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A Basic Theory of NeuropsychoanalysisA Cursing Brain?A Dream of Undying FameA Map of the MindAfter LacanAgainst AdaptationAgainst FreudAn Anatomy of AddictionAnalytic FreudAndré Green at the Squiggle FoundationAnger, Madness, and the DaimonicAnna FreudAnna Freud: A BiographyApproaching PsychoanalysisAttachment and PsychoanalysisBadiouBecoming a SubjectBefore ForgivingBerlin PsychoanalyticBetween Emotion and CognitionBeyond GenderBeyond SexualityBeyond the Pleasure PrincipleBiology of FreedomBoundaries and Boundary Violations in PsychoanalysisBuilding on BionCare of the PsycheCarl JungCassandra's DaughterCherishmentConfusion of TonguesContemporary Psychoanalysis and the Legacy of the Third ReichCrucial Choices, Crucial ChangesCulture and Conflict in Child and Adolescent Mental HealthDarwin's WormsDesert Islands and Other Texts (1953-1974)Dispatches from the Freud WarsDoes the Woman Exist?Doing Psychoanalysis in TehranDreaming and Other Involuntary MentationDreaming by the BookEnergy Psychology InteractiveEqualsErrant SelvesEthics and the Discovery of the UnconsciousEthics Case Book of the American Psychoanalytic AssociationFairbairn's Object Relations Theory in the Clinical SettingFed with Tears -- Poisoned with MilkFeminism and Its DiscontentsForms of Intersubjectivity in Infant Reasearch and Adult TreatmentFour Lessons of PsychoanalysisFratricide in the Holy LandFreudFreudFreudFreudFreudFreudFreud and the Question of PseudoscienceFreud As PhilosopherFreud at 150Freud's AnswerFreud's WizardFreud, the Reluctant PhilosopherFrom Classical to Contemporary PsychoanalysisFundamentals of Psychoanalytic TechniqueGenes on the CouchGoing SaneHans BellmerHappiness, Death, and the Remainder of LifeHate and Love in Psychoanalytical InstitutionsHatred and ForgivenessHealing the Soul in the Age of the BrainHeinz KohutHeinz KohutHidden MindsHistory of ShitHope and Dread in PsychoanalysisImagination and Its PathologiesImagine There's No WomanIn Freud's TracksIn SessionIn the Floyd ArchivesIntimaciesIntimate RevoltIrrationalityIs Oedipus Online?Jacques LacanJacques Lacan and the Freudian Practice of PsychoanalysisJung and the Making of Modern PsychologyJung Stripped BareKilling FreudLacanLacanLacanLacan and Contemporary FilmLacan at the SceneLacan For BeginnersLacan in AmericaLacan TodayLacan's Seminar on AnxietyLawLearning from Our MistakesLove's ExecutionerMad Men and MedusasMale Female EmailMelanie KleinMemoirs of My Nervous IllnessMental SlaveryMind to MindMixing MindsMoral StealthMourning and ModernityMovies and the MindMurder in ByzantiumNew Studies of Old VillainsNocturnesNoir AnxietyOn Being Normal and Other DisordersOn BeliefOn IncestOn Not Being Able to SleepOn the Freud WatchOn the Way HomeOpen MindedOpera's Second DeathOvercoming Destructive Beliefs, Feelings, and BehaviorsPhenomology & Lacan on Schizophrenia, After the Decade of the BrainPhilosophical Counselling and the UnconsciousPractical Psychoanalysis for Therapists and PatientsPsychiatry, Psychoanalysis, And The New Biology Of MindPsychoanalysisPsychoanalysisPsychoanalysis and Narrative MedicinePsychoanalysis and NeurosciencePsychoanalysis and the Philosophy of SciencePsychoanalysis as Biological SciencePsychoanalysis at the MarginsPsychoanalysis at the MarginsPsychoanalysis in a New LightPsychoanalysis in FocusPsychology, Psychotherapy, Psychoanalysis, and the Politics of Human RelationshipsPsychotherapy As PraxisPutnam CampQuestions for FreudRe-Inventing the SymptomReading Seminar XXReinventing the SoulRelational Theory and the Practice of PsychotherapyRelationalityRepressed SpacesRevolt, She SaidSecrets of the SoulSerious ShoppingSex on the CouchSexuationSigmund FreudSoul Murder RevisitedSpectral EvidenceSpirit, Mind, and BrainStrangers to OurselvesSubjective Experience and the Logic of the OtherSubjectivity and OthernessSubstance Abuse As SymptomSurrealist Painters and PoetsTaboo SubjectsTalk is Not EnoughThe Arabic FreudThe Art of the SubjectThe Brain and the Inner WorldThe Brain, the Mind and the SelfThe Cambridge Companion to LacanThe Challenge for Psychoanalysis and PsychotherapyThe Clinical LacanThe Colonization Of Psychic SpaceThe Condition of MadnessThe Couch and the TreeThe Cruelty of DepressionThe Dissociative Mind in PsychoanalysisThe Dreams of InterpretationThe Examined LifeThe Fall Of An IconThe Freud EncyclopediaThe Freud FilesThe Freud WarsThe Fright of Real TearsThe Future of PsychoanalysisThe Gift of TherapyThe Heart & Soul of ChangeThe Knotted SubjectThe Last Good FreudianThe Late Sigmund FreudThe Letters of Sigmund Freud and Otto RankThe Mind According to ShakespeareThe Mystery of PersonalityThe Mythological UnconsciousThe Neuropsychology of the UnconsciousThe New PsychoanalysisThe Power of FeelingsThe Psychoanalytic MovementThe Psychoanalytic MysticThe Psychoanalytic Study of the ChildThe Psychoanalytic Study of the ChildThe Psychodynamics of Gender and Gender RoleThe Puppet and the DwarfThe Real World Guide to Psychotherapy PracticeThe Revolt of the PrimitiveThe Seminar of Moustafa SafouanThe Sense and Non-Sense of RevoltThe Shortest ShadowThe Social History of the UnconsciousThe Surface EffectThe Symmetry of GodThe Tragedy of the SelfThe Trainings of the PsychoanalystThe UnsayableThe World of PerversionTherapeutic ActionTherapy's DelusionsThis Incredible Need to BelieveThoughts Without A ThinkerTo Redeem One Person Is to Redeem the WorldTrauma and Human ExistenceTraumatizing TheoryUmbr(a)Unconscious knowing and other essays in psycho-philosophical analysisUnderstanding Dissidence and Controversy in the History of PsychoanalysisUnderstanding PsychoanalysisUnfree AssociationsWalking HeadsWay Beyond FreudWhat Does a Woman Want?What Freud Really MeantWhen the Body SpeaksWhere Do We Fall When We Fall in Love?Whose Freud?Why Psychoanalysis?Wilhelm ReichWinnicottWinnicott On the ChildWisdom Won from IllnessWittgenstein on Freud and FrazerWittgenstein Reads FreudWorld, Affectivity, TraumaZizek
As the title suggests this series of papers is about narrative medicine-or, more accurately, about narrative and medicine or, narrative in medicine. These distinctions are not just pedantry-they are the core of the book. Each small preposition shifts the focus of the book into allowing the reader to consider how much a small difference makes. And to consider the whole question of personal narrative. Simply the question of the book is "Who owns the patient?" Is a patient-and their story- the "property "of the clinician or the property of the patient? The answer from the various contributors to this book is that it is, at best, shared "property". The patient comes to the clinician with a story to tell and wants someone else to hear this story and to reverence it. But the clinician's role is not simply to be the passive hearer, but to become a participant observer and listener. Bruno Bettleheim in his book "The Uses of Enchantment" makes the point that fairy tales "... carry important messages to the conscious, the preconscious , and the unconscious mind, on whatever level each is functioning at the time" (Belleheim:1975) Our own narratives carry a similar message, both to ourselves and to whoever we are asking to share them with us.
Rita Charon In her paper "Where does Narrative Medicine Come From? Drives, Diseases, Attention, and the Body" comments that "Narrative medicine has evolved as a means to honor the stories of illness, whether told by the patient, family member, doctor, or nurse. More sharply it has become a way to probe the narrativity of disease, of health, of healing, and of the relation between the sick person and the one who tries to help." Charon's use of honoring a patient's story is important because it is another o f the themes that runs through many of the papers- that one's story is more than "just" information. It is us giving to another a part of our soul-our essence. A person's story is more than a case history of symptoms to be noted as part of a medical assessment; it is something to be prized and honored. And here, it seems to me, is where nurses are particularly privileged. We get to spend days, weeks and, sometimes, years, with our patients giving us ample time to hear their stories.(It seems to me ironic-and tragic-that in many psychiatric units now we have the concept of "protected time" i.e. an hour a week where nurses are free to go and talk to their patients. An hour a week is a pitifully small allowance of time which we can give to our patients. Small wonder that schizophrenic voices can become so important-they are least always present and not busy with ward rounds, medication, care plan writing etc!) Writing of time spent with her patients Charon has this to say "Through the attention I donate and the authenticity he displays, we grow together in knowledge, in action and in grace, hoping for the best, making it out together". This makes narrative into a shared experience where both clinician and patient can give to each other and learn from each other.
This notion of mutuality and its attendant challenges is written about by Fred Griffin in his paper "The Fortunate Physician- Learning from Our Patients". Speaking of traditional medical training he says "Like psychoanalysts, physicians on the front lines of patient care are continuously afforded moments where they can achieve a partnering of self reflection with engaged, attuned clinical work. But because medical training has traditionally devalued subjective (and intersubjective) experience, it may not adequately prepare physicians to appreciate the unique experience they are creating with their patients at particular moments of time" Griffin here touches on a continuous tension for clinicians between external demands and internal ones. I want my doctor to attend to me; yet , equally, I have made an appointment for a time that allows me to get to work , pick up my children , walk my dog etc. Sometimes I only want 5 minutes with my G.P., I have no wish or need to tell my whole story to him. Nor does he have the time to listen to me. Yet somewhere there has to be a mechanism for understanding the message that says "I need and want more of you than just a prescription for my ailment". Much as I might appreciate the chance to tell my story to my doctor, if I am still sitting in the waiting room an hour later because the person before me is telling their story, I shall not be sympathetic! It is these tensions that Terence Holt explores in his essay "Narrative Medicine and Negative Capability" where he writes about what we can, realistically, offer our patients. He says "Let me be clear. I am not at all suggesting here that doctors and nurses do not deeply, passionately, and in some sense personally care about the work they do. We do. But just what personal means is the central issue in this essay. What we have to offer our patients isn't (ideally) eros, or even agape. At best it rises to caritas, which may be the least personal (in the traditional sense); the most institutional form love can take. It is also, I think, the most powerful. It is certainly the most effective" (Holt here seems to be echoing the Winnicottian idea of the good enough mother.) Later in his essay he demonstrates, in an interesting way, a therapeutic use of splitting. He is describing an experience of being in the room of a patient who is about to die where, at the request of the family and the patient herself, he has just turned off the pump that was keeping her alive. He describes the scene. "As I lean against the wall, tears are coursing down my face. I am being very quiet about it, but I am sobbing as freely as I know how. And meanwhile I am thinking: if this is over by12:30, I have got a chance of getting lunch before I replace the art line in twenty-four. The tears are streaming down my face, and I am utterly haunted by memories of my father's nearly identical death ten years before. But somewhere a voice is also thinking: maybe today I can sign out by three." The extract is part of his paper which looks at the tension between confessional writing by health care professionals and the need for these same professionals to be the recipients of all manner of fantasies from their patients. How much is self disclosure an indulgent luxury for care staff and how much is it a useful therapeutic tool?
There is much more in this book. A moving chapter by Vera Camden about how her work with a patient was illumined by re-reading L.P.Hartley's novel "The Go Between"; "Pinel and the Pendulum" by Richard Holt looks at the contribution of Pinel and his influence on ways of understanding madness; there is a chapter on "Desire and Obesity" and one on narratives of real and imagined trauma. Schulyer Henderson's essay "Uncertain Truths" is an uncomfortable one, challenging notions of resistance and reframing them as discourses of defiance." Whereas resistance serves to maintain the status quo… the function of defiance is to recognise how much is at stake in the psychiatric encounter, that the nexus of therapist and patient is not formed solely by personal transferences and counter transferences, but is charged with social and political consequences"
This book is stunning. I shall be using it in my future lectures.
© 2008 Terry Burridge
Terry Burridge is a Senior Lecturer in Mental Health Nursing at Buckinghamshire New University. He has spent most of his professional life as a psychiatric nurse and now spends considerable time and energy trying to inspire future psychiatric nurses to be the best kinds of nurses that they can be! He is very much influenced by psychoanalytic thinking and sees analytic theory as offering a valuable critique to many other areas of human activity. He can be contacted at [email protected]