Is it possible for medicine to be too cold and, for want of a better word, clinical? Could physicians become preoccupied with treating disease and ignore their patients, to the detriment of medical practice? Is not medicine as much a caring profession as a scientific one?
Such are the concerns of the narrative medicine movement, founded by Professor Rita Charon of Columbia University in New York. Prof Charon holds a PhD in English literature alongside her medical degree and, as her movement’s name suggests, much of narrative medicine’s philosophy is informed by the importance of story-telling.
Narrative medicine encourages practitioners to listen attentively to patients’ histories, develop their own communication skills and thereby engage patients as active participants in their own care. It represents a subtle move away from the traditional, more authoritarian approach to medicine.
Narrative medicine has applications in all specialties but has been particularly influential in psychiatry where an approach to patient consultation called narrative therapy is gaining favour.
Dr Paul Wallang, a specialist registrar in forensic psychiatry at the John Howard Centre in London, is a proponent of the narrative approach. His paper on the subject in The Psychiatrist last year drew several responses: positive (in Dr Wallang’s words, “a lot of people who responded positively saw narrative as means of regaining a certain humanism within psychiatry”) as well as negative.
Concerned as it is with the mind, psychiatry is perhaps the medical specialty with the greatest tendency towards the abstract. In recognition of this, James Brooks fuses excerpts from his interview with Dr Wallang with the solo guitar of avant-garde musician Elliott Sharp in an experimental audio feature.
Listen to this audio feature:
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Transcript of the audio:
OK, I’m Paul Wallang, I’m one of the specialist registrars in forensic psychiatry at the John Howard Centre in London.
Well, I think probably the best place to start is talk about the history: where narrative medicine arose.
If we go right back to the 1700s and the enlightenment there was a general view at that point that reason should be very securely removed from unreasonable elements of society – people, generally, with mental illnesses.
And that’s how the whole asylum system came about. When those asylums were established people were basically detained there against their will, they weren’t given any opportunity to prove their reason.
Until probably the, I would say, the 1880s, coming into the 1900s, when, probably as a consequence of the work of Freud… and I know that not everybody is an admirer of Freud, but I think that one thing that he did do was give the patients a voice. But the important element there is that they’re given a voice through the analyst, through the therapist.
What narrative medicine tries to do is liberate the patient’s voice so that you no longer need the therapist.
People will probably ask: “Why’s that important?” Well, it’s important because the therapist inevitably puts certain biases on the voice or will ultimately misinterpret what the patient wants to say.
So, really, it’s not only a technique but it’s also a philosophy.
And actually the term ‘narrative medicine’ can be used in many different scenarios: it can be used in narrative therapy to help people confront problems that they have in mental health or it can be used to… what I’m particularly interested in is helping people to advance their communication skills to have a greater feel for patient narratives – the history that they tell – and also being able to express themselves as healthcare providers.
Now, you asked me about narrative therapy in particular and, like I said before, that’s to be differentiated from narrative medicine which is an umbrella term; narrative therapy is a very specific method that people use.
Narrative therapy came about probably in the 1990s, into the 2000s, and there was a very influential man called Michael White who worked in Australia.
So Michael White came up with Narrative therapy and really it’s about allowing the patient to express their story, and then therapy comes about by trying to find alternative narratives. And when I say an alternative narrative I mean one which is more helpful.
It would be different from a normal therapy session in that family members might be asked to come along and to explore the patient’s story, their narrative, the problems that they’d encountered and then there would be some collaboration about how an alternative narrative could be built. So, for example, a patient might have only one viewpoint of how that history could be interpreted and I suppose narrative therapy tries to show them that there are actually many viewpoints of that history.
Critics of narrative therapy say: “Well, how can the patient know which is the right one for them?” and really, I suppose, they don’t get the point of narrative therapy because it’s all about the exploration in itself, is what the therapy’s about: it’s not coming to the right answer particularly. Whereas in psychoanalysis, or certainly CBT [Cognitive Behavioural Therapy], you’re looking for a specific answer to these questions, whereas narrative therapy’s more about a kind of collaborative exploration with the patient: trying to give them tools or a different viewpoint to allow them live a better life.
It’s about trying to get away from knowledge being the privilege of one particular person in healthcare. Knowledge should not be the domain of only the healthcare provider, it should also be shared with those people who are being cared for as well and that’s a very big difference to how therapies or psychiatric philosophy has been in the past.
It really spearheads a philosophy of patient autonomy and that’s really my goal out of all of this.
Images: James Brooks (C) 2011, all rights reserved.
Music: “Otolith” by Elliott Sharp published by zOaR Music (BMI), available on the album The Velocity of Hue (2003, Emanem). Used with kind permission.
Wallang, P. (2010). Wittgenstein’s legacy and narrative networks: incorporating a meaning-centred approach to patient consultation The Psychiatrist, 34 (4), 157-161 DOI: 10.1192/pb.bp.109.027474
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