Last week, examining Greg Mahr’s ideas about assessing a patient’s decision-making capacities, I found it odd that there is nearly no difference between the outcome of a traditional decision-making assessment and a proposed, new narrative assessment. Mahr does a wonderful job of explaining why narrative is important and how a narrative assessment is focused on the patient’s understanding, rather than a physician’s wishes. The question remains, though: if the outcomes of a narrative assessment don’t differ from what is currently in place, why is it necessary?
Writing in Nursing Research and Practice, Joanne M. Hall and Jill Powell examine some real differences between current medicine and narrative medicine. Their article presents a wide review of available scholarship on narrative in use, specifically as it relates to mental health nursing.
With regards to the difference between the outcomes of current clinical language and proposed narrative practice, several dialogues are included in the paper from Powell’s experience:
In a third example, Heidi comes to the clinic often seeking benzodiazepines, on which she has become highly dependent.
Heidi: I need something for my nerves. Just give me a prescription.
Nurse: I cannot do that, Heidi; I won’t participate in your addiction.
Heidi: You are a bitch. I can always go somewhere else to get [alprazolam].
Nurse: I won’t participate in your addiction. I can refer you to treatment, because I have a goal that you could someday get along without it, do you think that could also be your goal? What about that?
Heidi: Bitch, all you can do is call me an addict. I am never coming back here!
In this case, a narrative approach was not tried. The client is not able to put her needs into the context of her life, feels labeled, and does not feel known, even though the nurse is consistent in terms of setting limits. We provide an invented dialogue that begins similarly, a dialogue in which a narrative based approach is used to get at the life or self-narrative.
Heidi: I need something for my nerves. Just give me a prescription.
Nurse: What happened to you to upset your nerves?
Heidi: You wouldn’t believe me anyway, so what is the use?
Nurse: Well, it would help if you told me about a time when the alprazolam made you feel less nervous.
Heidi: What do you want to hear? How about when I think of having 2 teenage kids and the medication makes me worry less about them.
Nurse: I am sorry that you have trouble with the kids. What have they done that worries you?
Heidi: One has ended up in jail for assault. Is that what you wanna hear?! So give me what I need—a prescription.
Nurse: I cannot write you a prescription, because I’m not sure it will make the situation better in the long run. How do you want this story to end?
Heidi: Bitch, I am never coming back here!
While the outcome of this story is similar to the real case, the addition of a narrative approach provides a context (her children) for her life, and provides for a clearer vision of Heidi as an individual, versus a label that keeps her a flat character, without a story. The second conversation might make Heidi feel known, and she may be surprised at this approach, when her usual experience is like the first exemplar. We believe there would be a greater chance of keeping the nurse-client relationship alive with a narrative approach.
Even in the midst of Heidi’s anger that she won’t receive a drug, the narrative approach is more likely to result in a patient realizing that there is long-term help available. It’s true that both conversations ended in
I am never coming back here!, but it’s also true that a client experiences that someone cares about the pressures behind their addiction.
Narrative Medicine is sometimes presented as an alternative to Evidence-Based Medicine. I don’t necessarily think the two are at odds. One of the big ideas behind narrative in clinical practice, though, is that the patient is elevated beyond a data point, and the provider-patient interaction is free to be human, as opposed to an algorithm. Although Hall and Powell are specifically discussing mental health nursing, I think their treatment of “Algorithmic Dialogue” is useful for any branch of practice:
Sometimes patients begin relating their initial presenting condition in terms of a story. Too often this story is interrupted because of the need to stay on track in assessing symptoms, with a focus on pathology. Mishler has analyzed the physician’s interview as interruptive of narrative. In this case, algorithmic thinking is informed by symptom accounts. This kind of questioning on the part of providers calls for yes or no client responses that are fitted into a decision tree, often also including specific medications to prescribe based on the yes/no answers about symptoms. Because this algorithmic line of questioning is tied to prescribing, advanced practice nurses who prescribe often also use the method in communicating with clients. The algorithmic method of questioning is thought to provide adequate information in the short time frames in which caregivers work. However, if the life narrative is not clearly understood, clinical decisions may be based on erroneous conclusions on the part of the provider, that ultimately cost more time and suffering before the right medication or therapy is found.1, 2
Hall and Powell also touch on specific techniques to elicit narratives. Their emphasis is always on questions asking “How?” Questions such as “How did that come about?” are ways to get someone talking about the events leading up to them coming in to seek treatment. The authors also take on the stereotypical therapist’s question, “How does that make you feel?”, noting that the question
may even make clients anxious or annoyed, especially if they have mixed feelings, hard to put into words. They much prefer to get details narratively, because
in narratives information about feelings and meanings are implicit. We can get the information with a few prompts for detail in stories.
One of the wonderful things Hall and Powell bring up is the idea of not directly asking a patient about their trauma or illness, but instead, asking for narrative information around events, and letting the information come out at a level the patient is willing to process. Asking a question such as “Were you abused as a child?” is not only a yes/no question, it’s something many people who haven’t dealt with the pain of abuse are willing to even recall. Instead, the authors recommend
providers might instead ask
What do you recall happening when you were young? Were there hard times? This phrasing was found to be helpful in a recent narrative study of thriving after abuse … but many of the lines of evidence of abuse were elicited when questions were framed as hardship stories of early life.3
Hall and Powell, like most proponents of narrative in clinical practice, know that more work is needed. I take it as a good sign, however, that there are concrete ways the authors describe successful clinical implementation of narrative techniques. These include narrative as an aide to face-to-face interactions with patients and clients, and also include ways that they see narrative communication encouraging patients to realize that they are cared for and encourage them to seek continuing care.
Narrative research methods, they write,
are being refined4 and adapted to illness and wellness contexts, and will be especially useful in the mental health field because many extant therapeutics depend on the language encounter between client and caregiver. The core of medicine has been described as communication, and although this paper describes one specific branch of practice as a
language encounter, those methods could well spread to other areas.
The article reviewed: Hall, Joanne M., and Jill Powell. “Understanding the Person through Narrative.” Nursing Research and Practice 2011 (2011): 1–10. https://doi.org/10.1155/2011/293837.
1 Mishler, Elliot G. The Discourse of Medicine: Dialectics of Medical Interviews. Norwood, NJ: Ablex Publishing, 1984. ↑
2 Mattingly, Cheryl. Healing Dramas and Clinical Plots: The Narrative Structure of Experience. Cambridge University Press, 1998. ↑
3 Hall, Joanne M., Marian W. Roman, Sandra P. Thomas, Cheryl Brown Travis, Jill Powell, Clifton R. Tennison, Karen Moyers, et al. “Thriving as Becoming Resolute in Narratives of Women Surviving Childhood Maltreatment.” American Journal of Orthopsychiatry 79, no. 3 (2009): 375. ↑
4 Riessman, Catherine Kohler. Narrative Methods for the Human Sciences. Sage Publications, 2008. ↑