Hidden in Plain Sight on Locked Wards—On Finding and Being Found

A few days after 9/11 my wife and I drove to New York City to be with our daughters, one of whom had just started college, the other who had begun a new job at City Hall. The horror of the moment hung in the air—the world seemed to be coming apart at the seams—and we all needed to be together. We stayed at a favorite hotel, one with a familiar comfort that we badly needed. The city was still, calm; everyone quietly heartbroken, friendly, concerned, even courteous—respectful of whatever the other might be going through. We were all family.

Usually bustling, our hotel was only partly full, a crash pad mostly for exhausted relief workers searching around the clock through the rubble, hoping to find life, hoping to find anything at all. But the mission was not going well—and this was just now beginning to sink in: some people had fallen—or jumped—out of the towers, but others seemed erased, literally vaporized. Still, at the end of the day a search dog of remarkable charisma and warmth, a big black Labrador, greeted everyone in the lobby as if she were its host. People smiled at her wagging exuberance. We needed her vitality. Her owner had come from Canada to help out, and I felt grateful to them both.

A few days later, headed back to Boston, I bumped into the search worker and his dog. I patted the dog and thanked the searcher for helping out, telling him how much I appreciated his putting himself on the line: it must, I said, be hard. No, he replied, he was OK, it wasn’t too much for him, he had experience with disasters, but he worried about his dog. She is trained to find survivors, or at least bodies, but day after day they were coming up empty handed, finding no one at all—and she was becoming palpably depressed. Realizing she needed some urgent relief, some therapy, the wise owner and his team decided to hide—to bury—living search workers in the rubble so that his dog might find them. They knew her well, and they got it right—she perked up. And this also helped me understand her joy in greeting everyone at the hotel: finding us, that too was a kind of therapy.

This tail-wagging dog still remains a surprising memory for me, an uncanny condensed symbol that I come back to time and again. I still don’t know what it means, but surely this remarkable creature intuited the terrible sense of something wrong: for me she is an uncanny presence. The uncanny, by its nature, marks the moment when the world becomes strange and unstable, when we feel the familiar ground beneath us tremble. Trained to search for those gone missing, yes, I get her urgency. Maybe, we are not so different.

Lost and falling, the feeling that life is disorienting: none of us escapes the experience; strangeness shadows the human condition. For those clinicians who venture on to inpatient wards, lost-ness and the dense haze of strangeness are all around—and finding the other takes on a special urgency. Yet what does it mean to “find” another? And what does it feel like to find—and to be found? Feeling lost, one can also feel lost to oneself. And is this lost-ness to oneself also a way the unconscious speaks to us? Surely feeling lost is at the heart of our existential search for grounding. And so how does one find oneself? And why is another so important in this self-search?

This paper finds its grounding in two clinical moments, brief encounters on an inpatient ward. The fog of psychosis, desperation, and despair often covers the shock of unbearable feelings that can destroy a person’s world and leave her falling (Margulies, 2015). But, here can be an opening for the clinician because a crucial, not-yet-spoken, intolerable story is often displayed as both a symptom and a sign, inscribed in the body, an uncanny symbol hidden in plain sight. And here, at this intersection with strangeness, may be a way in, and a way out.

I chose this vignette for several reasons; on reflection, and more to the point, this vignette chose me. That is, this brief encounter, long passed, haunts me still. I had written about this case 25 years ago, briefly, and I thought that I understood. Indeed, I did understand—but how I understood then is not the way that I do now. That is, I realize now that there was a limit to what I saw back then. My countertransference? Surely, but one that is rooted in the humanly intolerable.¹ So now I return with you, to look at this story in my recognition years later, afterwards, knowing that the story will still not be concluded even as I tell it.

Let me sketch the context. For many years now I go up to the inpatient ward at Cambridge to interview patients with medical students, postgraduate-year 2 residents, and other trainees and staff. These teaching sessions are too short, about an hour, and the interviews themselves only about 30 minutes. Still, for me, teaching in these settings feels authentic, unrehearsed, and often surprising and deeply moving. Somehow I feel as if I am coming home to myself as a clinician. When it comes together, to me these moments seem more like encounters² rather than interviews, two people talking, one person to another, about how life can go terribly awry.

I appreciate the clinicians on these wards; they are on the front lines. The sense of duty of the clinician is, understandably, rapid diagnosis to blanche the psychic hemorrhage and the interpersonal, situational danger (for example, physical violence or homelessness in the dead of winter). Under this pressure the clinician urgently tries to stabilize while avoiding missing potentially hazardous medical conditions. The clinician initiates the appropriate somatic treatments, knowing all the while that the admission will usually be too short, even for meds, to know if you have nailed the right regimen. The time horizon is, then, short and pressured, a matter of days—and the next task is to triage the patient rapidly to another, longer-term service. There is a lot of wear and tear in doing this kind of clinical work, and I admire the grace under pressure of the staff. But, still, all acknowledge that we barely get to know the patient beyond the acute and dangerous symptom picture.

There is an ambient, speeded up, ADHD quality on these wards, reflective of much of contemporary medical and psychiatric practice and training. We ask of our clinicians that they sprint from one clinical urgency to the next. The inpatient ward, once a haven for interpersonal connection and individual reflection, is now primarily an extension of emergency services. The criteria for admission are, strictly speaking, legal (versus solely psychiatric), invoking a holding area for acute safety. Once when I typed “inpatient ward” on my iPhone my way-too-smart-device auto-corrected me, adding the missing affect. It wrote “impatient ward.” And, yes, that is my sad experience in these settings; we are “impatient,” because things barrel along so quickly there is precious little time for the clinician to find the person behind the symptoms, which remain entangling and unconscious mutual enactments in plain sight. And the pressure on our clinicians, particularly in the public sector, is not getting any easier.

An old woman, thin and sad and with long flowing hair sat next to me. Her ear lobes were painted white. The medical student said she had used typewriter white-out fluid. Her teeth, too, were painted.

Why erasing fluid on the ears? I wondered to myself. While driving together, my daughter once jokingly told me to turn up the music because it was too quiet and she could hear herself think. White noise. Hearing too much, thinking too much. I surmised that there was something this old woman could not bear to hear, and I told her my thought. Sadly, she replied that her son had died; he had killed himself shortly before she had come to the hospital. She was told all of this by her nursing home caretakers. I thought I understood: She couldn’t bear hearing this news.

No, she explained, it wasn’t hearing the awful news so much—it was hearing his voice inside her head that she could not stand. The white-out was to get rid of his voice, to blank it out.

I asked about her son. She sketched her story simply, with few words. He had been a good boy who worked hard at a job that was beneath him. He had loved his wife and daughter, and his wife left him for another man. He had never gotten over this grief, particularly not being able to see his daughter. He had come faithfully to see his mother; she had never known about his self-torture, he had protected her. He had always been this way. She looked back in regret over her lifetime as a mother: She had become sick when he was just a boy; she, too, had been in love with a spouse who had treated her wrongly. Her poor boy had been on his own. He had been very handsome and independent. Perhaps his suicide was the result of her inadequacies as a mother.

“Why the teeth covered with white out?” I asked. She told me she had swallowed the white out to remove him from inside of her. She looked up at me with tears in her eyes, “I guess the voices have to do with my not being ready to give him up yet”—and she cried. I had not expected this degree of insight; she no longer seemed psychotic. She was an old woman grieving her son, filled with regrets and guilt about her mothering, and she was just now beginning to give up her boy ….

But first, a word about polyphonic awareness, pluralism, or, the music of infinite theory. An interviewer once asked an expert kayaker what, with all of his experience, had he learned over the years? The expert reflected a moment and replied, “I have become much more aware.” Very Zen. This captured my own attempts to try to kayak—with each mistake I became more aware of the world around me, things I had never noticed before. I began to apprehend wave patterns, shadows and white caps, and how they moved; I took note of the wind, of tide levels, of my boat; of temperature, of my response to temperature and the experience of beginning hypothermia; I became aware of me-in-my-boat-in-the-water. My awareness of the world of water opened up—and with this I had a new respect for its beauty and hazards. I remain still very much a beginner.

Our teachers and clinical theories, I submit, open our awareness. With this guidance our world expands, we realize we are not alone in our strange calling. When I go about my work—not self-consciously, but reflexively—I respond to a polyphony of almost infinite theories, a complex pluralism. If we had more time we could tease out some of the voices in the chorus of theories implicit in my vignettes—they are all here! We might look at the four schools sketched out by Leston Havens’ (1973) pluralistic blueprint: the biological, or objective-descriptive school; the psychoanalytic; the interpersonal; and the existential. Further, we might expand out the many sub-schools of each primary school; we might re-vision the shifting social and cultural contexts of our work, take a look at Semrad’s Triad of grieving (Khantzian, E., Dalsimer, J., & Semrad, E. (1969); Garfield, 2009) and what I call Haven’s Triad of the encounter, and so on. These theories are background, noticed more in retrospect. But in this next vignette notice how my perspectives seem to shift rapidly, even abruptly, moving from the biological, to the legal, to the social milieu of the wards, to the existential, to the interpersonal, to the psychoanalytic approaches to the intrapsychic and intersubjective (including my appropriation of classical psychoanalysis, self-psychology, Kleinian, Lacanian, Bionian, relational understandings, and more). On the inpatient wards, I usually do not foreground transference patterning in the unfolding conversations, rather, I listen for affect and the complex pull of unconscious processes and countertransference enactment. Where and when I feel it is helpful, I might bring these patterns into awareness in the hopes of extending mutual awareness and freeing the conversation to go where it will, together amending, elaborating, correcting, and opening up. Often the encounter moves into complex grieving, but most of all, we move into and through the encounter itself, and what Warren Poland (2000; Margulies, 2000) calls “witnessing.”

A clinician usually has many theories operative at a given moment, each opening up patterns of awareness and possibilities (Margulies, 2014). Indeed, the satisfying complexity of clinical work is the simultaneous awareness of multiple patterns. This simultaneity of theory in the clinician’s mind creates a complex polyphony of understanding, a way of being that continues to evolve over time, afterwards—and one very hard to describe.⁵ We reveal patterns on patterns, a palimpsest, sometimes puzzling, but often rich and deep and resonant. Maybe the complexity of a field might be measured in the richness of its patterns that open awareness and ways of being for its practitioners.

Not much was known about the medical student’s patient except that he came close in his plan to kill himself—to “slice his neck.” He displayed an old, thick scar to show that he is deadly serious. Just admitted, the patient has a long history of poly-substance abuse, and, in his 50s, he has no work, no friends, and he feels that he is a failure in life. The medical student says, the patient has been tried on a “ton” of medications: large doses of antipsychotics, antidepressants of all classes, anti-anxiety agents—the works.

“A ton of medications:” I see this all of the time on the wards, and, no wonder, the staff is alarmed, and so the range of their pharmacologic interventions is also a sign—a marker—of their desperation, too. Things are dangerously out of control, and how can we help? The brutality of his scar pulls us into urgency. Slicing his neck becomes a shared symptom. Responding, we are inexorably drawn into an unconscious force field that enacts his essential struggle. Are we witnessing the self-staging of his execution? Just who is this man I am about to meet?

As he comes through the door, I’m struck by discrepancies: he seems a proud-shy man, handsome with a rough elegance, but he seems underwater, dazed by his medications—and I wonder if we’ll be able to carry on a conversation, if I will be able to reach through this haze. But, I think, maybe he’s more dazed by life than by the drugs; surely he’s fallen into a nightmare. His shirt collar is opened to an extensive, angry, red scar, it is out there and meant to be seen, defining him and shaping anyone who comes close, whether acknowledged or not. I wonder: will we be able to connect—and do I want to?—do I want go to that place, that symbol, now right here between us?

I thank him for meeting with me and the students, but, I tell him that he seems tired, is it OK for us to talk? He responds quickly, even eagerly—“Sure!”—letting me know that he is struggling to come to the surface toward me. There is a light in his eyes, intelligence shining through and across some gulf. I think of Lazarus, back from the dead, someone in between, liminal, literally on the doorstep between two worlds, vacillating for a moment. No need for chit-chat, I think—here is a man from the depths—and so I ask him: “Just what is it like to come so close to killing yourself, to reach out and touch death by your own hand?”

When he nearly died, he tells me, he felt relief, no pain, and free from all the suffering. Life had become too hard. And here he wells up, sad—then, he gets sadder still, quiet, and struggling to hold back his tears.

“It couldn’t always have been this way,” I say, “there must have been a time when you still had dreams for yourself.”

“Oh yeah,” he responds, “when I was a teenager, I wanted to be a doctor, but that was an impossibility in my environment.”

“Please, tell me, what does that mean?”

He tells me of his father’s abuse and contempt. “He used to scream at me: ‘You’re nothing! And you’ll always be nothing.’ (He’s quiet…) My father hated me. He just hated me.”

“Why?”

His father was mean and nasty, a drunk who would “beat the shit out of me, yelling at me that I was nothing and I’d become nothing.” At some point, he says, “I just gave up, and dropped out of high school.” And with that he got heavy into drugs, a new direction.

I say, “You got the ‘fuck-its.’”

He laughs, “Oh yeah, big time—the ‘fuck-its,” and he partied, quite literally, as if there was no tomorrow.

“Tell me why slicing your neck is the way you wanted to die. It seems so filled with hatred, as if it’s execution style.”

“Oh yeah! I can hate myself. I want to punish and do away with myself (he slashes his hand across his neck), and I call myself names: You bastard!”

I say, “I get it”—because I suddenly do, and so I say: “I’ll bet your father called you names, too.”

“You’re right. Oh yeah! He called me (hotly): ‘you little bastard!’—Yeah!—(coldly) ‘you little bastard.’”

Me, softly: “‘You little bastard’—like you weren’t his son, a ‘bastard’, he disowned you, as if he hated you.”

“Oh yeah, he hated me all right. He hated my guts.”….

It’s now in the room, hate, like a ghost; so I move us inwards: “So, when you want to hurt yourself, kill yourself, and slice your neck, and you start calling yourself a bastard—you’re channeling your father. He’s alive, inside of you. Inside of you, hating you.”

“Yeah … I’m just a little bastard who should die.” Sadness washes over us both—I feel it badly—and he starts to cry softly.

We are both back there—but he is back there, caught. And so now I go towards him, to take him by the hand through words, and to weave us back outwards into the world: “So the scar on your neck, there for everybody to see, is a living symbol of your father’s hating you, and of you hating you. It’s like you’re wearing a sign.”

“… Yeah … I guess it is. I hadn’t thought about it that way … but, yeah … you’re right. And, yeah, I never wanted to hide that scar. I want it out there, all of the time.”

His symptom, I think, is also his badge, his identity, who he is; the scar defines him: He is the damned—and I decide to put this out there:

“So you want others to know, the world to know, of your father’s hating you, of you hating you—it’s a symbol to remind you and everyone else of just who you are: someone to hate.”

“Yeah … I do.” And here he cries.

(His father has come alive in the room, present to us both, a ghost; but father is also part of a scene from the past, replaying like an endless video loop. So, I think, let’s look at this scene together, let’s now go there again, bring it to us and into focus, but more, let’s enter that childhood scene, that memory, together.) And so I say: “When you drink and hate yourself and want to die, and you slice your neck, when you start screaming at yourself, ‘You little bastard!’ at the same time you’re recreating your father inside of you. But you’re also recreating the experience of you as a boy being with your father, how it was back then, and how it felt to you. It’s like you are back there with him, back then.”

Tears run down his face—and it feels as if we are back there, back then, but also right here, right now. He says “Yeah … Yeah … That’s spot on … The whole thing.”

He has taken me to the center of his symptom, his scar as a scene of abuse, his grief, his identity, his badge, his conflict at the heart of who he is. We are there, and I want us to stabilize this coming together so that we both can be with—and stay with—the intensity. To combat the fragmenting forces of mind, we need now to deepen and extend this scene, to weave it outward and inward, forward and backward in time (to link, as Bion might say)—and all through his intolerable feelings, which are pulling him apart. And so I ask him if his tears are familiar to him, is he able to let himself be with them, stay with them, does he, will he, let himself cry?

Now he’s crying deeply, sobbing. “Yeah … Yeah … I do cry … I miss my father … Yeah. I miss him.”

A sudden curve in the road: He misses his father! We’ve lurched to a new place, also one to enter, one to expand: “I know this must be painful—but, if you’re ok with it, tell me about missing your father. Help me know about this father you now miss.”

“I loved him. He was different the last seven years of his life. And I … loved him. And when I was a boy, and he wasn’t drinking, I know he loved me, too. We had some good times, too. We did!”

“Wow! What you’re helping me see is just how impossible and sad this was—and still is—because your father loved and hated you at the same time. Now how could a boy, how could any boy, how could you, make sense of this? How could you even begin to understand a father who hates and loves you at the very same time?”⁶

“You’re right all right, it’s confusing. As a boy, I didn’t understand. I thought I was evil, just bad. Real bad. I thought there was something evil inside of me.”

“So, when you want to slice your neck, you’re killing off that evilness, that evil boy, inside of you.”

“Yeah, I feel the evil is still inside of me.”

I want now to situate and question that boyhood understanding, still with him, and still threatening to destroy him. I want to destabilize that conviction, and open it up to the light of day: “Now how could a boy ever understand that the father he loved would hate him?”

“Well, I figured with my father that he loved me—so I must be bad, evil, for him to hate me. And that’s not all, I’ve thought this all my life with other people, too. So I’m critical of me when people are bad to me—it must be me. It has to be me—something is inside of me that deserves to be hated.”

“So inside you feel there’s an evil boy and, at the same time, you’re the father who hates that evil boy, and you should kill him.”

“Yeah!” He wells up and sobs. And we sit silently for a while, sad, taking in the sadness of that boy then, and this man now ….

We are nearing the end of our too brief time together: “How does it feel for us to talk?”

“It’s intense, it’s sad. But it’s good to talk about, I need to talk about it—I’ve avoided talking about this. But it’s a part of me.”

“You know, you’re grieving—and I bet all of your life you’ve been grieving. But, still, you don’t really know how, maybe you never learned how, to grieve.”

“I go to my father’s grave, and I miss him, and I cry. And I cry a lot.”

Still going to his father’s grave, like a heartbroken boy! I say: “How in the world do you grieve the father who loved and hated you and who you loved and hated, too!”

He sobs …

“And so you carry with you this scar. And this scar keeps your father present, alive and with you, that father you still love. And hate. And, at the same time, you feel you deserve this scar, because you feel he was right, and you are evil … “

He is quiet, reflective: “I never cover up my neck—I’ve always wanted it to be seen. I always wanted it out there.”

We are silent again, taking it all in, being together with the intolerable. He thanks me for talking to him—it was helpful, he’s never talked to anybody in this way, and it feels better.

And I thank him, too, for sharing his life with me and the students. I end with: “I’m glad you are here in the hospital, that you didn’t choose to die. You’re ripe to talk about your life. Now you need to find your way into therapy. And we can help you with that—even though you’ll want to run from it. But now is the time. I hope you make your way.”

Our complex pluralism of clinical theory reflects the larger infinity of the Other: Patterns of clinical theory and understanding don’t exhaust what they match—rather, they abstract from an infinity of information and possibilities. The philosopher Emmanuel Lévinas (1987) thought that the earliest experience of the Other as an Other is our first experience of infinity. And this too-muchness, this strangeness of not fully knowing the other before us, is unsettling, an experience that we try to obliterate through presuming to know more than we do know. In our quest for familiar patterns we thereby “totalize” our understanding, reducing and erasing the other. And so this totalizing impulse carries great hazards. How then do we find—better, apprehend and witness the suffering, should be the suffering, the infinity, of—the infinity of—the other? Sometimes we find this immensity in wonder (Poland, 2000; Margulies, 2000). And, sometimes, this infinity finds us, in strangeness and humanity, too. In closing, let me return, afterwards, to both vignettes.

It is in the nature of uncanny symbols to take us to strange places, to those moments when we fall out of our familiar world (Margulies, 2000, 2012). At some point in my reflections on this disorienting strangeness, it occurred to me that there is yet another meaning to white-out and that is, precisely, a blizzard.

Being caught in a blizzard is like free fall—except it’s sideways. My associations took me to my experience of whiteout on an interstate highway in Maine. Whiteout is like tumbling horizontally with your eyes closed—except they are open, wide open—and searching, literally, blindly. At night at turnpike speeds, whiteout is terrifying: no markers, no depth—headlights on bright make it worse. Suspended at high speed. Velocity without orientation. Yes, of course, pull over! But what if you can’t? What if you can’t see the road margins? What if others can’t see you? Someone once described psychosis as no-where and no-when. But they left out the velocity part, the hurtling.

And so I looked up the definitions of “whiteout” online, and here is what I came up with. Whiteout:

“No object casts a shadow”! Speak of uncanny: Now we are into really strange places! Consider that this is, precisely, Freud’s (1917) language to describe mourning and internal objects, splitting and introjection, and so on:

Thus the shadow of the [mourned] object fell upon the ego, and the latter [i.e., the ego] could henceforth be judged by a special agency [i.e., the superego], as though it were an object, the forsaken object. In this way an object-loss was transformed into an ego-loss and the conflict between the ego and the loved person into a cleavage between the critical activity of the ego and the ego as altered by identification. (p. 249)

And here we have it: Isn’t this the very project of our patient’s (indeed, both patients’) psychotic attempt at erasure? To take in to herself, into her being, the ambivalently held and lost object, the loved one who is also hated (now an internalized object who impossibly must be protected from that hate), and then to obliterate that loved person, so that no shadow is cast? I’m reminded of that uncanny movie, The Eternal Sunshine of a Spotless Mind, set far into a future to imagine a time when one can literally obliterate unpleasant memories through advanced neurophysiologic manipulation. The protagonist, in a rage with a lost love, decides to erase her internal presence, to erase any memory of her. The problem is, one can’t simply erase the object, because, in doing so, one erases the fabric of one’s being-in-the-world. A spotless mind is not filled with eternal sunshine; it is an impoverished, emptied inscape (Margulies, 1989), devoid of what matters most. Grief is part of the essence of our humanity, of being who we are, with all of our history. To rid oneself of the object, then, is to rid oneself of oneself!

Our second patient knew this—his hated/beloved father was part of who he was. He didn’t know how to grieve him. Maybe he feared that in grieving him he might lose him. So the scar stayed with him, inscribed on his body. Which brings me to one last story, an ancient one, back to the dawn of Western literature.

After being lost in the fog of war and wandering, when 20 years later Odysseus finally returns to Ithaca, he comes back to his beloved island wary and heavily disguised. He knows there are many dangers present in his return, and he must be wily. Looking decrepit and worn out, he passes easily as a harmless beggar in rags. But two souls, and only these two, recognize him. One is Argos, the puppy he left behind, now an old dog, who on seeing Odysseus is not fooled at all: Argos wags his tail in joy at being with his master again. Argos, just like the search dog I mentioned earlier, the one who never gave up—it is no wonder that I love that scene in Odysseus’s story!

And then there is Odysseus’s old nurse Eurycleia who is initially oblivious to his ruse. She is told to bathe the guest stranger, and she does. And, as she is washing his legs, she is startled into recognition of who this stranger really is—she encounters the King’s distinguishing scar, a wound inflicted in his adolescence by a wild boar, a scar she knows well (see, Auerbach, 1953). She nearly cries out, but Odysseus grabs her by the throat to silence her, there is simply too much danger all around. What genius for Homer to dramatize this recognition—a man whose identity is known through his scar. And, here it gets doubly ironic and uncanny, because among the root meanings of the name of Odysseus (Dimock, 1956) are the following:

Odysseus: He who is pain. And, Odysseus: He who causes pain. Odysseus: The man of trouble.

Odysseus then is the man of pain and trouble, identified by his scar, pain inscribed in his body, for all to read, hidden in plain sight.

Various incarnations of this work were presented at The Learning Consortium, Columbia, SC (April 21, 2012); the Lifson Psychodynamic Psychotherapy Conference (March 22, 2013), Boston; Cambridge Health Alliance Grand Rounds (Sept. 18, 2013); the Chicago Psychoanalytic Society and Institute (May 27, 2014); and the Michigan Psychoanalytic Society and Institute (Nov. 8, 2014). Discussions by Drs. David Garfield and Harvey Falit much deepened my own understandings. I would also like to acknowledge: Todd Griswold (present at many interviews), Leah Lake, Janna Smith, Susan Pollak, students, and inpatient staff and especially patients who shared their lives with me, but who must remain disguised.