Authors’ Note: This story refers to childhood sexual abuse. Isaac’s name has been changed. He consented to his story being told, but identifying details have been omitted and obscured.
I had to change my job description last summer. That’s when Joan Didion taught me that I am not so much a psychiatrist for people who are physically ill, as my CV maintains, but more of an architect of sentiment.
My wife and I were traveling through Montreal when my sister suggested that we visit a bookstore that sells graphic novels and feminist literature. Opting for the latter, I bought The White Album, a collection of essays by Didion, first published in 1979 but new to me, entirely on the promise of its first line:
“We tell ourselves stories in order to live.”
In the title essay, Didion describes a period in the late sixties when she was writing about the Black Panthers, The Doors and, mostly, the Manson family murders. She describes how she lost the urge to create stories during those years.
At the start, “we look for the sermon in the suicide, the social or moral lesson in the murder of five. We interpret what we see… we live entirely, especially if we are writers, by the imposition of a narrative line upon disparate images.” The narrative is an illusion, or a choice, but its imposition seems compulsory.
After Didion experienced what I would call depression, she says “I discovered that I was no longer interested in whether the woman on the ledge outside the window on the sixteenth floor jumped or did not jump, or in why. I was interested only in the picture of her in my mind: her hair incandescent in the floodlights, her bare toes curled inward on the stone ledge.”
She decided that all narrative is sentimental.
This struck me as true. It is an important idea because helping people to build stories is part of a psychiatrist’s job. And this is what made me think of Isaac.
Isaac is a man with chronic gut disease who has been coming to see me for many years. When he first came to see me, Isaac was succeeding in his life as measured in the usual ways. But he couldn’t survive any longer without talking to someone about the sexual abuse he had experienced, recurrently, unpredictably, and painfully, for several years as a child.
One of the many malignant consequences of painful and terrifying experiences early in life is how they can incapacitate a person’s ability to link things together. For most people, most of the time, one memory links to another; sequences of more-or-less continuous memories link to feelings; memories and feelings link to beliefs, expectations and attitudes. A somewhat coherent sense of “this is where I came from and this is who I am” emerges from that.
Whether we like who we are or not, whether we see ourselves as masters of our fate or not, those who grow up without severe trauma, brain injury, or brain disease mostly live in a world that seems to make sense. Kids who are terrorized, on the other hand, often don’t make those links and so they live in a much less organized world.
Isaac often asks,
“What happened to me?”
with a look that is equally anguished and perplexed. The question is not rhetorical, but when I try to respond, my answers leave Isaac baffled. Not only that, but his bafflement puzzles me, so confusion ripples between us. His perplexity doesn’t makes sense because he is a man who most people would find intimidating in an argument because of his command of logic and clear thinking. I wouldn’t play chess against him if I cared about the stakes. And yet, we talk about his old memories or a recent dream and he asks again, “What happened to me?”
Traumatic experiences are overwhelmingly frightening. Sometimes, repressing memories and disconnecting the links between thoughts and feelings are defenses against remembering that overwhelming experience, but that might not always be true. Sometimes, it might be true instead that terrifying experiences prevent links from being made in the first place, because they overwhelm the brain’s capacity to understand what is happening.
The explanation that resonates for Isaac is that his brain is broken. What he actually says is that his brain is completely fucked up.
A person who cannot tell a compelling and more-or-less true story about pain, or fatigue, or fever, is at a great disadvantage getting good health care. That is what has happened for Isaac, in spite of being an extremely articulate man.
Disease is a Rorschach ink blot.
The meaning that a person finds in being sick comes from within. Although we talk about diseases using metaphors, as when people talk about cancer using battle metaphors, none of the metaphorical stories that allow us to live with illness is quite true. Their value lies in their utility rather than in truth.
Often, medical patients who come to see a psychiatrist are living with stories that have ceased to serve a useful purpose. The idea that cancer is a battlefield can feel very unhelpful to someone who is unable to win the battle. Or, thinking of someone else, the idea that we get what we deserve can become harmful when a terrible disease is obviously undeserved. My job in that situation is to help patients question their metaphors, or experiment with living as if something else was true than what they have always thought. For those patients, our conversations are like wrecking balls of sentiment. We disassemble stories in order to build new ones. For Isaac it is the opposite, he needs an architect, not a wrecking ball.
Isaac has grotesque and terrifying dreams. They are fragmented, visceral and awful. His dreams are both frightening and incoherent. When Isaac finds meaning in being sick it is like the meaning that he finds in his dreams. He has imagined that the relentless pain in his gut is from a monstrous parasite like in the movie Alien, waiting to burst through his abdomen. He has imagined that the solution to the pain might be to nail one end of his intestine to a tree and run as hard as he can away from it. There are many other images like these.
These tortured shreds of meaning distort the options that are available to Isaac to deal with his illness.
Take surgery. He has a disease that has required him to have an operation a few times. He is now a veteran of the operating room, which should make it easier to anticipate and prepare when another operation is required. But that is not what happens. Instead, guided by nightmare fragments of meaning, he imagines that he will wake in the middle of surgery, paralyzed and powerless, but no one will notice and the operation will continue. Or that he will be ignored in his hospital bed afterwards, abandoned with untreated pain. Add to that his very realistic expectation that he will find himself once again in an antagonistic interaction with a surgeon and it is no surprise that Isaac avoids surgery when it would be in his interests to seek it.
That is one example of something that happens all too often. The Rorschach inkblot of his disease receives the meaning projected on it by awful fragments of Isaac’s memory and this defines the options that he sees. Rather than the all of the options that medical science has to offer, he sees choices that are deformed by pain, helplessness, cruelty, and shame.
If it is dry, keep it wet; if it is wet, keep it dry.
There is a joke about dermatology, that the entire specialty can be reduced to that one maxim.
There is a similar maxim in psychiatry, I can see since reading The White Album, which applies to the stories that we tell ourselves in order to live. If you suffer from a story that used to make sense but is no longer useful, bring in the wrecking ball. It is time to pay attention to the evidence that has been suppressed, and to brave acting upon new assumptions, to face the lousy possibility that the meaning you have found in life is sentimental.
On the other side of the maxim, if trauma has so broken your capacity to find a “continuous me” in your memories and to construct a coherent story from your experiences, then you don’t need a wrecking ball, you need an architect.
And so, I now realize, the strangely intimate conversation that Isaac and I have shared has been a long, circuitous attempt by us to build a healing story of his life.
We trade divergent interpretations of his dreams, often waiting for the next dream to provide a missing angle that makes the story make more sense. In one dream Isaac’s father screams at him to shoot his own son; we are perplexed and aghast. In the next, the scene is the same, but while Isaac’s father screams abuse, his son turns and kills the old man. The horror doesn’t diminish, but the plot thickens. We make connections between these images, and his memories and feelings.
As we talk, I notice the people who love Isaac, and that their love comes at a cost. We have shared that Leonard Cohen verse that ends “I have torn everyone who reached out for me.” His relationships with doctors are also complicated. He shares his contempt for the physicians who will not give him the drugs he needs to calm his pain, but explicitly exempts me from membership in that group because we have agreed to avoid the scenario where I become one more authority who refuses him solace. And I see his respect for those rules of engagement as a remarkable act of reciprocity, which is something that could just as easily have not survived the traumas of his early years.
When Isaac tells me stories about his friends or family, he makes his point and makes me laugh. Far from being unable to weave a story, Isaac knows how to engage and intrigue a listener. But his story of “me,” a continuous Isaac with a past and a present and a future has been very slow to build.
Here is a key point. Over our long conversation, Isaac has become a better manager of his disease. The signs of change are obvious: he consults with a doctor without it ending in a confrontational stand-off, he refrains from buying pain medication on the street, he has surgery when he needs it, he dreams less often of ending his life to take control of his disease.
Architects and wrecking balls
Joan Didion found a new truth when, in the midst of depression, she relaxed her reflex compulsion to impose a narrative sequence, cause and effect, or meaning, on her observations. It is different for Isaac, who lacks an ability to find or create a meaningful story of himself and his disease. For him, the absence of a coherent story does not feel like truth. It is a nightmare, a broken dream from a broken brain, and it compromises the care that is available when he is ill.
If it is wet, keep it dry; if it is dry, keep it wet. Psychotherapists are wrecking balls and architects of sentiment, builders and destroyers of stories.
Isaac comes into my office, and tells me that he has had another dream. I get out my notepad and write the pieces down. He has also made an appointment to see his surgeon. Weird, that these two sentences belong together, and yet that is how it goes. We tell ourselves stories in order to live.
Jon Hunter and Bob Maunder write about the interface of mental and physical health and the power of relationships (for better and worse). Links to their work are found at attachmentandhealth.com.