Greg Mahr’s article on using Narrative Medicine to evaluate the medical decision-making capacity of patients is a wonderful case study in the implementation of the medical humanities. Appearing in the Journal of Evaluation in Clinical Practice, the paper contains frequent, concise insights into the goals and possibilities of Narrative Medicine.
The article is well-written and presents the traditional model of assessing patients’ abilities, the issues inherent in it, Narrative Medicine’s viewpoint, and an alternative, narrative decision-making assessment. (The presentation is very much like a story!) Mahr says, and I agree, that
Narrative medicine has been an effective and powerful tool in reshaping medical practice. It’s odd, then, that when contrasting the outcomes of the “traditional” assessment and the “narrative” assessment,
narrative assessments should arrive at the same conclusions as traditional assessments, but without the ethical and philosophical difficulties embedded within the traditional assessment.
The three case studies which Mahr provides come out the same, whether the “traditional” rubic or the narrative rubric are used. One case study comes out the same,
but for slightly different reasons, one
avoids the complex inference of a patient’s mental state, and one helps the treatment team caring for a drug user sleep better at night.
I understand the necessity of showing that Narrative Medicine isn’t quackery, that it comes to similar conclusions as “traditional” or “evidence-based” medicine, except that it keeps the patient, their humanity, and their experiences in the center of care. I also appreciate Dr. Mahr’s delicate handling of a sensitive, essential topic: whether or not a patient is able to decide the course of their own medical treatment.
One of my great life goals is to show that stories and narratives aren’t just pretty or nice. (The technical term for this is “namby-pamby-wishy-washy-artsy-fartsy”.) We understand one another and ourselves through the telling of stories, which makes them essential. Mahr does a wonderful job of demonstrating the importance of narratives in his own field of Psychiatry and for medicine in general:
The [psycho]analyst attends to the patient’s story, empathizes and serves as a holding container for elements of the patient’s story that he cannot himself yet bear. At the proper time, the analyst interprets; that is, reframes and recontextualizes the patient’s narrative, incorporating drives, impulses and past material that enrich the story.
Human experience is captured by story; different stories can be articulated, the choice of narrative path enriches or constricts freedom, choice and meaning. Narratives are neither true nor false, just as great works of fiction are neither true nor false, but rich and meaningful.
Central to this outlook, patients are persons seeking help with their health. They are not their symptoms or symptom clusters, not their diagnoses or their illnesses. Patients are persons who come to our offices with expectations, fears and hopes. Narrative is the core human way of giving meaning to experience. People act on the basis of meaning, the constellation of ideas and interpretations people have about what is going on. Narratives organize experience; they are shaping and forming tools. Daily and primal, the stories we tell and hold about our lives inform and reflect meaning we create and discover in our lives. Telling the story allows us to express what is significant in our lives, to communicate how things matter to and for us.
The big question, then, is what does an understanding of narratives do for us as patients, what does it do for those in healthcare who heal us? The most concrete evidence Mahr writes about is that a healthcare team
can feel less doubt about [their] conclusion and sleep better at night about a young man refusing treatment and announcing his intention to return home and continue a cocaine binge. I don’t want to minimize how difficult it must be to treat someone who promises to keep destroying their own body, and how it must keep people up at night.
There are a number of ways to deal with the stress of less-than-ideal health outcomes, however, and if we’re going to make a case that Narrative Medicine is a sea change in the care of patients, the question is bound to come up: “What else have you got?”
This particular article is a wonderful microcosm of what happens with medical humanities and Narrative Medicine in general. Mahr writes that
Narrative medicine is a philosophy and a skill set. The trouble is that the Narrative Medicine skill set is usually divorced from the practitioner’s interactions with the patient. Mahr writes about the narrative, participatory nature of psychoanalysis and psychotherapy from their beginnings with Freud and Jung. If a psychiatrist
reframes and recontextualizes and
mobilizes people’s prerogative to … plot alternative stories, the patient is at the center of their own care. If all a narrative assessment does is assess and not allow the patient to participate in the direction of their treatment, of course the assessment will come to the same conclusions as the older models.
Most of the “skills” elucidated by Narrative Medicine are much like this assessment: they are analytical skills divorced from the practice of medicine face-to-face with the patient. If Narrative Medicine is to continue to have an impact on patient care, there must be a tangible change in how the patient’s narrative and story are handled at each stage in medicine.
The article reviewed: Mahr, Greg. “Narrative Medicine and Decision-Making Capacity.” Journal of Evaluation in Clinical Practice 21, no. 3 (2015): 503–7. https://doi.org/10.1111/jep.12357.