I’ve been thinking lately about the nature of the historical details I acquire as I speak to my patients each day. As important as we’re taught this is and as much as I wish these details would answer the questions I have about the condition I’m trying to manage, I’ve concluded that history is often an incredibly unreliable indicator of what actually happened at any time in the patient’s past. And I mean last year as well as yesterday.
Of course, this conclusion troubles me. I have shelves packed with charts full of information that is supposed to be reliable, helpful, accurate, and legally binding and in case anybody important is actually reading this they certainly are. But the foremost authorities on the subject of recall all agree that there is a thin veil between memory and imagination. If this is the case how can I be expected to believe everything I’m told? When I go back through what I’ve written I can’t help but wonder if it describes what actually happened or even what I think I remember the patient told me. I’ve come to feel that what the patient tells me is akin to an autobiography, often full of flattering details and colored by desire. What I end up writing down isn’t any more reliably true than an unauthorized biography. There are important things missing and an emphasis on others that aren’t really relevant or significant.
I don’t think that this is a fixable problem but it’s worth discussing. Maybe my discomfort with those charts will ease a bit if understand more about how history might be described. Toward that end I’ll offer something I recently read in a fantasy by Ursula K. Le Guin.
In the forward of Tales from Earthsea (Harcourt 2001) the author writes:
“The way one does research into nonexistent history is to tell the story and find out what happened. I believe this isn’t very different from what historians of the so-called real world do. Even if we are present at some historic event, do we comprehend it–can we even remember it–until we can tell it as a story? And for events in times or places outside our own experience, we have nothing to go on but the stories other people tell us. Past events exist, after all, only in memory, which is a form of imagination. The event is real now, but once it’s then, its continuing reality is entirely up to us, dependent on our energy and honesty. If we let it drop from memory, only imagination can restore the least glimmer of it. If we lie about the past, forcing it to tell a story we want it to tell, to mean what we want it to mean, it loses its reality, becomes a fake. To bring the past along with us through time in the hold-alls of myth and history is a heavy undertaking; but as Lao Tzu says, wise people march along with the baggage wagons.
When you construct or reconstruct a world that never existed, a wholly fictional history, the research is of a somewhat different order, but the basic impulse and techniques are much the same. You look at what happens and try to see why it happens, you listen to what the people there tell you and watch what they do, you think about it seriously, and you try to tell it honestly, so that the story will have weight and make sense.”
I’d like to think that my patients give me something sequential, verifiable and consistent. But in fact what I get are their stories. They come in with the story of their injury, fall from health or descent into a painful existence. Often their emphasis is not so much on the behaviors that perpetuate the problem but on the drama of the initiating event if there happens to be one. For the new patient the story of their illness complete with its drama and tragedy, heroes and villains, triumphs and failures must be told first. If the therapist doesn’t allow this something important is likely to be lost. Perhaps it will be a clue leading toward an accurate and relevant essential diagnosis. Remember that Le Guin suggests that the truth in any story is dependent upon the teller’s energy and honesty. Keeping any story close to reality takes an effort quite different than that required to manufacture a lie. Understanding this encourages us to listen again each time the patient appears, comparing the nature of delivery with that previously seen and then placing the latest story in the chart with proper emphasis and interpretation. I wouldn’t suggest that this is easy, and I feel that doing it well is one of the things that distinguishes the expert from the novice.
Finally, we need to listen for a new story. Specifically, we need to hear the story of recovery. When that appears consistently and rings true, treatment comes to a close. At least for now. Just remember that now very soon becomes then, and another story will be born.