Efforts to use literary texts and methods to enhance the training of physicians go back more than 40 years (1–4). As these efforts have matured, they have branched out in various directions. Rita Charon, director of Columbia’s narrative medicine program, instructs students in close reading of texts and in formulating narratives of their experiences with patients. As she puts it, “I do not feel I know a patient until I’ve written about her or him” (5). Another program, New Directions, affiliated with the Washington Psychoanalytic Center and codirected by Robert Winer, aims specifically at helping clinicians refine their writing skills and has thrived for over a decade. There is encouragement to trainees to describe their reactions to learning clinical medicine (6). The Bellevue Literary Review receives 70 submissions of poetry, fiction, and essays for every manuscript it can publish (D. Ofri, editor-in-chief, personal communication, November, 2008). Felice Aull founded and continues to edit the Literature, Arts, and Medicine Database (7). Howard Spiro founded the online Yale Journal for Medical Humanities (8), and currently there are medical humanities departments across the country. A group of psychiatric educators found over a decade ago that a seminar using short stories focused on medically related themes could help draw “patient-oriented students” to psychiatry (9).
Nobel Laureate Eric Kandel provided a bellwether of the application of great literature to medical teaching when he began his celebration of Donald Klein’s contribution to the study of anxiety with the famous dictum of Tolstoy: “All happy families are happy in the same way; each unhappy family is unhappy in its own way.” He went on to equate “happiness” to “safety,” and “unhappiness” to “anxiety” (10).
Still, the trend in psychiatry toward biological and cognitive behavior interventions and away from the dynamic psychotherapies, along with the pressures toward greater patient volume arising from ever more arcane reimbursement schemes, has reduced our field’s focus on medical humanities (11). They continue to remain outside the mainstream of psychiatric teaching, and their application to clinical settings remains sporadic. One possible way to counter the alienation, dehumanization, and diminished empathy that seem to be present in many clinical settings, and to restore excitement to the clinical encounter, is to use short stories and narratives in these settings.
What follows is a systematic method that psychiatric educators can use, in a workshop format, to introduce medical students, psychiatric residents, practicing psychiatrists, and perhaps their patients to the value of understanding narrative. Over the past 25 years, I have developed this method through presentations in resident seminars, at hospital grand rounds and national meetings, and in a weekly workshop for mental health professionals, now entering its fifth academic year.
Each workshop session involves the discussion of a preassigned story around four general areas: What conflicts or behaviors require change? What is the framework in which the change takes place? What are the specific details that promote the change? How could this story be applied to relevant or similar clinical situations?
A weekly workshop with a group of six to eight participants is ideal, and the series can be planned as a set number of meetings or be open-ended, depending on the parameters of the overall teaching program. It is useful for all participants to have the same anthology of stories illustrating change, so that they can easily locate the same passages during discussions (12). Participants quickly appreciate the importance of reading each story in advance, so that they can participate actively. Just as quickly, they learn to keep the four areas in mind when reading the story, anticipating the course of the discussion.
The goal of using short stories in this way is to encourage participants to identify their own struggles and issues with change, in order to empathize and identify better with patients; appreciate the trajectory of each central character’s narrative as a whole and thus be able to formulate more coherent case histories for their patients; and suggest possibilities for improved outcomes in specific clinical situations requiring a patient to change, analogous to those that the story has illustrated. Responses reflect the life experiences of each workshop participant, so a range of responses emerges—usually two to three different responses to each discussion area. There is no effort to develop a consensus; rather, participants regularly help one another develop their own individualized responses more fully.
This method relies heavily on the power of great writers to convey life convincingly. It requires no specialized knowledge of literary theory, history, or criticism—indeed, it eschews such knowledge as tending to intellectualization and thus avoidance of a direct response to the characters and events of the story. Nabokov (13) describes this tendency thus: “You must have seen some of those awful textbooks written not by educators but by educationists—by people who talk about books instead of talking within books. Traitors, not teachers.” Rather, he continues, we should regard the characters in stories as “the delightful familiar people [who] had been sitting all round us, joining in our life.” The psychiatric educator’s charge to readers is analogous to a judge’s charge to a jury: use only the facts presented, your experience of life, and your common sense.
Focusing on change is intended to bridge the fictional story and the actual patient. Change may be found in many—though by no means most—fine short stories (a list of 75 “workshop-tested” stories is available upon request). It implies more than normal growth and development; it implies a new level of understanding and a new capacity for action that emerge from the successful resolution of a crisis. Erikson has described the specific terms of the generic crises that occur at each of the “Eight Ages of Man” (14). These terms provide a background within which the specific conflict in the story unfolds and may be useful in bridging the fictional and clinical realms, because they challenge the reader to take an overall view of the character’s life. Examples of change in the clinical setting would include giving up self-destructive habits such as medication nonadherence, poor diet and exercise regimens, unsafe behaviors, and aspects of one’s narcissism, as well as learning to appreciate one’s adult children or one’s parents as individuals. One experienced reader, using a method similar to the one offered here, provides an example of how a story supplies a “neutral space” between himself and the patient at a point of impasse (15).
What follows are the plot summaries and participant responses to three short stories.
O. Henry’s “A Retrieved Reformation”
Jimmy Valentine, a confirmed and expert safe-cracker, has been sprung from a prison through the intervention of influential friends and returns to his calling. His old nemesis, the detective Ben Price, is soon in hot pursuit. On checking out his next target, however, Jimmy runs into a young woman, Annabel. He “looked into her eyes, forgot what he was, and became another man.” She turns out to be the bank president’s daughter, and Jimmy decides to go straight. He establishes himself in town, pursues her, and is about to put his past behind him. Ben, unconvinced, is closing in, when another unexpected event occurs: Annabel’s niece is accidentally locked into her father’s bank’s new safe, and there is fear for her survival. Jimmy asks for the rose Annabel is wearing on her bosom, dons it, and cracks the safe, thus rescuing the child. Then he walks up to Ben, anticipating arrest. Ben, however, rising to the occasion, pretends not to recognize him and sends him on his way.
“The guy changed in the context of its being an innocent time in America—maybe the cop did, too.” “It is about the transformative power of the good deed. We do not know what may have been going on in his life before—maybe he was ready to change. Maybe Ben was, too.” “We have no sense of their inner feelings—it is like a magic show or a cartoon: no shadings, no clues of inner workings.” “Why did he even want to go straight? He must have thought of that even before falling in love.” “He’s like Jean Valjean—not a bad guy.” “It is about how change occurs—like the AA process. It reminds me of an alcoholic patient I was determined to ‘cure.’ He showed up drunk on the day of his discharge, but then he spent a year with the Franciscans, went to college, and became a school superintendent. Later, he told me, ‘It was not what you said, but your coming out and rescuing me once, that mattered.’” “Maybe taking Annabel’s rose was a recognition that he’d be revealed and was grieving.” “The rose meant saying good-bye to love, but in style.” “I’m going to see what my child patients write about this story, what they think the outcome will be.” “I’m going to give this story to a 9-year-old patient of mine, very much a ‘rascal,’ who, when I asked why he thought he was sent to me, replied, ‘Because I’m bad.’”
William Carlos Williams’ “The Use of Force”
A simple, uneducated couple has called their pediatrician for the first time to tell them what is wrong with their daughter, who is quite sick. They are polite and embarrassed but not forthcoming. “They were not telling me more than they had to, it was up to me to tell them; that is why they were spending three dollars on me.” He finds her “an unusually attractive little thing, and strong as a heifer. She had magnificent blonde hair, in profusion.” He learns she has had a fever for 3 days but has denied having a sore throat. That symptom would be significant, because both the parents and the doctor know of a current, local outbreak of diphtheria. He knows he must check for it, but when he approaches, she rips off his glasses. He insists the parents hold her down. “In the ensuing struggle they grew more and more abject, crushed, exhausted while she surely rose to magnificent heights of insane fury of effort bred of her terror of me.” He has “seen at least two children lying dead in bed of neglect in such cases…[so I] went at it again. I too had got beyond reason. I could have torn the child apart in my own fury and enjoyed it. It was a pleasure to attack her: a blind fury, a feeling of adult shame, bred of a longing for muscular release.” Finally he succeeds in forcing her mouth open with a metal spoon, revealing the deadly diphtheritic membrane. “She had fought valiantly to keep me from knowing her secret; tears of defeat blinded her eyes.”
“This story is about the inherent sadism of the desire to cure.” “The feeling is universal among doctors—female ones, too. Exerting control brings us close to unreason. You give up so much to become a healer, but having control requires keeping it under control.” “He can feel sadistic but know he’s doing the right thing.” “He was ‘into it.’” “He mobilized his anger to do something effective, activating himself.” “He needed his anger to make himself do this, and he liked this child, whom he found beautiful.” “There was no change, but I trust him more for acknowledging these feelings.” “No, his being conflicted saves him, so he does change.” “He’ll be a better doctor with the next patient, more reflective.” “He has greater insight and self-control. He will be more aware and empathic.”
Raymond Carver’s “Cathedral”
A man in his mid-30s loves his wife and finds her attractive but does not have a close relationship with her because his petty jealousies and belittling opinions keep him from giving her what she sometimes desperately needs from him: a sympathetic ear. He is not pleased that she has invited for a visit a somewhat older man, Robert, who, despite being blind, has been her closest confidant for many years. His jealousy erupts in anticipation, but she presses him in kind to make Robert feel welcome. Alcohol and cannabis help things along, but it is Robert’s uncanny warmth and sensitivity that finally win him over. The central event is both men watching a TV program about cathedrals during which the man is challenged to describe the show to Robert: “How could I even begin to describe [a cathedral]? But say my life depended on it. Say my life was being threatened by an insane guy who said I had to do it or else.” Robert proposes that he draw a picture of one, placing his hand on the man’s own during the process. He asks the man to close his eyes, saying, to encourage him, “I think you got it.” Then he asks him to open his eyes and take a look at what he has drawn, but the man keeps them closed, amazed at what he and Robert have managed to do together, and savoring their closeness.
“I liked the man, even early on, because of his vulnerability, which rubbed off from his wife’s relationship to Robert—and this story is not only for men.” “He tolerated being touched [by Robert], after initially being so mocking.” “He was spiritual, after all: he got into [introducing Robert to] a cathedral, not a battleship.” “We can rise to an occasion, if there’s enough reason for it.” “Robert fits in anywhere and gradually takes over—the man is smitten with him, too.” “When Robert leaves, the couple’s change will remain, because the man is more understanding, and his wife will appreciate his new tenderness.” “No, the man will be ‘snarky’ again. Robert was like a bridge for them.” “I once taught a class where there was a blind 14-year-old girl who captivated the others by telling them to close their eyes and imagine.”
From responses such as these it is apparent that participants learn the method easily. Though they are aware of the four areas for discussion and of the goal of using stories clinically, they do not feel constrained to respond systematically in workshop discussions; rather, they respond to the story—to the characters and events—as a whole. Thus, they do not allow Jimmy’s antisocial traits, the doctor’s sadism, and the man’s narcissism to define them, but instead seek more encompassing views which only narratives can provide. Crucial questions of readiness to change arise in the fictional setting and are relevant to the clinical one. The respective “change-agents”—Annabel, the young blond girl, and especially Robert—provide models for the kinds of encounters and therapeutic interventions that might be required in similar patients.
Some participants are comfortable with offering stories to patients, anticipating a range of reactions just as other interpretations do. Others have expressed reluctance to suggest stories to patients, who they fear might misread the story and take it as criticism.
The psychiatric educator’s role is primarily to encourage any responses that can be supported by the text, rather than to aim for consensus, and only secondarily and gently to move the discussion to other areas. Participants thus appreciate the validity of their own emotional responses, and these become a springboard for awareness of self and others.
A systematic method that psychiatric educators can use to encourage trainees and colleagues to construct coherent narratives of and for their patients is available. It is easily mastered, fits into a familiar workshop format, and draws on the dramatic power of great writers to create excitement. Depending on their own backgrounds, personalities, traits, and emotional responses to others, readers will interpret the intentions, motives, and behavior of the characters in these stories differently. They will express varying degrees of sympathy with them and of hopefulness about their possibility of changing. Similarly, readers bring in their own particular associations to patients they have treated, especially to moments where change appeared to arise. Energized by the workshop discussions, they look for ways to introduce the stories into the treatment of ongoing, challenging cases. Using stories can help humanize patient care and the personal development of physicians. Facing a challenging point in the treatment of any patient, which of us would not welcome a consultation, drawing on this method, with an author such as Chekhov, Joyce, Camus, or Flannery O’Connor?