Literature & Medicine: Eye Witness
Paul Genova’s essays, which offer a humanistic and humanizing vision of psychiatry, have been widely read in Psychiatric Times and other publications. He is the author of The Thaw: Reclaiming the Person for Psychiatry (Analytic Press, 2002) and has been a supporter of the Literature & Medicine program for a number of years.
What Does Suffering Do?
Know that love has chosen you
to live his crucial purposes.
Know that love has chosen you.
And will not pamper you nor spare;
demands obedience to all
the rigorous laws of risk...
Words in the Mourning Time
An hour had passed in a sterile exam room at the Veterans’ Hospital. I had completed the disability evaluation, receiving honest and thoughtful answers from this Vietnam combat veteran. Feeling that I should give him something in return, I’d made a few informal suggestions about treatments that he might pursue. He didn’t seem very interested.
Then he looked at me and delivered his own evaluation. I was as glad for the utter self-possession he showed in making it as for what he said.
“You seem like an intelligent man,” he said. “Have you ever read the Psalms?” And then this man, who lay awake nights alone in his trailer in northern Maine reading them, proceeded to recite from memory:
I am sinking in deep mire and there is no place to stand:
I have come to deep waters and a flood overwhelms me.
I have cried until I am exhausted.
My days go up in smoke:
My bones are inflamed as a bonfire.
Like grass my heart is crushed and withered....
I lie awake and feel like a sparrow alone on the roof.
—Psalms 69:2-3; 102:3-4,7;
Revised Berkeley (Gideon) Version
“That David, he knew about pain,” concluded the veteran.
It was the late 1980s. I had exhausted myself in the first few years of my private psychiatric practice, trying to “make things happen” for my roster of severely disturbed, often traumatized patients. Here in backwater Maine I decided to slow down before I crashed. I took a part-time job at the local VA doing psychiatric disability determinations. The idea was that no “treatment” would be involved. I took my time, walked over lunch and saw fewer patients than anyone else. The veterans often asked to see me again at the next required evaluation. I learned how powerful “just” listening can be, and I began to realize that there is a world of human suffering that will forever dwarf our interventions.
Knuckling at her tears as she remembered her father, she asked with apprehension if medication would take these tears away. “At least this way I feel connected to myself,” she said...[My] patients had taught me that in any medical intervention I might attempt with this woman, I would need to respect the fact that, like the psalmist, she valued her suffering.
Fifteen years later, I sat discussing antidepressant medications with an orphaned, chronically depressed young woman in graduate school who was just beginning psychotherapy with me. Knuckling at her tears as she remembered her father, she asked with apprehension if medication would take these tears away. “At least this way I feel connected to myself,” she said. The veterans and my other patients had taught me that in any medical intervention I might attempt with this woman, I would need to respect the fact that, like the psalmist, she valued her suffering.
Suffering. The word today has a largely archaic or technical usage, as in lawsuits alleging “pain and suffering,” or in case presentations where patients “suffer from” something unearthed in the review of symptoms. Modern western medicine has given us options about when, where and how much we endure, and, of course, we are thankful for the relief we now can, and should, provide for our patients. But then the need to name and consider suffering as a dimension of human experience may be, as it were, reduced to an icon on our busy screens. If we want to understand our patients’ suffering, we need to click on that icon. No matter what we do, there will be those who suffer, and some who have learned to see the act of suffering very differently than we might.
Many approaches to suffering, traditional religious as well as contemporary spiritual and scientific, center on a teleological discussion of the purpose of suffering. Such explanations have a natural appeal to desperate people looking for explanations. If one “knows why” (or “what for”) there is some sense of control, even if the suffering can’t be stopped.
I have speculated that this “knowing why” serves the same protective function for humans that “knowing when” serves for rats. In the cruelly “classic” paradigm developed by Seligman in the 1950s, one group of animals is electrically shocked at random intervals, while another group is given a warning sound beforehand. The unwarned rats develop predictable physiological abnormalities “stress hormone” over-secretion, spontaneous startle reactions, weight loss which are also characteristic of humans with posttraumatic stress disorder. The group that is warned does not.
But the relief offered humans by understanding the causal or teleological explanations of suffering is typically short-lived. Soon it begins to drive a tyrannical “cure” that is all but impossible to follow. In earlier days the cure was specifically religious: do a better job obeying this or that law. Today we also have dietary and exercise regimes; the injunctions of self-help books; spiritual and pop-therapy leaders and movements; and, failing all else, psychiatry itself, either in its psychoanalytic version that claims to decode our histories and our symptoms, or in the pharmaceutical variety that purports to treat biological diseases. But whether it is Job facing his “comforters” or our patients facing us across our prescription pads, the common denominator is compliance.
click for enlargement Engraving of William Blake’s “Job’s Evil Dream” from Illustrations of the Book of Job. London: William Blake and John Linnell, 1825 . Courtesy of the Charles Deering McCormick Library of Special Collections, North Western University.
And for Job, as for some of our patients, suffering just doesn’t stop. The conclusions to draw are divergent: either the sufferer hasn’t been compliant, for long enough, or the diagnosis is insufficient. Patients often receive many such diagnoses and treatments. If they seem, strangely enough, to value their suffering, and to look upon the next explanation with suspicion, we should not see them as people who have lost hope. If they had, they wouldn’t be talking to us. The sleepless veteran reading the Psalms, and the depressed young student finding a connection in her tears, demonstrate a more profound and radical hope than ours, though they might not be able to express it. They choose to live as if their suffering were a transformative process—as if it had a purpose in their lives.
Here is where clinical psychiatry has something to offer philosophy, ethics, religion, and medicine itself. We who have known sufferers well over prolonged periods have seen some of them survive and come out on the other side changed. However skeptical we may be of any particular religious or scientific worldview, we know that suffering indeed can transform individuals, and we can describe some of its results. We ourselves may not be in a position to answer the question “What is suffering for?” but we can begin to answer the question, “What does suffering do?”
Since the sources of suffering are so outwardly diverse, and its successful survivors so unique, it is difficult to generalize about them. It would be next to impossible to round up a group of these individuals for the kind of statistical “outcome study” which lately has become the gold standard of truth in behavioral science. Nonetheless, any traditional psychiatrist who has known patients well over periods of years recognizes something special about certain people who emerge intact from a prolonged period of suffering. Whatever their history—physical or psychiatric illness, chronic intractable pain, catastrophic loss, sexual abuse, concentration camps—these inspiring individuals have an unshakable acceptance of self that does not submit to the judgments of others. They don’t compare themselves to others or compete with anyone else. They make themselves heard, but don’t try to impose a personal agenda on others, and, more than leading their lives, they are open to going where life leads them. Compassionate and receptive, they tend to be rooted in the present moment, all in one place rather than conflicted and at war with themselves. Regardless of religious belief, or lack of it, they embody the connectedness to other people and the living world that many of our greatest religious teachers have held as a primary value.
How has suffering changed these people? Our science tells us that suffering can alter the brain’s functioning and even, in the extreme, its cellular architecture. How then does it sometimes also refine and temper the soul?
This transformative process has been described many times by those who have lived through or witnessed it. These accounts, almost as old as the written word itself, range from ancient Hebrew poetry (most famously, in Psalms and the Book of Job, through Juan de la Cruz’s Dark Night of the Soul in the 16th century, down to the writings of depth psychologists, novelists, and poets in our own day. The African-American master Robert Hayden (1913-1980) is among the latter.
The most fundamental lesson sufferers learn flows directly from the failure of explanation: no one is in control. Typically, sufferers begin by struggling to comply with a treatment process or psycho-spiritual regime that promises deliverance in accordance with a particular explanation of their plight. They tolerate the side effects of a medication, sit for hours in meditation, or bring the “right” dreams and insights to the psychoanalyst or the “right” prayers to the “right” conception of Deity.
If those approaches fail, the sufferer may seek solace in an imagined past or future constructed from the governing explanation: “If only I had...” or “I’ll feel better when....” But if this tack yields to rage and/or despair, when it becomes clear that being “good” doesn’t work and that no authority is in control, the first hidden fruit of the suffering process starts to blossom. This is autonomy, an acceptance of one’s own perceptions and needs as valid apart from externally derived values, judgments and comparisons.
Now that ego—or Will—is on its own, internal judgment replaces external compliance in the attempt to control the suffering. Contemporary psychiatry sees self-judgment as entirely pathological: “excessive or inappropriate guilt”, in the words of our most popular quantitative rating scale for depressive symptoms. Psychiatry fails to acknowledge any value in the deep and urgent interrogation of a person’s previously unquestioned beliefs, attitudes, and habit-driven actions. This “treatment” position may be taken with compassion as well as objectivity, but it closes off any further understanding of suffering as a process. Some patients feel distanced or even abandoned by such medical-model reassurance that their moral anguish is a disease.
In other ages and cultures there were universally accepted vocabularies available to sufferers like our young graduate student: well-described sins to atone for (medieval Christianity) or earthly attachments from which to free oneself (classical Buddhism). The “searching and fearless moral inventory” of Bill W’s Fourth Step in Alcoholics Anonymous is one contemporary replacement for these. But this patient is not looking for reassurance, but for help in inventing a vocabulary of her own. And, as good a person as she already is, she will no doubt become a better one by following this moral imperative.
As the suffering process wears on, though, the internal judge will become every bit as tyrannical as any external authority. William Blake captures this well in a painting of Job’s tortured dreaming [see end note for web links to this work]: the dream figure that persecutes Job is identical to himself, except for the Devil’s cloven hoof in lieu of a left foot. Boiling in their own juices, sufferers find that even the fiercest self-examination may not make the suffering stop. They cannot regain control by dint of inner moral force, any more than by complying with external authority. Sooner or later, these undeserved agonies free the suffering ego from its oppressive dream of finally getting it right. At last there is nothing left for sufferers to do but defy all judges internal and external; accept, forgive and love themselves; and then face whatever happens.
Jung once described the psychiatrist’s job as helping patients to “hang on until nature grants a reprieve.” In my experience, that reprieve is more often a quiet and gradual miracle than a dramatic turn like Job’s vision of God in the whirlwind. But when it comes and it can come even to the dying and to the chronically ill and disabled it is experienced as a gift, only secondarily connected to anything sufferers or their allies, including ourselves, may have done.
Perhaps ill or scarred, certainly imperfect and fallible, the survivor of suffering emerges still somehow more vital, more intact as a human self than many who have never lost soundness of mind or body. All of us can think of great figures from history and literature that fit this description: Abraham Lincoln with his incredible litany of personal losses, or William Blake himself, abed for weeks on end enduring hallucinations. More importantly, most psychiatrists can point to these same attributes among some of our patients. Such individuals may be less articulate than the giants of history; perhaps they are only known to a family or a neighborhood. Yet in that more intimate context these exemplary people can be regarded with special affection and even awe. Others tend to seek their counsel, whose wisdom passes beyond words.
In human history, many more sufferers have fallen off the road I have described than those who reached this end. Some have been destroyed literally; others psychically, ending in resignation, embitterment, addiction. Now medical science, including psychiatry, can help many more to “hang on.” What kind of world is this going to make?
If we have no awareness of the transformative process that suffering engenders in some of our patients, if we simply abort or arrest suffering whenever possible before listening for the meanings our patients may find in it, we may unwittingly contribute to a society flattened of emotional depth. If we, in that society, extrude suffering people from our midst, or insist that they conceal their pain, we will thereby discard our most ancient and durable source of wisdom about living. We will become a smiling, compassionless culture that retreats behind locked gates from the less fortunate.
Let us instead invite suffering back in and give it a seat of honor. For if we listen with respect to suffering people like the ones I have described, whose survival depends upon engagement with this mysterious process they have discerned within themselves, then the world may yet be a wiser and more compassionate place. We may not presume to know the purposes of suffering, but we can learn from sufferers as we seek a purpose for ourselves.__________________________________
Note regarding Blake’s engraving and watercolor known as “Job’s Evil Dreams”, #11 in his series of illustrations to the Book of Job: This illustration (the watercolor) was included, with copyright permission from the Pierpont Morgan Library, in an earlier version of this essay. A transparency can be obtained from Art Resource, NYC.
Eye Witness is a column devoted to the stories of Literature & Medicine participants. We invite you to submit short essays about your experiences in the seminars, and to share your reflections with a larger audience.
Design : Harley Design
Web : West End Webs
Literature & Medicine has received major support from the National Endowment for the Humanities.