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Narrative Medicine Rating: 8 on a scale of 10 Review This is a seminal work. The book is about using the techniques of literature analysis to explore writing samples created by medical students, house staff, nurses, social workers or other healthcare workers involved caring for patients. This process is used in order to better understand ourselves, patients, reactions to our patients and our working realm. The process involves us writing "stories" about our patients. The stories can be any manner of writing that tells about our personal reactions/interactions with patients, events in caring for patients, stories about disease, etc. She describes the process of presenting these writings in a small group discussion with a facilitator. The facilitator uses the elements of literature analysis to explore the stories, exploring the relationships we have with our patients, their life story and the relationship it has to us. This would appear to be a very powerful process. Most of us do not have doctorates in literature as Ms. Charon does. However, the skills for doing this kind of work can be learned. It might take some effort to develop the emotional sensitivity needed to do it well. This task is perhaps more likely to be taken up by the intuitive feeling types of the world. It would be a valuable process for people of all personality types, yet I imagine certain types of people with particularly sensing and thinking styles of personality would find it quite tedious if not outright revolting to do. She describes having medical students, residents, nurses and social workers write in what she calls a "parallel chart". They do this in a way so as to not create "discoverable" information from a legal standpoint. They are listening for stories in their work or describing their reactions to the stories they hear while working with patients. She does not view this as journaling. I would quibble with this to a degree. As a person who has been writing for 40 years, I am not sure the distinction is justified. She also does not believe it is psychotherapy either. I would quibble with this, too. Of course it is a form of therapy. It may not be as deep as psychotherapy in some respects, then again, the deeper you explore things emotionally the more therapeutic it might become. The writings in the parallel chart are presented to a small group with a facilitator present who is skilled in the analysis of literature. She describes using the concepts of literature analysis to analyze the writings. This involves using concepts of plot, form (genre, visible structure, narrator, metaphor, allusion, diction), time, frame, and desire to accomplish what she describes as "close reading". Becoming aware of these elements in each story can lead to a deeper understanding of the self, the patient, the people you work with, and the relationships of all of these people. What she describes then is a process using literary analysis techniques that allows us as practitioners to have increased awareness. This is a very profound and powerful undertaking. Obviously, the skills of a facilitator of such a group are critical to the success of such an undertaking. She describes the process for doing this with medical student or house staff groups. I suspect to be good at facilitating a group would require a fair bit of practice and experience in such a group for some period of time. As I read her descriptions of the groups and the examples given I can't help but reflect on the similarities to psychotherapy groups. The process does not seem as deep as psychotherapy. This would of course depend on one's prior experiences to a degree. Someone like myself or a psychiatrist might find it easy to pursue various symbols, metaphors, and other developmental issues much more deeply. The difference between literary analysis and psychotherapy begins to seem vague. Regardless of whether or not you call it therapy there is a therapeutic result which she describes fairly well though she insists this is not therapy. She never discusses much with regard to the unconscious aspects of those involved in this writing. In my experience, when I write, I become aware of much that I did not know before I wrote about the situation. Writing can allow unconscious material to surface in the awareness of the writer. Unconscious material can also be evident to those listening, but unheard or seen by the writer. Some of her more interesting examples of writing are interesting because they are from the realm of writing I would call "active imagination". When ever one begins to get into these realm you enter a world of therapy in my opinion. It may or may not be extremely deep, but it is able to reveal things unknown or unseen before. This is just natural and evident in the process of active imagination. It is at this point that some degree of skill must be employed by a facilitator to work with such material. It might be possible to leave it at some superficial level, but I suspect this would be difficult for a well trained literary person to do. This is where I wondered a little about this whole process. I listened to her examples and was impressed by the awareness she generated for discussion. Most of the time these examples of awareness were quite appropriate. I suppose, for me, I prefer a deeper understanding of what I become "aware" of. Sometimes, it seems like the literary process cuts off a bit to soon. As I read some of her discussions, I was reminded of literature professors from college and their proclivity to have "their" opinion about things as a sort of truth. When you begin to examine symbols, the depth you attain can go far beyond literary analysis. I would simply prefer to recognize this possibility and be willing to dive deeper. There may be institutional and educational reasons to not call this therapy, and I understood the tight rope she is walking, but the difference is subtle at times. It seems to me that one of the fundamental goals of therapy is to increase awareness. Therefore, anything that increases awareness is a form of therapy. The awareness being generated by these processes was far beyond simple information sharing and dove deep into the realm of associations from family of origin, spiritual issues, relationships to hard to accept issues, unconscious associations, philosophical/ethical discussions and many other realms. I think this is all just dandy fine. I would encourage us all to be involved in such activity in one form or another. We will, as she notes very clearly, be better for it; our patients will be better for it, and our relationships with everyone will be better for it. This process is really a quite generic process to increase awareness and could be used by any group of people to increase awareness and thereby be better at what they do (for example, administrative people, church groups, housewives, men's group, etc.). I applaud her work and efforts to help us all. I was watching the program on Public Broadcasting one day where they followed a group of medical students through the training process. There was one particularly telling moment somewhere around their 3rd year when one of the female students was talking to a friend and commenting about how they did not want them to "feel". This process can help us all reclaim the importance and power of finding those feelings again. They may be buried under years of training, but they are there, and becoming aware of them will benefit us and our patients. Awareness changes in us all as we progress through training and through life. The awareness of a 30 year old is different from the awareness of a mid-life 50 year old or a retiring 70 year old physician. Every phase of life may see the same situation from a different perspective, so we must grow through each phase of life as we mature toward our final destiny. We can all become better at this as we go along the paths and spin through the cycles of life. All opinions are those of Curtis Climer, MD, MS Copyright 2010 |
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