Psychiatric Bulletin (2006) 30: 432-434. doi: 10.1192/pb.30.11.432
© 2006 The Royal College of Psychiatrists
Psychiatric Bulletin (2006) 30: 432-434
© 2006 The Royal College of Psychiatrists
The use of literary analysis in advanced communication
Paul Wallang, Senior House Officer
Department of Psychological Medicine and Psychotherapy, University
College Hospital, 5th Floor, Rosenheim Building, 25 Grafton Way, London
WC16AU, email:
Paulwallang{at}hotmail.com
Declaration of interest
None.
 |
Introduction
|
|---|
Narrative medicine is a well established academic field and has been shown
to increase clinical skill and improve the therapeutic relationship of those
who study its principles (Banks et
al, 1995; Jones,
1999). Literary analysis is a convenient means of fostering
advanced communication skills. Moreover, the skills gained from such an
education are highly applicable to everyday psychiatric practice. The evidence
for the efficacy of narrative medicine is well established, and on this basis
a strong argument can be made for its inclusion as a compulsory part of the
current MRCPsych course.
|
|
Background
|
|---|
Several months ago I was lucky enough to attend a lecture given by the
neurologist Oliver Sachs at King’s College, London, which focused on his
interest in patient narratives and included many anecdotes from his years of
practice. It was highly amusing and interesting on two levels. The first was
the emphasis Sachs placed on the patient’s history or so-called
narrative structure and its central importance in understanding the internal
ruminations of its bearer. The second was a reminder to myself of a course I
was fortunate enough to participate in while an undergraduate at the
University of Manchester School of Medicine.
A list of possible study modules, especially medical ones, usually includes
the most banal choices, however hidden among my undergraduate options was the
intriguing title ‘Tolstoy and the art of patient perspectives’.
None of my friends had the faintest idea what this was about, and the title
was so peculiar that most steered clear of the course. I telephoned the doctor
running the course and he explained to me that through analysis of literature,
students could gain a greater sensitivity of the subtleties of language, which
would, in turn, lead to a greater appreciation of patient narratives and
histories. I was hooked and have been ever since. Which is why Sachs’s
lecture was so resonant. What I learned in that 3-week course at medical
school changed my perception of language and still endures in the way I
practise today.
Narrative medicine is not a new concept. Many readers will be familiar with
its broad principles, but it is unlikely that they will have studied its
theory formally or applied its concepts since its inclusion in undergraduate
or postgraduate courses in Britain remains rare.
In the USA the story is very different. Narrative medicine is well
represented in most medical departments and has been an academic subject in
its own right for around 30 years. In 1994 around one-third of American
medical schools taught literature to undergraduates and since then the number
has grown substantially (Banks et
al, 1995). Its benefit has been demonstrated in many studies
and is now seen as a convenient means of enhancing communication skills
(Charon, 2001). Because very
few British medical graduates will have experienced any tuition of this sort,
my experience remains fairly rare. I wish to demonstrate in this article how
narrative medicine can be extremely useful and how the principles can be
readily added to the curriculum.
|
|
Personal experience
|
|---|
In those 3 weeks at medical school, along with the course tutor Dr Tim
Dowling, and another student, I read and analysed a series of stories and
poetry and discussed the texts after every piece had been digested. The
initial and most important was Tolstoy’s short story The Death of
Ivan Ilyich. This gives a detailed account of a man’s insidious
slide towards death. Along the way we are presented with the physical and
mental anguish that accompanies his demise, and the story forces us to reflect
on our own perception of what death constitutes and the emotional maelstrom it
creates.
The course also included poetry by T. S. Eliot, W. B. Yeats and Sylvia
Plath, all of whom display a profound sense of the human condition and
demonstrate a remarkable understanding of the intricacies of both verbal and
non-verbal communication. These texts were analysed and discussed, with
particular emphasis placed on the themes, content, metaphor and imagery
employed as vehicles for emotional resonance. The basic premise of the course
was to allow the student to gain an appreciation of literature and therefore a
familiarity with and skill when dealing with narrative structures. These
skills could then be transferred to everyday clinical practice. There were
three main elements to the approach as taught by Dr Dowling: narrative
appreciation, substitute experience and narrative as a therapeutic tool.
|
|
Narrative appreciation: honing language sensitivity
|
|---|
Narrative appreciation involves becoming highly accustomed to the structure
and nuances of a piece of writing. The very act of systematically analysing
and digesting The Death of Ivan Ilyich or The Bell Jar by
Sylvia Plath will equip the reader with an ability to tease out important
features, phrases and subtle meanings of speech or writing. The flexibility
and idiosyncrasy of language is frequently encountered in clinical practice
and any development in the appreciation or interpretation of such language
will immensely aid the understanding of particular narratives.
|
|
Substitute experience
|
|---|
Most people will have very little understanding of what it is like to
suffer the stress of a hereditary brain disorder or having to undergo
electroconvulsive therapy. However, literature allows the reader to access a
vast repository of experience. Many writers demonstrate such a profound
understanding of the vicissitudes of disease that their writing could be used
as verbatim case studies. For example Plath’s The Bell Jar is
an intense account of the mental illness suffered by the lead character Esther
and the experience she undergoes while being treated for intractable
depression. (The story parallels Plath’s own life closely.) As well as
being highly emotive, the prose supplies an experience by proxy, delivered
through the eyes of an accomplished communicator. Moreover, Esther’s
fear, inner turmoil and disorientation are all laid bare, which gives one some
sense of her condition. The following extract gives a sense of her
predicament:
‘Whenever I sat on the deck of a ship or at a street café in
Paris or Bangkok, I would be sitting under the same glass bell jar, stewing in
my own sour air’ (Plath,
1963).
Plath chose the image of a bell jar because it is enclosed and alienating,
forming a barrier between Esther and the rest of the world. Its use also
suggests she has no control over her circumstances. Patients seen in clinic
every day will also use personal analogy to describe their own symptoms.
Many works of literature paint such extraordinary and
‘realistic’ descriptions of emotional experience that keen
observers can find within them a lifetime of human psychology. For this reason
they are essential teaching resources.
|
|
Narrative therapy
|
|---|
It has long been known that the very act of expressing one’s
anxieties has a positive effect on the mind
(Banks et al, 1995).
It seems that the divulgence of personal experience forms a vent, releasing
anxiety and stress, and acting almost like a pressure valve
(Panichelli et al,
2005). An enhanced ability to allow the divulgence of personal
history is an area that has been underdeveloped in mainstream clinical
practice, perhaps because of time constraints or possible ignorance. Reading
and appreciating well-written literature can help one to explore the universal
traits of the human condition and allow one to focus on the cathartic elements
of patient history by developing an understanding of the patient’s
perspective. It cannot be stressed enough that it is this sensitivity which
allows the patient to share their burden
(Curbow et al, 1999).
It follows from this observation that having a greater understanding and
ability to appreciate their ‘story’ will be more rewarding in
therapeutic terms. Many studies have continually demonstrated that patient
satisfaction stems from the practitioner understanding the patient’s
anxieties and most importantly demonstrating this
(Arborelius & Fossum,
2004).
|
|
Discussion
|
|---|
My undergraduate study module ‘Tolstoy and the art of patient
perspectives’ was successful in melding together two ostensibly
unrelated subjects and demonstrating how they can be used together and taught
effectively to enhance clinical practice. One must not forget that literature
is not the only means of developing a keen sensitivity to human emotional
states; music and fine art are both as important. However, literature provides
the most applicable and expedient means of fostering enhanced sensitivity to
patient communication because of its verisimilitude.
Some previous articles reviewing narrative medicine have advocated the
introduction of a dedicated reading list but have not made a case for tuition
in analytical skills (Beveridge,
2003). It must be emphasised that the mere reading of books is not
sufficient. A degree of formal analysis must be employed to allow reflection
on the themes, structure, content, nuance, imagery etc, which infuse not only
literature but all speech in general and provide intricate clues to the
emotional state of an individual. These analytical skills cannot be mastered
by reading alone. Initially such techniques could be taught in a discussion
group, with the basic analytical skills being refined through future exposure
to literature and patient narrative in tandem. It is this process of analysis
and therefore transferable skill that is paramount.
Those best placed to provide this tuition would be well versed in the
process of literary analysis. A truly multidisciplinary approach incorporating
members of the English faculty would be preferable. This model is used to
great effect in the USA, with ‘literary scholars’ participating in
discussion groups (Banks et al,
1995). Those providing the tuition would not require any esoteric
knowledge of medicine. As argued above, the principles of analysis can be
applied as readily to a consultation as to a poem by T. S. Eliot.
The current MRCPsych course could easily accommodate a short series of
illustrative lectures and discussions equipping students with the required
analytical skills. No formal examinations would be required, emphasis should
be placed on enjoyment of the material itself. The process, if practised over
time, would become ‘unconscious’, enriching the consultation but
not interrupting its flow. It is hoped that in time the tuition would be
disseminated among other colleagues and undergraduate students, eventually
becoming ubiquitous and a necessity for best clinical practice.
The arguments above demonstrate that the principles of literary analysis
can be used as an adjunct to diagnosis and therapy in everyday clinical
practice. Furthermore, I would argue that the addition of arts courses to the
syllabuses of medical schools is not something to be considered an
extravagance or exotic extra but an essential aspect of the future direction
of medicine (Charon, 2001).
Evidence from the USA and the UK shows that ‘literary medicine’
courses can be taught easily (Calman et
al, 1988) and with good cost-benefit parameters
(Banks et al, 1995).
The inclusion of such teaching in the MRCPsych course is long overdue and
would enhance patient-doctor interaction immensely.
Psychiatry more than any other specialty is at the interface between art
and science. This is why the College should be the first to acknowledge the
potential benefit of narrative medicine and should endeavour to take the lead
with the addition of a dedicated course in literary medicine to the MRCPsych
programme.
|
|
References
|
|---|
ARBORELIUS, E. & FOSSUM, B. (2004) Patient
centered communication: videotaped consultations. Patient Education
and Counselling, 54, 163
-169.[CrossRef][Medline]BANKS, J.T., CHARON, R., CONNELLY, J.E., et al
(1995) Literature and medicine: contributions to clinical
practice. Annals of Internal Medicine,
122, 599
-606.[Abstract/Free Full Text]
BEVERIDGE, A. (2003) Should psychiatrists read
fiction? British Journal of Psychiatry,
182, 385
-387.[Free Full Text]
CALMAN, K. C., DOWNIE, R. S., DUTHIE, M., et al
(1988) Literature and medicine: a short course for medical
students. Medical Education,
22, 265
-269.[Medline]
CHARON, R. (2001) Narrative medicine: a model for
empathy, reflection, profession and trust. JAMA,
286, 1897
-1902.[Abstract/Free Full Text]
CURBOW, B., FOGARTY, L. A., LINGARD, J. R., et al
(1999) Can 40 seconds of compassion reduce patient anxiety?
Journal of Clinical Oncology,
1, 371-379.
JONES, A. H. (1999) Narrative based medicine:
narrative in medical ethics. BMJ,
318, 253
-256.[Free Full Text]
PANICHELLI, S., FLANNERLEY, E., SHRODER, A., et al
(2005) Disclosure of distress among anxious disordered youth:
differences in treatment outcome. Journal of Anxiety
Disorders, 19, 403
-422.[CrossRef][Medline]
PLATH, S. (akaVictoria Lucas) (1963) The
Bell Jar. London: Heinemann.
TOLSTOY, L. N. (1960) The Cossacks, The
Death of Ivan Ilyich, Happy Ever After (trans. Rosemary Edwards).
London: Penguin Books.
Top
Introduction
Background