AMA Journal of Ethics^®

Abstract

Behind the immediate pathophysiology of a medical condition often lies the emotional turmoil of an uncertain patient. As a result, many patients suffer from distressing thoughts and emotions, and their caregivers play an important role in comforting them. But to comfort a patient one must first have some framework to understand thoughts, emotions, and the relationship between the two. In this piece, the author draws from a collection of essays, Serious Noticing, written by the literary critic James Wood, to provide such a framework. In his work, Wood writes of 2 methods of reading literature, both embodied in the question: “What is at stake in this passage?” This framework is useful for both the analysis of literature and the understanding of psychological turmoil.

Two Methods of Reading Literature

In his recently published collection of essays, Serious Noticing: Selected Essays, 1997-2019, the Harvard professor and literary critic James Wood writes of 2 broad methods of reading literature.¹ Both are embodied in the question: “What is at stake in this passage?” This is not a question directly put by most physicians, I imagine, yet Wood’s approach is instructive for those of us who, moved deeply by emotional suffering, seek new frameworks by which to understand the mental turmoil of our patients.

Wood’s first method of reading is deconstructive. When reading a piece of literature, he interprets a question originally posited by a mentor of his—“What’s at stake in this passage?”—as asking: “What is at stake in maintaining the appearance of coherent meaning, in this performance we call literature? How is meaning wobbling, threatening to collapse into its repressions?” Here the critic seeks to determine how the meaning of a passage is different from what the reader, or indeed the author, might believe. Wood calls this method Stakes¹: an approach that makes no assumptions that literature has coherent meaning in the first place; fosters no attempts to question the accuracy or distortion of that meaning; and certainly refrains from saying that the meaning should have been different from what it was. The content of a text per se, the direct interpretation of words on a page, is less important here than the understanding of how interpretations and words hold unexpected meanings or no meaning at all.

Stakes²—Wood’s second method of reading—is more familiar to most. In asking what is at stake, “The common implication here is that meaning has to be earned, that a novel or poem creates the aesthetic environment of its importance.”¹ When reviewers evaluate a novel, they assume it has direct meaning, purpose, and an intended goal, and they are evaluating the success or failure of that novel by asking whether it has conveyed that meaning or purpose and achieved that goal. When a reviewer reads in this fashion, “the text’s success is anxiously searched for, with the assumption that the piece of literature’s lack of success cannot be productive for reading, but simply renders the book not worth picking up.” Meaning, success, importance: these are strictly evaluative terms that imply that content is at the heart of Stakes². They suggest there is such a thing as a successful or failed piece of literature, that words and interpretations should be taken as they are and praised or criticized, as opposed to deconstructed. Here, unlike Stakes¹, we might say that an author should have used different words or that the narrative lacked tension, but we would be hesitant to say that the words or narratives did not mean what the author thought they meant.

Two Methods of “Reading” Psychology

“I’m struck by the differences between these two usages,” Wood writes of the 2 Stakes. “Both are central to their relative critical discourses; each is close to the other and yet also quite far apart.” I, in turn, am struck by the psychological implications of 2 separate theories—applied by psychiatrists to emotional disorders—that we might associate with these usages of Stakes. There is, for instance, a way to “read” thoughts in the sense of Stakes¹. Treating a patient with an anxiety disorder, a physician might suggest that the experience of anxiety is neither inherently true nor meaningful, merely contextual, one of many possible truths or meanings with no inherent bearing upon the patient’s behavior or emotional state. Stakes¹ mirrors the approach taken by psychiatrists who practice acceptance and commitment therapy (ACT). Much as the Stakes¹ reader is less interested in direct content and more interested in how literature is “an always-frail ideological achievement, only ever a sentence away from dissolution,” the ACT therapist is intent not on changing the content of thoughts per se but on making the patient aware of the automatic, contextual, nonliteral nature of their distressing thoughts.² In doing so, the therapist attempts to distance cognition from its immediate relation to suffering. Here, the key step in healing emotional turmoil is in seeing thoughts for what they are: simply thoughts, only ever a sentence away from dissolution.

If what we are really after is a deeper understanding of patients, clinicians must be able to think about suffering through multiple lenses. 

There is another approach, however, akin to Stakes², wherein it is what we think that truly matters, not merely how we think about it. In Stakes¹ the strategy is to accept negative cognitions and defuse their emotional consequences, allowing one to commit to value-based actions as opposed to constantly battling with intrusive thoughts. Under the assumption of Stakes², however, maladaptive thoughts contribute directly to emotional disorders and must be addressed if the patient is to alleviate their distress. Just as an author may write unsuccessful novels by using the wrong words, so the patient suffering from anxiety might exacerbate their condition by maintaining irrational fears. Here Stakes² begins to mirror the theory behind cognitive behavioral therapy (CBT). Compared to mindfulness-based approaches like ACT, CBT takes a more causal and evaluative stance on the relationship between thoughts and emotional distress: maladaptive thoughts produce distressing emotions, and the former must be modified or revised before the latter are resolved.³

Both methods provide an invaluable, yet perhaps incomplete, portrait of human suffering. Wood illustrates this incompleteness in the literary realm when he writes that Stakes¹ “is non-evaluative, at least at the level of craft or technique,” while Stakes² is “only evaluative, and wagers everything on technical success, on questions of craft and aesthetic achievement.”¹ Both methods are valid, useful, necessary, and insufficient for the critic. “Not to think about literature evaluatively,” to think only in Stakes¹, “is not to think like a writer—it cuts literature off from the instincts and ambitions of the very people who created it.”¹ But to think only in Stakes², “in terms of evaluation, in terms of craft and technique—to think only of literature as a settled achievement—favors those categories at the expense of many different kinds of reading (chiefly, the great interest of reading literature as an always unsettled achievement).”¹ Wood implies that we, as readers, must be willing to employ both meanings of the question—“What’s at stake in this passage?”—if what we are truly after is a deeper understanding of literature.

Two Methods of Healing Suffering

I believe that we, as healers, must be able to view suffering through multiple lenses—if what we are really after is a deeper understanding of patients. Patients often arrive at the clinic concerned, frightened, fatigued, or otherwise overwhelmed by the implications of what is happening or has already happened to their bodies. Their emotions are associated, more often than not, with specific thoughts. The question, then, is what to do about these thoughts. Does one attempt to change what the patient is thinking? How the patient relates to their thoughts? Neither?

To put it more concretely: imagine a woman in hospice care suffering from anxiety at the end of her life. As the weeks and months progress, she begins to imagine herself wracked with a near-unbearable, aching pain wherein her tumor has metastasized to the bone, and this terrifies her. It prevents her from enjoying time with family or focusing on anything in the present moment.

Beyond the goal of alleviating her pain, what can the physician do? Thinking of Stakes¹, the physician might help the patient realize that her worries are natural, valid, and deserving of acknowledgement but that she need not wrestle against them because, like all thoughts, they are just thoughts, and distress is often propagated by ceaseless inner battles against words and images. In contrast, the physician using Stakes² might find the patient’s intrusive thoughts a direct impediment to her well-being. Positing a causal link between cognition and emotion, the physician would instead help the patient question the probability, intensity, or consequences of the situation she so deeply dreads. The content of the thought would be questioned—replaced with more “rational” cognitions, which could be further tested and evaluated for their rationality and emotional impact.

Ultimately, however, both methods are incomplete. With that in mind, Wood’s recent collection of essays helps us, as caregivers, to think broadly about psychological suffering—and in doing so, it provides a unique service to the medical humanities. When we typically think of the art of medicine, or of art and medicine, we consider how literature, music, painting, philosophy, or any of the humanistic traditions offers new ways of looking at some aspect of medical practice: end-of-life care in Leo Tolstoy’s novella The Death of Ivan Ilyich, the sanctity of caregiving in Sir Luke Fildes’ painting The Doctor.^4,5 What Wood offers, however, is something to look through: a diverse set of lenses through which we can reflect on and talk about that to which our gaze is properly attended—human suffering. Just as each piece of literature is wholly unique, so each patient is an unrepeatable amalgam of stories and experiences; and both reading literature in only one fashion and thinking of mental anguish in only one paradigm are equally limiting. As Wood’s title implies, we in medicine must be “serious noticers”—able to think like thinkers, to think of cognition as an always unsettled process. That was formerly the task of the literary critic: it is now the task of our medical art.

High stakes, indeed.