by Jan Parker
©Emma Barnard @PatientAsPaper
in Representing Trauma; Honouring Broken Narratives Special Issue
There are occasions when ‘literary’ academic writing abuts and can profitably engage with other disciplines and other professional practices. Life-writing, archaeological and land- and sound-scape writing and many other ‘New Humanities’ tackle the possibilities and practicalities of making Humanities narratives – meaning-making, significance-highlighting accounts – out of their subject matter.
None more urgent than Narrative Medicine; like life-writing to [auto]biography, literary geography to both literature and topography and material culture to both fine art and historiography, Narrative Medicine is charged with exploring, interrogating and challenging the received wisdom in and about the ethical and epistemological processes of both its disciplines.
For Medicine, based as it is in traditions of case study and pathography, Narrative Medicine stresses the hermeneutics of patients’ accounts, of attending to the silences and silenced as well as what is said. And the ethics, problematics and effect of mediating the experience and condition of those who, perhaps disenvoiced by that very condition, are unable to speak for themselves: the affordances of constructing ‘Broken Narratives’.
For literary narrative studies, patients’ narratives demand scrupulous attention to the ethics and responsibility of interpretation: to the effect of ‘applying’ analytical critical tools to an individual’s particular life story, life experience, pain.
For both there is the ethical challenge of constructing a narrative at all: of creating an ordered account with claims of ‘before and after’; ‘cause and effect’; and perhaps attributing or denying culpability.
Theatre directors talk about the contract they set up between stage and audience: about the structures of the world that the audience is entering, about the shape and affect of the experience. Literary critics are practised in analysing the contract between text and reader but have been accused of practising ‘cultural hygiene’: of developing, and teaching students to ‘apply’, techniques to distance the text.
For practitioners of medicine, this perhaps has two important implications: to be aware that they ‘stage’ the clinical encounter onto which they demand or invite the patient to ‘present’; and second, that they create, or better co-create, a narrative when they turn observations, vital signs and ‘data’ into an ordered account. That created narrative has to use the constructions that the discipline offers: about the role of medicine, its discriminating processes (of health from sickness and between diseases and treatments). And, in complex ways, those narratives are illuminated by as they illuminate non specialist models of health and sickness.
Together, the two fields, with such different ethical demands on them but with common or overlapping knowledge-making processes, can round out and explore the meta questions that both need to take for granted in day to day practice. As interrupted life stories (the narratives that patients develop in response to medical or other crises) reveal the unformulated expectations that are now challenged by illness, so the patient entering the consulting room ‘presents’ an account that reveals much about conceptions of health and illness, minds and bodies but also potentially about constructions of identity, integrity, moral worth, formation of character, guilt, shame … and finally, the human condition.
So, given that health and illness narratives are constructions:
- How can particular narratives be best ‘co-created’ between clinician and patient?
- What are the ethics and proper processes for turning [medical/psychiatric] ‘cases’ into ‘material’?
- What is it, and how best, to give that material its due?
- What is it to give an account of that material?
- What are the ethics and impact of ‘accounting for’, of [necessarily] interpreting, of giving one’s account when others’ accounts may be differently located?
- What is the effect of being so ‘accounted for’?
- What is the effect of exposing oneself to another’s narration?
- What is the effect of re-telling, re-presenting a traumatic event?
- How does one give a meaningful, significance-highlighting account of the material without appropriating it, alienating it from the teller, rendering it closed to other and others’ narratives?
- What are the ethics of electing and re-presenting ‘test’ cases?
- [As raised in the later articles in this issue] What are the ethics of electing and re-presenting test cases not in narrative but as ‘scenarios’?
This Special Issue is interested in narrative practices around medical, psychiatric and trauma care and in what it is to first hear and then to give an account of complex, psychological and ‘psychosomatic’ conditions.
For medical and clinical practitioners, it asks what it is to listen to, attend to, be co-present with a ‘patient’: what are the power relations and ethics of re-presenting and re-narrating someone whose narrative is broken – by illness, trauma, psychosis or a ‘condition’.
In so doing, they each raise questions about that accounted for and the ethics of the accounting: in both senses.
First, the Issue explores ‘Broken narratives and the lived body’; narratives of self harm as embodied expressions of pain; the psychiatrist experiencing, witnessing and co-constructing meaning while ‘weathering a violent storm together’ with her patient and the problematics of the ‘narrative work’ involved in ‘honouring a life’.
Then in a section about trauma narratives in/and art, we turn to narratives of ‘emotional breakup, suffering and wilfulness’, to visual and textual dialogues in a photo essay of mental illness, to music and post-traumatic discourse and finally in this section to visual media and intergenerational transmission of violence.
Representation and theatre
Finally, a different kind of envoicing in encounter is discussed in an article about using participatory theatre with medical practitioners, where audience members are drawn into participating and speaking for both the patient and others involved and implicated in a chronic problem’s treatment.
For whereas Narrative Medicine has emphasised the importance of attending to the patient as narrator and the clinician as co-constructor of narrative, many aspects of the medical encounter are actually multidimensional, formed of mutual and common interactions: intersubjective dynamics and affect that can be ‘played out’ in theatre.
Using theatre in this way draws attention to the power dynamics of the patient-clinician interaction: issues of control and ‘noncompliance’, challenge to authority; and also to the possible problematics of ‘empathy’: to negative intersubjective ‘affects’ which are usually unacknowledged, such as irritation, disgust, dislike – critical and judgmental reactions so far from the model of empathy!
And so in a final dialogue, a professor of medical ethics and her theatre director daughter explore the commonalities and differences between the two practices.
Narrative identity presupposes a storied life; broken and fragmented narratives show rather some of the layers that go to make up a narrative identity: the master and meta narratives that frame and structure experience; the counter and cover stories formed in times of trial. Such ‘master’ and ‘meta’ narratives come from social convention and sensibilities: concerning ‘health’; gender; medical intervention; behavioural norms …
In constructing any narrative, ethics demand that ‘selfhood’ be respected, even or perhaps especially when dealing with conditions affecting memory, recall or a unified sense of self. For ‘identity’ is a tricky term, connoting two overlapping but not identical (sic) ideas: of unique ‘quiddity’ and of ‘constant sameness’: yesterday as today. Memory plays an important role in constructing and maintaining both; certain of the cases referred to deal with conditions where memory impairment or fragmentation or trauma repress or debilitate the ‘storying’ self. In so doing, such cases ‘beat the bounds’ of the model of unitary identity.
All the cases here raise issues for identity and narrative studies, for instance by drawing attention to such terms as ‘the storied life’, ‘performative identity’ and a ‘narrative arc’. But they also raise the issue of the representation of trauma, repression, violence and mental illness. They involve encounters with those who are dis-envoiced in one way or another in a clinical setting, whose ‘storied selves’ have to be represented. We question what is the epistemological, educative, ethical, therapeutic and even, perhaps, re-traumatising effect of being so re-presented…