Book Review

Psychoanalysis and Narrative Medicine

N Engl J Med 2008; 358:2303-2304May 22, 2008

Article

Psychoanalysis and Narrative Medicine
(SUNY Series in Psychoanalysis and Culture.) Edited by Peter L. Rudnytsky and Rita Charon. 308 pp. Albany, State University of New York Press, 2008. $89.50 (cloth); $29.95 (paper). ISBN: 978-0-7914-7351-1 (cloth); 978-0-7914-7352-8 (paper).

The emerging interdisciplinary field of narrative medicine has benefited in recent years from media attention and from formal institutional support. Psychoanalysis and Narrative Medicine is a collection of recent scholarly research in the field by professors of literature and the humanities, as well as by practicing physicians, psychotherapists, and patients — with some authors holding credentials in several camps. What is unique to this volume, as coeditor Peter Rudnytsky emphasizes in his excellent introduction, is the integration of psychoanalysis into the literature–medicine dyad.

The first chapter, written by coeditor Rita Charon, is a useful overview of recent initiatives to introduce humanities courses and courses focused on reading and writing skills into the medical curriculum. Advocates of such pedagogical reforms seek to counteract the image of the doctor as a detached figure of authority, knowledge, or power by encouraging practitioners to “recognize, absorb, interpret, and be moved by” patients' illness narratives.

The weakness of much of the theorizing behind these reforms is that the concept of narrative tends to be overgeneralized. For example, Neil Scheurich writes in his chapter of this book that narrative gives therapeutic power to medical practice and psychoanalysis and that it is the source of such “essential values” as “autonomy, complexity, curiosity, and . . . patience.” Unfortunately, such inflation of the meaning of the term “narrative” impairs its theoretical usefulness, makes it vulnerable to gross misreadings, and may lead some to dismiss it as irrelevant.

Almost all the essays in this collection, however, acknowledge the danger of such generalizations. Several essay titles alert readers to a healthy impulse toward ongoing critique from inside and outside the field — for example, “It's Really More Complicated Than You Imagine: Narratives of Real and Imagined Trauma” (by Bennett Simon), “Uncertain Truths: Resistance and Defiance in Narrative” (by Schuyler Henderson), and “Narrative and Beyond” (by Geoffrey Hartman). This willingness to confront the complicated and uncertain leads toward a “beyond” that is the very domain of psychoanalysis.

This volume poses the challenge for narrative medicine to, as Henderson writes in his chapter, “set an example for other branches of medicine by learning how to appreciate the defiance and analyze the resistance both in its own texts and in those that it scrutinizes.” “Narrative competence” can be understood to include a respect for counternarratives (accounts that challenge traditional methods of treatment and attitudes toward illness); ongoing self-critique; tolerance of conflict, contradiction, and multiple perspectives; and acceptance of the impossibility of reconciling the distance between doctor and patient. Many of the authors in this collection argue convincingly that the careful study of literature enhances medical practitioners' ability to function productively on that uncertain ground.

Like the term “narrative,” the term “literature” is subject to some broad overgeneralizations and some defensive justifications of its allegedly beleaguered values. Uneasy metaphors of “contamination,” “pendulum swings,” and “culture wars” that appear in several essays reflect the persistence of the oppositional thinking from which narrative medicine is trying to escape. In several instances, metaphor itself emerges as a model for more integrative, interactive relationships among disciplines and among patients, doctors, and illnesses.

Metaphor is embraced especially in the essays written by patients as “a potentially productive kind of not-knowing,” a “transformational technology” that helps us to imagine our “capacity for vitality and aliveness,” even in the midst of chronic illness or catastrophic loss. This emphasis on metaphor draws attention to the limits of a “practical and humane” narrative medicine that neglects the nonnarrative disturbances described by Hartman as the “hidden, oblique, unresolved aspects of patients' accounts of their illnesses.” Several essays reveal how crucial these counternarrative disturbances are to the transmission of trauma. As Hartman writes in his chapter, it is in these moments when the narrative thread is disrupted that “strong poetic figures come into play as forceful condensations.” Metaphor marks the “beyond” of narrative as mastery, and that beyond offers the rewards of aesthetic pleasure in form and the possibility of doctors hearing a new language — what Charon describes as “the language of pleasure, the language of loss, the language of life,” and not just the “tongue of complaint.”

This volume identifies the goal of narrative medicine, of psychoanalysis, and of teaching as a balance of “involvement and detachment.” Those who work and write from that double perspective will produce not neat chronological narratives, contained and masterful, but a “crazy quilt” or “tapestry” of multiple motives and insights that will be open to empathic as well as analytic ways of reading and relating.

Robin Lydenberg, Ph.D.
Boston College, Chestnut Hill, MA 02467