The use of literary analysis in advanced communication

Narrative medicine is a well established academic field andhas been shown to increase clinical skill and improve the therapeuticrelationship 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 gainedfrom such an education are highly applicable to everyday psychiatricpractice. The evidence for the efficacy of narrative medicineis well established, and on this basis a strong argument canbe made for its inclusion as a compulsory part of the currentMRCPsych course.

Background

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Background

Several months ago I was lucky enough to attend a lecture givenby the neurologist Oliver Sachs at King’s College, London,which focused on his interest in patient narratives and includedmany anecdotes from his years of practice. It was highly amusingand interesting on two levels. The first was the emphasis Sachsplaced on the patient’s history or so-called narrativestructure and its central importance in understanding the internal ruminations of its bearer. The second was a reminder to myselfof a course I was fortunate enough to participate in whilean undergraduate at the University of Manchester School ofMedicine.

A list of possible study modules, especially medical ones, usuallyincludes the most banal choices, however hidden among my undergraduateoptions was the intriguing title ‘Tolstoy and the artof patient perspectives’. None of my friends had thefaintest idea what this was about, and the title was so peculiarthat most steered clear of the course. I telephoned the doctor running the course and he explained to me that through analysisof literature, students could gain a greater sensitivity ofthe subtleties of language, which would, in turn, lead to agreater appreciation of patient narratives and histories. Iwas hooked and have been ever since. Which is why Sachs’s lecture was so resonant. What I learned in that 3-week courseat medical school changed my perception of language and stillendures in the way I practise today.

Narrative medicine is not a new concept. Many readers will befamiliar with its broad principles, but it is unlikely thatthey will have studied its theory formally or applied its conceptssince its inclusion in undergraduate or postgraduate coursesin Britain remains rare.

In the USA the story is very different. Narrative medicine iswell represented in most medical departments and has been anacademic subject in its own right for around 30 years. In 1994around one-third of American medical schools taught literatureto undergraduates and since then the number has grown substantially(Banks et al, 1995). Its benefit has been demonstrated in manystudies and is now seen as a convenient means of enhancingcommunication skills (Charon, 2001). Because very few Britishmedical graduates will have experienced any tuition of thissort, my experience remains fairly rare. I wish to demonstratein this article how narrative medicine can be extremely usefuland how the principles can be readily added to the curriculum.

Personal experience

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Personal experience

In those 3 weeks at medical school, along with the course tutorDr Tim Dowling, and another student, I read and analysed aseries of stories and poetry and discussed the texts afterevery piece had been digested. The initial and most importantwas Tolstoy’s short story The Death of Ivan Ilyich. Thisgives a detailed account of a man’s insidious slide towardsdeath. Along the way we are presented with the physical and mental anguish that accompanies his demise, and the story forcesus to reflect on our own perception of what death constitutesand the emotional maelstrom it creates.

The course also included poetry by T. S. Eliot, W. B. Yeatsand Sylvia Plath, all of whom display a profound sense of thehuman condition and demonstrate a remarkable understandingof the intricacies of both verbal and non-verbal communication.These texts were analysed and discussed, with particular emphasisplaced on the themes, content, metaphor and imagery employedas vehicles for emotional resonance. The basic premise of thecourse was to allow the student to gain an appreciation ofliterature and therefore a familiarity with and skill whendealing with narrative structures. These skills could thenbe transferred to everyday clinical practice. There were threemain elements to the approach as taught by Dr Dowling: narrative appreciation, substitute experience and narrative as a therapeutictool.

Narrative appreciation: honing language sensitivity

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Narrative appreciation: honing...

Narrative appreciation involves becoming highly accustomed tothe structure and nuances of a piece of writing. The very actof systematically analysing and digesting The Death of IvanIlyich or The Bell Jar by Sylvia Plath will equip the readerwith an ability to tease out important features, phrases andsubtle meanings of speech or writing. The flexibility and idiosyncrasyof language is frequently encountered in clinical practice andany development in the appreciation or interpretation of suchlanguage will immensely aid the understanding of particularnarratives.

Substitute experience

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Substitute experience

Most people will have very little understanding of what it islike to suffer the stress of a hereditary brain disorder orhaving to undergo electroconvulsive therapy. However, literatureallows the reader to access a vast repository of experience.Many writers demonstrate such a profound understanding of thevicissitudes of disease that their writing could be used asverbatim case studies. For example Plath’s The Bell Jaris an intense account of the mental illness suffered by thelead character Esther and the experience she undergoes whilebeing treated for intractable depression. (The story parallelsPlath’s own life closely.) As well as being highly emotive,the prose supplies an experience by proxy, delivered throughthe eyes of an accomplished communicator. Moreover, Esther’s fear, inner turmoil and disorientation are all laid bare, whichgives one some sense of her condition. The following extractgives a sense of her predicament:

‘Whenever I sat on the deck of a ship or at a street caféin Paris or Bangkok, I would be sitting under the same glassbell jar, stewing in my own sour air’ (Plath, 1963).

Plath chose the image of a bell jar because it is enclosed andalienating, forming a barrier between Esther and the rest ofthe world. Its use also suggests she has no control over hercircumstances. Patients seen in clinic every day will alsouse personal analogy to describe their own symptoms.

Many works of literature paint such extraordinary and ‘realistic’descriptions of emotional experience that keen observers canfind within them a lifetime of human psychology. For this reason they are essential teaching resources.

Narrative therapy

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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 avent, releasing anxiety and stress, and acting almost likea pressure valve (Panichelli et al, 2005). An enhanced abilityto allow the divulgence of personal history is an area thathas been underdeveloped in mainstream clinical practice, perhapsbecause of time constraints or possible ignorance. Reading andappreciating well-written literature can help one to explorethe universal traits of the human condition and allow one tofocus on the cathartic elements of patient history by developingan understanding of the patient’s perspective. It cannotbe stressed enough that it is this sensitivity which allowsthe patient to share their burden (Curbow et al, 1999). Itfollows from this observation that having a greater understandingand ability to appreciate their ‘story’ will bemore rewarding in therapeutic terms. Many studies have continuallydemonstrated that patient satisfaction stems from the practitionerunderstanding the patient’s anxieties and most importantlydemonstrating this (Arborelius & Fossum, 2004).

Discussion

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Discussion

My undergraduate study module ‘Tolstoy and the art ofpatient perspectives’ was successful in melding togethertwo ostensibly unrelated subjects and demonstrating how theycan be used together and taught effectively to enhance clinicalpractice. One must not forget that literature is not the onlymeans of developing a keen sensitivity to human emotional states;music and fine art are both as important. However, literatureprovides the most applicable and expedient means of fosteringenhanced sensitivity to patient communication because of itsverisimilitude.

Some previous articles reviewing narrative medicine have advocatedthe introduction of a dedicated reading list but have not madea 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 toallow reflection on the themes, structure, content, nuance,imagery etc, which infuse not only literature but all speechin general and provide intricate clues to the emotional stateof an individual. These analytical skills cannot be mastered by reading alone. Initially such techniques could be taughtin a discussion group, with the basic analytical skills beingrefined through future exposure to literature and patient narrativein tandem. It is this process of analysis and therefore transferableskill that is paramount.

Those best placed to provide this tuition would be well versedin the process of literary analysis. A truly multidisciplinaryapproach incorporating members of the English faculty wouldbe preferable. This model is used to great effect in the USA,with ‘literary scholars’ participating in discussiongroups (Banks et al, 1995). Those providing the tuition wouldnot require any esoteric knowledge of medicine. As argued above,the principles of analysis can be applied as readily to a consultationas to a poem by T. S. Eliot.

The current MRCPsych course could easily accommodate a shortseries of illustrative lectures and discussions equipping studentswith the required analytical skills. No formal examinationswould be required, emphasis should be placed on enjoyment ofthe material itself. The process, if practised over time, wouldbecome ‘unconscious’, enriching the consultationbut not interrupting its flow. It is hoped that in time thetuition would be disseminated among other colleagues and undergraduatestudents, eventually becoming ubiquitous and a necessity forbest clinical practice.

The arguments above demonstrate that the principles of literaryanalysis can be used as an adjunct to diagnosis and therapyin everyday clinical practice. Furthermore, I would argue thatthe addition of arts courses to the syllabuses of medical schoolsis not something to be considered an extravagance or exoticextra 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 theMRCPsych course is long overdue and would enhance patient-doctorinteraction immensely.

Psychiatry more than any other specialty is at the interfacebetween art and science. This is why the College should bethe first to acknowledge the potential benefit of narrativemedicine and should endeavour to take the lead with the additionof a dedicated course in literary medicine to the MRCPsych programme.

References

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