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Review: “Narrative Medicine in Education, Practice, and Interventions”

Review: “Narrative Medicine in Education, Practice, and Interventions” Anders Juhl Rasmussen, Anne-Marie Mai, and Helle Ploug Hansen, Eds. (Anthem Press: 2023)

The new collection Narrative Medicine in Education, Practice, and Interventions primarily evaluates the accomplishments of our field—whatever name we give it—when it comes to conveying and activating affect in practice, with most work coming out of Denmark and a Nordic context that serves as the collection’s locus of evaluation. The collection keeps top of mind the development of narrative medicine programs in that region, as well as the therapeutic interventions narrative medicine has had in the development of those pedagogical and practical systems, while also looking eastward from an American academic and training context. This is a book with an ambitious goal: to encapsulate the challenging and healing experiences of patients (from acute illness to addiction and recovery, and in settings ranging from cancer treatment to writing groups) along with academic understandings of and influences on such experiences, while also taking into account the ways those two milieu are shaped by and shaping healthcare as a global business. This business of healing, though often not hospital-based, is depicted as one which inflects and is sculpted by narratives produced by patients. The questions Narratives in Medicine asks are field-encompassing, while the base assumptions its authors make—and the answers they give—are based on personal experience teaching and practicing at the University of Southern Denmark, Columbia University, the University of Oklahoma, and Rutgers University. It’s an approach that allows local, site-specific insights to flourish alongside global inquiry.

The book opens with a foreword by Rita Charon, one of the co-authors of, among others, the landmark collection The Principles and Practice of Narrative Medicine (Oxford UP: 2017). Fittingly, at the center of Charon’s foreword is a new paradigm of narrative medicine. She cites the evolution of narrative medicine into what she calls “systems narrative medicine” (7)—a new way of understanding how narrative medicine touches and is shaped by multiple populations that both produce the field and are studied by it, including those outside academia. Charon asks us to understand ourselves—and how this collection showcases the power and reach of narrative medicine as embodied now, in this moment and collection—as “autopoetic and emergent” (8), self-constructing, collaborative, and constantly evolving.

At the center of the collection is the question of what role narrative medicine plays—whether in the context of courses for medical students or the diagnosis and treatment of patients, who so often need to have their stories believed to obtain care—in inculcating empathy and identification with others in students, patients, health professionals, and all who interact with those overlapping populations.

In “Is Teaching Empathy Possible?” Ann Jurecic, who teaches narrative medicine at Rutgers, notes the historic and contemporary difficulties of defining empathetic affect, and of detecting the effectiveness of literature in cultivating it. She notes that in her classes, empathy is something that students search for within texts about illness, rather than aiming to achieve empathy through reading them. Jurecic makes a compelling case for questioning easy mnemonics and diagnostics in favor of insisting that medical students and undergraduates in medical humanities courses—and others engaged in the work and analysis of narrative medicine—take care to engage from a humanistic perspective, while being mindful that humanistic inquiry as a whole cultivates empathy, rather than narrative medicine checklists. This leads to important insights. For example, when teaching the title essay of Leslie Jamison’s Empathy Exams, Jurecic encourages students to consider not only whether empathy can be taught, but, when patients need and seek it out from healthcare providers, friends, and even journalists, “why does it often fall so short of what is needed” (31)? It’s a compelling line of inquiry, especially when teaching Jamison who, as both patient and observer, sees empathy fail and succeed from the perspective of both carers and the (un)cared-for.

Other entries combine musings on both contemplation and praxis. In “The Role of Narrative Structures and Discursive Genres in Healthcare Education and Practice,” Ronald Schleifer suggests that “even rudimentary explicit knowledge of narrative structures and discursive genres can position healthcare workers to more fully comprehend the narratives that patients brings to clinics” (40). Schleifer combines linguistic insights with a literary interpretation of temporality and the unfolding components of narrative sequences to provide a roadmap to patient speech—a unique approach to the real-time and challenging job of listening carefully to what patients are trying to tell others about their experiences and needs. Meanwhile, in “Vulnerable Reading: Stories as Good Companions,” Arthur W. Frank encourages practitioners and other readers of medical narratives, including those who have been patients (but are not actively in treatment) to be vulnerable, and to muse on the complexities of illness and medical care by asking a series of questions meant to make literary texts not only legible but companionable roadmaps to mutual understanding. Using King Lear as a sample text for asking questions about physical and emotional suffering, Frank demonstrates how to help readers reflect on a texts’ “characters, storyworld”—that is, it’s setting and context—“dialogical relationships, vulnerability, and rightness,” or moral conclusions, in order to locate analogies to one;’s own and others’ lives from the text, and therefore see the lessons about caretaking it models. (57)

Other practitioners’ contributions to the collection take up this question of cultivating fellow-feeling in the service of the healing arts from the perspective of medical practitioners. In “Prescribing Stories before Medicine: Narrative Medicine in the Teaching of Medical Students and Physicians,” Anders Juhl Rasmussen and Morten Sodemann discuss how new and established physicians might balance an education in narrative and practical medicine alongside self-care practices, applying a “People First” approach not only to patients, but themselves.

In “Connecting Classwork to Clinic,” Cindie Aeen Maagaard, Helen Schultz, and Anita Wohlmann demonstrate how an education in narrative medicine not only allows students to understand medical narratives, but enables them to assist others—namely, patients—in constructing them, using creative writing prompts to encourage representation and sharing, thereby instrumentalizing the narrative process as a component of treatment: “By engaging in close reading, healthcare professionals train attention; through creative writing, they train representation of that which they have attended to; and by sharing their writing, they may approach an affiliation between teller and listener.” (88) Maagaard, Schultz and Wohlmann, like Frank, contemplate the utility of vulnerability in medical students—those who anticpate treating, rather than being, patients—noting that “the acknowledgment of vulnerability is insightful because the students may discover that a familiar power structure is turned on its head; here, they are the ones [rather than patients] who may be uncertain about an answer or may be asked to share personal information” (97). Rather than weaken, such insights allow future practitioners to detect vulnerability among their patients, and to respect the insights and crucial details it allows to be revealed.

Annette Søgaard Nielsen and Jakob Emiliussen direct their attention even more specifically toward use of narrative medicine as a conduit to treatment, in their essay on its use to combat alcohol abuse. In “What’s with the Drinking?” Nielsen and Emiliussen suggest that by identifying and discussing different narratives around alcohol—“pathological” and “cultural drinking” (107); “symptomatic drinking” (108), characterized by personal crises or alcohol use as a gradual crescendo of symptoms that accumulate and build; and “anomic drinking” (109), a newer, less-familiar narrative around alcohol abuse that they elucidate as a response to and a trigger for “sorrow, apathy, and violence”—a cultural explanation for alcohol dependency that goes beyond celebratory norms or genetically-informed addiction, and considers, instead, the larger social and systemic forces and declines that might drive alcohol abuse. Most intriguing is how they outline a narrative archetype they call “incomprehensible drinking” (110), a kind of self-reportage that hints at the mystery and unknowability of the self, and an acknowledgment that not all diagnoses are linear or simple.

Other contributors note how narrative medicine can have even more practical implications. In “Email Consultation in General Practice: Reflective Writing and Co-Created Narratives, Annette Grøning and Anne-Marie Mai model how that medium enables not only “digital consultation” but the sharing of illness narratives, including those surrounding either “restitution,” a “quest”—a medical journey patient and provider embark on together—and “chaos,” giving name to the various certainties and uncertainties that written communication illuminates. (119; 123-4) Other use cases for narrative medicine include “Creative Writing as Rehabilitation,” in which Sara Seerup Laursen, Tine Riis Andersen, and Helle Ploug Hansen provide models of writing exercises to use in clinical settings. In “Poetry Prescribed for Loneliness,” Marie-Elisabeth Lei Holm, Peter Simonsen, Mette Marie Kristensen, and Anna Paldam Folker prescribe verse as a curative for isolation in older male patient populations, as poetry gives them access not only to “sensory impressions, recurrent thoughts, and feelings,” but alsoa medium that enables insight and provides language for the “ordinary and extraordinary, unique and use oriented” (156). A final essay, Jeannette Bresson Ladegaard Knox’s “Socrates and Sickness,” extends the boundaries of typical medical humanities education beyond visual and literary arts to philosophy, suggesting that using the Socratic method of dialogue is akin to a physical praxis, a kind of “Socratic midwifery…which consists of active help in giving birth to the thoughts of others.” (169) The observation that Dr. Rishi Goyal (one of the co-founders and editors of Synapsis) makes in his afterword about his cohort’s experience using literary analysis to begin “training in humans” applies equally to these writers, who have “stretched our”—and their—“imaginative capacity to care for, be curious about, and apprehend the predicaments of other human beings.” (183)

In all of this, there is a question of what those who need care say—and cannot say, but may struggle to communicate. While the collection does not address what close reading and looking for feeling might do in all therapeutic modes (psychological treatment and support for people with disabilities are not covered here), its lessons are applicable to texts and contexts beyond its temporal and spatial boundaries, and to many of the socioeconomic and race-based barriers to care that many in the U.S., as Goyal notes. What Narrative Medicine in Education, Practice, and Interventions does best is to model and articulate the importance of searching for the inarticulable—the ephemeral gestures and hints that people give about what they mean, and what they need, in both the patient-caregiver and writer-reader contexts—in order to make empathetic caretakers of us all.

Image source: Anthem Press

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