by Dawn Garisch
I can hear the scientists shrieking at such a notion, as I once did. But it is an astonishing image: Zeus residing in the solar plexus, causing havoc. I think it is a measure of impoverishment that, once we know that electrically charged ions cause lightning, we laugh at those who believe in Thor. Yet Thor's antics in the stormy skies speak deeply to the poet in us.
If our difficulties become too great, we might turn to therapy in an attempt to resolve the tension. Analysis is the re-imagining of the story of our lives. It holds the space open for a battle of stories to take place. It values the symbolic life.
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From the time humans pushed out frontal lobes, we have been trying to understand and to communicate what it means to be alive. During the past six hundred thousand years, humans have developed an aesthetic sensibility. Wherever Homo sapiens has gathered – around a fireplace in a cave or a dwelling, around a waterhole or a bar counter, a conference or dinner table, around preparations for ritual, worship or war, or around the birthbed and the deathbed – we have told stories to each other to explain how we came to be here, the purpose of our lives, and where we go when we die. These stories are powerful, helpful containers for our anxiety. They assist us to find purpose and meaning, and they help direct our choices.
We are born into collective stories: the history of our family, our culture, our country, our time. The woman with heartburn entertains a story that both entraps and sustains her. Her body is objecting to inordinate stress in the only way it can – through symptoms. As a doctor I am suggesting to her that the way she is living her story is not the only one. She requires both courage and curiosity to venture outside the loop that both binds and contains her. It seems to me the psyche challenges us repeatedly in varied ways to alter our track. Symptoms are a form of feedback from the body that require a corrective to re-establish health. They are a means the body employs in an attempt to heal itself.
Changing your story can be terrifying. Adam Twerski, rabbi, psychologist and writer, has suggested that there is a ‘Law of Human Gravity’24. He says that human beings will usually gravitate from a situation that appears more stressful to a situation that appears less stressful, meaning that we will only leave a stressful situation if the alternative is perceived to be less so. For my patient, changing the established dynamic with her husband feels more stressful than staying in it. We all have friends who won't change their lives, even though they might want to, and even though it is obvious to everyone else that change would be for the better. If we have lived long enough, we have all experienced a version of this predicament.
The story that you are immersed in can appear better or truer than any other version.
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Human beings think and speak in words, images and stories. Our experiences form the basis of our world view, however skewed they might be. You can check this out very easily. Next time you meet a stranger, take note of the story that comes up immediately about him or her. We can even fall in love with someone we see for the first time across the room, or take an instant dislike to someone we have never met, but whom we can hear speaking in another room. We have a memory bank of associations linked to every single aspect of another person's appearance – the shape of the eyebrows and nose, the colours and clothes they wear, the accent and the tone of their voice, their complexion and expression, whether they make eye contact or wear make-up, their gait, their smell.
Practising medicine can be an effective antidote to making assumptions about people, because doctors meet so many people from all walks of life. The elderly, dishevelled person turns out to be a professor, the shifty character is merely shy, the charming man has given his wife a black eye, the man with gonorrhoea is not the one who is sleeping around, but has a girlfriend who is cheating on him, and the couple who look like mother and son are actually husband and wife.
Nevertheless, doctors can be as prone to false assumptions and prejudice as other people. When I was an intern in the gynaecology wards, a fifteen-year-old girl was admitted for an operation for excessive bleeding. She was Muslim, and her mother insisted on a doctor's certificate stating that her virginity had been breached by a medical procedure, and not by a sexual encounter. I don't know why a pregnancy test was not performed, but in theatre the gynae registrar found products of conception in her uterus. She was having a miscarriage.
Back in the ward, in front of medical students and other patients, the registrar attacked this frightened girl. ‘What do you mean, you don't have a boyfriend, ’ he shouted. ‘Do you have a girlfriend then, huh? Huh? ’
It is one of the events that stand out in my training with rage and shame. I said nothing to this arrogant young man. Nobody stood up for the patient. Perhaps she had willingly taken a lover. Maybe she had been raped or been subjected to incest. I will never know what had happened to her. But I do know that the bad behaviour of the person supposedly in charge of her healing had just scarred her for life. The registrar had not only made assumptions about her pregnancy, he had victimised and publically humiliated her for a range of stories he tells himself about women, sex and Muslims.
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Patients bring doctors their stories – about their lives and their illnesses. They also bring us their bodies: body as slave, child, robot, vehicle, machine, map of the unconscious. Body as terrorist, saboteur, hindrance, betrayer. Body as friend, guide, guard; as faithful servant, fragile membrane, resilient warrior. The body as process, repository of memory and trauma, of lineage, genetic pool.
One of the strengths of the medical model in which I have been trained is also a weakness, in that, in terms of disease, we are not interested in the personal details, or the subjective experience. There is a set of questions we ask to assist us with arriving at a diagnosis. We know from experience that most illnesses behave in predictable ways most of the time. The pain of gallstones is usually different in nature from that of a stomach ulcer, pancreatitis or gastroenteritis. The pain of migraine presents differently from sinusitis or a bleed in the head. Most illnesses can be diagnosed by categorising and correlating symptoms, even before an examination or investigations like blood tests, X-rays or ultrasound. Doctors ask directed questions: is the pain burning or tight? Is it sharp, dull or cramping? In medicine we don't want the whole subjective, perambulating story. The waiting room is full.
Yet disease occurs not only in the human body on the examination couch. It is present in the psyche and in the context in which the person lives. There is always a bigger picture or story attached to the ill or sore person seeking relief.
Sometimes doctors forget that. Sometimes, patients are not interested in investigating their own stories.
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4. The Psyche Doesn't Speak English
One great part of every human existence is passed in a state which cannot be rendered sensible by the use of wideawake language, cutanddry grammar and goahead plot.
James Joyce25
I wrote the following poem for a friend who was suffering recurrent symptoms, and complained that she didn't understand what her body was saying.
Breaking the Code
My body's riddled through with flaws; My dog's a whirling dervish. At work I can't see out-of-doors; My coffee's always warmish.
My face keeps breaking out in sores; My dreams are full of catfish. At night I clench and grind my jaws; The psyche should speak English2.
The problem is, it doesn't. The language of the body manifests as symptoms; the language of the unconscious emerges as symbols. The workings of the psyche are deep currents, invisible but for the ways in which they form and inform the visible surface. Like geologists, we have to extrapolate from the surface disturbances and characteristics in order to determine the subterranean dynamics.
Jacques Lacan, a psychiatrist and psychoanalyst, whose interdisciplinary work drew on philosophy, linguistics and mathematics, proposed that a symptom was an embodied metaphor. The differences between simile, metaphor and symbol are as follows. In simile, we migh
t say ‘the moon is like a finger-nail’ – the two parts are distinct. In metaphor we'd say ‘the moon sails across the sky’ – the parts are merged without our noticing, but the moon is still the primary object of attention. ‘The moon rises in our blood’ – the object takes on a broader and deeper association with an aspect of human experience, and we call this symbol. We find metaphors and symbols in poetry: ‘All the world's a stage’,26 or ‘Today I read entrails / over the low Drakenstein’.27
Lacan's view suggests that the twinges and flushes and snot of our bodies are a kind of poetry. Arnold Mindell, a physicist turned Jungian analyst, agrees. He says that unconscious information manifesting as symbols in night dreams is evident in our bodies during the day as symptoms, sensations and gestures. He maintains that our symptoms and our dreams are trying to wake us up to the fullness of our lives.28
Of course, if you suffer a heart attack, your body might be informing you that the way you have been living needs review. Or if cholera sweeps through a township, the authorities need to be brought to account for failing to ensure an adequate water supply. But what Mindell adds is a teleological, as opposed to purely consequential, view of life. He would claim that there is something drawing you to itself through your personal experience of illness. Attending to the medical condition at hand is, of course, important, but Mindell claims that if the underlying metaphoric condition is not processed, the information will recur, perhaps in another form, for example in a relationship difficulty. His is not a join-the-dots theory. Subjective experience is crucial, and investigating meaning can take unexpected non-rational turns.
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A lecturer, whose living depends on speaking to lecture theatres full of students, developed dysphonia, or a hoarse voice. He saw a specialist, who sent him for tests, all of which came out normal. His physician recommended physiotherapy to alleviate his problem, but his condition did not improve. Working with me on the symptoms in a process way, he discovered that even outside the lecture room, he talked incessantly. His wayward larynx was trying to shut him up. On processing this further, he admitted that what he really needed to do was to write a novel that had been brewing for some time. In order to do this, he needed to be alone, and to be quiet.
He also admitted that he never felt heard as a child. Now his failing voice is making certain that he is not heard as a classroom teacher either. His task is to develop a different way of communicating what he has to say.
A woman who had travelled abroad developed a chronic, mild, smelly diarrhoea. Her symptoms were classic of an infestation by an intestinal parasite called Giardia. The treatment for this is metronidazole. Five tablets a day for three days would cure her, but she refused treatment, preferring to let her illness take its course. For eighteen months she had low grade symptoms on and off, and I was concerned for her, but still she was against taking medication. Then, overnight, her condition was cured.
Of course, it is possible for her body to heal itself, which usually takes longer than if one goes for the quick fix. What occurred just before this woman got better was that she recognised her tendency to ‘leave the back door open’ as she put it! The issue at stake was her ambivalence about her impending divorce, despite all the evidence that things were not reparable between her and her husband, who was living with another woman. Once she had resolved to bring the marriage to a close by instructing her lawyer to serve divorce papers on her husband, her diarrhoea stopped, and has not come back.
A mild-mannered woman had a red itchy rash on her scalp. She got a deep satisfaction from scratching until the rash oozed. Then she would keep scratching the scabs off. When I suggested she scratch something other than her own flesh, and carefully pay attention to what she was feeling as she did this, she snatched up a guava and began stripping the skin of the fruit off with her nails. Only when she got at what lay underneath did scratching become satisfying to her. She suddenly realised how furious she was with her husband, who worked a very long day. She felt he was avoiding her, but she rationalised her frustration away because he had a very important job. She wanted to tell him how she was feeling, and to try to get at what was underneath the skin of her husband's behaviour, but she was too afraid that approaching him would drive him still further away.
A scientist would argue that these examples are anecdotal, and do not withstand scientific scrutiny. Yet these outcomes are impossible to measure using scientific tools. There is enough anecdotal evidence for us to take seriously the theory that the psyche and the body have self-correcting strategies that go beyond the immune system, and that are aligned to the power of story and symbol.
It is arrogant to dismiss this aspect of illness. It denies us a fascinating way of getting to know ourselves better and to deal with core issues through paying attention to the physical difficulties that come our way, rather than stopping at popping a pill in order to get rid of them.
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2 Or any other verbal language.
5. The Wounded Healer
When just a girl, I thought I'd fill the cup Of those who choked with thirst, and never dreamt Again, again, my frail veins would freeze up.
Siddiq Khan29
Recently, as I had been well for ages, I considered changing from a comprehensive medical aid to a hospital plan. First I did a whip-around of all the tests one ought to do at the age of fifty. Mammogram, bone density, thyroid, PAP smear, colonoscopy It was an effort – time taken away from my lovely life to sit in waiting rooms, and to turn my flesh and bones and blood over to the probings of professionals.
My GP phoned me with the results. She told me that my bone density scan showed marked deterioration over the past eighteen months, and that I am hypothyroid.
My first thought: it's because of the bloody book. If I stop writing the book, everything will be fine. It's dangerous entering this terrain – things start happening.
My next thought: I either scrap the theory that your body is trying to talk to you, or the theory does not apply to me. I mean, all the people I know whose thyroids are under-active are rushing around, trying to juggle kids and work and deadlines, and beating themselves up because they feel exhausted. That's not me. My life is well-balanced. I have worked diligently to get to this point of equilibrium. I am engaged and curious, I am a good example to my patients, and – as a friend of mine once joked – I have passed all my therapy exams.
The inner scientist smirked: You see! Sometimes shit just happens! So much for your New Age mumbo jumbo.
I was reeling. My body had betrayed me. I took good care of her, and this was how she repaid me.
I told my GP that it wasn't fair, that none of this applied to me. She laughed, and told me that she checked herself for hypothyroidism all the time, as she was tired and sore and putting on weight. She said she wished she had hypothyroidism, so she could just take a pill and feel better.
I don't want to take pills. Not every day. OK, sometimes, when my backache is really bad, I will take something, but generally speaking, I am remarkably pill-free.
At work my colleague put his hand on my shoulder and looked into my eyes. He said, patiently, that taking a pill isn't that big a deal. My inner scientist agrees. She reminds me that I should be grateful.
I am grateful. My aunt had what must have been a severely under-active thyroid for years. She refused point blank to see a doctor. As a child I noted with horror, every time we visited her, how she bloated out, her voice turning to gravel, her movements increasingly slow and dull, her skin becoming coarse and dry, her legs elephantine. She eventually died of heart failure as an end stage consequence of the lack of thyroid hormone, the essential ingredient that maintains metabolism. She died because her fear of her body – or of doctors, or of taking medication – was greater than her fear of illness and death.
I thought of Emily Brontë, dying on a sofa aged thirty-nine, refusing to the end to see a doctor. I thought of Charlotte Brontë, dehydrating to death due to vomiting in pregnancy, and both John Keats and D. H.
Lawrence wasting away from TB, and Robbie Burns dying of rheumatic heart disease, and Sylvia Plath, morbidly depressed, eventually managing to kill herself – all very young, all at the height of their creative endeavours, all dead of causes that are now treatable.
I couldn't think straight. Why? I demanded of my doctor. Why isn't my thyroid behaving?
We are getting older, she reasoned. Your thyroid is getting tired. It is not responding as it should. You must remember, she said, that we were not meant to live this long. We used to die of other causes long before parts of our bodies began giving way, giving up. And you have an autoimmune disease, which can affect the thyroid.
The word hubris came to mind. Eight years ago, the last time I was convinced I was doing really well, my whole life was pulled out from under my feet. My marriage ended, my adolescent sons both fell into deep but differing life-threatening trouble, my mother became very ill, I lost my job, and my health deteriorated. My sons and I all made it through intact, in fact better able to deal with life on life's terms, but when you are in the middle of crisis, it is terrifying. You don't know how the story will turn out.
Since then, I have felt wary of congratulating myself when things are going well. Instead I enjoy the respite and gather strength for the next wave of difficulties, or challenges. I try to be mindful when I am in the middle of difficulty, or when my life feels great, that the glass is usually both half full and half empty at the same time.
At this moment, all I can feel is water lost. Half-empty Thyroid life force and bone minerals leaching out of my body, slipping through my grappling fingers, draining away. The poet inside is in mourning. She doesn't care about pills and potions. She wants to document this slow decline. She throws ash about and beats upon her chest, and accuses me of thinking that I am in control, of the hubris in believing that I can strike deals with my life, my fate. And of the pathetic conceit of thinking that if I am a really awake and conscious person, my body will be rewarded, or will reward me.