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Tell Me Your Story: Narrative Medicine in the Therapeutic Relationship

 In Mind/Body

Tolle Totum

Lauren (McKinney) Mandych
Paul Epstein, ND

Before every session, I take a moment to remember my humanity. There is no experience that this man has that I cannot share with him, no fear that I cannot understand, no suffering that I cannot care about, because I too am human. No matter how deep his wound, he does not need to be ashamed in front of me. I too am vulnerable. And because of this, I am enough. Whatever his story, he no longer needs to be alone with it. This is what will allow his healing to begin.  (Carl Rogers)

We human beings are more than our lab numbers, our diagnoses, or the events of our lives. We are all of these things and yet, if we were to write down only the facts of our lives, we would not really know each other; we might not even know ourselves. Practicing medicine with the intention to connect with our patients, understand who they are and how they came to be this way, and then to empower them in their health, embodies the principles of naturopathic medicine and can be enhanced through the use of narrative medicine.

Narrative Medicine

Narrative medicine allows the patient to tell their story, and the doctor to listen, without having to “do” something or to “fix” the patient. It engages the patient’s consciousness and awareness and allows them to be – and feel – heard. It also acknowledges that healing requires a biopsychosocialspiritual approach to the person and not just the disease. We need to know who our patients are and what has happened in their life to bring them to this moment in time. The challenge for naturopathic doctors is to listen to the story of the self, as well as to the cells, and to remember that disease tells both stories.

It is more important to know what sort of person has a disease, than to know what sort of disease a person has. (Hippocrates)

Narrative medicine is understood to be a patient-centered and relationship-centered clinical intervention. It emphasizes the importance of understanding and integrating the experiences of all people involved in the illness experience, as well as the inherent value of collaborating with a patient in their own healthcare.1 The therapeutic relationship is a critical component of healing and involves compassionate inquiry and empathic listening from the doctor. It is a genuine and unconditional positive regard for another human being, without judging them or trying to fix them. There is a growing body of knowledge that recognizes the dramatic impact of stress and trauma on the health of an individual. Narrative medicine is another element that we can use in patient visits to enhance the therapeutic relationship in a way that benefits both the patient and the practitioner.

For the Patient

Decrease in pain perception

Pain management is a common primary-care concern, and something with which many people struggle. Self-management of chronic pain is often recommended to the patient. However, patients may encounter barriers in this endeavor, including the communication style of the provider and feeling unsupported in their healthcare.2 A 2007 study revealed that cancer patients who had more emotional disclosure in their narratives reported a statistically significant reduction in pain and an improved score on well-being questionnaires, as compared to their peers who had less emotional disclosure.3 If patients are genuinely encouraged to share their story with their practitioner, their perceived pain may decrease. This has the potential for a profound impact at a time in our country when we are struggling with pain management and addiction.

Empowerment in healthcare

Patients report increased confidence and engagement in their own health when they are able to have their personal story heard.3 Creating the space for patients to share their story and the impact of their illness on their life allows them to be more empowered in their own healing process. It helps them to feel less like a passive bystander in their healthcare and more of an active collaborator with their healthcare practitioner.

Decreased stress in a healthcare setting

Anxiety and perceived stress in a healthcare setting can prevent patients from being able to fully engage with their practitioner and can stunt the therapeutic relationship. A pediatric study identified that when children were allowed to tell their story through pictures, they experienced a reduction in perceived stress in the hospital and were more willing to cooperate with their healthcare team.4

Alice Miller writes about the “liberating experience of facing painful truth” and how part of that is being able to tell one’s story and have it heard with compassion and acceptance. As practitioners, we must be able to sit with our patients in their pain and not be overwhelmed by our own pain.

For the Practitioner

Greater empathy and compassion

The context of a patient visit, as well as the empathy demonstrated by the practitioner, can have a profound impact on the patient experience and treatment compliance.5 A 2018 study demonstrated that the practice of narrative medicine increased nursing students’ empathy scores on the Jefferson Scale of Empathy (JSE).6 Similarly, a 2017 study on the long-term effects of practicing narrative medicine demonstrated an increase in practitioner empathy scores, as measured by the JSE – an increase that was maintained over the following 1.5 years.7

Enhanced therapeutic relationship

The therapeutic relationship between a patient and an empathic and non-judgmental practitioner is a critical component to patient-centered care. More effective providers have been shown to be those who provide care in a “…warm, friendly, and reassuring manner.”8 Similarly, medical students have reported that training in narrative medicine has helped prepare them to be more competent for their residency programs. It has helped them to improve communication, support their ability to be patient-centered and collaborative, and enhance their own overall personal and professional development.9 Narrative medicine enables us to be the kind of practitioner and healer we aspire to be.

Increased patient compliance and treatment management

As patients feel more empowered and engaged in their own health, they are more likely to be compliant with their treatment. A 2018 study on patients with COPD identified that the use of narrative medicine improved the doctor-patient relationship, and enhanced patient compliance and overall clinical care.10 The results of the study were so strong that narrative medicine was recommended to be included in official COPD protocols.10 Treatment compliance is obviously critical for patient success.

Narrative Medicine & Naturopathic Medicine

To treat the whole person (Tolle totum), we must know who our patients are, what they have been through, and how these life experiences may still be influencing them. Developing a strong therapeutic relationship requires empathy and compassion. Many practitioners already intuitively want to know a patient’s story to get a better understanding of how their health concerns are impacting their quality of life. Studies are increasingly supporting this, as well as identifying specific positive impacts on the healing process from having patients tell their stories.

Are we willing to listen? As naturopathic doctors, we must give ourselves permission to listen and to serve, not just to fix. Naomi Remen makes this differentiation when she writes, “Helping, fixing and serving represent three different ways of seeing life. When you help, you see life as weak. When you fix, you see life as broken. When you serve, you see life as whole. Fixing and helping may be the work of the ego, and service the work of the soul.”11

May we have the courage to listen and serve.

References:

  1. Fioretti C, Mazzocco K, Riva S, et al. Research studies on patients illness experience using the Narrative Medicine approach: a systematic review. BMJ Open. 2016;6(7):e011220.
  2. Gordon K, Rice H, Allcock N, et al. Barriers to self-management of chronic pain in primary care: a qualitative focus group study. Br J Gen Pract. 2016;67(656):e209-e217.
  3. Cepeda MS, Chapman CR, Miranda N, et al. Emotional disclosure through patient narrative may improve pain and well-being: results of a randomized controlled trial in patients with cancer pain. J Pain Symptom Manage. 2008;35(6):623-631.
  4. Massimo LM, Zarri DA. In tribute to luigi castagnetta–drawings. A narrative approach for children with cancer. Ann N Y Acad Sci. 2006;1089:xvi-xxiii.
  5. Charon R. The patient-physician relationship. Narrative medicine: a model for empathy, reflection, profession, and trust. JAMA. 2001;286(15):1897-1902.
  6. Yang N, Xiao H, Cao Y, et al. Does narrative medicine education improve nursing students’ empathic abilities and academic achievement? A randomised controlled trial. J Int Med Res. 2018;46(8):3306-3317.
  7. Chen PJ, Huang CD, Yeh SJ. Impact of a narrative medicine programme on healthcare providers’ empathy scores over time. BMC Med Educ. 2017;17(1):108.
  8. Di Blasi ZD, Harkness E, Ernst E, et al. Influence of context effects on health outcomes: a systematic review. Lancet. 2001;357(9258):757-762.
  9. Arntfield SL, Slesar K, Dickson J, Charon R. Narrative medicine as a means of training medical students toward residency competencies. Patient Educ Couns. 2013;91(3):280-286.
  10. Banfi P, Cappuccio A, Latella ME, et al. Narrative medicine to improve the management and quality of life of patients with COPD: the first experience applying parallel chart in Italy. Int J Chron Obstruct Pulmon Dis. 2018;13:287-297.
  11. Remen R. Helping, Fixing, or Serving? August 6, 2017. Lion’s Roar: Buddhist Wisdom for Our Time. Available at: https://www.lionsroar.com/helping-fixing-or-serving/. Accessed February 5, 2019.

Lauren (McKinney) Mandych is a member of the Canadian College of Naturopathic Medicine (CCNM) Class of 2020 in Toronto, Ontario. Prior to attending CCNM, she studied child development at Tufts University and outdoor education with the National Outdoor Leadership School. Lauren’s focus at school has been on mindfulness and unconditional presence in the therapeutic relationship, as well as the profound effects of connection with nature on our mental and physical health.

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Paul Epstein, ND, a pioneer and leading voice in Contemplative Medicine, has been leading the charge to bring awareness to the mind-body connection – and its extraordinary role in healing – for over 30 years. In his private practice, Dr Epstein integrates naturopathic principles with mindfulness meditation and other life-changing mind-body therapies. As a speaker and teacher for professional healing arts practitioners, he has taught holistic medicine and counseling at the undergraduate and graduate levels, and has trained psychotherapists, social workers, mental health professionals, physicians, nurses, medical students, yoga teachers, and other healthcare professionals in the art and science of Mind-Body Integrative Medicine. Website: www.drpaulepstein.com

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