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Psychoanalysis and Narrative MedicineReview - Psychoanalysis and Narrative Medicine
by Peter L. Rudnytsky and Rita Charon (Editors)
State University of New York Press, 2008
Review by Terry Burridge
Jul 8th 2008 (Volume 12, Issue 28)

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 Terry@dancingbears.co.uk


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