Sunday, November 8, 2009

Talking the Walk (1)


Recently I came across a quotation that I’ve been turning over in my mind. It’s by the philosopher Ludwig Wittgenstein, who said: “You must always be puzzled by mental illness.” What did he mean? I wondered. I decided it was not a statement for confusion or against certainty, but rather for curiosity and respect for the mystery of others, and against a too-easy certainty. And I would broaden it; I would say: You must always be puzzled by other people. Not because puzzlement is a good in itself, but because if you aren’t puzzled, you aren’t paying attention, and if you aren’t paying attention...what can you discover that you don’t already know?

Every psychiatric history, no matter how long (and mine is over 35 years long now), begins with something very simple: an encounter. Typically, this encounter occurs between a doctor and a patient, maybe late at night, maybe in an emergency room. In one sense this is a unique situation, but it shares features with any other encounter between strangers: curiosity, fluctuating levels of trust and suspicion, needs (on both sides), hope...and fear, assumptions, and expectations. What it always contains is a large portion of the unknown. Whatever knowledge and experience both persons bring to the encounter–whatever inner stars they have learned to steer by–these can’t change the fundamental fact that the person facing you is unique, unlike anyone you have met before.

A passage early on in The Lily Pond describes such an encounter:

The emergency staff of North York General Hospital could not have had much more than questions on the morning of November 11, 1977, when a twenty-two-year-old white male, agreeably calm and strangely articulate, presented with a deep transverse incision in his belly and shorter slashes across his abdomen and above his left knee. The main wound was of the size and in the place that a later examiner would ask about the patient’s appendectomy, and the patient himself spoke wryly of his “self-Caesarean,” adding that he guessed it was “in the wrong direction.” He also produced a thick hardbound book with a pebbly red cover, which contained some two hundred pages of close-packed writing alternating with drawings and collages, the artwork garishly colored and badly smeared in places from the artist’s taste for thickly applied oil pastels. An interviewer, glancing from time to time up at the patient, riffled through the massed output, too quickly to take in more than an impression of frantic copiousness; the crucially telling point that the book had been new and empty a week before probably did not emerge. I sometimes wonder about those first examiners, whose faces I cannot remember. Where are they now? What are they doing? If still alive, the oldest would be long retired, in advanced old age; the very youngest, residents then, would be in the latter third of a career in medicine. It was twenty-eight years ago, longer than the life of Keats. But whoever they were, and whatever little they had to go on, one thing was certain: they had to do something. The stitching up must have been in some sense soothing to both patient and practitioner: here, at least, was an unquestioned good. An obvious need fitly addressed. Now what?

“Now what?” sets the stage for a new encounter.

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