by Dawn Garisch
It is the role of the frontal lobes to sort and organise data into some kind of congruence. That congruence is the foundation from which we make the necessary judgements to plan and execute a course of action. Judgement implies that we are able to check our perceptions against the truth – something that we are sometimes woefully incapable of, or unwilling to do.
In denial, we either make no attempt to check whether an assumption is true, or we actively make attempts to bolster a skewed idea of reality. A friend, having warned her drug-abusing son that her home is a drug-free zone, made her son and his friend strip down to their underpants on their return late one night. She found marijuana hidden in their socks, and called the other boy's mother to come and fetch her son. When the mother arrived, she was furious about my friend's assertion. She turned to her son, declaring, ‘You didn't have drugs on you, did you? ’ Her son was only too pleased to comply with his mother's demand that he deny it.
Rue postulates that there are three motive forces in the human psyche, curiosity, hedonism and self-esteem, and it is often the conflict between these areas that force us to choose between satisfying one while denying another. In the drug-denying story, the friend's mother's self-esteem was at stake, so she wasn't about to become curious about her son's habits.
Denial is a psychological device whereby painful truths are not admitted. We refuse to acknowledge what is right in front of us, even when it is apparent to everyone else, for example, that one is an alcoholic. A friend from a twelve step programme says denial is wonderful while it is operating, because it allows you to think that everything is fine in circumstances that might otherwise be untenable, like not knowing that your spouse is cheating on you, or believing that your adolescent son's large crop of plants behind the garage, that he harvests and sells, indicates an interest in horticulture.
In order to deceive ourselves, we must be capable of accepting as truth one set of perceptions and cancelling out any contradictory information. Rue suggests that this capacity to pull the wool over our own eyes helps individuals, relationships and groupings to cohere and function altruistically as though inherent contradictions were not present. He says it allows us to subscribe to the ideas of marriage, a rainbow nation, and even the stock exchange.
James Hollis54 warns against the religious, political and psychological constructs in society that encourage us to deny shadow material rather than to engage with the subterranean features of our humanity. He argues that it is the artists and depth psychologists who venture into this difficult terrain, and who are therefore instructive guides in our efforts to heal ourselves and our relationships to others and the earth.
***
Imagine reality.
I love this bumper-sticker advice. Yet our brains hide from our consciousness the fact that we are hiding something. What entity decides what to hide and what to reveal? There is a sorting going on.
We have to cross a threshold to perceive something that we have not been able to notice before. One way is by waiting until we are smacked in the face by the cold fish of reality: when you come home earlier than usual one day to find your husband in bed with your best friend, or when the police come over to question you about your nice, quiet neighbour who has body parts in his fridge. Or you find that the weight you have been gaining constantly for some months despite dieting, followed by cramps that you assume to be a touch of gastro, results astonishingly in a little head popping out between your legs.
Another way to survey for what is really going on – if we don't want to wait for the cold fish – is to do a reality check. Ask everyone around you what they think about the matter under question. If the consensus is that you are too old or drunk to be behind the wheel and are a menace on the road, even if you are of the opinion that your driving is fine and everyone else drives recklessly, perhaps it is time to take note.
Most of us most of the time are very defensive. We discourage feedback. Our self-esteem has been too damaged, or we have been too manipulated by those close to us to be able to take a step back and review the situation. Yet feedback can be lifeblood. We know who we are and, simultaneously, we cannot see ourselves. Literally. Even in the mirror, what we see is a reverse image. We get a surprise when we hear a recording of our own voice.
I find it very discomforting to realise that most people will not say to your face the very thing everyone is discussing about you behind your back. You might consider yourself a kind, caring and devoted doctor, and on the whole you could well be, but, unbeknown to you, your nickname at the referral hospital due to your tendency to refer patients very late, is Dr Death. You might announce that your daughter is an uncaring parasite, but behind your back people might be shaking their heads over what an impossible mother you are.
Moving people over the threshold and out of denial is something I regularly try out in the consulting room. Increasingly, I also attempt to review my own life: a more difficult task than one might imagine. Who can you trust to tell you the truth? What is reality? Is reality a reliable measure of the truth? How important is it to get at the truth?
We have all experienced moments where the world or life turns out to be different from what we thought it was. The terrible moment you break through denial and discover that your daughter is a heroin addict, that your heart or lungs have been irreversibly damaged due to poor lifestyle choices, that your government has reneged on its promises, that the lump in your breast that you have been hoping will go away by itself is cancer, that your doctor, homeopath or energy healer cannot prevent you from dying, that AIDS is caused by a virus, that having sex without contraceptive protection has resulted in a pregnancy.
We have all at some point been forced to change the way we see things.
***
Every day I meet people who take medication for high blood pressure, high cholesterol levels, diabetes and joint pain rather than change what they eat and lose weight, who take antidepressants and anxiolytics rather than leave a chronically abusive job or marriage, or take asthma medication rather than stop smoking or find a new home for the cats. Athletes arrive regularly at the clinic for injections of anti-inflammatories so that they can carry on running. They want the doctor to collude with the abuser.
We all have our blind spots. Some seem more mind-boggling than others, especially when they are not yours. The pharmaceutical companies know there is a fortune to be made out of this human tendency to be blind to the thing that is in front of you. There is even a glossy advertisement that promotes an antacid as treatment for our modern lifestyle. The visual depicts cigarettes, alcohol, caffeine, fast food and stress – all of which promote indigestion. The explicit message is: you don't have to change your ways, just pop one of our products.
A sales representative for anti-inflammatories predicted with a gleam in his eye that arthritis is going to increase enormously in the upcoming generation due to the amount of time growing children spend in front of the television and the computer instead of running around with a ball, climbing a tree or dancing. Strenuous movement is necessary to develop normal joints.
I sometimes ask patients what they do for exercise, and a surprising number tell me that they walk around at work.
A patient of mine who had an ongoing battle with her weight, lost two kilograms in a week. She rewarded herself by going out and ordering a piece of cake. This woman has an eating disorder, which is a form of addiction. Addiction, says the twelve step programme, is a disorder of thinking. But addictive thinking is not confined to addicts. We all rationalise, justify, manipulate, deny and lie to ourselves about the bad habits we are terrified to give up.
It seems that we cannot rely on logic alone to release us. We need a little help from non-rational quarters.
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13. Physician, Heal Thyself
Home
bit my hand last night; the door released me from Its jaw then skulked away, leaving me to dance upon a bright hot coin of pain.55
Again I am learning something I thoug
ht I knew, but did not really understand: I cannot write this book from the outside. I cannot write it retrospectively, from a superior vantage point, casting a wise eye back into the ignorant past. I, too, am deep in the soup, clinging to a noodle.
This book has to be written from the inside, from the here and now, out of current trial and error, out of the pain, confusion and relief of the present. By the act of taking up my pen to put down all that I have discovered as a doctor and a scribe, I have awoken ancient ghosts and poets. They seethe eagerly at my elbow, seeking to influence my life through my writing, and my writing through my life.
For the past few months I have had pain in my upper and lower teeth on the left. My dentist tried this and that, but could not diagnose the cause. I have been chewing on the right side only, and I dread the pain of the cold rinse after brushing. I am raging about the terrible dentist who ruined my teeth when I was a child. He was a character out of a horror movie, surly, sadistic, and a hater of children.
My current dentist, a sweet, concerned man and a pianist, asks me: ‘Do you grind your teeth at night? ’ Of course not. It is a question I have asked my patients often enough when trying to diagnose unusual cases of headache or earache. It might apply to a patient, but not to me. I am not that neurotic, and I am not stressed. ‘You have well developed masseter muscles, ’ he persists, irritatingly. ‘Do you clench your teeth at night? ’
Never.
Ever since he dangled this question, I have been aware, subliminally, that I clench my teeth when I swallow or turn while sleeping.
I am shocked. I know about the unconscious, yet when I stumble upon certain manifestations of it in my own life, I can hardly believe it. How could I have been unaware for all these years that I clench my teeth at night? How long has this been going on behind my back? Long enough to cause dental pulp to go into revolt, screaming. Now I must wear a bite plate at night, like a bit inserted to tame the nocturnal spirit that seizes me.
The bite plate is slowly reducing my symptoms, but I cannot stop at that. What comes to mind is wailing and gnashing of teeth. I have always understood this phrase as synonymous with grief, but googling it, I discover that it has more to do with rage, anguish and hatred. Yes, I do experience these feelings. On and off during my life I have bitten my nails while reading ever since I went to boarding school at the age of nine. Annoying. Intractable, even though I have bought gloves (which I never wear) and consider sitting on my hands while engrossed in a book.
Also, I sucked my thumb until the age of six. There is a mouth thing going on.
***
In a dream last night, my son, suddenly back to age nine, kissed the President of Argentina, a woman who, in my dream, is married to the King of Naples. The kiss was indifferent, dutiful; they were merely going through the motions. It was a pretence, underneath which lay their teeth – rage and aggression. A kiss can become a bite in a nanosecond.
These images of mouths and teeth, hunger and rage are sunk deep into my flesh – my muscles are tense and inflamed, in pain and crackling with crepitus. Now that the tension and pain of my autoimmune and psychological condition has entered my jaw, expanding, amplifying my process and drawing more attention to itself, again I feel despair. My body has lived in varying degrees of pain for so long, I am desperately sorry for her. Like a slave or a child, she is forced to bear the unbearable, and I don't know how to help her.
Yes, I have worked with my body processes most of my life, through therapy, dance, embodied imagination, process work, reiki, family constellation therapy and Tomatis, and I have learnt a huge amount about myself and the world, all of which has helped me with this difficult and beautiful gift of life, all of which I am grateful for. Yes, I have come to a place where I think I have let go of cure, and accepted that there are limits to being human, starting with death, and that I live with an incurable, chronic illness. Yes, this illness has led me by the nose down alleys I would never have gone down otherwise. It has made me a better doctor, a better person. It has released more compassion in me, and has opened my mind and my physical self to the complexity of illness and health and what it is to be human.
This dreadful ancestral curse I carry, handed down in my genes – HLA B27 – has also been a blessing. But I am tired of pain. I weep for the suffering of my body, a body that has served me so well. The unconscious still rides her, still has her muscles in its bony grip. I want to rage: what else do you want of me? Why won't you speak to me?
For the moment, my body stays mute.
***
Doctors are in trouble. They have a higher than average incidence of suicide, addiction and depression. At a recent lecture for doctors on workaholism, the lecturer pointed out that we are amongst the worst. Medical students are selected for it. Their high school grades largely determine whether they will be accepted into medical school. The teenagers entering the halls of learning for the medical profession have already proven themselves to be both driven and high achievers, attributes that do not come with rebelliousness. Doctors are therefore more likely to accept abusive working conditions. During my neurosurgery internship I was expected to work a one-hundred-and-ten-hour week. They are also less likely than the general population to protest, or to go on strike.
Doctors do complain, however – amongst themselves. It is rare to go to a doctors' meeting without being snagged by a colleague grumbling about income, medical aids or the impending Health Insurance Act.
It's enough to make anyone clench their teeth.
***
Today I visited the Tibetan Tea House to witness some visiting Buddhist monks creating a sand mandala. They do this as their life work, spending days or even weeks making exquisitely intricate and symmetrical patterns within a large circle using naturally coloured sand. Just watching them work gave me backache; it also moved me to the brink of tears. When they have finished, they equally gently and carefully sweep their creation up, section by section. They then carry the sand to a body of water nearby, and deposit it into the flow. It is a symbolic act of distributing harmony and beauty via the rivers and oceans to the world.
Years ago, when I was first told about this practice, I remember feeling puzzled, even disdainful. Something in my chest hurt at the thought of painstaking work coming to nothing, and beauty deliberately being destroyed. Only now that I am in the second half of life have I begun to understand the value of such an act. All the beautiful constructs we work hard to put in place during the first part of our lives – relationships, children, financial security, a home, a career, works of art – will be swept away at death. We might leave children behind when we die, or paintings, or possessions and money, but our bodies will decay back into the land. Our children's bodies will follow, as well as the musical scores and mosaics and literature and bank notes; everything eventually will be reclaimed, will disintegrate and dissolve.
The study of death at medical school was confined to the anatomy laboratory, the post-mortem room and the forensic mortuary, which were simultaneously macabre and academic. The practice of medicine had to do with the living. It was about living. Our long training was designed to defeat illness and prolong life. Implicitly, for most doctors, death is an adversary.
When my own father developed an illness which paralysed him slowly over many months, a senior neurologist investigated him thoroughly, but could not find a cause. My father deteriorated until he was unable to walk, feed himself, or look after himself in any way. He lost an enormous amount of weight, and was struggling to come to terms with his terrible disability.
To my distress, the neurologist suggested yet another battery of tests. I approached this respected man who had taught me previously, and asked him whether it would not be better to stop investigating my father and help him prepare for death. ‘You must never give up, ’ he reprimanded, in a tone that conveyed I had uttered a blasphemy.
The first two occasions when people died in my care during my internship I felt devastated. There was no-one to talk to about
it, no mentoring, no debriefing. I felt overwhelmed and very alone.
Late one night, an elderly man who was having a heart attack was admitted to my ward. I called the cardiology registrar, who refused him admission to ICU because of his age, as was the state hospital policy. He told me to administer morphine, then left me at the bedside. The curtains around the bed were drawn and the bedside light was on. The dying stranger and I were brought together by this moment, illuminated in the same pool of light in an otherwise darkened ward in the middle of the night. He wasn't coping with the tremendous crushing pain in his chest; sweat was trickling down his temples. He kept begging me to help him. In the absence of any other options, I kept on giving him intravenous morphine until his eyes emptied and he stopped breathing. His coronary thrombosis probably killed him, but I was left worrying that I had done so with a morphine overdose. Six years in medical school had not prepared me for this. I was way out of my depth.
The second occasion involved a middle-aged woman who had recently been operated on for a subdural haematoma – a collection of blood that slowly accumulates under the skull after trauma, compressing the brain. The neurosurgeons had cut her scalp open, then had drilled burr holes into the skull to drain the blood. Then she had been sent to a convalescent hospital to recover.
One morning she was discovered semi-conscious. The doctor in charge was concerned that the blood was re-accumulating, and had booked her for transfer back to our hospital for urgent scanning and probable surgery. It took the whole day for her to be transferred, and by the time she arrived in the neurosurgery ward, she was in a coma. The CT scanner was occupied with another patient, and the neurosurgery registrar was in theatre. Soon after arriving, she stopped breathing.
I rang the bell for help, and the cardiology registrar arrived with the resuscitation equipment and put the patient on a ventilator. Her heart was still going, but she was deeply unconscious. I called the neurosurgery registrar in theatre on the intercom. He said her only chance was for someone to stick a brain needle in through the burr hole in her skull and extract the blood. The cardiology registrar threw up his hands, saying it was not part of his job description, so I found myself, three months into my apprenticeship, trying to perform brain surgery in the middle of a ward on a dying patient. All I managed to suck out of her head was brain tissue; then she died.