Finding Ishmael: Using a Patient’s Connection With Story to Foster Insight and Progression in Treatment

Story has the power to move man. Perhaps this is because stories reflect universal human experience, providing a mirror of analogy between the universal and the individual. When a patient struggles to talk about emotionally laden experience, identification with a fictional character can be used to increase diagnostic clarity (1) and develop a personal narrative in the service of healing. Rather than directly confronting a patient, story can be used as a tool for reflection, bypassing defensiveness, allowing distancing, and the development of insight, as demonstrated in this case report (1, 2).

Case

“Mike” was the older of two brothers. He took responsibility for protecting his brother as they moved from foster home to foster home. As teenagers, the brothers were reunited with their mother, who was a heavy drug user. Both brothers began to use heroin. At age 17, Mike’s brother was diagnosed with AIDS. A few months later, he died alone in a hospital room; Mike did not go to see him. Nearly 2 years after his brother’s death, Mike was taken to a hospital for a non-resolving abdominal mass and diagnosed with HIV. He took no food, was sick, and on the verge of death. When I started seeing him, he was living in a residential home struggling to stay clean. He had asked to start treatment for help.

He described an ever-present urge to return to his mother’s home, knowing that this may lead to relapse and worsening health. He reported it as something out of his control, saying “I don’t want to die, but I can’t help it.” He struggled to go into more detail about this, using most of his time to complain about the residence and how they policed him. For the first few months, he would sit slouched in his chair playing on his cellphone. He would often report that he had nothing to say and leave early.

One day, after about 8 months, he came into the session talking about the movie Moby Dick. “What did you think of it?”; I asked. “Ahab wasted his life over a stupid whale. For what? What did he spend his whole life running after a stupid [expletive] whale for?” Mike repeated the question a number of times.

Discussion

Such a strong reaction to Ahab, from a usually nonchalant Mike, took me by surprise. It was the first intense emotion he had displayed. Kirmayer (1) describes the importance of paying attention to “the metaphorization of distress,” stressing its value in the creation of meaning both for the therapist and the patient.

Mike often used metaphor and symbol to describe his struggles. For instance, after an operation, he came in lifting his shirt literally bearing his scars for me to see. His intense association to the character of Ahab in Moby Dick was another symbolic communication. Shechtman (2) believes that the process of identification with a character allows for a reconnection with feeling and experience. Symbolic associations can thus aid a therapist in uncovering, and then understanding, emotionally charged experiences that cannot yet be put into words (1, 2).

Moby Dick

The story.

Moby Dick was written by Herman Melville in 1851 and has been dubbed a “world classic” novel (3). The story is written in the first person by Ishmael, a sailor on a whaling ship. It tells the story of the ship’s captain, Ahab, who puts his ship and men in peril as he pursues a vendetta against a white whale, Moby Dick, which cost Ahab his leg. In the end, only one character survives Ahab’s quest—that is Ishmael.

Ahab and His Obsession

The discovery of meaning in analogy.

Many aspects of the Moby Dick story mimicked Mike’s struggle to separate from his destructive impulses, reflected in the figure of Ahab relentlessly pursuing his whale and his doomed fate. Ahab says of analogy, “O Nature, and O soul of man! How far beyond all utterance are your linked analogies!” (4). Ahab here is noting that what one sees on the outside, in “nature,” reflects what one is experiencing on the inside, in the “soul of man.” Mike’s resonance with Ahab was reflecting an inner experience. Kirmayer (1) argues that metaphors hold diagnostic value via their origin in a patient’s “unself-conscious self-representation.”

When a patient is struggling to say what the inner experience might be, like Mike, one method of discovery is to research archetypal symbolism. Archetypes are the repeated underlying patterns seen in the themes and images of a story. Jung (5) believes that archetypes, as represented in mythology, folklore, fairy tales, and images, represent aspects of the deeper levels of man’s psyche, containing within them universal psychological significance.

In Moby Dick, the white whale is laden with archetypal symbolism. According to Edinger (6), the whale is described at one point as being, “Cellini’s Cast Perseus,” likening the whale to Medusa, with the ability to petrify and stultify life. Ahab, according to Edinger, is “petrified into a single obsession” with an inability to let go of his aim.

Mike’s addiction gripped him and “petrified” him into an inability to reflect upon and question his urge to return to his mother. He could resonate with the idea of being propelled thoughtlessly forward on a destructive path, like Ahab was. His emotional reaction to Ahab “wasting” his life away offered an opening, a way to shift this petrification.

Authors (1, 3, 5, 7, 8) stress that the reflective nature of art, literature, and drama provides a mirror in which a greater world of being can be reflected and mediated upon. By evoking emotion and felt experience, the symbolic nature of story can elicit a shift in patients who are stuck within a rigid pattern of thought or behavior (1).

Ishmael and His Survival

The clarification of conflict.

A metaphor or story describing a certain problem holds its own suggestions for resolution (1, 7). In Moby Dick there lies massive destruction—yes. But there also lies hope in the survival of Ishmael.

Edinger (6) wrote that Ahab met with his destruction because he lacked an ability to reflect upon his actions and to attend to others’ responses. He did not gain insight into his unconscious intentions as mirrored in the reaction of others. Gomez (3) concurs that Ahab could not reflect upon what he was doing and put his life and those of his crew in peril, but Ishmael, on the other hand, reflected on the events of his life. This was through his interaction and friendship with his crewmates and through the writing of his book.

In the above case, Mike had asked to start treatment. He had an inner Ishmael, an inner desire to reflect and so survive, instead of thoughtlessly returning to his old life. By using his attraction to the story, which opened up a way to maneuver beyond initial defensiveness, his access to this reflective capacity could be found and strengthened. Mike’s willingness to seek treatment and then to explore his connection to Ahab and Moby Dick, fostered his ability to connect with his urges on a deeper level, and he began to put his experiences into words.

By the 16th month of treatment, Mike described a fear that if he did not return to his mother, she would abandon him to die alone, as he had once abandoned his brother. He did not want to die of the complications of AIDS, but he also did not want to die alone and abandoned. It was this fear of dying alone that had “petrified” him. He became able to talk about and connect emotionally with this fear. Ishmael survived clinging onto a coffin, symbolically accepting loss. Mike had to process and accept the loss of his relationship, albeit a toxic one, with his mother. He had to metaphorically stop chasing his whale and risk feeling disconnected and alone.

The use of Moby Dick as an indirect analogy to Mike’s plight revealed itself to be less threatening then direct confrontation. Mike’s resonance with the story provided an opportunity to explore his destructive as well as constructive desires, which allowed the treatment to progress from a position of stagnation to one of movement and exploration. The type of therapy shifted from supportive in nature to insight-driven with a focus on his ambivalent desires (symbolically his Ahab and his Ishmael), and the ability to create a narrative about them.

Goldwyn (9) argues that one way in which psychotherapy works is through the co-creation of a more resonant narrative through the development of insight. Such a narrative can provide meaning, purpose, and connection, uniting disparate themes and contradictions (1, 9), such as Mike’s desire to stay healthy and live, which seemed to contradict the ever-present urge to return to his mother and consequent relapse.

Mike first told his story in therapy. A few years later, he told his story in a newspaper article in order to help others in similar situations. He still struggles but has stayed at the resistance and remained sober. Like with Ishmael, a painful experience when reflected upon through the mirror of art had redeeming value.

Key Points/Clinical Pearls