There are some things in life which, once they’ve been invented, we can never do without.  These include electricity, the mobile telephone, the Internet, and the serotonin receptor. Identity is no different.  All of a sudden it existed and then everybody needed it. Historians attribute the birth of identity to certain events of the late Renaissance: the collapse of monarchies, the disempowerment of God, the increased mobility of people formerly bound to their homes.  And my English-speaking friends often observe that the words we use to talk about identity begin with the letters “co:” continuity, consistent, conflict.

    But as an Austrian psychiatrist, such historico-linguistic theories are outside my scope of practice.  In their place, I can only observe that continuity—the need to feel at one with yourself on an ongoing basis—appears to be a fundamental human need, something we pursue from the moment we come into existence.

    I experienced my first birth in 1983 at Allentsteig Hospital.  Allentsteig is a sleepy town in Lower Austria. It has just 5,000 inhabitants, and it owes a substantial portion of its income to its hospital.  That hospital, in turn, owes its existence to Adolph Hitler, who in 1938 felt compelled to wipe his father’s birthplace, Dollersheim, from the face of the earth.  Dollersheim was about 15km south of Allentsteig, and on its ruins the Germans built one of the largest military training zones in all of Europe (about 200km2 in size).  The inhabitants of Dollersheim were resettled, i.e. expelled, and the building and countryside given over to military use, i.e. destroyed. Allentsteig remained and became a garrison town.

    Hitler ultimately went, of course, as did the German Army, but the training zone remained.  For ten years, during the occupation, the Russians used it for shooting practice. The Austrians took over in 1955, when—as a testament to my homeland’s military might—it promptly changed from a place of extreme danger to a sort of nature sanctuary.  If I were a lynx immigrating from Poland or the Czech Republic, I would certainly settle down there for the prospect of a quiet life. As a medical student, the enticement of a rural idyll was a key reason why I chose Allentsteig, and its tiny community hospital, as the site for all of my clinical training.  I took blood samples, stitched wounds, and, thanks to an obliging senior surgeon in 1985, became probably the only living Austrian child psychiatrist to have removed an appendix. About a third of the admissions were soldiers from the training zone: bone fractures, lacerations, alcohol binges. Whether a solder was involved with my first birth I no longer remember.

    The mother was a short, reddish-blonde woman—that I remember well.   She arrived with contractions that had been going on for some time, and after placing first his hands and then the ultrasound probe on her stomach, the senior physician took on an expression of grave concern.  “It’s transverse,” he said. As a budding psychiatrist I remember thinking that oppositional behavior started young. But from an obstetric perspective this was a high-risk situation. When the senior doctor and midwife failed to turn the baby, they called for the anesthetist and the surgical nurse.

    I still remember the moment when the senior doctor, staring with concentration at the back wall of the operating theater, put his hands into the open woman.  He glanced at me for a second, then pulled out the child in one sweep and laid it in my arms. “There,” he said, and turned away. It was a girl with dark hair, and tears flooded my eyes with a ferocity I hadn’t expected.  

    What happened next must have been as follows: the midwife took the baby and cut its umbilical cord; the baby cried; I wiped my own tears and attempted to help with the placental separation, the stitching of the uterus, the closing of the wound.  But I remember none of this. Instead, I remember those few seconds when the girl lay in my arms—no breathing, no sound, no feeling—and encountered the world. Or rather, she encountered a totally unprepared medical student who, thirty years later, considers this scene not only as the starting point for an ontological-poetological theory of identity, but even a sort of essential poetological form in itself:

    A child is there.

    After the stabilization and reunion of mother and child, the senior doctor ordered large amounts of beer and sausages, which we consumed in the ante-room of the operating theater.  He confessed that this had been his first Caesarian section, a fact he’d been wise not to mention beforehand, and one mentioned my crying—neither that day nor for the rest of my training.  I vaguely recall the midwife later treating me with a subtle maternal friendliness, and I think I welcomed it. I don’t know what happened to the girl. I sometimes imagine her married to an officer in the Austrian army.

    A child is there.  This phrase outlines the strange condition in which we enter life, a condition that is probably the second-biggest outrage of our existence.  We arrive and are unable to think about our future. We can’t even form memories of the present. No images, no scenes, no categories; nothing, from the first eighteen months of life, for us to reformulate, reanalyze, even recall.  Instead we’re reliant on reconstructions: parents’ photo albums, cellphone snapshots, and, most importantly, on stories. “It was a beautiful early summer’s day, and your father had just finished building the crib, when I could feel the first tugging sensations in my tummy.”  Or, “You had a lopsided head, fluff on your cheeks, and webbed fingers, but to me you were the most beautiful baby in the world.” These stories can be vexing because we have no way of verifying them. But we must believe in them because they’re the only account we have.

    A child is there and doesn’t have language yet.  

    A child is there and doesn’t remember.  

    A child is there, and may not have a mother.

    I am thinking now of a different child—Leonie—from a different part of my career.  After my brief cameo in the operating theater I set an early course for child psychiatry, so that now, instead of transverse fetuses, my practice includes broken children: anorexic girls, sullen boys walking a self-conscious tightrope between world-weariness and dope addiction.  Sometimes, my practice includes babies, specifically babies who have a problem with their mothers, and vice versa. Always vice versa: for any disruption in early mother-child bonding is always a problem for both.

    This was the case with little Leonie and her mother, Mrs. S.  Mrs. S suffered post-partum delusions, believing that Leonie was not her daughter but the spawn of the devil.  This is a critical situation—the child psychiatrist’s equivalent of a Code Blue—because in the grips of such delusions psychotic mothers are at risk of harming their children.  On the other hand, we know that these situations usually turn out fine with the right medications, circumspect psychotherapy, timely reunion of mother and child. I do not wish to say any more about the psychiatric craft that midwives these good outcomes.  Rather, I’d like to discuss the moment when we were sure Mrs. S would not suffocate her daughter, or shake her violently, or leave her disinterestedly in some corner to die.

    In the days after Leonie’s birth we kept returning to the baby unit to observe Mrs. S caring for her daughter.  We watched her feed Leonie and change her nappy; watched her burp Leonie and gaze into her eyes before she fell asleep.  We watched, in short, a series of mini-scenes that constituted elaborations on my essential poetolotical form.

    A child is there.  A child is drinking.  A child is naked. A child sleeps.   

    A child hears a story.  The most important moment in our observations—the moment when we knew mother and child could be safely brought back together—occurred one week into Leonie’s life.  Mrs. S was feeding her daughter. “Look Leonie, look at them,” Ms. S whispered, drawing her face close to the baby and gesturing toward my team. “They’re wondering whether they should take you away from me.  I won’t let them do that. I won’t let them; you can be quite sure of that.”

    Why was this moment so important?  What is the takeaway of this scene, for reader, doctor, and writer?  As readers, the scene’s essence is its pathos, a basic poetological material with which we all are familiar: a child is protected by her mother.  As a psychiatrist, my lesson was to trust my doctor’s instinct and the sustainability of the parent-child relationship (two things, these days, that are increasingly fashionable to doubt). These lessons have been eminently useful for me in one of the hardest parts of my job: deciding when to leave an infant in the care of a recently psychotic person.  

    But more valuable still was a lesson that, as it turns out, has been redemonstrated in child-psych research for much of the last 25 years: that early parent-child bonding is dependent on stories.  Several years ago, a team in Austria performed the following experiment with a group of three-month olds. First, the experiment leader establishes eye contact with the infant and says “Look over here!”  Then he leans forward, put his hands in front of his face, takes them away again, and says “Peek-a-boo!” Finally the experimenter leans backward, with a drawn-out “yesss” that tapers off into silence, and records the child’s responses.  It’s not surprising that the children liked this game; parents have been playing peek-a-boo with their babies for centuries. But what is surprising is that the infants did not like any changes to the permutation of the elements or the crescendo-diminuendo pattern—for example saying “Yessss” before “Peek-a-boo, or saving “look over here” until the very end.  Their attentiveness and concentration plummeted.

    The authors’ conclusion is an observation I have made over a lifetime of talking to children: babies like suspense.  All children, in fact, like interactions that have an introduction, a climax, a release of tension—forms which Daniel Stern, the deceased doyen of child development research, calls “protonarrative.”   Like little Leonie, infants are receptive to protonarrative structures long before acquiring language. And through mimicry, gesture, and fluctuating attention, children tend to ask at a very early age a question that, to my mind, is the essence of healthy identity development:

    Are you telling me something?

    In response, the healthy parent tends to ask a complementary question—shall I tell you something?—and then to respond with a continuous stream of short stories.   From this exchange arises a third question—“How do I know who I am?”—which all of us spend of our lives trying to answer, and to which this narrative give-and-take appears to be our natural response.  This behavior is not highbrow, mind you, but is rather like walking, talking, and having sex: driven by instinct and rooted in neuroanatomy. Humans need to tell stories. We want to have stories told to us.   It is a continuity-seeking process that is especially important in the fragmented condition of infancy, where, again, there are no images, scenes, or categories to ground the poor infant. To quote German philosopher Odo Marquard, storytelling creates continuity in a context of discontinuity.  A world explained in ever more diverse fragments remains a world of fragments; it only attains continuity through narrative.

    In this way, storytelling is the basis of identity formation.  The stories we exchange are our identity card. People who forego their stories forgo themselves.  Children need to know their parents’ stories—their favorite foods, their intense feelings, their lowest moments and highest ideals.  And we ought to tell them, just as we ought to tell them their own biographies. Sure, they may become irritated with their mothers’ sentimental birthday stories—“It was a beautiful summers day when I began to feel a tugging sensation in my tummy.”  Just as we Austrians roll our eyes to hear, for the hundredth time, about the Russian soldiers who smashed up our grandparents’ bikes during the occupation. But we need to hear these stories, just as surely as the future needs a past.

    I do not know how little Leonie’s story turned out any more than I know the outcome of the little girl in the operating theater.  Leonie is now five, and the question of whether she will have a happy ending—the ending we secretly want of all stories—is still open.  As her mother’s doctor, I find this uncertainty uncomfortable. But what is certain is that Leonie and her mother have something that no one can ever take away: an initial narrative, a common first story, a creation myth, a beginning.



    Walking, talking, and having sex are more easily learned if there is someone there to help you, and the same is true of storytelling; it is easier and more fun as a dialogue.  The child who is regularly asked “Shall I tell you something” will naturally learn to ask the complementary questions–“Are you telling me something?” and “How do I know who I am?”  And she will begin to answer with the story of herself.

    For child psychiatry patients, this process takes longer.  Such patients have either never been asked the first of those key questions–“shall I tell you something?”—or have had their own storytelling misunderstood, ridiculed, or ignored.  Sometimes these children remain silent, falter, get stuck in a loop. Sometimes they just scream. Out of this silence and screaming, the psychiatrist’s job is to pick out the question–“Are you telling me something?”—and then diligently tell stories until the child begins telling stories of her own.  Some children use words, some pick up a paintbrush or crayon, some slip into a costume or a virtual identity. Our task is to take all these stories seriously.

    A child is there—more than there.  He is everywhere. A child fills the room.      Marco is eight, short and stocky, with a slight limp and an inability use his left arm.  He has Martin-Albright syndrome, an illness of the parathyroid gland that leads to a painful build-up of calcium deposits in the joints, muscles, and subcutaneous tissue.  He comes to us because he’s been behaving uncooperatively and aggressively at school.

    “The teacher says he can’t do anything and is pooping his pants” Marco’s mother tells us.

    “Don’t give me that stupid look!” says Marco.  Then: “I’m a mess!”

    This latter expression turns out to be his preferred way of describing himself, his trademark so to speak, and Marco does everything he can to re-inforce his self-image.  He writes on the walls, spits at people he doesn’t know, breaks the elevator, grabs the social worker’s breasts, decapitates the occupational therapist’s papier mache dolls, takes food from other children’s plates.  Out of the blue—sometimes minor frustrations can be reconstructed, sometimes not—he throws himself onto the ground and screams loudly; if he’s not offered the appropriate relaxant, like a piece of candy, he defecates in his pants.

    “I stink,” he’ll say.  “Who’s going to clean me up.”

    His mother says he’s always had attacks like this.  And after a few particularly messy ones—Marco soon takes to smearing their results on my doorknob—the whole team loses their enthusiasm for working with Marco.  The whole team, that is, except Franz. Franz is our physical therapist—perhaps the only physical therapist I know who manages without his own room. Apparently our administrators forgot to set one aside for him when planning the department.  Franz says it doesn’t matter. In his spare time Franz lifts weights; “Real weightlifters,” he says, “don’t need a fitness club.” And so with his schoolchildren. His work, he tells me, takes place in the field: both literally on our athletic fields, and figuratively in the classrooms, the corridors, the small arenas where small children’s contests are lost and won.

    Franz is on vacation when Marco arrives, but when he comes back he sees Marco and laughs.  Marco hesitates: “Don’t give me that stupid look!” All of us watch as they stare each other down, the requisite distance between them.  Finally, the social worker blurts to Franz what the rest of us have no doubt been thinking. “He looks just like you!”

    What Franz and Marco do afterwards is not completely clear.  We see them with balls, or wooden sticks, or clubs. We see Marco on a bike with training wheels, usually howling; Franz usually stands next to him looking bored.  Sometimes the two of them simply disappear into the meadows. Franz always brings a bag of spare clothes. But he ends up not needing them.

    Some weeks later Franz comes into my office.  Marco wants to show me something. Together we go to the soccer goal on the sports field, and Franz stands in the goal.  Marco puts the ball on the penalty spot. He takes a run-up, kicks, and scores. I applaud.

    “We’re playing soccer,” Marco says.  “Franz is a rubbish goalie.” Then he says: “I’ve got to show you something else.”  Franz looks surprised and shrugs his shoulders. Marco takes us to the jungle gym, puts his coat on the floor, and starts to climb.  When he’s roughly one meter from the top—about three meters from the ground—his legs start to shake. He holds on tensely, unable to go further.  Franz senses my impulse to intervene and gestures for me to stop.

    “So what now?” Franz asks.  

    Marco turns to me and says: “Don’t give me that silly look!”

    “What could you do now?” Franz asks.

    Marco seems to think for a while.

    “I could have a temper tantrum.”

    Franz rolls his eyes and looks bored.  Marco waits another minute. Then his face assumes an expression of triumph.

    “What?” asks Franz.

    “Or I could just fly from here.”

    Then Marco starts climbing down.

    What is the meaning of this story, for doctor, reader, and writer?  As caregivers, we might draw a variety of lessons: platitudes about it “taking a village,” paeans to the virtues of interdisciplinary care, morals about physical activity as a means for finding one’s strength.  For the psychoanalysts among us, Marco’s story probably evokes connections between anality and aggression, between Freud’s psychosexual stages and Marco’s mother. “He’s unable to do anything and he’s pooping his pants.”  Was she a good mother? A “good enough” mother?

    But as readers, we register the mini-scenes between Marco and Franz as narrative: another set of riffs on the essential poetological form.

    A child is there.  A child rants. A child is defiant.

    A child plays.

    We see the strange physiognomy of the boy, the brawny eight year-old man-child, whose build is surely a reflection of his years of humiliations endured as much as the result of his obscure metabolic disorder.  We see a lonely, wounded warrior who, aware of his impotence and his handicaps, takes on an identity that is almost always available as a last way out: an identity made up of regression and nastiness. We see him fight, we hear him rant.  We smell him.

    And finally we see how Franz appears and saves the boy.  We see Marco score a goal. We see Marco succeed with what is in fact the essence of play: applied metaphor.  Put simply, Marco transfers meaning from a reality he finds unbearable to a football field, where for once he can be the victor.  We’re touched by this. We are not spared pathos.

    Marco’s last metaphor is his metaphor of flight: “I could simply fly from here.” The question is on our lips already— What does he mean?—and it’s a question as natural for us as it is essential for our children.  If we want to understand them—and this is equally true of healthy kids and sick ones—this is exactly the question we ought to ask time and and time again. It is the crucial fourth question of identity formation: “What does that mean?”  It is not a question that digs after an objective reality—to do so would be a mistake. Rather, we should know that a question posed to a child about meaning is fundamentally a question about two things: the child’s reality and the child’s narrative.  Sometimes there is a gulf between the two, and sometimes they converge. Just as they converged with Marco at the moment when he flies away, a not so slim duck with a lame wing.

    Three children: Marco, Leonie, and the little girl in Allentsteig.   Four questions: Are you telling me something? Shall I tell you something?  How do I know who I am? What do you mean? Narrative and meaning, imagination and stories.  With the help of these tools I have tried to outline the zone of contact we enter daily with our patients.  I have tried to demonstrate that the things we usually describe phonomenologically or categorically, scientifically or analytically, may also be accessed perfectly well using stories—the essential poetological forms which run in our DNA.

    I began with a child born into an Austrian identity, on a strip of land uniquely burdened with Austrian history.  For reasons of symmetry, I will close with a child whose identity is indisputably American, in a scene from one of my favorite texts in the child psychiatry literature: The Adventures of Huckleberry Finn.  It contains all of the elements we have been discussing: storytelling, imagination, meaning.  But it also illustrates that science and poetry are more closely linked than we imagine.

    The scene takes place on the Mississippi.  It is nighttime, and Huck and Jim are lying on their raft looking up at the sky.  Huck describes their conversation.

We had the sky up there, all speckled with stars, and we used to lay on our backs and look up at them, and discuss about whether they was made or only just happened. Jim he allowed they was made, but I allowed they happened; I judged it would have took too long to MAKE so many.  Jim said the moon coulda LAID them; well, that looked kind of reasonable, so I didn’t say nothing against it, because I’ve seen a frog lay ‘most as many, so of course it could be done.

The moon lays stars like a frog lays eggs.  A runaway slave tells a boy whose mother is dead, and whose violent hard-drinking stepfather is after him, about how reproduction works in the sky.  Absolutely wonderful.