The Empathy Exams: Essays

by Leslie Jamison

  I could tell you I got an abortion one February or heart surgery that March—like they were separate cases, unrelated scripts—but neither one of these accounts would be complete without the other. A single month knitted them together; each one a morning I woke up on an empty stomach and slid into a paper gown. One depended on a tiny vacuum, the other on a catheter that would ablate the tissue of my heart. Ablate? I asked the doctors. They explained that meant burning.

  One procedure made me bleed and the other was nearly bloodless; one was my choice and the other wasn’t; both made me feel—at once—the incredible frailty and capacity of my own body; both came in a bleak winter; both left me prostrate under the hands of men, and dependent on the care of a man I was just beginning to love.

  Dave and I first kissed in a Maryland basement at three in the morning on our way to Newport News to canvass for Obama in 2008. We were with an organizing union called Unite Here. Unite Here! Years later, that poster hung above our bed. That first fall we walked along Connecticut beaches strewn with broken clamshells. We held hands against salt winds. We went to a hotel for the weekend and put so much bubble bath in our tub that the bubbles ran all over the floor. We took pictures of that. We took pictures of everything. We walked across Williamsburg in the rain to see a concert. We were writers in love. My boss used to imagine us curling up at night and taking inventories of each other’s hearts. “How did it make you feel to see that injured pigeon in the street today?” etc. And it’s true: we once talked about seeing two crippled bunnies trying to mate on a patchy lawn—how sad it was, and moving.

  We’d been in love about two months when I got pregnant. I saw the cross on the stick and called Dave and we wandered college quads in the bitter cold and talked about what we were going to do. I thought of the little fetus bundled inside my jacket with me and wondered—honestly wondered—if I felt attached to it yet. I wasn’t sure. I remember not knowing what to say. I remember wanting a drink. I remember wanting Dave to be inside the choice with me but also feeling possessive of what was happening. I needed him to understand he would never live this choice like I was going to live it. This was the double blade of how I felt about anything that hurt: I wanted someone else to feel it with me, and also I wanted it entirely for myself.

  We scheduled the abortion for a Friday, and I found myself facing a week of ordinary days until it happened. I realized I was supposed to keep doing ordinary things. One afternoon, I holed up in the library and read a pregnancy memoir. The author described a pulsing fist of fear and loneliness inside her—a fist she’d carried her whole life, had numbed with drinking and sex—and explained how her pregnancy had replaced this fist with the tiny bud of her fetus, a moving life.

  I sent Dave a text. I wanted to tell him about the fist of fear, the baby heart, how sad it felt to read about a woman changed by her pregnancy when I knew I wouldn’t be changed by mine—or at least, not like she’d been. I didn’t hear anything back for hours. This bothered me. I felt guilt that I didn’t feel more about the abortion; I felt pissed off at Dave for being elsewhere, for choosing not to do the tiniest thing when I was going to do the rest of it.

  I felt the weight of expectation on every moment—the sense that the end of this pregnancy was something I should feel sad about, the lurking fear that I never felt sad about what I was supposed to feel sad about, the knowledge that I’d gone through several funerals dry eyed, the hunch that I had a parched interior life activated only by the need for constant affirmation, nothing more. I wanted Dave to guess what I needed at precisely the same time I needed it. I wanted him to imagine how much small signals of his presence might mean.

  That night we roasted vegetables and ate them at my kitchen table. Weeks before, I’d covered that table with citrus fruits and fed our friends pills made from berries that made everything sweet: grapefruit tasted like candy, beer like chocolate, Shiraz like Manischewitz—everything, actually, tasted a little like Manischewitz. Which is to say: that kitchen held the ghosts of countless days that felt easier than the one we were living now. We drank wine, and I think—I know—I drank a lot. It sickened me to think I was doing something harmful to the fetus because that meant thinking of the fetus as harmable, which made it feel more alive, which made me feel more selfish, woozy with cheap Cabernet and spoiling for a fight.

  Feeling Dave’s distance that day had made me realize how much I needed to feel he was as close to this pregnancy as I was—an impossible asymptote. But I thought he could at least bridge the gap between our days and bodies with a text. I told him so. Actually I probably sulked, waited for him to ask, and then told him so. Guessing your feelings is like charming a cobra with a stethoscope, another boyfriend told me once. Meaning what? Meaning a few things, I think—that pain turned me venomous, that diagnosing me required a specialized kind of enchantment, that I flaunted feelings and withheld their origins at once.

  Sitting with Dave, in my attic living room, my cobra hood was spread. “I felt lonely today,” I told him. “I wanted to hear from you.”

  I’d be lying if I wrote that I remember exactly what he said. I don’t. Which is the sad half life of arguments—we usually remember our side better. I think he told me he’d been thinking of me all day, and couldn’t I trust that? Why did I need proof?

  Voiced concern for my situation/problem. Why did I need proof? I just did.

  He said to me, “I think you’re making this up.”

  This meaning what? My anger? My anger at him? Memory fumbles.

  I didn’t know what I felt, I told him. Couldn’t he just trust that I felt something, and that I’d wanted something from him? I needed his empathy not just to comprehend the emotions I was describing, but to help me discover which emotions were actually there.

  We were under a skylight under a moon. It was February beyond the glass. It was almost Valentine’s Day. I was curled into a cheap futon with crumbs in its creases, a piece of furniture that made me feel like I was still in college. This abortion was something adult. I didn’t feel like an adult inside of it.

  I heard making this up as an accusation that I was inventing emotions I didn’t have, but I think he was suggesting I’d mistranslated emotions that were actually there, had been there for a while—that I was attaching long-standing feelings of need and insecurity to the particular event of this abortion; exaggerating what I felt in order to manipulate him into feeling bad. This accusation hurt not because it was entirely wrong but because it was partially right, and because it was leveled with such coldness. He was speaking something truthful about me in order to defend himself, not to make me feel better.

  But there was truth behind it. He understood my pain as something actual and constructed at once. He got that it was necessarily both—that my feelings were also made of the way I spoke them. When he told me I was making things up, he didn’t mean I wasn’t feeling anything. He meant that feeling something was never simply a state of submission but always, also, a process of construction. I see all this, looking back.

  I also see that he could have been gentler with me. We could have been gentler with each other.

  We went to Planned Parenthood on a freezing morning. We rummaged through a bin of free kids’ books while I waited for my name to get called. Who knows why these books were there? Meant for kids waiting during their mothers’ appointments, maybe. But it felt like perversity that Friday morning, during the weekly time slot for abortions. We found a book called Alexander, about a boy who confesses all his misdeeds to his father by blaming them on an imaginary red-and-green striped horse. Alexander was a pretty bad horse today. Whatever we can’t hold, we hang on a hook that will hold it. The book belonged to a guy named Michael from Branford. I wondered why Michael had come to Planned Parenthood, and why he’d left that book behind.

  There are things I’d like to tell the version of myself who sat in the Planned Parenthood counseling room. I would tell her she is going through something large and she shouldn’t be afraid to confess its
size, shouldn’t be afraid she’s “making too big a deal of it.” She shouldn’t be afraid of not feeling enough because the feelings will keep coming—different ones—for years. I would tell her that commonality doesn’t inoculate against hurt. The fact of all those women in the waiting room, doing the same thing I was doing, didn’t make it any easier.

  I would tell myself: maybe your prior surgeries don’t matter here, but maybe they do. Your broken jaw and your broken nose don’t have anything to do with your pregnancy except they were both times you got broken into. Getting each one fixed meant getting broken into again. Getting your heart fixed will be another burglary, nothing taken except everything that gets burned away. Maybe every time you get into a paper gown you summon the ghosts of all the other times you got into a paper gown; maybe every time you slip down into that anesthetized dark it’s the same dark you slipped into before. Maybe it’s been waiting for you the whole time.

  STEPHANIE PHILLIPS

  Psychiatry

  SP Training Materials (Cont.)

  OPENING LINE: “I’m having these seizures and no one knows why.”

  PHYSICAL PRESENTATION AND TONE: You are wearing jeans and a sweatshirt, preferably stained or rumpled. You aren’t someone who puts much effort into your personal appearance. At some point during the encounter, you might mention that you don’t bother dressing nicely anymore because you rarely leave the house. It is essential that you avoid eye contact and keep your voice free of emotion during the encounter.

  One of the hardest parts of playing Stephanie Phillips is nailing her affect—la belle indifférence, a manner defined as the “air of unconcern displayed by some patients toward their physical symptoms.” It is a common sign of conversion disorder, a front of indifference hiding “physical symptoms [that] may relieve anxiety and result in secondary gains in the form of sympathy and attention given by others.” La belle indifférence—outsourcing emotional content to physical expression—is a way of inviting empathy without asking for it. In this way, encounters with Stephanie present a sort of empathy limit case: the clinician must excavate a sadness the patient hasn’t identified, must imagine a pain Stephanie can’t fully experience herself.

  For other cases, we are supposed to wear our anguish more openly—like a terrible, seething garment. My first time playing Appendicitis Angela, I’m told I manage “just the right amount of pain.” I’m moaning in a fetal position and apparently doing it right. The doctors know how to respond. “I am sorry to hear that you are experiencing an excruciating pain in your abdomen,” one says. “It must be uncomfortable.”

  Part of me has always craved a pain so visible—so irrefutable and physically inescapable—that everyone would have to notice. But my sadness about the abortion was never a convulsion. There was never a scene. No frothing at the mouth. I was almost relieved, three days after the procedure, when I started to hurt. It was worst at night, the cramping. But at least I knew what I felt. I wouldn’t have to figure out how to explain. Like Stephanie, who didn’t talk about her grief because her seizures were already pronouncing it—slantwise, in a private language, but still—granting it substance and choreography.

  STEPHANIE PHILLIPS

  Psychiatry

  SP Training Materials (Cont.)

  ENCOUNTER DYNAMICS: You don’t reveal personal details until prompted. You wouldn’t call yourself happy. You wouldn’t call yourself unhappy. You get sad some nights about your brother. You don’t say so. You don’t say you have a turtle who might outlive you, and a pair of green sneakers from your gig at the minigolf course. You don’t say you have a lot of memories of stacking putters. You say you have another brother, if asked, but you don’t say he’s not Will, because that’s obvious—even if the truth of it still strikes you sometimes, hard. You’re not sure these things matter. They’re just facts. They’re facts like the fact of dried spittle on your cheeks when you wake up on the couch and can’t remember telling your mother to fuck herself. Fuck you is also what your arm says when it jerks so hard it might break into pieces. Fuck you fuck you fuck you until your jaw locks and nothing comes.

  You live in a world underneath the words you are saying in this clean white room, it’s okay I’m okay I feel sad I guess. You are blind in this other world. It’s dark. Your seizures are how you move through it—thrashing and fumbling—feeling for what its walls are made of.

  Your body wasn’t anything special until it rebelled. Maybe you thought your thighs were fat or else you didn’t, yet; maybe you had best friends who whispered secrets to you during sleepovers; maybe you had lots of boyfriends or else you were still waiting for the first one; maybe you liked unicorns when you were young or maybe you preferred regular horses. I imagine you in every possible direction, and then I cover my tracks and imagine you all over again. Sometimes I can’t stand how much of you I don’t know.

  I hadn’t planned to get heart surgery right after my abortion. I hadn’t planned to get heart surgery at all. It came as a surprise that there was anything wrong. My pulse had been showing up high at the doctor’s office. I was given a Holter monitor—a small plastic box to wear around my neck for twenty-four hours, attached by sensors to my chest—that showed the doctors my heart wasn’t beating right. The doctors diagnosed me with SVT—supraventricular tachycardia—and said they thought there was an extra electrical node sending out extra signals—beat, beat, beat—when it wasn’t supposed to.

  They explained how to fix it: they’d make two slits in my skin, above my hips, and thread catheter wires all the way up to my heart. They would ablate bits of tissue until they managed to get rid of my tiny rogue beat box.

  My primary cardiologist was a small woman who moved quickly through the offices and hallways of her world. Let’s call her Dr. M. She spoke in a curt voice, always. The problem was never that her curtness meant anything—never that I took it personally—but rather that it meant nothing, that it wasn’t personal at all.

  My mother insisted I call Dr. M. to tell her I was having an abortion. What if there was something I needed to tell the doctors before they performed it? That was the reasoning. I put off the call until I couldn’t put it off any longer. The thought of telling a near-stranger that I was having an abortion—over the phone, without being asked—seemed mortifying. It was like I’d be peeling off the bandage on a wound she hadn’t asked to see.

  When I finally got her on the phone, she sounded harried and impatient. I told her quickly. Her voice was cold: “And what do you want to know from me?”

  I went blank. I hadn’t known I’d wanted her to say I’m sorry to hear that until she didn’t say it. But I had. I’d wanted her to say something. I started crying. I felt like a child. I felt like an idiot. Why was I crying now, when I hadn’t cried before—not when I found out, not when I told Dave, not when I made the consultation appointment or went to it?

  “Well?” she asked.

  I finally remembered my question: did the abortion doctor need to know anything about my tachycardia?

  “No,” she said. There was a pause, and then: “Is that it?” Her voice was so incredibly blunt. I could only hear one thing in it: Why are you making a fuss? That was it. I felt simultaneously like I didn’t feel enough and like I was making a big deal out of nothing—that maybe I was making a big deal out of nothing because I didn’t feel enough, that my tears with Dr. M. were runoff from the other parts of the abortion I wasn’t crying about. I had an insecurity that didn’t know how to express itself; that could attach itself to tears or to their absence. Alexander was a pretty bad horse today. When of course the horse wasn’t the problem. Dr. M. became a villain because my story didn’t have one. It was the kind of pain that comes without a perpetrator. Everything was happening because of my body or because of a choice I’d made. I needed something from the world I didn’t know how to ask for. I needed people—Dave, a doctor, anyone—to deliver my feelings back to me in a form that was legible. Which is a superlative kind of empathy to seek, or to supply: an empa
thy that rearticulates more clearly what it’s shown.

  A month later, Dr. M. bent over the operating table and apologized. “I’m sorry for my tone on the phone,” she said. “When you called about your abortion. I didn’t understand what you were asking.” It was an apology whose logic I didn’t entirely follow. (Didn’t understand what you were asking?) It was an apology that had been prompted. At some point my mother had called Dr. M. to discuss my upcoming procedure—and had mentioned I’d been upset by our conversation.

  Now I was lying on my back in a hospital gown. I was woozy from the early stages of my anesthesia. I felt like crying all over again, at the memory of how powerless I’d been on the phone—powerless because I needed so much from her, a stranger—and at a sense of how powerless I was now, lying flat on my back and waiting for a team of doctors to burn away the tissue of my heart. I wanted to tell her I didn’t accept her apology. I wanted to tell her she didn’t have the right to apologize—not here, not while I was lying naked under a paper gown, not when I was about to get cut open again. I wanted to deny her the right to feel better because she’d said she was sorry.

  Mainly, I wanted the anesthesia to carry me away from everything I felt and everything my body was about to feel. In a moment, it did.

  I always fight the impulse to ask the med students for pills during our encounters. It seems natural. Wouldn’t Baby Doug’s mom want an Ativan? Wouldn’t Appendicitis Angela want some Vicodin, or whatever they give you for a ten on the pain scale? Wouldn’t Stephanie Phillips be a little more excited about a new diet of Valium? I keep thinking I’ll communicate my pain most effectively by expressing my desire for the things that might dissolve it. If I were Stephanie Phillips, I’d be excited about my Ativan. But I’m not. And being an SP isn’t about projection; it’s about inhabitance. I can’t go off script. These encounters aren’t about dissolving pain. They’re about seeing it more clearly. The healing part is always a hypothetical horizon we never reach.