End of Story

September 1, 2002
Paul Genova, MD
Volume 19, Issue 9

The patient, a young gay man who once lived for a time in Salt Lake City, describes his pursuers: Mormons who know where he is and are trying to kill him. As the clinic visit goes on, I see the doubt in his eyes when I explain my medication increase, and ask about it. He admits he can't be sure; his voices are saying that I'm a Mormon too. Only, with much persuasion and oversight will he comply with my prescription, because he trusts his case manager more than anyone else in the world.

(Dr. Genova returns to his column after an eight-month hiatus--with something of an explanation--Ed.)

The patient, a young gay man who once lived for a time in Salt Lake City, describes his pursuers: Mormons who know where he is and are trying to kill him. As the clinic visit goes on, I see the doubt in his eyes when I explain my medication increase, and ask about it. He admits he can't be sure; his voices are saying that I'm a Mormon too. Only, with much persuasion and oversight will he comply with my prescription, because he trusts his case manager more than anyone else in the world.

But the case manager is not present when two clean-cut young men in suits happen to knock on his apartment door the following week. Terrified, the patient runs out the back door, half-dressed, and keeps on going. That night, exhausted, he will be found by the police, committed and forcibly medicated--as he imagines, by Mormons--his worst fears fulfilled, he thinks, before he falls into a sleep from which he does not expect to waken.

Back in my private office, I listen to a middle-aged professional man describe his new second wife in idealized terms. She knows what he's thinking before he says it; they never fight; they like the same music; he's never felt this way in a relationship before. As an aside, he notes with suppressed glee how unhappy his first wife seems to have become (it was she who had rejected him), and how she resorts to making things difficult with children and money to punish him for his own luck in love. But this only confirms and adds to his sense of happily-ever-after.

Then, consider another private patient, a bright 30-year-old man who never quite finished college or got his life underway and works as a waiter--armed, no doubt, with the same sarcastic wit he displays to me. He is unhappy; many of his contemporaries are moving on, but he can't quite deign to enter the mundane flow of bourgeois life to which his intelligence and background would easily give entry if he were willing to trim his beard, perhaps put on a tie and hold his contempt in abeyance for a spell. Every alternative involves "selling out."

Eventually, even his rather passive girlfriend tires of cleaning up after him and quits the scene. But this boy-man who fancies himself uncompromised (even as he subsists on restaurant tips from doctors and lawyers in an upscale caf,) will not leave off his story of a misunderstood and unknown genius. He remains the classic pothead intellectual, going nowhere.

The above examples were chosen to make a simple point. People become trapped in their own stories. The literature of psychotherapy has oversold the concept of healing-through-narrative-construction. We have taught beginning therapists to help their patients gain a sense of coherence and control over their lives by making those lives more resemble stories of which they, the patients, are the authors. In various forms of therapy, we even covertly supply the story lines: A hero's journey from exile or abandonment, through various trials, and ending in a triumphant return to wholeness. Overcoming adversity. Making the best of a bad hand. Mind over matter (now rehabilitated by PET scans and brain-derived neurotropic factor). The risk of such ego-strengthening maneuvers is that the development of faith in something that can't be anticipated or understood, let alone "authored," may be inhibited. There is no place in therapeutic narrative for the old gospel refrain, "Farther along we'll know all about it"; for letting go and seeing what happens.

Granted, our efforts to "re-story" our patients' often fragmented and chaotic lives, so that they make sense or acquire a consciously discernible meaning, are frequently and powerfully effective. Real life, however, is not a story, at least not as the ego conceives of stories. There is too much noise in it; too many loose endings never again picked up; digressions that do not end up relating to the whole; lacerating, jagged edges never to be filed smooth; ambiguities never to be resolved. Such messiness is the very substance of life--and the fertile source of surprise. Order can only be imposed on it in retrospect, by selective inattention to whatever doesn't fit the chosen story line. This is most easily done when nothing new is happening, and patients like those above, good storytellers all, make it their business not to allow anything new to happen. For some reason, story has become more important to them than real life, real relationships, real events. The story must be preserved at all costs.

The young psychotic man, were he not a unique sacrificial victim of the Mormon conspiracy, would have to cope with being lonely, gay, very ill and without resources in small-town Maine; a handsome man becoming obese on the only medications that have ever quelled his paranoia and voices. But giving up the story, if indeed he can, might allow something new and surprising to happen. Better treatments may come along; prolonged remission might allow more improvement than anyone expects; someone out there may be able to see the wonderful things about him and love him, illness and all. None of this can happen if he remains possessed by the predetermined story.

And what will happen to the "happy" second marriage of the professional man? Will his new wife finally chafe at her role as the pot of gold at the end of the rainbow? Will he see her as the full person she really is, fight with her, dislike aspects of her? If he can't, their real relationship will not develop, and they will continue to inhabit a script, which includes the first wife as evil sorceress. In essence, the man will have never really left his first marriage, because he has allowed it to continue as the dominant narrative of his relational life. His new wife will never surprise him, but will only play her part as an opposite to wife number one.

And if the pothead intellectual never cleans up and tests his grandiosity in the real, sold-out world as it is given to him, he can remain safe in his unchallenged conviction of specialness even as he descends to even lower circles of addiction or stabilizes as an embittered, underachieving caricature of himself. The world will never be good enough for him. For the young waiter, leaving this story behind involves the risk of being ordinary, the necessity of compromise and false starts, both in relationships and with the larger social world. Cutting loose from the unsung genius is, however, his only chance at real fulfillment, real love, real mastery, transient and imperfect as they are. Will he remain forever deafened by his internal narcissistic applause?

Toward the end of his final novel, Mr. Palomar, Italo Calvino carries narrative imprisonment to its logical conclusion in the mind of his elderly narrator.

Mr. Palomar decides that from now on he will act as if he were dead, to see how the world gets along without him. For some while he has realized that things between him and the world are no longer proceeding as they used to; before, they seemed to expect something of each other, he and the world; now he no longer recalls what there was to expect, good or bad, or why this expectation kept him in a perpetually agitated, anxious state

This is the most difficult step in learning how to be dead: To become convinced that your own life is a closed whole, all in the past, to which you can add nothing and can alter none of the relationships among the various elements...

But in the end Palomar/Calvino, old and decrepit as he is, just can't bear to smother himself with a completed story.

Therefore, Mr. Palomar prepares to become a grouchy dead man, reluctant to submit to the sentence to remain exactly as he is.

Irascible as ever, he remains open to the new until his life's last instant.

Now, one last story. A tired psychiatrist in his late 30s, despairing over the direction his profession has taken toward diagnostic and biological reductionism and away from the art of listening, begins to write about it. Through a series of coincidences, this writing is eventually published ("Is American Psychiatry Terminally Ill?" June 1993 Psychiatric Times, p19).

To the psychiatrist's surprise, an outpouring of letters from other clinicians in the trenches leads to his becoming a regular columnist. Over the ensuing decade, he is privileged to hold forth on a variety of subjects. He even collects and self-publishes some of these pieces.

But his lack of success in penetrating official psychiatry and influencing its course, the deepening eclipse of psychotherapy in everyday practice, the metastasizing regulatory and documentation requirements in community treatment, the dumbed-down world of mental health trade publishing--all of these things persuade him that he is back where he started, a self-appointed Voice Crying in the Wilderness. Telling his editor that he needs time off to teach, he privately resolves to quit the column. His operative story is that of Herman Melville retiring to the customs house after the failure of Moby Dick. Like Melville writing poetry at his desk and going through the motions of his mindless job, the psychiatrist will write prescriptions and check off boxes at the clinic, do a little therapy on the side, play guitar, sail his little boat, get the kids through college. Such is the narrative drift of "negative inflation," operating much as it does in the life of the young waiter above.

But in this case, the psychiatrist's own hope, flying below the radar of his despair, sabotages the airtight story. He hasn't officially quit the paper, and he has kept on perfunctorily sending his book around. Like Palomar, he is a grouchy dead man, refusing to quite lie still. One fine day, a call from a sympathetic publisher changes everything, and leads the psychiatrist, in his next column, to proffer another of his presumptuous definitions: hope (as opposed to the aspirations of the ego) is that part of the self that doesn't already know the end of the story.

And so, dear reader, "No Shows" is back for another round. I don't know for how long or to what effect, but I am too grouchy to be a dead man, and these pages will yet see more of me.