Aspects of medical practice: insight from Narrative Therapy

Michela Galzigna Ph.D., Medical School, University of Padua, Italy

“My own view is that narrative therapy is post-psychological, and forms part of a broad movement that has recognized the extent to which psychological models and concepts have contributed not only to the diffusion of what Kenneth Gergen has called a “language of deficit” but also the erosion of collective and communal forms of life and being in relationship”.
J. McLeod, “Foreword” in : M. Payne, Narrative Therapy


Introduction

Medical practice is characterized by different verbal constructions which go back as far as Hippocratic tradition. Physicians were instructed to collect from patients their clinical history, the report of previous ailments which, together with the description of their symptoms, i.e. their subjective complaints, make it possible to define an anamnesis word that in ancient Greek, as well as in modern one means nothing more than memory. The ensuing clinical examination complemented with all possible objective signs lead to a diagnosis and a prognosis with a therapeutic prescription. All these different actions mostly consist of words uttered both by the patient and the physician, while in several cases words are also the main component of therapy. It is known in fact that a great percentage of the therapeutic action may be ascribed to a placebo effect and that most of this effect consists of the physician’s words when prescribing the cure and sometimes explaining its advantages to patients. In psychiatry in particular, placebo effect may account for up to 70% of the total effect of the medication as it happens, for instance, in the case of antidepressant drugs. On the other hand in Hippocratic medicine, pharmakon was the name of drugs and natural remedies administered to patients but not only that. The same term was used to indicate in fact also words, songs, prayers, enchantments and charms uttered by the physicians to heal and cure the disease.
Past and present medicine, therefore heavily rely upon words and verbal constructions and it is not surprising that many physicians eventually became also professional writers, e.g. ?echov, Bulgakov, Schniztler, Greene, Rabelais, Winckler, etc. All this should be considered as a background for what today goes under the name of narrative medicine.
Nowadays a new term has been introduced in the medical sciences, i.e. that of narrative medicine and it is necessary first to define it and explain its meaning. Apparently the term may seem to collect all practices used in the patient/physician relationship to describe an illness and to cure it. The physician who uses narrative tools in his/her activity may be defined as a narrative physician. In fact he/she first listens to a tale told by the patient called clinical history and then tells his/her own tale containing a description of what he chooses to disclose to the patient about his/her illness.
The clinical history has some features of an autobiography which, first of all, is not free since all information not relevant to familial anamnesis, remote pathological anamnesis, recent pathological states, and clinical symptoms, is excluded by the constraints imposed by the questioning physician.

In this way a first step of a process of de-personalization aiming at transforming the patient into a mere clinical case, the person to be cured into a sick individual, is taken. The patient in this way is indirectly invited to give up his/her own identity while is expropriated of his body and mind with a more and more totalizing process along an itinerary within the hospital institution in which he will completely identify himself/herself.
Very often when the patient tries to enrich and further clarify the description of his/her suffering condition during the initial interview, his/her personal remarks are often dismissed as irrelevant or ignored. In particular, with female patients there is a tendency to quickly label as hysterical reactions some subjective feelings reported by them, making use of a XIX century psychiatric category nowadays quite obsolete.
The subject’s voice is thus stifled in the name of an objectivity only attentive to clinical signs and symptoms in a body often considered independently of its mind: this allows us to call clinical history as a denied autobiography. It is evidently a price to be paid for a high tech medicine which has become a mass medicine recently defined as an evidence-based medicine.
In present days medicine handbooks and treatises every clinical history seems to concern a particular medical specialty (e.g. cardiology, neurology, gynaecology, gastroenterology, psychiatry, etc.) since every patient admitted to the hospital is from the very beginning channelled to the wards that appear, on a first evaluation, more suitable to his/her problems.
In what seems to be the most sophisticated among clinical histories i.e. psychiatric anamnesis, the interested specialists are reminded that “A rigid interview conducted hastily in an emotional way will very likely cause the patient to conceal relevant information than to help him to divulge it” (The Merck Manual of Diagnosis and Therapy, 14th ed., 1982). Official medicine is therefore aware of a danger of de-personalizating clinical history. It is not casual the fact that general population is increasing its attention towards alternative medicines which favour long, accurate and as personal as possible narratives or stories of the case that the patient is encouraged to tell. This indicates the need that official medicine considers patients mostly as subjects who should not be handled to therapy just as suffering bodies.
A physician who, after many years of practice in which he extensively used a narrative approach to patients, started to write on his experience and has become a full time writer is the French M. Winkler (see his Sacks’ Disease, Paris, 1998) a living example of the close connection between medicine and literature. Such connection is at the basis of a programme called narrative ethics offered by the College of Physicians and Surgeons of Columbia University, N.Y. to medical students aimed at improving their narrative competence necessary both to read and report the stories of their patients. Rita Charon, an internist physician and literature scholar has worked out a program called Narrative Medicine in the same institution.
This endeavour documents the occurrence of what has been called the linguistic turn (Rorty, 1967) also in the medical field in which the need to improve the medical encounter and communication between patient and physician is now considered with particular attention. At the Harvard Medical School this problem has been tackled by Byron J. Good who wrote an essay on anthropological aspects of patient/physician relationship starting from a linguistic analysis of this dialogue with its peculiar rhetorical aspect and figures of speech and discourse. The anthropological approach concludes with the need to reinforce the search for empathy and to try to avoid the danger of arrogance which always seems to undermine the medical profession all over the world.

In the relationship between patient and physician emerging from this approach the empathy of the physician should be matched by the sympathy of the patient and culminate into a true partnership between the two. Within such partnership the physician should mediate between the needs of an evidence-based medicine and a narrative-based medicine with the final goal of facilitating patient’s compliance to treatment and therapy which is a prerequisite to the full success of such therapy. The awareness that both illness and healing must negotiate their dependence on cultural constructions including narrative phases and ritual aspects makes it necessary to put in a correct perspective medical acts which cannot limit themselves to mechanistic interventions on a supposedly inert body-machine.

Towards a definition of narrative
To define narrative is not an easy task, although it is true that in order to do this we have access to a rich and varieted narratological tradition that can be used for support. Under the term narrative we can, for instance, distinguish between a narratological orientation and a narrativistic one (Formenti, 1997). In the Humanities the most widely accepted definition of narratologist is that of a scholar who study narratology, a set of theories of narrative which are independent of the medium of representation . In this sense the narratological approach considers narrative in itself as an object, or, stated in other words, this orientation is static, it is used as a means of analysing a tale as a text, and, above all, it distinguishes and separates life from text. In psychology this approach coincides with the narrative forms of thought different from the paradigmatic or logical one (Bruner, 1986) which gives us the script or format which help us to organize the very act of narrating into organizational structures.
The narrativistic approach, on the contrary, aims at recognizing and identifying the generative processes, the different ways in which human experience is constructed as discourse or better, the ways in which consensual linguistic practices are involved in discursive processes. The narrativistic approach entails a much more dynamic, interactive and socio-constructionist orientation which sees meaning as negotiated and created through dialogue and social exchanges.
As a consequence, the logical question that comes to one’s mind when speaking of narrative medicine or of literary studies to help and support medical ones, is: do we refer to a mere narratological or a narrativistic orientation which the broad term of narrative does not in itself specify? My suggestion from now onwards is that, in order to study the patient/physician interaction a narrative-narrativistic orientation should be used.

The narrative metaphor in therapy

The narrative turn, while part of the wider linguistic turn (Rorty, 1967) has occurred as part of a broader movement within philosophy, the social science and the Humanities in general including psychology, and has stressed the importance of studying the language of representation instead of the objects or referents of the same. A forerunner of this in philosophy has been L. Wittgenstein and his later work Philosophical Research (1953) because by his use of the Sprachspiel (Language game) concept he has stressed how common language works and the way in which meaning is created, informing also socio-constructionism or post-modern theories and thinkers in general, which tend to consider words not has having meaning in themselves but rather that they derive their meaning from the contexts in which they are produced or constructed (Monk, 2003). A strand within therapies which is not only post-modern but also informed by socio-constructionism and attentive to the way in which language and social interactions affect how we frame our notion of “identity”, “self” or simply our way in which we make sense of the world we live in, is what goes under the name of narrative therapy. What I refer to by using this term is the form of psychotherapy initially developed by M. White and D. Epston during the 80’s (White & Epston, 1990) which emphasizes the importance of stories and language in the development of interpersonal and intrapersonal problems (Shapiro & Ross, 2002: 96).

This distinction has to be made because it is not the only form of therapy where conversation and language are the core concepts. Another kind of therapy similar to it and informed by the narrative metaphor is what goes under the name of “Collaborative Language System Approach” originally formulated by H. Anderson and H. Goolishian at the Galveston-Houston Institute in Texas (Anderson & Goolishian, 1988, 1990; Anderson, 1997).

The Narrative Therapy of M. White and D. Epston
The core concept in Narrative Therapy is that our lives, identities and sense of self are shaped and made up by the meaning we attribute to our experiences which, roughly speaking, are simply stated the stories we tell ourselves to ourselves (and eventually to others).
When a person seeks therapy it is because his/her story is problem-saturated and has also became the person’s dominant story in his/her life.
When this story is told to a narrative therapist he/she does not contend the fact that it is true or false whatsoever, but simply, that it is subject to the distortion and removal which all our memories and experiences are subject to, that it is a “thin” description.
Through the process of narrating, aided by the therapist questioning, the final goal for narrative therapy is to help the person to re-author or re-write a new story much more detailed, rich and wide which contains a “thicker” description of the first one, and by which the client/person is able to face and overcome the initial sense of helplessness and of being overwhelmed by the dominant or problem-saturated story.
However, mine also is a thin description or just the surface description of what a narrative therapist does. The reason why this form of therapy is important is probably another one and namely, using J. McLeod’s words: because “?being philosophically grounded (it) represents an alternative to the pragmatic, empiricist, instrumental therapies and health-care systems that have come to dominate the global psychotherapy scene in recent years” (Mc Leod, 2000: 333).
The philosophical ground underpinning it is the Foucauldian discourse critique of any forms of institutions, and, as a consequence, a critique of the dominant discourses in all the “psy” sciences, but in the medical one as well.
The way narrative therapists utilize this implicit/tacit “asymmetry” or power discourse in their work or in any form of power relation in which their clients or themselves are embedded, is by using deconstructive techniques (careful and detailed analyses) within therapeutic tales or conversations of social and political issues.
As also therapy itself is recognized as potentially harmful when based on unrecognised power relations, narrative therapists attempt to reduce this potential by continuous critical examination of their practice, and by regular checking-out with persons that they find therapy acceptable (Payne, 2000: 13; emphasis added).

Narrative Therapy Theory and Family Medicine: A Philosophical Viewpoint
A recent contribution by Shapiro & Ross (2002) has demonstrated the importance of the principles and practices of narrative therapy to provide family doctors with additional tools to assist them especially when dealing with difficult patients, or translated in medical terms with noncompliant ones. The authors report, in particular the case of Mr. A suffering from diabetes mellitus and secondary complications “which seemed to ignore the physician’s recommendations” (Shapiro & Ross, 2002: 97) and Doctor B. who “described the patient as chronically non compliant and in denial, frustrated by his care and “tired of telling him what to do” (ibid: emphasis added).

In the section heading entitled “Renaming the problem” , the author says “Technical medical language emphasizes pathological processes and deficits and often makes difficult for patients to accept more preferred or desirable stories about themselves ? non compliance, for example, is a term rooted in the medical model disease that has been criticised as pejorative, coercitive and disempowering” (ibid.) If we include also the term “in denial” I would suggest to consider both terms using the definition of language game as initially proposed by L. Wittgenstein “the whole of which consisting of language and the actions into which it is woven” (Wittgenstein, 1953: 7) which are “part of a frame on whose basis our language operates” (Wittgenstein, 1953: 240) and are all embedded in our forms of life .
Doctor B. initially utilized them simply because she was “relying on a disease model” (Shapiro and Ross, 2002: 97). Our focus on narrative medicine means a focus on language and its use, but also on the idea that: a) words are actions (Foucault, 1970, Wittgenstein, 1953) and b) words have power . Considering medicine as a subject, the definition of the same given by Neil Postman is: “a situation in which and through which people conduct themselves largely in language” seeing that “if one learns to speak history or literary criticism, one becomes by definition a different person” (Postman, 1979: 165-66). Postman reminds us that “as one learns the language of a subject, one is also learning what that subject is. It cannot be said often enough that what we call a subject consists mostly, if not entirely, of its language. If you eliminate all the words of a subject, you have eliminated the subject. Biology is not plants and animals. It is language about plants and animals. History is not events. It is language describing and interpreting events” (Postman, 1979:165). But language games “condition our behaviour as a “picture” that held us captive and we could not get outside it, for it lay in our language” (Wittgenstein, 1953: 115) as was the case with “in denial” and “noncompliant” language games embedded in Dr. B. Form’s of life. What Shapiro and Ross did was to invite Dr. B. “to switch from making directive statement to ask questions, lots of questions”, a basic tenet in Narrative Therapy (Shapiro & Ross, 2002: 96).
Contrary to the type of questions used by physicians whose aim is to create information, narrative questioning emphasizes patients making their own interpretation of events and formulating their own insights (Shapiro & Ross, 2002: 97).
And, while answering this specific kind of questions, the patients, as A. Kohn (1994) says: “... get the message that their voices count ... and gain a sense of belonging and active participation “ in their healing process.

A tentative conclusion
Psychotherapy, in general and Narrative Therapy, in particular with its practices can be seen as an additional tool to inform Narrative Medicine for practical purposes. But as Narrative Therapy is philosophically based, also Wittgensteinian discourse analysis can be considered as an additional tool, considering that : “living a human life is a philosophical endeavour. Every thought we have, every decision we make, and every act we perform is based upon philosophical assumptions” (Lakoff & Johnson, 1999, 9).
There are also other practices typical of Narrative Therapy and which seeks to reduce asymmetry of power in client/therapist linguistic interactions and narratives by using the “Reflecting team work” (Andersen, 1987; White, 2000) or, simply when the therapist asks the person if she is or not comfortable with the questions posed or the argument tackled.
As the work by Shapiro & Ross shows, the application of narrative therapy practices can lead “to a healing and empowering dynamic among doctor, patient and the problem” (Shapiro & Ross, 2002: 100) demonstrating that “a successful therapy is, in the end, a collaboration among narrations” (Hillman, 1983).

References
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