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  • Story and Narrative

    I’ve been listening lately to podcasts from the American Writer’s web site, specifically on creative writing. Yesterday I learned the difference between narrative and story: Story – the entire set of events that are accounted for in your tale, not just what you write but also what you imply. Narrative – specifically the things you mention and nothing more.

    On this first day of 2007 I thought I’d write a bit about what this might mean about our profession and, beyond that, what it means to the profession’s center – clinical life.

    Last week while getting my haircut I was seated next to some guy and his barber while they discussed their dogs’ sleeping habits. This began before I sat down and went on beyond my leaving the chair (this guy has a lot more hair than I do) and it had a profound effect upon me – it drove me to distraction. Specifically, it revealed my ever decreasing tolerance for small talk and meaningless conversation; that sort of talk full of repetition and points so obvious anybody can see them coming. For me, it is characterized primarily by a lack of respect for the listener’s understanding.

    Though I appreciate the patient’s need to impart information via story, I also appreciate how seductive and literally false stories may prove to be. Full of modifiers and inflection, the patient’s story draws the therapist into the world seen from the patient’s perspective – and guess who the hero is? There’s also this; the patient probably has no idea that their story has strayed far from the truth and does not contain the elements essential for the therapist’s understanding. This was discussed in depth in the thread about confabulation a few weeks back. In there I said this:

    When people begin to talk too much I have a look that cuts them off. I think I got it from my mother, a wonderful nurse.

    In the Feb. 10 2005 issue of The New York Review of Books there is an essay about a new collection of Sherlock Holmes stories. The author speaks of Conan Doyle being trained by a physician named Joe Bell, a legendary diagnostician in London. Not only were his observational skills and interpretive abilities acute, he attended to the patient's story in an unusual way:

    "To succeed as a narrative diagnostician...you needed the feeling for story, both for the 'history' to be inferred from the signs and symptoms and for the way that story could be reconstructed, in therapeutic terms, for the good of the patient. Bell treated his patients, in part, by telling them their own stories, as if threading a coherent narrative were itself a kind of therapy."

    Here I can see that the author had a wonderful understanding for the difference between narrative and story; how both contained therapeutic elements but that the narrative finally constructed by the therapist reduced the confusion and irrelevance stories commonly contain. I think it’s important to remember how important the patient’s story is to them. In fact, in German there’s a word for this; Lebensluge. It means “the lie that makes life bearable.”

    So, I’d conclude that an effective diagnostician turns the patient’s story into narrative and then repeats it back to them in a fashion that satisfies the needs of everyone involved – not always an easy thing to do – and the therapist needs to do this at the proper moment and at the proper pace as well.

    Now, back to the barber shop. My intolerance for repetition and mundane speech doesn’t help me here, but at least I can acknowledge that and work to change it. In fact, I’ve created an evaluative form that minimizes my exposure to it.

    I’m wondering; how do others separate story from narrative? How important an issue is this in the clinic? How has modern practice affected all of this?
    Last edited by Barrett Dorko; 01-01-2007, 03:19 PM.
    Barrett L. Dorko

  • #2
    I heard my favorite story from a patient a couple of years ago. This man in his mid twenties was my office manager’s son.

    “About eight years ago I was in the front row at a rock concert, dancing around and really into it. The crowd was getting kind of rowdy and the security guard in front of me made it clear that he wasn’t letting any of us up on the stage. I took this as kind of a challenge, dodged by him and leaped. I made it but soon found that all of the other security guards were pretty mad about this too. They dragged me off down to the front row where my friends grabbed my legs and tried to pull me back into the audience. The guards had me by the arms and for a little while I was the rope in a tug of war. The guards won, but this just made them madder.

    Four guys carried me out, face down, one on each limb. We came to some double doors and they used my head as a kind of battering ram to open them, then they threw me down a flight of stairs on the other side.

    I haven’t really felt right since.”

    Okay, this is a great story and I enjoyed it thoroughly, right up to the point where I recounted it to his mother. I didn’t know it would be news to her. Oops.

    My point is this; none of that information helped me understand where to put my hands or what to do, but certainly grew closer to understanding this patient and appreciating his honesty.

    I’m not so sure about his mother.
    Last edited by Barrett Dorko; 01-01-2007, 08:44 PM.
    Barrett L. Dorko

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    • #3
      It's always good to remember to put patient confidentiality right up there as the eleventh Commandment. Or maybe it should bump up a bit higher in the list.
      Diane
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      "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

      “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

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      • #4
        Parents are in that (in)enviable position of finding out, one way or the other, what their kids have done in the past. As the kids get older, more and more startling facts come to light; but as they are alive and functional now, it is just as well the parents didn't know at the time.
        Parents are always the last to find out.

        Nari

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        • #5
          For the record, my patient was sure he’d already told his mother this story.

          Often on the TV show CSI the crime scene investigator will look across the way at a dead body and say quietly, “Talk to me.”

          The implication is that the remaining body will reveal enough to tell the investigator exactly how it came to be dead, and often this happens. But I’d like to take this situation a bit further than CSI on CBS does.

          As we continue to differentiate between story and narrative, perhaps we can extend that understanding to what the patient’s body “tells” us as it responds to testing and treatment. I bring this up because it is a commonly held notion that the body’s consequent movement reflects the circumstances of the trauma, supposedly “reliving” the “vectors of force” that flowed through the body some time in the past. This is an interpretation often reiterated by both Upledger and Barnes when they go about eliciting ideomotion in their own way. I, of course, can’t see how this makes any sense, especially since it evokes the belief that “tissue memory” in the periphery exists – and that’s absurd.

          Instead, I’d propose that the body’s movement is akin to a narrative, not a story. It is spare and direct and about the present much more than it is about the past. It tells us what we need to know now and nothing more. It isn’t small talk, it’s profound and meaningful.

          Just the sort of communication I’m always looking for.
          Last edited by Barrett Dorko; 01-01-2007, 10:10 PM.
          Barrett L. Dorko

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          • #6
            I’m wondering; how do others separate story from narrative?
            I listen for descriptions of painful movements/functions, frequency/duration/intensity of pain, subjective signs of something more sinister for narrative. The rest tends to be the story. This seems to be a descriptor of the impact on life and the explanation that the person is currently working under. Of course, all of this is told concurrently which makes weeding it out a bit of a challenge at times.

            How important an issue is this in the clinic?
            The narrative will give us the answers to what we are dealing with. The story tells us of the operating explanatory model. I think this is of paramount importance. My thoughts on this are already described here and here.

            How has modern practice affected all of this?
            If we don't care about the "why" then we cannot provide a narrative (or at least a feasible one) to a patient to give them an accurate working explanation. We have to have a narrative of our own to provide first.
            Cory Blickenstaff, PT, OCS

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            • #7
              I’m wondering; how do others separate story from narrative?
              Well here is one strategy.

              Acad Med. 2004 Apr;79(4):351-6.

              Personal illness narratives: using reflective writing to teach empathy.

              DasGupta S, Charon R.

              Reflective writing is one established method for teaching medical students empathetic interactions with patients. Most such exercises rely on students' reflecting upon clinical experiences. To effectively elicit, interpret, and translate the patient's story, however, a reflective practitioner must also be self-aware, personally and professionally. Race, gender, and other embodied sources of identity of practitioners and patients have been shown to influence the nature of clinical communication. Yet, although medical practice is dedicated to examining, diagnosing, and treating bodies, the relationship of physicians to their own physicality is vexed. Medical training creates a dichotomy whereby patients are identified by their bodies while physicians' bodies are secondary to physicians' minds. As a result, little opportunity is afforded to physicians to deal with personal illness experiences, be they their own or those of loved ones. This article describes a reflective writing exercise conducted in a second-year medical student humanities seminar. The "personal illness narrative" exercise created a medium for students to elicit, interpret, and translate their personal illness experiences while witnessing their colleagues' stories. Qualitative analysis of students' evaluation comments indicated that the exercise, although emotionally challenging, was well received and highly recommended for other students and residents. The reflective writing exercise may be incorporated into medical curricula aimed at increasing trainees' empathy. Affording students and residents an opportunity to describe and share their illness experiences may counteract the traditional distancing of physicians' minds from their bodies and lead to more empathic and self-aware practice.
              PMID: 15044169
              How important an issue is this in the clinic?
              I think the implications could be profound but many clinics seem to be able to "thrive", as if that's the goal of the whole thing, without such a practice.

              How has modern practice affected all of this?
              Neither the Ministry of Productivity nor the Cult of the Beautiful Body have seemed to enhance someone's ability to translate story into narrative.
              "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

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              • #8
                Additional thoughts

                Instead, I’d propose that the body’s movement is akin to a narrative, not a story.
                This reminds me of the adage that "actions speak louder than words". Although well chosen words certainly can profoundly impact actions.

                I'm not sure which I'm more impressed by.
                The mighty Oak,
                Or the wind that blew it down.
                "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

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                • #9
                  This could be posted in a variety of threads but this one seemed most related

                  Of thought and metaphor
                  "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

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                  • #10
                    Great link Jon, again.

                    I found this passage especially interesting: “I (Steven Pinker) have a chapter on verbs in this book because verbs are how we talk about causation, who did what to whom, who's responsible for someone's death. The answer to that is very much like who gets to be the subject of a verb. I argue that we have a sense of causal agency or responsibility that both governs our language and governs our moral and legal reasoning."

                    Try as I might, I struggle to get many students to understand that it is origin and not causation that leads us toward rational care. Trying to figure out how somebody got to be the way they are or making rapid pronouncements based upon intuition alone – the essence of the initial search for causation – is both useless and perfectly human. I think that this human tendency detracts from clinical success and, in my opinion, our patients need less “humanness” and more science when they see a therapist, so I discourage going into what I call the “black hole” of causation.

                    But if Pinker’s right (and arguing with him is a fool’s errand) and the search for the verb that is related to the cause is part of “our moral and legal reasoning” process, that would explain a lot about why so many therapists cannot easily abandon it, no matter the reasonable arguments against it.

                    I think there’s a relation to story and narrative as described here as well. After all, when Joe Friday said, “Just the facts mam,” he was cutting the story short and looking instead for the essential clues to solve the case; the narrative. Oh yes, and he wasn’t trying to make the person he was interviewing his friend.

                    Sounds like me.
                    Barrett L. Dorko

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