I figured my stories could interest him.
Many years ago my family and I were lunching with Bob, a surgical colleague, and his family. The occasion was winding down, and he and I had subsided into a corner to share work perspectives. Both of us had unusual work histories. He was an altruistic and principled man, who, out of a sense of Christian service, had devoted years of his life to medical work in a developing country. I had been an academic clinical immunologist who had turned to psychiatry in mid-life, then became a psychotherapist, and then blended my clinical immunology and psychotherapy practices together, all this reflecting a personal aspiration to integrate body, mind and spirit aspects of human reality into my clinical and healing endeavours.
I shared with him my experiences of people with diverse well-recognised physical diseases that seemed to be full of meaning, and sometimes even glaringly symbolic. I had written about many such patients.
I told him about patients with facial disorders who in one way or another had had trouble ‘facing’ the world or ‘being seen’ (and more). Yes, they would spontaneously and unconsciously use words that expressed the symbolism perfectly. (Note: I am not saying that all facial disorders are symbolic).
I then described for him:
A patient with a very long list of medically unexplained fractures and tendon injuries, occurring over several years. She was in a relationship in which she felt obliged to follow her partner in his rather excessive outdoor pursuits. The ‘injuries’ effectively prevented her participation in these activities, and during the year prior to consultation she had become an invalid and unable to work. Digging deeper there was a powerful and poignant story of leg fracture in her childhood that was experienced as a way of holding on to the attention of her father.
This injury tendency disappeared entirely and immediately once all this was acknowledged and then discussed with her partner, and she was able to become pregnant. A crucial element in the story was that he had previously fiercely resisted having a child because he did not want his outdoor activities disrupted. In sum, she was unconsciously resisting him via measureable musculo-skeletal manifestations, which effectively disrupted his life focus, whilst avoiding direct communication, conflict and threat to the relationship.
I have many such stories.
My colleague had lived and worked well outside the norms of Western medical and cultural structures. I imagined that he, being a religious person, might be open to a wider view of disease than that in which he had been trained. I hoped he might be interested, curious, or receptive.
He was not. The conversation stopped, dead. I was disappointed but did have some understanding. All of us develop and inhabit ‘enclosures’ of mind or thought. It is unavoidable. These enclosures take many forms, but I believe he was confined by two enclosures very familiar to me. And I had experienced very significant challenges during the processes of releasing myself.
The first ‘enclosure’ is that of Western biomedicine, which affects all clinical disciplines. Biomedicine is an important part of my working life and identity, and I value its powers greatly, but in one perspective it is a system of categorising and responding to illness and disease according to several restrictive, intersecting principles and forces. I get tired of reiterating these, but they include: dualism--the separation of body from subjectivity or mind and spirit; scientific reductionism--with its exclusive privileging of quantitative measurement, the associated dominance of technological intervention, the general denial of ‘experience’ as a crucial aspect of disease causation, and the gradual decline of healing as an ‘art’ or relational form; and professionalism--with its valid focus on maintenance of standards, which can have inadvertent secondary effects of excessive conformism and suppression of knowledge outside that approved by dominant vested interests. My stories fly in the face of all this.
The second ‘enclosure’ is that of (certain forms) of Protestant Christianity. Like Western scientific medicine, and since the Reformation, it has had at its heart a desire to establish the absolute ‘truth’ of things, though its aims and means of achieving this are of course are rather different. Truth for believers generally lay in establishing the historicity of the biblical record, and in interpreting the Bible in exactly the right way, thus securing eternal facts.
In both of these enclosures there has been an accepted striving for exactitude and ‘certainty’, a conviction that we have (perhaps all) the ‘truth’ we need in our grasp if we achieve this exactitude. In a way both enclosures entail a drive towards mastery and control. I hasten to add that these drives are not confined to the two examples given here.
An unfortunate side effect or cost of this is that the softer elements, the relational dynamics and priorities at the centre of human experience and reality, the visceral experiences of living and suffering, the arts of healing, and other mysteries of life are subordinated to hard data or dogma, indeed even erased from the consciousness or awareness of (in these two instances) the science-focused clinician and the ‘absolute truth’ focused believer. In other words there is an excessive seeking of a certain kind of truth and a critical neglect of other kinds.
And, so, my friend instantly closed himself off from my stories, consideration of which might have pointed towards an uncomfortable revision of his ‘enclosures’. On further reflection, given my subsequent experience of many colleagues, a simpler narrative could be that my companion was merely settled and comfortable in his work and did not want his life complicated.
While enclosure formation is intrinsic to social formation, there is a risk that excessive closing down around a limited perspective will tend towards de-vitalisation, and even stark, cold, black-and-white places that lack heart for anything that might threaten the equilibrium and ‘safety’ achieved.
We see some vivid examples of this currently around the world.
Edmund Husserl, the father of phenomenology, might have described my friend’s reaction as an example of the ‘natural attitude’—that tendency in all of us to be inculcated, to just see what we have been taught to see. In this perspective, cultural education can be very stifling and repressive of imagination and creativity.
But his reaction seemed a bit more than this. The shutting down response was so immediate and final that I believe he must have been reacting to some kind of threat.
Jules Evans, an experientially adventurous London philosopher, in his provocative book “The Art of Losing Control. A Philosopher’s Search for Ecstatic Experience”, colourfully describes this tendency towards apparently ‘safe’ limitation as akin to dwelling in ‘a rickety old shed in a haunted forest’. This is a powerful if somewhat homely and mystical metaphor. The haunted forest element suggests a mysterious and scary world beyond our usual perspectives, a place we would be reluctant to go. The rickety house suggests that the worlds we personally construct are limited, potentially inadequate for the job of living, and likely to collapse under pressure. There are limits to any metaphor. I know people whose world view is so rigid that a more appropriate metaphor might be ‘an unyielding fortress’.
For the moment I will stick with the rickety shed. Given our exposure to multiple contributory forces – genetic, developmental family influence, trauma, cultural beliefs, and much more - we tend to construct confined ways of seeing. They protect us from the bigness of the wider world. But under pressure such constructions can be very vulnerable, and collapse. We strive to keep them intact. Staying with the imagery, this means not stepping outside the shed to see what there might be in the forest, with its diverse pathways, possibilities and mysteries. Doing so could be unsettling at best and overwhelming at worst.
This tendency to hunker down inside safe but confined and restrictive frameworks is more than personal. We do it as couples, families, social and ethnic groups, organisations, cultures, and professions. We enclose ourselves in social webs of interdependent vested interests. And to keep it even safer we tend to resist and suppress elements that might demand deconstruction and rebuilding. Not uncommonly we step from one enclosure to another. It is hard to keep truly open and retain stability.
There are, of course, many other reasons why people will not or cannot look beyond their favoured or habitual perspectives.
A couple of examples will suffice.
Personality is important, and different personalities do it differently. Some people, for instance, are very ‘concrete’ and factual. Imagination is dedicated to structural modes of thought and action. Hard facts, so-called, are what they live by. Relational phenomena are a mystery to them. Feelings are shadowy, puzzling and hardly accessible realities that loose-minded and emotional people fuss about. My stories are indeed outside such a frame.
Turning to healthcare again, professionalism and power structures play a role in sustaining this particular rickety shed (or perhaps fortress). Modern medicine, and all clinical practice, is built on the importance of knowing, on being the expert who understands the right thing to do, and can be trusted to do so. As one lay friend of ours says, somewhat plaintively and despairingly, ‘but the doctor should know!’ Within the enclosure of biomedicine the doctor is ‘top-dog’.
But my stories disturb this structure which, generally-speaking, denies the role of subjectivity in disease. What happens to the clinician when the door is opened and the story is suddenly there in full view? The biomedical, story-excluding top-dog is suddenly disempowered. Not knowing what to do with the story (nor trained to do so), his or her world suddenly becomes incoherent. Better not to open the door, or if it springs open ignore it or suppress it.
But, to sustain this, defenses must be mounted. Stories are characterised as fuzzy and subjective ‘noise’, even though their meanings and rich nuances constitute the core of living experience. Medicine must be scientific and evidence-based! Ironically experience shows that, even if evidence is produced for the role of subjectivity in disease, practice does not change. For instance, there have been hundreds of articles published over the last five decades showing the influence of mind/brain factors on the immune system, but there is no hint of this literature influencing immunology practice or clinical practice generally, and it has not figured in the many immunology conferences I have attended.
Sigmund Freud had something useful to say here. Human beings are commonly afraid of facing themselves, and will generally avoid doing so. A clinician who genuinely opens herself to the story of the patient is tacitly opening herself to her own story, to a larger call upon her own self, her relational capacity and limitations, and to a whole new arena of healing. She steps into the forest with its uncharted potential pathways. Listening properly and responding to these stories requires not just expert knowing but an open explorer mentality, a whole person model of health and disease, maintenance of professional relating, imagination and capacity for intimacy, and most importantly qualities like warmth, generosity, empathy, resilience around uncertainty, and more.
Our current enclosures in healthcare are not sufficient for whole person healing. Just outside, there are rich resources, possibilities and mysteries, and being open to these can be rewarding and vitalising for the clinician, and very helpful for ill and suffering people.
Perhaps it is easier to do another laboratory investigation, write a prescription, prescribe exercises, recommend a diet, manipulate a shoulder, get on to the next patient, and then hurry home in time to see the kids.
Good for the kids. But, in a wider perspective, costly.
And sad too.
Brian Broom 28 June 2018 Copyright