Travelling with…

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“In the Revised Confessions de Quincey tell us how much he suffered from ‘the pressure on my heart from the incommunicable.’ This pressure, no doubt, is known to us all; but it may approach the most agonising level in patients whose sufferings are not only intense, but so strange as to seem, at first, beyond the possibilities of communication.

Such difficulties in communication, clearly, can arise from the very strangeness, the extraordinary quality, of patients’ problems, their experience; but an equal, if not greater difficulty may be created by physicians themselves who, in effect, decline to listen to their patients, to treat them as equals, and who are prone to adopt – from force of habit, or from a less excusable sense of professional apartness and superiority – an approach and language which effectively prevent any real communication between themselves and their patients.

Thus patients may be subjected to interrogation and examination which smack of the schoolroom and courtroom – questions of the form: ‘Do you have this… do you have that…? which by their categorical nature demand categorical answers (yes and no answers, answers in terms of this and that).

Such an approach forecloses the possibility of learning anything new, and prevents the possibility of forming a picture, or pictures, of what it is like to be as one is.

The fundamental questions – ‘How are you?’ and ‘What is it like? – can only be answered analogically, allusively, in terms of ‘as if’ and likeness, by images, similitudes, models, metaphors, that is, by evocations of one sort and another.

There can be no reaching out into the realm of the incommunicable (or scarcely communicable) unless the physician becomes a fellow traveller, a fellow explorer, continually moving with his patients, discovering with them a vivid, exact a figurative language which will reach out towards the incommunicable. Together they must create languages which bridge the gulf between physician and patient, the gulf which separates one man from another.

Such an approach is neither ‘subjective’ nor ‘objective'; it is (in Rosenstock-Hussey’s term) ‘trajective‘. Neither seeing the patient as an impersonal object nor subjecting him to identifications and projections of himself, the physician must proceed by sympathy or empathy, proceeding in company with the patient, sharing his experiences and feelings and thoughts, the inner conceptions which shape his behaviour.

He must feel (or imagine) how his patient is feeling, without ever losing the sense of himself; he must inhabit, simultaneously, two frames of reference and make it possible for the patient to do likewise.”

Oliver Sacks discusses the psychology of communicating with distressed or impaired people, in footnote 104 of Awakenings.

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