Oliver Sacks © 2007 Elena Seibert

‘Exchanges’ – Conversations with… Oliver Sacks

Julie Walsh, University of Warwick

 

Renowned neurologist and author Dr Oliver Sacks is a visiting professor at the University of Warwick as part of the Institute of Advanced Study. Dr Sacks was born in London. He earned his medical degree at the University of Oxford (Queen’s College) and the Middlesex Hospital (now UCL), followed by residencies and fellowships at Mt. Zion Hospital in San Francisco and at University of California Los Angeles (UCLA). As well as authoring best-selling books such as Awakenings and The Man Who Mistook His Wife for a Hat, he is professor of neurology at NYU School of Medicine in New York. Warwick is part of a consortium led by New York University which is building an applied science research institute, the Center for Urban Science and Progress (CUSP). Dr Sacks recently completed a five-year residency at Columbia University in New York, where he was professor of neurology and psychiatry. He also held the title of Columbia University Artist, in recognition of his contributions to the arts as well as to medicine. He is a fellow of the Royal College of Physicians and the Association of British Neurologists, the American Academy of Arts and Sciences, and the American Academy of Arts and Letters, and has been a fellow of the New York Institute for the Humanities at NYU for more than 25 years. In 2008, he was appointed CBE. (University of Warwick, 2012)

 

...it still strikes me myself as strange that the case histories I write should read like short stories and that, as one might say, they lack the serious stamp of science. I must console myself with the reflection that the nature of the subject is evidently responsible for this, rather than any preference of my own. (Sigmund Freud, 1895)

 

I have no “literary” aspirations whatever, and if I write “Clinical Tales” it is because I am forced to; because they do not seem to me a gratuitous or arbitrary compound of two forms, but an elemental form which is indispensable for medical understanding, practice, and communication. (Oliver Sacks, 1986)

 

I have always been intrigued by the logic of writing down notes (clinical or otherwise) in order then to write them up. What is it exactly that happens between these stages of writing? Can we really say that the first is a simple act of recording or documenting, while the second is a more elaborate process of reconstruction?  The ‘write up’ perhaps brings to mind the more ambiguous notion of the ‘stitch up’ with its connotations of fabrication and wilful misrepresentation. Similarly, the figurative use of the verb ‘to doctor’ – as in to doctor the evidence – might remind us of the multiple powers that reside in the personage of the physician who may be writing up and/or stitching up your case. It would seem that the capacity to disguise or dissemble is somehow integral to the project of clinical writing. But so too must the idea of the ‘stitch up’ imply the physician’s care, his work of suturing a wound, or attending to the frayed nerves of a patient. Finding its highpoint in the clinical narrative or case-history, the ameliorative power of storytelling can also be read as a desire to assuage the patient’s suffering; to give form to the fractured or dislocated elements of experience. And what of the pleasures of spinning a yarn?

From his first book, Migraine (1970), to his most recent, Hallucinations (2012), Oliver Sacks has finessed the art of the ‘clinical tale’. With it he has conveyed the many ways in which the fabric of one’s personal identity can become unstitched by a range of neuropathological phenomena. As a medical practitioner and a writer, Sacks holds that the greater endeavour of medicine is to help an individual construct a life; this means that medicine’s modes of communication need to be equal to the task.  For Sacks, to rehabilitate the case history as a form of writing inevitably means that the patient’s story becomes the tale of an embattled protagonist striving to preserve a coherent identity in adverse circumstances.^[1]  

In his recent lecture here at Warwick (available on video via the University website), Sacks reminded his audience of the historical drift since the nineteenth century that has occurred in science writing – and in medicine in particular – towards greater classification at the expense of detailed descriptions of the patient’s idiosyncratic experience.  Sacks’ attention to the idiosyncratic details, and the care he takes in presenting them, doubtless accounts for his appeal as a writer and his success as a physician.  But are there any tensions between the dramatic impulse of the case history, thus conceived, and the physician’s fidelity to the facticity of the case?  If the case history is to become germane to medical methodology once more, how are we to think about its production of ‘truth’ (whether for the patient, the doctor and/or the reader)?  And most curiously, for me at least, in what ways does the storyteller reveal himself in the act of telling another’s story?

I first engaged with Sacks’ work on my undergraduate Sociology degree here at Warwick.  We were learning to think about the relation between identity, memory and trauma, both from the personal or autobiographical perspective, and in relation to questions of collective identity in the context of twentieth-century cultural history.  In The Man Who Mistook His Wife for a Hat (or his Hat book, as Sacks calls it) we found stories to demonstrate the precariousness of personal identity. Critically, for the student of sociology, Sacks’ work offered an unusual lens – what we might call the lens of ‘neurological self-hood’ – for viewing how one’s capacity to sustain a stable sense of self can be disrupted.  More recently I’ve returned to Sacks’ work with a view to thinking about the affinities between his research questions and those of psychoanalysis. When I asked Dr Sacks to reflect on the place of psychoanalysis, and of Sigmund Freud, in his life and work it was clear that there were several lines of thought to pursue. Freud the writer of case histories provides a clear precedent for Sacks. Then there is the therapeutic experience of psychoanalysis to consider, especially its clinical practice of reading the self beyond its most obvious presentations.  Indeed, Sacks discussed with me how his long standing personal analysis may have strengthened his habit and skill as a listener.  But perhaps it is the early Freud – the neurologist in gradual pursuit of a scientific psychology – that Sacks is most able to admire.[2] In the course of our interview Sacks told me about his great love for marine biology, and how at one point in his career – ‘between the chemical days and the medical days’ – he had wanted to spend his life’s work on the nervous systems and behaviours of invertebrates. If it is difficult to reconcile such a wish with the deeply human commitment to medicine and science for which Sacks is now renowned, we should remember that the impulse to keep these dimensions distinct – to carve up the world according to different kinds in order to limit one’s engagement with it – runs counter to Sacks’ general approach. Sacks told me that one of the things Freud had a very clear feeling about was the importance of continuity between all life forms: ‘in his paper on crayfish ganglia [Freud] brings out that the nerve cells are essentially similar to the nerve cells of mammals or human beings; it’s not the nerve cells […] which are different, but their number and organisation’. The provocative question that Sacks raises from Freud’s commitment to continuity concerns the boundaries of mental life: where does mental life begin and end? For Sacks’ Freud, the mental is not confined to human beings.

When I met with Dr Sacks earlier this month he warned me that he had a tendency to ‘gabble’ and that my questions were ‘liable to release ten minutes of nonsense’ from him.  Nothing could have been further from the truth, but we did hit upon a felicitous affinity between his areas of research expertise and the particular mode of attention that allows for productive meanderings off topic (or seemingly off topic).  I had asked about the rituals that attach themselves to his writing habit. Sacks, by and large, has always been a hand writer. His desk was sectioned with different papers, pads, and numerous pens ordered for various purposes, and his shelves were stacked with journals and notebooks going back years; there were three journals (A5 hardback notebooks) that contained notes from a single month in 1987.  He mentioned his preference for a particular thick-paged notebook in which one can write on both sides and, critically, that has no lines. ‘Do you know what delirium means, literally?’, asked Sacks ‘it means not staying between the lines’. A quick consultation with the nearby dictionary confirmed it: delirium from dēlīrāre: prefix de as in from, and lira as in furrow; ‘so it’s to turn, to turn away from the furrow’.  Likewise, he told me, Hallucinations – the title of his most recent book – connotes a wandering in mind, or a not sticking to the point. 

Many of the wanderings our conversation took have not been captured in the extract below: for example, the importance of recognising the existence of mental life in non-human species; the distinction between ‘mind’ and ‘brain’; the possibility of a basic incompatibility between ‘organic’ aetiologies and what we might call ‘psychosocial’ ones. Such are the omissions of this particular write up. What follows focusses on the line of discussion to which we kept returning: namely, what it means to write a case history. By the end of our time together Sacks had impressed on me the challenge of being ‘essentially faithful’ to the clinical material in question whilst not disavowing the inevitable ‘gap between experience and art’. 

***

OS: I’m in a writing spell now, but I wasn’t a month ago and I had an arid time in the summer.

JW: Can you sit quite comfortably with that? 

OS: No! I’m a miserable person then, and I make other people miserable.

JW: Unless you’re writing?

OS: When I’m writing I become much happier, the neuroses fall away, I don’t bother people, I see the best of people, I elicit the best of people. And, in this way, writing is absolutely essential for my health and wellbeing.

JW: One of the questions you ask in your work, and it’s a problem I’m also very taken by, is the question of what constitutes a tenable life.  I noticed in The New York Times recently [The Joy of Old Age], you evoked the Freudian wisdom whereby what makes a life tenable is the capacity to love and work.[3]  It’s interesting to hear you reflect on the fact that writing, for you, makes your life tenable, so to speak. I think this really does key into your emphasis on the value of narrative, doesn’t it?

OS: On the value of work.

JW: Yes, and work.

OS: Yes, in particular your work; one’s work, which is also one’s identity, or part of one’s identity.  Although I don’t know that I’ve ever quite identified myself as a writer.  I was asked in an interview some years ago, what are you first, a physician or a writer?  I said a physician but they inverted the order and said a writer, which sort of annoyed me. Though I think the real answer is that they tend to go together and perhaps (as if I were a novelist) people around me – my friends as well as my patients – are in danger, so to speak, because they may be turned into material!

Although with my patients I’m slow to write about them, I feel I have to know them fairly well, and then I will discuss the matter with them and see how they feel.  I’m not satisfied with a formal consent, I have to feel they would be comfortable and I will usually send them what I write and ask them to correct or comment. By that time they may say, I’ve changed my mind; leave me out.

JW: Ah, okay, and will you do that, if they have changed their mind?

OS: If it’s a radical change of mind I might.  Or there may be minor changes. This was the case with one relatively early piece of mine on a man with Tourette’s called Witty Ticcy Ray which was later collected in the Hat book.[4]  [When I wrote the piece] I’d been seeing him at that point for ten years, since ‘71.  And I asked Ray (this was not his real name) if he’d care to read it and he said no, that’s okay, I trust you. And I said, well I think you should read it, and he said, well, okay, why don’t you come to dinner on Friday.  As he was reading it, I noticed various tics and I was getting nervous and he said rather explosively, you take some liberties!  I pulled out my red pen and said, what should I erase, what should I change? In the end he shook his head and said, leave it, it’s essentially true, he said, but don’t publish here in New York – why don’t you publish it in England. So it was published in The London Review of Books.  At that point I thought that if I published in London it would, to some extent, protect my patients in New York – although I’d learned with Awakenings that this was not always the case.  One of my Awakenings patients, a very bright woman, who got wind of the fact that the book had been published in England, somehow got a copy.  And now, if I write a piece, it’s ‘out there’.

Which reminds me, I’m bewildered and often horrified about the nature of blogs, which seem to erase some of the distinction between private and public, and I think they’re rather dangerous.

JW: But isn’t that also a danger that your work inevitably encounters?

OS: Yes.

JW: So, Ray’s response, ‘you take some liberties’ is relevant here. First of all there’s the very simple truth that we can never know whether the patient is going to be able to say, ‘yes, that does me justice’ or ‘yes, that accords with my own understanding of the situation’ or ‘that is essentially true’.  And this is precisely one of the dangers of clinical writing; the inevitable misrepresentations and moments that expose a disconnect between two different accounts of an experience. It can be quite anxiety inducing!  But then again, and I think your work demonstrates this so well, clinical writing is also enjoyable.  In my own work, I worry about that enjoyment. Because, well, it’s a difficult type of enjoyment – or pleasure – to take, isn’t it?

OS: It is.  And it’s a very central thing for me.  My Migraine book has only little vignettes and there are really no recognisable characters. But then in 1970 I submitted some letters, medical letters, to the Lancet about some of my patients on L-dopa. A few weeks later the sister of one of my patients came up to me holding the New York Daily News in her hand and she said, is this your medical discretion?  Unknown to me, the Lancet had released the letter to a wire service, and it had been picked up by a newspaper here.  She wasn’t upset or offended, she said probably no-one but immediate family would have recognised her sister. But this worried me somewhat.  I usually make some disguise, alter identifying details, but obviously in that letter I had not disguised enough.

JW: And perhaps even the notion of ‘disguise’ is problematic?

OS: Yes.

JW: Because that’s actually about literary creation, isn’t it?  So, in ethically disguising the identity of the patient one is also creatively dissembling.

OS: Yes.

JW: And fictionalising!

OS: Right.  Yes, well with Ray it was fairly light: I changed his name and I changed where he lived.  But to what extent is dissembling, as you put it, compatible with truth?  Big question!

JW: It is the big question!

OS: Something drifted in and out of my mind. I want to say this: It has been brought up in various forms, sometimes rather traumatic forms; a critic called Tom Shakespeare once called me “the man who mistakes his patients for a literary career,” which hurt, and which stays in my mind even thirty years later.  I feel that first as a physician I have to respect the patient, and to be tactful and delicate. There are some things where curiosity would make me want to push further and I have to say, no, at least not now. I hope my writings, such as they are, are in the mode of delicacy and respect.

I was very pleased when Mrs P, the woman mistaken for a hat, after her husband’s death, went to see the opera by Michael Nyman.[5] I watched her closely at the performance, wondering what [she’d make of the piece], but she came up to us, the script writer and the musician and myself, and she said, you have done honour to my husband. And that was very nice; we all gave a big gasp of relief.

JW: Yes! So I wonder if your solemn feeling of responsibility impacts on whether or not you wish to collaborate with others in your writing? I mean I‘ve noticed that you include your readers and the correspondence you get with your readers as part of your practice.

OS: I do now.

JW: So in a way I suppose we can think of your use of letters as a collaborative writing practice. But, exempting the artworks, have you ever wanted to actually sit down and write collaboratively with another?

OS: I think the simple answer is no.   Peter Brook phoned me some years ago and said he wanted to do a theatre evening called ‘The Man Who…’ drawing on many things.  I introduced him to one or two patients, and I then basically said, it’s up to you.  And I felt the same with Pinter when he wrote A Kind of Alaska.[6] In the movie of Awakenings, I was there only as a sort of technical advisor, for medical details.[7]  I disliked one scene in the movie when there’s a sort of fight in the lobby of the hospital and I walked off the set angrily.  When I saw it made no difference, I came back to the set quietly and kept my mouth shut and thought, it’s theirs, not mine. 

JW: I’m really curious to hear how you understand the relationship between your clinical writing and the writing of your own memoir; your own case history. These two modes of writing have to be in dialogue somehow. And I think my feeling is that all writing is autobiographical.

OS: Yes, Tolstoy said that everything he wrote was part of one giant confession.  And then of course Joyce talks about the artist being ubiquitous but invisible.  I fear I’ve let myself become more and more visible!

JW: And why would that be a fear?

OS: Well, in Awakenings more than Migraine I had become a figure in patients’ lives. I got the drug, I watched them, I felt guilty and appalled when they started to get bad effects of one sort or another, and when one of my patients then called L-dopa ‘Hell-dopa’. I lived through the whole experience with them. But in a way my Leg book [A Leg to Stand On] became a sort of case history of myself, and in The Mind’s Eye I’ve given an explicit account of being a patient.  But also I think in other books I’ve sort of thrown myself in, as I would throw anyone in, because of a particular phenomenon or symptom. So say in my chapter on amusia, in Musicophilia, I mention a couple of times when I had amusia with a migraine, as part of a migraine aura.  And in The Mind’s Eye, when I’m writing about alexia, I again mention a personal example. 

JW: So, you become a character in the lives of your patients, and you can also use yourself as a resource when you’ve been a patient in a particular medical context.  But there’s another context in which your patient-hood is at stake, and you allow us just a slight glimpse of this in your Hallucinations book.

OS: Oh yes, my Chapter Six.

JW: Yes, your chapter on ‘Altered States’. So, you tell us that in the mid-sixties you entered an analysis following your friend’s astute observation that your experimentation with mind-altering drugs may in fact be masking some inner conflicts. I’d be very interested to hear about what it was like to be that type of patient, and also to think with you about how the experience of analysis may have mapped on to the development of your ethos and your style as a writer.

OS: Well, in December, New Year’s Eve of ‘65, when I was fizzing and sort of manic with amphetamine, and had lost a great deal of weight, I had a sort of lucid moment when I saw my gaunt – my then gaunt – face in the mirror and I said to myself, you will not see another New Year’s Day unless there’s intervention.  I had been seeing an analyst a little bit in Los Angeles, it didn’t seem to get anywhere, partly I think because I was always stoned when I saw him, or often stoned. This allowed me to produce some associations with vertiginous rapidity but they were somehow, you know, all on the surface of my mind; nothing really got in, or went deep. In Los Angeles when Doctor Bird said to me, why are you here? I said, ask Doctor Bonnard, she referred me! So, you know, my heart wasn’t in it.  Whereas in ‘66, I sought help for myself, knowing I was in danger. The analyst I saw then is still my analyst; I saw him yesterday and we are now in our forty-seventh, forty-eighth year.

JW: My goodness me!

OS: I see him twice a week and if I’m away somewhere I will phone if I can. I’ve even phoned from a cell phone from the middle of a desert, or something like that.  And I dedicated my Hat book to him.  

I think that the habit and skill of listening carefully, not interrupting too much, and trying to divine what may be going on behind the words is a sort of – I think this has to be the case with all doctors and maybe with all people – has been strengthened by seeing him.

I think one no longer speaks of analysts as ‘Freudian’ or whatever, but although my own analyst has the Collected Works [of Freud], doubtless, he is very sensitive to biological factors as well. I think I mentioned this actually in Hallucinations in the chapter on delirium: I’d started having some very peculiar dreams when I was in Brazil, but I’d had diarrhoea and a fever and this and that, and I thought they would settle down but they didn’t.  I had these extraordinary Jane Austen-like dreams which were very atypical and I would wake and have a cup of tea and go back and I would be in the same dream except it would have moved on a chapter, or two months later.  I had the feeling it was a narrative saying itself, whether I was awake or asleep. After about a couple of weeks my analyst said, you’ve produced more dreams in the last two weeks than in the previous twenty years, are you on something?  And I said no, and then I said well, actually I am, I was started on Lariam to prevent malaria.  Lariam used to be given to all the armed forces here, and may have played a part in their breakdowns and violence when some of them came back.  But it is now a drug handled very carefully and it really shouldn’t have been given to me, it’s only of use for the sort of malaria one has in South East Asia.  But Lariam is now well known for producing bizarre dreams, hallucinations, and psychoses.  Anyhow this was an example of [my analyst] saying, something else may be going on here.

I should say that he himself [has] written several books and he displays far more reserve and reticence than I do when he talks of his patients.  With some difficulty I detected a possible reference to myself, maybe conflated with others, in one of his books.  I was actually rather sorry it wasn’t more of a reference.

***

 

References

Breuer, J and Freud, S.   (1955 [1895]),  Studies on Hysteria in The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume II (1893-1895). (Trans. & ed.) James Strachey. London: the Hogarth Press.

Sacks, O. (1970), Migraine. London: Faber and Faber Limited.

--- (1973), Awakenings. London: Duckworth.

--- (1984), A Leg to Stand On. New York: Touchstone Books.

--- (1985), The Man Who Mistook his Wife for a Hat. London: Picador.

--- (1986), ‘Clinical Tales’ in Literature and Medicine 5: 16-23.

--- (2000 [1998]), ‘The Other Road: Freud the Neurologist’ in Freud Conflict and Culture: Essays on His Life, Work, and Legacy. (ed.) Michael Roth. New York: Vintage Books: 221-234.

--- (2007), Musicophilia.  London: Picador.

--- (2010), The Mind’s Eye.  New York: Alfred A. Knopf

--- (2012), Hallucinations. London: Picador.

--- (2013),  ‘The Joy of Old Age. (No Kidding.)’ in The New York Times (July 6), Accessed online 10/7/13, http://www.nytimes.com/2013/07/07/opinion/sunday/the-joy-of-old-age-no-kidding.html?_r=0

University of Warwick (2012), Press Release 173, 10^th October 2012, Accessed online 30/9/13 http://www2.warwick.ac.uk/newsandevents/pressreleases/dr_oliver_sacks/