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Charon, Rita; DasGupta, Sayantani ; Hermann, Nellie; Irvine, Craig; Marcus, Eric; Rivera Colón , Edgar ; Spencer, Danielle ; Spiegel, MauraLast Updated: Feb-07-2017
- Carter, III, Albert Howard
Writing for all the co-authors, Rita Charon challenges “a reductionist, fragmented medicine that holds little regard for the singular aspects of a person’s life” and protests “social injustice of the global healthcare system” (p.1). She gives a history of narrative medicine, lists its principles, and summarizes the book’s chapters, mentioning that several come as pairs that present theory then practice. The six principles are “intersubjectivity, relationality, personhood and embodiment, action toward justice, close reading (or slow looking), and creativity” (p. 4). The basic thesis is that healthcare can be improved by narrative medicine because “narrative competence can widen the clinical gaze to include personal and social elements of patients’ lives vital to the tasks of healing” (p. 1).
This is a dense, theory-laden book from the group at Columbia University. The summaries below touch of some of the major points.
PART I, INTERSUBJECTIVITY
Ch. 1, Account of Self: Exploring Relationality Through Literature
Maura Spiegel and Danielle Spencer describe the richness of literature that allows readers to respond creatively. In clinical settings, a caregiver may similarly listen attentively and help co-construct a narrative with the patient. Literature can help us explore “the limits of rationality and positivism” (p. 29) and move from “a model of autonomy to one of relationality” (p. 34).
Ch. 2, This is What We Do, and These Things Happen: Literature, Experience, Emotion, and Relationality in the Classroom.
Spiegal and Spencer write that current medical education does a poor job of helping future physicians with their emotions. Clinicians profit from a more integrated self and will listen better to patients and respond to them.
PART II, DUALISM, PERSONHOOD, AND EMBODIMENT
Ch. 3, Dualism and Its Discontents I: Philosophy, Literature, and Medicine
Craig Irvine and Spencer start with three literary examples that illustrate separation of mind and body. This dualism has pervaded modern medicine, causing losses for patients and caregivers, especially when there are power imbalances between them. The “clinical attitude” (p. 81) dehumanizes both caregivers and patients.
Ch. 4, Dualism and Its Discontents II: Philosophical Tinctures
Irvine and Spencer argue that both phenomenology (appreciative of embodied experience) and narrative hermeneutics (privileging reciprocal exchange of persons) help us move beyond dualism. Theorists Edmund Pellegrino (also a physician), Richard Zaner, and Fredrik Svenaeus help us understand how caregivers and patients should relate.
Ch. 5, Deliver Us from Certainty: Training for Narrative Ethics
Craig Irvine and Charon write that various humanistic disciplines “recognize the central role narrative plays in our lives” (p.111). There is, however, “indeterminacy” in stories that “cannot be reduced by analyzable data” (p. 113). Narrative ethics urges us to consider issues of power, access, and marginalization for both the teller and the listener. The authors review recent ethical traditions of principalism, common morality, casuistry, and virtue-based ethics. They believe that narrative ethics, emerging from clinical experience and now allied with feminist and structural justice frameworks, will provide a better approach for many reasons. “Narrative ethics is poised to integrate the literary narrative ethics and the clinical narrative ethics” (p. 125).
PART III, IDENTITIES IN PEDAGOGY
Ch. 6, The Politics of the Pedagogy: Cripping, Queering and Un-homing Health Humanities
Sayantani DasGupta urges attention to issues of power and privilege in classrooms, lest they “replicate the selfsame hierarchical, oppressive power dynamics of traditional medicine” (p. 137). “Cripping” and “queering” provide new perspectives on knowledge, for example the untested binaries of physician/patient, sick/well, elite/marginalized, teacher/student. Drawing on disability studies, health humanities, and queer politics, DasGupta challenges “medicalization” and the “restitution narrative” (p. 141).
PART IV, CLOSE READING
Ch. 7, Close Reading: The Signature Method of Narrative Medicine
Charon stresses “the accounts of self that are told and heard in the contexts of healthcare” (p. 157). Close reading, traced from I. A. Richards through reader response theorists, is “a central method” for narrative medicine (p. 164). Close reading enhances attentive listening, and both of these deepen relationality and intersubjectivity, allowing for affiliation between caregiver and patient (pp. 175-76). Such linkages aid healthy bodies and minds, even the world itself (p. 176).
Ch. 8, A Framework for Teaching Close Reading
Charon describes how she chooses texts and provides prompts for responsive creative writing. She illustrates “the cardinal narrative features—time, space, metaphor, and voice” (p. 182) in literary works by Lucille Clifton, Henry James, Galway Kinnell, and Manual Puig.
PART V, CREATIVITY
Ch. 9, Creativity: What, Why, and Where?
Nellie Hermann writes that “healthcare in particular has a vexed relationship to the notion of creativity,” in part because of issues of control (pp. 211-12); values of “evidence based” and “numbers-driven” medicine are also factors. Narrative medicine, however, “is about reawakening the creativity that lives in all of us” (p. 214).
Ch. 10, Can Creativity Be Taught?
Hermann reports on techniques used in the College of Physicians and Surgeons at Columbia, including prompts and a Portfolio program. A “Reading Guide” helps clinical faculty (and others) respond to student writing. Responses to writing can nourish the “creative spark.”
PART VI, QUALITATIVE WAYS OF KNOWING
Ch. 11, From Fire Escapes to Qualitative Data: Pedagogical Urging, Embodied Research, and Narrative Medicine’s Ear of the Heart
Edgar Rivera Colón suggests that “we are all lay social scientists of one kind or another,” seeing people in action in various contexts. He affirms an “assets-based approach to public health challenges, as opposed to a deficits-based and pathology-replicating paradigm” (p. 259). We are all embodied actors in relationship to power, privilege, and social penalty. Research through interviews and participant observation show “meaning worlds” in tension with “systemic inequality and structural violence” (p. 263).
Ch. 12, A Narrative Transformation of Health and Healthcare
Charon presents and analyzes a case study of patient Ms. N. as treated by internist Charon. They’ve been working together for decades. Charon writes up her perceptions and shares them with Ms. N. Speaking together, they “became mirrors for one another” (p. 274). Psychiatrist Marcus discusses transference and transitional space in that experience. A caregiver as witness can shift healthcare from “instrumental custodianship to intersubjective contact” (p. 288).
Ch. 13, Clinical Contributions of Narrative Medicine
Charon describes applications of narrative medicine, all with the aim of improving healthcare. She describes techniques for interviews of patients, writing methods, and ways to improve the effectiveness of healthcare teams, as well as changes in clinical charts and other narrative descriptions of patients.
- Spiegel, Maura
The voice of a young girl leads us through this spare and tautly told story of a closely-knit family upon whom tragedy falls like a plague. Before death and mental illness take up residence there, we meet the Bronstein’s, two parents and four children, in their comfortable, well-run home outside of Boston. Hermann delicately renders the portents of change and pain that haunt all loving families. The novel opens with the nine year-old Ruby Bronstein’s discovering, while walking along the beach with her three older brothers on a winter afternoon, an old rusty pistol poking out of the sand.
The family story deepens as the teenage Ruby recounts a sojourn with her parents to Terezin, the Nazi concentration camp where her father was interned as a child. Hermann’s restraint and precision in this sequence make this potentially familiar journey entirely new. With her young eye trained on her father’s every muscle-twinge of reaction to what he sees, she crisply conveys the unknowability of even an adored father –let alone the events that took place within these walls. Her father’s inaccessible childhood memories are not miraculously jarred by this return to the scene of trauma – but he learns shortly thereafter of a brain tumor that soon will end his life.
One tragedy follows another, the emergence of mental illness in one brother, the death of another. The narrative traces Ruby’s efforts to carry on in the face of these devastating losses. Here is where the novel explodes in cold fire, in its quiet accounting of a young person’s grief as it is lived in its ordinary, daily course. Loss begins to deform her social life, giving her the feeling that she is a freak. The scale of things is too disproportionate; she dresses for the prom while her brother lies dying in the intensive care unit. Carrying the stigma of disaster, she hides news of family developments for which she has no vocabulary. What good would talking do anyhow, she asks –until she finds the listener she needs.