contemporary philosophers of aesthetics. The fundamental idea behind it is that our encounter with certain objects – whether natural or human-made – leads to a special kind of experience different from any other form of experience arising from our cognitive and practical engagement with the world. Further and beyond this generally agreed understanding, everything that pertains to aesthetic experience – the way in which it can be captured and described, the way in which it informs our response to works of art, its function in explaining the task and value of art, its very existence as a distinct kind of experience – has been a matter of extensive debate in the philosophical literature.Footnote ¹⁹

The particulars of these debates shall not concern us here, but two points of orientation will be helpful. First, the traditionally prevalent understanding of aesthetic experience is a rather narrow one, both regarding its content and its overall aim. The content is limited to the appreciation of variously defined formal properties of the object – the unity, complexity, or variety of a composition, or its expressive purposiveness, i.e., the optimal relation of its form to the content it signifies. The aim of aesthetic experience is taken to be reflective pleasure, made possible by the temporary exclusion of any personal, cognitive, ethical, or socio-political interests. Second, given this narrow understanding of aesthetic experience, it is not surprising that its relevance for illuminating our complex responses to contemporary works of art motivated by all kinds of agendas that both exceed the traditional pursuit of beauty and undermine a conception of art as an autonomous social activity, have been increasingly questioned from the early 1960s, which, in the 1990s, even led to the identification of aesthetic experience as ‘the central blunder of modern aesthetics’ and to a ‘reasoned account of its demise’ (Shusterman, Reference Shusterman1997, p. 29).

On both these counts, invoking the notion of aesthetic experience in the context of the theme and the provenance of works like the ones presented at the Phantom Limb exhibition would seem even less helpful than employing a ‘heroic’ Nietzschean framework, to the point of being inappropriate or disrespectful. Clearly these are not works particularly suited to a primarily formal appreciation, while their artistic motivations and objectives, as well as the audience's response, evidently go against the appreciation of art for art's sake associated with an aesthetic understanding of art.

However, adopting a broader account of aesthetic experience, a trend evident in the recent revival of theoretical interest in the notion of aesthetic experience, may provide a more promising point of reference for determining the specificity and significance of art in the context of dealing with pain. Perhaps the broadest of these accounts has been articulated by Alan Goldman in a series of publications.Footnote ²⁰ According to Goldman, our response to a work of art must focus on ‘the interaction of formal, expressive, and representational aspects of the works appreciated’ (Goldman, Reference Goldman2013, p. 329). Aesthetic experience, as the subjective counterpart of this interaction, includes ‘cognitive, imaginative, and emotional engagement with artworks, along with perceptual grasp of their formal structures’ (Goldman, Reference Goldman2013, pp. 326–7). Moreover, to the extent that the work develops moral or political themes in a way that is relevant to our overall appreciation of it, ‘prompting engagement with a work on a moral level’ and thus, for example, gaining moral insight or knowledge, can also ‘be an integral and inseparable aspect of our full experience of or engagement with the work’ (Goldman, Reference Goldman2013, p. 331). In this broad sense, then, aesthetic experience cannot be radically distinguished or separated from the interests or capacities (theoretical, practical, and affective) that inform both our experience in general and our engagement with art in the context of our life. Rather, we should try to understand aesthetic experience in a fully inclusive way: the conditions of the reception of a work of art allow for ‘the simultaneous and harmonious interaction and engagement of all these mental capacities’ (Goldman, Reference Goldman2013, p. 329). In other words, what the experience of the work of art affords us is a reflective mental space in which all our interests, despite their relative priorities and antinomical tensions that inform and fracture our ordinary life experience, are allowed full and free simultaneous expression. In the case of works like the ones discussed here, these will include our interest to know the worst and hope for the best; our desire to do the right thing, but safeguard our happiness; our curiosity for the life of others and our respect for their privacy; our urge to sympathy and our concern for our self-preservation; our ‘unsocial sociability’, to use a Kantian phrase, that motivates equally both our pursuit of self-interest or relief for being spared some suffering and our capacity for empathy or longing for community.

It is important to note however, that inhabiting this reflective space is not the result of one's choice, but points to a certain passivity that characterises aesthetic experience: ‘one must be captured or “grabbed” by an artwork in order to have an aesthetic experience of it, and one cannot normally successfully will to be so fully engaged’ (Goldman, Reference Goldman2013, p. 330). One may thus consider aesthetic experience as the experience of losing oneself in the unfamiliar territory of an artwork, while at the same time recovering a new and reflective sense of oneself through a ‘fully active’ engagement of ‘all mental faculties operating in concert’ (Goldman, Reference Goldman2013, p. 330) with the content of the artwork in terms of the interests expressed or captured in the work itself.

So, how can works of art like the ones included in Phantom Limb help their creators and their audience make sense of pain? The first step, which is made by the artist, is the effective realisation that one cannot make sense of one's pain through art as one's own pain. This claim can be understood in two senses. First, whether we say that her pain is inherently private and hence cannot be publicly communicated, or that her pain, like any other specific experience, cannot be captured in its full particularity, the fact is that by creating the work, a public material sign highly motivated through an indefinite and opaque mixture of conventional generality and significant particularity, the artist effectively gives up her pain in its ineffability or particularity. At the same time, the artist gives up her pain as an immediate and legitimate object of her cognitive and practical interests, renounces, that is, the project of communicating her experience of pain in the way one may try to communicate it in the context of a medical interview or an ordinary testimonial record. We may think of this as the contribution, or even the sacrifice, of the artist: she gives up the specifics of her pain in order to build a common world around the semblance of her pain, which can invite multiple interpretations and meanings.

The accomplishment of the artist is to create a significant object motivated enough as to capture the attention of the spectator, making thus possible the aesthetic engagement with the work. The distinctive mark of this intense engagement, the absorption in the world created by the artwork, is precisely the inclusive and ‘lingering’ nature of aesthetic experience. When one reads, for instance, an article on pain in an academic journal, there is clearly a cognitive interest; there may also be corresponding practical interests (e.g., how to use this knowledge to alleviate the pain of patients) of a moral or self-interested nature (to help others or to become a famous doctor). However, the way in which the relevant motivations, intentions, or circumstances inform the experience precludes the exploration of innumerable other interests and issues that would be present during the appreciation of a work of art dealing with pain. For example, a doctor listening to a patient giving an account of their pain need not reflect on the simultaneous resilience and fragility of beauty in the defiant gaze of the patient in the way suggested by Wilke's self-portraits. At the same time, in our normal engagement with reality on the basis of our interests, we do not typically ‘linger’ on our experiences, exploring carefully the various aspects of their contents, not only because, as in this case, they may be painful, but also because we need to refocus our attention on the ways we can deal cognitively or practically with the demands of this experience (e.g., the doctor listening to a patient's account of their pain may be, justifiably or even necessarily, already thinking of the relative merits of different medications). The affective component of the aesthetic experience is especially important in this respect. Depending on the circumstances of any actual encounter with an experience of pain – for example, whether it is my pain, or the pain of someone I love or I feel indifferent about, or whether this is a pain pointing to the prospect of recovery or of death – one's affective response will be correspondingly determined, both in quality and quantity, by the immediate exigencies of the situation. The aesthetic experience makes possible the communication of these affective states to people who are not facing the same circumstances. And it is the inclusivity of the aesthetic experience that grounds the specific contribution of art in this context because it makes possible the kind of global orientation towards an experience that we usually seek when we try to make sense of the lived experience of pain.

Art of the kind I have been discussing succeeds in attracting us, absorbing us in a peculiar interplay between the private and the public, the personal and the universal, the familiar and the strange. It is this interplay that holds together the world opened up by the artwork – the world, to recall Arendt, which acts as the in-between that simultaneously unites and separates those that have it in common. In artistic creation, the artist renounces the privacy or ownership of her pain by creating a public semblance of it potentially owned by everybody, an accomplishment much more difficult, and thus rightfully praised, if wrested directly from an actual lived experience of pain. In aesthetic experience, the receptive counterpart of artistic creation, the ‘being’ in pain, deeply rooted in the human condition, is experienced as if the being in question were each one of us, something made possible precisely because the pain is not ours in the ordinary sense. While in art therapy art is undoubtedly valued as an alternative treatment for patients, here we see the potential for art to play a more central role in the holistic approaches to public mental health needed to meet the increasingly more complex and urgent socio-political challenges we are now facing. And this is because, as I have been arguing, the aesthetic experience of art uniquely allows the bringing to the fore of all different aspects of one's lived experience at once and their effective communication to others. If one of the goals of new approaches to public mental health is indeed to treat mental health in a holistic way, to make sense of the lived experience and see the patient more as a person, then the aesthetic experience through art that expresses and communicates publicly the lived experience of pain may provide a new model for reaching this goal.Footnote ²¹