Psychoanalysis and Narrative Medicine

She lay there like a hieroglyphic: her enormous head permanently turned to the right… her arms wasted and contorted into cryptic gestures, her legs flopped to either side with ankles touching, forming a diamond. She had only the timeline of her parents to confirm that she was a 13-year-old girl…Every morning her father, a soft-spoken man with infinite patience, would translate her spasms and tracheostomy smells, while mom slept…

Her fever broke without provocation on the fifth day…She began to smile more and flail less…And all at once every past thought of “let her die” gave way to the reality that the family will once again depart intact; that the mystery of her continued existence may be solved by musing in self-defense that perhaps it isn't as much an exhausting prolongation of life as it is the preservation of an opportunity to love.

This narrative was written by a third-year medical student during a weeklong class on narrative medicine that was taught by a psychoanalyst and an English professor. Although this piece is written by one who likely knows something of the craft of writing, it is a story that mostly comes from an invitation to this student to write about his experience with this patient and her family—to allow his senses to play freely within an imaginative space that creates a kind of capacious language, that transforms the sensory world into something that is comprehensible as a story. In speaking of the interweaving—and reconciliation—of primordial, affective-sensory-motor, and cognitive realms in language, Hans Loewald in his 1980 paper, “Primary Process, Secondary Process, and Language,” quoted Paul Valery: “Poetry is an attempt to represent or to restore, by articulate language, those things, or that thing, which tears, cries, caresses, kisses, sighs… try obscurely to express.” Not unlike psychoanalysis, the emerging field of narrative medicine strives to find words to capture what is truly going on in clinical experience. And for the physician, it is an attempt to restore and to represent the subjective (and intersubjective) domain as a complement to medical training that is dominated by the objective—a reconciliation of the two registers of discourse with oneself.

Not unlike psychoanalysis, the emerging field of narrative medicine strives to find words to capture what is truly going on in clinical experience.

Evolving out of the tradition of literature and medicine and the medical humanities, narrative medicine directs medical students and physicians to write about their encounters with patients. The discipline's founder, Rita Charon, a professor of internal medicine at Columbia who has a doctorate in English literature, possesses the trained ear of a listening physician and the skills of textual analysis honed as a literary scholar. In 1993 Charon invented a teaching tool she called the Parallel Chart, in which students write about the emotional experience of their engagements with patients.

“Students have written powerfully about their deep attachment to patients, their awe at patients' courage, their sense of helplessness in the face of disease, their rage at disease's unfairness, the shame and humiliation they experience as medical students, and the memories and associations triggered by their work,” states Charon in her book, Narrative Medicine: Honoring the Stories of Illness. “They have found comfort in hearing one another read Parallel Chart entries, commenting often that they no longer feel alone in their mournfulness or sadness or guilt.”

Writing narratives and reading them aloud to fellow students enhance narrative competence, defined by Charon as “the competence that human beings use to absorb, interpret, and respond to stories.” Having developed greater capacities for self-awareness, self-reflection, and insight, as graduate physicians they may become better listeners and thereby extend their diagnostic and therapeutic reach. What is more, by becoming more cognizant of what is happening within the force field between doctor and patient and less disconnected from their own emotional experience, physicians are more capable of creating engaged connections that permit them to accompany patients in their illnesses. In the end, this leads to a medical encounter that is more satisfying to patient and doctor alike.

In 2002, I began leading evening discussion groups for experienced physicians in which we read and discussed published works written by physicians such as William Carlos Williams. A 2003 interview of Charon about her work on National Public Radio alerted me to the existence of narrative medicine. At the same time I saw an announcement of a February 2004 conference on “Psychoanalysis and Narrative Medicine” organized by Peter Rudnytsky at the University of Florida. I submitted a piece for the meeting based upon my experience in teaching John Berger's A Fortunate Man. Rudnytsky and Charon have brought together a collection of essays (including mine) from that conference in Psychoanalysis and Narrative Medicine, which was published earlier this year.

When I arrived at the University of Alabama School of Medicine in 2004, I discovered that introducing my interdisciplinary work with physicians as narrative medicine opened many doors: I was not seen as a psychiatrist but as a fellow physician who shared in common with other doctors the physician-patient relationship. Without resorting to alienating psychoanalytic terminology, I was able to make use of narrative medicine to create a language that my medical colleagues could grasp, one in which I could meaningfully convey the experience that has come from my years of being immersed in therapeutic relationships.

Along with a colleague in internal medicine, I gave a series of grand rounds on narrative medicine to a number of medical departments, and I started a monthly narrative medicine discussion group for senior medical faculty in which we read and discuss works by published physician writers and our own narratives. I inaugurated a course in narrative medicine for the medical student curriculum, beginning with an annual weeklong course for third- and fourth-year medical students and, recently, adding one for first- and second-year students. The narrative at the beginning of this article was written for one of my classes.

My version of narrative medicine is not exactly the same as that of Charon, who uses the skills of textual analysis to illuminate medical narratives. Rather, I use what I have learned from my experience of listening to my patients' stories and of “reading” what is “written” within the transference-countertransference. However, the kinds of discussions created by these approaches to narratives generate similar conversations.

My work in narrative medicine has provided many opportunities for interdisciplinary exchanges between this psychoanalyst and faculty and students in other departments in the medical school and in undergraduate and graduate programs in the larger university. For example, I gave a presentation on narrative medicine to the nationally renowned honors program at the University of Alabama at Birmingham, which led to another invitation for me to speak to that program on “The Enduring Influence of Freud.” In addition, I have been interviewed for articles on narrative medicine in four university and medical school publications. In sum, I have made good use of narrative medicine as an effective and mutually enriching medium of exchange between psychoanalysis and other disciplines on this campus.

When I asked Charon to provide a comment about the relationship between psychoanalysis and narrative medicine for this article, she invoked voices from our discipline to join her own:

In deep ways, our two fields not only overlap but are fully transparent. In Sublimation, Loewald explains that the sensory-motor acts of writing transform the immaterial into material, enabling the writer to see, for the first time, what has been disembodied perception. I believe that. I believe that writing grants us access to what Christopher Bollas calls the “unthought known,” that vast continent of ours simply unavailable until we reach it through dreams, treatment, or, I submit, writing. You can imagine what a difference all this makes for doctors, nurses, social workers—to have full-bodied access to one's knowledge of, feelings about, and fears for, and love toward those sick persons in our care. We are accruing evidence that this newly found access matters a great deal for the patients in our care as well. It is for their sake only that we do it.

Randall Paulsen and I co-lead an ongoing discussion group at APsaA meetings, “Conversations with Doctors: From Balint Groups to Narrative Medicine.” In January 2009 Rita Charon will be the guest presenter at this discussion group.