Ghosts on the Page
When your body writes from old defenses
This concludes the series on nervous system states and writing voice. Previous essays
Nervous System, Nervous Writer
I think I’m becoming accustomed to my mentor reading my first drafts and stating that my voice isn’t there. This time, it was for my psychiatry residency application. I rewrote my personal statement twice. The first version took about twenty drafts. I was tired of writing it and thought it just needed some outside advice.
The second took a couple of days. When he was going through the first draft, he responded, “I’m having a hard time finding your voice in this.”
It didn’t take more than a cursory glance at what I’d spent three weeks writing to know he was right. It was like a scale fell from my eyes and I noticed how detached and disinterested it read. It was a statement. I’m not sure it was personal. It was writing in search of approval. It wasn’t a story of “why psychiatry.” It read more like an answer to “Why, psychiatry?”—as if the field were raising an eyebrow.
I could see it in the sentences—technically competent, but missing the story of my long, winding journey to medicine and why it led me here. It read like someone had taken a checklist and came up with stories on how to be a good Psychiatry Resident™. I reached for the safest experiences, arranging them into a version of myself I imagined program directors would recognize and approve of. If my voice was anywhere in it, it was stiff and formal, like the depersonalized clinical vignettes from lecture slides.
Where was the real voice—the one who went to medical school because the desire to help people felt larger than any other path, the one who opened a neuroscience textbook in college, stared at a brain diagram, and said, “I haven’t a clue what the hell this is, but if I learn it, I think I can help someone.” The one who walked into his psychiatry clerkship and knew, without needing to justify it, these were his people.
There’s a concept in Polyvagal Theory called neuroception. Stephen Porges uses the term to describe something distinct from perception. Perception requires conscious awareness. Neuroception operates beneath it—a neural process that evaluates risk and safety by detecting cues in the environment and in one another, then reflexively shifts autonomic state before we have any idea it’s happening.1
Even simple organisms react to threat without needing a brain to think about it. In mammals, that capacity expanded: we detect danger instantly, and we detect safety instantly.2 That capacity allows defense to quiet and social engagement to emerge. A warm voice, a familiar face, a gesture that signals “I’m not a threat”—these cues can shift the nervous system toward connection before we consciously register them.
Porges describes neuroception as bidirectional.3 Top-down pathways interpret cues of threat and safety—the prosody of a voice, the intention behind a movement—and those interpretations shift autonomic state. Bottom-up signals from the body—heart rate, breath, visceral sensation—travel back to the brain where they are interpreted and felt. We may not know what triggered the shift, but we feel its effects.
On the page, when neuroception fails to update—when the body codes an environment as threatening despite cognitive recognition of safety—sentences carry the structure of threat. The prose becomes guarded, prematurely closed, vigilant. Viscerosensory signals are integrated before reaching awareness, and the brain updates its model through prediction and error correction.4 When predictions were formed under prolonged threat, the system privileges those priors even in the presence of new evidence. The body carries forward the probability of threat. For some of us, depending on our histories, updating takes time.5
Autonomic state shapes attention. Attention shapes language. When the nervous system is organized around threat, it scans for risk, adjusts for exposure, and then selects for expression. In writing, this can mean language becomes strategic rather than relational. The page reflects the body that produced it.6
The two drafts I wrote map different nervous system states. The first was composed under defensive sympathetic activation—vigilant, braced, metabolically organized around survival rather than the kind of relational communication I hope to embody as a psychiatrist.7 My neuroception, scanning for cues of evaluation, found them everywhere. It interpreted the process as evaluation rather than connection.
The second, as I hope you’ll see, emerges from a mobilized state that invites connection and shares in the excitement of applying to a field I fell in love with, reflecting a shift in what my nervous system felt about being evaluated for psychiatry residency.
“She’s having a panic attack, and she asked for you.”At 22, leading volunteers in a NYC food kitchen, I was called over to help a distressed 16-year-old during her panic attack. Without any medical training, I simply sat with her until her breathing steadied. Those experiences pushed me to investigate what happens when people lose their sense of self and experience mental and behavioral health illness.
In college, the humanities had been my answer to those questions, until I opened a neuroscience textbook in Georgia State University’s library. Humanity became reimagined through science. Born was a lifelong desire and consuming fascination with neuroanatomy and pathology. Eager to see these concepts in practice, I pursued a psychology practicum at Grady Memorial Hospital. Working with African American women at suicide risk revealed how psychiatry uniquely positions physicians to address mental health across cultural backgrounds, spiritual beliefs, and diverse life experiences. The gap between my theoretical fascination and clinical calling had closed. I transformed my non-traditional background into an asset through a post-baccalaureate program and earned my way into medical school to become a psychiatrist.
The clinical experiences during medical school deepened my understanding of psychiatry’s scope. As a volunteer at Grace Village Refugee Clinic, one of my patients was a former engineer from a war-torn country who now labored in a freezing meat-packing plant. During clinical visits, he would share stories of his prestigious career in his homeland, surrounded by family and friends, then his voice would flatten as he described his current reality. Sadness, anxiety, apathy. His depression became clear to me not as an isolated illness, but as his psyche navigating the impossible gap between who he had been and who he now had to become to survive. He was working in a foreign country, practicing religions not his own, separated from family and everything familiar. Working with a supervising physician, we adjusted both his medication and helped him connect with cultural community resources. By his final visit, he spoke of his past without his voice flattening completely, a small but significant shift in how he inhabited his own story.
During a psychiatric consultation in my second year of medical school, I played the role of a patient’s partner as she rehearsed a difficult conversation that had kept her awake for weeks. We practiced her words, anticipated his responses, and built her confidence. When we finished, tears came. “I am not as anxious to talk to him now,” she declared. In that moment, I glimpsed psychiatry’s vast therapeutic arsenal – medication, psychotherapy, behavioral interventions, and countless others yet to discover – used to address clinical problems.
Each patient presents a unique puzzle of matching the right tools to their specific needs, an intellectual and therapeutic challenge that exactly drew me to psychiatry My place of belonging in medicine was coming to fruition when I made it to my third year psychiatry clerkship. This was how I wanted to practice medicine. These were the types of patients I wanted under my care. My psychiatry mentor’s words furthered my patient care development: “They know their lives better than we do.” A patient with bipolar disorder was visibly anxious as she explained how her medication helped but feared any changes that might worsen her symptoms. She felt her previous psychiatric care had never truly listened. Drawing on what I had learned, I said, “We are not trying to change everything with your medicine. We are trying to listen to who you are.” Her shoulders dropped. “Nobody has ever said that to me,” she said quietly. Similarly, a young woman with schizophrenia, typically silent during morning ward rounds, began opening up when I asked about her artwork. She described the colors she chose for different emotions, how the voices influenced her brushstrokes, the way creating something beautiful helped quiet the chaos in her mind. In both cases, trust emerged from both my clinical knowledge and from meeting each patient where they were, honoring their experiences as the starting point for treatment plans that lead to healing and management of psychiatric illness.
During the Covid-19 pandemic, working as a research coordinator in infectious disease, I was part of a team advancing treatment protocols at a critical moment in global public health, revealing how research directly transforms patient outcomes. In medical school, I pursued projects studying resilience through computational and neurobiological methods while founding research opportunities for fellow students to engage with advancing medical science. I see psychiatry at an inflection point as advances in brain imaging, computational modeling, and personalized medicine are reshaping how we understand and treat mental illness. The field is moving beyond symptom management toward precision approaches that account for individual neurobiological signatures, cultural contexts, and lived experiences. I continuously engage with research in predictive processing, data modeling, and pharmacogenomics because I believe the next generation of psychiatrists will integrate these tools seamlessly with therapeutic relationships. This convergence of psychiatric research and deeply human care represents the future I want to help build.
I can still feel the cold tile sitting beside the young woman mid-panic attack in New York City. She later wrote that my calm presence had helped change her life’s direction and encouraged me to find a career where I could replicate that helping spirit towards others. I did not know that moment or discovering neuroscience in a quiet library would lead me to pursuing medicine and a psychiatry career. In residency, I seek training that accelerates my contribution to psychiatry’s evolution toward integrated, patient- centered care. Psychiatry is where my scientific and intellectual curiosity converges with my clinical compassion. I am ready to refine both into expertise that can further discover and understand the mechanisms of mental illness, how we treat it, and alleviate the suffering that each patient experiences.”
Imagine being a kid asked to do chores. Simple tasks meant to teach responsibility, to practice caring for something beyond yourself. Except the chores carried more weight in your body. Your parents offered constant direction. Their teaching style came from their own childhoods. As a child, you did not yet have the capacity to translate tone through an adult lens.
Sweeping felt like a test. Your dad stood in the doorway with folded arms and steady commentary.
“You missed a spot.”
“Try it this way.”
“Not like that.”
He may have been teaching. He may have been offering guidance in the only language he knew. Your nervous system received scrutiny.
Your body organized itself around that truth, encoding into memory and sense-making that chores were never neutral. Cleaning carried evaluation. Small errors carried consequence. The simple act of putting dishes away meant one misplaced plate could summon commentary again. Taking out the trash felt lighter. You earned praise there.
So your physiology learned that safety lived in precision and compliance. The most reliable strategy was to shrink your body, quiet your voice, reduce the chance of error, and move deliberately.
Years passed. You grew up. You shaped a life that belongs entirely to you.
One afternoon in your twenties, you look around your apartment and see dishes in the sink and laundry waiting. You tell yourself you value order. You think more clearly with a clean space. Yet when you reach for the broom, your chest tightens. Your shoulders rise. A heavy sense of “I can’t” spreads through your body.
No one stands in the doorway. The room is quiet. Even so, your physiology prepares for evaluation, the earlier calibration unfolding before thought can interrupt it.
You stand in a different decade, in a different room, with full autonomy. You hold a different broom, yet your body carries an older encoding.
Sometimes the most disorienting part of adulthood is watching your physiology respond to ghosts your mind has already revised.
Your mind searches for reasons. You blame the date on Friday night that drifted off course. The work pressure. A low bank account or the sense of falling behind that keeps you too tired. You scroll. Anything to distract from your world gaining a heavier tone. You reach for order again, and an old sentence fills the soundscape: This doesn’t measure up.
I told myself a story like this. I think we might all tell ourselves some type of similar story.
I shaped myself around what medical training teaches with the pursuit of objective output. The institution communicates through measurement. There are seemingly endless metrics, evaluations, rankings, narrative summaries distilled into numbers and phrases. Over time, those measures can begin to feel like the primary language of belonging.
In medical school, you sign up for constant evaluation. That vigilance refines you. It teaches you to listen carefully, to notice where your reasoning falters and where your skills need sharpening. All of it is oriented toward safety and healing. Yet a system organized around continual assessment begins to shape identity over time. If that vigilance hardens into identity, every room begins to feel like a test. Every interaction carries the possibility of being scored. Without awareness, it becomes easy to translate life itself into an index of performance and lose contact with the parts of you that were never meant to be scored.
I shaped my application around expectations that felt objective and institutional. Hierarchies, boardrooms, evaluations—I wrote as if defending myself against what they might measure.
When my mentor read my draft and said I’d written through someone else’s voice, it was enough. I had mistaken the residency application, a process of connection, for that old chore. I had to choose which thesis I was writing from: the one organized around measurement, or the one organized around the reason I chose psychiatry in the first place. In that first draft, I could see the old thesis lingering. New ones needed writing.
So I rewrote it.
Letter #2, draft what felt like 345
I was 22, an undergraduate intern in New York City, when I found myself helping a student through a panic attack. On a cold tile floor, with no training, I offered only a calm presence until her breathing slowed. I’ve wondered why she asked for me—perhaps she sensed a steadiness in me as I led her group of high school students through the streets of Harlem and the Bronx. Perhaps she found my presence safe.
Walking home that night, I began to carry a question that has shaped the last decade of my life. It guided my post-baccalaureate studies and anchored me through medical school, as I learned to bridge the science of medicine with the person at the bedside. And now, as I apply for residency, it is the question I will take into every patient encounter: what happens when someone loses their sense of self, and how do we help them reclaim it?
As an undergraduate, this question led me to the Nia Project at Grady Memorial Hospital, where I witnessed healing rooted in cultural and personal story. This was what I’d been looking for—a field where science, human narrative, and medical intervention refused to be separated. I had found psychiatry and psychiatry had found me. My clinical experiences in medical school brought me back to the same choice: Do I see a diagnosis walking through the door, or a person carrying one?
During my first year at a refugee clinic, I met a former engineer whose depression lived in the gap between his past and present. Treating him meant honoring the self he had lost when he came to his new country. In my second year, I helped an anxious patient rehearse difficult conversations until her mind grew quiet. “I am not as anxious to talk to people now,” she said. We can practice our way back to our own voice.
Throughout my psychiatry clerkship, my mentor’s teaching—”Listen first; patients know their lives better than we do”—became my guide. I carried it into the outpatient clinic, where a woman with bipolar disorder feared medication changes would erase her stability. Instead of citing guidelines, I centered her agency: “We are not trying to change everything with your medicine. We are trying to listen to who you are.” Her shoulders dropped. “Nobody has ever said that to me,” she replied.
Each patient I encountered offered a piece of the answer. Healing happens through connection. This connection develops by honoring their past, meeting them in their present, and helping them envision their future. Yet, for me, a critical tension remained. If psychiatry is the field where human narrative and the science of mind are inseparable, why did they so often feel like separate languages?
This became clear during my sub-I with a former college baseball player whose paranoia was so profound his parents barely recognized him. My attending assured me medication would help, but I needed to understand how. How does a self unravel? How does a brain that once flawlessly modeled the physics of a fastball come to misperceive a father’s love as a threat? I needed to understand how our interventions could reach these foundational mechanisms of how minds construct reality. I began reading late into the night, searching for the architecture of belief itself. It was an endless process of discovery—the brain as a prediction organ, constantly building our sense of reality. The baseball player’s paranoia was his mind doing exactly what minds do, building the most probable model from the signals it received. His brain had learned that certain parts of his world were dangerous. Our task was to help him predict that safety was achievable. Every single one of psychiatry’s interventions—the medications we prescribe, the therapeutic conversation, the environment of the clinic—is information we can use to help someone’s brain learn new ways of recognizing themselves.
Ten years ago, a question found me on a cold tile floor. Residency is where I will live inside that enduring question, using better tools, deeper medical knowledge, and stronger clinical judgment to continue seeking a reliable answer. This, I am learning, is what it means to help people reclaim their lost sense of self.
I see now that no one is standing in the doorway.
Porges, S. W. (2004). Neuroception: A subconscious system for detecting threats and safety. Zero to Three, 24(5), 19-24.
Porges, S. W. (2021). Polyvagal Theory: A biobehavioral journey to sociality. Comprehensive Psychoneuroendocrinology, 7, 100069. Porges describes this as a uniquely mammalian innovation: “mammals have an expanded neuroception capacity in which they not only react instantaneously to threat, but also respond instantaneously to cues of safety.”
Porges (2021): “Polyvagal Theory proposes that neuroception functionally involves both top-down and bottom-up mechanisms. The process is assumed to be initiated via top-down pathways involving cortical areas located in or near temporal cortex that reflexively interpret cues of threat and safety... The bottom-up limb of the neuroception is functionally equivalent to interoception.”
Barrett, L. F. (2017). How Emotions Are Made: The Secret Life of the Brain. Houghton Mifflin Harcourt. Barrett describes how the brain continuously constructs experience through predictive processing: interoceptive signals are interpreted against learned predictions before reaching conscious awareness
Porges (2021) discusses this as the persistence of defensive states even after threat has passed: the autonomic nervous system may remain organized around threat patterns established during earlier experiences, creating what he describes as "faulty neuroception."
Porges, S. W. (1995). Orienting in a defensive world: Mammalian modifications of our evolutionary heritage. A Polyvagal Theory. Psychophysiology, 32(4), 301-318. The theory’s principle of dissolution describes how defensive autonomic states constrain cognitive and behavioral repertoires.
Porges (2021) describes sympathetic mobilization as metabolically costly and incompatible with the social engagement system: when the ventral vagus withdraws, "the autonomic nervous systems move into a sympathetic state that supports mobilization" but compromises nuanced social communication