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2024 Convos_ Sarah Ruhl V2 PUBLISHED EP

Emily Silverman  

You're listening to The Nocturnist Conversations. I'm Emily Silverman. When I was in college, I went with some friends to see a play called "Melancholy Play". And, it was about a bank teller named Tilly, whose melancholy mood was strangely magnetic to all the people around her: her tailor, her psychiatrist, her hairdresser. All of them fell in love with Tilly, because of her melancholy. Then one day, Tilly inexplicably becomes happy, and all of her admirers are left confused and despondent, one of them even surreally transforming into an almond. It's a whimsical play. It's a beautiful play. It's an evocative play. And, it has stayed with me for a long, long time. The playwright, Sarah Ruhl, eventually went on to pen numerous other theatrical masterpieces, becoming a legend in the theater world, and eventually earning a MacArthur Genius Award. But something else of significance happened to Sarah. Over a decade ago, shortly after giving birth to her twins, half of her face fell down. She was diagnosed with Bell's palsy, and suddenly embarked on a long and difficult journey to understand why this had happened to her, and how she might navigate the world now without the ability to properly smile. Sarah documented this ordeal in a memoir called "Smile: The Story of a Face", and it was truly my honor to have the opportunity to sit down with Sarah and speak with her today about it. In the conversation, Sarah describes what it was like to lose her smile, talks about her direct experiences with clinicians of all kinds, the impact of acupuncture and physical therapy on her recovery, the importance of subtext in the clinical encounter, the way that partial or slow recoveries resist traditional narratives, and the reasons why she chose to tell this story with a book instead of a play. Sarah is one of the great artists of our time, and it was such a pleasure to be able to speak with her. But before we dive into the conversation, let's first hear Sarah reading an excerpt from her book "Smile".

Sarah Ruhl  

The next day, the lactation consultant came in to see how the babies were feeding. My mother was in the corner holding one baby, while I breastfed the other. The patient lactation consultant tried to teach me how to feed both of them at the same time. There was a football hold... That one was tricky... and some other hold that I do not remember. Then the lactation consultant looked at me curiously. "Your eye looks droopy," she said. Taken aback by the apparent non sequitur and comment on my appearance, I tried to joke. "Yes, my eyes are a little droopy," I acknowledged. "I'm Irish. Most of my ancestors, after one or two gin and tonics look sleepy, so crinkled and heavy do their crescent eyes become." "That's not what I mean," she said, kind but firm. "Go look in the mirror." I got up to look in the mirror in the bathroom. The left half of my face had fallen down. Eyebrow fallen; eyelid fallen; lip fallen. Frozen, immovable. A stroke? I was astonished. My face hadn't felt any different before I looked in the mirror. Before looking in the mirror, I was the same person. After looking in the mirror, entirely different. I tried to move my face: impossible. Puppet face, strings cut. I came out of the bathroom. My mother saw my face and was alarmed. I called my husband, who was always preternaturally calm (Did I mention that he's a doctor?), and told him that I couldn't move the left side of my face. He told me to call the obstetrician immediately, and have him call a neurologist. Then he said, "I'll be over in 10 minutes."

Emily Silverman  

I am sitting here with Sarah Ruhl. Sarah, thank you so much for speaking with me today.

Sarah Ruhl  

So happy to.

Emily Silverman  

So, Sarah, you went to Brown, which is where I went. And I definitely spent some time in the theatrical department of Brown, seeing student-written plays and things like that. I was wondering if you could tell us about your time at Brown, and especially, connecting with your mentor Paula Vogel.

Sarah Ruhl  

Sure. I love that connection. When I started as an undergraduate, I really wanted to be a writer, but I was focusing on poetry. And then I met this extraordinary teacher at Brown, the really beloved playwright Paula Vogel, and she brought me over to the dark side of playwriting. Or maybe not the dark side, the fun side. I took her class junior year, and then she snuck one of my new plays into the New Plays Festival, which was at Trinity Repertory Company (down the hill in Providence, Rhode Island), and that really changed my life.

Emily Silverman  

And how do you think differently about dramatic writing? I think in the healthcare space, there's a lot of doctors and nurses who write memoir, and write for the page, but dramatic writing is really different. And so, what did you learn about that at Brown? And how do you think about that differently?

Sarah Ruhl  

That's so true. I had never thought about that before. And, in a way, it makes total sense that I wrote this story about Bell's palsy as prose, rather than dramatic literature. And I think it's because illness can be a very interior experience. It might be inwardly dramatic, but it resists catharsis, particularly chronic illness. I feel like you see more movies about illness than plays even. I wonder why that is. I mean, I will say I feel like the theater space in general is one for well bodies, even just as a lifestyle. There's this "the show must go on" mentality, and we don't make a lot of space for actors to be sick, playwrights to be sick, directors to be sick. It's not really part of the ethos. And, I think that shifted a little bit in the pandemic. But, I think there's something about the theater where you go there to have a catharsis if it's a tragedy, or forget your troubles if it's a comedy, but you don't really go there to contemplate illness.

Emily Silverman  

When you sat down to write "Smile", did you find yourself having to shift yourself psychologically back into the prose mind rather than the playwriting mind?

Sarah Ruhl  

I did. And, I had written a book of essays before, called "100 Essays I Don't Have Time to Write". They were micro- essays, and I wrote them when my twins were a baby. So I had three kids under the age of four, and I couldn't really think in long form, so I wrote these distillations. And so I'm comfortable writing in prose, but I hadn't written something in long form before. And, I think for me, the biggest shift was having no place to hide. In a play, you have these extraordinary avatars, these actors, and you have characters which are often different facets of yourself. But, in memoir, that's it. You are taking the mask off. And I think that was very liberating for me, actually. I think I needed to do that. But it was a shift, you're right.

Emily Silverman  

And the event that you just read, where you discover that you have Bell's palsy, that was a while ago now. It was over a decade ago. When did you start writing about it? Did you wait ten years, and then write about it? Or were you writing about it all along?

Sarah Ruhl  

I wasn't writing about it all along. I was actively not writing about it and not talking about it and just hoping it would go away if I didn't talk about it or think about it or write about it, and then it kept not going away, and it kept not going away, and it became a really chronic thing, and I think I finally decided to write about it about ten years later.

Emily Silverman  

I think a lot of us take health for granted, and then when something goes wrong, when we get sick... In your case, with half your face falling down..., we realize all of the ways in which we use the body part that is not working anymore. And so for you, you become suddenly aware of all of these different ways that a smile functions in society. So, as a way to express joy, yes. But also to signal politeness, and it has all these social functions. Tell us about those new awarenesses that you are having.

Sarah Ruhl  

It was a bit of a nightmare, to be honest. I'm from the Midwest. I like to be friendly. I felt I couldn't communicate friendliness. I felt I couldn't communicate even simple approval. I remember sitting at a play, of mine, on opening night. My mother was sitting next to me, and she was looking at me, and she was looking more and more anxious, and she said, "What's wrong? What's wrong? Do not like it?" And I said, "Mom, I have Bell's palsy". And my mom has had Bell's palsy, so I thought surely my mother would understand. But even my own mother couldn't read my facial expression. And I had these two little babies, and I really wanted to smile at them, to show them that I love them, and to show them my joy at their arrival. And I felt like I couldn't. So it was a nightmare, both for my intimates, in my mind. You know, that I couldn't show them how I felt, and it also felt like a nightmare navigating social situations with strangers who didn't know me at all, and I thought they'd think I was aloof or opaque.

Emily Silverman  

And there's also this spiritual or metaphysical aspect of a smile, this idea that if you lose the ability to smile, there's some dampened joy that actually happens internally, and this neurologic question of which comes first: the smile or the joy. And I'm wondering what your experience was of that.

Sarah Ruhl  

I was depressed, and I think I didn't know if it was that neurological loop where the more you smile, the more you experience endorphins and joy, or if I was just depressed because I didn't like the way my face looked. I was sick of not getting well. I was sleepless. It was a little loop. I still wonder, frankly, if I lack some happy ... (I don't know what you call them) molecules, because I don't really have a full- tooth smile. I can now do a closed mouth smile, but I can't do a big, hearty, full smile. And sometimes I wonder: Am I not getting some extra serotonin? Or, itwouldn't be serotonin. I don't know what it is exactly that you get from the physical experience of smiling. But I remember reading some meditation books at the time, and Thich Nhat Hanh saying, "Sit in meditation and smile," and "You can always smile," and "If you smile on the outside, you'll feel it on the inside," and being like, "Oh my god, No!" Like, I don't want to be angry at Thich Nhat Hanh and want to throw it across the room, but smiling was sort of the one thing I felt I couldn't do

Emily Silverman  

That reminded me of something I read recently. In meditation and Buddhist practice, it's a lot about focusing on the breath. And it was somebody who was critically ill in the ICU, and they were on a ventilator, and they were really struggling to breathe, and they were breathing irregularly, and trying to pull breaths through the ventilator.But, they were awake and conscious. And people were trying to figure out how to help this person meditate, and they couldn't use the breath, because the breath... It wasn't the rock that it normally is, and so they had to look to other things. 

Sarah Ruhl  

That's so hard. 

Emily Silverman  

I don't even remember what other anchors they tried. But, for you, did you find any other anchors for...? Youmentioned you were gesturing more, for example. Like, different outlets for expression.

Well, I do think human beings are extraordinarily resilient. I mean, that story is incredible. So when you don't have the breath, what do you go to in meditation? I guess my mind would go to counting, if you don't have breathing. When the very thing that's supposed to calm you down is making you anxious, it's so upsetting. With meditation, I tried to just think about an internal smile, for example, and not the physical smile. But I tried to avoid that image, honestly, and go back to the breath. And then for conversation, I really wanted to show people I was actively listening, even though I couldn't mirror their facial expressions. And we do that so unconsciously, to show people we're listening. So I would murmur more. I'd go, "Mmm, mmm." And I would gesture, and I'd say, "Oh yes." I just unconsciously started to add those. Or if I saw someone walking down the street, I'd give a little wave, because I couldn't smile at them at a distance. 

Emily Silverman  

There was a bit of a diagnostic journey in this book. Initially you think that there isn't much of a diagnostic journey, because you get the diagnosis of Bell's palsy, but there was a surprise diagnostic twist with the celiac disease discovery. Tell us about that plot twist.

It turns out there were two plot twists. But yes, the first plot twist was celiac disease. I had a wonderful neurologist, Russell Chin, who I'd gone to for a second opinion when I wasn't getting better. And Dr. Chin had me tell the story of the diagnosis, the initial diagnosis, and I mentioned that little joke, "Oh, I'm Irish; my eyes are droopy". And his ears perked up, and he said, "Oh, you're Irish?" And I said, "Yeah," thinking, what bearing could that possibly have on this? And he said, "Let's test you for celiac". I didn't even know really what celiac was, but I guess it's more prevalent in the Irish gene pool. So, I was positive for celiac. And I guess he thought, or speculated, that maybe I wasn't getting better because I wasn't absorbing B 12 or other vitamins that would help the nerves grow. I don't really know if that's true, because it's not like I magically got better when I started not eating gluten, but it was a profoundly helpful diagnosis, because it's genetic. It turned out my daughter has it, and she was having trouble growing and stomachaches. And then, in this totally bizarre twist, my mom and I were looking at my father's baby book, and he had died of cancer when he was 52. And, it said, "Baby Patrick Ruhl, possible celiac disease. Give only bananas and milk for first year." And I was like, "What?!" Hewas much shorter than his brother. He had autoimmune issues, and celiac was thought of as a pediatric illness in the 50s. So, that was a shock; he never mentioned that. There are medical professionals listening, so they know this,but your risk of cancer if you're celiac goes way up if you're not treating it, but it goes down to baseline if you're on a gluten-free diet. So I was so grateful. So it was almost like this chronic disease of Bell's palsy gave me the opportunity, or the gift, to find another diagnosis out. And then the crazy, other plot twist was after I published the book. A doctor called me, and said, "I think you have neurological Lyme disease. That's why you're not getting better." And I said, "Oh no, no. I tested for that right in the first month." And he said, "Well, how much did you test? What test did you do?" And the truth is, that I remembered suddenly... Well, Tony, my husband, and I had been in Long Island while I was pregnant. Tony got a classic bulls-eye tick bite and went on antibiotics immediately. I didn't think of going on, even though we'd been in a tick-infested area, and I never saw one. So after that doctor called me, I did more bloodwork, which was a little ambiguous. I didn't realize what a political minefield it was too, trying to get a diagnosis in New York City. And then finally, I went out to Stony Brook, Long Island, and got a spinal tap, and it was in my cerebral spinal fluid. And that doctor, who was a neurologist, said, "I don't get it. You have multi-systemic symptoms. Like, how have you not gotten a spinal tap before?" And I said, "Don't ask me." So, on top of celiac and the Bell's Palsy, I had Lyme disease. So, I went on IV antibiotics, and I think recovered quite a bit of energy after that. I don't know if it really made a huge impact on the Bell's. Maybe a little bit?

Emily Silverman  

Yeah, in addition to the diagnostic journey, there's this therapeutic journey that you had, where you are seeing a lot of different medical doctors. You saw a couple of surgeons; you saw acupuncturists; you saw physical therapists. I want to start with the medical doctors, in part because I am a medical doctor, and a lot of our audience is medical doctors. So, you experienced doctors, obviously as a patient, but you also have a lot of doctors in your life: your husband, your sister, your grandfather (I believe), your best friend from childhood, and ...

Sarah Ruhl  

and two uncles!

Emily Silverman  

...and two uncles.

Sarah Ruhl  

Surrounded.

Emily Silverman  

So, as an artist, and a writer who's such a keen observer...I know you can't generalize too much, but I'm wondering, what do you make of us doctors? And have you noticed ways in which doctors see the world differently than you do as a playwright?

Sarah Ruhl  

I mean, I think there are all kinds of doctors, And doctors can be the most incredible people who give up their entire lives, in many cases, for their patients. Just an astonishing level of care for humanity and a great sacrifice to care for others. And that's the ethos I grew up with, watching my grandfather, watching other people in my family. And I remember when Tony took the Hippocratic Oath and feeling the weight of that, that he would prioritize that for his whole life. I unfortunately saw a not great doctor when I first got diagnosed with Bell's palsy. At first, he did all the tests. He said, "It's Bell's palsy, and we don't know really what causes it, but you'll probably get better. We don't know how much better. See me in six months." And then I saw him in six months, and he seemed almost accusatory when he saw me and said, "You're not better. Do you realize that? You're not at all better." I felt blamed, almost, for not being a good patient and not getting better. And I said, "Well, I have twins, and I haven't rested. Maybe it's the lack of rest." He said, "It's not that." I said, "Well, maybe there are other modalities I could do." And he said, "No, acupuncture won't help. Nothing will help you. The only thing that will help you is getting experimental surgery at NYU to reconnect the nerves; they've grown back wrong." He used that language, like, "Your nerves have grown back wrong." I just felt like my body was wrong. My body was not behaving for him. I was so upset, and I didn't want to see a doctor for a long time after that. I felt ashamed. It was very strange. I felt like, oh, I failed to get better; my body's not doing the right thing. I'm just going to pretend this isn't happening, basically. So I really retreated from it, and then it took me, I think, maybe another year, before seeing that other neurologist to get a second opinion.

Emily Silverman  

Right now, we at The Nocturnists are working on a series on the topic of uncertainty in medicine. And the reason that we got a grant to do this project is because the ABIM, the American Board of Internal Medicine, recognized that our profession needs to start talking about uncertainty. And so we've done a deep dive into this topic, and the way in which uncertainty provokes discomfort, fear, anxiety, anger,and then can lead, potentially, to these moments of tremendous harm, like you just described, where patients feel shame and blamed, and like you said, you didn't want to see a doctor again for a while. And I don't know if you have any thoughts on the uncertainty piece of it.

Sarah Ruhl  

I love that you're doing that. I do think it makes some doctors very uncomfortable to not know, and they're in a position of needing to be authoritative and to know, and when they don't, maybe they feel like a failure. So then they turn around and make the patient feel like a failure, or they get defensive. And my..."Journey" is such a word, but I waslike, in my "Lyme journey", I did find a lot of doctors got really defensive because there's so much ambiguity in Lyme and so much unknowingness. And a lot of doctors, I think, felt uncomfortable saying, "The blood work is inconclusive. I don't know." So instead, they'd be like, "You don't have Lyme!" (according to the CDC or whatever). There's ambiguity, but we're just gonna say that you don't have it. And looking at the bloodwork instead of the whole picture, the whole human, the whole story. I think it's a leadership thing, in general, uncertainty. And the most confident leaders I know, say in theater directors who are really seasoned, can sit in a room full of actors looking to them to tell them what to do. And a really incredible director can say, "Hmm. I don't know, right now," and everyone will respond to that authority. But I think insecure teachers, directors, doctors, when there's uncertainty, there's a kind of frantic doubling down on authority and knowingness.

Emily Silverman  

Hmm. That's a really interesting analogy to the director. I don't know that much about directing for the theater. I mean, you have this text which is certain, I guess you could say it's written in stone. And then you have the actors who are these live wires. How much certainty and how much uncertainty is there in directing? Like, you want to guide the actor in a certain way. You don't want to bulldoze the actor, but you also have to direct. So how does that work?

Sarah Ruhl  

I mean, I've been thinking about writing a book about the art of collaboration because I spend 70% of my time doing it, and probably only 30% of my time writing. And it's such an art, making all of those three elements you just mentioned coalesce. There's such an alchemy to it, and everyone does it differently. I don't know. Is it like Tolstoy said, "All good families are alike." Or all bad families? I always get it backwards with Tolstoy, because I actually think he was wrong about it. I don't think good collaborations are alike; I don't think bad collaborations are alike. But there are things they have in common, how they go right and how they go astray.

Emily Silverman  

Well, let's move away from the medical doctors into some of these alternative practitioners that you saw who were very helpful for you, starting with acupuncture. So, there was a couple moments in the book where you go to acupuncture and you do notice an improvement afterward. The moment where you blink for the first time came after acupuncture. And the moment where you smiled and you saw a tooth that you hadn't seen in a while: that was after acupuncture. Tell us about your experience of acupuncture.

Sarah Ruhl  

I love acupuncture, and I know a lot of Western doctors are like, "Mmm...I don't know," including my husband Tony. But I feel like the proof is in the pudding when you experience it. And I've experienced the benefits so many times, including with Bell's palsy, but also with back pain, and it helped me induce labor once. I don't really understand how it works, and I think that might be also why Western medicine is skeptical, because we don't really.... I mean, there are theories, but they're descriptive theories. But I think we don't really know why. Is it because I was just laying down and resting for an hour, and I needed to? Or was the acupuncturist moving qi? Or nerve pathways? I don't know. But I do know that after not being able to blink for three months, I was able to blink after seeing an acupuncturist regularly. I got a lot of improvement for acupuncture, and then I finally found a physical therapist. The neurologist I'd seen, who had been really negative about interventions, and said, "Oh, PT. There's no PT for Bell's palsy." Well, that's not true. There is, and it's just really hard to find and it's hard to find qualified practitioners. But I found someone who herself had had Bell's palsy, and I found that so therapeutic, because it was like looking into a mirror, and she knew empathetically what I was going through. And so I wasn't ashamed also to look at her, and for her to say, "Smile, wrinkle your brow," and she would do it with me. And that felt like a really different modality than what I'd been used to. And then, even after my book was published, I found another amazing PT up at Columbia who works in concert with a doctor named Dr Scott Troob. He's an "Oto"... help me out "Oto...laryn..." 

Emily Silverman  

Otolaryngologist.

Sarah Ruhl  

Thank you. He is that, and he's wonderful. And he works with a physical therapist who tries to identify particular areas of synkinesis. Synkinesis is hell for a patient. It is when, with Bell's palsy, either the nerves don't grow back correctly, or the muscles atrophy or learn to do things in a different way, so that on top of feeling ugly from the asymmetry, you start to recruit muscles that aren't supposed to be recruited to do things like smile or raise your eyebrows, and it causes weird things like a grimace when you smile. Your mouth can start to turn down when you try to smile. This muscle starts pulling in a weird way and popping out when you try to smile. Your eye closes a little when you try to smile. So, what Dr Troob does, is he'll give you a teeny bit of medical Botox in places where you're having a synkinesis reaction. So I have some in my eye right now. So that when I smile, my eye doesn't close. And when I smile, this muscle on my neck doesn't pop out and try to pull downward. There just is less tension in your face, because you're not pulling the muscles in bizarre ways. That was a game changer for me, and I only learned about that after the book came out. 

Emily Silverman  

And you said the physical therapist that you worked with... One of them, her name was Elaine. She's the one who had Bell's palsy herself. And you said it was like looking in a mirror. And that's figurative, but it's also literal in a way, like you sat opposite her, looking at each other's faces and correct me if I'm wrong, but she would do something with her face and then tell you to mimic it. And this was experimental, just something that she was trying. But, maybe the idea was pulling on those mirror neurons that we have, trying to pull on other strengths inside the brain. Is that what it was like? 

Sarah Ruhl  

Yeah, that's it. And I think she was somewhat experimental, in terms of what she was having me do. And then this other PT up at Columbia, Delia, she's incredible too. And she would do things like put a glove on, stick her hand in my mouth, and stretch out the muscles inside the cheek, because sometimes it was that tightness that was not allowing enough relaxation to smile. So, she was incredible. And then she would talk to Dr Troob and say, "I think she needs a little medical Botox here, or here, so she's not pulling on the muscle." I'm happy to talk about this because I feel like a lot of people don't know about the resources. I didn't. I was sort of given a sentence. I felt like that first neurologist was just, like, there's nothing you could do except experimental neurosurgery. And there were other options, and even really good doctors in New York didn't seem to know about them.

Emily Silverman  

And you were able to recover. Not a full recovery, but tell us about how much function you were able to recover. 

Sarah Ruhl  

I feel like I can smile, a closed mouth smile, and not worry about it. Like, not be self-conscious. I don't worry about people knowing what my affect is anymore, which is huge. Do I want to smile with teeth for a picture? No. I probably never will want to. But can I smile with teeth when I'm laughing? I can. So, it's been a lot better. I would say probably 70% better. 

Emily Silverman  

I want to ask you about subtext. I was recently reading this book. It's called In Shock, and it's by a physician, Dr Rana Awdish. It's an incredible book. And, she is an ICU fellow, and ends up having a ruptured benign tumor in her liver;starts losing all her blood into her liver, and gets hospitalized in the very ICU that she works in. And so she experiences the ICU through the eyes of a patient. And comes out of it alive, miraculously, and writes this beautiful memoir about it. And she goes on in the book to talk about subtext. And one of the examples she gives is there's a hernia that develops, and she needs mesh, and she's perseverating on the different types of mesh and the different materials, and how much tensile strength does it have, and should I use this one or that one, and the pros and cons. And she's sending the email to her surgeon, and peppering him with all these questions. And, she said "His answers were perfect, well thought out and honest, and yet I still felt terrified." So, he was answering the concrete questions that she was asking about the mesh, but missing the understory, which was, "I'm afraid". And later, this doctor writes in her book, we doctors hear our patients ask questions, and we believe they want data, facts and explanations, so we dutifully provide them, as we were trained to do. And then we listen as our patient again asks a permutation of the same question, and we wonder if perhaps we weren't clear. So we explain it again. And the problem with responding to emotion with data is that emotion doesn't recognize data. And then she says, "Emotion demands to be acknowledged." So, as a playwright who works a lot with subtext, I was wondering if you've ever thought about subtext inside the medical encounter?

Sarah Ruhl  

Absolutely. That's an amazing story. It's something I think my husband's really gifted at, as a child psychiatrist. And I see him navigate uncertainty all the time in his profession. And I think, because psychiatry in general is about emotion and about uncertainty, like really about trial and error, you have to acknowledge a certain amount of uncertainty to do it well. But I think about other medical experiences I've had where a doctor is reassuring, and I'm trying to think, like, what makes it reassuring has nothing to do with the data actually. I remember my son, William, had to get strabismus surgery, and he'd literally have his eyeball like moved over when he was three. I was terrified of the surgery, and I remember the doctor saying to me... He didn't come out with facts or figures. He just said, "For the next two hours, I'm going to be a parent to your son. I have him." You know, "It's okay. I've got him. For two hours, and then you'll have him back again." I found that so reassuring. Now, another parent might find that creepy, like, "No, I'm the parent. You're the doctor." I personally found it incredibly reassuring. I had cholestasis of the liver when I was pregnant with the twins, and so I had a pretty dramatic induction at 36 weeks, and it was scary, and my doctor was very reassuring, and he gave me the epidural. And rather than having the anesthesiologist hold me while I was shaking, Dr Silverstein was like, "Hold on to me." He was like the midwife, the doctor, the comforter; he was all the things. He gave me an academic paper about how giving birth to twins vaginally with my presentation could be fine. So, there was the academic part, there was the practical part, and there was the emotional piece of it, which was like, "I'm going to take care of you. You're going to be okay." What a thing to be able to do all those things. I'm in awe of people who can do that.

Emily Silverman  

In Smile, you wrote, "It strikes me that the difference between a good doctor and a less than good doctor is one part expertise and three parts quality of listening." 

Sarah Ruhl  

Yes. I mean, I think it is about the stories we tell and the doctor putting it together, like a Sherlock Holmes or a detective. And sometimes you listen to the most bizarre non sequitur to make a diagnosis. And sometimes there's no diagnosis, but the patient feels listened to. I think some of my most frustrating experiences, in terms of subtext, were when my doctors thought I was just emotional, stressed out, a malinger or what have you, because I kept being on this quest to feel better. And they'd hand me questionnaires about stress. It was like, "Yes, I have stress. I have three babies; I have a career. I'm not sleeping, but that's not actually the issue. I still don't have a diagnosis."

Emily Silverman  

I want to ask about narratives of illness. So toward the end of your memoir, you're meditating on this idea of the slow recovery and also the partial recovery. And you write, "The partial recovery is not terribly dramatic. It's the stuff of life, not art. But the partial recovery is, I believe, very much like life. Most people have partially recovered from something: a childhood burn, a childhood trauma, a broken bone, a broken heart. How rare is it for someone to hear proclaimed about their heart or their body: You have made a full recovery?" How did this experience of the slow recovery, the partial recovery, change the way that you think about storytelling?

Sarah Ruhl  

I think it partly just reminded me that telling a story about your suffering is important. And for a writer, making sense of the narrative of what happened to me. My smiles may be recovered like 70%; the rest of the percentage turned out to be writing my story down and making it available for others who might be suffering, and actually talking to other people who have Bell's palsy. That was the remaining bit, and it wasn't physical; it was spiritual and emotional and psychological. In the chapter I read from, looking at myself in the mirror one way before and feeling one way and then feeling another way, it was not congruous. It was dislocating, and I couldn't bridge the gap for a really long time, and I just pretended it didn't exist. And it was interesting when I first started, when the book came out, doing interviews, and people would ask me about that moment, I would actually go blank. I actually had a really hard time talking about it at first, and then I realized, Oh, that was traumatic. Your brain didn't want to go back there and talk about it or write about it, so I think even just to be able to talk about it has been very healing.

Emily Silverman  

And you mentioned earlier that you chose to tell this story on the page rather than on the stage, in part because the chronic resists plot and resists epiphany. And you wrote,"When diseases and stories are chronic, doctors and writers often both run for the hills." A woman slowly gets better. What kind of story is that? How do you think we can reshape narratives in art to embrace partial recoveries and slow journeys? 

Sarah Ruhl  

There was a really beautiful play last season by Annie Baker about chronic pain, called "Infinite Life". And anyone who's experienced a chronic illness, I think would recognize themselves in it. I teach playwriting at Yale School of Drama, and I was having them read this crazy Belgian playwright from the turn of the 19th century. Maurice Maeterlinck, who has an essay called "The tragic in daily life." And, even all the way back, then he's saying, "I'm sick of melodrama. Drama shouldn't have to be swashbuckling and swords, and I want the interior drama of these silent, invisible things that go on in consciousness." Then Samuel Beckett discovered Maeterlinck, and took his ideas and created his esthetic. So we're always rediscovering these other ways, and I'm very interested in doing that in my writing in general, and in dramatic writing: trying to find space for the interior. And, maybe I should make a play out of Smile. You know, maybe it would be the extra catharsis, to have it embodied.

Emily Silverman  

Well, if it happens, it started here, on The Nocturnists. 

Sarah Ruhl  

Exactly.

Emily Silverman  

When I was at Brown I watched a production of your play, "Melancholy Play". And... It was a long time ago, so I don't remember every single part or every single scene, but it did strike me as a play that externalized the interior in a way. You know, it's about the emotion of melancholy. It's about a mood. It's not necessarily following that traditional hero's journey plot-heavy story, and so maybe already in your work, there's just a lot of that interiority coming out.

Sarah Ruhl  

I think it always has been an obsession. I love a quiet moment, and I love a moment where the audience has to project their own emotional history and landscape onto what they're seeing. And I think in order to do that, you have to make space, and you can't fill in all the edges. So, I agree.

Emily Silverman  

Well, to end, I'm wondering if you want to leave our audience with any messages, any words of wisdom or advice. These are people who are going to be taking care of patients. So, any last parting words?

Sarah Ruhl  

Well, first of all, I want to thank you for being in a profession that's so caring, that's so helpful, that requires so much sacrifice. And, if you're a person who's listening to this podcast, you're already interested in people's stories. So, I thank you for that. And I think what I would say for a doctor who is dealing with a patient with Bell's palsy, to just consider how psychological and how emotional it is to not recognize your own face. It is so much more than a bundle of nerves that you're treating. It is a whole person, whose identity has just gone through a seismic shift, and you need to offer them other tools and more hope. I wish my doctor had told me to join a support group. I had to write a book to actually meet other people with Bell's palsy. It would have been so helpful. And then, for doctors who are dealing with people who might have chronic Lyme, or might be seeking a Lyme diagnosis after years, I guess I would say, look at the whole patient, not the bloodwork. There's so much we don't know yet. And, just a lot of gratitude for all the healing work that doctors do post-pandemic. It's such a hard time to be in the healing professions. When I look at the difference between what it was like for my grandfather in a small town in Iowa to practice medicine, and what it's like, say for my sister in Chicago, it's night and day in terms of the amount of hours.  Even just whether you could put your kid through school on one doctor's salary. I mean, that sounds, coming from a position of privilege, but I just think it's fundamentally changed. And so, I just really appreciate the sacrifice people make to be a physician, to be a nurse, to be a healthcare worker. So, thank you.

Emily Silverman  

Thank you. This has been such a pleasure. I have been speaking with the wonderful Sarah Ruhl. Sarah, thanks again.

Sarah Ruhl

Thanks for having me.