Ron Capps, a 25-year Army Veteran who completed two tours in Afghanistan and also served in Iraq, Rwanda, Darfur and Kosovo, left the service in 2008 traumatized by the violence he encountered. Diagnosed with post-traumatic stress disorder (PTSD), Capps did not find therapy, prescription medications, or drinking helpful. (I) came very close to committing suicide I was actually interrupted. I survived, obviously, and now Im here. Writing helped me get control of my mind.[1]

Ron Capps teaches at a Veterans Writing Project seminar in 2011. | Photo credit Jacqueline Hames

In 2011, after receiving an MA in writing from Johns Hopkins University, Capps founded the Veterans Writing Project (VWP), a non-profit organization in Washington D.C. that helps Veterans heal through writing. His goal in offering free seminars and workshops to service members and Veterans across the nation is to get military people and the families of military people to tell their storiesthere are a lot of stories to be told.[1]

Capps own survival, and that of many Veterans who participate in VWP programs, is a testament to the healing power of story: I wrote myself out of a very dark place Writing allows us to shape and control traumatic memories.[1]

Capps and fellow VWP colleague Dario DiBattista teach weekly creative writing workshops for Veterans with PTSD and traumatic brain injury as part of the four-week intensive outpatient program at the Walter Reed National Military Medical Center at Bethesda for The Veterans Writing Project. DiBattista describes their approach, We say, Heres how writing has helped us, maybe this is something that will help you too. We give them encouragement to keep writing (D. DiBattista, personal correspondence, January 28, 2014). He observes how writing seems to work, for both himself and those he teaches, The more you tell your story, the more you have control of it, and at some point, its not as powerful anymore.

The special operators Capps and DiBattista mostly work with at Walter Reed are used to thinking outside the box, and thus tend to be quite receptive to writing. DiBattista observes, They want to get well, and so they're willing to try whatever is going to help them get better. With fair frequency, people say: This is the first time Ive ever been able to tell my story, the first time Ive ever been able to get it out, I feel so much better. For somebody who tries it, more often than not, its something that helps them. DiBattista says Veterans who stick with a writing practice report sleeping better and having fewer trips to the doctor. He postulates, All forms of therapy are some form of communicating your story, so it seems that writing can be a particularly effective tool. And the benefits do not only affect the authors; reading Veterans writing can help create awareness, provide insights, and foster empathy and compassion. Its going to give somebody a new insight, a new way of thinking, a compassion that they didn't have before.

Story is an age-old mode of healing being reinstated into our culture by leaders like Ron Capps in a contemporary health care practice called narrative medicine. Neurologist and psychiatrist Jonathan Shay, another individual at the forefront of this movement, postulates, We are just discovering some modes of healing, and others need to be rediscovered from the vast experience of many ages and cultures.[3]

For over 30 years, Shay has listened to Veterans stories about the psychological impact of war at the Boston-area Veterans Affairs Outpatient Clinic. He is the author of Achilles in Vietnam: Combat Trauma and the Undoing of Character,which draws upon Homers classic work The Iliad to illuminate experiences of combat Veterans. Shay believes that literature can elucidate experiences that are often obscured and sidelined in clinical encounters; it centralizes them and brings their significance to light. He sees the art of storytelling as imperative to healing because it enables people to express themselves, tell the truth, emote, and connect with others. The ideal model for combat Veteran health care, Shay argues, holds that the central treatment must be moral and social. The best treatment restores control to the survivor and actively encourages communalization of the trauma. Healing is done by survivors, not to survivors.[3](p187) This premise of a story treatment reflects a central tenet of narrative medicine.

Narrative medicine is not easy to describe. The very terms narrative and medicine seem to fall in fundamentally different fields. But their fusion is critical to address some of the issues in our modern medical system that often diminish the human aspects of the clinical encounter.

The art of telling stories and the art of deeply listening to stories used to be central to the relationship between patients and clinicians. Today, those arts are often undervalued in medical encounters that tend to privilege the biology over the biography.[4] This creates disconnection between patients and caregivers that can be repaired by promoting the role of telling and receiving stories as central in clinical exchanges. Patients have a story that needs to be heard, not just symptoms that need to be treated. Pain is often as much psychological as somatic: our emotions, thoughts, and stories influence our awareness of pain and its effect on our lives.

Practicing narrative medicine can facilitate better health care, because it restores value to the subjective experience of suffering that is often lost in the objective stance in which clinicians are trained. Narrative medicine has been deemed one of medicines most important internal renovations,[5] and is being integrated into the system in myriad ways.

Narrative medicine emerged as a response to patients complaints that their clinicians did not listen to them, or did not seem to truly care about their suffering. Internist and literary scholar Rita Charon coined the term narrative medicine and launched the Program in Narrative Medicine at Columbia University in 1996. Her goal was to help health care professionals improve communication and collaboration with their patients and to bridge the gap between the humanities and the sciences. At the heart of her mission lies the belief that effective health care requires the ability to recognize, absorb, interpret, be moved by, and act on the stories of illness.[6] Charon considers narrative medicine a basic science mandatory for medical practice.[7] Though not always called narrative medicine, many endeavors in medical education and practice bring together literature and medicine, as well as the social and behavioral sciences, under this umbrella category.

More than 2,000 years ago, Hippocrates articulated one of the founding principles of narrative medicine, stating, It is more important to know what sort of person has a disease than to know what sort of disease a person has. [8] In order for clinicians to provide truly effective health care, they need to care for people, not just cure diseases. They need to understand the meaning of the patients experience, not just their symptoms. To do that, they need strong skills in both verbal and nonverbal communication. Narrative medicine equips clinicians with the tools to achieve these goals.

Address illness, not just disease

Medical anthropologist and psychiatrist Arthur Kleinman distinguishes illness from disease. He depicts disease as the biological problem that science addresses and illness as the human experience of the disease. Good health care must tend to both, must attempt to cure the biological disease and care for the psychological and social experiences of illness. Biological science can tackle the disease, but a narrative science approach best addresses the illness. Kleinman writes, Each patient brings to the practitioner a story. That story enmeshes the disease in a web of meanings that make sense only in the context of a particular life.[9]

As a first year resident at Columbia University, Yira De La Paz wrote a reflective narrative about a 30-year-old patient who came to the hospital having seizures, presumably due to alcohol withdrawal.[10] De La Paz listened to the mans story, which involved being adopted, disconnected from his adopted parents, jobless, estranged from his young son, and bound to alcohol as his best friend since age 12. In his written reflections on witnessing this patients suffering, De La Paz wrote:

He wept as he told us his story and how alone and depressed he was. Looking at him, I felt so helpless, thinking about how anything I say would sound like a sermon repeated over and over again, or shallowwe always bring our own prejudices into our questioning, but this time, I was ashamed of it because this person gave me a glimpse into his world and it could have been anyone, even myself, or my son.[10](p354)

De La Paz models how to recognize the way a disease is enmeshed in a web of meaningsthat can foster an empathetic connection between clinician and patient. Receiving a comprehensive story stirs a clinician to reflect on his/her own life story, whereas obtaining medical data for the patients chart does not, and often leaves the patient bereft of the compassionate presence of the clinician.

Make meaning

A medical student on a pediatric rotation wrote the following narrative about an adolescent male patient with a neurological disease:

Id rather not talk about it, he politely responded. Did I cross the line? How often do I find myself wondering this in medicine? Because of what? My fear of knowing the intricacies of my patients life? But he did talk about it. He talked a lot. To be seventeen, a prisoner in the hospital and a prisoner outside of the hospital; this is unacceptable to me as his provider. I tried hard to see beyond. So I asked. I asked questions I would ask anyone. He shared how his disease affects life in the juvenile detention center.

Other providers criticized his admission, attributing his symptoms simply to his desire to get out of the detention center. But can you blame him? He quietly described his difficulties in the center. Balance difficulties made walking without assistance not only hard but terrifying. Without liberty to use the restroom when desired, his bladder difficulties worsened simply because of fear of losing control. I cant imagine the other inmates would take lightly to this situation.

I didn't understand until he explained. I didn't understand what his disease meant to him; a life of uncertainty and missed opportunities (A. Waldner, personal correspondence, 2014).

Human lives are woven out of intersections between story and biology. Psychiatrist and medical humanities professor Bradley Lewis asserts, In addition to bodies, organs, and tissues, (humans) also live meaning-centered lives, and they have complicated emotional and historical relationships with their bodies.[5](p11) As such, health care practitioners must know how to help their clients make meaning out of their embodied and illness experiences. Narrative medicine endows clinicians with concrete skills and strategies to help patients make meaning.

Physician and literary scholar Howard Brody proposes two ways stories and health care engage with one another. First, he postulates storytelling is healing, which speaks to how the stories patients tell themselves about their illness experiences determine those experiences. Conversely, healing is storytelling, which refers to the narrative construction work clinicians do in an effort to understand and explain their patients experiences.

But this medical authoring usually draws from scientific models of interpretation and organization, which results in many of the human aspects of the patients story getting lost in translation, Patient stories and the doctor stories often do not work well together.[5](p16) With narrative training, clinicians can better co-author stories of illness with their patients and foster collaborative partnerships imperative to holistic healing.

Improve communication

A third year medical student who took part in a narrative medicine rotation at the Washington D.C. VA hospital described how writing narratives of patients and reading the stories to them afterwards, led to new clinical insights about patients, deepened relationships between students and patients, and altered patients willingness to comply with health care team recommendations for work-up and treatment.[11] By understanding patients stories, practitioners can deliver better medical care.

Narrative training equips clinicians as co-creators of illness stories. It enables them to heal the divide that often exists between patients and practitioners. This divide results from insufficient training in generous listening skills, differences in the languages spoken by sick people and scientists, and the default clinical communication techniques that often do more harm than good. One study examined how clinicians can use narrative techniques to help brain injury patients through rehabilitation.[12] The authors concluded that a narrative approach can be an effective tool that informs clinical decision-makingeliciting a patients full story proffers comprehensive information needed to steer the course of treatment. Whats more, listening deeply to patients full stories decreased patients sense of isolation and empowered them in developing new identities.

The relationship between clinician and patient is a narrative relationship, not strictly a scientific one. It is based in verbal and body language. It is semiotic; a clinicians work is to decode a patients description of the illness experience to translate a patients symptoms into medical meaning and significance. It is reciprocal; clinician and patient both play the roles of speaker and listener during the clinical encounter. To effectively decode, translate, and co-construct the healing stage of a patients illness experience, a clinician must master skills in narrative competency.

Narrative medicine seeks to influence health care in a variety of ways:

• To introduce the concepts of narrative competency into the delivery of health care
• To implement narrative interventions in clinical practice
• To enhance and broaden medical education
• To train clinicians to more effectively communicate with their patients
• To endow clinicians with skills to listen attentively to complicated and sometimes incoherent narratives that are told partly in words, but also in silences, gestures, test results, and body language
• To teach how to identify and unpack metaphors
• To open up, expand, and deepen medical practice, not provide an alternative to or distraction from it
• To explore how clinicians are touched by the stories they receive, so they will act with compassion and empathy on their patients behalf
• To offer clinicians a way to process what they themselves undergo in caring for their patients
• To investigate how clinicians own stories impact their ability to hear and interact with patients and colleagues
• To acknowledge the weight of witnessing patients sometimes intense and traumatic experiences
• To mitigate burnout, cultivate resilience, and support self care

The phrase narrative competency is used to describe the narrative skills that practitioners gain through rigorous training in narrative medicine. Medical sociologist Arthur Frank, explores the relationship between bodies and narratives in his book The Wounded Storyteller. He identifies the central skills needed as ones which enable a clinician to learn to thinkwith stories. Not think about stories but think with them. To think about a story is to reduce it to content and then analyze that content. Thinking with stories takes the story as already complete; there is no going beyond it.[13] To think with a story, as resident De La Paz did with his 30-year-old patient whose disease he came to see entangled in a web of meaning, is to experience it affecting ones own life and to find in that effect a certain truth of ones life.

The three primary skills taught in narrative medicine are called Attention, Representation, and Affiliation:

• Attention concerns how clinicians can be fully present with and listen attentively to their patients stories, and know their own stories. Attention is based in a reciprocal, intersubjective relationship.
• Representation concerns how clinicians can examine the meaning of the stories patients tell, and explore how they are, or are not, constructing meaning out of those experiences. Representations of patients to consider include how the patients are written and spoken about to four different groups of people: medical colleagues, the patients themselves, the patients families, and clinicians themselves.
• Affiliation concerns how clinicians can use the experience of telling and listening to stories of suffering to deepen their empathy and compassion in relationships with patients, as well as between fellow clinicians. Affiliations are the outcomes of narrative work, the collaborative actions and care-giving communities that result from the practices of attention and representation.

Research shows that narrative medicine is significantly impacting health care. Numerous articles published in a wide range of sources illustrate narrative medicines intentions and influence, which has helped confer narrative medicine credibility as a science. Evidence of the usefulness of narrative practices, rigorous ethnographic and outcomes studies using samples of adequate size and control have been undertaken[14] at universities and medical centers across the country to evaluate how narrative competence affects the delivery and resonance of health care over time. A central hypothesis being tested postulates, The physician equipped with the narrative capacities to recognize the plight of the patient fully and to respond with reflective engagement can achieve more effective treatment than can the physician unequipped to do so.[14] (p1900)

Three obstetrics and gynecology training programs participated in a study examining the correlation between narrative medicine session attendance with burnout and empathy measures. [15] The study found that participants who attended more sessions experienced decreased burnout on the Emotional Exhaustion scale. Another study explored the efficacy of narrative writing as a supplemental treatment to psychotherapy for PTSD.[16] Findings indicated that patients tolerate the intervention well and report satisfaction, leading researchers to conclude it holds promise, but its efficacy still needs additional study. Outcomes from international research on narrative medicines impact acknowledge recognition of emotion, perceptual sharpness, tolerating uncertainty, decreasing burnout, improving healthcare team function, and deepening individual clinicians knowledge of individual patients situations are all being demonstrated as consequences of narrative training. [17] Research on this burgeoning field ongoing.

Narrative medicine uses a multidisciplinary approach to make space for comprehensive, unique life stories to be shared and received in medical contexts. Originally derived from narrative theory, autobiographical theory, phenomenology, psychoanalytic theory, and trauma studies, narrative medicine converges with many disciplines. It involves the study of literary texts, including classic novels and poetry, as well as autobiographies, films, performance, music, graphic narratives, visual art, oral history, psychology, autobiography, philosophy and ethics.

While traditionally taken up by small groups that do close reading and writing exercises, there are numerous ways to practice narrative medicine. Beyond the traditional classroom model, educational opportunities are increasingly available for practitioners, medical students, and patients. Refer to the tool, Exercises and Readings for Narrative Medicine Groups. Creative applications of narrative in medical settings and VA communities, like Ron Capps Veterans Writing Project, are evidence of the versatile power of story to help heal.

Classroom model

In a traditional narrative medicine meeting, participants are guided by a facilitator through close reading, writing exercises, and group discussion. This model resembles hospital rounds, during which a medical team gathers to consider their patients stories, examine their bodies, review information, and come to conclusions about their care.

A typical one-hour session in a medical setting often begins with a brief introductory didactic portion providing an overview of narrative medicine. The days topic is then introduced and discussed brieflyfor instance, Managing Uncertainty or Death and Dying or Camaraderie. The participants then read a piece of literature together, or examine a piece of visual art. A short story, a poem, or one visual work are best suited to a limited time frame. If it is an ongoing group, they may choose to read a longer piece prior to the meeting. After reading, participants discuss what struck them about the piece, either as a whole group (or in dyads or triads, if it is a group larger than 15).

The facilitator then offers a writing prompt, to which everyone responds for approximately five minutes. Participants are then encouraged to share what they wrote with the larger group, or just with a partner. Listeners are encouraged to comment on the writing itselfthe craft, not the experiencesthe content.

Ground rules and safe space

The intention is to create an environment for people to talk about themselves and their experiences in a meaningful way. To do so, it is important to establish ground rules to assure participants they are in a safe space. Everyone must agree that what is spoken of and shared will be kept confidential. It is advised that during the writing portion of the session, participants write down their ideas as they will be read, not in note format. The feedback after someone reads her/his work should concentrate on the craft and expression in the writing, not therapeutic processing of the content. Facilitators should always pay attention to the emotional temperature of the room, and moderate the session if need be.

Participants

Groups can consist of health care trainees, practitioners, patients, or family members. Clinicians often form writing groups to share personal writing they do on an ongoing basis pertaining to their medical experiences, or to practice writing exercises together without incorporating close reading. The possible formations of narrative medicine are innumerable, and individuals are encouraged to create innovative manifestations tailored to their interests, skill-sets, and schedules.

Resources

While the traditional classroom model of narrative medicine practice usually takes up a literary sourcebook, short story, or poemadditional formats may include the discussion of a visual artwork, an article pertaining to narrative medicine or stories, a film screening and discussion, a theater outing, or other outside-the-classroom experiences. Resources used with Veterans and VA practitioners do not necessarily have to be tailored to Veteran experience; many sources based on other topics relate. Refer to the tool, Exercises and Reading for Narrative Medicine Groups.

Reading benefits us as human beings. When we read a story, we take ideas into ourselves, into our bodies and minds. What are we absorbing when we read? How does the story affect us? Medical humanities professor Arnold Weinstein compares a book to a pill; they both go into us and can have powerful effects. We read, and take medicine, for nutrients and nourishment.

At the heart of narrative medicine lies the belief that training in close reading makes better clinicians. As Rita Charon puts it, Good readers make good doctors.[6](p113) Clinicians are readers of complex, sometimes contradictory texts, e.g. multiple viewpoints told by the patient and family members depict various scenes. In addition, not all of the text of an illness narrative comes in words; the body speaks its own language, in words, silences, gestures, expressions, and lab results. Clinicians must be well versed in how to decipher and translate what a patients body and self communicate in a medical experience in order to provide the most appropriate and comprehensive care.

Charon emphasizes the parallels between acts of reading and acts of healing,[6](p17) which both involve a story offered by a teller to a receiver who has to make sense of it. If one can learn to closely read a literary text, one can learn to closely listen to an oral narrative. Competency in close reading endows clinicians with clinical imagination, empathy, ethical awareness, and attention. Training in close reading enables clinicians to listen to their patients, read medical charts, and reread their own writing with acute awareness. A clinician skilled in close reading will be able to receive all of what their patient tells them, and then be able to represent and respond to the narrative in a comprehensive way that honors the patients story.

Reflective and creative writing enables clinicians to be more fully represent what they learn about their patients and about themselves. Reflective writing surpasses the boundaries of the conventional medical chart it allows a clinician to become an I. Writing narratively about a clinical encounter demands attention in that present moment and makes the clinician more invested and attuned.