(1)
University of Virginia, Charlottesville, USA
Abstract
Doctors and health-care professionals have recently developed a vigorous new interest in narrative. The new medical interest (obvious in the titles and subtitles of research studies) follows the success of a so-called narrative turn in psychology, education, social sciences, political thought, policy analysis, law, theology, and cognitive science (The travelling concept of narrative, 2006, pp 20–41). A narrative turn has even supplied the framework for an entire rethinking of medical education and practice, as described in an important JAMA article on “narrative medicine” (Journal of the American Medical Association 286: 1897–1902, 2001). This new medical attention to narrative is international and cross-cultural. The British Medical Journal published a series of articles on “narrative-based medicine,” subsequently collected as a book (Narrative based medicine: Dialogue and discourse in clinical practice, 1998). It is now accurate, as awareness deepens, to speak of narrative-based medicines, plural, indigenous as well as postindustrial (The Permanente Journal 12: 88–96, 2008). Pain medicine too has begun to explore narrative. In 2005, the International Association for the Study of Pain published Narrative, Pain and Suffering (Narrative, pain, and suffering, 2005), and medical journals regularly include studies that employ narrative as an instrument for understanding pain and pain-related states. The traditional medical landscape—where narrative was barely tolerated as a sign of high culture—has changed forever.
The brain is the organ responsible for all pain.
John D. Loeser (1991)
Introduction: Narrative and Cognition
The medical interest in narrative coincides with new attention to the narrative quality of human cognition. Human neurobiology, according to this line of inquiry, equips us with an inherently “narrative brain” (Newman 2005). An emerging scholarly consensus finds narrative indispensable to mind or consciousness (Bruner 1990; Turner 1996; Michael and Sengers 2003; Fireman et al. 2003; Gottschall and Wilson 2005). More precisely, narrative proves indispensable to mind or consciousness as they are dominated by the language-rich left hemisphere of the human brain. Brain neuroanatomist Jill Bolte Taylor, after suffering a massive left-hemispheric stroke, discovered during her 8-year recovery that the “most prominent” functions of her left hemisphere included “its ability to weave stories” (Taylor 2006). She fondly refers to her left brain as “my storyteller.” Stories kept pouring forth without her intent. Taylor was not telling stories: rather, storytelling is what human brains, left to their own biological and cultural devices, just do.
The neurobiology of narrative remains imperfectly understood, as do the complex relationships among narrative, health, and illness. Certain stories—erotic or comic tales—implicitly affirm the interrelations between minds and bodies, as evidenced in the effect of laughter on vascular and respiratory systems or in the biology of sexual arousal. “Narrative therapy” holds a respected place among recent innovations in clinical psychology, Family dynamics, and community work (White and Epson 1990; White 2007; Madigan 2010). Mind/body medicine, however, rarely focuses on narrative, and pain medicine–with a few exceptions (Carretal 2005)–mostly ignores it in favor of a scientific knowledge of neurons, neurotransmitters, opiates, and analgesics. It is still unclear what exactly narrative has to do with pain. This chapter, in posing neglected questions about the intersection of pain and narrative, explores not only how narrative influences pain but also how narrative, in its largest medical application, might provide an analogy for the invention of a new and integrative model of pain.
A new integrative model of pain will have to encompass a role for narrative, and narrative offers a useful analogy (no more, no less) for thinking about a new integrative model of pain. Narrative thus holds at least indirect relevance to the professional thinking that relies on mental maps and models. The key point: narrative is not trouble free, and therefore an integrative model of pain that accounts for narrative cannot be trouble free. Pain and narrative are both irreducible to certainties. Quantitative analysis alone cannot master the open-ended matrix of variables at stake in pain (Carr 2005). In fact, core uncertainties make fully objective knowledge of pain a pipedream. Uncertainty is constitutive of pain—especially chronic pain—much as it is a constitutive principle in quantum mechanics. (Simply put, if you measure the position of an electron, you cannot know its velocity; if you measure velocity, you cannot know position: uncertainty is built in.) A new integrative model is valuable not because it is trouble free but because it seeks to account for the uncertainties intrinsic to pain as the experience of a brain-based, culturally inflected, and narrative-driven human consciousness.
What Is Narrative?
Narrative, while open to endless complications in the hands of skilled narratologists (Hyvärinen 2006; Herman 2007), lends itself to a straightforward definition useful in medical settings. Philosopher and novelist Richard Kearney (2002) reminds us of its basic communicative function when he defines narrative—from the Latin narro = to tell—as “someone telling something to someone about something….” Kearney’s approach is significant for defining narrative through its function, and his functional definition helps move the discussion of narrative beyond a narrow concern with fiction. “Tellings” occur in nonfiction and in everyday lifes as well as in stories, and (in preference to the more restricted concept “story”) narrative extends to various communicative forms and practices from dialogue to description. Narrative thus makes immediate contact with pragmatic everyday activities clearly relevant to medicine in which, despite charts and tests and a preference for evidence-based data, someone is forever just telling something to someone about something.
A definition of narrative restricted to its communicative function nonetheless fails to encompass its widest social and personal significance. Narrative matters finally because people do not just tell stories. We live stories (Eakin 1999; Holstein and Gubrium 2000). Physician and therapist Rachel Remen makes the strongest case when she writes, “Everybody is a story” (1996). The deceptively simple statement merits a second look: it does not say that everbody has a story but that everybody is a story. Storytelling, as Remen describes it, is not only something we do. Stories are not only something we possess, like a credit history. In Remen’s account, the performative activity of storytelling constitutes the self. We are stories, stories are us. Narrative, in this sense, can offer clinical insights especially relevant to the lives of chronic pain patients, who regularly adopt a strategy of silence to conceal their day-to-day condition even from close friends and family members. Even the absence of story—beyond any difficulties in communication—may in fact prove an important clinical observation that exposes the erosion selfhood so common and perilous among people in pain.
Narrative, to summarize, is increasingly regarded as a basic human cognitive activity. Its biology, involving networks concerned with language, memory, time, and causation, among others, is centered in the left hemisphere, and its communicative function holds implicit, if unacknowledged, relevance to standard medical practices from patient histories to interviews and “clinical tales” (Sacks 1985). Modern medicine, despite its close association with scientific and technological change, has always been a cryptonarrative enterprise in which stories contributed implicitly to the structure of medical knowledge (Hunter 1991). The recent narrative turn, by contrast, brings an explicit focus to medical communication and to the uses of narrative in diagnosis, treatment, and beyond (Green halgh and Hurwitz 1998). Its serious challenge to traditional medical education and practice is well represented by the Program in Narrative Medicine, founded in 2000 by Rita Charon at the Columbia University College of Physicians and Surgeons.
What Is Narrative Medicine?
Narrative medicine, as Rita Charon describes it in her ground-breaking JAMA article (2001), is medicine practiced with “narrative competence.” Narrative competence, as Charon defines it in a strategic move, complements (rather than disrupts or calls into question) standard Western biomedical procedures. It is an add-on, reformist rather than revolutionary, improving what already exists. This strategy serves a useful purpose in recommending narrative within the pages of a medical journal dedicated to scientific studies and to evidence-based claims. Charon’s argument challenges standard biomedical thinking, however, in its departure from the usual patronizing medical-humanist claims that reading so-called great literature somehow (in ways unspecified) produces better doctors. Narrative, as she recommends it, offers medicine a fresh vision.
The importance of narrative for understanding medical issues is a persistent, if minor, theme in recent scholarship (Kleinman 1988; Mattingly and Garro 2000; DasGupta and Hurst 2007; Diedrich 2007). Doubtless it is more accurate to refer to narrative “medicines,” Plural indiegnous and ongoing as well as postindustrial and newfangled (Morris 2008). Charon’s crucial innovation, however, is to identify “narrative competence” as a specific medical skill. Moreover, she bases the argument for narrative medicine on two fundamental principles: epistemological and educational.
The epistemological foundation of narrative medicine identifies narrative as a form of knowledge. Knowledge is the key term. That is, narrative can no longer be erroneously identified with fiction alone. Charon’s account defines narrative competence as a specific means of knowing, and it defines narrative knowing as a distinctive kind of knowledge. The emphasis on knowledge effectively disarms long-standing dismissals that impugn narrative as inherently resistant to scientific analysis. Instead, narrative competence and narrative knowledge assume a complementary position alongside the traditional data-driven, high-tech, medical knowledge that Charon calls “logicoscientific.” This new epistemic status for narrative as a form of knowledge that complements logoscientific knowledge, however, accomplishes only the conceptual reform. Its implementation in reforming the practice of doctors requires significant changes in medical education.
Narrative competence requires, Charon argues, that doctors and health professionals learn the specific skills and ways of thinking necessary to access narrative knowledge. It is the job of medical education to teach such skills in narrative competence. The specific skills—not relevant to describe in this chapter—all of course support the implicit argument that narrative is worth attending to. But is it?
Almost all pain patients have personal stories to tell about their pain. Cultural stories also abound. For example, many patients openly believe the discredited story that pain holds a one-to-one relationship with tissue damage. They may also be unaware of the economic narratives at play, including possibly harmful links between pain in the workplace and disability payments (Mendelson 1992; Fordyce 1995). If narrative knowledge is to be as valid by its own standards as logicoscientific knowledge, gaining new skills is indispensable. In particular, medical practitioners must learn to deal with the two most significant sources of predictable uncertainties basic to every narrative encounter and basic to every valid claim of narrative knowledge: interactivity and intersubjectivity.
Predictable Uncertainties: Interactive and Intersubjective
Certainty in medical matters comforts patients as much as it reassures doctors, but second options and false positives indicate how often in practice medicine must deal with real-world uncertainties. Complication is already a familiar medical term, referring to extrinsic morbid processes or events that arise during the course of a disease or its treatment: in short, to predictable uncertainties. Pain is a magnet for complications and uncertainties. Appropriately, in Complications: A Surgeon’s Notes on an Imperfect Science, Atul Gawande (2002) devotes an entire chapter to pain. It is thus not a fatal objection to observe that narrative (like pain, disease, and medical treatment) requires professional vigilance to monitor uncertainties that are built into the structure that makes its knowledge possible.
One main source of predictable uncertainties in narrative (which makes it such an irritant within logicoscientific or strongly science-based disciplines) is a human interactive structure. Unlike a moon rock or an inflamed tendon, narrative requires at least two human parties who interact. This interactive structure—requiring teller plus receiver (or an implied receiver)—proves at least as important as whatever is said. When someone tells something to someone, the narrative content (the “something”) varies with tellers or tales, but the interactive structure remains constant. Any account of narrative content is flawed, then, if it ignores the interactive process between teller and receiver that ultimately produces the content. Narrative theorists in recognizing the importance of receivers invented a new subdiscipline known as “reader-response” criticism (Tompkins 1980), and renewed attention to the act of reading typifies late twentieth-century literary analysis from various schools of thought (Iser 1978; Jauss 1982; Miller 1998). While narrative content varies, then, from Greek myths to medical case histories, the stable narrative structure of teller-plus-receiver makes storytelling always (as Kearney puts it) a “quintessentially communicative act.”
Communicative action adds predictable uncertainties to narrative, since communicative acts (unlike physical actions such as a bike ride) cannot be performed alone. Narrative, as Kearney insists, is “intrinsically interactive”—and for Rita Charon the pluralized two-person interactive process means that narrative knowledge cannot be reduced to objective data. “Narrative considerations,” she writes, emphasizing a social, multivariant, interactive process, “probe the intersubjective domains of human knowledge and activity, that is to say, those aspects of life that are enacted in the relation between two persons.” Persons here is a structural term indicating not two actual humans but rather the dual narrative positions of teller and of receiver. Uncertainties multiply with multiple actual receivers, as any group watching a film (and disagreeing about it) attests.
Predictable uncertainties implicit in its interactive structure mean that narrative resembles a verb as much as a noun, like the tango. It takes two to story. The intersubjectivity of narrative knowledge can introduce significant complications in medical settings, but it is important to distinguish intersubjectivity from the scarecrow subjectivity. Intersubjective knowledge differs fundamentally from subjective knowledge because it escapes from solipsism: individual claims enter a social realm where they are tested and contested alongside other evidence, as in a courtroom. Medicine, in its reliance on more than objective data, is learning to deal with inescapable forms of intersubjective knowledge, as when doctors need translators to communicate with nonnative-speaking patients. The predictable uncertainties that arise (is a family member translating correctly? does depression carry the same values or meanings in Asian and in Anglo cultures?) make uncertainties about meaning impossible to foreclose. Medicine regularly deals with the unforecloseable idiosyncrasies of organic life, however, as when doctors encounter a woman with two wombs (Bates 2009), and the narrative uncertainties predictable in an intersubjective and interactive communicative process assume, by comparison, a modest place amid the unruly scene of human illness.
The uncertainties native to narrative, as well as to pain, cannot be safely ignored. A patient’s illness narrative simply cannot be extracted quickly, cleanly, completely, like an impacted wisdom tooth, as if the receiver now possessed an objective fact. Narrative just does not work that way. Its inherent intersubjective and interactive structure means that narrative is irreducible to an objective stable content: a story told today may change tomorrow, or a nurse may learn significant details withheld from the doctor. In addition, narratives are never mere containers for meanings. Words and images may carry an emotional charge far in excess of their social meanings. Emotions, like a personal subtext or supplement, may prove far more important and inexplicable than thoughts, just as certain myths invite centuries of reinterpretation by receivers from renaissance neoplatonists to contemporary Jungians and poststructuralists.
Narrative texts, then, always include predictably unstable elements—emotional nuance, words, metaphors, symbols, sounds, or sheer mumbo-jumbo—that open up meaning to a conflict of interpretations. The importance of linguistic texture and its uncertainties applies even to the verbal codes that narrative analysts assign to themes and content. Agreement about such codes already requires an intersubjective and interactive process among researchers, open to the human variables of institutional power, personal schedules, and funding guidelines. Such processes open narrative to uncertainties, but they do not disable understanding. In fact, language, despite its inherent slipperiness, is a rich field of clinical observations, as when a chronic pain patient describes her experience in a punitive religious vocabulary (Morris 2009). Inescapable uncertainties in interpretation are testable by—however radical it sounds—asking the patient (Cassel 1982). The exchange will fail to produce certainty, but it does create an intersubjective knowledge, and it may well advance treatment.
Pain and Narrative: Predictable Uncertainties
Pain specialists, in particular, might benefit from an attention to narrative and to its implicit uncertainties, for several reasons. First, narrative, like pain, always comes with filaments attaching it to the social world. Moreover, patients may conceal or remain unaware of filaments they find shameful or distressing, such as chaotic families or spouse abuse. Social differences of age or race or gender can also inflect narrative toward silence or oblique disclosure. Individual narratives too often reproduce patterns circulating within a culture. Patients may unknowingly produce personal narratives that, without conscious intent, replicate patterns from an episode on Oprah or from an article in People magazine. The point is not to debunk patient accounts as unreliable but to stress that narrative interactions—even and especially in pain medicine—always reflect, if indirectly, specific sociocultural circumstances (Morris 2010b).
Second, narrative uncertainties mirror and help explicate the predictable uncertainties implicit in pain. Is reflex sympathetic dystrophy a meaningful diagnosis, or is it destined to occupy the limbo of exploded diseases like the nineteenth-century pain syndrome “railway spine?” A professional task force asserts that pain is “always unpleasant and therefore also an emotional experience” (Merskey and Bogduk 1994). How far do nebulous or compounded emotional states—grief, guilt, loneliness—alter or interpenetrate pain? Meanings also possess the capacity to slide away from clear and distinct ideas. In an assisted care facility, an elderly arthritis-ridden patient with a touch of dementia keeps repeating that she wants to go home. Her family brings her home for Thanksgiving. She walks inside, looks around, and says, “I want to go home.” Content analysis alone will not dissolve the uncertainties, cognitive and emotional. No authority can say exactly what this mini-narrative means. Pain specialists face such problems daily in understanding not only people with special difficulties in communication (such as the elderly, children, Alzheimer’s patients, and nonnative speakers) but also people whose pain entails difficult personal or social circumstances (such as torture victims, HIV/AIDS patients, incest survivors, and the poor).
Everyone (it seems) has a story to tell about pain. The stories, however, usually do not treat pain as an object of description—in the manner of the famous McGill Pain Questionnaire (1971), which regards pain as a noun-like state knowable (or at least trackable) through its location on a grid of adjectival descriptors. In narrative contexts, by contrast, pain emerges mainly as a verbal, lived experience situated within a complex social world with filaments that reach beyond job, family, and substance abuse. Further, such narratives may infiltrate and modify the very pain they describe, much as a victim-narrative or disability-narrative can modify pain by enlisting it within a specific social practice or individual form of life. Pain is among the more elusive human experiences and changes not only over a day or year but also within particular social situations (worse at a lecture, say, better at a concert). Pain specialists are de facto clinicians and scientists of the uncertain. Narrative competence is a skill useful especially for its power to articulate and to anticipate relevant uncertainties predictable in the experience of pain.
Narrative in Pain Medicine: What Good Is It?
Narrative competence is not yet a skill required for pain specialists, but narrative already holds a firm, if often unappreciated, presence within pain medicine. Interviews, for example, are a standard source for data in the recent medical literature on pain, especially semistructured, unstructured, and open-ended interviews. Researchers often study such interview data through qualitative “narrative analysis.” The recent medical literature on pain contains specific studies of patients’ stories (Werner et al. 2004; Winslow et al. 2005; Råheim and Håland 2006; Corbett et al. 2007; McGowan et al. 2007; Morone et al. 2008; Steihaug and Malterud 2008). There is even one study of physicians’ stories (Vegni et al. 2005). These published studies do not reflect the largely undocumented use of oral patient narratives within support groups at pain management programs. Narrative thus already makes a solid if somewhat secretive contribution to pain medicine, both in research and in treatment.
The relatively low profile of narrative within pain medicine, despite increasing numbers of studies that employ it, suggests the need to address openly a basic pragmatic question. What, in particular, can narrative do for pain medicine? Bluntly, what good is it? What, specifically, is it good for? Rita Charon has discussed possible contributions of narrative in pain medicine (2005). Here, as a supplement, it seems worthwhile to examine the value of narrative to pain medicine in five specific areas: communication, diagnosis, treatment, ethics, and education. A brief survey of each area can suggest how and where narrative performs specific, valuable work.
Communication
Communication in medicine is a perennial problem, much discussed, but pain medicine faces problems in communication that are distinctive if not unique. Clinical medicine depends on a gaze that penetrates into the body and effectively engineers out narrative (Foucault 1973). A formerly narrative, dialogical encounter between physician and patient (beginning with the open-ended invitation what is the matter?) shrinks into a closed-off query that can be answered with one finger (where does it hurt?). Attention to the interactive and intersubjective structure of narrative, then, offers to help pain specialists develop the communication skills crucial for dealing with patients for whom lesions and organic signs often correlate poorly (or not at all) with their lived experience. Narrative competence can uncover data otherwise inaccessible in standard interview questions whose results are interpreted regularly by erroneous assumptions about patient subjectivity and medical objectivity.
Narrative competence enriches clinical data in pain medicine, then, by opening up the field of discourse, but it does more. It directs attention. While listening to patients is a skill regularly lamented as missing or badly flawed, effective listening requires more than good will: it requires skills in identifying specific types of recurrent narratives. Sociologist Arthur Frank (1995) shows how individual patient narratives tend to fall into general types, such as chaos narratives (about lives falling apart) or restitution narratives (about unexpected gains that accompany illness and its losses). The medical literature already identifies some specific types of pain narratives, such as women’s pain narratives (McGowan et al. 2007), survivor pain narratives (Markovic et al. 2008), and stigma narratives of pain (Holloway et al. 2007; Goldberg 2010). The narrative payoff for pain medicine lies not only in a general improvement of listening skills but also in the competence to know what, specifically, to listen for.
Narrative inescapably raises questions about point of view (McKee 1997), and narrative competence holds proven value in addressing difficult questions that can be answered only from the patient’s point of view. What, for example, do victims of domestic violence want physicians to understand? Narrative has proved the right tool for addressing this question (Nicolaidis 2002). Narrative holds similar value for pain specialists not only in situations, such as sexual abuse, where secrecy or shame impedes communication but also where the patient alone knows the facts. Or in working with children, whose point of view does not necessarily coincide with adult vision (Carter 2004; Meldrum et al. 2009). Narrative has a proven track record too as a resource for understanding and for addressing the needs of patients in palliative care—where pain control is a primary objective and where the patient’s speech and point of view may be irretrievably compromised (Barnard et al. 2000). Narrative skills cannot offer access to changeless nuggets of objective truth, but they do provide supportive data and supplemental insights reliable within their limits. All instruments are limited, of course, and some fail. The key question is not what narrative can’t do, but what it can do.
Diagnosis
Diagnosis, as a technical matter of matching symptoms to diseases, may seem off limits to narrative, but who exactly sets the boundaries? And do the usual rules apply to pain? The answer might surprise a patient. Distinguished pain specialist Scott Fishman puts it this way: “When somebody comes in with 25 years of chronic pain, I might sit with them for 90 min to get the beginning of the story, to really understand what’s happening. The insurers would rather pay me $1,000 to do a 20-min injection than pay me a fraction of that to spend an hour or two talking with a patient” (quoted in Wallis 2005). The decision to exclude narrative, that is, comes here not from a physician skilled in pain medicine but from an insurer—an insurer with a financial agenda who may in fact or in effect overrule the physician.
What about the insurer’s legitimate concern over cost? Narrative is time-intensive when compared with an injection. If Fishman is correct about the clinical value of narrative, then there is a need to invent a cost-effective system that facilitates and advances narrative interactions: maybe a system in which paramedical aides do the more expensive preliminary narrative data-gathering. Interviews by medical sociologists or by trained doctoral candidates might reduce costs and pinpoint problems, with direct benefit (in cost and in effectiveness) to subsequent physician/patient interactions. Inventiveness in contemporary health care—so successful at discovering new technologies and new drug therapies—certainly can contrive cost-effective means to employ narrative in pain medicine if indeed narrative holds the benefits that Scott Fishman and others claim for it.
Narrative as a diagnostic instrument offers particular benefits through its privileged access to particularity and subjectivity: helping, specifically, to elucidate the irreducible differences in individual pain response. Age, gender, race, and ethnicity are well known to affect personal pain responses (Morris 2001), and narrative permits clinicians to probe behind such generic categories. The same age and race, for example, may hold different meanings for different individuals. It does not invalidate narrative as a limited instrument if, as happens rarely in medical settings, patients lie. (Then the clinical question, which narrative has crucially helped to elicit, is why the patient lied.) Narrative data, like all clinical data, also requires careful evaluation, but careful evaluation differs from hasty dismissals that misrepresent narrative as merely subjective, always unreliable, and medically insignificant. A patient narrative, albeit uncertain, intersubjective, and interactive, may often prove indispensable: the best evidence available.
A diagnosis in pain medicine already involves identifying what specialists call “pain beliefs.” Especially important are beliefs about cause, control, duration, outcome, and blame (Williams and Thorn 1989; Jensen et al. 1991), as well as beliefs about the need to protect individual identity (Eccleston et al. 1997). Such beliefs affect not only chronic pain but also acute pain and even postoperative pain (Williams 1996). Researchers find that patients function better who believe they have some control over their pain, who believe in the value of medical services, who believe that family members care for them, and who believe that they are not severely disabled (Jensen and Karoly 1992). In fact, specific pain beliefs can predict pain intensity (Williams and Keefe 1991) and correlate directly with treatment outcomes (Shutty et al. 1990). Quality of life in chronic pain is more associated with beliefs and perceptions, it turns out, than with pain intensity (Lame et al. 2005). An effective diagnosis simply cannot focus on tissue damage alone and ignore what patients think and feel. The brain—including its built-in cognitive, behavioral, emotional, conscious, and nonconscious capacities to alter any nociceptive stimulus—is the organ responsible for all pain (Loeser 1991).
The diagnostic value of narrative, as providing access to beliefs, coincides with its value in improved medical communication, and narrative is especially useful for identifying uncommon or idiosyncratic beliefs, hybrid beliefs, or conflicting beliefs. Narrative also proves useful for diagnotic purpose in identifying areas in which communication fails. The unsaid—as in the blocked out experience that torture victims cannot put into words—is sometimes just as important from a clinical perspective as what is said (Waitzkin and Magaña 1997). Narrative, as an instrument that registers significant absences, also points toward the social circumstances (including economic systems) under which speech occurs or fails to occur (Macherey 1978). Patients whose pain stops them from working, for example, may be unable to imagine a life without paid work. A conflict of narratives creates a mental-emotional dissonance worth noting, in a diagnostic spirit, for its possible impact on health.
Narrative can make an especially useful diagnostic contribution to pain medicine in focusing on emotion. Stories from King Lear to Little Red Riding Hood serve to express and to evoke feelings. Pain patients may tell stories in which emotions matter more than plot—stories, for example, that convey helplessness or guilt or anger. Although the manifest content (physician neglect, bureaucratic roadblocks, family strife) may be familiar, the latent emotional content of patient narratives can lead in strange, significant directions. Further, in addition to registering an absence of speech, stories may also expose telltale absences of emotion, perhaps indicating where depression imprints its blank signature on pain. Narrative in its close links to emotion thus proves sensitive to subtextual nuances of feeling that elude the broad net of “code-able” content. What is the code for the emotions—not the content or actions—reflected in a teenager’s bland half-truth about how he put out cigarettes on the back of his hand or how she razor-cut her upper arms?
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