Rita Charon

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Commentary

What to do with storiesThe sciences of narrative medicine

Rita Charon MD PhD

Beforeherdeath lastyear,DrMiriamDivinskyandIcorrespondedaboutstorytellinginmedicine.Herwork introduced readersof this journal tonarra-tivemedicine1andpavedthewayforthisspecialissueofstoriesand reflections frompractice, joiningwidespreaddevelopments in this youngdiscipline inNorthAmericaandworldwide.Her essay Stories for life1 eloquentlydescribesthepersonalinsightandactiveaffiliationphysi-ciansderivedfromtellingoneanotherstoriesfromprac-tice.Here Iwant to extend this affiliationwithher, nomatter if she ison theother sideofmortality, andwithreadersandwriters summonedbyher, togivevoice tothesestoriesthatsaturateourpracticesandourlives.

Development of narrative medicineI first used the phrase narrativemedicine in 2000 torefer to clinical practice fortified by narrative compe-tencethe capacity to recognize, absorb,metabolize,interpret, andbemovedby storiesof illness. Simply, itismedicinepractisedby someonewhoknowswhat todowith stories.My colleagues and I have conceptual-izedandputintopracticesomebasictenetsofnarrativemedicine.Toacknowledgeourcocreationoftheseideas,Imustintroducemyteam,forourworkcouldnothavebeen donewithout us all: SayantaniDasGupta, CraigIrvine,EricMarcus,MauraSpiegel,PatriciaStanley,andme.Iwillrelyonworkpublishedbyeachofustopointreaders toward the intellectual and scientific bases ofouremergingtheoryandpractice.

MethodsAt ColumbiaUniversity inNewYork, NY,we providenarrative training (ie, rigorous training in close read-ing, attentive listening, reflectivewriting, and bearingwitness to suffering) todoctors,nurses, socialworkers,psychoanalysts, therapists, literary scholars, andwrit-erswho attend our intensive trainingworkshops.Wealsoprovidesuchtrainingtostudentsofmedicine,nurs-ing, physical and occupational therapy, pastoral care,oral history, socialwork, literary studies, and law.Ourresearch projects are accruing evidence that studentsand clinicians who have undergone narrative train-ingwithus strengthen their therapeutic allianceswithpatientsanddeepentheirabilitytoadoptoridentifyoth-ersperspectives.2

Narrativemedicine curricula andprojects are prolif-erating throughout theUnited States, Canada, Europe,

Great Britain, Latin America, the Middle East, andAustralia.Wetakethisexplosivegrowthofinterestandpractice as evidence that capacities that are currentlylackingwithinclinicalpracticeand forwhichcliniciansandpatientsyearnsingularrecognitionofpatientsandauthentic use of the self by clinicianscan be devel-oped throughour emergingpracticeof bringingnarra-tiveknowledgeandskilltobearonthecareofthesick.

We have proposed a conceptual framework forunderstandingwhynarrativeskillsmatter forcliniciansand for patients andhaveproposed intermediates andmechanisms bywhich narrative training bestows itsbenefitsonclinicians.Thescienceofourpracticegradu-allyrevealeditselfaswestruggledtoarticulatewhatweobservedinournarrativeteachinginmedicalsettings.

Adopting a method of concentrated and closelyobserved and recorded teaching of one another in a2-year intensive seminar followed by self-consciousteachinginaselectedgroupofclinicalsettings(humani-tiesseminars forsecond-yearmedicalstudents,writingseminars for staffmemberson in-patientwards, litera-tureseminarsforphysicians,creativewritingworkshopsfor health careprofessionals, andwriting seminars formixedgroupsof cliniciansandpatients),wegeneratedand then testedhypothesesabout thesequelaeof forti-fyingnarrativeskillsinthesesettings.Whatemergedasoursciencederivedchieflyfromnarrativetheory,autobi-ographical theory, phenomenology, psychoanalytic the-ory,traumastudies,andaesthetics.

The following discussion will review our currentthinkingabouteachof the3movementswehave iden-tified in narrativemedicineattention, representation,andaffiliationandwillcitethesourcesofourevidenceforeachone.

AttentionThe clinician caring for a sick personmust begin byentering the sick persons presence and absorbingwhat can be learned about that persons situation. Acombination ofmindfulness, contribution of the self,acute observation, and attuned concentration enablesthedoctor to registerwhat thepatientemits inwords,silence, and physical state. Contemplative practices,aesthetic appreciation, and Freuds evenly hoveringattention all have something to teach narrativemed-icine about the attainment and use of attention. Bybecomingarecognizingvessel,thedoctorcanreceive

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the patient, acting as a container for a flow of greatvalueor,withadifferentimage,registeringatransmit-tedradiosignalfromfaraway.

Pediatrician SayantaniDasGupta invokes Buddhistlearning andwhat she has coined narrative humil-ity to describe the stanceof the clinicianwhowouldhopetopaynarrativelycompetentattentiontopatients,embracing patients as teachers and recognizing our-selves as lifelong learnerswho always begin to knowhowtolistento,andsurrenderto,theother.3DasGuptahas also applied concepts andmethods of oral his-tory to clinicalwork, reasoning that the oral histori-ans nonjudgmental acceptance of the testimony ofthesuffereraddstoourunderstandingoftheattentivepresence requiredof thedoctor. Seeing these similari-ties between clinical practice and both contemplativestates and oral history not only givesintellectual clarity to our practice, butalso enhances clinical training by sug-gesting for our use some of the tech-niques used in preparing trainees fortheseotherpractices.

In addition to being a psychologi-calorinteriorstate,attentioninclinicalpractice is a peculiarly narrative state.Howevermaterialitsconcernswithfleshandboneseemtobe,medicineattendstowordsthespokenlanguageof patients, thedictated languageof discharge summa-ries,thescrawledlonghandofinternprogressnotes,theincreasingly keyboarded signout onto the electronicmedicalrecord,themessagesofloveandlossgivenandreceivedneardeath.

Philosopher Craig Irvine brings the philosophy ofEmmanuel Levinas to bear onour narrativemedicinetheory, suggesting that Levinass ethics of the faceacceptingthemoraldutiesincurredbyvirtueofahum-ble facing up to the otherness of the otherorientsclinicianstowardpatientswithfreshvisionandethicalstrength.4 For Levinas, only discourse has the capac-itytounite2distinctothers,andsotheseriousstudyofdiscoursebetweenpersons,whether inclinicalcon-versation or in literary text, is essential to the task ofattending fully to the other.We find that by teachingtrainees the skills of close reading (and generallyweask themto read literary textsofproseorpoetry),weare conveying the basic skills of clinical attention, bywhichdoctors, nurses, and socialworkers canabsorballthattheirpatientsandcolleagueshavetotell.

RepresentationNarrativemedicine is by nomeans the first or onlydiscipline to turn to narrativewriting for help under-standing complexeventsor statesof affairs.While thedividendsofclarityandcomprehensionforthewriterinaclinicalsettingarebecomingwidelyunderstoodtoday,ourhypotheses aboutwhywritinghelps cliniciansand

patientsofferparticularilluminationformedicine.Unlikethe feelingascribed to Freud that onewrites about anunpleasant experience inorder to rid oneself of it,wehave come to realize that narrativewriting in clinicalsettingsmakesaudibleandvisiblethatwhichotherwisewouldpasswithoutnotice.

In ourwriting sessions,we invite participants todescribe complex clinical situations, in effect takinga chaotic or formless experience and conferring formonit.Whatemergesasawrittentextmightbeaproseparagraph,apoem,a scenicdialogue,anobituary,anencomium, or a love letter (one nurse oncewrote arecipe forus),which,whenexamined closely by read-ersorlisteners,conveysitsmeaningbybothitscontentandits form.Evenunpractisedwritersfindthemselvessurprisedbythediscoveryprocessofwriting,andoften

themost strikingdiscoveriesaremadenot inwhat iswritten but inhow thetext is configured. Our students learnto examine their texts genres, figura-tive language, temporal structures, thestanceofthenarrator,andallusionstoother textsthenarrative features thataliteraryscholarwouldconsiderinthestudyofanywrittentext.

Novelist Henry James and literary scholar RolandBarthesboth remindus that expression connotesput-tingsensationsandperceptionsintowordsandalsothemuscular process of delivering the essence of some-thing into viewlike expressing juice froma lemonormilk fromanipple.5Hence, themeaningofwhat getsexpressed comes simultaneously from theonewritingand thesubjectof thatwriting.The representationalactrequires theexpressive forceandcreativityof thewriteralongwith thecontainedmeaningof thatwhich isnowinview,unifyingseerandseeninthecreationofthetext.

When patients or family caregiverswrite accountsof their illness experiences, readers have an intimateandurgentroletoplayinresponse.Neithercasualnorcoy,thesetextsareaskingsomethingoftheirreadersasking forwitness, for presence, for answer. Healthadvocate Patricia Stanley proposes that the patientsimultaneouslysuffers isolationfromlovedones, fromhisorherhealthybody,andfromtheself.Representingthe events of illness offers hope that others canheedthe isolatedonesand reconnect thosepeoplebyhear-ingthemoutfully.6Whethersickorwell,thereaderofanillnessnarrativeissummonedbytheauthortojoinwith the tellerto form community that can combattheisolationofillness.

We see coming intoview, then, thehigh stakesandurgenttasksofnarrativewritinginclinicalsettings.Notmerely reportsagainst forgetfulnessor solipsisticdiary-making, these narrative reflections take on the forceof both creation and clinical intervention. Thewritingrenders thedoctor audible, thepatient visible, and the

There is hopefor connection, for recognition, for communion

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treatment a healing conversationbetween them.Untilthewriting,thereare2isolatedbeingsthedoctorandthe patientboth ofwhom suffer, and both ofwhomsuffer alone.By virtueof thewriting, there is hope forconnection,forrecognition,forcommunion.

AffiliationThemovements of attention and representation spiraltogether toward the ultimate goal of narrativemedi-cine:affiliation. It is this thatweareaftertheauthenticandmuscular connectionsbetweendoctor andpatient,between nurse and socialworker, among children ofa dyingparent, among citizens trying to choosea justandequitablehealth carepolicy.Theaffiliationextendsinward,too,tojoindoctorsornurseswiththemselvesinasustainedhabitofclinicalreflectionortoallowthesud-denly ill patient to recognize the sameselfwhoexistedbefore illnesscame. Insteadof lamenting thedeclineofempathy amongmedical students or the lack of altru-ismamongphysicians,narrativemedicinefocusesonourcapacitytojoinoneanotheraswesufferillness,beartheburdensofourclinicalpowerlessness,orsimply,together,bravelycontemplateourmortallimitsonearth.

Thescienceundergirding thismovementofnarrativemedicineexamineswhathappenswhenhumanbeingscontemplatepainandsuffering.Weturn,foronesourceofclarity,toaestheticsandcinemastudies,whichillumi-nate thestateofaffairswhenawitnessseesasceneofpain. Literary scholarMauraSpiegels pioneeringworkin thenarrativepermeabilityof filmanddreams recon-ceptualizesempathytosuggestnotonlyaninternalstateofvirtuous self-negationandother-direction,butalsoacreativeandactivestateofabsorptionandcocreationofstoryinwhichtheviewer,too,ispermeabletoremakingof experienceand thought.7We, theviewers, aremobi-lizedinwitnessingotherssuffering,beitinanintensivecareunitoradarkenedmoviehouse,notonlytocompre-hendwhatthatsufferingmightmeantothepatientorthesubjectof thefilm,butalso towitnessandcomprehendwhatsuchsufferingmightmeanormighthavemeanttoourselves.Andsotheinterpenetrationofselfandotherthegoalofaffiliationisseenwithintheveryseatoftheobservation.

Suchdiscoveriesunitefilmandbyextensionanycre-ative and textual productwithdreams. PsychoanalystEricMarcusenrichesournarrativemedicinetheorywithhis evidenceof the thematic struggles toward selfhoodundergonerepeatedlybyhundredsofstudentsandtrain-ees.8 Bymobilizing psychoanalytic theories of Freud,Winnicott,andLacan,andbringingthemtobearonourwork,Marcusdeepens the theorizingpossible innarra-tivemedicinetoprobeintrapsychiceconomiesandther-apeuticgoalsofcare.Anyformofcareofthesicksharessomeaspectsoftheanalyticsituationitstransferences,its formal intimacy, and its privilegedanddutiful expe-rienceof anothers inward states.Morepractically, the

careofthesickrequirestheanalystscreativityininhab-itingwithoutcolonizingthelivedexperienceoftheonewhosuffers.

Narrativemedicinetrainingis,asaresultofMarcussinsights, recognized as a formof analytic supervision,requiring candidates to examine and undergo theirown affective experiences and requesting trainers tomakesustainedcommitmentstotrainees.AsaresultofSpiegelsinsights,weseethatsuchtrainingrequiresthewillingnesstocreativelythinkwithstoriestowardper-sonalandpublicmeaning.7

ConclusionThis short reviewof the conceptual foundationsofnar-rativemedicine isoffered ina spirit of explorationandasaninvitationtothinkwithusaboutthephenomenonofnarration inmedicine.Aswehealth careprofession-als andpatientsdelve into the challengesand rewardsof serious storytelling in illness,we seewithnewclar-itydeepaspectsof the illness, the sickperson, the situ-ationofcare,andthepersonwhocaresforthesick.Wesee,too,newlyopeningavenuestowardthehumanaffili-ations that alone can ease suffering, those bonds thatindeeduniteuswithDivinsky,wherevershenowis,andwithallwhohavebeenandwhohavesuffered.

Dr Charon is a Professor of Clinical Medicine in the Department of Medicine and Director of the Program in Narrative Medicine at Columbia University in New York, NY.

Competing interestsNone declared

Correspondence to: Dr Rita Charon, Department of Medicine and Program in Narrative Medicine, Columbia University, 630 W 168th St, New York, NY 10032 USA; telephone 212 305-4942; fax 212 305-9349; e-mail rac5@columbia.edu

the opinions expressed in commentaries are those of the authors. Publication does not imply endorsement by the College of Family Physicians of Canada.

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Physician2007;53:203-5(Eng),209-11(Fr).2.CharonR.Narrative medicine: honoring the stories of illness.NewYork,NY:OxfordUniversityPress;2006.p.155-74.

3.DasGuptaS.Betweenstillnessandstory:lessonsofchildrensillnessnarra-tives.Pediatrics2007;119(6):e1384-91.p.1391.

4.IrvineCA.Theothersideofsilence:Levinas,medicine,andliterature.Lit Med2005;24(1):8-18.

5.CharonR.Narrativelightsonclinicalacts.Whatwe,likeMaisie,know.Partial Answers2006;4(2):41-58.

6.StanleyP.Thepatientsvoice:acryinsolitudeoracallforcommunity.Lit Med 2004;23(2):346-63.

7.HeisermanA,SpiegelM.Narrativepermeability:crossingthedissociativebarrierinandoutoffilms.Lit Med2006;25(2):463-74.

8.MarcusER.Medicalstudentdreamsaboutmedicalschool:theuncon-sciousdevelopmentalprocessofbecomingaphysician.Intern J Psychoanal2003;84(2):367-86.