1

Whenbodiesspeakandwordsact

- poetry,psychosomaticillnessandthelostartofmedicine

SandyGoldbeck-Wood

Amonograph,submittedtoUiT,NorgesArktiskeUniversitet,forconsiderationforthedegreeofDoctorPhilosophiae

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Contents PageForeword 3

Chapter1–Insearchoflostperspectives 9

Chapter2–Apoeticmethodforcapturingcomplexity 29

Chapter3–Whenwordsact 47

Chapter4–Poeticprocessandpurpose 89

Chapter5–Whenbodiesspeak 105

Chapter6–Epistemicjusticeandthelostartofmedicine 123

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Foreword

ThisPhDthesiscomprisesamonographbasedonthelivedexperienceofpractising

clinicalmedicine,writingpoetry,andeditingmedicaljournals.Italsodrawsonabody

ofpeerreviewedwriting,teaching,andpresentationIhaveundertakenovera20year

periodintheareasofbiopsychosocialmedicineandpsychoanalyticunderstandingsof

creativity.

Whilethisthesiscontainslargelynew,unpublishedwork,italsodrawsoneditorials,

commentaries,bookchapters,andpoetrywhichhavepreviouslybeenpublished.1-16

AnabridgedversionofChapter5hasrecentlybeenpublishedasacontributiontoa

new textbook of Psychosexual Medicine,17 and thanks are due to its editors for

significantpresentational improvement.Thecase reportscontained in this chapter

haveeitherbeenpublishedinthejournaloftheInstituteofPsychosexualMedicine18-

20 or presented at Institute of Psychosexual Medicine conferences. All have been

anonymisedinrespectofbothnamesandsignificantrecognisabledetailstoprotect

patientconfidentiality,butinsuchawayastoretainatruesenseoftheencounters.

Many of Chapter 5´s underlying ideas – those addressing psychosomatic illness´s

epistemological challenge to biomedicine - have appeared in different forms in

textbooksofpsychiatryandpsychosomaticobstetricsandgynaecology.2122

Chapter4buildsonanunpublishedmaster´sthesisonrawnessinvisualart,23inwhich

Ipresentedamongotherthingsaself-analyticaccountofmakingapainting,justas

here,Ipresentasimilaraccountofmakingapoem(Chapter3,Whenwordsact,pXX).

BothdrawinspirationfromthemethodadoptedbypsychoanalystMarionMilnerin

herself-reflectivebookondrawing,OnNotBeingAbleToPaint.24SomeofChapter3

and4´sideasrelatingtotherelationshipsbetweenpoetryandtherapyandpoetryand

sexhavebeenpresentedatmeetings,includingtheInternationalHippocratesForum,

andtheTheNordicNetworkforNarrativityandMedicine.Eightoftheninepoems

havebeenpublishedinpoetryjournalsorprizeanthologies.25-32

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Thisprojecthashada longgestation. Ithasbeencarriedoutalongsidea complex

working life across national, organisational, and epistemic boundaries. It was

interruptedin2012byamovefromtheUKtoNorway.Theprojectitselfwasmoved

fromthecreativewritingdepartmentattheUniversityofEastAngliatothemedical

department of theUniversity of Tromsø.Navigating different jurisdictions, homes,

universities, disciplines, employers, data systems, computer passwords, and

mechanismsforbooking leavehasposedchallenges,butalsokeptmeclosetothe

subjectmatter.

Ihaveneithersoughtnorreceivedfinancialfunding.However,manyindividualpeople

have supported this project generously with their time, space, hospitality, and

thought. IowemanydebtswhichIcanneverhopetorepaytofriendsandhelpers

whohave sharedmyexcitementat thematerial, urgedmeon, and supportedme

practically.Notallcanbenamedhere,butsomemusthavespecialthanks.

ForemostthanksforacademicmentoringgotobothGeorgeSzirtes,oneoftheUK´s

great poets, and former lecturer in poetry at the University of East Anglia, who

supervisedthisprojectinitsearlystagesasacreativewritingdoctorate,andtoTore

Sørlie,ProfessorofPsychiatryattheUniversityofTromsø,whofostereditthroughto

completionasaninterdiscplinarymedicalthesis.WithoutGeorge´spoeticbrilliance,

wit,warmthandtruthfulnessIdoubtthatmyaccountofpoetry,suchasitis,could

everhavetakenshape.EnliveningconversationsinWymondhamaboutthepointand

nitty-gritty of poetry, as well as the example of George´s own poems, have been

amongtheproject´sgreatpleasuresandinspirations.

Likewise,withoutTore´sgenerosity,academicbreadthofvisionandpsychoanalytic

patience, I cannot imaginehow thisprojectwouldeverhave come to completion.

Havingagreedtofosterthisfoundlingprojectprobono,Torehasofferedpreciselythe

unearnedhospitality,forbearance,containmentandreflectionwhichwereneededfor

it to come together. I am grateful for many enjoyable conversations at Aasgård

HospitalinTromsø,andonthephonefromCambridge,aboutallthatisworstandbest

inmedicine.

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Others have made key contributions to the thinking, rewriting, and editing. Nick

Inghamhasbeenpresent inconversationsaboutthisworkfromits inceptionto its

completion.Heisfamiliarwithboththework,thelifewhichhasgivenrisetoit,and

muchoftheearlierworkuponwhichitisbuilt.Hehasreadcountlessdraftswitha

good friend´s generosity, an experienced psychotherapist´s understanding of the

material,andaYorkshireman´sintoleranceforcant.

Many interdisciplinary researchers have inspired and informed this work, and are

acknowledged in references. However, I am especially grateful to Anna Luise

Kirkengen, who, as well as being an international groundbreaker in medical

epistemologicalreform,hasalsosupportedmepersonallyinpursuingthiswork,asa

colleagueandfriend.Thankyou,AnnaLuise,forarichconversationwhichbeganon

thestepsofNorway´sRoyalPalacein2011andhascontinuedtoencouragemeand

sharpenmythinkingeversince,inLondon,OsloCambridge,andTromsø.

VeryspecialthanksareduetoGaneshandespeciallyLarissaAcharyaforgenerously

offeringmeahome-from-homeduringsupervisionvisitstoTromsøduringtheautumn

andwinterof2017-18.Itwasagreatpleasuretosharefoodandwalks,pickberries,

shovelsnow,andpainteggs,andaprivilegetosharethecompanyoftheirfamilyand

friends.

Duringthissameperiod,DavidHorwell,retiredconsultantgynaecologistandformer

actingEditorinChiefoftheJournalofFamilyPlanningandReproductiveHealthcare,

kindly deputised for me as Editor in Chief of the Journal of Family Planning and

ReproductiveHealthCare,atthemostawkwardpossiblemoment,onthecuspofits

transitiontobecomingBMJSexualandReproductiveHealth.OnlyDavidcouldhave

handled this featwithout detriment to the journal, and I am grateful that hewas

generousenoughtoagreetothistallorder.ThanksalsotoJanieFoote,thejournal´s

managing editor for skillfully minimising the impact of my temporary absence on

authors,peerreviewers,andthejournal´seditorialboard,andtheFacultyofSexual

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and Reproductive Health Care and BMJ Publishing Group for approving this

arrangement.

TomyresearchbuddyHildeTørnquist,psychiatristandresearcher,Isayaheartytakk

forlaget–forsolidarity,insistence,theinspirationwhichyourownworkrepresents,

and many good conversations in Bodø and Cambridge, including the one at

Wittgenstein´sgrave.WarmthankstootoRoseCameron,friend,fellowtherapistand

researcher, and expert in capturing in words things which are hard to capture in

words, for conversation, encouragement, and role-modelling the completionof an

unusual PhD. Thanks to Kjellaug Hatlen Lunde, artist and educator, for thought

provokingconversationsatKunstkvarteret,Lofoten.

Asifbymagic,ThorEirikEiriksenappearedatthemomentofwritingup:aphilosopher

versedbothinthefieldofmedicallyunexplainedsymptomsandthedrillofcompleting

aPhDinTromsø,heofferedmetwolongafternoonsofinsightfulsupervisionatakey

moment.Thanks,ThorEirik,foryourkindnessandchallenge,especiallyforpushing

metointroducethisworkinlessdefensive,moreauthenticterms.

Manyothershavealsobeenextremelygenerous.SharonDavies,letterseditorofThe

BMJandBMJSRH,andfriend,haswithextraordinarykindnessandgoodcheeroffered

essentialpresentationalrevisionduringthefinalstagesaswellasthoughtfulfeedback

on the work´s content. Will Beharrell and Lindsay Fursland each made valuable

commentsondraftsofchapters,andMonaKiilsharedherhome,heroffice,andher

thoughtsduringthewritingupperiod.GunnarKirkesætheraccommodatedmeathis

homeinSørvågen,Lofoten,duringthefinalweeksofediting,toleratedmyendless

writing,andofferedanewreader´sfresh,honest,andthoughtfulfeedback.

Colleagues from the Department of Obstetrics and Gynaecology of Cambridge

UniversityHospitalshavebeenkindlysupportiveofaprojecttheyhadnodirectstake

in,aswellaswelcomingtheclinicalapproachitrepresentsintotheirclinicalthinking:

these includeMark Slack, Peter Baldwin, John Latimer, and Catherine Aiken. The

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patientsandpoetswhohavetaughtmetolistenbettertoembodiedknowledgeare

toocountlesstoname,butIamgratefultothemall.

WarmestthanksofallgotoTimianandCamillaGoldbeck-Wood,whohavebornewith

thisinterdisciplinaryandinternationalworkinglifeforover30years,withgenerosity,

solidarity,thoughtfulinsight,andgoodhumour.

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Chapter1:Insearchoflostperspectives

Poeticknowledgeisborninthegreatsilenceofscientificknowledge-AimeCésaire

Keywords: medically unexplained symptoms, multimorbidity, evidence based medicine,epistemologicalgap

1.1 Awareness,lostandfound

Thisisanexplorationofhowimportantthingscaneludeorescapeawareness,how

theirlosscausesuneaseordysfunction,andhowtheycanberecovered.Itdrawson

mypracticeasapsychoanalyticallytraineddoctorandpoet,andpointstoknowledge

andskillheldwithinbothpoetryandpsychoanalysiswhichisrelevanttohealthbut

haslargelygonemissingfrommainstreammedicaldiscourse.Itisabouthowmedicine

attimesriskslosing,butcanregain,itshumanity.

Lossorlackofunderstandingaffectsallindividuals,groups,andcommunitiesattimes.

Editingawarenessisnecessarytoallowactionandprogressindailylife.Specificthings

elude awareness in specific settings for specific reasons, often because at a given

momenttheyseemirrelevanttoorinconflictwithconsciousutilitarianpriorities,and

sometimes because acknowledging them is compromising or costly. Sometimes,

though,thematerialwhichismissingprovessoimportantthattheindividual,group,

orprojectbecomesfrozenorparalysedforthewantofthem–blockedfromprogress,

andunabletoachieveitsgoals,tothrive.33

Anexampleisfoundinthosephysicalillnesseswhichareintractabletothebiomedical

model.Bothmultimorbidity34andso-calledmedicallyunexplainedsymptoms,35pose

major challenges to health care in being highly prevalent, and expensive:36 37

Estimatessuggestthatmedicallyunexplainedsymptoms(MUS)mayaccountforupto

45% of all general practice consultations.38 The annual cost to the health service

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attributedtoMUSinadultsofworkingageinEnglandbe£2.89billionin2008/2009

(11%of totalNHS spend),while sicknessabsenceanddecreasedqualityof life for

peoplewithMUSwasestimatedtobecostingtheUKeconomyover£14billionper

annum.39 40 and notoriously poorly addressedwithin the empiricalmodelwhich is

medicine´sprimaryepistemologicaltool.Bothhavesteadfastlyresistedexplanation

andresolutionwithinamodelwhichtreatsbodyandmindasseparateobjectswholly

encompassablebyobjectivemeasurementandpopulation-basedgeneralisation.41

Theextenttowhichtheseacademicdeficitshavebeenacknowledgedwithinmedical

literatureandcultureislimited–perhapspreciselybecausethebiomedicalmodelis

insomeareassopowerfullyexplanatory.Themorepowerfulamodelis,themoreit

becomesestablishedinthinkingasthoughitwerefactortruth,themoreacommunity

comes to ”believe in” anddependupon it, inwayswhich aremore religious than

rational.4243 Likewise, thegreater thepowerandprestige conferredon its leading

proponents and institutions, thedeeper go their unconscious competing interests,

and the stronger the structural disincentives to considering alternatives. But

whenever strong, useful theories become dogmatised – that is, protected against

challenge by disconfirming data – they usurp and silence the ongoing process of

honest enquiry, and risk causing harm, as might a good surgical instrument used

wrongly.4445Conscientiousre-examinationofestablishedtheoriesandmodelsinthe

lightofsustainedlydisconfirmingdataisthereforeasmuchtheconditionofscience

andscholarshipasitisofpersonaldevelopment,anditistothiswemusthavethe

humilitytoreturnwhenevertheoryfailstodescribeexperience.

I will illustrate and discuss in two sections, spread across chapters 3, 4, and 5, a

creative,material-responsiveapproachtodealingwithdifferentkindsofdisturbingor

awkwardmaterial,orexperience. Iwill showhowapracticeofpayingclose,open

minded heed to inconveniently uncategorisable phenomena which seem to be

seekingattention,canleadtobetterunderstandingofourownontologicallimitations

or “boundary conditions”,46 and to opportunities for development. Rather than

clinging to familiar models come what may, and projecting “difficulty”,

“inexplicability”,or“fault”ontotheillness,patient,orsubjectmatter,wecaninstead

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taketheopportunitytoexpandourownexplanatorypotential–learntodealmore

effectively and humanely with complexity, heterogeneity, and individuality or

uniquenessineverydaypractice.

Inthefollowingchapters,Iwilluselivedexperiencefromfirstcreativeandthenclinical

practice to illustrate how meeting disruptions or challenges with open-minded,

intersubjectiveinvestigation–akindwemightforthesakeofargumentcallpoetic–

canresultinremedy.Iwillexemplifyhowanopen,undogmatic,andrigorousreturn

totherawdataofunderlyingphenomenacanpermitvaluablelostunderstandingto

berecovered,allowingconnectionstobemadewithinandbetweenindividualswhich

help restore natural development or self-regulation and promotewellbeing. I will

show, for example, how an individual distressed by a psychophysical or relational

block canuse a therapeutic conversation tomake senseof perplexing experience,

recovering liveliness and a sense of agency; and also how a poet can capture

stimulating, lonelyexperience inshareablewordswhich increasewellbeing inboth

poetandreader,inakindofpsychologicalwin-win.

The point of this will be to show how creative curiosity can – across different

disciplinarysettings-replacedenialoraversionasawayofmeetingchallengeand

complexity, and increase insight and resilience. Put another way, this is an

interdisciplinary exploration of the proper role of creativity and human

intersubjectivityinhealthandillness.

Theremainderofthisintroductionwilladdressinthreepartswhyandhowthisstudy

hasarisen.FirstIwillidentifyanepistemologicalgaporprobleminmedicinewhich

hastroubledme,becauseitseemstome,whenunacknowledged,toharmpatients

andcliniciansandtobreachthefirstHippocraticinjunction,primumnonnocere–first

do no harm. Secondly, I will by way of context point to some research traditions

alreadyworking to address this problem, alongwith some specificmethodologies

whichmyownmethodresemblesincertainways.Finally,bywayofintroductionto

myownmaterial,Iwillchartmyownepistemologicaljourneyinto,within,andbeyond

biomedicine.

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InChapter2,Apoeticmethodforcapturingcomplexity,Iwilloutlineinmoredetail

thematerial-responsivemethod throughwhich this thesis has arisen – onewhich

mirrorsthepoeticandpsychoanayticpracticeswhichformmysubjectmatter,echoes

otherqualitativeandcreativemethodologies,andanswerscallsformethodological

development.

InChapters3,4,and5,thebackboneofthisthesis,Iwilldiveintomycorecreative

and therapeutic material, examining first in some detail the poet-poem-reader

relationship (Chapters 3 and 4) and then the patient-illness-doctor relationship

(Chapter 5), characterising the mechanisms whereby stimulating or troublesome

experiencewhich has proved hard to encompass in thought and language can be

madeapproachableviatightlyframed,creative,subjective-and-objectiveexploration

in the presence of another person. Psychoanalytic accounts of both creativity and

therapyexplainhow theseprocesses actually happen, andhow they achieve their

effects.Bydemonstratingtheintrapsychic“workings”ofthesetwoprocessesinafine

grainedway,Ihopetoshowhowthetransformationfrom“difficult”rawmaterialto

satisfactoryfinishedproductisnotmagicalorsupernatural,norirrelevantoraliento

the practice of healthcare. Rather, its achievements can be conceived in terms of

ordinary human observational capacities and learnable skills, analogous to those

requiredforgoodscienceorscholarship.

Finally,Iwilldiscussdirectlyanawarenesswhichgrewduringthisstudy–namely,that

manyofthecharacteristicsandskillscalledforherearemoralratherthantechnical.I

will explore how these activities invite reconsideration of the ethical aspects of

medicalworkmoregenerally–howtheydemandandsharpenaparticularsubsetof

virtues relevant to healthcare which, though present in clinical practice, are not

routinely taught, assessed, or discussed in health discourse. These characteristics,

discussedinthefinalchapter,6,includehumility,open-mindedlistening,scrupulous

attentiontophenomena,thepatiencetotolerateuncertaintyorapparentdisorder

until genuineorderemerges, a capacity forplayfulness, andanunquantifiablebut

essentialmoraldrivingforcewhichwemightcalldevotionorlove-of-neighbour.

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Iwillconcludebysuggestingwhatthismeansformedicalepistemologyandpractice

inthepost-evidencebasedmedicineera.Atpresent,awarenessoftheessentialrole

ofrelationshipandcreativityinhealthcareislargelyunintegratedinthepolicywhich

guides practice – the academic “mind” of medicine. The tension of this missing

awarenessisbornedailybypractitionersandpatients.Bothgroupsmayfeelitsstrain,

dimly anduncomfortably, in the clinical encounter: ordinarypractitioners strive at

personalcosttoretain“ordinaryhumanity”under increasingtechnical,operational

pressure, while the humanitarian, non-technical aspects of their practice are not

formallyrecognisedinthemetricswhichdetermineefficacyandfunding.Letuslook

morecloselyatthenatureofthismissingawareness.

1.2 Medicine´sepistemologicalgap

Thereisagrowingconsensusthatinburgeoningasanaturalscience,medicinehasto

a significant extent lost itsway as a humanitariandiscipline.47-49 As the volumeof

effectivebiomedicaltreatmentswhichmustbedeliveredefficientlyandequitablyhas

proliferated,othersubtle, individualisedkindsofknowledgearising inthepatient´s

individualstoryandelicitedintherelationshipbetweenclinicianandpatient,become

drownedout.Ashealthcarecostshaveburgeoned,theauthorisedaccountsofhealth

andillnesshaveincreasinglybeensolelythosewhichfacilitaterationalallocationof

resources.50 Types of evidence considered admissible have become strictly

circumscribed.Treatmentswhichhavecometobeknownas“evidence-based”have

been those based on that subset of relevant evidence which is empirical,

generalisable,quantitative,andbiomedical, inotherwords,evidencewhichreadily

allows diagnostic and therapeutic lines to be drawn, benefits and harms to be

balancedat a population level, anddecisions tobemadeaboutwhich treatments

shouldbefundedforwhom.

Thishasinmanywaysbeenanecessaryandbeneficialphaseinmedicine´scultural

and ethical development. Lines have needed to be drawn and difficult rationing

choicesmade,and“evidence”basedmedicinehasrationalisedandreformedaculture

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wheretraditionandhierarchyhadpreviouslytakenprecedenceovertruth,andtheory

over experience. “Evidence” basedmedicine arrived, in that sense, as a force for

epistemologicalliberation,underpinnedbyitsownmoralimperativeofdemocratising

rationality–proposing theconscientious,explicit,and judicioususeof currentbest

evidenceinmakingdecisionsaboutthecareofindividualpatients.51

However, the pragmatic accounts of illness delivered by the new orthodoxy of

evidence based medicine are necessary, but themselves partial – prioritising

population-leveloperationalisabilityoverindividualisedunderstanding.Theydeliver

clinicalefficacyinjustandethicalwaysonlywheretheirunderlyingassumptionsabout

thecausesandsolutionstoillnessapply.Inmanycasesthesegeneralisedassumptions

donotapply,butcomplementaryaccountscapableofreflectingtheindividualityof

theclinicalencounterhavenotbeenintegratedinpolicyandpractice.Rather,these

remainasachorusofdissatisfactionatthemarginsofmodernhealthcare.47-49

Whathas resulted isanew formofepistemological imbalance–apreferencingof

knowledgebasedoneaseofmeasurabilityratherthanondiagnosticandtherapeutic

importance.Sowhilenumerousareasofhealth,biomedicine,andepidemiologyhave

delivered unquestioned benefits – the eradication of smallpox, cardiac stenting,52

antiretroviral therapy,53 and improvements inmaternal andneonatal survival -5455

progressinotherareasofpracticeandpolicyremainselectivelyblocked,becausethe

sortofknowledgerequiredtounderstandandtreatthemhasbeenrenderedinvisible,

inadmissible,orgivena lowstatuswithinorthodoxmodels. Those illnesseswhich

remain resistant to established diagnosis and treatment – or to put it more self-

critically,thoseweasanacademiccommunityhavenotyetlearnedtounderstand–

areapttobeneglectedordenied.

Butsuchelusiveinformationandunorthodoxillnessdonotgoaway,orceasetocause

suffering and consume resources. Rather, as subtle, subjective, individualised

accounts of illness are overwritten by orthodoxmodels, patientswith unorthodox

problems complain about not being listened to, heard, or taken seriously,56-60

clinicians complain about overregulation, lack of freedom, and disregard for their

15

ethical values, and “perform” their distress in the form of high rates of burnout,

alcoholism,divorce,anddrugaddiction.61-66Researchersmeanwhilerepeatedlypoint

to gaps in our guideline-based approach to many common and costly illnesses –

notably,thosewhicharecomplex,irrational,orbiopsychosocial.3346768

Part of the problem is that beneath this evidence gap yawns an epistemological

crevasse–agapatthelevelofwhatsortofthing,inhealthcare,isallowedtocount

asknowledge,andhowweacquireit.4869Biopsychosocialcomplexityisacknowledged

andaddressed inclinicalsettings,where itsimplycannotbewholly ignored,but in

partial, piecemeal, local, ways which lack integrated academic underpinning: As

biological reductionismhasgrown inbothsomaticmedicineandpsychiatry,earlier

attemptsatintegratedaccountsofillness,suchasthoseofferedbyacombinationof

psychoanalysisandbiomedicinehavedeclined.70

Inthefaceofthiswideninggapbetweenacademicreductionismandholisticclinical

need,single-organ-basedspecialities,increasinglytightlyboundtoapurelyempirical

approach and decreasingly equipped to handle illness in its human context, have

resortedtodevelopingnew,bolt-on,adhocsubspecialtiessuchasliaisonpsychiatry,

chronic pain management, and psychosexual medicine.71-73 For the want of an

academically integratedapproach,eachcountryandspecialtyhas invented itsown

local solutions, addressing a slightly different subset of biopsychosocial,medically

unexplained, or “functional” problems. These subspecialties tend to be staffed by

clinicianswithunusual,interdisciplinaryskillsonthemarginsofbiomedicalspecialties

whoremainunintegratedintheacademicdevelopmentofthosespecialties.Iamone

of these clinicians. Lacking a firm academic base, these perspectives have been

underrepresentedinmedicine´sacademicdevelopment.

Instead of pooling strongly overlapping interests and interdisciplinary skills, these

individualsandgroupshaveoftenbeenleftisolated,competingforscarceresources

and struggling even to name their practice in internationally recognisable and

interchangeable ways. Meanwhile, uninformed by the important, generalisable

insights gained from these scattered subspecialities, academic medicine has

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continuedtoevolveabewilderingseriesofoverlappingsyndromesand“diagnoses”

inoftenunconvincingattemptstocategorise,systematise,andtakecontrolofareas

itlackstheacademictoolstograsp.74(seetable1inreference)Atworst,aforestof

overlapping, inconsistent, and contested syndromes and acronyms – hypoactive

sexual arousal disorder, is an example,74 reflect the shortcomings of biomedical

epistemologyfarmoreclearlythantheyilluminatethecomplexhumanproblemsthey

seektodescribe.

1.3 Epistemological remedies: interdisciplinarity, biopsychosocial disciplines, and

medicalhumanities

None of the criticisms summarised above is inherently new. Indeed, concern for

missingelementsinmodernhealthcarehaslongexpresseditselfinthedevelopment

ofalternativeepistemologicalapproaches.Medicalacademicswithunderstandingof

for example psychoanalysis, the social sciences, and philosophy have formed

interdisciplinarynetworksinthefields,forexample,ofpsychosomaticmedicine75-77

and the medical humanities78 79 to build interdisciplinary bridges, develop new

methodologies,andfind“alternateepistemicpositions”sensitivetocomplexclinical

problems.80 In these fields, attention has been refocused on the body as locus of

experience rather than as object; the irreducibility of lived experience is explicitly

recognisedasadeterminantofhealth,74andmeaning,oritsloss,isrecognisedasa

coreelementinthehealthandillness.81Thebiographicaldeterminantsandeffectsof

illness are explored,47 andwehavebeen amply reminded thatmedicine is among

otherthingsanarrativediscipline.7982-84

Whilesomeclinicalspecialties,notablyprimarycare,takemoreinterestthanothers

inepistemologicalplurality, itsactual integrationinmainstreampolicyandpractice

has overall been limited.85-89 Hermeneutic (meaning based, interpretational)

approaches have remained largely semi-detached, pursued as individual initiatives

championedbyindividualswithspecialinterests,remotefromtheordinaryconsulting

roomandtheordinaryclinicalviewpoint.

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Hence,numerousandpromisingindividualinitiatives,suchaspoetryordanceaspart

of dementia treatment,90 91 or singing in the treatment of chest conditions,92 are

pursuedandevenstudied,butnot integratedasmainstream. Indeed,viewedfrom

theperspectiveoftheaverageclinicianwithalongcliniclisttogetthrough,medical

humanitiescanappearanexotic“ghetto”–aspecialareainwhichmattersregarded

bythemainstreamasesotericarepursuedinwayswhicharenottroubledbyanddo

not trouble day to day clinical endeavour. Clinicians largely lack access to a basic

academicunderstandingof hermeneuticmethods,while large swathesof relevant

hermeneutic evidence relating to disease and treatment remain uncollected and

overlooked.

1.4 Anoverviewofsomespecificmethodologies

Beforeoutliningthepersonalepistemologicaljourneywhichyieldedmyownmixed-

methoddata, Iwillnamespecifically someother formsof interdisciplinaryenquiry

especiallysuitedcapturingelusivesubjectmatter-formstowhichmyownworkat

timescomesclose.

Inreflectingonmyownmethodofmovingback-and-forthbetweenartandscience,

andseekingtodiscoverconnectionsbetweenthepersonalandthesocial,cultural,

andpolitical,Ifindsimilaritieswithothercreative-analyticpracticeswithinscienceand

thearts.These includebricolage,artistic curation,narrative research,hermeneutic

phenomenology,andautoethnography.Infocusingspecificallyonexperiencewhich

cannot be separated into mental and physical, dealing with both conscious and

unconsciousprocesses,andwithembodiment,Iamalsoinformedbytheself-analytic

methodswhichpsychoanalysisandartshare.232493

Bricolage,amethodfamiliartobothculturalanthropologyandpsychology,describes

akindofanalytic,reflexiveback-and-forthing,likethepassageofneedleandthread.94

It is recognized as a method whereby societies95 or individuals46 retrieve and

recombine existing knowledge in new ways.94 Analagous practices exist across

creative and academic disciplines from mosaicing, collage, assemblage, and

18

patchwork,totheacademicjournal"specialissue,"inwhichdissonantandconsonant

voicesareassembledonatheme.96

Originalityinsuchworkarisesinrecombination,reconception,andre-presentation,

rather than in the generation of new rawmaterial, much of which pre-exists the

finishedworkinpiecemeal,fragmentedform.Theprocessisoneofre-framingandre-

conceivingandbringingthingsintoappositionwithoneanother,toaffordaglimpse

of the formerly-invisible. It is original in hermeneuticways, because it brings new

perspectiveandinsight,notbecauseitproducesnewdata.

Curation is an area of interdisciplinary practice which has attracted increasing

attentionintheartworld–regardedbothasakindof“meta-art”inwhichindividual

worksacquirenewmeaningintheproximityofothers,generatingnewentities,but

alsoaformofsocialscientificinvestigation.97Curatorswritingabouttheprocessspeak

ofanopenstanceandtheneedtobeginwiththeartworkitself;oftheinclusionof

relevant work from less known artists, and of a critical distance from established

convention.97 They speak of non-didactic investigation, which is at the same time

playful and serious,which can capture elusive elements, andwhich addresses the

observeremotionally,physicallyandmentallyatthesametime–investigationwhich

canincreasetheheartrateandbrainactivity.97Itoffersneithermerelythoughtnor

merely sensation, but both together, intimately enmeshed in the same work -

rephrased,wemightsayitaimsatembodiedorpsychosomaticcommunication.

Narrativeresearchistheanalysisofwrittenororalaccounts,andmedicine´sidentity

as an inherently narrative practice69 82 has been richly discussed in both

psychoanalysis98andthemedicalhumanities.8299100Whilethephysician´staskisto

understand both patient and disease,101 102 the criticism goes, clinicalmethod has

focusedselectivelyonwhathas(somewhatblithely)beentermedtherelativelysimple

matter of the diagnosis of disease,101 rather than on understanding patients.

Qualitative research - described as a systematic approach to the organisation and

interpretationof text,101 oneof the areas inwhich this imbalance canbepartially

rectified,remainsunderrepresentedinthemedicalliterature.

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TheclinicaldataIpresent inChapter5- contemporaneouslyrecordedaccountsof

encounterswithmypatients - arenarrative innature,workingpsychoanalytically,

withwhatHolmescalled recognitionof theunconsciouselementsofahalfwritten

personal story103 what Frost called the incoherence in events and breaches in the

individual’s senseof identity,104andwhatAaslestadcharacterisesas thepatientas

text.105

Likewise,datapresented in the formofpoetry inChapter3,and thediscussionof

epistemologicalmoralityinChapter6,bothcritiquetheinherentcapacityofexpertise

to suppress rather than reveal experience, and challenge medicine´s failure to

recogniseitsowninterpretivecharacterortherulesitusestonegotiatemeaning.69In

Chapter5, Ishowhowpsychosomatic illness, likepoetry,canusefullybereadasa

performative “text” which, far from being meaningless or simply “unexplained”

becomesmeaningful in thepresenceof receptive, resonant, constructive listening.

TheconclusionIdrawisthattheinexplicabilityisinfactafunctionoftheinadequacy

oftheexplanatorymodel,andnotofthe“senselessness”ofhumanexperience.

Hermeneutic phenomenology is a research method involving close, immersive,

participatoryobservation–amethodofpayingcloseattentiontophenomenaasthey

present themselves to consciousness, sometimes described as being with.106 107 It

acknowledges the importance of multiple perspectives, and underlines

intersubjectivityastheclosestpossibleproxyforobjectivityinsomeareasofstudy.

Derived from the pure philosophy of Husserl and Heidegger, it was developed by

Gadamer, Ricoeur, andMerleau-Ponty106 108-111 as a philosophical approach which

acknowledgedthefundamental interconnectionofbodyandmind,asdistinctfrom

otherphilosophicaltraditionsinwhichtheseareregardedasseparate.Itamountsto

aphilosophicalrecognitionthatweare,irreducibly,embodiedsubjects–aperspective

which is also consistent with psychoanalysis, which takes explicit account of the

intersubjective,relationaloriginsofhumandevelopment.112

20

A resonant term which phenomenology adopted and extended from biology to

describeembodiedpsychologicalandculturalphenomenaisthatofthelifeworld-the

universeofsharedexperienceandassumptionswithinwhichanorganismorperson

lives.Thelifeworlddenoteswhatforanyindividualorgroupisconsideredself-evident

or given. Indeed, forHusserl,who rejected the concept of objective research, the

lifeworldformsthebasisofallepistemologicalenquiry.113

LifeworldisatermwhichseemshelpfulinexplainingwhatIamattemptingtodohere,

andwhyitmightbeoriginal:itislivedinterdisciplinarityofaparticularkindwhichhas

givenrisetomyobservations–andinHusserl´sterms,Imightarguethatmyparticular

perspective arises precisely from the repeated crossing of lifeworlds – a kind of

epistemological bricolage, or journeying back-and-forth between assumptions and

“givens,”therebycontinuallyregainingboththeinsiderandtheoutsiderperspective

oneachsituation.Costlyintermsoftimespenttravelling,andreadjusting,andlossof

prestigewithinonesinglegrouporfield,suchapracticebringsrewardsintermsof

overview.

Phenomenologyholdsthatpersonsshouldbeexploredbecauseoftheuniqueways

they reflect the society they live in, and rather than traditional data, conscious

experienceisgathered,withafocusondiscoveryandanopennesstoapluralityof

methods.Myaccountcouldbereadasanexplorationofmyownlifeworldsasthey

intersectwiththoseofmypatients–anaccountofwhatitislikebeingadoctorand

poet–inthehopethatifthesedataarefaithfullyenoughreportedtheymaycontain

insightintothecontextsIlivein.

Heidegger modified Husserl´s traditional scientific approach to phenomenology

further,shiftingtheemphasisfromknowingtounderstanding,andtorelationshipas

thegroundofunderstanding.Gadamerdevelopsstillfurthertheideaofhermeneutics

as an intersubjective, dialogicKunst der Verständigung or art of understanding –

exactly thekindofprocesswhichcharacterises theoverlappingdialoguesbetween

medicine,poetryandpsychoanalysiscontainedwithinthisstudy.114

21

Autoethnography is amethod of research based on self-observation and reflexive

investigationaspartofethnographic fieldworkandwriting.115-117Ellisdefines itas

research,writing,story,andmethodthatconnecttheautobiographicalandpersonal

tothecultural,social,andpolitical.118Unliketheorydriven,positivistresearch,this

kindofresearchmightbedescribedasexperienceinsearchoflanguage,ordatain

search of theory, not vice versa. Rather than attempting to limit the researcher´s

subjectivity,itembracesandforegroundsit.Elliswritesthatautoethnographyispart

autoorselfandpartethnoorcultureandatthesametime,somethingdifferentfrom

bothofthem,greaterthanitsparts.117

An autoethnography is a reflexive account of one's own experiences situated in

culture. Inotherwords, aswell asa criticaldescriptionofpersonalexperience, an

autoethnography is also a cultural practice. For example, Holman Jones,119 in

(M)othering loss: Telling adoption stories, Telling Performativity, describes her

experienceswithinfertilityandadoptioninrelationtoculturalattitudesaboutthese

issues.Inseekingtounderstandherownstory,shealsoquestionsculturaldiscourse.

Reflectiononherownexperienceactsasamirror,orsourceofpotentialinformation.

In psychoanalytic terms, this might be presented as an individual researcher´s

countertransferencetoculturalelements–countertransferencewhich,whilenota

cleanmirror,iscapableofreflectinginformation.MarionMilnerusesasimilarmethod

inOnNotBeingAbleToPaint(citedinchapters4and6),andIusedthesamemethod

inaPsychoanalyticmaster´sthesisonRawnessinVisualArt.

Icitetheabovemethodsnotto layclaimtoanyofthem,buttoacknowledgethat

whatIhavedonehere,whileitismethodologicallyoriginaltosomedegree,isnotout

onalimborcompletelynovel.Rather, itexistswithinafieldofmethodswhichare

themselves variously narrative, constructive, phenomenological, hermeneutic,

relationalanddialogic–characteristicswhicharenotmutuallyexclusive,butoverlap.

Autoethnographydoesnot, forexample,excludenarrativestudy:accordingtoEllis

andBochner,120anauthoethnographer is firstandforemostacommunicatoranda

storyteller,depictingpeopleintheprocessoffiguringoutwhattodo,howtoliveand

22

themeaningoftheirstruggles.Nowforanaccountofthestruggleswithinwhichthis

storydeveloped:

1.5 Anepistemologicaljourney

Beforetrainingasadoctor,aspartofabachelor´sdegreeinNorwegianandGerman

literature, I studied linguistics and critical theory, learning to let go of notions of

objectivityandacknowledgetheinevitabilityofanyresearcher´sstandpoint,critical

perspective,orsituated-ness.Amedicaldegreethentrainedmetothinkempirically

and quantitatively, and, given the sheer volume of learning needed to become

clinically competent, invited a temporary and expedient return to pragmatic,

provisional certainties about the distinction between subject and object and the

primacy of the empirical viewpoint. Untroubled, for now, by notions of

intersubjectivity,Ilearnedtostudythehumanbodyandpsycheasanobject,andto

don,alongwithmywhitecoatandthesocialprivilegesofbeingadoctor,theposture

of so-called objective observer – clean, pristine, and interchangeable with other

objectiveobservers.

Alongwithawealthofusefulbiomedicalknowledgecameasetoflargelyunconscious,

unacknowledged,andunexaminedbeliefsregardingthevalueofobjectivetruthover

subjective perspectives and accounts – beliefs which proved less useful in clinical

practice.Althoughwiseteachersexhortedmetolistencarefullytopatients´accounts,

not all colleagues modelled this effectively, and the subjective account was still

treatedprimarilyas rawmaterial inaprofessionally-leddiagnosticandtherapeutic

process–anobjectofmedicalscrutiny,ratherthanpartoftheevaluativeframework

itself.Whetherintheconsultingroom,thelectureroom,orthemedicaljournal,the

biomedicalaccountof illnesswasaccordedautomatic,un-negotiatedprimacyover

alternativeaccounts.InacovertactofwhatIwilllaterargueisepistemicinjustice,121

biomedicine,psychologicalmedicine,andevidence-basedmedicinetrumpedallother

perspectives,claimingtheprivilegedrighttodeterminewhichfactswererelevant,and

whattheymeant.

23

Thirteen years of clinical practice in hospitals and community settings, mostly in

obstetrics and gynaecology and sexual health, challenged this medical school-

mediatedviewthoroughly.Thebiomedicalperspectivebecamerichlysupplemented

withahalf-formed,uncomfortableawarenessofotherstoriesandmeaningsrunning

parallel,orcounter,tothe"official"gynaecologicalnarrative.Sexualandreproductive

healthwasanareaparticularlyresistanttoscientificreductionism:onadailybasis,

subjectiveaccountsof,say,miscarriage,contraceptivefailure,orsexualdysfunction

jarredwithgynaecologicalaccounts,andthreatenedtodisrupttheirreductiveclarity.

Theseunauthorisedaccounts,evenwheretheyhadobviousfacevalidity,wereoften

difficult to shoe-horn into the succinct, objective case notes and truncated oral

summarieswehadlearnedaspartofmakingthetransitionfrommedicalstudentto

doctor–summariesinwhichallbutthemostobviouslypathophysiologicallypertinent

personalinformationwastoberigorouslyeditedout.Welearnedtonoticeandreport

onlywhatourseniors feltable to treat.Weexchangedournativeappreciation for

patientnarrativesforthelearnedexpertiseinconstructingamedicalhistory.82122

Hence,thefactthattheabdominalpainbegansoonafterfirstsexwithanewpartner

(andmay therefore signal infection, a biomedical concern) wasmandatory in the

medicalreport,butthefact itbeganafterachild lefthome(whichhasnoobvious

biological meaning but may nevertheless signify relevant psychosocial distress) is

traditionally inadmissible, in a context where psychosocial distress is considered

beyondmedicalresponsibilityandtherapeuticcompetence."Alternative"narratives,

ever-present in the doctor-patient encounter, were simply neutralised by being

"zipped"intospecial,reductivewordswhichdidnotsomuchilluminatetheircontent

ormeaningaswrapthemupanddefinethemasbeingbiomedicallyirrelevant.

Thus we continued to learn a new language and way of thinking – patients not

followingouradvicewerenon-compliant, symptomswhichwedidnotunderstand

weremedicallyunexplained,patientswhofailedtobereassuredbyourexplanations

wereanxious,anapparentlyneutralwordcommonlyusednotsomuchasthestarting

24

point foranexplorationas towhat theymightbeanxiousabout,butasa label to

relieve the doctor of the need to engage more deeply with their troublesome

thoughts. It was remarkable how, though commonplace in the gynaecological

encounter, feelings and subjective views were treated as a contaminant to the

therapeuticsetting.

Italmostseemedasthough,lackingtoolsforthinkingproperlyaboutthesubjective

dimensionofthepatientencounter,wewereasaspiringmedicsbeingtrainedtolose

interest in these areas, to scotomatise them – consign them to a kind of

epistemological scotoma or blind spot, or the sort of selective inattention which

followsischaemicstroke.Hencethepsychosocialdeterminantsandconsequencesof

gynaecological illness, though frequently as present and attention seeking as an

elephant ina room,wereapt tobeeithermissing fromprofessionaldiscussion,or

presentonlyincrude,uninformative,vestigialterms.

Patientviewswereofficiallywelcomewhenitcametotreatmentchoices,buttheir

alternativeunderstandingsoftheirownillnesswereneithersolicitednorespecially

welcome. Interpretation was our prerogative, not theirs. Hence the woman still

refusingeffectivecontraceptionafterasecondabortionowingtoanaversiontothe

idea of hormones or foreign bodies, the healthy primigravidwoman demanding a

caesareansectionowingtoterrorofchildbirthwastobenotsomuchunderstoodas

"educated,"whichintheworstcasesamountedtoakindofskilful,rhetoricalcoercion.

Theiraccountsweretobenotsomuchexploredaspolitelybutfirmlyoverwritten.

Althoughpatientconsentwasmandatoryforallso-called“invasiveprocedures”and

intimateexaminations,itwasnotrequiredfortheinterpretiveprocess.

This doctor-centred approach served certain purposes better than others. It

sometimesspeededupconsultationintheshortterm–aninevitableandlegitimate

priorityunderpressure.Givenfiniteresourcesoftimeandenergy,gettingthepatient

outoftheroomwithareasonableplanwassometimesallthedoctorseemedtohave

mentalspaceortimefor,andoftenthiswas“goodenough.”Butdependingonhow

muchtheexcludedmaterialmattereddiagnostically,therapeutically,or intermsof

25

treatment adherence, it sometimes proved retrospectively not to havebeen good

enough after all. Shortcutting away from complex material seemed to be a busy

clinician´sdefenceagainsthavingtodealwithwhatwasoftenreferredtoasacanof

worms, – something conceptuallymessy for which she felt unskilled. But it often

seemeda relatively ineffectivewayof achieving thekindof concordancebetween

doctor and patient which supports treatment adherence and response, or clinical

improvement.123

ItookabreakingynaecologytrainingbecausetheUKRoyalCollegeofObstetricians

and Gynaecologists at that time required all trainees to gain a year´s experience

outsidethespecialty.ApostastraineemedicaleditorattheBritishMedicalJournal

(nowTheBMJ)offeredachancetoacquirebothfurthernarrativeskillsanddeeper

critical appraisal skills in predominantly empirical, predominantly quantitative

methods.Evaluatingarticlesacrossmedicalspecialties,Ihelpedthejournalreviewthe

around130newmanuscripts it receivedeachweek todecidewhich six shouldbe

published,andhowthesecouldbeimproved.Thisentailedcriticallyappraisingwhat

hadbeendoneand said, inways strongly influencedby theprinciplesofevidence

basedmedicine.Italsoentailedlookingcarefullyforwhathadnotbeendoneandsaid

thatmaybeoughttohavebeen,andinhelpingauthorstoreworktheirmaterialinto

aplausible,coherent,andgraspableshapewhichrespectsboththematerialandthe

reader.

In parallel with this work, clinical and academic training in psychotherapy and

psychoanalyticstudiesexposedmetoanewnarrativemethod–onewhichisbotha

“scienceofself-analysis”andatoolforexaminingculturalphenomena.Intheclinical

setting,psychoanalysisrestoredpermissiontothinkopen-endedlyandsymbolically,

totolerateandmaketherapeuticuseofwhatisnotyetknown,toattendtoemotions

andactionsintheconsultingroom,includingthoseofthedoctor,andtobeopento

thesignificant roleunconscious factorscanplay indiagnosisandtreatment. In the

creativesetting,amaster´sthesisonrawnessinvisualartbecameafirstencounter

withpowerfultheoryaboutthenutsandboltsofcreativework,anditsrelationship

withillnessandhealth.

26

I became determined to find ways to integrate this psychoanalytic learning with

clinicalmedicalpractice,andafouryearpsychodynamictrainingwiththeInstituteof

PsychosexualMedicine,followedbyfurthertrainingtobecomeatrainer,offeredjust

suchanopportunity.Designedasbriefpsychodynamicworkforusebyexperienced

physiciansseeingpatientswithsexualproblems,themethodintegratesmedicalwith

psychotherapeuticandempiricalwithhermeneuticmethodsinthesameconsultation.17124AndifIinitiallyfearedthatsexualproblemsmightbeanarrowfield,Iincreasingly

realisedhowfirmlythisclinicalareadisciplinesintegrated,biopsychosocialthinking:

sexis,parexcellence,abiopsychosocialexperience.

Finally,artandliteraturehaveremainedasnecessaryapartofwellbeingasphysical

exercise.Nourishedbytheinspirationofothers´work,Ihavemadeandexhibitedart

and written and published poems.25-32 125 In the parallel tasks of psychosomatic

consultationandwritingpoetry,Ihavebeenstruckagainandagainbythefeltsense

thatthesetwoactivitiesaresomehowoneandthesame–drawingonthesameparts

ofmyself,thesameskillsorstances–thatIam,asitwere,thesameperson,making

thesamemoves.

Thesamequestionsandthemeshavepresentedthemselvesindialoguewithpatients

asincreative,editorial,academic,andself-reflectivework.Thesethemesincludethe

relationship between dominant and suppressed narratives, the way the meaning

embeddedor “frozen”within phenomena canbeunlocked given the right kindof

enquiry,andtheconditionsneededforthistooccur.Suchconditionsincludetheneed

toplaceoneselfhumblyatthedispositionofamaterial,notshirkingcomplexityand

particularity,orrelevantknowledge,andacommitmenttoaconstantsearchforthe

rightlanguage.

Insummary,thisisanaccountofaprofessionallifelivedinanacademicborderland.

Ithasdrawnontheoryandpracticeinapparentlyunconnectedareasnotsimplyonce,

in a unidirectional journey towards a unitary final destination, like collecting

qualifications, but traversing the same professional and academic boundaries, in

27

different roles, locations, and languages, over many years, until the repeated,

comparativeexperienceshavebeguntoweavethemselvesintoafabricofnewinsight.

Intheprocess,Ihavecometoviewtheseparationbetweentheseformsofknowledge

asartificialandunhelpfultopractice.

This receptive, containing, and digestive work – in my case, the resolution of

apparentlyconflictual“selves,”doctorandartist,eachrefusingtobesubsumedbythe

other– issomething Ihavecometoexperienceaspsychicgrowth. Ihopethatthe

attempttoarticulatethisprocess–aprojectcarriedoutinpartformyownsake-may

have relevance to a wider academic community. It has certainly broughtme into

contactwithmany others – likeminded interdisciplinarians –who alsowrestle to

balance objective and subjective perspectives, empirical and phenomenological

approaches,theartsandthesciences,andtoembodywhatGadamerreferredtoas

the tense relationshipbetweenmodern scienceand the concretewealthof human

experience.83

Keymessages

• Modernmedicinesuffersfromanepistemologicalgapbecauseofanoverrelianceonpurelyempiricalmethods

• Medicallyunexplainedillness,psychosomaticillness,andmultimorbiditychallengemedicineinwayswhicharenotadequatelymetbypurelybiomedicalandempiricalapproaches.

• Evidencebasedmedicinemayinsomecasesbeinsufficientorevenharmfulifapplieddogmaticallyandunbalancedbymeaningbasedapproachesandindividualdata

• Newinsightrequiresbothdeepunderstandingof,anddistancefrom,orthodoxmodesofthinking

• Inthepostevidencebasedmedicineera,academicmedicineneedstorenewitsconnectionwithhermeneuticformsofknowledge.

28

29

Chapter2:ApoeticmethodforcapturingcomplexityJegharlevdetroteteliv-ihvertfalleitomskifteligliv.Språketharværtsomeithus-someinheim.Ihavelivedacomplicatedlife–atanyrate,avariedlife.Languagehasbeenlikeahouse–likeahome. -JonFosse

Keywords:embodiedexperience,livedinterdisciplinarity,epistemophilia,poeticmethod,borderlandresearch

2.1Nosetothewindandtravellinglight:gatheringexperienceacrossborders

JohannTuriofKautokeinolivedavariouslifeasareindeerherder,wolfhunter,and

trapperacrosstheboundariesofSwedenandFinland.Inthisfirsteverwrittenaccount

ofSamilife,Muitalussámiidbirra,126hebeganthus:

IamaSamiwhohasdoneallsortsofSamiworkandIknowallaboutSamiconditions.

IhavecometounderstandthattheSwedishgovernmentwantstohelpusasmuchas

itcan,buttheydon´tgetthingsrightbecausenoSamicanexplaintothemexactlyhow

thingsare.Andthisisthereason:whenaSamibecomesclosedupinaroom,thenhe

doesnotunderstandmuchofanything,becausehecannotputhisnosetothewind...

ButwhenaSamiisonthehighmountains,thenhehasquiteaclearmind.Andifthere

wereameetingplaceonsomehighmountain,thenaSamicouldmakehisownaffairs

quiteplain.

Thismodest beginning is a powerfulmethodologicalmanifesto.Without criticising

mainstream ways of living and thinking, Turi pins down both the minority (Sami)

problemoflanguagingembodiedexperience127andthe(Swedish)limittoknowledge

notbornof livedexperience.128TheSwedishgovernment,despitegood intentions,

getsthingswrong.TheSamifailstorepresenthisexperienceadequately,forthewant

oftherightconditions.Therearecertainthoughtspropertonomadic,transnational

experience, Turi implies, which can only be thought by a nomadic, transnational

person,andonlyincertainplaces.Thetaskofcommunicatingtheseeffectivelytoa

30

non-Sami interlocutor (howeverwell intentioned) is a feat of translation; and the

commitmenttothateffortisamarkofthatSami´sinvestmentintherelationshipwith

thatSwede.

We can read Turi´s introduction more broadly as a statement about the

psychosomaticconditionsaparticularpersonneedstofirstgatherandthendescribe

herorhisownexperience–namely,sufficientsensoryproximitytothatlifeworld–a

place automatically distant from other people´s – but also the ability to act as

participant-observer, outsider-insider, in one’s own lifeworld.108 There is of course

oftenapoliticalcontextwhichconstrainssuchattemptsatcommunication–inthis

case, Sami oppression by Scandinavian settlers.129 However, social and political

injusticesinthemselvesarenotmyprimaryconcernhere.Rather,myfocusisonthe

epistemological impoverishmentwhichresultsforthemainstream,and inthiscase

the mainstream academic discipline of medicine, whenever it loses the data and

perspectivesofnon-mainstreamindividualsorgroups.

IfwesetasidethepoliticalhistoryofSami-Scandinavianrelations,Turi´sdilemmais

morebroadlyaparticularlypoignantexampleoftheuniversalhumanproblemofwhat

bodypsychotherapistscallembodied-relating130–theproblemofrelatingacrossthe

boundaryofone´sownskin,orlivedexperienceandsomeoneelse´s.Turihasbeen

likenedtoanethnographer,131andwemightcallhisaccountanautoethnography–

anaccountconnectingautobiographicalreflectionwithwiderculturalanalysis.118

StumblingacrossTuri´saccountwhilestrugglingwithmyownaccountofalifelived

acrossdisciplinaryboundaries,Ireadhisnoseinthewind,hismeetingplaceonahigh

mountain,asbothgeographicallyliteralandametaphorcapableofcapturingmyown,

material-driven, improvisatory methods. In terms which are both simple and

condensed,bothspecificandopentowiderresonance–inpoeticterms,onemight

argue–Turihadmetaphorisedformetheproblemoflivedinterdisciplinarity,andwas

offeringmeawayintomakingmyownaffairsplain.

31

2.2Materials:anintertextualconversationwithasingleauthor

WhatIpresentinthefollowingchaptersisasynthesisoforiginaltextswrittenfrom

thedifferentpositionsofpoet,clinician,andself-analyticobserverinbothroles.They

and the themes they introduce are discussed “polyphonically,” drawing together

elements from different discourses of biomedicine, psychoanalysis, art, literary

criticism andmoral philosophy into a synthesis. The texts share common themes

relatingtohealthandthecreativeprocessingofexperience.Theyaddressthepressing

question of irreducible humanity in medicine, and the relationship of this with

medicine´scorescientificandhumanitarianaimsofinvestigatingandtreatingillness.

First (Chapter3), Iofferexamplesandanalysisofpoetryasaproductandprocess

whichcanchallenge,andnourish. Ipresent itspotentialasacritical tool,andasa

vehicle for communicatingabouthumanexperiencewhichhas thepotential tobe

psychologicallyusefulforpoetandreader.Iuseasubsetofeightpublishedpoemsof

my own which critique the insufficiency of biomedical language as a vehicle for

describinghumanillness.Theythemselvesformakindofcritiqueofmedicineinpoetic

form–butIalsousethemasexamplesofwhat,morewidely,poetrycandoandhow

itcanwork:eachpoemisfollowedbyanaccountofwhyandhowitemergedfrom

the poet´s identity and practice as a doctor, or in one case, as a patient. Each is

discussedinaspiritoftraditional“practicalcriticism”–thatis,astowhatitmightdo

forareader,andhow,intechnicalterms.

Attheendofchapter3,Iturntotheprocessofwritingpoetry,offeringasecondpiece

ofrawdata-acontemporaneous,self-analyticaccountoftheprocessofwriting,in

thetraditionofMarionMilner,andothers.ThisisamethodIhavepreviouslyusedin

relationtomakingapieceofvisualart,inamaster´sthesisonrawnessinvisualart.In

presentingthis,Iaddtoillustrationsofhowapoemmightworkpsychologically,and

whatmightpromptit,anexplorationofhowitmightcomeintobeing.Allinall,this

chapter discusses not only a poem´s conception or aetiology, and its final

characteristicsandeffects,butalsoitsembryogenesis.

32

Theseexamplesarefollowed(Chapter4)byanintegrating,psychologicalaccountof

thepointofpoetry–thatis,ofitscommunicative-restorativevalueforpoet,reader,

andcultureatlarge.GroundedinperspectivesfromtheBritishobjectrelationsschool

of psychoanalytic theory – with a particular debt to Bion,Winnicott, Milner, and

Ehrenzweig – this accountbuildson thepsychoanalyticmaster´s thesis Iwroteon

visualartin2004.Here,Idevelopandexploreforpoetry,asIpreviouslydidforvisual

art23howartarisesinresponsetoneedorrawness,howitscreationdemandsaskilled

andsensitivebalanceofconsciousandunconsciousachievementsiftheproduct–in

thiscaseapoem–istoworkforarecipient,andhowthisisaninherentlytherapeutic

activity.

Chapter 5 introduces a different and analogical form of rawness and therapeutic

redress–namely,medicallyunexplainedbodilydistress,orpsychosomaticillness,and

itspsychodynamictreatment.Themodelusedisthatestablishedinthe1970sinthe

psychoanalytictraditionoftheUKInstituteofPsychosexualMedicine(IPM),inwhich

Iamapractitionerandtrainer.Threetraditionalpsychosexualcasereports(Chapter

5),explorepsychosomaticsymptomspresentedtoadoctorasaformofincomplete

communicationaboutdistressingexperience–physicalexpressionsofhiddenstory,

perplexingbothpatientandclinician,andinneedofbeing“heard.”Iwillshowhow

theIPMmethodapproachesthese“symptoms”orphenomenawithcreativecuriosity,

asakindofunexpressedcommunication–likeanartisticrawmaterial-ratherthan

as a pathology or “thing,” to be removed. I will demonstrate and discuss how,

paradoxically, this focus on understanding rather than fixing symptoms becomes

therapeutic, and how this kind of approach can be effective where biomedical

approacheshavenotbeen.IndoingsoIhopetoillustratewhysuchunderstanding-

focussedattitudesandskillsbelongattheheartofmedicalpractice.

Thefinalchapter,6,givesspacetosomeepistemologicalandethicalreflectionswhich

emerge from the previous discussion. Here, somemoral claims about the kind of

stancewhichbothmedicalandartisticworkdemandsofthepractitioner,claimwhich

havebeenpressing inon theargumentsofChapters 1-5, arebrought to the fore.

33

“Poet-like skills and characteristics” are set alongside “therapist-like skills and

characteristics,”aselementswhichdonotmerelyenhancethepracticeofmedicine,

assomekindofoptionalextra,butareattimesneededtodeliveranykindofclinical

efficacyatall,inmanysituationswherediagnosisandtherapyremainstuck.Iplace

thisinsightalongsideevidencebasedmedicine,andconcludebymakingamoralcase

that if we are to pursue efficacy and avoid harm, these poet-like, therapist-like

characteristicscannotcontinuetobeviewedasicingonthecakeofpracticeatbest,

subjectivecontaminationatworst–rather,theymustberecognisedandintegrated

asakeyingredient,amongothers.

2.3Methods–outer:capturinginterdisciplinarylivedexperienceintext

Methodisatermmeaningawayofproceeding,andIoutlinedinthelastchaptermy

epistemological journey across disciplinary boundaries towards a position ofwhat

couldbecalled“livedinterdisciplinarity.”Thefollowingmaterialcouldbeseenasa

setofrepresentativeobjectsornarrativesouvenirsfrommyjourney–akindofdiary,

writtenfromdifferentpositions.Theyareofcourseindividual,personalpiecesoftext,

butthekindofinsightstheycontainwouldIsuggestberecognisabletoanyonewho

weretofollowmyjourneyfromthehumanitiestobiomedicineandthenonwardinto

acombinationofmedicine,thehumanitiesviapsychoanalysis.Isuggestthatanother

travellerof thesameroadmightalso recognize the thepicture Ipaintofaclinical

worldmorecomplexthanbiomedicallanguagecanacknowledge,andrecognizethe

kindofremedytobefoundinhermeneuticpracticessuchasartandpsychoanalysis.

WhatIpresentaresamplesofthekindofthingitispossibletofirstsenseandthen

articulatewhenonehasnotbeensubsumedwithinasingledisciplinaryframework.

Twoareasofworkregardedasseparatehaveseemedtometocontainsomecommon

psychologicalprinciples,andthisismyattempttoclarifyor“precipitateout,”those

principles.Inaddressingthequestionofhowelusivematerialimportanttohealthand

wellbeing is recovered, I have used a method familiar to both artists and

psychoanalysts: creative, interpersonal merging with a material, accompanied or

34

closelyfollowedbyanalyticseparating.Itisamethodwhichinvolvestheuseofthe

self as a relational-analytic tool. The material presented here has been gathered

throughcreativemergingwithandanalyticseparationfromthetwofieldsofpoetry

andtherapeuticpractice.Andtheclaim Imakefor it is liketheclaimapoetmight

makeforapoem–thatthisiswhatresultedfromacreativestrugglewithamaterial

elusive to other methods, on the one hand; and on the other, that this was the

analytic-improvisatory method whereby these particular insights could be made

articulate.

Thisopen,reflexive,living-working-thinkingjourneyhasnecessarilyproceededfreeof

prior commitment to one or another specific methodology or epistemological

tradition. Instead, interdisciplinary ”turns” have been repeated over time, until

interdisciplinarityhasbecomean immersive livedexperienceor”wayof life”–not

simplyacrosssectionalmomentofpurelyintellectualcomparison.

Sowhatofrigour?Althoughfreeofpreconceivedmethods,inthesenseofarecipeto

befollowed,thisworkhasnevertheless,likeapoemoratherapeuticencounter,been

disciplined by themethodof close, undogmatic attention and radical openness to

experienceandphenomenaovertime.Whatpsychoanalysismightcallmergingwith,

andwhatanthropologymighttermimmersionindifferentlifeworlds,inordertolive

inandnotpurelytostudythem–allowsaqualityofengagementnotpossiblefroma

standpoint which is purely superficial, eclectic, or preconditioned by prior

commitmenttoasingle,fixedworldvieworepistemologicalapproach.Thesedatadid

notarisefromadualisticintentionto“knowabout”or“observe”poetry,orhealth,

rather from the experience of “being with” or “in” them. Analysis then followed

experience,asamatterofintellectualneed.AndechoingTuri,Icontendthatwemust

find spaces in medical academic discourse for unique, experience-based analysis

alongsideotherformsofknowledge.

2.4Methods–inner:mentaltensiondrivesepistemophilia

35

If the above is an account of how I have proceeded outwardly, the following

paragraphsareanattempttoacknowledgeoralludetointernalprocesseswhichgave

risetothiswork.IstatedinChapter1thatthisworkwasstimulatedbythediscomfort

of cognitive dissonance - a form of discomfort which is in fact developmentally

optimistic,andauseful startingpoint for research.Addressing thequestionof the

ontogenesis of health research, Atkins and Murphy identify three stages of the

reflective process, beginning with a sense of inner discomfort or unfinished

business.132Meanwhile,inaKleinian,psychoanalyticviewofpsychicdevelopment,it

isanxietywhichformsthestimulusforallthought–thegroundofallreflexivity.133

Arising from the absence of the breast – a term meaning both the infant´s

psychosomaticunionwithhismother, andall latermomentsofeffortlessmerging

withexternalsourcesofnourishment,anxietyisinKleinianlanguagetherocket-fuel

whichmotivatesustoformulatethoughtsandstretchtowardsunderstanding.Where

mother´s care stops–givensufficient inner resources - ourown,mental self-care

begins,bymeansoftheepistemophilicinstinct134

Naturally, we continue to be plagued throughout life by further departures from

“breast-like experiences” – that is, environments133 where things are generally

familiarandcosy,andwhereunexaminedconnectednesscanbetakenforgranted.

But if sufficiently resourced, we use these separations to grow, emotionally and

intellectually, learning to explore theworldmore personally and directly, in all its

wonderandstrangeness.

A life lived outside the safe confines of a single discipline has offered me ample

epistemophilic potential. Separate internal relationships with the clashing, partial

accountsofhealthand illnesswhichbiomedicineandpsychoanalysisoffer,haveat

timesfeltlikeaninvitationto“split”intoseparateselveswithseparateallegiances,

likeachildwithwarringparents. Ihavefoundmyselfsearching, instead,forsome

neutral ground of epistemological independence from which to integrate and

contextualisethesepartialaccounts.Ihavebeendriventothinkmyownthoughts.

2.5Reflexivityandtherestorationofthinking

36

Reflexivityisanattitudeorpracticeinwhichresearchersubjectivityisdeclared,used

anddiscussed,ratherthanavoidedordenied.Althoughwidelyacceptedandpractised

inqualitativeresearch,itisseldomexamined.Themeansbywhichreflexivityachieves

itsscientificaimsisseldomdiscussed.135Kleinianpsychoanalytictheoryishelpfulhere,

and Doyle, a researcher versed in both social scientific and psychoanalytic

understandings,citesBioninexplainingtheroleofreflexivityassustainingcuriosity

and thoughtfulness evenwhen feelings of discomfort or bewilderment threaten to

overwhelm.136-138 This scientific, or in psychoanalytic language, epistemophilic

positionistheoppositeofonewhereonlythatwhichiscomfortable,tolerable,and

immediately manageable can be known, and that which unsettles cannot be

considered. What seems to flow from this is a vision of all research as an act of

reflectiverelating–neithermechanicalobservation,ontheonehand,inwhichone

claimstobeanuninvolvedoutsider,norintrospectiveself-revelation,ontheother,139

inwhichobjectivitytakessecondplacetofeeling;neitherwhollysubjectivenorwholly

objective,alwaysintersubjective,requiringacapacitygenuinelytotakethingsin,and

tousethemtodevelopatruerpictureoftheself-in-the-world.140

So reflexivity represents a different form of rigour, entailing the explicit

acknowledgment and use of an involved human self in the co-production of

knowledge. It involves a willingness on an individual researcher´s part to take in

troublesomerawmaterial,toleratebeingstretchedbyit,andworkwithit,untilitcan

beproperlyintegratedwithpriorknowledge,ratherthansimplyexcludedorignored.

Both social scientists and psychoanalysts recognize these elements. Atkins and

Murphy characterise reflexive research as a three stage process, whereby

uncomfortablefeelingsandthoughtsleadviacriticalanalysistothedevelopmentofa

new perspective,116 chiming with Bion and Klein´s accounts of individual mental

development.133141142Butanotherstrikingparallelisthatwithakeypsychoanalytic

accountofcreativeprocess–AntonEhrenzweig´sthreestagepsychologicalprocess

ofmakingart.

Ehrenzweig´sthreestagemodeloftheprocessofmakingart,whichIdescribeinmore

detailinChapter4.143-145beginswithaninitialprojection,whichisworkedthroughvia

37

anunconsciouslyled,manic-oceanicprocess,toberesolvedinconsciouslyledprocess

of reintrojection.143-145 Thispsychoanalytic accountof creativityoffers a key, inmy

opinion,tounderstandingtheconnectionsbetweenpersonaldevelopmentandwider

academic or epistemological development. It offers us a tool for tracking the

connectionbetweenpersonalgrowthandculturalandacademicgrowth,byclarifying,

Isuggest,howallthreeare irreduciblycreative, intersubjectiveprocesses–neither

mechanisticandreducibletodepersonalisedorabstractedtechnicalprocedures,nor

wholly individual, solipsistic, and narcissistic.138 Together, these interlinking

theoreticalaccountsfromsocialscience,thepsychoanalysisofpersonaldevelopment,

andthepsychoanalysisofcreativity,explainthecentralrolewhichthedisciplinesof

relationshipandcreativityplayintheacquisitionofknowledge.

2.6Psychoanalysisasanintegrativeanalyticframe

The capacity of psychoanalysis to address intersubjective phenomena gives it

particularpotentialinaddressingbothartandhealthcare.Ithasprovedinvaluablein

interdisciplinaryareasofstudy,especiallythosewhereunconsciousinfluencesinthe

research field need to be taken into account. Despite its unfamiliarity to many

academics, and its own relatively weak tradition of ontological questioning,146

psychoanalysis´s capacity for bringing unconscious elements into consciousness

representsauniquecontributiontoresearch.136

Althoughnotasingleapproach,psychoanalysisoffers,collectively,oneofthemost

comprehensive,dynamictheoriesofhumannatureanddevelopment.147Integrating

twocomplementaryevidencecultures–empiricalorneopositivistic,ontheonehand,

andhermeneuticorinterpretational,ontheother–ithasformedanepistemicbridge

between the humanities and the social sciences, and between therapeutic and

culturalphenomena.147

Psychoanalysis can, admittedly, be a difficult field of discourse, rich in apparently

mutually contradictory dialects, and elaborate terminologies. At times is has been

heedless of the duty to make itself understood, and in places, it has taken its

metaphorstooliterally,betrayingitsownhistoricalgroundinginclinicalphenomena,

38

andappearinghermeticandself-referential.148Verymuchwouldbelost,however,if

theworstexamplesweremisunderstoodasrepresentativeofthefieldasawhole.The

psychoanalytic commentators I introduce are writers whose accounts of the

relationshipbetweencreativityandhealthIhavefoundbothlegibleandessential–

writers such as Bion, Winnicott, Milner and Ehrenzweig whose theory is firmly

groundedinpractice.Withoutthesewriters´insightsIcouldnothavethoughtclearly

aboutmysubjectmatter.

2.7Poeticmethodology–fostering,containing,synthesising

Intheintroductorychapter,Idescribemymethodaspoetic,anadjectivederivedfrom

theGreekverbpoiein–tomakeorcreate.Imightthereforeequallycallitacreative,

constructiveorartisticmethodology.WhileChapter4discussespoetry´soriginsand

methodsindetail,IwillsummarisewhatImeanbyapoeticmethod,briefly,asfollows:

aneed,oraniggle, is feltbyapoetor researcher in responsetoanexperienceor

material.Thisdriveisbothemotionalandepistemologicalinnature,callingonfeeling

andthought.Thepoetorresearcherapproachesthematerialinanopen,receptive

manner,listeningandsearchingnotonlyforitsobviousorwell-articulatedelements,

but also those which are elusive, unimagined or surprisingly absent. The sense

impressionscomingfromthematerialareheld,provisionally,withinthepersonofthe

researcher/poet, alongside the feelings and thoughts they elicit, and this mix is

subjectedtoacondensing,constructive,orintegratingprocesswhichalsodrawson

pastknowledgeandacquiredskill.Althoughhostedwithin,andalsoshapedby,the

researcher/poet´sinnerworld,andtheextentandlimitsoftheirpriorknowledgeand

skill,thisprocessalsoobeystheexternal,non-negotiableconstraintsofthematerial.

The researcher or poet is required to place him/herself “at the disposal” of the

material,inanattitudeoflistening.By“palpating”foror“feelingout”connections,

theresearcher/poetusesabalanceofconsciousandunconsciousprocess,abalance

of thought and feeling, to create a new piece of understanding capable of being

graspedandusedbyanexternal recipient–apieceofworkwhich if it is to reach

anotherperson,mustbeembodiedinaformwhichcanbetakeninorswallowed,and

39

forthis,itmustbearthehallmarksofaestheticcoherence.149Letuslookatthesethree

stages–fostering,containingandintegrating-inmoredetail:

Fosteringrawmaterial–theintersubjectiveoriginsofnewknowledge

For a poem to arise, a poetmust first be “captured” by amaterial, and agree to

“foster”itorgiveit“houseroom,”-time,energy,love,andotherresources-inits

immature state.Wemight think of this in terms ofWinnicott´s primarymaternal

preoccupation,150 a state of devotion characteristic of ordinary good mothering,

withoutwhich, ingoodenoughmeasure,nohumancanemerge into independent

existence.There´snosuchthingasababy,Winnicottproposesplayfully,meaningthat

viable, independent consciousness is not congenital but acquired ex-utero,

intersubjectively,throughthegraceofamaturationalenvironment.151

Winnicott´spoint–thatnewhumanlifeandthoughtarisesintersubjectively–isworth

pausingtotakein,inadiscussionofmethodologybecauseofitsscientificimplications:

Althoughourintersubjectiveontogenesisisuncontroversialinphysicalterms–who

woulddreamofdenyingthatababy´sbodydevelopswithinamother´sbody?And

although, increasingly, the role of intersubjective influences in health and

pathogenesisarealsowelldescribed,whetherweconsiderinheriteddisease,thefetal

(somatic)originsofadult (somatic)disease,152or thepathogeniceffectsof chronic

psychosocialstress,153154whenitcomestothinking–todatagatheringandanalysis,

our intersubjectiveontogenesis is largelyoverlookedordenied inhealthdiscourse.

Somehow,whetherbyfamiliarityorconvenience,humanhealthresearchcontinues

toadhere in largemeasuretofalse,harddichotomiesbetweensubjectandobject,

leavingitselectivelyblindtointerconnectedness,evenwhereinterconnectednessis

wherethegroundsofhealth,illness,andtreatmentaretobefound.

The contemporary American philosopher Hustvedt picks up on this unhelpful

oversight, accusing Western philosophical and scientific traditions of clinging to

dualism,despitethefactthattheverydefinitionofmindissubjecttoheated,ifnot

tortured,debates.155Shechallengesthesimplisticnotionthatknowledgeisacquired

40

whenamansitsalone ina roomand thinks,155apparentlyuntroubledby reflexive

questionsas tohowhisownhistory,experience,and relationshipsare shapinghis

thoughts. Insteadsheinvitesustoconsiderthequestion:Whatsignificance, ifany,

doesthefactthatmammalsgestateinsideanotherbodyhaveforthemind?155

WhatIattempttoofferhere,therefore,isnotmoredataofthesamekind-afurther

instanceofobjectivelyacquireddatainonepre-existingfield-butaproposalabout

howwecanaccessdatainaccessibleoroverlookedbycommonmethods.TheclaimI

make for my method is therefore not of objectivity in any one area, but that of

reflective intersubjectivity across a number of different relationships and subject

areas,generatingcomparativeinformationwhichwouldnothavebeenaccessibleby

anyothermeans.

Containingandprocessingchaos:thecreativeconditionsofacademicdevelopment

Forapoemtoemergeintoauseableform,chaoticrawmaterialhastobeheldonto

and processed, in ways which are both adaptive and assertive. Bion describes a

mother as the container for an infant´s mental development – an individual

volunteeringherselfasachamberinwhichimmatureexperiencecanbeheld,digested

andmadebearableandnourishing.InBion´smodel,theinfant´shismindcanmerge

with the mother´s, creating an intersubjective environment which can hold and

processhisincomprehensibleexperienceuntilitcanbemademeaningful.156

In thismodel, a space is configuredwhichdidnot exist before, except virtually or

potentially.Itemergesviaoneperson´selasticresponsetoastretchingmaterial.This

processiscentraltotherapeuticandartisticmethods,andtomyresearchmethod,

here.Thewillingnesstofosterandmergetemporarilywith,amaterial,balancedbya

capacity for synthesis or condensation (and I suggest that the two are connected,

becausepsychologicallyonecannotaffordtheriskofentertainingatensionwhichone

isnotconfidentof“surviving”)allowsa“pop-up”,psychologicalspacetobecreated

in which a set of connections or contradictions can be held and explored while

something newmay emerge.157 This creative, synthetic act requires a capacity to

41

balancethoughtandfeeling,consciousandunconsciouselements,andthisbalance,

is,Isuggest,“read”byarecipientasbeingadequatelypresentorabsent,theproduct

thereforeassatisfyingordisappointing.143Suchintuitivelyinformedmethods,honed

bytrainingandpractice,arerecognisableinmanyartists´descriptionsoftheircreative

process, as well as in psychoanalytic accounts of both therapeutic and artistic

practice.24144

Insummary,Ipresentthispoetic,or“receptive-containing-constructive”approachas

a material-responsive tool for capturing important cultural, psychological, or

interpersonal material which might be lost in a purely conscious, or theoretically

drivenapproach.Iproposeitasamethodwhichisparticularlysuitableforstudying

unexplainedembodieddistress,orothermaterialwhichisdifficulttoaccess,grasp,or

speak,orbear.Indoingso,Ijoinforceswithotherqualitativeresearchersworkingat

themethodologicaledgelandsofthefieldofhealth.

2.8Otherborderlandexplorationandresearch

Likeadisturbingwindblowingacrosstraditionalboundariesandcertainties,therehas

beenaburgeoninginboththeartsandsciencesofinterdisciplinaryprojects,including

what has been called borderland research and exploration. An exhibition of craft

objectsrecentlypresentedtotheartgoingpublicofTromsø,forexample,madeby

peoplewhoselivesareconductedacrossnationalboundaries,158wasaccompaniedby

aninterdisciplinaryaestheticmonograph,invitingthereadertoconsiderwhatwetake

with us when moving from one place to another – what is essential and what

expendable.159VoicesfrommedicalhumanitiesdepartmentsintheUK,meanwhile,

areadvocatingedgelandresearchinhealthandsocialcare–creativemethodologies

which relax rigid frameworks around the presentation of results and the

interpretationoffindingstoallowroomfortheunexpectedtohappen.160

Meanwhile,theunbalancedpositivismofclinicalguidelinesandmedicaljournalsand

theinstitutionaliseddiscriminationagainstresearchwhichdoesnotapethereputed

42

certainty of the methods of natural sciences49 160 is under criticism. In an open

disagreement between leading international researchers and a leading medical

journaloverthedeprioritisationofqualitativeresearch,76seniorresearchersfrom11

countries challengededitorspublically todevelopamoreproactive, scholarly, and

pluralistapproach to research.161 Inanattempt toescape interpretive subjectivity,

critics argue, medicine threatens to expunge its primary subject – the living,

experiencingpatient.162 Itsone-sidedcommitmenttoquantitativeenquiryrulesout

essential elements of clinical interaction and judgment – topics that involve,

communication,opinions,andexperiences.101

Therearecallstodevelopandextendthequantitativebiomedicalmethodswhichrule

outessentialelementsofclinicalinteraction,toincludecommunication,opinions,and

experiences.101 Rather than viewing methodology as a standardised recipe to be

followed ritually, “alternative epistemic positions” are being called for,160 – those

whichcanrestoreanideaofresearchasaformofdiscoverywhichretainsasenseof

theunknown,evolvingcontinuallythroughongoingexperimentation,reflexivityand

theoreticaldevelopment,160perpetuallyonthewaybecausecontext,subjectmatter,

andresearcherarealsoalwayschanging.

Aspartofthiswidermethodologicaldebate,therearealsospecificadvocatesforarts

basedresearch.Shidmehrhasadvocatedthere-integrationofpoetryinresearch.She

criticisesitsexcisionfromsciencefollowingPlato,80withthedivisiveexclusionofthe

possibilityofknowledgetakinglyricform,orofpoetryascarryingconceptualcontent.

Shidmehralmostseemstobepointingtoakindof“epistemologicalcleansing”(my

reinterpretation)ofpoetryfromknowledge,adevelopmentrichinunacknowledged

violence.163Poetry´sintersubjectivepotential–thatblurringofboundariesbetween

selfandotherwhichPlatoconsideredscientific“cheating”–isthepreciselocationof

itspotentialtocaptureandvoicedifficult,elusivematerial,accordingtoShidmehr.80

In difficult or marginalised areas of knowledge, she argues, poetry may offer a

differentkindofepistemicopportunity,adifferentkindofhonesty,tothatofferedby

the positivist164 Aristotelian-Cartesian-Kantian approach. The hard distinction

43

betweenartandscience,arguesShidmehr,isbothfalseandromanticised,andpoetry

isneededas“achorusofinquiry..atthemarginsofacademicresearch.”

Myintentionhereisnottotakesidesinanargumentbetweentherelativevaluesof

poeticandscientificformsofknowledge,buttoproposetheuseofpoetry-enriched

science where poetry-depleted science fails to address its human subject matter

adequately.Iamaimingatatathreedimensionalviewofacomplexsubject,which

hasadequaterichness,breadthanddepthtomakethatsubjectrealforareader.The

method I haveuseddoesnot claim fixedobjectivitybutunique, experiencebased

insight gathered and analysed with rigour and reflexivity. In contrast with the

biomedical research tradition,which has been accused of a refusal to accept that

resultsofitsownresearcharealsooutcomesofinterpretation,69100itstartsfroman

acknowledgmentthatobjectscanonlybeknownthroughtheirrepresentations.165

Howcouldonepossiblyestablishthevalidityofacreativestudy?Doesanaesthetically

groundedstudy,oraworkofart,havethecapacityto“tellthetruth”or“lie,”orIsit

merelyamatteroftaste?Szirtes,afigurewhosecredentialsasaleadingcommentator

onpoetryareuncontested,givesanuncompromisingaccountofpoeticrigourasa

testwhichbefailedassurelyasascientifichypothesiscanberefuted.Thisisdiscussed

inchapter4.166Ehrenzweig´saccountofgoodness(oritsabsence)inartestablishesa

psychologicaldefinitionofwhatwemightcall“aestheticrigour.”Koppemoredirectly

addresses the relationship between aesthetics and research using the notion of

aestheticcoherence,167atermdenotingresonanceinanaudienceorthefitoftheparts

to the whole. For an inherently intersubjective subject matter such as mine, this

approachhelpfullyavoidsthelimitationswhichdualisticnotionsofresearchinterms

of subject and object would impose. It takes account of art as an inherently

intersubjectivepractice,andalsoofresearchasapracticeinwhichintersubjectivityis

necessarilypresent,whetheracknowledgedorignored.116167

Arguably, we could rephrase Szirtes´ poetic truthfulness and Koppe´s aesthetic

coherence in the psychoanalytic language of countertransference. The critical

reader´s reflexive analysis of their reading experience can be seen as a kind of as

44

academiccountertransferenceanalysis–theanalysisofwhatyoufeelandthinkinthe

faceofanotherperson´sself-representation.Whatdoyoumakeofher?What,ofher

self-representation,strikesyouasconvincing,andwhatasanomalous?Wheredoyou

findyourselfsympathetic,pleased,gratefulorsomehow“inharmony”withthetext,

andwhereconfused,irritated,bored,oraffronted?20Theself-reflexive“reading”of

aperson,apieceofartormusic,apoem,oranacademicpaperformalisestheintuitive

knowledgeembodied inexperience.Andwhilea readingcannot reduceapoemto

meretechnicalities,itcantellussomethingaboutitsqualities–itsexternalvalidity.

Finlaysuggeststhatthequalityofresearchcraftsmanshipshouldresultinknowledge

claimsthataresoconvincingthattheycarrythevalidationwiththem,likeastrong

pieceofart.168Thismeansavoidingreflexivity´spitfalls–degenerationintoinfinitely

regressive,apparentlypurposeless“legitimisedemoting”.Finlayarguesthatreflection

ononeself(inactionandrelationship)shouldnotbeanendinitself,butcarriedout

togainnewinsight.Itsdangersaremitigated,sheargues,byasincerefocusonthe

participants or texts involved.137 Research is not therapy,138 and the proof of the

puddingisintheeating.

Allmethodsilluminatecertainaspectsofaproblemandobscureothers.Inadditionto

strengths,my individual, creativemethod has numerous obvious and unavoidable

limitations.Unlikehighlyfixed,multiplyrepeatable,abstractablemethodssuchasthe

cohortstudyorrandomisedtrial,mymethodcannotgeneratethekindofvaluewhich

results from discrete, categoric pieces of knowledge such as the establishing of

optimum blood sugar levels to reduce mortality in diabetes. The power of such

knowledgeisintheintensityandclarityofthesignal,anditswidegeneralisabilityin

very specific, albeit narrow, ways. The utilitarian benefits of such knowledge are

unarguable,andifwedidnothaveawealthofsuchspecificbiomedicalknowledge,a

thesislikeminemightappearredundantorirrelevanttohealthcare´smostpressing

needs.

However, much data relevant to health is neither graspable by these means nor

generalisable,exceptintermsofprinciplesandprocesses,attitudesandapproaches.

45

Here,highly individualisedorembodiedmethodscanbemoreinclusiveofrelevant

perspectives,andlesspronetothekindofthekindofbiaswhichcanarisefromlack

oftriangulation,perspective,or“binocularity.”Methodswhichoffermoreextensive,

associative insight, taking account of material which is elusive to other methods,

because it is dynamic, hidden in symbolic representations, or unconscious, are

needed.

Likeapoem,apoeticstudycannotpossiblebeafullydefendedintellectualassault,so

muchasanexploratoryoverture. Inherently intersubjective,appealing toboth the

consciousandunconsciousmindofthereader,itcannotclaimtohavesucceededuntil

andunlessoneormorewilling readers find it tohaveresonatedmeaningfullyand

fruitfullyprovokedthoughtorcontributedtodebate.

AccordingtoDoyle,“comingout”throughreflexiveanalysis isultimatelyapolitical

act.Donewell, sheargues, ithas thepotential toenliven, teach,and spur readers

towardamoreradicalconsciousness.136Ifresearchisanattempttocaptureanimage,

wemustacceptthatwhilesomesubjectscanbe“posed”orcomposed,othersmust

bechasedafter,camerainhand,generatingresultswhichmaynotbecrystalclear,

noreasilyrepeatable,butmayneverthelessofferinsightunavailablebyothermeans

andcapableofrevisingunderstandingsignificantly.ItisthisthatIhaveattempted.

Keymessages

• Thisstudy´smethodologyentailsfostering,containingandsynthesizingcomplexmaterial,andcanbecalledpoetic

• Itmakesuseofreflexivity,whichbalancesproximitytoanddistancefromone´slifeworld

• Itgivesanaccountofinterdisciplinarylivedexperience,whichaffordsaviewnotvisiblefromwithinasingledisciplinaryframework

• Poetry,psychosomaticmedicalconsultation,andconductingreflexiveresearchareallcharacterisedbycreativeinterpersonalmergingfollowedbyanalyticseparating.

• Suchmethodscanbeusefulforexploringcomplexorelusivematerialunamenabletoothermethods

46

47

Chapter3–Whenwordsact“ .. althoughpoetsaremostneededwhenfreedom,vitaminC,communications,laws,andhypertensiontherapyarealsomostneeded.. apoemisnotoneofthelastbutofthefirstthingsofman.” MiroslavHolub

Keywords:poetryasasemioticform,embodiment,holisticcommunication

Whatfollowsisaseriesofpoemsinwhichaspectsoftheworldofillnessandhealth

arereimagined.Theyareofferedasexamplesofwhatpoetrycanachievemorewidely

–ofpoetryasaspeciallycompressedwayofdramatisingandinvestigatingtheworld

inthelightofsubjectiveexperience,onewhichcanbridgethegapbetweenouterand

innerworldsforbothpoetandreader,andconnectoneperson´semotionallycharged

experienceof living, and another´s. Iwill argue that it this emotional gap-bridging

between fact and feeling, and between one person and another, whichwe value

poetryfor,ifwedo.

And it seems that collectively,wedovaluepoetry– thatevenpeoplewhodonot

otherwisefeeltheneedforitintheireverydaylivesturntoit,alongwithreligion,at

moments of overwhelmingly strong experience. It is among the special gestural

responseswe reach for in the faceof experiences like falling in love, birth, death,

natural beauty, themassacre of teenagers at a summer camp, or the death of a

presidentoraprincess.Whetherpoetryproducedbyanygivenpersonsolelyonsuch

an occasional basis is “any good” –whether it does anything for anyone else – is

secondarytotheevidencethatinreachingoutforit,weknowwhatpoetryisgood

for.169Weseemtounderstanditasausefulplacetoputexperiencewhoseintensity

isalmosttoomuchtocontain.Poetryis,itseems,forexpressinginwordsthingswhich

cannotbeexpressedinwords.

Indeed,inpoetry,wordsareexplicitlystretchedbeyondtheirnormalusesandformed

intogestures.Inthis,poetry´sachievementsresemblethoseofnon-verbalartforms

suchaspaintingandmusic,morethanthoseofplainprose.Atableattheendofthis

chaptersuggestssomewaysinwhichpoetryandprosediffer.Kristevaobservedthat

48

unlike prose, which uses language in primarily semantic ways, or at least has

straightforward semantic meaning as an alibi, poetry is inherently semiotic or

performative.170Itaddressesthewholeperson,mentally,emotionally,andphysically,

ratherthanofferingathesisorthoughtwhichcanbegraspedpurelymentally.The

poet,therefore,isakindofword-artistwhoruthlesslyrepurposesordinarylanguage

as an art material, supersaturating apparently innocent or mundane words with

encodedpersonalmeaning.Indoingso(s)hedrawsattentiontothematerialityand

contingencyofwordsthemselves–theslipperinessoftheverymediumuponwhich

wedependtoexpressrawexperience.Inthisway,ordinaryorsurfacemeaningina

poem is no more nor less than the “armature” around which the poem´s actual

potencyisbuilt.

Thisrepurposingofwordsamountstoaformofseriousplay,Isuggest.Throughword

games, thepoet carvesout a kindof “pop-up,” intersubjective, reflective space in

whichemotionally chargedexperience canbeencodedandpassedon, like charge

passing along a wire between separate electrodes of a battery, or a specially-

compressedfilebeingpassedfromoneperson´scomputertoanother´s.Whatbegan

asdeeplypersonalinvestigationturnsout,ifthepoemisanygood,totouchonthe

universal-in-the-particular,andtherebytotouchanotherperson,ormanyothers,and

therebytoachievewhatwemight,extendingKoppe´snotionofaestheticvalidityor

Stimmigkeit,callaestheticgeneralisability,orexternalaestheticvalidity.171

A working poem is brought into being, I will argue in chapter 4, by a mixture of

intuitionandcraft,amixtureofunconsciousandconscious intention.Poetry,of its

nature, makes conscious use of unconsciously-active elements. Hence words are

selectedforthealternativemeaningsandassociationstheyalsocarry,whichtease

thereaderbypressinginatthemarginsoftheprimarymeaning.Theyareworkedinto

ashapewhichgivesaphysicalexperienceonthelips,throat,orear,orarhythmical

experience in the body: musical, liturgical devices such as rhythm, repetition,

alliteration,assonance,andpercussionmakeaphysical,notpurelymental,mark.In

this capacity to address the body and themind in one and the same gesture lies

49

emotionalpower.Tofeelourselvesaddressed“whole,”inthisway–mindandbody,

consciousandunconscious–isdisarming.

Inthisway,poetryholdsaseductivepotentialwhichthepoetmustdeployjudiciously,

if there istobepleasureratherthansimplydutifulendurance,oraversion, forthe

reader.Atbest,apoemoffersthepoetanopportunitytohavehisorherowndeepest

experiencevalidatedinanother´sreception,whileforthereader,itisawayofhaving

hisorherownexperiencevalidatedthroughanotherperson´sskilfulre-presentation.

Thoughpoetand readermostlynevermeetandmaybe separatedbycenturies,a

poemisatbestthecomfortingtraceofanintimatehumanpresenceinalonelygrown-

upworld.

Inthediscussionofpoetrywhichfollowslaterinthischapter,Iwillsidestepattempts

todefinepoetryasdistinctfromotherartisticorverbalforms,suchasprose,visual

art, film,orother formsofexpressionwhichmightat timesalsobe referred toas

“poetic”. Iwillnotengagedirectlywiththemany,oftenevasivedefinitionsoranti-

definitionsofpoetrywhichhavebeenoffered,suchasDylanThomas´sthat“poetryis

whatmakesmytoenailstwinkle”.RatherIwillfocusonwhatpoetrydoes,howitdoes

it, and how and why it is made. These I will address primarily as psychological

questions.

A tentative definition of poetry as a psychological achievement will follow my

observations,ratherthanprecedethem–andnotbecauseIthinkpoetryisinneedof

psychological definition, but because I think understanding what it achieves

psychologicallyisusefulforhealth.Iwillendbysuggestingthatwecanthinkofpoetry

as a condensed, highly crafted, holistic communication device in which we can

exchange and retrieve valuable, sensitive, elusive material in someone else´s

presence.Akindofembodied-relational“app”,whichcombinespleasurewithmulti-

levelcommunicationtoachievepersonaldevelopment.

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Ipresentthesepoems–selectedbecausetheydealwiththebody,andhavesatisfied

externalpoeticpeerreview1,becauseinbeingtheirwriter,Ihaveaccesstothepoet´s,

aswell as a reader´s, perspective. I can at least to some extent speak aboutwhy

(psychologically),andhow(technically),eacharose.Eachofthefirsteightpoemsis

presented in its own right, and then discussed from a reader´s and a poet´s

perspective,inparallel.Inthecaseofpoem9,Bonetalk,Ipresentcontemporaneously

collecteddataonhow(bothpsychologicallyandtechnically)thepoememerged.In

doingthis,Ihopeto“track”howapoemcanoriginate,emergeandfunction,looking,

asitwere,intothemechanismwherebyoneperson´sexperienceorconcerncanbe

encodedsuchthatanotherpersoncan“feel”it.Itisawayoftryingtoimageamoment

ofcreative intimacybetweentwopeoplewhomaynevermeet–onewhich,while

apparently valueless in utilitarian terms, is nevertheless highly prized. It is no

coincidence, in terms of the development of my thesis, that this highly prized,

intimate,interpersonalpracticeisatthesametimeanepistemiccritiqueofmedicine

misunderstoodasadehumanisednaturalscience.

1The8poemspresentedhaveallbeenpeerreviewedbypoetsandcommendedand/orpublishedinpoetrymagazinesorprizeanthologies.Asoundfileofeachbeingreadaloudissuppliedelectronically.

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BitterTreatment

Itwastheareabetweenthemidlinesofthetwotemporallobes,andbackforeighttoninecentimetres–thehippocampus,theparahippocampalgyrus,theentorhinalandpararhinalcorteces,theamygdala–thepatientwasawakeonthetablethewholetimeasDrScovilleinsertedasilverstrawandsuckedoutnearlytheentiregreyish-pinkmassincludinghismemory,likefinestmatéamargothroughabombilla.

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3.1Afoundpoem

This little two-stanza poem, almost but not quite a sonnet, summarises the

therapeuticeventssurroundingafamouscasehistoryoftenreferredtoas“theman

withoutmemory”.172Beginninginwhatlaterturnsouttobetheoperatingtheatre,

butcouldaswellbetheanatomydissectingroom,thepoemparachutesitselfdirectly

intothelanguageofspecialistneuroanatomicaldetail.Itmakespoeticcapitalofthe

unfamiliarityofneuroanatomicalterms,fillingstanza1withasmoke-screenofspecial,

resonant,repetitive,“brain-words”–wordswhichplacethereaderontheoutsideof

aprofessionalsanctuary,peepingin.

Like a child, the reader, including theordinarydoctor, is lulledby specialistwords

whose meanings are elusive – hippocampus, parahippocampal gyrus, pararhinal

corteces,amygdala–wordswhichusedlikethis,mightaswellbeliturgypronounced

byapriest–…innominePatrisetFiliietSpiritusSancti…invitingthesimpleassentof

Amen. Itscomplacent incantation invitesnotsomuchadultunderstandingasawe,

alienation, and that dreamlike suspension of rational thinking which fairytales, or

songs,alsoinvite.

A-my-g-da-la ´sdactylic judderbreaks this rhythmic intoxication. It strikes theear,

physically.Disruptingthedreamychild-parent,priest-parishionercollusion,itbrings

stanza1´sprofessionalmumbo-jumbotoaphysicalstandstill,andpropelsthereader

intotheshockofstanza2.Itshakesthereaderawake,likeatraintravellerarrivingat

thestationofdisembarkation.

Leavingstanza1,thereaderismetwithanewandstartlingview,asthepoempans

backtorevealawidercontext.Thelanguageflipsfromtheacademicandhieraticand

to the clinical and everyday. If stanza 1 presents a disembodied brain, stanza 2

confrontsuswiththepatient–arealpersonwhoisnotonlyawake–asthereader

nowperhapsalsois–butonanoperatingtable.Thepatientisthenameless,passive

objectinthehandsofanameddoctor,DrScoville,whoisinthemiddleofcarryingout

anintricateandgrotesqueprocedurewithabeautifulinstrument.Heisremovingfrom

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the patient a greyish pinkmass, which turns out to have contained the patient´s

capacityforformingmemory.

Memoryisthepunchlinetowardswhichthepoemhasbeenbuilding.Abruptly,this

wordwithdrawsemotionalpermissionforstanza1´spurelyobjectifiedviewofthis

brain,forcinginsteadanidentificationwiththeexperienceofthepersontowhomit

belongs, the man whose capacity for memory formation it holds. If stanza 1´s

impenetrabilityhaslulledusintocosy,scientificallyclean,emotionalirresponsibility,

stanza2isanemotionalawakeningasvertiginousandrudeasafallfromahighplace.

Wethoughtwewere inthe innersanctumofhighneuroscience,butsuddenlyfind

ourselveswitnessing a terrible injury occurring in real time, inflicted inmedicine´s

name.

Thepoemcouldhaveendedhere,butdidnot.Havingmet its traumatic climax, it

movesrighton,likethebiblicalPhariseepassingbythewoundedmanontheother

side. A conventional little couplet comparing the events of the poem with the

ceremonialdrinkingofmatéteahintsatmedicine´spotentialforsadism–itspotential

to cause trauma by refusing empathy with suffering – to insist on objectivity,

remaininguntouched, refusingemotionalengagement.This isanaccusatorypoem

with a smoking gun, and a culprit - not the flesh-and-blood Dr Scoville, hapless

amanuensis of a higher force, but the impersonal force of objectifying medical

academiaitself.

3.2Oropportunisticrevenge

Why was this poem written? Superficially, I remember simply hearing the case

discussedontheradioandthinkingitaready-madepoem,ripewithitsownirony,

awaitingpoeticcapture likeaviewasking tobephotographed.Less invented than

discovered,Irememberitsarrivingalmostfullyformed,likeafoundobjectinneed

onlyofa littlecleaningup,framing,anddisplaying. Butonminimalreflection,this

accountofthepoem´sontogenesisinwhichthepoetfiguresassovereign,“material-

selecting”subject,seemslikeahalf-truthwhichdeniestheplayofthe“poem-finder´s”

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hiddenconcernsandinterests.Closerexaminationrevealshowthismaterialmatched

myownunconsciousrebellionagainstaspectsofmedicine,rebellionwhichexistedin

atleastthreeareas:

First,therewasastraightforward,Freudian,ego-conflictbetweenworkandplayof

thekindweallknow–yearsoffeelingsqueezedbetweentheinfantileid´sdesirefor

playandgratification,andthedemanding,parentalsuperego´sinjunctiontowork.173

174Whileworkwasengaging,Istillalmostconstantlycravedmorerest,timewithmy

family,andcreativefreedomtopickblackberriesorreadnovels.AttimesIfeltlikea

slaveofmyownambitionsandintentions.Thechildishid,consignedtoabackseat,

harbouredasomewhatdark,rebelliousviewofmedicine.

Secondly, there was an emotional-energetic conflict within the work itself: The

empathy with which I aspired to balance technical competence was frequently

overstretched–attimes,Iranoutofpatiencewithmypatients–IfearedthatifIdid

not“tuneout”frombeingfullypresentImightburnout.Whilecolleaguesseemedto

feelsimilarly,stoicismwasabadgeofofficeandwedidnotcomplainmuchorfeel

anything couldbedoneabout this.Denial helpedus through theday, butdidnot

disposeofthediscomfort.Soevenifbeingagooddoctorweremyonlydesireinlife–

whichitwasnot–Iwasstillinconflict–betweenbeingthedoctorIwantedtobeand

the one I felt I could be under the circumstances. My idealised professional self

contemplatedDrScovillewithhorror,thinkingtherebutforthegraceofGodgoI.

But,thirdly,inadditiontoinfantilerebellionandhumanweakness,therewasalsothe

constant,internaljarringbetweenwhatIwasencouragedtonoticeandattendtoat

work – a reductionist repackaging of human experience in closed, pre-existing

diagnostic categories, with only brief, marginal scope for meaning or subjective

experience–andwhatIactuallynoticed,whichincludedfeelings,medicallyunwanted

bitsofstory,andinterpersonalinteractions.Ilivedwithavaguesenseofcomplicityin

akindofhalf-truthorinjustice–therootsoftheepistemologicalconflictInamedin

theopeningofthisthesis–butwhichIstruggledtoarticulate.

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In other words, I did not approach theman with no memory innocently. Rather,

burdenedbythesethreemundaneconflicts,butalsoinpossessionofasecretweapon

or“getoutofjail”cardintheformofagrowingcapacitytoplaypoeticallywithwords,

Iseizeduponthematerialwithaviewtohavingaseriousgameandsquaring-upsome

psychologicalandmoralimbalances.ConsciouslyImaymerelyhavebeenhopingto

amusemyselfandareader,butcursoryself-analysisrevealsmydeeperproject:here,

likemannafromheaven,wasamaterialwhichmatchedmyconcernswellenoughthat

thetwocouldmeet:fromoutofthisreal-worldstoryIcouldfashionasmallrepository

outsideofmyself capableof carrying someof burdensome conflicts Iwas tiredof

carrying.Andifratherthansimply“dumping”theseinthematerial,Icouldalsofuse

andcraftthetwotothepointwheretheymightbecomesomethingnewandinterest

areader,Imightmomentarilyre-establishasenseoffeeling“real”inaworkingworld

where Isometimesfeltunreal–re-establish, inthefaceofanxietyordisruption,a

senseofwhatWinnicottcallscontinuityofbeing.175

Freuddescribes thisprocesswhereby theartistpossesses themysteriousability to

moldhisparticularmaterialuntilitexpressestheideasofhisphantasyfaithfully;and

…toattachtothisreflectionofhisphantasy-lifesostrongastreamofpleasurethat

foratime,atleast,therepressionsareoutbalancedanddispelledbyit.Whenhecan

dothisheopensouttoothersthewaybacktothecomfortandconsolationoftheir

ownunconscioussourcesofpleasure.176Liketheinfantwhoreachesforthesecurity

blanketwhich ismother´spermanent representativewithinhisgrasp -Winnicott´s

transitionalobject,whichisbothmeandnot-me-thepoetreachesforapoemasa

me and not-me space, an external material capable of absorbing her intractable

disquiet.Thatway,thedisquietcanbecontained,quiteliterally,physicallyandfirmly,

inthepoem´stight,condensedstructure.Sobeneaththecover-storyaboutafound

poem,theontogenesisofthismightmorecompletelybesummarisedas“rewarding

materialmeetsdisturbedartist.”

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AnosmiaNevermindthenicetiesofpettitgrainandmusk,topnoteandbasenote,orsurvival´ssniffingforunlikelysmokeinahome,orgasinatrench–Searchtheoldbrain´screvicesforthemislaidmother-milkyragofmemory–theabsolutepleasureofroseotto,risinglikeacharmedsnake,baconsireningbreakfast,stockfishsouringthewindwiththestenchofmoney,andthecomfortandjoyofbeeswaxandcinnamon–Ah,binyourdeadmetaphorslikeusedtissues!Stopupyourmockeryofscentedwordsandweephonestlyforlosthoneysuckle,leafmould,andbitterorange,clingingtoalover´sskin.

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3.3Awritingexercise:thedeliberatepracticeofempathy

This four stanzapoemarose in response toan invitation to submit apoem for an

anthologyonthethemeoflossofsenseofsmell.Itisapieceoffree-association–a

quest for themostpoignantexamplesof thisparticular sensory loss.Hinshelwood

characterises psychotherapeutic endeavour as a journey towards the point of

maximum pain,177 and this exercise might be seen as its poetic equivalent – the

laboriousbringingtoawarenessofaburiedfeeling.Whatintherapyisthemomentof

releaseisinpoetry,themomentofemotionalreward.TherelevanceofHinshelwood´s

epithetbecomesclearerifwegeneraliseitasajourneytowardsthepointofmaximum

sensation:thepointofapoem,oroftherapy,isthatwegettofeelsomethingatthe

same time aswe “see” it. So a poemwhich attempts to demonstrate or propose

something without succeeding in kindling an emotional response is impotent,

purposeless,andprosaic.

3.4Aseduction

Inasense,afunctioningpoemisaformofseduction.Ihaveelsewhere178compared

poetry with other consensual erotic experiences, such as the merging or reverie

experienced by lovers, or infant-mother couples – in both states, the (ego-)

boundaries between two people are transiently blurred, in a shared state of

regression.Asuccessfulpoem,Iargued,involvesjustthiskindofpleasurablecollusion

– literally, “playing together,” inwhich the sense of being separate is temporarily

replacedbyasenseofconnection.Beneaththesurface-meaningofthepoem,beyond

thereader´sconsciousawareness,usingspecialformsoftouch,thepoetnegotiates

theopeningupofanintersubjectivespace,inwhichpreverbalfeelings,oryearnings,

areshared.

Thistouchisneitherrandomnorinnocent,butinvolvestheharnessingofunconscious

or“natural” impulseswithintechnique.Forexample, itmeansknowinghowtouse

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ordinarylanguageinspecial,physicallyandemotionallychargedways,suchasdouble-

meaning,pleasurablesoundpatterns,unconsciousassociations,andatacitinvitation

to enjoy “private” understandings. It involves the conscious use of unconscious

communication. And because poetry has no functionalist alibi – either this bid to

establishintersubjectivity(merging)succeeds,orthepoemfailswholly:ifbadprose

invitesdisapproval,badpoetry invitesdisgust.Highlightingthebalanceof freedom

andstringencywhichseductionrequires,contemporaryAmericanpoetMichelRyan

saysinapoemaboutsex:Iwantmytouchingintelligent,likeabeautifulsong.179His

wordsapplyequallytopoetry´sfreedomsanddemands.HequotesfellowAmerican

poetWallaceStevens:Youcandowhatyouwant,buteverythingmatters.180

Questing formaximum sensation –what reallymatters emotionally about smell –

Anosmia´sfirststanzadismisseswithalordlyhand-wavethetrivial,theimprobable,

or purely historic. The perfume industry´s shallowmarketing patter is dispatched

alongwiththeunlikelyeventofsmokesignallingfire,orgasasaweaponofwar:ours

isnolongerWilfredOwen´sfirstworldwarenvironmentofgasintrenches.

Insteadthepoemdivesdeeper,instanza2intotheineluctablephysicalityofmundane

needandpleasure.Weenter the territoryof theoldbrainor reptilianbrain,deep

beneath the cerebral neocortex,wherebrain stem, cerebellum, and limbic system

processreflexandrepetition,trauma,andnurture.Here,wearedownintheprimitive

partofourselveswhichconnectusanatomicallywithanimalsandourowninfantile

origins–line3´smother-milkyragisWinnicott´sintimatetransitionalobjectitself,rich

with the scent of mother-and-self mixed, without which the child is lost in the

world.181Thepreciousessentialoilofroseotto,initsabsoluteormostconcentrated

form, conjures sheer olfactory loveliness. Stanza 3 expands into the wider

significances and emotional associations of smells: bacon means breakfast to an

Englishperson;toaNorthNorwegian,thesoursmellofstockfishonanonshorewind

ismoney.

Butthefinalstanzacutsofftheindulgenceofitsownolfactoryreverie.Likethebitter

turnofatragicprotagonistonstage,thepoetinvitesherselftorenouncethesere-

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imaginedsmellsasmereconceits.PursuingHinshelwood´spointofmaximumpain,

thefinalstanzaurgesdepressiveconfrontationwithgrief–Binyourdeadmetaphors!

Clippedsarcasmconsignsthenostalgicreferencesofthepreviousstanzastothewaste

binlikesomanycrumpled,tear-soakedtissues.

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Achilles

Tendinosis:adisruptiontothesmoothrunningofcollageninitssheathcausingirritation,andpainofseparationfromnightwalksacrossadarkenedfieldhuntingthebarnowlandfromlocomotion'scalmingcontinuo,balmagainsttheworldanditsunpurgedtoxins:sogivemeyourremedies!Eccentricexercises,insoles,pills–orsurgery–anointmeinambrosia,burnawaymymortalpartsonapyreorthrowmeheadlongbackintotheStyx:onlygivemebackthesmoothrunningrhythmofmyself!

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3.5Acridecoeur

IfAnosmiawasanexerciseinempathicimagination,Achillesisapersonalcridecoeur,

bornofthephysicalfrustrationofaprolongedboutofAchillestendinosis.Walking,a

simple,accessible formofgoodness,bringingrelaxation,exercise,stressreduction,

andconnectionwiththenaturalworld,wassuddenlygone,leavingfrustrationverging

attimesondespair.Iquiteliterally“didnotknowwhattodowithmyself.”SoAchilles

arosearoundanexperienceofpsycho-physicaldistress,likeacrystalgrowsaroundan

impurityorapearlaroundapieceofgrit,asakindofself-protectivesecretion.Ittakes

theformofanelaboratehowlofpainfrompatienttodoctor.

Ten-di-no-sis,thefirstword,occupiesawholelineofitsown.Whenreadingitaloud,

Isometimeslingeroverit,spittingoutitsfourtechnicalsyllableswithadissatisfied

patient´s scorn at a medical label which has not helped. The double entendre of

disruption in line two conflates technical disruption andwider disruption to a life,

dramatised on the page by a mid-sentence stanza break. This creates a kind of

stumbling or rupturing of subject and object of the sentence, an effect repeated

elsewhere,suchasinthesinglelinestanza3:thewholepoemlimpsalong,asitwere

–itsownsmooth-runningdisrupted.

Until theendofstanza2,the languagecouldeasilycomeverbatimfromamedical

textbook.Butstanza3´ssinglelineisafulcrumwhichtiltsthereaderfromliteralto

metaphoricalmeanings,frompurelyphysicaltophysico-emotionalpain,andfromthe

doctor´s objectifying, biological perspective to the patient´s compound, subjective

livedexperience.Thepoembeganwithadoctorobservingherownbodyatarm´s

length,presentingherownpathophysiologyinareductiveprofessional languagein

whichshe,asithappens,hasastake.Butthewordpain,atransitionalwordbelonging

to both professional and personal discourse, recreates the lost connection with

subjectiveexperience.

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As the dry, pathophysiological account ends, the poem begins to come to life,

emotionally. The language becomes, if you like, more poetic, more capable of

transmitting feeling. Stanza 4 has moved on from the theoretical discussion of

pathology to something more palpable – the meaning of an illness in a person,

expressedintermsofgoodnesslostandmourned:contactwithnature,contactwith

theself-comfortingrhythmicityofmyownbody,nightwalksthroughadarkenedfield

hunting the barn owl and locomotion´s calming continuo. The poem´s staccato

stumblinggiveswaytoapassagesuddenlyextensiveandfluentwithenthusiasm,rich

insensualwordsforthelostpleasureIwanttomakethereaderfeel.Thepoemhas

escapeditsownconfines,asthepoethasmomentarilyescapedhers.

Andthisimpositionoffeelingsontoareceptivewitness,anessentialelementofthe

poem´sfunctionforbothpoetandreader,isaformofprojectiveidentification:just

as a patient finds ways to make the therapist feel their feelings before they can

reorder things for themselves, using the processes known as projective

identification182andworkingthrough,183thepoetstrivestoplacethefeltsenseoflost

barnowlsandcalmingrhythmicitydirectlyintoareader,borrowingtheiremotional

space,orthepossibilityofit–spinningthestrawoflonelydistressintothegoldof

empathyandappreciationgained.

Butifthereareparallelsbetweenthepatient´sgainfromthedoctorandthepoet´s

fromthereader, thedirectionof responsibility,andmovementbetweenconscious

and unconscious communication, are opposite: A patient presents unconscious

materialraw,owingthedoctornothingbutminimalengagementinthetherapeutic

encounter.Thoughthecreative-therapeuticwork ismutual, the jobofhelpingfind

insightandclarityisthedoctor´s. Thepoet´sresponsibilityisopposite:herreader

owes her nothing – on the contrary, it is the poet´s job to make the reader´s

experience worthwhile. So while the patient´s projections are, by definition,

presentedpriortocreativeworkingthrough,thepoetmustearnherreader´sempathy

byworkingthroughherownprojections.

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Thedirectionof travel between conscious andunconscious communication is also

opposite. Whereas the patient presents emotionally charged unconscious raw

materialfortherapeutic“decoding”–aprocesswhichreducestheemotionalcharge

andpromotesconsciousunderstanding–thepoethasthereversejob,ofencoding

rawmaterialwhich is both felt andunderstood, via the creativework, inorder to

touchthereaderemotionallyaswellasmentally.Tofail inencodingtheemotional

charge,whenwritingapoem,istobemerelyprosaic.

WhatWinnicott´sbabyorthepatientcarriesoutmoreorlessunconsciously,thepoet

learnsasatrick:thetrickofmakingpeoplefeel.Itmightcalluponinstinctiveabilities,

toanextent,butit isatleastinpartacraft, learnedlikesurgery,spoon-carving,or

psychotherapy–inthiscase,thecraftofverbalseduction.Likeaseduction,thestakes

are high. However open the reader potentially is to themedium and the subject

matter,thepoethastogetitright.Ifthepoemfailsforthereader–meaningformost

orall readers– it isatbestanembarrassmentandatworstahumiliation.Apoem

whichfailstoreachitsreaderisasembarrassingasanunwantedsexualadvance.

Suddenly tiredof reflectiononpain, justwantingacure, thepoetexclaims, in the

middleofstanza6,Givemeyourremedies!I´lltryanything,nomatterhowstrange,

sheseemstobesaying–theimplicationof“strangeness”alsoencompassinginjust

sixwordstheentiremedicalmanagementofAchillestendinosis.Brushedoverwith

casualdisrespect,eccentricexercises,insoles,pills,andsurgeryareshrunktofitthe

line,givenequalstatuswithwildlyimplausiblemythologicalremedies.Thedisrespect

is compounded by the dismissive, generic vernacular pills in place of specifically

selected medicines, and the ironic subversion of the technical use of the word

eccentric.2Withbarelyabackwardglance,thepoetstepsfrommodernmedicineinto

thelanguageofclassicalmythologyoftheoriginalAchilles,withhisequallyineffective

Styx-dipping, as though nothing therapeutic had been achieved in three thousand

years.

2Meaning,inNorwegian,“ekssentrisk”asin“ekssentrisktrening/belastning”butalsosær.

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Thepoemisself-ironicinitsmockgrandiosity,butitjabsatmedicine´sgrandiosity,

too–medicine,withitsinsultinghabitofnamingwhatitcannotfix,andthentalking

asthoughitsownimpotentdiscoursewereprimary–asthoughitweredisruptionto

collagenwhichmatteredratherthanthe lossofbarnowls.Butthe ironycutsboth

ways:itis,afterall,tothedoctorthispoemaddressesitselfinitsdespair.

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MessPauseamomentamongyesterday’sruffledanddistractedpapersandthesmelloftikkamasalafromthetinsonthepooltable,spreadspongiformbreadwithmargedisturbedbyahundredhurriedknivesintoalividlandscapeofcrumb-strewnhills,spooncoffeepowderintoamugfromthejumbleinthesinkbeneaththatreminderthatdoctorsareresponsiblefortheirownwashingup,drawbreathbetweentheasthmaandtherepeatenzymes,collapseifyoumustintothearmsoftheplasticchairbytheTVrehearsingtheday´snews,butdonotsleep!–becausesleepwillbecutfromunderyou,likeunderwearfromthecriticallyinjured.No–keepvigilwiththeonce-whiteclogswornoutrunningthenightcorridors:watchthemjostlebeforeyoureyes,andmutterintheSisypheanlanguageofsickness–dreamifyoulike,offreshair–butyou´lllikelyfindthewindowsaresealed,

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andeventhemilkinthefridgehasrunout.

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3.6Masochisticnostalgia

Mess isadystopianreverie fromtheperspectiveofa juniordoctoronnightduty.

Someoftheimageryofamedicalon-callwillbeinternationallyrecognisable,butthis

is a poemabout location asmuch as roles, responsibilities, and experiences – the

grungydoctor´smessoftheBritishNationalHealthService,repletewiththeironic,

alienating pseudo-comforts of plastic armchairs, poor coffee, cheap margarine,

blaringtelevision,apooltablecateringforonlyasubsetofthepopulation,takeaway

foodinfoiltins,missingmilk,andpatronisingremindersaboutwashingup.

Doctors´messesIhaveknown,acrossthecountry,havefusedintoakindofuniversal

character.Withakindofmetonomy–thepoeticdevicewherebyapartrepresents

thewhole–therundown,neglected,depressingdoctors´mess–theconventional

nameforadoctors´commonroomforrestandrecreation–standsfortherun-down,

neglected doctor, and the run-down, neglected health service – “distracted”, like

newspapers, both in the superficial sense, and in the deeper sense of “pulled

apart.” The word “mess” escapes from its conventional meaning into its wider

meaningofchaos.

In the poem, a junior doctor depersonalised with tiredness addresses herself in

simple, short injunctions– likememorised stepsofemergency treatment–or like

kickingawearymule.Pause,spread,spoon,drawbreath,collapse…dream,even,but

donotsleep!

No-onecaresforthecarers,thepoemseemstoaccuse.Doctorsareresponsiblefor….

thelinebreakmakesitsreaderwait,createsamomenttoimaginethemanythings

doctorsoncallmightberesponsiblefor–checkingbloodtests,deliveringemergency

treatment,relievingpain–butalso,wheneverythingelseisdone,theirownwashing

up. Thedoctorfeelsmockedinhercomfortlessresponsibility.Inthelanguageofa

poem,shemocksback.

The line between doctor and patient becomes blurred, as the doctor is invited to

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collapseifyoumust….todrawbreathbetweentheasthmaandtheenzymes,almost

asthoughthebreathlessnesswereherown,notthatoftheasthmaticpatient.Sleep

willbecutfromunderyou,thepoemwarns,makingherintoanaccidentvictim,and

atthesametimebringingechoesofenforcedsleepdeprivation.Liketheoncewhite

clogsherhallucinatingbrainseesjostleandmutter,thedoctor´sonce-whiteidealism

andvervearebecomingwornoutfromrunningthecorridorsofthehospital.

Freshair is justadaydream,andmilk–thatfinal,maternalsymbolofcomfortand

nourishment,thatminimal,sinequanonofaBritishcupofcoffee–hasrunout.The

windowsaresealed.Thedoctorisaprisoner.

Ifthevisionisdystopian,itisneverthelesslacedwithmasochisticnostalgiaanddark

humour,suchasarecommonintheretellingoftalesofstruggle.Doctors,soldiers,

andfishermenonthehighseasmightattimespresentthemselvesasvictims,butat

othertimesromanticisethemselvesasheroes–bloodybutunbowed.Thebelief in

thecapacitytomasteradversitywhichwouldbreakotherscanbeaworkingdefence

against being overwhelmed. It can also be a dangerous invitation to hubris – a

misplacedbeliefinone´sownsuperiority:The“heroic”doctor,havingdenied,oras

shebelieves, triumphedover,herownfrailty is illequippedtoempathisewiththe

frailtyofothers.

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InappropriateADHWHOInternationalClassificationofDiseases10:Syndromeof inappropriatesecretionofantidiuretichormone (SIADH). A condition found in patients diagnosed with small cell carcinoma of the lungcharacterisedbyexcessivereleaseofantidiuretichormone,hyponatremiaandfluidoverload.–I’llsay!Toxiclittlenodule,insinuatingitselfintoprimeposition,rightwherethebreathcomesin,smugasagatecrasherataparty,peddlingpoisonasiftheverystuffofhonestself-regulation.Smallcell,itcallsitself,butdon’tfallforthefalsemodesty:youjustwatchitwringfromhimhislastmoleculeofsalt,trashallproperfluidbalance,blitzhisbrainwithfits,hallucinations,coma–youjustwatchitdilutehimtodeath.

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3.7Interruptionandinsult

Thisshortdramaticmonologueaboutrudeinterruptionsis inthevoiceofagossip,

discussingatumourwiththeatricalcontempt,asthoughitwerearudeintruderata

party.Itbeginsabruptlybyinterruptingapre-existingmedicalconversationwhichhas

been established in the title, singling out the technical word inappropriate for

deliberatemisunderstandingandsarcasticcounter-attack.Itselfarudeinterruption,

the poem´s first twowords herald a haranguingmonologuewhich takes over the

wholeoftherestofthepoem.Medicineanditsdefinitionsareneverallowedbackin

intheirownwords,thoughthebiologyofdeathbysmallcellcarcinomaisrenderedin

everydayspeech.

Instead, medicine is (unfairly) ridiculed, its technical jargon mocked, deliberately

misunderstoodasanexampleofhowinappropriatecanbeusedinpoliteconversation

asapompous,judgmentalcoverforvisceraldislike.Withdarksarcasmthegossipboth

reassertstheword´severydayuse,andmocksawordwhichappearstocharacterise

adeadlytumourincool,unemotionallanguageasmerely“misplaced”.Thetumouris

anthropomorphisedastoxic littlenodule,echoingvernacularexpressionsofdisgust

such as “nasty little madam” or “namby-pamby little so-and-so.” Small cell, an

innocentsoundingnameforadisaster,isreframedasfalsemodesty.

This poem is just a word game, but with a dark underbelly: in playing with dual

meaningsofwords,dualdialectswithinasinglelanguage,anddualperspectiveson

illness,itisnotoffering“faircomment”orreflectiveinsight–rather,itisadramatised

verbal assault by what we might see as the despairing id on the maddeningly

unemotional superego: it acts out rage and disgust at the insult of illness,

compoundedbytheinsultoflanguagewhichisbothimpotenceandsmug.Asthough

words,definitions,andfinelyturnedphraseshelped.Itisagame–inwords–about

theuselessnessofwordsinthefaceofdeath,thefinalrudeinterrupter.

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BigGameIinspect.QuietatlastonthetableIfindauniformlydistendedabdomenconsistentwithpregnancy,asweweretaughttosay.Largeforgestationalage,largeevenforfortyweeks,ortwins–despitethescan,despiteherage,it’shardtocreditthediagnosiscannotafterallbethat.Ipalpate.Findyourcharacteristicsbeneathhertautwhiteskin:smooth,discrete,mobile,dulltopercussion;fluctulantasweweretaughttosay,andsomehowsatisfying,aswewerenot.Wescrub.Gatherinbluepapergowns,aflutteringofglovedcuriosityandmaskedexcitement:priestsinthesanctuarytoblessthesacrament;carrion-fowl,atthekill.Someoneincises,breasttopubis.Skingapes,fatsplays,thetoughsheathisdivided,thefinemembraneripped,todeliveryou:fortycentimetresormoreofcysticovary,firmasanut,warmandheavyasababy,dusky,now,onyourtwistedpedicle,starvedofbloodbyyourowngreed.It'salmostashame.YoursurfaceIslikepolishedmarble,tracedwiththefinestvenules;forallyourhubris,yourcurvesliedelicateandsmoothinmyhands.Greatbean,extraordinarybean,growninsidethepodofherbytheindulgencesofstrangemothernature–sleekformintheimageofHepworthorMoore,didyounotdeserveaplinthinagallery,sothepubliccouldmarvelatyourcurvesandtracery?Butonlythepathologistwillseeyou:

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liftyoufromyourplasticbucket,cutyouupandjudgeyouoncriteriaoflegitimateinterest:contents;thickness;histogenesis;differentiation:benign,ormalignant.

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3.8Thesurgeondisrobes

Thispoemisaside-steppingofthesurgeon´s“proper”role–akindofdivestingofa

purelyprofessional viewpoint, like themomentat theendof a surgicalprocedure

whereglovesandgownsareremovedandthrownintowastebinsandlinenskips,and

normalclothesareputbackon.Butthisswitchoccurs,transgressively,inthemiddle

ofasurgicalprocedure. Inamoment´sreverie,withherhands insidethepatient´s

abdomencradlingacyst,a surgeonallowsherself to stepaside fromherhabitual,

morallypreconditionedviewofpathologyasthebadthing,whichshemusthuntand

killlikebiggame,andtolookwithartisticallydispassionateeyes.Shepausestoindulge

inamoment´saestheticappreciationforthisproductofnature,this“creature,”about

tobekilled–liketheInuithunter´smomentarypausetoreverehisprey.

Abenignovariancystthesizeofarugbyball,initiallyreminiscentoftwinpregnancy,

turnsoutoncloserartisticinspectiontohaveastrange,smooth,patternedbeauty,

likealivingsculpture.Thisneutral,aestheticobservationistransgressivebecauseitis

thedoctor´s.Whatrightdoesadoctorhavetoanaestheticviewofpathology?Has

sheabandonedherstruggleonthepatient´sbehalf,likearenegadesoldierwhohas

desertedhispost?Asuddenethicalvacuumopensup,inwhichtissueiscontemplated

merely as tissue,with aesthetic qualitieswhich can be admired, regardless of the

personal meaning to the patient or doctor. An unauthorised viewpoint has been

admittedtotheoperatingtheatre.

Theshiftisreflectedinthechangeoflanguage,whichbeginswiththeshortsentences

andbeautiful,liturgicaleconomyofmedicalprocedureandnote-taking–Iinspect...

Ipalpate...Wescrub...Someoneincises.Dutifulreferencetowhatweweretaught

tosaybeginstogivewaytoacknowledgmentofwhatwewerenot.Mentionofthe

normallytaboocreepsin–conventionallyunacknowledgedexcitement.Thethrillof

thechase–athrill Isuggestmanysurgeonswillrecognise,butwhichisnotreadily

acknowledged.Theseamoral,understandablehumanemotionalresponses,normally

contained firmly within professional codes, are now, in the poet´s imagination,

peeping out transgressively from behind themasks and gowns of operating room

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procedure.Bystanza5,thedoctorhassetasidethetherapeuticcontextandbegunto

address the pathology as you – the cyst anthropomorphised as though it were a

newbornbaby–andthewholepoembreaksoutintothelanguageofuntrammeled

imagination,likeaprisonerescaped.

It is a reflection on what a doctor is allowed to notice: about the balance and

oppositionbetweenartisticandscientific,aestheticandtherapeuticperspectives.Itis

aboutboththesadismandthelovecontainedinbothscientificandartisticgaze-both

unempathic,observationalwaysofknowing.ItisareverieIfeltpermittedinrelation

toabenigntumour,whichIsawasanunthreateninginterruptiontoalifewhichcould

resume unaffected, but one which I could not have allowed had the cyst been

malignant.Itwasanawarenessrelevanttothemedicineandartwhichcouldperhaps

onlyarise intheveryparticularthreedimensionalpsychologicalspaceofferedbya

pathologywhichwas at one and the same time unarguably aesthetic, unarguably

pathological, and unarguably benign. It was a safe perspective on sadismwithout

actuallyfeelinglikeaperpetratorofacrime.Itwalksafineline.Poetrymightbeseen

asatoolforwalkingfinelines.

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SlipItwasjustamistake.GTGforGAG–atypo,bothlookedlikenonsensetome.ImeantGAG–wasbeingsocarefultomatchtwithaandcwithg,Idon’tknowhowithappened.HowwasItoknowitwouldendinthesubstitutonofvalineforglutamateatthesixthposition?Andnowlook:Thebloodisclotting,sicklinginsideher.God.Ihadnoideaitwasacodingregion–oneslip,and…MyGod!–lookathernow–doubledandtwisted,cryingforherbaby,deadinside.

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3.9God´samanuensisslipsup

Slipwaswrittenlateonenight,whilerevisingforadifficultexamwithalowpassrate.

It seemed a Sisyphean task, rich in the kind of anxiety that might invite poetry.

Fascinatedbythematerial,butoverwhelmedatthelevelofdetailrequiredtopass

theexam,Iwaslosingconcentrationonthegeneticpathologyofsicklecelldisease.

Thewritingofthispoemofferedmomentaryescapeintoadream-likeidentification

with an imaginary, diligent, but tired and fallible transcriber of DNA. I created for

myselfapsychologicalthirdspaceinwhichIcouldre-engagewithmystudymaterial

onmyownterms.Eludingthesuper-ego´sdemandforunbrokenconcentration,the

idstolesomerestandplay–acompromiseinthatIplayedclosetomywork,rather

than far away from it, though far enough to re-establish a sense of freedom and

agency.

Ifthisisapoemwhicharosebetweenthepressureoftwoneeds–toworkandtoplay

–itisalsoonewhichmakesexplicituseofboththematerialIaminflightfrom,and

myemotionalresistancetoit.Itre-workstheobjectivematerialundertheauspicesof

feelings.HadInotbeenmentallyclosetothegeneticpathologyofsicklecelldisease,

Iwouldnothavehadtheconscious,cognitivematerialforthispoematmyfingertips.

HadInotbeeninastateofalmosthallucinatorytiredness,andfearoffailure,Imight

nothavehadaccesstoitsemotionalcontext.

The poem is a hand-wringing lament in the voice of God´s genetic editor – an

imaginarytranslatorandproofreaderwhosejobithadbeentoensurecorrectDNA

transcription and translation. On this occasion, she made a tiny, terrible single-

character error with disastrous consequences – sickle cell disease, placental

abruption,fetaldeath,andallmannerofmaternalagony.Likeasystemoutofcontrol,

thebriefpoemacceleratesrapidly,toitsabruptconclusion–themomentwherethe

fragilities of all parties concerned – dead baby, agonised mother and hapless

translator–meetintragedy.

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Anotherpoemplayingwithmedicine´stechnicallanguage,contrastingcodingregions

andglutamateatthesixthpositionwiththeeverydaylanguageofawoman,doubled

andtwisted,cryingforherbaby,deadinside,thisismoreconfessionthanchallenge.

A fallible human confesses fatal failure to the genetic creator. Her rationalising

explanatory narration, the poem´s surface meaning, is no more than an anxious

elaborationofthemortaltruth–aperformanceoffragility.Itattemptstocapturethe

fragilityofeditor,mother,babyandbiology–humanstrappedintheirownandeach

other´sinadequacies,andthedreadfulplayofchance.Itis,inawidersense,about

thefragilityofthings.184

Thefragilitywhichbecomesthepoem´sendpointwas,Isuggest,thepoet´sstarting

point–inthiscasephysicalandmentalexhaustionandfearoffailure.Thepoetseizes

the opportunity to transform andmetabolise these by working them into a form

emotionally recognisable to others. Or put anotherway, uses her own exhausted

anxiety,which is nomore nor less than the trace of her sentient humanity under

pressure–astheenginetodriveapoem.Itisthroughfirstmergingwith,andthen

wrestlingwith,thesubjectmatterthatthisisachieved.Itinvolvesenteringakindof

intersubjective,interpersonalrelationshipwithaninertbutpromisingmaterial.185The

poet lends the subject matter her empathy and emotional liveliness, while

“borrowing” its fixedexternality, itsenduringrealness,asacontainer.Thisparallel

givingandtaking.Throughthismergingofme,andnotme,181andthenwrestlingwith

thematerialinakindoflovingfight,anew,thirdobjectandanewsetofemotional

circumstancesarises:adrysubjectmatterhasbeenenlivened;anoverwroughtdoctor

hasdischargedaburdensomeemotionandfoundanewwayto“inhabit”herwork.A

brief psychological intervention has resulted in short term relief (restoration of

pleasure),theproductionofsomethinglaterdeemedusefulorpleasurablebyothers,

andthekindofeverydaygrowthwhichcomesfrompractisingaskill.

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SexeducationforboysIfnewlifeistooccuryoumustfirstfindstrength,speedanddeterminationtopenetratethepellucidzone,proteoglycanprotectorofherhaploid,double-Xcontents,thatthick,softshellwhich,thoughsee-through,istougherthanyoumightthink.OnlyifyouprickthatjelliedbubblecanyouhopetofuseyourDNAwithherssealthemembranetoothercomers,andimprinthercytoplasmwithyourgenesforposterity.Itwillcostyou.Allthosesharpenzymespoisedinyourarrow-head,allthemitochondrialreservesofenergystoredtightinyourendoplasmicreticulum,allyourglycolyticstrategies.Andwhetherit’llhappenandwhetherit’sworthallthatinanycasedependsentirelyonwhoyouare,andwhosheisandhowmuchyouwantit.

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3.10Seriousteasing

Thispoemisatease,andaromp,inandwiththelanguageofreproductivebiology.

Usingfertilisationasametaphorforsexualrelatingbetweenamanandawoman,it

addresses itself in the half-mocking voice of an olderwoman offering advice to a

youngman.

Reducing the serious biological business of reproduction to a meremetaphor for

erotic and relational connection, this poem lectures boys from an adult woman´s

perspective,ontheemotionalconditionsoffemalesexualaccessibilityornewlife.Like

thefairlytalehero,hemustovercomeobstaclesandprovehisworth,intheformnot

onlyofdesireandprowess (strength, speedanddetermination), and theability to

overcomeresistance(theproteoglycanprotector...thatthicksoftshellwhichthough

see-throughistougherthanyoumightthink),butalsotheunreservedcommitmentof

energeticresources(allthemitochondrialreserves)andcreativecleverness(glycolytic

strategies). The tone is flirtatiously tough – the language that of hard-headed

bargaining. It is both serious and playful, warning and inviting, and laced with

innuendo(prickthatjelliedbubbleandothercomers).

Partoftheteaseistheuseofboyish,action-movielanguageofreproductivebiology,

andit is inpartateaseofthatlanguageitself.BiologicalLatin´szonapellucida,the

egg´sprotectivelayerwhichthefirstandfastestspermmustpenetrate,isironically

anglicisedtopellucidzone–moreStarWarsthanIVFlaboratory.Likeaheroictaleit

laysoutthenear-impossibleobstaclestheromanticheromustsurmountinorderto

winthegirl.

Thepoem´sdramaticfulcrumistheshortline:Itwillcostyou.Inthelanguageofstreet

bargaining,itwarnsagainstemotionallyimmatureapproaches–againstthefantasy

ofpleasurewithoutrelationalresponsibility.Partwisecounsel,itisalsopartthreat.

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3.11Witnessingtheemergenceofapoem:self-analyticrawmaterial

Havingpresentedeightpublishedpoemsintermsoftheireffectsandorigins,Inow

offeraninth,unpublishedpoem,BoneTalk,withadiscussionofthewritingprocess.I

makenoclaimsforthisflawedpoemotherthanthat,immediatelyafterwritingit,I

alsohappened,formyowninterest,tohavewrittenacontemporaneousaccountof

thewritingprocess,usingthekindofblow-by-blow,self-analyticapproachusedby

MarionMilnerinOnNotBeingAbleToPaint.24ThisisamethodIalsofollowedina

master´sthesisonvisualart.23Theaccount,whichfollowsthepoeminfullbelow,can

broadly be summarised as describing 1. a libidinal bid for escape fromwork into

creative pleasure, followed by 2. a prolonged phase of concentrated, dream-like,

constructivework-play,concludedby3.consciousrefinementoftheproductwitha

readerinmind.ItisaprocesswhichcanreadilybereadintermsofEhrenzweig´sthree

stageprocessofmakingapieceofart,143144whichIwilldiscussinthenextchapter.

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BoneTalkOthershaveantlersorbeaks,wehavebonesforsupportandstructure,strong,fragilethingsonwhichwecandepend.Thattissueswrenchandunderminethem,eachtendontuggingitsownway,eachnerveandvesselstrainingonlyforitsownsafepassagethroughthematrix,yousenseintheforbearanceofgrooveandprominence,eminenceandtubercle;toeachcanalitspropersinus,eachcondyleitsepicondyle.Feelforthemarrow’squietebbandflow,thecirculationofclastsandblasts,andpausetoblessthedrybonesofthedead,thesoftbonesoftheunborn,theshackledbonesofchildreninacellar.Takecareofeachepiphysisanddiaphysis,growth-plateandshaft,head,andneck:lestsomedayyoushatterintobloodyfragments,twistedasagreenstick,ordryasabiscuit.

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Self-reflectivecontemporaneouslywrittennotesontheprocessofwritingapoem:BoneTalk

Bone Talk began as a response to the language of bones, its associations, and its material

qualities.Revising foranexam, I cameupona text fullofbonewords–condyle,epicondyle,

groove,prominence,eminence,tubercle–lovely,strangethingswhichIwantedtocapture.The

desireseemedprimitiveandlively,likeachild'sdesiretoplay-or,asadultsmightseeit,"mess"

–withgrown-upmaterialsproperlyintendedforotherpurposes.Oneofmychildrenwasonce

found,agedone,havingescapedthecot,blithely“painting”innappycreamonthewall.This

imageofinnocenttransgressioncapturesformethespiritofcreativity:nappycream,orwords,

canbeborrowedorstolenasavehiclefororiginalexplorationoftheworld,andoneself.

My“poet-self”–asomewhatchildlikecharacter–hadborrowedorstolenthesewordsfrom

my“professionalself”.Thepoetwantedthemforsomethingbeyondtheirmedicalfacevalue–

fortheirpowertoconjureadream-like,anatomicallandscape,totellstories,andalsoforthe

sheerpleasureoftheirphysicalproperties–thesoothing,liturgicalwaytheytripoffthetongue

andstriketheear.Ratherthanallowingthemtoremainconfinedintheirconventionalsemantic

boxes,staticsubjectsdefiningfixedobjects,thepoetsawthemasobjectsinthemselves,tobe

exploredandenjoyed–takenoutoftheanatomyroomandshowedofftofriends,bathedin

one´sownemotional responsesasbeautiful, fascinating, recontextualised things. In showing

bothfindingsandfeelings,bothmaterialandself,thepoetislookingforcompany–invitinga

readertoplaywithher,withthesewords.

Structurally,BoneTalkbeganlikeotherpoemsasa"bagofbits."Therewerefarmoredesirable

wordsthancouldbeaccommodatedinthepoem–spaceisalwaystoosmall,justaslifeisalways

tooshort–sothepoethastostartsomewhere,committoaprocessofcondensation,andaccept

that some words will fall away, including some good ones. This capacity to accept loss of

desirableelements,tomournandrelinquishthemandacceptlimitation,inKlein´sterms,ispart

ofthelearnedskillbothofwritingapoemandofbecominganadult–askillneveracquiredonce

andforall,butlearnedandrelearnedthroughpracticeandcourage,inthefaceofapersistent

unrealistic,childishdesiretoincludeeverything,haveeverything,losenothing.

At this stage, thepoemwasn't laid out in sentences, but existed as groupingsofwords and

phrases, fragments scatteredon thepageor in theelectronicdocument in thekindof loose

arrangementwhichismyhabitwhenbeginningapoem:6or7stanzasof3to6lineseach.Each

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fragment was a complex of raw material loosely rendered or elaborated by early personal

responses. Individual words, newly arrived into my internal world, laden with imaginative

potential andpromisingdoublemeanings,are,by the time they reach thepage,wrapped in

traces of my own thoughts or feelings. Like digestion, or immunological processing – the

renderingandpresentationofnewlyinvadingmaterialincombinationwith“self-representative”

proteins,soastoenablefutureintrusionstobemetprocessedwithminimumdysregulation–

thesewordsare“rendered”forpersonaluse.

Thiscompositematerialisstillmuchtoorawforinclusioninthefinalproduct,butInowhave

mywork laidout:theworkofmakingthepoemwillrequire(asaprocess)andbecome(asa

product)theintegrationofthesetwo,innerandouterreality,inamannerpresentabletoathird

party–areader.Imust“format”thebiologicallyrealsubjectmatterofbonesandthephysically

realmediumofwordsviathefilterofmyresponses,soastoimbuethem,butnotoverloadthem,

withatraceofmyhumanpresenceorliveliness.Theaimistoenhance,butnotoverload,the

subjectmatterwithpersonalresponses.Havingbeendisturbedandexcitedbythematerial,my

innerworldmustgotoworktoreassertitself;anegotiationmustbebrokeredbetweeninner

andouterexperiencewhichleavesroomfortheauthorityofboth; inotherwords,aworking

intersubjectivespacemustbecarvedoutoftheslipperyandresistantmaterialofwords.

Theideathatbonesarebreakablesuggestsitself,asamatterofbiologicalfact,earlyoninthe

process,hencetheideaoffragilitycreptintoeventheearliestdrafts.Rapidly,fragilitytookover

asatheme,re-emerginginthefinalstanza´sviolentimagery,andofferinganarchitectural“arc”

forthepoem´sdevelopment."Twistedasagreenstick",and"dryasabiscuit,"imagesreferring

totypesoffracture–seektogroundapoemwhichisotherwisethreateningtobetoodreamy

andloose.

Asthepoemdevelops,Idivedownintoakindofenquiryintothesubjectmatter.Itisasthough

Iwereaskingmyself,orasthoughmyconsciousmindwereaskingmyunconsciousmind–which

isfullofimagesandassociationsandadifferentkindofknowledgeabouthowthingsconnect–

whatit“is"aboutbonesthatmightbeworthsaying.Whatisthepointaboutbones?Whatisit

thatbonesmightmetaphorise?Myansweringofthisquestioninevitablytakesonthemarkof

myownpreoccupations.

Inaway,thewordgameorexplorationwithwhichthewritingbeganismorphingintoaself-

analyticenquiryintomyownoriginalinterestinthewords,muchasatherapistmightenquire

moredeeplyintoapatient'ssurfaceresponsetoaquestion.What'sthisabout,really?Iseemto

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beaskingthepoem,andalthoughitostensiblyrelatestowhatbonesare“about,”theanswers

come,willynilly,intermsofwhattheyrepresentforme,andthereforeaboutwhatIamabout.

Instinctively,inevitably,asallofusdowithallmaterialsatalltimes,Iprojectmyimaginative,

psychologicalworldintothematerialinhand.Thepoem,therefore,comestoreflectmeasmuch

asitisareflectiononbones.ItbecomeswhatWinnicottcalledatransitionalspace–bearingthe

unmistakablehallmarksofbothmeandnot-me.

The particular preoccupation I find has been stimulated by the bone words and their

associations,andwhichIfindmyselfprojectingintothematerialisakindofmeta-psychological

interestintheself,andtheintegrityoftheself.Theself´sfragilityandstrength.Howdothose

relate to each other?Where does the boundary lie?When andwhere do you need to pay

attentionlestsomethingdreadfulhappen?Thebonesarestillpresentintheirownright,butare

alsobeginningtobecomeavehicleforsomethingelse.Theyhoverinthepoemasbothliteral

andmetaphoric,takingonanimaginativemultidimensionality.

SohereIam,inthemiddleofthepoem,wrestlingwithwords,justasthetissueswrestlewith

bonematrix, undermining, tugging, and straining to findmy own safe passage through the

medium of the poem, seeking to bring awareness to bear on this material. It is an act of

penetration,orimposition,butinordertowork,itmustalsobeacollaboration:thewordsmust

remain true to the bones, and accessible to a reader, not simply overloaded with personal

material.

As I write the second and third stanza, these hidden preoccupations begin to emerge. My

consciousmindisbusywithbonylandmarksandtheiranatomicalandfunctionalimportance,as

doctors,ormedicalstudentsknowthem;whichtendonormuscleattacheswhereandwhatthis

meansfunctionally.Butwhilemyconsciousmindisthusoccupied,andthereforeinsomesense

“outoftheway”-asT.S.Eliotsuggeststheconsciousmindneedstobeforapoemtoemerge-

other,associativethoughtsandimagesarebubblinguplikedreamsinthe“backroom”ofmy

mind: my unconscious mind is engaged in a kind of reverie or meditation on containing-

structures-which-when-stressed-are-strong-but-not-unbreakable.An imaginativeabstraction is

taking place, without fully letting go of the bones-as-metaphor: a discourse about forces,

containment,andbreakingpointsistakingshapewithinthearmatureofthebone-ideas.Iam

scanningmyawarenessforotherinstancesofthesethings,inawaywhichfeelsmoreintuitive

thanidea-driven:moreemotionalthanmental.Theconsciousmind,trainedwithdifficultyinto

adegreeofhumility,forthesepurposes,seemstobeenquiringrespectfullyoftheunconscious:

whatdoesthisremindusof?Asthesedeeperconcernsemerge,Icanfeelaspaceopeningup

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inside myself and inside the poem´s structure – a resonance chamber between literal and

metaphoricalmeanings.

Asmyworkwiththepoemdevelops,theworkedandre-workedconscious,subjectmatterof

thebonesand themuscles, itselfbecomesa temporary container,or chrysalis,withinwhich

something softer and darker and less consciously formed begins to emerge. I know from

experience that this emergence is important in bringing life to the poem. I also know that I

cannotcontrolthisinafullyconsciousway.

Somepoetstalkaboutthisprocessintermsof"listening"tothepoemanditsimages.Eventhat

almostsoundstoomuchlikeanactiveprojectthattheconsciousmindcandrive.Itfeelstome

morelikeadiviningordowsingprocess,lesslikeanactive,questingstanceandmuchmoreof

anopen,expansive,soft,receptivestance:somethingmorelikeanantennatuningintodifferent

frequencies,oramid-cycleendometriumpreparingtoreceiveanembryo.

Fromoutofthis“deeperdivining,”theideapopsintomyconsciousmindof“themarrow'squiet

ebb and flow, the circulation of class and blasts” – language borrowed from craniosacral

osteopathy,inwhichitiscustomarytopalpatingthecraniosacralrhythm–apracticeIwasonce

invitedtotry. Intermsofthewriting, thisseemstobeanexpansionandblurringawayfrom

Westernmedicine,andintolessconscious,moreinstinctivepartsofmyself.

Thepoem,orrathermywritingprocess,thentakesaseriesofsuddenandprobablyill-judged

turnsfromanOldTestamentreferencetoEzekiel'sValleyofdrybonestoasudden,shocking

referencetotheshackledbonesofchildrenfoundinanorphanagecellaratHautdelaGarenne.

Adoubtfulandloosestanzaendswithaninjunction,apparentlytothereader,presumablyin

facttomyself,totakecare. Iappear,suddenly,tobetryingtogetatsomething–somewhat

clumsily.

Each time unconscious process has interrupted the conscious mind's play, the resulting

countercurrenthasbeguntoopenthingsup,andthepoemhasbecomemorethreedimensional

andlively.Thisrequiresakindofacquiredorlearnedhumilityonthepartoftheconsciousmind;

awillingnesstosetasideitsup-frontshaping-and-structuringambitionsforjustlongenoughfor

somethingnewtoemerge.Itinvolvesawillingnesstotoleratetherelinquishingofcontrol,and

thesurrendertouncertainty,apsychologicalrisk,preciselybecauseeachpermittedincursionof

unconscious material brings, along with liveliness or depth, the risk of greater chaos, of of

spoiling what is already there. In addition, every new uconscious incursion entails more

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integrativework,tointegratingthestructureofthework.Inthiscase,itseems,thenewmaterial,

liketheEzekielreference,seemstogotoofar,breaksthestructureofthepoem,andspoilsthe

workalreadydone.Creativityisnotarecipeforsuccessbutforliveliness.

Theconsciousmind,presentthroughouttheprocessthoughnotalwaysincontrol,actsinthe

finalstagesastheelectedambassadortotheoutsideworld,withspecialresponsibilityfortaking

careofthereader´sexperience.Theconsciousmindisthepoem´sfirstreaderandeditor–the

morecritical,thebetter–andisonthelookoutforbadnotes,lazyorself-imitativehabitswhich

donotservethepoem.Inthiscase,forexample,thecriticvetoedasentimentaluseoftheword

“cherish,"separatedoutthepenultimatelineforemphasis,debatedaboutwhetheritshouldbe

“you”or“they”whoshattered.Itrequiredrevisionofahabitualuseofaninjunction–“listen!”

asadeviceforchangingtheemotionalenergyofaline,becauseitdidnotfitandwasmoreofa

self-importantflourishwhichgot inthepoem’sway.Workalittlehardertobefaithfultothe

poem, the editor urged. Stop trying to impress. As I work on this individual poem, or any

individualpoem,Iamalsochallengingmyselftodevelopasapoet.

Thewholeprocessremindsmeoflearning,whiletraininginpsychosexualmedicine,tosetaside

interventionswhichservedmyneedto"feeluseful"morethantheactualneedsofthesituation.

Atendencytosaytoomuch,forexample,totakeuptoomuchspaceintheconversation,totry

and"takeover"thinkingonbehalfofthepatient,ortoadoptsoempathicarolethatIdenymy

patient the space to feel the anxiety or space inwhich theymight - usefully and properly -

discoversomethingnewforthemselves.

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Whatisthepointofaself-analyticexercisesuchasthis?Clearly,understandingwhereapoem

came from andwhy is not its point. It is not necessary to understand the poet´swriting

experienceinordertoappreciateapoem´sweaknessesormerits–oncewritten,apoem,

likeanyartorotherpieceofwriting,muststandorfallfreeofanumbilicalconnectiontoits

author,andbiographicalorpsychologicalbackgrounddetailisarguablyirrelevanttoapoem´s

valueorreception.

Thepoint,Isuggest,isthatthesekindsofreflexivedataoffertheonlykindoflongitudinal

imagingwehave–datagatheredinrealtime,albeitretrospectivelyrecorded-oftheinterior

aspectsofcreativeprocess.Thisaccountattemptstoshowthereal-timebuildingofapoem-

material-reader relationshipwithin the person of the poet, in ways which are otherwise

invisible and unmeasurable – to show what actually happens when a physical material

connectswithathoughtandafeelingandthethreebecomeembodiedinsomethingnew.

Itisallverywellexaminingtheeffectsonareaderofthe“facture”ofafinishedpoem,–as

Idid in the firsteightpoems –of thephysicaleffectof legatoorstaccato,alliterationor

assonance; vowels ringing with onomatopoeia; pulses like a heartbeat or breath; how a

phrase conjures sensory memory and the emotion which clings to that; where a word

suddenlyfizzeswithdoublemeaning,orsmacksyouinthefaceafteralinebreakbecauseit

isnotwhatyouwere led toexpect.Butnoneof this tellsusanythingdirectlyaboutwhy

valuabletimewasspentcreatinganapparentlypurposelessproduct,andhow,privately,the

poetnegotiatedwiththematerial,topersuadeorcoerceitintotheserviceoffeeling-in-need-

of-expression.Ifpracticalcriticismoffersacrosssectionalview,whichaddressesthequestion

“what has been done,” self-analytic accounts of creative work add longitudinal data

answeringthequestions“why”and“how”ofcreativeprocesses.Theyaddressthequestion

ofhow,asitwere,spirit,becomesembodiedinmatter.Itisalittlelikefetoscopy.

Suchprivate,psychologicaldataarenormallyhiddenfromviewintheprivacyofthepoetor

artist´sheadorworkspace,possiblyburiedsomewhereunconscious. Paintershavebeen

filmedpainting–KarelAppel,forexample,whosealmostviolentengagementwiththecanvas

explainssomethingofthelivelinessandspontaneitywefeelwhenviewinghiswork.186Butit

isof limitedvaluetoseeonlytheexternallyvisibleobjectiveaspectsofwhat is inpartan

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internal,subjectivelydrivenprocess.Fordeeper insightwerelyoncontemporaneous first

hand accounts, in the tradition of Paul Valery187 or Marion Milner.24 And although

introspection is prone to recall and self-observation bias, andmust beweighed as to its

plausibility,internalconsistency,andconformitywithknownexternalpatterns,andaesthetic

validity,171 self-analyticaccountshavebeen important indevelopingunderstandingof the

processandpointofart.

KeyMessages

• Reflexiveaccountscangiveessentialinsightintootherwisehiddencreativeprocesses

• Poetry,likeothercreativeactivity,demandsamixtureofcraftandintuition,consciousandunconsciousintention

• Poetryissemiotic,embodyingandshowingwhatishardtotell,semantically• Poetrymakesareaderfeelsomething,ratherthanmerelythinkingsomething• Itinsistsonphysicalelementssuchasalliteration,assonanceandrhythm,wherein

prosetheseareoptional• Poetryisseductive-usespleasuretoinvitesurrendertoanintimate,intersubjective

encounter• Itmakesuseofdualmeanings,allusion,andunconsciousassociation• Poetryiscapableofbeingtruthfuloruntruthful,andbadorgood

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Chapter4–PoeticprocessandpurposePoetry...istherevelationofafeelingthatthepoetbelievestobeinteriorandpersonalwhichthereaderrecognizesashisown.SalvatoreQuasimodo

Keywords:rawness,benignregression,conscious-unconsciousbalance,integration,voicingtheinexpressible

4.1Thisobscureimpulse:wheredopoemscomefrom?

Ifwelookatwhatartistsandpoetshavetosayabouthowtheirworkarises,manyspeakof

arawimpulse,need,orburden–GottfriedBennreferstoadumpfer,schöpferischerKeim

(nagging,creativeseed),188T.S.Eliottosomerude,unknownpsychicmaterial,189Szirtestoa

smell,169 and Newton, a psychoanalytic commentator on painting, to the primitivist

impulse.190Inthelastchapter,Ioutlinedtheroleofsuchimpulsesininitiatingmyownpoems

–forexample,adesiretoescapefromworkintoplay,torebelagainstprofessionalconstraint,

ortorailagainstthelossofwalking.

Whether artists and poets are particularly vulnerable people who feel such burdens

especiallykeenly,orwhether,havinglearnedaknackforturningpsychicburdensintocultural

capital, they come to view intense feeling as valuable raw material, is debatable.

Psychoanalysis has always understood art as a special response to the vicissitudes of

experience,butFreud tookanarchviewof it asa kindof infantile “messingaround”–a

chaotic,ifrich,primaryprocesswhichrepresentsanescapefromreallife.Heviewedworks

ofart in largelyreductionistwayswhichignoredthevaluepeoplefoundinthem,asmere

encodedsymptomsoftheartist’spsychopathology.191

Kleinian commentators such as Stokes192 and Segal193 194 presented a more optimistic,

developmental view of art´s psychological purposes and achievements as a means of

processinganxietyorconflict inembodiedform,whileobjectrelationsanalysts,withtheir

emphasisonintersubjectivityastheveryconditionofpsychologicaldevelopment,sawartas

anintersubjectivephenomenon,involvingatleasttwopeoplefromitsinceptionrighttheway

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throughto itsreception.Winnicott inparticular identified itasaformofplay,vitaltothe

growth of the individual and culture at large. (Indeed, play, in Winnicott´s terms, is an

absolutepreconditionforgrowth, itsabsenceadevelopmentalemergencywhichmustbe

addressedbeforeothermeaningfulworkispossible.195

ButitwasAntonEhrenzweig,anartist-analystwhosepsychoanalytictheoryarosefromhis

own painterly practice, who developed the first coherent psychoanalytic theory of the

creativeprocess,anditsrelationshiptothequalityandsuccessoftheartisticproduct.143145

RejectingFreud´sideaofprimaryprocess,whichhadofferednohelpinunderstandingeither

howart ismadeorwhy anyonebeyond the artistwould care for it, Ehrenzweig did two

important things. First he identified the balance of conscious and unconscious elements

requiredtomakeaworkofartgood,creatingadistinctionbetweenarticulateandinarticulate

formelements.143 144 Secondly, he identified threedistinct phases in the creative process

whichtheartistmustundergoiftheproductistosucceed.

Inathreestagemodelfromthe1950s,Ehrenzweig,describesthisinitialimpulseasprojection

–theexportingofprimitivepartsoftheselfintotheartmaterialinabidforpsychosomatic

merging,theboundariesbetweenselfandtheoutsideworldtemporarilysuspended.144Itis

a gesture psychologically analogous to the infant´s cry, smile, or outstretched arms – an

appealtotheenvironmentforthekindofreceptive,containing,interpretingresponsethat

willsupportdevelopment.

Unlessyoubecomelikelittlechildren,youwillnotenterthekingdomofart,Ehrenzweigseems

tobesaying.Inhismodel,anartmaterialperformsaserviceforanartistlikethatamother

offersher infant,oratherapistherpatient: abenign,tolerantmatrixorframeyieldsand

accommodates,but isalsoseparate, substantial,andmakescounter-demands,promoting

maturationevenasitsupportsandchallenges.185Theartist’s innerworldmergeswiththe

materials, inwhatWinnicott characterisesasa transitional, “meandnon-me” space.The

infanthaspermissiontomergeandmuddleelementsofhimselfandelementsoftheoutside

world,unchallenged.181

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For the purposes of a thesis on poetry´s contribution to health, two things are worth

reinforcingabout this kindofdevelopmental, transitional space.One is theunconditional

accommodationoradaptationrequiredinitially,andtheotheristheresistancethatmustalso

beoffered, ifdevelopment is to takeplace. In themother-infant reverie, innerandouter

elements,orselfandother,mustbeallowedtofuse,symbolically.Theymustnotbeforcibly,

prematurely separated or reduced into separate elements – “analysed,” if you will. The

motherwhomakesdemandsonherinfantwhichhecannotyetmeetviolateshisintegrity.

Somethingsimilarappliestootherformsofcreativemerginglaterinlife.Tothechildplaying

imaginativelywithahobbyhorse,Winnicottemphasises,thehobbyhorseis,temporarily,in

akindofnecessarysuspensionofdisbelief,ahorse,andtoassertthatitismerelyastickof

wood is a violation of the creative reverie.195 Likewise if a therapeutic relationship is to

develop,atherapistmustaccommodateapatient´sraw“bitsandpieces”ofthoughtfeeling

andaction,withoutinsistingonconventionalorderorcommonsense.Inallthreeexamples,

abasicneedismetbymeansofsomeoneelse´sgrace,ratherthanviarightorreason,butin

eachcasethisgraceistheabsolutepreconditionforsomethingvitaltooccur.

Soyieldingisessentialattheoutset,andthematrix–themother,theartmaterial,orthe

therapist-mustbeaccommodatingandwelcomingenoughtoreceivetheprimitivegestures

aswellasstrongenoughandmalleableenoughto“hold”or“contain”themwithoutbreaking

or retaliating or punishing them. But an inbuilt propensity to offer resistance by “being

oneself”isequallyessential,becauseinthis,thematrixalsofunctionsasatruerepresentative

oftheoutsideworld.Anartmaterial,motherortherapistwhich/whosimplyreflectedfantasy

in a completely passive, compliant way, would be too insubstantial to be useful as a

representativeoftheoutsideworld.Acreativemediumisinitiallyreceptive,butalsoimposes

therigourofitsowninalienablecharacteristicsandlimitations.185190196197

Theanalogybetweeninfancy,therapy,andart,onlygoessofarbeforeweneedtodrawa

distinction in termsofwhosemind is fulfillingwhich function. In this, theartistdiffersby

playingtworolesatthesametime–onepartoftheself,asitwere,parenting,orhelping,the

other. Unlike the infant or patient who relies on the external agency of the mother or

therapist´smind tohelpmetaboliseunintegratedelements of lived experience, the artist

playsbothrolesinparallel.Havingusedherexternalmediumormatrixasarepositoryforher

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primitiveprojections,shethenturnstoherownmoresophisticatedpsychologicalcapacities

toprocessthem.Shebringstothematerialbothherprimitiveprojections(hersensitivityto

provocationby theoutsideworld´s impingements anddemands) andherquasi-maternal,

quasi-therapeuticcapacityforworkingthrough(hermaterialskillsandartisticexperience).

Ofcourse,sheisonlyableeventobegindothisforherselfwithpractice,aftermany,many

“doses”ofgoodnessreceivedfromcreative“foster-parents-”otherartistswhoseexamples

haveinspiredandnourishedher.

Intryingtograspthisprocesswherebyrawexperienceiswelcomed,containedandturned

intogrowth,Bion´sdevelopmentalmodelofthepsycheishelpful.Ifrawexperienceisnotto

“stickinourcraw,”asitwere,likeacollectionofhard,indigestible,anddistressingobjects

whichBion called thesebeta fragments – helpmust be available to transform them into

somethingdigestibleandnourishing–inBion´slanguage,alphaparticles.InBion´smodel,

themotherortherapistactsasbothareceptivepsychological“container”plusamindwhich

canhelpdigestindigestibleexperience,or,inBion´slanguage,performalphafunctioning.198

Givensuchaspaceandsuchamind,distressingproductsofindigestiblelivedexperiencecan

betakenoutoftheembodiedself,wheretheylodgeasaforeignbodiesorintrusions,and

“re-embodied”insharedexperienceviaverbalorvisuallanguage,makingthembearableand

tractable.Atroublesharedisatroublehalved,asthesayinghasit.Thiscanbeseenofasa

kindof“meansofgrace”–somethingunearnedinanytransactionalsense,butneededbyall

ofus,atdifferentmoments,andreceivedasagift.Andpoetry´sgift,when itworks, is to

speaktoandforusaboutourowndeepest,mostrawexperience;thepoetexpresses,“in

verse–usingallhisresource,ofwords,withtheirhistory,theirconnotation,theirmusic–

thisobscureimpulse”.189

4.1Wrestlingwiththeangel:joiningthingsup

Eliotassertedthatpoetryisnecessarilydifficult,acommentSzirteshasinterpretednotasan

aim,butaconditionofpoetry.169Lifeisirreduciblycomplex,Szirtessuggests,andthepoint

ofEliot´sassertionwouldbethatthepoetmust“makeawholeofoutfragmentsandshards.”

(Szirtesibid)Inotherwords,ifprojection–thespewingofabunchofwordsontoapage,or

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thehaphazardattackona canvaswithpaint – is anecessarybeginning toart, it is not a

sufficientend.Inordertomeettheaestheticrequirementswhichcansatisfyarecipient,and

therefore the artist´s own need to be heard, theremust be a successful strugglewith a

material,andfacingthisrequiresoftheartistacertainstanceordispositionoftheself.

Elementsof this stancearecommontoanycraft, suchas surgery, cookingorplumbing–

knowledge and experience combined with diligence and close attention to external

phenomena–theconcentratedgivingofone´strainedmentalandphysicalselftoataskin

hand.Butincommonwithotherlessutilitarianpursuits,poetry,likepsychotherapy,play,or

prayer, also requires attention to internal phenomena, a particular kind of open-minded

listening, and submission to a process whose outcome (like life itself) is not consciously

controllable. It demandspsychological risk-taking, andacceptance that success cannotbe

guaranteedup-front.Hencetheseactivitiesrequire,inadditiontoskillandconcentration,a

particularhumility:awillingnesstocommittimeandenergytoengagingwithwhatonecan

neverhope fully tograsp. This statehas variouslybeendescribedbypoetsandartists as

strugglingwiththeoctopus169orangel.189

ReturningtoEhrenzweig´stheory,wefindanexplanationforhowitcomesaboutthatthis

octopus-wrestlingyieldsgoodart,andhowitispower-sharingbetweentheconsciousand

unconsciousmindwhichistheguarantorofthatgoodness.InEhrenzweig´ssecond,manic-

oceanic stageof the creativeprocess, thework initiatedbyprimitiveprojectionproceeds

under the auspices of the unconscious mind. Using unconscious scanning, a formulation

markedlydifferentfromandfarmoredeliberatethanFreud´s(chaotic)primaryprocess,the

artistisactivelybutunconsciouslyintegratingthework’ssubstructure.Astheworkdevelops,

articulate form elements – those obviously articulated structures and shapes which are

created by the conscious mind and will present themselves to the recipient´s conscious

awareness–are,crucially,balancedwithinarticulateformelements.Thelatteremergefrom

theartist´sdepthmind, andareessential toaestheticdepthand integrity,addressing the

observerunconsciouslyatthesametimeasthearticulateformelementsaddresshimorher

consciously. In painting, inarticulate form might reside in textural elements such as

brushstrokes, impastoandapparently randommarksordrips; inmusical performance, in

glissandi,vocalbreaks,andotherunscriptedphysicalphenomena. Inpoetry, it isso-called

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poetic devices, such as alliteration, assonance, rhythm, repetition, onomatopoeia, and

doubleentendrewhichcarrythepoem´semotionalweight,addressingthelistenerphysically

andemotionally,unmediatedbycognition.

Thispieceoftheoryrepresentedanimportantdevelopmentinunderstandingcreativity.Via

Ehrenzweig´s acknowledgment of the essential role of regression and unconscious

structuringinart,psychoanalysishadforthefirsttimedeliveredanaccountofthevalueand

processesatworkinart,intermswhichartistsandartloversrecognised.190197Isuggestit

alsoprovidesthebasisforunderstandingtheriskwhichcreativityentails,andallowsusto

explain why creativity is therefore resisted, within individuals and organisations.

Ehrenzweig´scontributionistoclarifythatcreativityrequiresregression–acompromising

state associated with infancy and other forms of powerlessness, generally felt to be

incompatiblewithpowerintheadultworld.Evenartistscontemplateitwithambivalence:

Stokesdescribestheanxietywhichattendstheaggressiveactofdefacingavirgincanvas,in

thefullknowledgethatoncemade,theinfractionwillhavetobemadegood.192194Myown

ninthpoemfromthepreviouschapter,BoneTalk,bearingtheembarrassinghallmarksofnot-

quite-succeeding,exemplifiestheriskoflossofface.Becausethenecessarymanic-oceanic

phase of creativity is outside conscious control, it is by definition unamenable to

systematisationand instrumentalisation,hence it isnotpossibletoguaranteeoutcomes–

even if this is howyouearn your living.Nowonderwe resist creativity: Failure canhave

existentialconsequences.

Because creativity occurs beyond the protection of guarantees and existing security

structures, itcarriesexistential risk.Hence, if itbegins insensitivityandvulnerability, it is

completedinresilience.Thisbalanceisimportanttounderstand,becauseitdetermineshow

far–uptowhatprecisepointofintersectionbetweendesireforfreedomandneedforsafety

–wearewillingandabletogo,asindividualsandgroups,indevelopingourselvescreatively.

Thequestionsweallfaceare:Howmuchpredictability,equilibrium,comfort,andprotection

willwesacrificeforthesakeoflivelinessandrenewal?And,ontheotherhand,Howmuch

constraintwillweacceptforthesakeofsafety?Atoneendofthespectrumliesalarming,

Nietzscheanabandonmenttocreativechaos;attheother,thestiflingpredictabilityBollashas

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called“normoticillness.”Lifecanbeseenasanexcerciseinnavigatingourownsweetpath

betweenthetwo.199

Inamaster´sthesisonrawnessinvisualart,23Iproposedthenotionofanindividualsweet

spotbetweenchaosandnormosisasatoolforthinkingaboutthepsychologicalrelationship

between the so-called inherentvalueofaworkofart, and the stylisticpreferenceof the

observer. Different observers prefer a different visual balance between “finish” and

“rawness”inpainting,orinpoetry,betweenwhatissaidexplicitlyandwhatisonlyimplied,

feltorleftopen.Butifpreferencevariesbetweenindividualsandgroups,howcantherebe

suchathingasgoodnessinart?Whatdothesetastedifferencesactuallyreflect?Whyisone

person´s “accomplished, fine art” another person´s “chocolate-box cliché”, while one

person´s “brave representationofdifficultmaterial” is anotherperson´s “horriblemess”?

And how is it that somuch art which later becomes canonised200 begin its life by being

resistedandreviled?

Isuggestthemistakewemakeisintheshorthandofseeing“goodness”asafixedproperty

ofadecontextualisedwork(albeitonewhichwecanifnecessaryagreetodisagreeabout),

withoutseeingthepartweplayinco-constructingtheexperience,withourownpreferences

andprojections.Toconsiderqualityinartmoreprecisely,Isuggestweneedtoseeitasan

embodied-relationalphenomenon–amaterialentitywhichisactingmoreorlesssuccessfully

asarelationalvehicle.Goodnessthenbecomesaboutthequalityofcommunionagivenwork

affords between a given artist and a given recipient, or range of recipients. Quality still

dependscruciallyontheworkandtheartist,butisonlyeverrealisedintermsofthescopeof

itscapacitytocommunicate.Fixednotionsofrightandwrongcanbereplacedwithmore

dynamicnotionsofsensitivityandfit.

“Goodness”inart,Isuggest,occurswhentheartist´ssuccessfulstruggleforself-containment

and self-articulation is sufficiently palpable as a kind of “souvenir” in thework, but also

sufficientlycleansedoftheartist´snarcissismtoserveasanaccountoftherecipient´s(ora

culture´s) ownexperience. Theextent towhich these conditions aremetdiffersnotonly

between individuals, but also within individuals and cultures and over time. This model

explainshowawork initiallyencounteredasconfrontingandobjectionable–bad–might

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latercometobeappreciateddeeply.Ithighlightshowtherejectionorembracingofawork

ofartcanarise,farfrompureobjectiveobservation,alsoineithermaturerecognition,orin

immaturerejectionoftheunfamiliar.Someworkislovedatfirstsight,andsome,never.Some

work–Bach,orShakespeare-achievesalevelofaestheticgeneralisabilityorexternalvalidity

sodeepandwidethatitelicitsalmostuniversalgratitude.

Toachievesuchintimacywithmanyunknownindividualsisanextraordinaryfeatofempathy.

Rogersdescribeditasahigh-wireactbetweenthedangersofsubjectivityandobjectivity:too

muchregression,andthework´ssymbolismbecomesprivateandthework“auto-erotic”or

masturbatory;toomuchcontrolandtheworkbecomescold,mechanicalanduntouching.201

The more ambitious the project, Rogers argues, the greater the need for control, the

combination of deep involvement with high control offering the recipient the greatest

satisfaction.201By contrast,wherever creativitybecomesuncoupled from“externalobject

relationships”–thatis,relationshipswithrealpeople–whereverapoemoranartinstallation

disregardsitsrealreaderoranartistitsrealviewer,itforfeitsitspowerandstatusas“art”at

all.190202203

Onceinthemanic-oceanicstage,thepoetisnotsomuchconcernedwiththeproductaswith

theprocessofvoicingtheobscure impulse:“findingtherightwords,oranyhow,the least

wrongwords.”189Thepoetisbynowinakindoflabourortrance–“oppressedbyaburden

whichhemustbringtobirthinordertoobtainrelief”hauntedby“ademon...which,with

words,hemustexorcise.”189Inotherwords,heisgoingtoallthattroubletogain“relieffrom

acutediscomfort”[myitalics].189NowonderNewtonreferredtothissurrendertoprimitive

partsoftheselfasakindof“intrapsychicrevolution”.190

Againtheneedforhumilityisclear:“Thefirsteffortofthepoetshouldbetoachieveclarity

forhimself,”who“doesnotknowwhathehastosayuntilhehassaidit”.189This involves

stretchingtowardssomethingasyetunknown,confrontingfear,persistingwhenthegoingis

hard,andperhapsbeingrewardedwithasenseofmastery.Szirtescapturestheinstinctive,

material-responsiveprocessofmakingapoeminanextendedskatingmetaphor:

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It sets out across the ice and begins to cut light patterns in it, following some trainable

instinct about the direction andway ofmoving, the notion ofmeaning arising out of the

motionofthedanceasaseriesofimprovisationsonthepattern.Thesepatternspresentthe

poetwithanumberofapparentlyarbitrarypossibilitiesatanyonetime.Butthatisthevery

nature of language: it iswhat language continually does. The poet's patterns, the twirls,

wheelsandwhipsofthedance,invitethechanceinterventionsoflanguage:youendaline

withthewordhouses,say,andyouaresooninvitedtoconsiderthepossibilityoftrousersor

blousesoralmostanythingthatcarouses.169

Szirtesinsiststhatthepoetisnottryingtodressupapre-existingmeaning,buttowritethe

best possible poem starting out with some as yet incoherent perception relating to an

experience or set of experiences.169 The reward, when it goes well, is being there when

somethingnewandlivelyemerges.

4.3Learninghowtodie:thefinalseparation

For a poem to be completed, rather than being left an unfinished, overwritten or self-

indulgentmess,theremustbeconstraint.Theremustbestructure,ofsomesort,however

loose,andthatmustrelatetowhatareadermightbeexpectedtotolerateandappreciate.

Notonlypoorqualitymaterialbutalsogood,highlydesirablematerialmustbe leftout–

somethingwhichrequiresacapacity formourningand lettinggo,demandingmaturity,or

whatKleintermstheachievementofthedepressiveposition.182Inthissense,agoodpoem

mirrorsalifewelllived,oneinwhichpromisingbeginningshavebeenbroughttofruitionto

anextentwhich isnecessarily limited,while theunattainablehasalsobeenmournedand

relinquished.Montaigneassertsthattolivewellistolearnhowtodie204:gradually,weaccept

the limited condition of our existence; gradually, if things go well, we mature into the

acceptanceoflossandsufferingaspartofloveandlife,relinquishaninfantile182insistence

on“splitting”experience intothepartswe like(success,health,pleasure,beauty,and life

itself)andthosewedisavow,relinquishourinfantilegrasponhalf-truthsanpart-objects,182

embracing a truer and more complete version of life. Segal, exploring the relationship

betweenart,daydreaming,play,andcreativethinking,emphasisesthatthesuccessfulartist,

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asdistinctfromthefailedartistordaydreamer,musthaveastrongholdonthepsychological

maturityofthedepressiveposition–ahighlydevelopedsenseofreality–ahighlydeveloped

capacitytofaceanddealwithugliness,pain,anddeath.194

Constraint inapoem is,as in life,notartificially imposed,but inheres in thematerial. To

differingdegrees,dependingontheformchosen, limitation ispresent inboththesubject

matterandwhatthewordswillallow.Sowhilethe“artmaterials”oflanguageofferthepoet

awelcomingspaceforchallengingsubjectmatter,theyalsopushback,andmakedemands

oftheirown–inthesamewayamotheralsomakesgraduallyincreasingdemandsonher

infantbybeingonlygoodenough, notperfectlyadaptive; by representing, therefore, the

outsideworld,aswellasfidelitytotheinfanthimself.Eliotisclearaboutthestrictureswhich

everyday language imposes on the poet, despite poetry´s special status as a musical

elaborationandadaptationofeverydayspeech.Evenfreeverseisnotarevoltagainstform

perse,heargues,butagainstdeadform.Thepoetmustalwaysfollowtheordinaryeveryday

languagewhichweuseandhear.Itsmusicmustbeamusiclatentinthecommonspeechof

itstime,andthepoetmust“usethespeechwhichhefindsabouthim.189

Ehrenzweig describes this final, integrative stage of creativework as reintrojection.What

beganasprojectionandcontinuedasanunconsciouslyguidedstrugglewiththematerials,is

finallyresolvedandassimilatedconsciously.Backundertheauspicesoftheconsciousmind,

partofthework’ssubstructureistakenbackintotheartist’segoonahigherlevel.144Thework

isfinished,orrenderedfitforanaudience.Szirtescallsthisthefinalseparationofthepoem

fromtheauthor169–themomentofumbilicalseverance;thefinallettinggo.

Poetry is inherently intensive rather than extensive, and economy is essential. Part of a

poem´svitalityderivesfromtheabsurdchallengeittakesonofsayingmorethancanbesaid

in a restricted space using a restricted material. Intense subtraction, omission, and

condensationareneeded.“Extra”words–ifonlyonecanworkoutwhichthoseare–dilute

and“damage”apoem, rendering itas incompetentasadilatedartery, scleroticvalve,or

atonicuterus.Nowonderamuchcitedpieceofadvicetoaspiringwritersistomurderyour

darlings205–sacrificingevenfinewordsandphrasesforthegreatergoodofthewhole.

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Szirtesusesthemetaphorofskating,andIalsofindthegravitationalimageofslalomskiing

helpful:theirresistibleforcedrivingtheskierdownthroughslipperyterrainforcesmoment-

by-moment, intuitive decisions. Not everything is possible, and constraint drives

commitment.Beginnersaretaughttolettheskishop,findingasingle,effective,perhapseven

graceful,way throughanddown.Aneffectivepoemmirrors the livingof a life – a short,

preciousthingwhichwecannotgetright,butmustbuskourwaythrough,improvisingfor

dearlife,inthefaceofuncertainty.

4.4 Yourorgans:whatpoetrydoesforthepoet

Thepoemsinthepreviouschaptereachtookadilemmaordiscomfort,dramatisedit,and

turneditintoaformofcritical-creativediscourseonsubjectssuchasthebalancebetween

objectiveandsubjectiveexperience,professionalandpersonallanguage,honestyandlying,

andhumanityandbrutality,inmedicalpractice.Theygavemesomewheretoplaceandmake

senseofmyconcern.Likeapatiententeringtherapywithanirksomepuzzle,Ifoundinpoetry

notapanaceaorwayofgettingridofmydilemmas,butaspaceandalanguageinwhichto

meetthem.

Making sense of experience –making one´s own affairs plain126 – is understood to be

essentialtohealth.81Poetshavevariouslydescribedthisself-reparativefunctionasasecret

andsubversivepleasure,169puttingpaininastory,206oralastattemptatorderwhenone

can'tstanddisorderanylonger,andnotoneofthelastbutofthefirstthingsofman207.Itis

inthiscapacitytotransformone´sownnagging,rudeimpulseintorelief,tospinpaininto

pleasure,anddifficulty intorecognition, thatanartist´smoralandexistentialvaluetothe

wider group or society lies.169 173 After a while, Szirtes says, it becomes who you are. It

becomesyourorgans.Youneedyourorgans.208

4.5 Voicingtheunsayable:whatpoetrydoesforthereader

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Ihavecharacterisedapoemasawayofvoicingsomethingelusive,andasthetraceofan

intimate human presence – a vehicle through which experience can be passed between

individualswhomaynevermeet.ForEliot,poetryaffordsthereadersomenewexperience,

or some fresh understanding of the familiar, or the expression of something we have

experienced but have no words for, which enlarges our consciousness or refines our

sensibility.189 For me as a reader, what matters is not that the poet communicates his

experience to me, but that he capturesmy own. Based on the blueprint of the poet´s

experience, if this ismadesharpandspaciousenough, I rediscovermyownunarticulated

experience.Anyballastorbaggagewhichties thepoemdowntothepoetwillhavebeen

excised,settingthepoemfreetobeusedbyothers.Atthesametime,thepoemwillavoid

vaguegeneralisation–itwillbefirm,clearandpalpable.Likeasail,itwillbebothfirmlyfixed

tothepoet´sexperience,andstillfreetofillupwiththeunchannelledwindofmyexperience.

Thepoet´sspecificpersonalexperience,crucialtothepoem´sgenesis,willhavebeenfiltered,

clarifiedanduniversalised,tomakeitavehiclealsoformyexperience.

Inaddressingthereadersimultaneouslyatthelevelofthought,feeling,andbody,apoem

offersthekindofrareholisticexperienceotherwiseassociatedwiththeintimacybetween

motherandinfantorloversorwithreligiousexperience.Itmomentarilyenfoldsourrudeness

andour sophistication, our thoughts andour feelings in a single, containingwhole; for a

moment,wecanbothbeourselvesandfeelclosetoanotherpersonorevenawiderwebof

mutuallysustaininghumanity.Sowhilepoetryisnopanacea,itistheunmistakeablesignof

ahumanpresence.169

Inaworldpreoccupiedwithutilitarianoutcomes,itisworthpausingtowonderatthehigh

value we place on a supremely non-utilitarian pursuit which “merely” frames and

acknowledgesourexperiencewhilesolvingnothing.Asdoctors,weshouldaskourselveshow

it isthattheactoftouchingunflinchinglyandskillfullyonthemosttenderspots,farfrom

weighingusdown,bringsrelief.Szirtes,whodescribespoetryasaformoftruthtelling,argues

thatthetaskofpoetryistotellthebesttruthitcanaboutwhateverithappenstobedealing

with.169Coulditbethatweexperiencenot-being-lied-toaboutmattersofimportanceasan

actofloveorrespectorkindness?Coulditbethatlikeothergraciousformsofrelating,poetry

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hasacapacitysomehowtomakewellthingswhichcannotbefixed?Tohealeventhoughit

patentlycannotcure?

4.6 Whypoetsarepersecuted:whypoetrymatters

Sincepoetryhasthecapacitytoshapeandinfluencemainstreamlanguageandthought,to

definewhatisours189andthereforewhoweare,toaffirmorchallengeidentityandtospeak

uncomfortable truths, it is easy to understand why it may be feared. In the 1950s, the

speakingofSamilanguagesinschools–viewedasthreateningtoNorwegianvalues-was

forbidden,butjoiking,apoeticorsongform,remainedaliveasameansofaffirmingSami

culture. It isalwaysfutile,accordingtoEliot, totrytakingfrompeopletheir languageand

compellinganotherupontheschools,becauseunlessyouteachthatpeopletofeelinanew

language,youhavenoteradicatedtheoldone,and itwill reappear inpoetrywhich isthe

vehicleoffeeling.189Poetryofteninsistsonbothamorelocalandamoreuniversalsensibility

thanthatembodiedwithinculturalconventionsandpoliticalregimes–akindwhichcanbe

rediscoveredinthediverseandparticularwhichmaypreciselythreatenthemorenarrowly

generalisableandmainstream.Poetrymayinviteorfacilitatenon-conformityofthoughtand

feeling–indeed,ifitdidnot,onemightaccuseitofunoriginalityandpurposelessness.

Sopoetry´spowertomove,itsspecificityasameansofpursuingtruth,isconnectedwithits

capacity to change and disturb.We have seen how poets vigorously resist definitions of

poetry.209Wehaveseenpoetry´spropensitytocrossboundariesandbreaktaboos–theway

it thrives on playing with what is supposed to be taken seriously, on questioning and

interrogatingauthorisedwaysofseeingandspeaking.Itscapacitytoplay,torepurpose,to

recontextualisewords,forexample,technicalmedicalwords;itspropensity,likereligion,to

pointtoorhintatimportantthingswhichcannotbeseenorgraspeddirectly.

Ifpoetrycanhelppeopleseeandsaythingstheymightotherwiseonlyhavefeltdimly,then

ithasthecapacitytobetraythesecretsandchallengethepartylineswhichprotectgroupor

family identity. It may at any moment name the children´s bones in the cellars of our

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collectiveawareness–theinconvenienttruthsorconcealedabuses.Oneneednotascribea

positiveornegativevalue topoetry to realise that in thehandsofanenemy, it canbea

weapon.

Soifpoetrycanbearevealerofmatterswehavehiddenfromourselves,ourresponseto

poetry´sinterventionwilldependonwhatwehavetogainorlosebytherestorativeprocess.

Awarenesssimplyforgottenintheflowofconcentratingonotherthingsmaybewelcomed

backeasilyorevenwithpleasure,butothermaterialwehavebuiltapersonalorcollective

lifeoverthetopofdenying–inconvenientorthreateningdata–mayrepresentanexistential

threat,provoketerror,undermineoursenseofcoherenceandcontrol.

Bion speaksof thepowerfulandprimitive“survival” responsesof splittingandprojection

which occur in a group when unbearable unthinkable elements of experience become

activelysplitofffromconsciousness,andlodgedinotherpeople.210Grouppsychodynamics

takesaparticularinterestinhowparticularindividualswithparticularcharacteristicsareleft

“carrying” particular forms of awareness on everyone´s behalf. In less threatening

circumstances, the awareness in questionmay, for example, be the sense of a need for

orderliness and time-keeping, on the one hand, or for spontaneity and creative

disruptiveness,ontheother. Inothers, itmaybeknowledgeofabusesordeceptions.The

process of analysis – noticing and naming phenomena – becomes the beginning of

redistributing awarenessmore fairly, but can threaten vested interests in an unequitable

distribution.

Whathasthis todowithmedicine?AmIarguingthatallpracticeandteachingshouldbe

constantlyguidedbythepoeticprinciplesofrestoringtoawarenesslostmaterial,underan

Ehrenzweigianbannerof relinquishingconsciouscontrol in thepursuitofdeeper creative

integration?AmIsuggestingweconstantlyreturntofirstprinciplesandtakenothingatface

value?Certainlynot:wewouldsurelydrownintoomuchawarenessandtoo littleaction.

Suppressingopposition,limitingorfocusingattention,andovercoming(ratherthanendlessly

entertaining)obstaclesare,withinlimits,anaturalpartofrealisingconsciousintentionand

completing a task. Creativity itself entails cost, and as Schumpeter famously observed,

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destruction.Ifomelettesaretobemade,eggsmustbebroken,andthisisanecessaryform

ofbrutality.211

What I amarguing, rather, is that there are times andplaceswhichweneed to learn to

recognize where things have become so stuck, where collective cultural collusion, or

groupthink210havesoinsulatedthemainstreamfromdissonantordisconfirmingdata,that

creativedisruptionandreleasearenecessary.Ihaveargued,ingoodcompany,thatthisis

thesituationwefaceinmodernhealthcare,andthatso-calledmedicallyunexplainedillness

offersacaseinpoint.49Sometimes,ittakesamaverickorwhistleblowerorsomeonewithan

outside view to name what is missing. Sometimes, it takes a poet to find new words:

sometimes,withinourownlives,ortheorganisationsweareapartof,itisnecessarytoallow

the smooth surfaceof things to bedisrupted – to take the risk of benign regression and

creative extension towards something unsettling but importantwhichmay lead tomore

integrated,moregroundedunderstanding.

4.5 Helpforthehelpless:afinalattemptatorder

WhatIamarguingissimplythatthereissomethinginpoetrywhichcontainspsychological

helpforthetroubled–andthatwearealltosomedegreetroubled,asaconditionofour

shared humanity. Our trouble can be defined broadly to include both the particular and

extreme,theuniversalandeveryday,thepainfulandthepleasurable.Butwhetheritispain

or joyweneed to share, it relates to thedifficultiesofbearingourembodiedexperience

alone.

Thismayhelpexplainthelongstandingconnectionbetweenpoetryandmedicine,84anarea

of endeavour which entails particular exposure to rawness. Suffused with a higher than

averageintensityofhumansuffering,medicinecanbeseenasarepositoryoflife´sunwanted

experiences–thosewefindhardtoacceptandintegrateandwhichleavemarksontheself:

pain,loss,frustration,malfunction,anddeath.The“woundedhealer”archetype,originally

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applied to doctors, has also been claimed for artists – individuals whose pre-existing

psychologicalvulnerabilitiesequipandpredisposethemtoplayahealingroleforothers.212

Andthatwashowthisworkbegan–withadoctor-artistseekingtosurviverawnessatwork

while remaining alive, sentient, and humane; looking to avoid the self-brutalisation of

mechanical, inhumaneresponseswithoutburningoutorbecomingoverwhelmed.Looking

forwaystopractisemedicineasbothascienceandahumanity.

KeyMessages

• Art,includingpoetry,arisesinarawimpulse,adesiretoresolveaconflictortoexpresssomethingstimulatingorprovoking

• Artrequiresawillingnesstosurrendertounconsciousprocessandacapacitytowithstandtheanxietythisentails

• Likescience,artrequirescloseattentiontoexternalphenomena,butinparallel,closeattentiontoone´sownresponses

• Goodnessinartariseswhentheartist´sstruggleforselfarticulationissufficientlypalpableasanemotional”souvenir”inthematerial,butsufficientlycleansedoftheartist´snarcissismtoholdtheobserver´sexperience

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Chapter5–Whenbodiesspeak

Iwasmuchfurtheroutthanyouthought

Andnotwavingbutdrowning

- StevieSmith

Keywords:psychosomaticexpression,intersubjectivity,containedspace,therapeuticboundary

5.1Psychosomaticsymptomsasincompletecommunication

Inthechapterwhichfollows,Iwillpresentpsychosomaticsymptomsasaformofpartialor

blocked communication – amuffled cry for helpwhich needs creative and openminded

attention in order to be understood. I will show how with the right stance and skills,

psychosomatic symptoms, exemplifiedherebypsychosexual symptoms, canbe read as a

hiddenstoryinneedofalistener.

First, we should acknowledge that this is an area where terminology has been difficult.

Psychosomaticmeansdifferentthingstodifferentpeople.Althoughinnocentenoughinits

etymologicalorigins,whereitsimplypointstotheindissolubleconnectionbetweenmindand

body, the word psychosomatic has frequently been used in confusing, stigmatising, and

uninformativeways.Somecommentatorsuseitbroadlyandneutrallytorefertoallillness

wherethereisasignificantinterplaybetweenemotionalandphysicaldistress,suchasangina

pectoris or severe asthma. Many use it to refer to purely symbolic, historically called

hystericalillness,suchasmedicallyunexplainedpainsyndromes.Butworstofall,clinicians

uninterested inmind-bodyconnectionsbutreluctant toadmit lackofunderstandinghave

usedittoimplyillnesswhichisnotrealorillnessinwhichIamnotinterested.Thismakesit,

in turn, difficult to raise as a possibility with patients, who reasonably enough resist a

diagnosticlabelwhichtheyfearmaycondemnthemtotherapeuticdisinterestandnihilism.

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This terminology-creep is particularly unfortunate given that all illness is to some extent

psychosomatic.We blushwith shame, and tremblewith anxiety.Myocardial infarction is

associated with angor animi. And while it is, of course, perfectly possible to deliver a

distressed baby or remove a tumour without recourse to a psychosomatic model, no

competentorhumaneclinicianwoulddeludethemselvesthatobstructedlabourandcancer

are purely biomedical phenomena, free of psychological and social dimensions. The fact

remains that while many illnesses can be treated successfully by a combination of

biomedicineandordinaryhumankindness,manyotherssimplycannothelpfullybethought

aboutatallwithoutapsychosomaticmodel.This includesmostofthosewecallmedically

unexplained, almost all sexual problems, and also a great deal of multimorbidity, where

commonpsychosocialriskfactorsmaydriveamultiplicityofapparentlyunrelatedillnesses.

Ratherthaninventnewwords,Iproposeforthepurposesofthisdiscussiontoreclaimthe

term psychosomatic at its face value, to mean simply illness where mind and body are

interactingtoproducerealsymptoms–illnesswherewecannothelpfullysplitthetwo.

SandorFerenczi,theHungarianpsychoanalystoftenregardedasthefatherofpsychosomatic

theory, argued thatWhen thepsychic system fails, theorganismbegins to think.213 Inhis

account,unprocessedpsychicdistressmanifestsasreal,oftenincapacitatingphysicalillness,

asthebodyis lefttoarticulatewhatcannotbeexpressedinanyotherway.Thisfocuson

symbolicformsofbodilycommunicationhasformedacoreelementofpsychoanalyticand

psychodynamic approaches, and the cases which follow illustrate its diagnostic and

therapeutic potential. But we should remember that chronic distress, as well as causing

emotional and psychosomatic distress, also impacts the body in literal, biological ways.

Dysfunctional or abusive relationships, chronic overwork, lack of control over one´s own

destiny,lossofmeaninginlife,andotherformsofchronicstresseventuallyovercomethe

body´sabilitytocope,drivingrisk,disease,anddeath.Thepsychoneuroendocrinologicaland

epigeneticmechanismsbywhichthisoccursareincreasinglywellunderstood.214215Theways

inwhichlifeexperienceaffectshealth,biographyaffectsbiology,isnotonlyrelevanttothose

ofusinterestedinpsychosomaticillnessinanarrowsensebutaffectsallofhealthpractice

andpolicy.47

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We could think of psychosomatic communication as a theatrical gesture – a piece of

improvised,incompletepoetryortheatre–aninstanceofwhatthephilosopherJuliaKristeva

calledsemioticcommunicationwhereordinarysemanticreportinghasprovedimpossible170

–asortofnon-verbalcryforhelplikethatofStevieSmith´sstruggling,misunderstoodman

whowasNotWavingbutDrowning.Understandingpsychosomaticsymptomsasincomplete

creativecommunicationisuseful,becauseitexplainswhyempathicimaginationisessential

totreatment,andwhynon-creative,purelyscientificorreductiveapproachessimplydonot

work.

A theatrical performance or poem gains its power by embodying something emotionally

importantinphysicalterms,andaddressinganaudienceorreaderinemotionalandphysical

terms at the same time. These holistic forms of expression invite, or perhaps force, the

observer or reader to feel and think in parallel. But unlike a successful poemor pieceof

theatre,whichwecanenjoyasacompletecommunicationonseveralchannelsatonce,a

psychosomaticsymptomisneithercomplete,norheard.Preciselythereverse–thestoryhas

becomesomehowblocked,andisnotmakingsenseeithertopatientorotherpractitioners.

Externalhelpisneededbecausetheblockiscausingdistress,andthathelpinvolvescreativity.

The taskof psychosexualmedical treatment is tohelp a person first complete the jobof

expressing,andthenhearing,hisorherownstory.

In psychosexual medicine, this is done using the combined skills of medicine and

psychodynamictherapy,inaprocesswhichrequiresthepractitionertothinkandfeelatthe

sametime.Thepractitionerreflectsonand integratesbothsubjectiveandobjectivedata,

using two different ways of listening, based on two different theories of knowledge or

epistemologies. The empirical approach of biomedicine which captures and analyses

objective,externaldata is complementedby thehermeneuticapproachofpsychotherapy

which captures and analyses internal and subjective data. Each approach is relevant to

understandingillnessandhealth,81butthetwobecamesplitduringthehistoryofphilosophy

anddevelopedinignoranceofeachother.216Butmanyareasofhealth,includingmedically

unexplainedsymptoms,multimorbidity,andpsychosexualmedicinedemandanintegrative

approach.Letuslookatsomeexamples.

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5.2Casereport1:Womanwithdarkglasses

“CanIhelpyou?”Iheardthereceptionistsay,asIwalkedtowardstheclinicwaitingroomto

meetEmilyandDave,andIheardDavereply,“Well,Icertainlyhopeso–nooneelsehasbeen

ableto.”Ifearedachallenge.

Emily was not, in fact, wearing dark glasses – that bit is an elaboration, inmemory, of her

extremefragilityanddefendedness–thoughshemayhavebeenwalkingwithastick.Butshe

rosetoherfeetslowlyandwithsomedifficulty,asthougharthriticorelderly;andDave,atfifty-

somethingtenyearshersenior,sprangtoheraid.

The referral had been for Emily, whose long-standing difficulties in having sex were now

interferingwiththecouple’sdesiretohaveafamily.Buttheyhadmadeitclearonthephone

thattheywouldbothliketoattend.Iinvitedthembothtotellmeaboutwhathadbroughtthem.

“It’sme”saidEmily,confessional:“Ifindsexpainful.Impossible.Thethingis,Igotothechronic

painclinic...”

Astoryunfoldedwhichseemedmuchwiderandmoreintractablethanaspecificsexualdifficulty

–astoryfeaturingseveralkindsofmusculoskeletalpainwhichmadesexuncomfortableinher

wholebodyaswellasvaginalpain,prettymucheverywhere,onpenetration.Myheartbeganto

sink.Therewereseveraldoctorsandevenacounsellorinthestory,allofwhomhadfailedto

help–somewerecharacterisedaswell-meaningbutimpotent,othersasunkindoruninterested.

I saw pitfalls everywhere, and feared walking across land mined territory only to join the

companyofinadequatecolleagues.

ConsciousthatIwasworkingwithacouple,Imaderepeatedeffortstoturntheconversationto

Dave,buthesimplyreferredmebacktoEmily’sdistresses.Sadly,tenderly,hedescribedhow

Emilyhadhadtogiveupherworkasatextiledesigner,andherpiano-playing,atwhichshewas

very talented, he said. The three of us agreed that somehow or other Emily’s passions had

becomestymied,rightacrosstheboard.

Onenquiry,Davesaidhe lovedEmily,would lovetobeable tomake lovewithher,butwas

reluctanttopush,when itclearlycausedhersomuchpain.EndorsingEmily’saccountof the

manyunhelpful doctors, heneverthelesspraised Steve-the-physio. I leaped toenquiremore

aboutSteve–keenforahintabouthowtoworkwithEmily.

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Steve-the-physiohad,accordingtoEmily,beengentlebutalsopersistent,accordingtoDave.As

the two of them described his work with her, I imagined someone focused, attentive,

compassionate,andhardtoliveupto.IreflectedbacktoEmilymyimpressionthatgentleness

wasextremelyimportanttoherandearnedaglanceofwhatmayhavebeengratitude,certainly

itfelt likemomentarycontact. Ifelt Ihadscoredafirstpoint inwhatpromisedtobeatricky

chessgame.

What was it about gentleness? Had gentleness been lacking somewhere in Emily’s life, I

wondered?Shebegantodescribehermother–acriticaltyrant:measuringthemilkinthebottle

inthefridgelestherdaughtertaketoomuch;criticisingherforholdingapenthewrongwayor

forinadvertentlydirtyingthewastebinwhilethrowingsomethingaway."Hypersensitive,"said

Emily–eversinceanepisodeofseverepostnataldepressionfollowingEmily’syoungersister’s

birth. Intolerant of vulnerability in her daughter, evenwhen ill or in pain, she accused her,

whereveritshowedof“hypersensitivity”.DidEmilyfeelangry?“Seething!”shesaid.

Ifeltrelief.Iwondered,aloud,whetherperhapsEmily´swholebodywasnowseething–saying,

“I’llgiveyouhypersensitivity!”Emily´sassentencouragedme,butwestillseemedalongway

from our agreed subject matter – sex. My job here was to offer a brief, four-session,

psychodynamic,psychosexualintervention,notlong-termpsychotherapy.Myanxietyaboutthe

scopeoftheworkandthetimescalegrew.

Ibecameabitmoreexplicitandpushy–wonderedaloudwhetheranyonehadeverhurther

sexually. “No,nothing like that,” sheassuredme.Physicalexamination–medically indicated

given painful sex, and expected ofme as an IPM trained doctor –was smoothly declined –

“Perhapsanothertime.”Iwasgettingnowhereandstartingtofeeldisempowered:unsurewhat

Emily’smanypresentphysicalproblemsandpastpsychologicaldistressmighthavetodowith

thesexualdifficulty;awarethatwhileshemightbenefitfromlongtermpsychotherapy,wehad

justfoursessionstofocusonsex;andthat,whiletheyhadcomeasacouple,wehaddespitemy

besteffortsspokenonlyofEmily.Ireflectedthisimbalanceback,suggestingEmilymightcome

onherownnexttime.ButwhileDaveleapedattheidea,Emilyresistedit,wantinghimather

side–herprotector:perhapsalsoherdefenceagainstworking,Ifeared.

IwassurprisedwhenatournextmeetingonlyEmilystoodupinthewaitingroom,afterall.She

explained she had come alone to answermy question aboutwhether anyone had hurt her

sexually.TotellmesomethingthatDavedidnotandmustnotknow.Shesaidthatsinceweonly

hadfourmeetings,shehad,“bettergetonwithit”.Butshethenstopped.Prevaricated.Didn’t

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knowwhethershewouldbeabletotellme;insisteditfelttoodifficult.Isensedbothakindof

game-playing in the prevarication, but also a genuine difficulty in approaching something

distressing.Feelingtantalised,Iregisteredanimpulsetotryand“wrest”herstoryfromher,by

bruteforce,asitwere.Instead,Iacknowledgedthedifficultyinspeaking,andwaited.

Betweensobs,ahalting,sketchystoryemergedofarelationshipwithauniversityteacherby

whomEmilyhadbeenbullied,undermined,and“forcedtodothingsshedidnotwantto”–yes,

sexually, sheadmitted,ondirectquestioning.Already inherearly30sat the time, thougha

virgin, she excoriated herself for having been "stupid" enough to allow these shadowy,

unspoken,unspeakablethingstohappen.Shebecamewithdrawnanddistant,hunched,fearful,

and inarticulate; she shook and sobbed, andwould or could notmake eye contact. For the

remainderofthemeetingsheseemedtoregretbitterlyhavingtoldmeherstill-sketchystory.

JustasEmilyfelt“stupid”fornotstoppingwhateverabusesshehadsuffered,Iwasleftafterthis

second consultation feeling vehemently self-critical: why had I failed to make clear, crisp

connectionsbetweenEmily’sdistressandhersexlife?Andtomakehertellmemoreofwhat

actuallyhappenedwiththebullyinglecturer?WhyhadIgotmiredwithherinthis“distressof

uncertainanalyticsignificance’”andwhy,forgoodness’sake,hadI,apsychosexualdoctorand

gynaecologist,againfailedtoexamineher(thoughtodoso,givenher“abusedchild”state–had

seemedinconceivable)?

To my great surprise, Emily seemed somehow different at our third meeting. Neither the

defensive,brittlewoman-childhidingbehindDavenorthebroken,lonely,abusedchildofour

lastmeeting,sheseemedmoreadultandcomposed;saidshefeltbetter,andthoughtshewould

“come through this”. She seemed in touchwith her creative, reflective self, had comewith

dreams suggesting healing, and about challenging her abuser. She took charge of the

consultation,andseemedintouchwithspace,strength,andself-compassion.

Fromthissituation,wewereabletowonderhowEmilycouldstillhavebeensodefencelessin

her 30s. The tyrannicalmother re-entered the conversation: and young Emily, smacked for

holdingthemopthewrongwaywhilecleaningthefloor.Emily,buyingherownfoodandkeeping

itonherwindowledge,toavoidcriticism;Emily,terrifiedtoremoveaswelteringwoolcoaton

along,hotbusrideonasummerschooltrip,lesthermother,whohadexpresslyforbiddenits

removal, findout andpunishher. Criticisingher father’s impotent attempts tomediate, she

wept:“Iwasonlylittle–Ijustdidn’tknowhowtostopit”.Still“onlylittle”therefore,whenit

cametoresistingfurther,sexualbullyingfromamaninauthoritywhomsheshouldhavebeen

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able to trust. Twice bulliedwheremost shewould have needed gentleness, Emilywas now

lockedinsideawoman´sbody“seething”withalittlegirl´sangerandpain.

Ourfinalmeetingyieldedthelong-postponedexamination.Itprovedsomethingofananticlimax

–littlemorethananepilogue.Ihadexpectedclampedlegs,andshrinkinguptheexamination

couch–butEmilytoleratedexaminationwithnomorethanaslightwince.Weagreedthatit

wasn’tasbadaseitherofushadexpected.“Tolerablediscomfort”wasthephraseweagreed

upon,anditseemedalsotodescribewhereEmilywasleftwithherabusivehistory.

Summinguptheworkdone,Emilysaidshehadknownfromthebeginningthatsheneededto

facethisstory.Shehadrevisitedit,privately,numeroustimessinceourfirstmeeting,andfound

each facing slightly less painful than the last. She was singing and playing her piano again,

interestedinamoreequalrelationshipwithDave,lesschild-like,morechallenging.Whatabout

sex,Iwondered?Shepulledaface,asthoughthisquestionwereanintrusiontoomany:“we’re

havingmuchmoreclosenessandnon-genitalsexualcontact.”Andpenetration?Iprobed,gently

–becausethishadbeenherpresentingcomplaint–well...shecouldimagineit.Ashysmile.

“DoesDaveknowthat?”“IguessI´llneedtotellhim”.Emilywassettingthepaceofthings:"In

myownspace,inmyowntime,”wasthemessageIwashearing,loudandclear,fromthisnow

moreassertive,moreadultwoman.

Icouldnot,atmyheart-sinkingfirstencounter,haveexpectedEmilytomaketheprogressshe

did, in just fourmeetings.Had I known inadvance theextentofherproblems, Imighthave

wonderedwhethersuchbriefworkwassuitableatall.Yet,modestastheywere,setagainsta

lifetime´ssuffering,thesefoursessionsfeltlikeasignificantopeningupofspaceandreclaiming

ofadulthood,relativetoourfirstmeeting.

Whatdidshethinkhadhelped?Abalanceofgentlenessandpersistenceinourconversation,

shethought.InthetraditionofSteve-the-physio,then.Maybealsotheknowledgeofthestrict

timelimitation,webothagreed–certainlyshehadreferredtoitsoclearlyastheworkevolved

that I had at one point decided against my impulse to offer her extra sessions, for fear of

disruptingherobvioususeofthetimeframe´srigour.Indeed,althoughEmilyandIeachworked

hardwiththe“content”ofthematerialshebrought–shetofacepainformerlylockedinher

body,Itotoleratetheanxietyofworkwhichthreatenedtodisempowerandoverwhelmme–I

think"theframe"wasthemysteriousthirdelementinthiswork.Astherapeuticasanyspecific

interventionIofferedormighthaveofferedwasthefirmboundary:afirmlycontainedspacein

which openness to Emily’s broad, intractable, more-than-sexual problems, coupled with a

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commitmenttoreturningtothequestionofsex,drovetheworkforward.Alsoasanobstetrician,

Iimaginedthisframeasakindofcontractinguterus:abenignlyrigorousmaternalspace,such

asEmilyhadlacked.Bynomeanscosy–uncomfortableforbothparties–butcontaining,safe,

andessentialtoprogress.

5.3Radicalopenness

Long before Emily entered the consulting room, her difficult lived experience was

communicating itself through her general practitioner´s referral letter, her husband´s

despair-laden opening comment, and her own pained body language. She was offering

unconsciouscluesaboutherextremevulnerability,andaboutherhusband´sassignedroleas

herasexualprotector.Theseclueswerefarfromafullstory,withoutherownverbalaccount,

butcould,withtheuseofakindofradical,imaginativeopenness,begatheredasup-front,

contextualevidence–factualmaterialwithemotionalresonance–presentingthemselvesto

thepractitioner´sawarenessintheformofvaguefeelingwhichcouldbenoticedandstored

forfuturereference.Ireadhercluesasanearlywarningagainstapproachingtooclose.

5.4Usingintersubjectivity

Thisbroadwelcomingofsubtleclues,accompaniedbyemotionalself-scrutiny,formsaway

of“reading”theotherpersoninthelightofone´sownresponses.Inpsychoanalysisthisis

calledcountertransference–aformofemotionalimagingwhich,likeradiologicalimaging,

doesnotidentifyaproblematicstructurewith100%certainty,butisausefulguidetothe

rightkindoffurtherinvestigation.Rightfromthebeginningoftheencounter,thepractitioner

iscapturingobjectivecluestogetherwiththesubjectiveresponsestheyproduce,inaprocess

whichisneitherpurelyobjectivenorpurelysubjectivebutintersubjective.Sheisobserving

and interacting, thinking and feeling at the same time. Subjective responses, such as the

practitioner´s sense of Emily´s extreme fragility, are not treated as contaminants to be

ignored, denied, or risen-above but as sources of potential information, in a carefully

qualified, provisional, hypothesis-generating sense. Maintaining a clear sense of what

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originated as fact and what as feeling, the practitioner holds the two side by side in

awareness,allowingpotentialconnectionstoemergewhichcanbeofferedtothepatientas

hypotheses.Thepractitionerallowsfeelingtoilluminatefact,facttoilluminatefeeling,and

aninnerdialoguebetweenobjectiveandsubjectivetruthtoemerge.

5.5Appliedsensitivity

Thisprocessmaybesubtle,but it isnotmagic: it issensory,notextrasensory. It isbased

firmlyonobservation,butincludesobservationsnormallyignoredineverydaylifeorordinary

medicalpractice.Itissensitive,inthatlikeanultrasoundscanitinvolvestuningupreception

ofaparticularsetofrealbutsubtlesignalsofakindeasilyswampedbyotherdata, ifnot

activelysought.Emily´ssubtleinjunctiontostayaway,alongsidetheinvitationtocomeclose

whichisimpliedbyseekinganappointment,wasausefulbeginning.

5.6Spaciousness

Thepractitioner´sstancecouldbeunderstoodasoneof“hosting”someunresolvedsubject

matter anddifficult feelings, to give thepatient space to completed the creativeworkof

integrating them. From early in the conversation, the practitioner was preparing inside

herself a space for something whose identity she could not possibly yet know, but had

allowed herself to sense “between the lines” of the patient´s clues. Shewas agreeing to

encounter this unknown element with warm, open minded curiosity – tolerating the

discomfortofsensingsomethingshecouldnotyetname.Itwasimpossibletounderstandin

advancetheconnectionbetweenthis“space”andthelackofaccommodationwhichEmily´s

childhoodneedshadbeengiven.Winnicottusesthewordholding,Bion,containing,forthese

“hosting”roles,whichcharacteriseallpsychologicallydevelopmentalrelationships,whether

betweenpractitionerandpatient,parentandinfant,orteacherandpupil.133151

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5.7Therapeuticendurance

Insightfulinterpretationisoftenhowwethinkoftherapeuticwork,andthiscanbethemost

satisfyingandflatteringpartforthetherapist.TheconversationwithEmilycertainlyoffered

occasional,pleasurablemomentsofinterpretivesuccess,suchasarticulatinggentlenessasa

key,missingdimension inEmily´s life–momentswhich restored in thedoctora senseof

therapeuticcompetenceandagency,andmitigatedthesenseofstruggleandmesswhich

characterisedothermoments.

Buttheworkalsobroughtseveralprolongedphasesofconfusion–“notknowingwhatwas

happening”,“notknowinghowtomoveforward”,“notbeingabletoimagineasatisfactory

outcome in the time available”. This therapeutic persistence in the face of difficulty, or

“hanging in”, is to my mind one of the most challenging, important, effective, and

underreportedinterventionsintherapy.Wemayoverlookitforvariousreasons:Thesemight

include perceptual bias – just as a figure in a painting strikes us more readily than the

background,elegant interpretations,obviousdefencesandneatbreakthroughsmaystand

outmorethanthetextureorbackground–thematrix,ifyouwill,of“muteprocess”.There

mayalsobenarcissisticbiasinwhatwechoosetoreport,too–anaturalifunconsciousdesire

tolookgood,soundinsightful,andpresentworkinsupervisionorgroupreflectionasthough

weknewwhatweweredoing.Butinoverlookingthebackground“commitmenttostruggle”

Isuggestweoverlookoneofthegreatesttherapeuticgiftsinatherapeuticencounter–moral

solidarityandemotionalrolemodelling.

Whathappenswhenwepersevereinthechaotic-seemingpassagesofanencounter,allowing

the patient to make us feel uncomfortable without turning away, tolerating our own

uncertainty,Isuggest,isthatweofferisourownvulnerability,asaformoftherapeuticrole

modelling. By not attempting to remain – or pretend to be – uniformly strong and all-

knowing,thesecurepractitioneriswillingtostrugglevisiblyandauthenticallyalongsidethe

patient,offeringvaluablemoralsolidarityandcreatingaclimateofdevelopmentaloptimism.

Thepatientis,then,notaloneinfloundering,andcansensethatitisnotshewhoisstupid–

thepractitionerisafterallalsopuzzled–butthematerialwhichisdifficult.Butasthework

proceeds,shecanalsoexperiencethatitisOKtoflounder–thatflounderingcanbetolerated,

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survived,metwithcreativeexploration,andcuriosity,andcanleadtogreaterself-awareness.

Considertheparticularplaceoftherapeuticvulnerabilityinthefollowingencounter:

5.8Casereport2:Onwomenandgearboxes

“HelloSandy, I´mAndrew.”Hewasnice-as-pie,well-presentedwithawarmsmileandafirm

handshake.Ihadnoideawhythereceptionisthadthoughthimangry.“HowcanIhelp?Your

doctorhaswrittenthattherehavebeensomeproblemswithsex.”“No–notproblemsreally–

I´mjustnotinterested–I´vecomebecauseI´llgetearacheotherwise!”hequipped.“Well–she

cares;wants someattention: all I reallywant, tobehonest, is a goodarmchair.” Theywere

marriedwith twogrownupkids, andagranddaughter theyadore,he related;heplaysbass

guitar in abandandhasmotorbikes. Lifewaspretty good. Sowhywashehere, then?The

conversationfelt like jousting–abit likea lad´sgame.Searchme!heshrugged,thenadded,

breezily,I´mprobablywastingyourtime...feelabitofafraud!

“Butsomethingbroughtyou?”,Ichallenged.“Yes,I´venoideareally,”heshrugged.Iwashaving

toworkharderthanusualtogetthisconversationgoingandfelt“atsea”.Retreatingintothe

familiarityofamoremedicalisedsexualhistory,Ielicitedaflat,factualaccountofvasectomy,

andalsodiabetes,meaningthatnow“themechanicsdidn’tworkverywell,”anditwashardto

“getaresult.”Hedidn´tsaywhatcountedasa"result"andfornow,Ididn´task.Yes,hehad

tried Viagra – but it gave him a headache and was not worth the bother. The alternative

phosphodiesteraseinhibitorsImentioned–retreatingintobiomedicine–thosewithfewerside

effects,raisednointeresteither–hehadnoideawhattheproblemmightbe,anddidnotseem

interestedinfindingout.

Itsoundslikeyou´re“outtopasture,”Ineedled,searchingforaresponse,wonderingwherehis

feelingswere.Yes,that´saboutright,hesmiled,completelyunruffled. I triedanothertack: if

someonecouldwaveamagicwandandfixtheerectionproblemsorheadache,didhethinkthis

wouldmake a difference to his desire for sex?Was it, I wondered privately, all too painful

because of the erection problems – was that why he had given up? I felt I was practically

“swinging from the chandeliers” in anattempt to get a response,but all he saidwas: In all

honesty?No.

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Andrew was firmly in control of the conversation, and I was frustrated and anxious –

disempoweredbyapleasantmanseekingtreatmentbutdenyinganyrealproblemorfeelings.

Observingmyowndiscomfort,IcommentedthatshecaresandIseemtocare,butnothim.“Oh,

right!Was that thewronganswer?”he said,blasé. Feelingpatronisedanda little irritated, I

nonethelessbattledon...“Whatconstitutes,"aresult"?”

Therewasa longpause.Thenhesitantly,Andrewsaid:“The thing is, I´veneverbeenable to

orgasmDebbie.”Hiswordswerepowerful,andvulnerable,andshiftedtheatmosphereinthe

room:suddenlyheseemeduncomfortable,whileIregisteredreliefandasenseofconnection–

withhisfeelings,andwithastory,whichmightbegintoexplainhispresentingcomplaint:astory

not,afterall,onlyabouterections,butaboutsomethinglesstechnicalandmoreemotional,to

dowithhisrelationshipwithhiswife´spleasure.I´vebeenmarriedtoDebbie26years,hesaid,

Iloveher.Weusedtohavealotofsex–usedtobeatitlikerabbits.ButIcan´torgasmher.Not

really.Icouldcountthetimesonthefingersofonehand.Shecandoitherself;wegotintoa

habitearlyon–I justfelt inthewayandlethergetonwithit. Itwasclear,hesaid,thatshe

wouldlikehiminvolvedinherorgasm,buthewasnotinterested.

Whatdidthatfeel like?Iasked,moregently,feelingforamomentthatwemightnowbeon

track.Ithinkit’sjusthowitis,hesaid,calmlyclosingthingsdown.Yes,butwhatdoesitfeellike

tobeinthatplace?Ipointedtoaplaceonmyownchair,asiftoindicatephysicallywhatImeant

bybeinginasituation.“WellIjustcan´tbebothered.”Dissatisfiedwithhisslipperyresponse,I

triedathirdtime:“yes,buthowdoesitfeel”–thistimehecompletedmysentenceforme:“to

besuperfluoustorequirements?"hesaid,hiswordshangingpainfullyinthespacebetweenus,

asthoughIhadwrestedthemoutofhimbyforce.“Nauseous,”hesaid.

Well sometimes it had happened, he said – taking a step back: What did that feel like? I

wondered. Good, he said flatly. I said I imagined it might be touching, or quite special –

somethinggood,thatdidn´thappenedmuch.Oh, I´mnotveryemotional,hesaid,unmoved.

Thenasifcatchingsomedissatisfactioninme,hesaid:"AmIsayingthewrongthingagain?"

Thereseemedtobebothpainandpleasureintheroom,now,butitwasIwhoseemedtobe

feeling them,while he remained flat. I reflected, internally, that it seemeda struggle to get

“hold”ofhimintheconversationandfeltabitanxious.Iwonderedwhetherhefeltanxiousin

relationtoDebbie.

Partlyasamatterofclinicalroutine,partlyinescapefromthisdifficultconversation,Iproposed

physicalexamination–“noproblem”forAndrew,whostretchedoutonthecouch,armsabove

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his head, teasing me that he hoped my hands were warm, maintaining control even while

undressed. I was more than usually businesslike and brief, perhaps in response to some

embarrassmentofmyownattheintimacyofgenitalexamination;perhapsalsoreflectingthis

mechanically-minded man’s discomfort about sexual relating. Abdominal and genital

examinationwereunremarkable.Exceptthatattheend,Andrewsatupabruptlyandsaid:“I´ve

reallygottosortthisout,haven´tI?”

I asked himwhere he felt his passionwent – if not into sex. I´m not passionate, he said. I

wondered,privately, if "notcaring" isawayofexpressingangerat feelingsuperfluous. “It’s

funny that I can’t be bothered,” he volunteered suddenly, “because I’m not like that about

mechanicalthings...gearboxes,forexample.Idoprefermechanicaltobiologicalsystems.I´d

beperfectlyhappytostaywithagearboxproblemtillit´sfixed–withDebbie’sorgasm,Ican´t

bebothered.”Hesaiditalmostsmugly,andI,maybeirritatedonDebbie´sbehalf,ormaybeon

my own, played devil´s advocate: Why? Was it that gearboxes were more interesting or

important?“Ofcoursenot!”Hethrewback,needled.

Weexploredthehigherstakes,lowerconfidence,andmoreuncertainoutcomeassociatedwith

the orgasm, compared with the gearbox. The way uncertainty combined with a sense of

responsibilityandwantingtogetitrightmadethesexualexplorationhardertostaywiththan

themechanicalone–hardertoknowwhereyouwere.Iknewthefeeling–fromthehereand

nowofthedoctor-patientrelationship.Iwonderedaloudwhetherthekeytaskmightprecisely

be to staywithnotknowinghow todo things.Andrewshifted theconversation tomanuals.

Slightlyboastfully,hetoldmeheneverusedamanualbecausehedoesn´tneedthem.Andthat

ifathingisuser-friendly,youshouldn´tneedone.Hewasbackinhiselement,andawayfrom

thesorespotofDebbie´sorgasm,andfromcontactwithme.

Icommentedonhislanguage:"user-friendly"...“gettingaresult”–clinical,distancingterms,I

suggested.“Oh,haveIsaidthewrongthingagain?”Weseemedtobehandingthediscomfort

back and forth between us – the more I found my feet in the conversation, the more

uncomfortablehebecame,andviceversa,until tappingonthetablenervously,hesaid,"I´m

tappingonthetable."“Areyouanxious?”Iasked.“Yes.”“Doyouknowwhy?”“Well,someof

thethingsyou´vesaid . . .”“WhathaveIsaidthat’smadeyouanxious?”“Well,we´vetalked

aboutwhyI´mhere. Isuppose.That,andthegearboxconversation.”"Well, Isupposemaybe

that’ssomesortofaresult,"Iquipped,laddishly,nervously.

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Almosttomysurprise,heacceptedmyofferofaseriesoffurtherappointments.Inthewaiting

room, in front of the receptionist, in a gesture that seemed suddenly, uncharacteristically

intimate,hesaid:"Thanksforlistening".

Thisinitialsessionhadseemedlikealongfootballmatch.Andrewhadbeenaslickopponent,

skilled at maintaining the upper hand without obvious aggression. Humour had proved a

powerful defence against intimacy – at times charming, at times irritating – heading offmy

initiativesandhypotheses.AsmybesteffortsfailedandIfearedlettingthislikeablemandown

–ashe,perhaps,fearedlettinghiswifedown–myanxietyhadmounted.Butallofthisanxiety

andresistance–Andrew´sanxiety,resonatinginme,aswestruggledtogether–wastheclueto

theproblem.

5.9Achievingtherapeuticintimacy

Each of these two individuals presented a hidden story in a kind of camouflage. Each

presentedaphysicalblocktosomethingconsciouslydesired–havingafamilyintheonecase,

maritalharmonyintheother.Inneithercasewastherelational intimacyofsexpresented

directlyasalostpleasureinitsownright–rather,itsabsencefiguredasamereobstacleto

somethingelse–a“thing”broughttothedoctorforremovalortreatment,almostlikean

inconvenient foreignbody. But inboth, amoreor lessdissatisfiedpartnerwaited in the

wings,unabletogetclose;andineachcase,itwastherelationalcontextinthetreatment

room,therapidestablishmentofakindoftherapeuticintimacyagainsttheoddsandwithin

atimeconstraint,thatmeltedthefrozen“thing”–thephysicalblockorsymptom–backinto

palpabledistress,andanaudiblecallforhelp.Partofthedoctor´sjobwastore-experience

in the doctor-patient (transference-countertransference) relationship, and tolerate, what

beingkeptatadistancefeltlike,butnottogivein,usingthetherapeuticroletosustainthe

pressureofwarmcuriosityandkeeppushingforintimacyofrealcontact.

Bothencountersinvolvedthere-establishmentofafreeflowoffeelingandthinking,around

a block,where things hadbecome twodimensional and fixed. Theprocess in both cases

required the practitioner to use her creative, spontaneous self to establish a climate of

“playing with” thematerial. The feelings initially “in play” in the room are those of the

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practitioner,accompaniedbyher imaginativehypothesesastowhatthepatientmightbe

feeling.Thesehypothesesaresometimesrightandsometimeswring,butcollectivelybegin

tosetatone,atermsofengagement.Thepractitioner´ssustained,warm,attimesinsistent

search formeaning in thepatient´s storybegins to createpressure towards intimacyand

insight.

5.10Performance

Inhisbookonmentalspace,Resnikcharacterisesthetherapeuticsettingasatheatre,or,by

analogywithethnography,fieldwork.157Thepatientpresentsakindofperformance,within

whichahiddenstoryisencoded.Thework,then,becomesakindoftextualanalysisofthe

patient´spresentation.105Thisanalysisrequiresaparticularkindoflistening–tooneselfand

thepatientatthesametime:whatemotiondoIfindinmyselfonhearingamandescribehis

intimate relationshipwith thewoman he loves in purely technical terms?Howdoes this

informationhelpmovetheconversationforward?Tolisten,accordingtoResnikistoleave

spacefortheothertospeakandtoallowoneselftointrojecthisprojections;ifyoulike,tocut

thepatientsomeslack–aninterventionwhichIsuggestpsychotherapyhasunderstoodand

usedmoreeffectivelythanclinicalmedicine,whereititequallyrelevant.

5.11Spaceandcontainers

Inunderstandingwhattookplace,Bion´swordcontainmenthelpsus,withitsconnotations

ofaphysicalspacewithfirm,ifflexible,boundaries,andthreedimensionality.Likethepsychic

growthorlearningofaninfant,andlikethecreativeprocesswherebyafeelingdevelopsinto

a poem, the therapeutic process requires a chamber or space intowhichmaterialwhich

cannotyetbeborneorintegratedcanbesafelyplaced,orprojected.133Beginningliterallyin

aphysicalroomandanagreedtimeframe,arelationalspaceisestablishedbetweenclinician

andpatient,andultimately,ifallgoeswell,apsychologicalspacewithinthepatient.Inthe

processknownasprojectiveidentification,thepatientusesthetherapyspace,borrowingthe

therapist´sownmentalandemotionalspace,asatemporaryrepositoryforfrozenfeelings,

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agreeingtoallowhisorhertherapist"feelhisorherdiscomfort."Thisrequiresacapacityin

thetherapisttotoleratethepatient´sintrojectedfeelingswithoutretaliatingorcollapsingfor

longenoughthatnewthoughtcanemerge.This“firmelasticity”ofthetherapist´smental

spaceallowstoughmaterialtobereviewed,rearranged,andbrokendownintosomething

moredigestibleanduseful.

5.12Thetherapeuticboundary

A therapeutic spacehasaboundary, in termsof timeplaceandconventions,and inbrief

psychodynamicwork, thiscanfeelquitetight.Timepressurecansometimesfeelextreme

relativetotheburdenofdistress,especiallyinapubliclyfundedhealthsettingwherepatients

mayhavewaitedmanymonthsfortreatment.Establishingthetherapeuticalliancerapidly

and efficiently is of the essence. Without the luxury of the extended development and

analysis of a transference relationship, such as is possible in long term psychotherapy, a

reflectivespacewithfuturepotentialforthepatientmustbeopenedandusedwithinafew

sessions.Ratherthanaimingtodeliverasetofdoctor-centredinterpretationsrelatingtoa

singlesetofcircumstances, issuedlikeamedicalprescription,thepatient ideallyneedsto

leavetreatmentwithastrengthenedsenseofhisorherowncapacitytointerprethisorher

own experience. Emily appears well aware of this urgency, and her awareness seemed

actuallytodrivetheworkforward.

At times, the intensity of this can feel almost surgical, as the need to move swiftly but

atraumaticallythroughlayersofresistanceandconfusion–"tocuttothechase"–canfeel

urgent.Butifsurgicalandobstetricanalogiesmaketheworksoundtenseandpressured,the

workalso containsplayful elements–a kindof seriousplay. Theability toplayhasbeen

identifiedasanabsolutepreconditionforpsychicgrowthanddevelopmentinadultsaswell

aschildren.Sothisisworkwhichconnectstherapeuticandcreativeactivities.195

Wemightthinkofthiskindofintense,serious-playfulworkasakindofpoetry.Psychosomatic

symptoms present a kind of disturbing but promising poetic rawmaterialwhich through

careful listeningandreconstructionbytwopeoplein intimatedialoguecanbemadeclear

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andcoherent.Practitionerandpatientembarkonaswiftbutcarefuljourneytowardsthe

place where important knowledge lies hidden – the point of maximum sensation. Time

limitationcanbeatoughally,helpingthehiddenstorytoemerge.

KeyMessages

• Psychosomaticsymptomscanhelpfullybethoughtofasincompletecommunication• Psychosomaticsymptomsareoftenbesemiotic,ratherthansemantic–aphysicalcry

forhelpwheredistresscouldnotbeexpressedinwords• Addressing psychosomatic symptoms requires attention to both objective and

subjectivedata• Feelings,factsandthoughtsareallrelevant,andconsidered• Thetherapeuticframeandrelationshipconstitutesadevelopmentalspace• Thedoctor´sexperienceofthepatientcanbeanimportantsourceofinformation• Therapeuticperseveranceonthepartofthedoctorcanbeasimportantasinsightful

interpretation

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Chapter6–EpistemicjusticeandthelostartofmedicineFormerly,whenreligionwasstrongandscienceweak,menmistookmagicformedicine;now,whenscienceisstrongandreligionweak,menmistakemedicineformagic.ThomasSzasz

Keywords:epistemicinjustice,unopposedempiricism,medicallyunexplainedsymptoms

Ibeganthisthesisbyoutliningageneralproblemofdrownedoutorsuppressedknowledge

or awareness. I gave examples of burdensome experience which can find expression in

poems,or intheunprocessed,creativerawmaterialwhich(Ihaveargued)psychosomatic

symptoms represent. But haunting this writing throughout has been a sense that these

parallel processes of poetry and psychosomatic consultation are not only about plugging

gaps, restoring balance, or even alleviating discomfort, but about restorative justice, or

righting wrongs. It seems to me that embedded within the aesthetic and therapeutic

dimensionsofthiswork,thereisamoraldimension.

While I am certainly no philosopher, it seems that I should at least consult somemoral

philosophersonthekindofphilosophicalargumentswhichmightunderpinthemoralclaims

I am making. It is not purely scientific, nor morally neutral, to speak of drowned out

knowledge,ofthetacitoverwritingofsubtle,individualisedaccountsofillnessorsymptoms,

or of the unacknowledged but systematic suppression of clinically relevant data on the

groundsthattheydonotfitmodelswhicharecurrentlyorthodox.Ihavespokenaboutthe

prioritisation of operationalisability over understanding and introduced the notion of

unopposedempiricismasaharmfuldevelopmentwithinhealthcare.Ihaveusedtermssuch

as emotional irresponsibility, and linguistic arrogance, and accused my profession of

delegatingtoothersthingswhichareproperlyourjobasdoctors.Insayingthesethings,Iam

suggestinginjusticewhichcausesharmandviolatesthefirstHippocraticinjunction,primum

nonnocere.Theseareseriousallegationsconcerningbothactionandattitude,whichifthey

aretobecredibleneedtobeplacedinamoralcontext.

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6.1Whenisexclusionunjust?

In thinkingaboutwhenandwhyexclusionmightbeunfair,wecanhelpfullyuseMiranda

Fricker´s notion of epistemic injustice.121 Fricker characterises as epistemic injustice the

situationwhereaparticularperspectiveisexcludedoraccordedadeflatedlevelofcredibility

onthebasisnotofitsintrinsicqualitiesorrelevancebutofitsprovenance.Whenaparticular

individual´stestimonyisdisregardedbecausetheyareforexampleforeign,female,ornon-

professionalFrickertermsthistestimonialinjustice.Thisinjusticehaslongappliedtopatients

ofallkinds,sincepatientaccountsofillnesshavetendedtobeoverwrittenbyprofessional

accounts.Andwhilepatientpartnership,orco-poductioninresearchisbecomingaccepted

asbestpractice,andisnowmandatorywithsomefundersandjournals,8688217thisproblem

isfarfromsolved:criticsstillaccuseresearchersofmere,tokenisticvirtuesignalling,inan

enterprisethatremainsskewedtoservingthevestedinterestsofprofessionalsandindustry–

notpatients.86

Where, on the other hand, a particular subgroup lacks the shared social resources and

language to represent their experience inmainstream discourse at all – examplesmight

includetranspeopleinacisworld,womensufferingfrompost-nataldepressioninthe1960s

before this was recognised as an entity, or nomadic minorities among a mainstream

populationofsettlers-thisistermedhermeneuticinjustice.Isuggestthisformparticularly

affectspatientswithmedicallyunexplainedillness-illnesswhichisbydefinitioninexpressible

withinconventionalmainstreamexplanatorymodelsandhencebydefinition,epistemically

marginalised.

Fromasocial justiceperspective,themainproblemwithepistemic injusticewouldbethe

wrong committed against the personwhose testimonywas ignored or the groupwhose

experiencecannotheardandthereforecannotbevoiced.Butfromanepistemologicalpoint

ofview,theproblemistheimpoverishmentandimpotencewhichaffectsthewholebodyof

knowledgewhenvitalinformationislostbecausecertainrelevantsourcesaresystematically

excluded. A striking example of this kind of epistemic loss occurred when the London

Metropolitan Police attended the scene of themurder of black British teenager Stephen

Lawrence,butfailedtoquestionthekeywitnessDuwayneBrooks,onthespuriousgrounds

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that Brooks, in being a young black man, was considered inherently ”unreliable.” The

testimonial injustice committed against Dwayne Brookes was compounded by the

hermeneuticinjusticewhichunderminedthecriminalinvestigation,affectingconfidencein

the integrity of the whole criminal justice system. A public enquiry found evidence of

institutionalracismintheMetropolitanPoliceandstimulatednecessaryreform.

Foranyoneconcernedwiththeemergenceofknowledgeinhealthcare,andthismustatthe

veryleastincludeallclinicians,researchersandeditors,Fricker´stheoryunderscoresavital

insightusuallyoverlookedinmedicaldiscourse-thatknowledgegatheringisnotamorally

neutral activity. Whether in the consulting room, research or teaching, our information

gathering is front-loadedwith our prior epistemic biases. As in other areas of conflict of

interest,epistemicbiasisbestunderstoodnotsomuchacrimeasafactoflife,butonewhich

is lessharmfulanddistortingwhenacknowledged.This isbetterunderstood in the social

sciences than in medicine. Unacknowledged epistemic bias, by contrast, risks becoming

academia´sinstitutionalracism.

Iamnotsuggestingthatmedicaldiscoursehasbeencompletelyblindtocontextualbiasesof

oneoranotherkind.Itis,ofcourse,astandardrequirementthatmethodologicaltermsof

referencebebroadenoughtoanswerthequestionofinterest,relevanttothefieldofstudy,

and that conclusions from data gathered under limited conditions must not be

overgeneralised.Butwhatmightconstituterelevantlimitationorinclusionisnotalwaysseen

clearly.Anditisrare,inmedicaljournalpublications,toseeauthorsacknowledgeexplicitly

thedeep,priorepistemicbiaseswhicharelikelytohaveinformedstudydesign,conduction

andanalysis-thosearisinginbackgroundandtraining,andthevariousformsofprofessional

”groupthink” (includingevidencebasedmedicine)whichmight as easilyobscure vision in

someareasas they sharpen it inothers.Evidencebasedmedicinearose fromadesire to

standardise,not to individualise, care,and its criticsargue that the insistenceon treating

individuals according topopulationnorms rather thanpersonal needs is, itself, a formof

bias.218

At worst, we risk academic hubris, or false pretence to an objectivity which is neither

attainable nor desirable. We risk blocking clinicians´ access to relevant individualised or

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contextualised information. A dogmatic, prior methodological commitment to numerical

generalisablitywithdrawspermissiontogiveproperweighttoindividualelements.Clinical

judgmentissubjugatedtodatawhichhavebeen,asitwere,epistemologicallycleansedof

the truecomplexity (acknowledgmentofmultifactorialcausation),heterogeneity (the fact

thatillnessvariesbetweenpeople),andembodiment(thefactthathealthandillnessexist

withinpeople)ofclinicalpractice.Intheprocess,eventhelanguageinwhichtothinkabout

theseiseroded.

Blanketexclusionsofwholegroupsonthegroundsofage,gender,comorbidityorlanguage

yield evidence depleted of these people´s experience, and therefore of real-world

heterogeneity.Theresultingsimplisticovergeneralisations,atbestavaluableshorthand,are

atothertimesanobstacletobothclinicalefficacyandthetherapeuticrelationship.Inthe

faceofillnesswhichiscomplexorindividualinorigin,mechanisticaetiologicalexplanations

or the proliferation of questionable diagnostic labels such as hypoactive sexual arousal

disorderneitherhelpusmakesenseofpatients´problemsnorguideappropriatetreatment2

This matters, because it wastes scarce resources while discriminating epistemologically

againstpatientswhoseekourhelp.

6.2Whatthingsgetexcluded?

If the old, the foreign and the complicated become excluded from medical knowledge

gathering,howcanwe stepbackandunderstandmoregenerallywhat kindof thingsare

typicallyexcludedfromawareness?Whatphenomenaandexperiencesdoweneverlearnto

seeandname,orperhapsevenlearnnottonameandsee?What,aswefocusinonpersonal

or professional goals, seems so inconvenient, ungeneralisable, complex, nebulous,

distracting, uncomfortable, or hard to grasp that it ends up beyond even our peripheral

vision,asthoughitdidnotexist?Theanswer,Isuggest,canusefullybethoughtofinterms

ofelementswhichcauseanxietybychallengingoursenseofmentalcontrol:theparticular,

the bewilderingly diverse, thewild and uncontrollable, the difficult-to-operationalise, the

irreduciblyembodied,thegreatorterrible-inshort,materialwhichinoneoranotherway

threatenstooverwhelmourcapacitytodealwithit.Letusconsidersomepoeticexamples:

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Addersandbuttercups:theindividual

Inapoetic tributewritten incelebrationanddefence ofwords lost frommodernEnglish,

Landmarks,RobertMcFarlanerevealshowmanyrelatetoexperienceofthenaturalworld.

Amongwords removed from themost recent version ofOxfordUniversity Press´s classic

Children´sDictionaryasnolongerrelevanttoamodernchildhoodare:acorn,adder,beech,

bluebell,buttercup,catkin,conker,cowslip,cygnet,dandelion,fern,hazel,heather,heron,ivy,

kingfisher, lark, mistletoe, nectar, newt, otter, pasture and willow.3 Replacing these are

generalisable words such as attachment, block-graph, blog, broadband, bullet point,

celebrity,chatroom,committee,cut-and-paste,MP3player,andvoice-mail.219

McFarlanereflectsontheecologicalimpoverishmentwhichthelossoftheseuniquewords

represents. He invites us to take responsibility forwhichwordswe cultvate or abandon,

becausetheydonotonlyreflectbutalsoshapeourexperience.Tojettisonwordsforthewild,

the particular, and the irreducibly embodied, he argues, is to abandon our potential to

experience these things.He offers the English dialectword smeuse - aword new to him

denotingthegapinthebaseofahedgemadebytheregularpassageofasmallanimal.Armed

withthenewterm,hebegantonoticethesesignsofcreaturelycommutemoreoften.Anyone

whohaslearnedanotherlanguagewillrecognizethisphenomenon–thosemomentswhen

anexperienceorgesturesilentinone´sownlanguagecomesaliveinanother,andhowthe

new word – what McFarlane calls scalpel-sharp words that are untranslatable without

remainder - so extends experience that it becomeshard todowithout. Both English and

Norwegianareall indebtedtoGermanforSchadenfreude.Wittgensteinproposedthatthe

barriersofourlanguagearethebarriersofourworld220-thatwordscanfacilitateorlimit

experience;andMcFarlanewarnsagainstdemoralizing,abstractmonoculturesoflanguage

andthought–againsttheaestheticandepistemicconsequencesofreplacingblackberrywith

BlackBerry219

3Norweigantranslationsfortheremovedwords:eikenøtt,huggorm,bøk,blåstjerne,smørblomst,gåsunge,marianøkleblom,svaneunge,løvetann,bregne,hassel,røsslyng,hegre,eføy,isfugl,lerke,mistelstein,honningsaft,vannsalamander,oter,beitemark,selje.Thesecondgrouprequirenotranslation,initselfaninterestingcontrast.

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Cansofworms:thecomplex

Conceptualcomplexityisanothercommonreasonforrejection.Generalisationissimplerand

moreefficient,andcomplexityinterruptsthis.Mentally,itcanproducecognitivedissonance,

astateofdiscomfortwhichifcannotbemetwithcognitivegrowth,resultsindenial.221but

balancing theneed for simplificationand the recognitionof complexity is anunavoidable

challenge.

In attempting to think about the delicate relationship between abstract philosophical or

scientific theory and day to day practical situations involving human beings, Toulmin is

helpful.Hepresentsaproperbalancebetweengeneralisationandspecificityasacondition

ofphilosophicalvalidity,opposingbothabsolutistandrelativistapproachesasunbalanced.

Criticisingbothmodernscienceandmodernphilosophyforanoveremphasisonuniversality,

Toulminproposesthatnoargumentcaneverbeuniversallytrueorapplicable–rather,each

containsfield-dependentaspects,whichvaryfromfieldtofield,andfield-invariantelements

whichdonot.Ifrelativismattimesoveremphasisesfielddependentelementstotheexclusion

offield-invariantones–andToulmincitesexamplesfromanthropology222Theproblemwith

absolutism,heargues,isthatitoverlooksfielddependentaspectsofarguments.Atworst,

thismakesabsolutismnotonlytheoreticallyflawedbutpracticallyuseless–irrelevant,infact,

totheactualfield.223

Kirkengenetalaccusebiomedicineofjustsuchanabsolutist,collectivedenialofinformation

relevant tohealth, in the formofoversimplistic studiesofcomplex issueswhichomitkey

contextualelements,betrayingbothindividuallivedexperienceandthecomplexityofclinical

phenomena.Sheis,ineffect,challengingmedicine´ssystematicrefusaltoacknowledgefield

dependentaspectsofknowledge,denyingpractitionerstheevidencetheyneedtomeettheir

patients.Thisleads,Kirkengenargues,toatravestyofcareinwhichthepatient´sillnessis

madeworsebythemedicalestablishment´ssystematicdisinterest initswideranddeeper

grounds,effectsandremedies.74224

Manyacademiccliniciansfromprimarycarehavepointedusinthesamedirection:Evans,

remindsus that themedical gaze is asmuchanactive constructionas it is adescription,

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underlining the necessary connection between themedical body, or body-as-nature – as

empiricism seeks to define it - and the lived body, orbody-as-self - as phenomenology

attempts to understand it.225 Ahlzén argues for the notion of bodily empathy as a vital,

epistemologicalbridgebetweenthesetwopositionsintheclinicalencounter–anempathic

act, on the clinician´s part, of sharing the predicament of being a vulnerable embodied

being.226

Shit:theunthinkable

Sometimes,thematerialwhichneedstobeconsideredisnotmerelyparticular,orcomplex,

butforsomereasonunbearableordisgusting.Suchmaterial isoftenactivelyexcluded,or

repressed.Repressionisthepsychoanalytictermforthekindofactiveforgettingwhereby

threateningmaterial is placed outside of consciousness – the psychological equivalent of

consigningdangerousmaterialtoanuclearbunker.227Examplesmightincludeimpulsesor

insightswhichthreatenone´stermsoflivingorstronglyheldvalues-thoughtsofleavinga

spouse,resentmentagainstadependentchild,parent,orpatient,suspicionsofmalpractice

inapopularandpowerfulcolleague,orexperiencewhichisunbearable,traumatic,inhumane

orphysicallyabhorrent.

Bowlbyarguedthatwecannotseewhatwecannotbeartosee228andprofessionalsworking

with victims of torture or abuse offer horrifying examples: Sinason, a psychoanalystwith

extensiveexperienceinworkingwithdissociativeidentitydisorderandritualabuse,givesa

confrontingexample,whensheacknowledgesherowninitialmisunderstandingofapatient´s

statement that theymademeeatshit.Evenasanexperiencedtraumatherapist, shehad

initially excluded the possibility that this statementwas true literally, rather thanmerely

metaphorically.229

The desire not to know or hear certain things can be powerful, accounting for the well

recognisedprocessesof socialdiscreditingwhichoften surroundabuse.228Withcollective

denial,families,groupsororganisationshidefromknowledgeofabuseswhichthreatentheir

integrity,attheexpenseoftheindividualsaffected.Suchdenialallowsabusetocontinuein

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trustedorganisations230-232ortight-knitcommunities233234Thiscollectivedenialalsoextends

to research,where the recognitionof traumaticphenomena, suchasdissociative identity

disorder is also resisted. For many years after the characteristics of dissociative identity

disorderwereclearlyspecified inDSMIV, thediagnosiswas ignoredbothclinicallyand in

medicaljournals.228Epistemicexclusionproliferates,causingharmatmultiplelevels.

In thinking about this type of instinctive, physical, prelinguistic rejection of unwanted

material, I findKristeva´swordabjecthelpful. Suchmaterial becomes repressed, Kristeva

argues, because it reminds us of our ignominious origins and ending and of what we

permanently thrust aside in order to live 235 At the same time, she suggests, the abject

representsaneruptionofwhatshecallstheRealintoourlives–aviewconsonantwiththe

psychoanalyticvoicesIcitedinchapter4whoargueforrawnessasthestartingpointofart

(Chapter4,Thepointofpoetry).235

Here, I suggest, lies a vital connection: the very material rejected from everyday living

becauseitismessyorraw,wouldseemtoformtherawmaterialforcreativerenewal.Itis

interesting that theabject is a sphereof enquirywell established in art,withexploration

incorporatingfur,bone,bodyfluids,deadanimals,andimageswhichchallengeasenseof

everydaypropriety.236Inamaster´sthesisonrawnessinvisualart,Ipresentedexamplesof

Thepart-physical,part-mental,part-conscious,part-unconscious recyclingandorderingof

lived experience which art represents. I argued that art takes over precisely where our

capacitytobearthingsineverydaywaysapproachesitslimit.Thestonewhichthebuilders

refusedisbecometheheadstoneofthecorner237theabjecthasinitiatedanewtherapeutic

orcreativeresponse.

Wecantracethisconnectionbetweenrawnessandrenewal,discussedinChapter3Thepoint

andprocessofpoetry,188190intothedebatearoundtheuseofartisticmethodsinresearch

andtreatment.Rapport,forexample,arguesinamoreliteralwaythanIdo,forpoetryasa

toolforresearchwithsubjectmatterothermethodscannotreach–thosewhofeeldisplaced,

disenfranchised or isolated ... vulnerable groups ...who have been caught up with an

extraordinaryeventbeyindtheircontrol.160Sheusespoetryasaresearchtoolwithholocaust

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survivorswhohavehadtorepressvitalinformationinordertosurvive238Therearealsomany

examplesoftheeffectiveuseofpoetryasatherapeutictool239

Myowninteresthasnotsomuchbeenintheliteraluseofpoemsinatherapeuticorresearch

setting,asinteasingout,epistemicallyandpsychologically,whatitisthatpoetryepitomises

thatmedicine (sometimes) needs: what are its active ingredients or keymethods which

shouldnotbeexcluded fromclinicalunderstanding. I havebeenconcerned to showhow

poetry´s welcoming, containing and processing of difficult or elusive material parallels

psychotherapeutic practice, and how such stances and skills can add vital diagnostic and

therapeuticunderstanding.Iammostinterestedinhowtheepistemologicalrebalancingof

health care, to re-include the kind of creative, interpersonal elements which poetry and

therapy represent could help us work more effectively with prevalent illness which we

currentlymanagebadly.

6.3Whatvirtuescanpoetryandpsychosexualmedicineteachhealthprofessionals?

How, then, in busy lives, do we avoid such unfair exclusions, and epistemic injustices -

overwritingimportantaccounts,shirkingemotionalresponsibilities?Andhowdopoetryand

psychoanalysishelp? I suggest that in extending towards, containing, conceptualising and

voicingelusivematerialcertainpsychological”muscles”arestrengthened,differenttothose

developed and strengthened through other tasks. The habitual practice of stretching to

accommodate raw material, attending to what might lie beneath the surface of things,

mulling and sifting large amounts of amorphous material efficiently for what is most

important,stayingopentotheunexpected,andattendingcloselytophenomenaandprocess,

rather thanseeking tocontrolanoutcome,developscertainvirtues.These, I suggest,are

humility,hospitality,honesty,hermeneuticbalance,anddevotiontophenomena.

6.4Humility

Inchapters4(Thepointandprocessofpoetry)and5(Whenbodiesspeak),Iexplainedwhyit

is impossible to be a successful poet or therapist while cultivating a preoccupation with

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”looking good” or only taking on work which is somehow orderly, or whose successful

outcomecanbepredicted.Theveryconditionof successful creativeor reparativework, I

argued, is awillingness to place oneself in the service of a task, acknowledge ignorance,

tolerateunpromisingbeginningsandentertainthepossibilityofanunsuccessfuloutcomefor

thesakeofintimateengagementwithsomethingimportant.Toallowtherich,supplementary

manic-oceanic144processofunconsciousintuitiontosupplementconsciousoverview.

Humilityrequiresthatexpertiseisheldlightly,andnotallowedtoovershadowtheclinician-

patientrelationshipandthepatient´sexpertiseabouttheirownillness.BothKierkegaardthe

philosopherandtheologian,andWinnicottthepaediatricianandpsychoanalyst,areequally

uncompromisingonthetechnicalimportanceofthismoralstance:Alltruehelp,accordingto

Kierkegaard,beginsnotwithexpertisebutwithhumilityandpatience.Thefirstqualification

isawillingnesstomeetapersonwhereheisandunderstandwhatheunderstands,andany

attempttoassertexpertisebeforethesehavebeenfulfilledisnomorethanaconceitedbid

for admiration. Helping, he emphasises,means tolerating beingwrongwhen you do not

understandwhattheotherunderstands.240Winnicottinsimilarvein,admonisheswould-be

therapiststhat itdoesnotmatterwhatyouknow,as longasyouknowhowtokeepyour

knowledgeoutofthepatient´sway.

Buthumilityalsoappliestoawillingnesstotakeonwhatevermaterialneedstobeworked

withratherthanonlykindswhichonefindspleasant.AsceneinRichardAttenborough´sfilm

GandhihastheMahatmaorderinghiswifetorakeandcoverthelatrine–an”untouchable”

tasksheexperiencesashumiliating.Hefirstbeatsherforresisting,then,repentant,rakes

andcoversthelatrinehimself.241Itisascenewhichneatlyencapsulateshowtheflightfrom

workwhichisperceivedasdirtyorunflatteringisunderstandable,futile,morallywrong,and

dies hard even among otherwise exemplary people. Such avoidance is based on a

misconceived splitting up of the world, in fantasy, into people and subjects which are

”untouchable” - difficult, awkward,messy or abject – ”them” – and thatwhich is clean,

healthy,sanitised,andsociallyrespectable.

Goodartandtherapywork,bycontrast,arebuiltonaprioracceptanceofshared,flawed

vulnerable humanity, in which no one gets to claim privileged status. One of the 20th

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century´s great poets and immunologists, Miroslav Holub, calls art fidelity to failure.242

Playfulnessandartistic reverieare impossible ifwecannotsetasidepriorknowledgeand

become, in a certain sense, like little children243 - curious, undogmatic, experimental

observersofphenomena,notperformersofexpertise.

6.5Hospitality

Bothpoetryandtherapyalsorequireinadditiontohumility,alsoaparticularopennessor

generosity.Awillingnesstostretch,accommodateandmeetapersonoramaterial–tomake

space.Buberdistinguishessuchradicalopenness-thekindofintimacyonefindsbetween

close friends, lovers, mother and infant, and religious and therapeutic encounters from

common, everyday forms of relating. He calls the former ich-du (I-thou) relating – an

authenticencounterwithoutqualificationorobjectificationoftheother,andnotbasedon

preconceivedideas,anddistinguishesitfromthemoreeverydayich-es("I-it")relating,244in

whichtheotherisreduced,inakindofemotionalshorthand,toanideaorrepresentation.

Theich-esrelationshipisinfactnotsomucharelationshipwithanotherpersonaswithone´s

ownmentalobjects–notatruedialogue,butamonologue.Whilemanytransactionsoccur

reasonablyenoughusing“ich-es”encounters,somecannotmeaningfullytakeplacewithout

genuinedialogueof the“ich-du”variety.These includeart,whichsucceedsor failsas the

palpable, intimatetraceofahumanpresence–andmanysituations inhealthcarewhere

“ich-es” mental representations have failed to deliver a sufficient understanding of the

patient´sproblemandperson.Agledahl´svideoanalysisofdoctor-patientencountersoffers

anexcellentexampleofdoctorsexhibitingpolitenesswhichmasksexistentialneglect.245Such

refusalstomeettheotherasapersonwhereitismostneededdevaluebothpartiesinthe

encounter.244

6.6Honestyandhermeneuticbalance

Bothpoetryandpsychotherapeuticworkrequireawillingnesstoacknowledgewithoutfear

orfavourwhateverappearsinthefieldofencounter,whetherornotitisunderstoodorcan

benamed,andwhateveremotionalresponseitelicits.Bothpracticesalsorequirereflexivity

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andalertness topractitionerperspectivesandbiases.Bothrequire,as Ihaveexplained in

chapters3,4and5,abalancebetweenemotionalandintellectual,objectiveandsubjective

engagement.

Marion Milner´s famous account of drawing offers advice about the need to balance

subjectiveandobjectiveelementsinalmostmoralterms:shewarnsagainstthedanger,on

the one hand, of erring on the side of something which is too inward, private and

incomprehensible - an extreme monologue of action out of touch with thought .. a

meaninglessbabbleoflines,orontheotherhand,orproducing,amonologueofthoughtthat

wouldnotlistentowhatactionhadtosay.24(p74)

Rabinow offers us a view of what such skilled, epistempological balancing means for

medicine,arguingthatitisemotionalandmoralaswellasintellectual,orasHunterargues,

isbestcharacterisedasamoralknowing,anarrative,practical, interpretativereasoning.69

But while health care in practice shares its methods of knowing with human sciences

concernedwithmeaning, itwronglyclaimsagoldstandardbasedonthenaturalsciences,

failing, therefore, to recognize its interpretative nature or the rules it uses to negotiate

meaning69At itsmostarid,Hunteraccuses,modernmedicine lacksametricforexistential

qualitiessuchasinnerhurt,despair,hope,grief,and..pain,whichfrequentlyaccompany,and

oftenindeedconstitute,theillnessesfromwhichpeoplesuffer.

When patients present symptomswhich do notmake immediate sense within a natural

scientific model, it is not good enough, in terms either of efficacy or ethics, to adopt a

narrowlybiomedicalperspectiveanddismisstheseas”meaninglessscribble.”Indoingso,we

betray the patient´s call for help and violate a developmental gesture, rather like an

unempathicadultsadisticallyinsistingthatahobbyhorseismerelyapieceofwood.189195246

Instead,suchphenomenaneedtobeunderstoodforwhattheyare-”actionoutofbalance

withthought,”inMilner´sterms–incompletecommunication,inneedofinterpretivehelp.

Kleinmancharacterisestheclinicianasananthropologistofsorts,whocanempathisewith

thelivedexperienceofthepatient’sillness,andtrytounderstandtheillnessasthepatient

understands,feels,perceives,andrespondstoit.”247

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6.7Devotion

Allwork,ofcourse,whetherscience,artorcraft,demandsmental,emotionalandphysical

devotion. IrisMurdochdiscussesthiskindofdevotionoftheself intermsofvirtue.Much

moral philosophy has taken a behaviourist, or utilitarian view of virtue - a quasi-natural-

scientificposition,inwhichvirtueisheldtoexistonlyinmeasurableactionsandbehaviours,

without reference to the relevance of inner attitudes or the possibility of inner objects.

Murdoch challenges this, arguing that the central concept of morality is not objectively

measurableaction,butlovingattentiontoreality.Criticisingwhatsheseesasphilosophy´s

uncriticalattachmenttoscienceandobservabilityasthecriterionofreality,shedefendsthe

ideaofinternalobjects,proposingwhatshecallsanalternativetheoryofmind.Shegivesthe

exampleofapersonwhoisabletomakeamoralshiftfrominitialdisliketoappreciationand

understanding,viaaprocessofgettingtoknow.Withouteverhavingactuallybehavedbadly

in the first place, she nevertheless makes a change of attitude via the inner work of

engagement.248

Murdoch´scriticismofmuchanalyticphilosophyseemstometochimewiththecriticismI

andothersaremakingofwhatIhavechosentocallunopposedempiricism inhealthcare.

AccordingtoMurdoch,philosophysimplydoesnotfitintotheworlddescribablebyscience248

and nomore, Iwould argue, does clinicalmedicine.Unless, that is,we expand the term

sciencebeyondempiricismtoincludehermeneutic,creativeandrelationalformsofenquiry.

Murdoch accuses her philosophical contemporaries248 (referring to Hampshire as an

example)ofimposinguponusaparticularvaluejudgmentintheguiseofatheoryofhuman

nature,resultinginakindofNewspeakwhichmakescertainvaluesnon-expressible-aform

of philosophical cheating, of sleight-of-hand, Murdoch seems to be suggesting, perhaps

consonantwithFricker´slaterterm,hermeneuticinjustice.

The sleight of handMurdoch is naming, I suggest, is not the direct presentation of false

information,butthefalsepresentationofunacknowledgedvaluejudgmentsasthoughtthey

were facts, and the false presentation of a partial view as though it were an overview.

Withoutdirectfalsehood,truthisdilutedoutbybiasordecontextualisation,underminingthe

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analytic neutralitywhich is philosophy´s aim,or claim. Likewise, awrong is committed in

Murdoch´sterms–itseemstome–ifapurelybiomedicalorempiricalaccountofillnessis

presentedasacompleteaccountofillness.Thewrongisnotinthescientificmethodperse

andthe(perfectlygood)knowledgeitgenerates,butinitsunacknowledgedincompleteness

–itsscientifichubris,ifyouwill,itsdistortionofthescientificrecordviaunjustexclusionof

relevant data and perspectives, and the epistemological violence and impoverishment of

discoursewhichthisrepresents.

MurdochoffersaphilosophicalbasisforwhatIillustratedusingpoetryinChapter3(When

wordsact)andclinicallyinchapter5(Whenbodiesspeak)–howtechnicalmedicallanguage

renders key subjective, emotional and relational aspects of epidemiology, pathogenesis,

history, examination, diagnosis and treatment inexpressible, and how this constitutes an

injusticeandabetrayalofahealingprofession´sethics.

It is easy to understand how the overvaluing of natural science has come about if we

rememberhowsciencegrewaspartoftheenlightenmentprojectofattemptingtofreethe

worldfromthe”darkages”ofreligiousandpoliticaldogmaandabuse.Thereis,inmodern

society,awidespreadconsensusthatsincereligioncannotbethebasisforcommonlanguage,

rationality is the only common language. Rationality, after all, guards against capricious

irrationality,andifthecostisthatmuchthatispersonalandparticulargetsexcluded,this

often seems a price worth paying. Evidence based medicine itself arrived as a kind of

academic liberation force from a preceding tradition where eminence and dogma had

trumpedevidenceandtruth.Itcamewithitsownepistemologicalmoralimperative.

Therisk,though,isthatrationality,withitsdeliberateblindnesstocultural,emotionalcontext

and metaphysical perspectives, is turned into an alternative God-concept – an

unacknowledgedreligionofdecontextualisedinformation,placinggeneralprinciplesbefore

people,riskingviolationofindividualismanddifference.Bransonaccusesmedicineofhaving

actedasakindofreligioussystem,withitsownsymbols,values,institutionsandrituals”.42

There are no easy answers, as we struggle to balance rational reductionism with social

inclusion: to draw fair and clear lines which balance protection for shared values with

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permissionfortheparticularandpersonal–whetherthatbejoiking,prayerorthewearing

ofreligioussymbolsatwork,non-discriminationagainstLGBTpeopleinpublicroles,orthe

righttoparadewithone´sownchosenflagonanygivenoccasion.Weconstantlyfacethe

need tobalanceobjective,observablephenomenaandunconscious, elusiveoremotional

phenomena;tovaluethebenefitsofsciencewhileavoidingreductionistdenialofallthatis

elusive,complex,sensitiveorhardtograsp.Murdoch,anavowedatheist,neverthelesschose

to describe her philosophical position on virtue as a rival soul-picture.248 It is not the

observableactionbut the individual, sheargues,which is thecentralconceptofmorality,

knowableby love.Good, sheargues, isan indefinableandunmeasurablebut realquality,

capturedinaestheticandcontemplativeterms,notreducibletoasetofexternallyobservable

actions.

TheethicsIamalludingtointhisstudy,itwillbynowbeclear,arenotthoseofexternalcodes

ofreferencewhichdefineacceptableprofessionalbehaviours,suchastheGeneralMedical

Council´sGoodMedicalPractice249–essentialthoughtheseare–butanethicsofpersonal

codesand internalmotivations. I amreferring toan innercompass,notanoutercodeof

conduct. Murdoch argues for morality as an area of study indissolubly enmeshed with

metaphysics,notmerelyatractablesetofinheritedcommandsorrulestobeappliedbythe

will. In a post-Kantian philosophy centred on the notion of will, she identifies the

metaphysicalasanimportantexcludedelement.ItistemptingtoseeMurdochasarguing,

fromheratheistposition,that”God”cannotbereducedtoguidelines.

6.8Concludingremarks

Wherearewe left, after thisextended reflectiononunjustexclusionand its creativeand

moralremedies?AmIarguingthatteachingchildrentechnologicalwordsorresearch into

moleculargenetics iswrong?Thateverythingpleasantanddesirablecanbe included ina

dictionary,amedicalcurriculum,oranation´shealthpolicy,withouttheneedforrationing

andprioritisation?Certainlynot.

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Thisisnotacharter–basedonahandfulofcloselyscrutinisedpoemsandsomecasereports

-forunexaminedsubjectivity,thereplacementofempiricalwithhermeneuticmethods,or

anend to thebenefits evidencebasedmedicinehasbrought. It is not evenanattackon

psycho-physicaldualismperse,whichisusefulforsomekindsofclinicalthinking;onlyagainst

itsheedlessovergeneralisationtoareaswhereitisunhelpful.226Rather,itisacallforusto

developourattitudesandourmethodsofgatheringandinterpretingdata,tobetterfitthe

complexhumanfieldweworkin.Iamnotadvocatingamoveawayfromnaturalscience,but

awayfromanaturalscientificmonoculturewhichleavespatientstroubledthatmostdoctors

arenotprimarilyinterestedinfindingoutwhatisthematterwiththem,butareconcerned

insteadwithdiscoveringwhatdiseaseisthesourceoftheirillness.250

Ihavenotspenttimeinthisthesisdefendingnaturalscientificviewpointsorevidencebased

medicine, because others have done this, and in any case they need little defence. I

acknowledgetheiressentialcontributionstohumanhealthwithgratitude.Myoppositionis

nottobiomedicine,whichIhavepractisedfor25years,buttoitsmisuseinareaswhereit

doesnothelp.Iamarguing,alongwithothersIhavecited,foraparadigmshiftinmedicine–

asoftrevolution,tomodifyanddevelop,notoverthrow,theassumptionsandrulesforhow

knowledgeabouthumanhealthshouldbegained,anddelimitedfromnon-knowledge.251I

favourToulmin´sviewofscientificdevelopmentasanevolutionaryprocessofinnovationand

selection, rather than, as Kuhn suggests, a fight to the death between competing and

mutuallyexclusiveparadigms.251

Thequestionishowandwheresuchevolutionmightoccur.Therehasbeenlivelydiscussion

inthemedicalhumanities literatureaboutthedifferencesbetweenmultidisciplinarityand

interdisciplinarity, andmuch collaborationofexperts fromessentiallydifferentdisciplines

andtheoriesofknowledge.Theproblem,asIseeit,isthatwhileinterestingconversations

takeplace,theunderlyingtheoriesandmodelsappeartocontinueonparalleltraintracks

relatively untroubled by each other, engaging in occasional conversations or shared

initiatives.Theriskisthatinterdisciplinaritynevermovesbeyondakindofflirtation.

There are many calls for reform, but far fewer serious attempts at integration of the

humanities suchasmoralphilosophy,orpoetry in theacademicmindofmedicine.Much

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valuablework isbeingdonebyhumanitiesacademics interested inmedicinebutwithout

clinicalexperience,orbycliniciansinterestedbutinexperiencedinthehumanities.Currently,

the humanities inmedicine have not yet adequately troubled coremedical thinking. The

humanities,oratworst,humanityasastance,arestillapttobeviewedasaluxury,ignorable

intheheatoftheclinicalencounter,likeDuwayneBrooks´missingtestimonyatthesceneof

StephenLawrence´sdeath.

Genuine interdisciplinarity insofaras itmatters topatients,doesnotbelong inoccasional

interdisciplinaryseminarsandconferencesbetweenexpertsfromseparatedisciplines,but

insidetheconsultingroom,themedicaljournal,themedicalschool,andthedoctor´shead.I

suggest we need to emerge from a view of interdisciplinarity as a polite conversation

betweenparallelbutseparateworlds,liketwopartnerssleepingsidebysideintwinbeds,

and instead promote genuine intellectual interpenetration of ideas andways of thinking

within the individual practitioner. This means taking the risk of allowing old, familiar

structurestoberemodelled,anditistothisIhaveattemptedtocontribute.

Isuggestweneedatthehighestacademicandpoliticallevelstoacknowledgethatunopposed

empiricism has become a systematic block to progress in health care, and that

epistemologicaldevelopmentisurgentlyneeded.Inanerawhereweunderstandbetterthan

everthattechnicalsolutionscannotsolvetheproblemsofhealthcare,thebesttechnological

andempiricaladvancesneedtobebalancedbyamaturecommitmenttocontext,meaning,

andindividuality,ifwearetogrowtothenextlevel,asaprofession.

I have written this analysis tomakemy own interdisciplinary affairs plain. It arose from

creative engagement with and analytic separation from two kinds ofmaterial, and from

allowingmyselfandmywritingtobe“invaded”bythemoraldilemmasthematerialraised.

Althoughnotusuallydiscussedinscience,Isuggestthiskindof”invasion”or”merging”with

a subject matter, though seldom discussed, is as much a part of scientific as of artistic

research,andthatresearchisthereforearelationalprocess.Myguessisthataresearcher

studyingclimatechange,theaccumulationofplasticintheoceanorthepathogenesisofpre-

eclampsiaalsobeginswithasetofskills,apuzzletosolve,andanepistemologicalpassionfor

asubjectmatterwhichforwhateverreasonattractsthememotionallyaswellasmentally,

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though this is traditionally excluded from scientific discussion. Each requires diligent

commitment of the self, via a chosen methodology, to the phenomena at hand. Each

combinescloseobservationofphenomenawiththehermeneuticactofinterpretationand

contextualisation. At thestageofpublication,ascientificnarrative is required,aswellas

demonstratingmethodologicalrigour,toanswerthequestions:whydoesthismatter?why

were resources spent on this study?what does itmean for practice? and therefore,why

shouldanyonereadit?Increasinglysomeofusnowalsoask:how,ifatall,didyouinvolve

patientsinthedesignandinterpretationofyourstudy?Isuggestthatthewholeprocessof

researchandpublicationischaracterisedbyaconcernfordiligenceandtruthfulness,butis

not, contrary to common assumption, defined by objectivity, so much as self-reflective

engagement.Mergingandseparating.

Iofferthisanalysistocolleaguesintheclinic,themedicalschool,andthemedicaljournal;to

othersinterestedinhealthandthehumanities,andtofellowpoets.Inpresentingmyselfas

adoctorwhoneedssomethingwhichpoetryrepresentsinordertofeelfullyhuman,Iam

arguingthatmedicineneedssomethingwhichpoetryrepresentstoremainfullyhumane.I

am remindingmyselfandothers that the languagewehabitually speak shapesand limits

whatwesee,andthattheremaybeotherthingsasyetunframedinlanguage,whichweneed

todiscover. I amarguing for academic ecology, for epistemological balance, and for self-

reflection.Iamencouragingpersistenceinquestioningmodelswhichdonotfitexperience,

and the courage to return in a spirit of wonder and scholarship to the live, raw data of

phenomena,withheartandmindopen.

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KeyMessages

• Unopposedempiricisminmedicineisineffectiveandunjust,becauseitunderminesclinicalrelationshipsandacademicunderstanding.

• Notallknowledgerelevanttodiagnosisandtreatmentispurelyobjectiveandcanbeapprehendedpurelyobjectively

• Hermeneuticknowledgeofthekindpoetryandpsychotherapydelivercomplementsnaturalscientificknowledge

• Maturemedicalpracticerequiresthatempiricalandhermeneuticelementsbeintegratedattheleveloftheindividualconsultation.

• Tobeusefultopatients,epistemologicalintegrationneedstooccurwithinthemindofindividualclinicians,notmerelyasoccasionalinterdisciplinaryconversationsbetweenexpertsfromdifferentdisciplines

• Theethicalpracticeofmedicinedependsoninternalattitudessuchashumility,hospitality,honesty,hermeneuticbalance,openmindednessanddevotiontophenomena,notonlyonexternalactionsorcodesofpractice.

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