When I reflect on my most cherished memories as an occupational therapist, recalling my clients’ stories has a lasting effect on my own life. Although I feel gratified knowing that I helped clients accomplish challenging goals, listening to their life stories has the most significant impact.
Through my clients’ narratives, I become a witness to their lives, their sorrows, joys, aspirations, triumphs, pain, and love. Instead of labels such as “addict,” I gain insight into how childhood trauma leads to anxiety, a need to escape from painful experiences, and drug misuse. The power of these stories elicits a greater sense of compassion, seeing a person vs. a label, and meeting my clients where they are.
What is narrative medicine?
Our fast-paced and ever-evolving healthcare system places demands for improved outcomes and cost containment, often at the expense of dehumanizing patients’ experiences. Integrating studies in humanities, art, and literature shows a promising approach for change. Narrative medicine, an innovative approach, encompasses the following:
- Storytelling is primarily the patient’s story and the practitioner’s story and how they interweave in the clinical encounter to create a new account with meaning, shared understanding, and change potential.
- Practitioners acknowledge each patient’s uniqueness, validate their “story,” and empathize through genuine interest and concern.
- Practitioners recognize the disconnect and take steps to bridge the divide by developing connections. For the practitioner, this involves deep listening; exploring fears, feelings, and emotions; and developing a deeper understanding of the illness experience and the patient and practitioner.
An innovative approach for practitioner and patient satisfaction
Narrative medicine’s genesis began in 2000 at Columbia University by Rita Charon, M.D. merging studies in the humanities with client-centered care. Narrative medicine brings physicians, patients, nurses, therapists, and health activists together to reinvent healthcare based on trustworthiness, humility, and mutual recognition. The goal is “to recognize, absorb, interpret, and be moved by the stories of illness” (Charon, 2001).
Narrative medicine draws on the study of art and literature to enhance practitioners’ listening and observation skills and expand their view of patients encompassing more than just medical histories. Narrative medicine’s core component involves “close reading,” reflective writing, or learning how to carefully and critically analyze a text. This approach strives to help students foster empathetic listening skills to better understand and connect with their patients.
In the disease-focused model of our current healthcare system, practitioners concentrate on eliciting a medical history rather than addressing patients’ real concerns. Understanding the illness experience is essential in healthcare. Trauma studies inform us of the importance of the trauma survivor telling their story and the listener acknowledging the suffering as real. The narrative medicine approach strives to develop empathy among practitioners by listening to their patients’ stories. Those stories can shed light on how a person became ill, the critical moment compelling them to seek care, and most importantly, the social challenges encountered in getting better.
Several outcome studies show that when healthcare practitioners receive narrative medicine training, it helps them understand, empathize, and communicate more effectively. In turn, this results in improved health outcomes. A systematic review found that narrative medicine is “a powerful instrument for decreasing pain and increasing well-being related to illness.”
Practicing narrative medicine techniques allows practitioners to reconnect their passion for helping others process their emotions working with the sick and dying, which are challenging given our current healthcare system’s demands. Burn-out among practitioners is an epidemic, with many leaving the profession. Students and practitioners may believe they are too busy to practice these techniques, but narrative medicine makes the limited time practitioners have with patients more valuable. Simple questions such as, “What do you want me to know about your illness?” can elicit vital information when obtaining a medical history.
The 4 divides
Rita Charon, the pioneer of narrative medicine, concedes that while practitioners may know about the disease, they are unaware that illnesses change everything for the patient. Therefore, listening closely, acknowledging, and exploring the four divides is essential in understanding the meaning of the patient’s illness experience. According to Charon, the following four divides contribute to a disconnection between the patient and practitioner:
The relation to mortality
Illness is an unexpected event eliciting many emotions, especially the fear of death. Prior experiences influence patients’ attitudes towards illness, while practitioners have a different perspective due to their training.
The context of illness
Practitioners view disease as a biological phenomenon requiring medical intervention. Patients view disease within the framework of their entire lives.
Belief about disease causality
Practitioners have a greater understanding of disease than their patients; therefore, its causes can differ widely. Care is compromised when opinions are conflicting.
Shame, blame, and fear
Patients are embarrassed disclosing certain aspects of their lives. Illness creates a sense of vulnerability and fear. Patients may self-blame about past wrongdoings. If the outcomes are not favorable, patients may blame the practitioner. Practitioners might feel embarrassed asking personal questions. They blame patients for making excessive demands or poor lifestyle choices and fear litigation. These strong emotions on both sides affect the illness experience considerably. Unless addressed, they may result in suffering that divides the practitioner-patient relationship irrevocably.
Patient stories and literary texts
Charon compares patients’ stories to literary texts where some stories are straightforward and easy to interpret, while others are more complex. Reading nonfiction texts stimulates the imagination and opens the mind to different ideas and possibilities, promoting a deeper understanding of the narrative. By extending the principles of literary analysis to patient stories, more can be learned and understood. However, imagination to view the patient’s perspective is not the only valuable thing. The practitioner gains a greater self-awareness and insight into their role and effect on the encounter.
The 7 Cs
Language is fundamental to any conversation. Therefore, speech and dialogue are useful in providing insights into patient narratives, promoting active listening, and improving understanding. A practitioner-patient consultation becomes a conversation where a shared perception develops and is closer to the patient’s reality. The practitioner requires good communication for a shared understanding. The 7 Cs are conversations inviting change, according to Launer. The 7 Cs include:
The practitioner allows patients to express their story adequately and in their own words while simultaneously exploring connections, new options, probing, and guiding the conversation intentionally to facilitate understanding without controlling or interrupting. The patient treatment is collaborative rather than imposed.
This is about a genuine interest in the patient without prying. Curiosity also extends to the practitioner exploring feelings, emotions, and reactions to patients’ stories.
This is relevant to both the practitioner and patient. It includes family, work, spirituality, community, beliefs, values, time management, personal and social expectations. It is useful to ask why the patient has presented at this time with this problem.
Nothing is simple or straightforward. Change is inevitable and creates a ripple effect. Therefore, an awareness of interconnectedness is required to counter fixed beliefs about cause and effect, inflexible thinking, and the concrete solutions with which patients burden themselves.
Challenging the patient and practitioner is vital for considering new ideas and contemplating change to achieve it realistically.
It is also essential to know one’s limitations and sensitivity toward patients’ needs, including willingness to go into unexplored areas and readiness for change.
Meeting the patient with an accepting and nonjudgmental attitude is critical for communicating a caring attitude.
Application of narrative medicine as a therapeutic intervention
Since narrative medicine’s inception in 2000 at Columbia University, many professionals have adapted close reading methods and used them as a therapeutic modality to reach health care clients. Clients can gain valuable life skills, develop self-awareness, self-compassion, and empathy by examining their biases, confronting past experiences, managing potential triggering events before they occur, and learning about themselves and their peers through storytelling.
Existential distress is frequent at the end of life, with some studies suggesting that only a minority accept death. One strategy is the use of narrative medicine through reflective writing. Some studies provide evidence regarding the benefits of emotional disclosure through patient narrative on pain and well-being scales. Stories with greater emotional revelation resulted in a significant decrease in pain and an increase in well-being scores.
An adaptation of narrative medicine is the 55-word story that requires no specific talent and is a fast and effective method for a busy healthcare team to cultivate the habit of noticing, reflecting, and healing. The process involves writing for about ten minutes on any topic or concern. Then, spending another 10 minutes cutting down the superfluous words for a powerful reflective tool. Patients can use the 55-word story to express frustrations and create a legacy project. Creating a life story can be a distraction from pain while passing on valuable life lessons.
Narrative medicine seeks to bridge the divide between practitioners and patients using storytelling. The practice’s primary goal is developing deep listening, shared understanding, and empathy on behalf of practitioners. By acknowledging a patient’s fears, emotions, and feelings about their illness experience, practitioners value the patient as a person rather than a set of symptoms.
- Bohanan, M. (2019). The Evolving Field of Narrative Medicine Reaches the ‘Core of the Human Condition.’ Insight into Diversity. https://www.insightintodiversity.com/the-evolving-field-of-narrative-medicine-reaches-the-core-of-the-human-condition/
- Charon, R. (2001). Narrative Medicine-A Model for Empathy, Reflection, Profession, and Trust. JAMA, 286(15).1897-1902. doi:10.1001/jama.286.15.1897
- Krisberg, K. (2017). Narrative Medicine: Every Patient Has a Story. AAMC News. https://www.aamc.org/news-insights/narrative-medicine-every-patient-has-story
- Mehrlich, K.D. & Wasmuth, S. (2019). Tell My Story: Narrative Medicine as a Unique Approach to Forensic Mental Health Intervention. https://www.aota.org/Publications-News/otp/Archive/2019/narrative-medicine
- Motivate Minds (2020). Narrative Medicine: A New Approach & A Potential OT Intervention. https://motivatemindsot.com/narrative-medicine/
- Samuel, S. (2020). This doctor is taking aim at our broken medical system, one story at a time. Vox. https://www.vox.com/the-highlight/2020/2/27/21152916/rita-charon-narrative-medicine-health-care
- Wong, C. (2020). How Narrative Medicine Might Benefit You. https://www.verywellhealth.com/narrative-medicine-benefits-uses-and-tips-4143186
- Zaharias G. (2018). What is narrative-based medicine? Narrative-based medicine. Canadian family physician, 64(3), 176–180. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851389/
Editor’s note: This post was originally published on February 9, 2021 and updated on March 2, 2022.