Narrative is evidence – Dariusz Galasiński

In his plenary at a recent conference on narratives of health and illness, Jonathon Tomlinson said that narrative is evidence. He said it a number of times. As much as I agree with him (if I may), in this blog I want to consider what it might mean for a person who deals with people’s stories.Some time ago I actually wrote about the use of ‘evidence’ by a doctor. I wrote about the expression:

So, the evidence is….

which inevitably referred to ‘objective’ evidence such as blood tests, at the same time completely blanking the ‘narrative evidence’, in other words, what I said. Of course, I do realise that I am not a doctor and I am not in a position to offer ‘advice’ on what you, the all-powerful, omniscient medic should consider, but I would have wanted at least some acknowledgement of what I said.

And that’s the first point I want make. If you seriously think about ‘narrative evidence’, consider the stories you have not heard, you have ignored. As I still don’t feel healthy, I can tell you what they are for me:

I have not exercised for about 4.5 months – this is the longest period without exercising for me for about 25 years.

I have put on weight (due to lack of exercise), which you criticise me for, as I apparently don’t take care of myself. It seriously angers me.

My mood has been going haywire, the consequences of stopping cold a very significant regimen of exercise went well beyond my expectations

I have not felt so unfit for about 25 years and it is seriously depressing.

I could continue, but you get the picture. I despair when I think about how many aspects of my ‘illness narrative’ you have completely ignored. So, yes, the biopsychosocial model I keep hearing about, with the more progressive of you, doctors, stressing the social and psychological, is reduced to the ‘bio’, while the psychological factors are limited to the unsavoury accusations of me being on the verge of delusions.

(To be honest, I am also sick and tired of hearing how dangerous and unnecessary antibiotics are, especially getting them 6-8 weeks later than needed without a word of apology. Please stop using me to further your ideological agenda. I am too old, too ill and too intelligent not to notice it. But that’s for another blog perhaps).

From the point of view of a linguist narrative evidence is not the ‘evidence of the stories you happen to like because they fit in with your ‘objective’ evidence’. How to do it is, of course, a matter for medicine and not linguistics, but if ‘Narrative is evidence.’ is to make sense, it must, in my view, cover the whole of my narrative account. Including the fact that I dream of putting my running shoes on and going for a run. It might be trivial for you, it’s far from trivial for me. Basically, al that you are completely uninterested in, doctor.

Now, as much as I think the above points are important to make, they have not yet left the realm of what is fairly obvious and written about in the social sciences of medicine. So here is something which is perhaps less obvious. If narrative is evidence, what about the narrative form? In other words, if medicine is to take the narrative as evidence, it cannot simply take the contents of the narrative on board and pretend it does not have a form.

Let me give you an example. When I interviewed men in depression, it struck me that despite the fact that most of them voluntarily attended an outpatient clinic at a hospital, they never actually said they had depression. Whenever they talked about their depression, they distanced themselves from it. For example, they would talk about ‘someone/one/a man having depression’, never directly. They positioned themselves away from the illness, they rejected the illness-like status of their depression. In the book, I raised the problem of insight into depression.

And so, here is a problem. It’s fairly obvious for a linguist to take the narrative form on board, but should you, doctor? Well, if narrative is evidence, then the answer is yes, no doubt about it. The problem, of course, is how – and I don’t have an answer to such a question. I am not a medic. But this doesn’t meant that the question is unimportant, actually.

This blog is about implications of saying ‘Narrative is evidence’. So far, I have talked about the ‘unheard narratives’ and the form of the narrative. There is, however, one more thing. If you actually do want to focus on the narrative, you need to start making doctors sensitive to the narrative. Not only to the fact that a patient must be able to tell her/his story. However strange it might seem, this is the easy bit. The difficult bit is to actually make sense of it. And this means not only just listen to what is said, but also to how it is said. And this opens a whole new world of medical training.

Do you still want my story, doctor?

7 Comments

John Launer Dec 10, 2016 at 14:38

I agree our views largely converge. As a doctor and medical educator with an English degree, I would love to sensitise my students and colleagues to the features of narrative (or narratology) you mention, but have to be content with lesser aspirations! I totally agree about the systemic inadequacy of medical conversations – the question for me is how you remediate this. For all its limitations, narrative medicine is the only approach I’m aware of that suggests that practitioners should recalibrate everything they do to what each patient wants / expects / hope for. This involves asking not only the question “what do you want to tell me?” but “what do you want me to listen to?” and “what kind of dialogue (or none) do you want? Hopefully, over time, the range of questions we dare to ask (or to think) will encompass more of what you as a social scientists can see in narratives.
1. Dariusz Galasinski Dec 10, 2016 at 19:01
  
  As much as I would like to teach medics linguistics, I understand it’s on the ambitious side. And so, I agree. I prefer giving up on my nominalisations, if you get the doctors to liste to a story I have.
John Launer Dec 10, 2016 at 10:04

An afterthought: You often describe doctors who have behaved/spoken in ways you disliked (and I would too). But if you asked them whether they regard themselves a practising narrative medicine, have studied it or even heard of it, I suspect they would say no. Their practices sound like the things that narrative medicine itself tries to critique.
1. Dariusz Galasinski Dec 10, 2016 at 11:11
  
  John, thank you very much for responding. I agree with what you said. There are two points I would like to make, though.
  
  1. I don’t want to challenge the notion ‘narrative is evidence’. In fact, I think it is very helpful, it focuses on what we, patients, do. The first experience of illness is a ‘story’. Put differently, it is through stories that we engage with illness. But then we have a problem. If narrative is evidence, then what constitutes it? And that’s really my point and one at which I probably part the ways with you (only a bit). I do not presume to know narrative medicine in its entirety, but it seems to me to focus on the macro-level forms of narratives, such as the genre, it does not, I think, focus on micro-level (apart from vocabulary). Narratives consist of passive voices, nominalisations, transitivity, modality, themes, rhemes and quite another few linguistic phenomena which, in my view, must at least be considered.
  
  2. I’m glad we agree on disliking my medical conversations. The problem is, however, that they’re not like that because I meet bad, unfriendly, nasty doctors. In fact, I would suggest that they are systemic. They are the way in which doctors talk. One of the retweets on my post about ‘The evidence is…’ sentence referred to it as standard. And I think it is standard. But making it ‘non-standard’ is not about introduction of narrative medicine, but just simply humanity.
John Launer Dec 10, 2016 at 9:43

Some thoughts too long to fit in tweets!

1. The axiom “narrative is evidence” was first proposed by Rita Charon in 2001 (she actually wrote “all narrative is evidentiary”) and was a specific response to EBM at its height. I agree that the looser equation of “narrative is evidence” is less helpful without a clearer definition of terms, but in its context the original assertion was important.
2. Narrative medicine is now a very protean movement, and some people who would describe themselves as narrative practitioners are indeed sensitive to form, genre etc. Much (perhaps most) narrative medicine activity isn’t about the patient encounter at all but about heightening humanity and sensitivity through reading and writing..
3. Perhaps most importantly, almost everyone involved in narrative medicine would themselves be highly critical of biopsychosocial medicine, as a construct which oppressively extends the medical gaze. They would be equally suspicious of “patient-centred” medicine, the Balint movement, and many of the “touchy-feely” mannerisms you have rightly criticised elsewhere. By attention to words (both content and form, and not excluding silence), narrative medicine as I see it is an attempt – however imperfect it may be in practice – to anchor one’s understanding and dialogue in someone else’s reality, and not to fall back on either scientific or emotional platitudes.
Linda de Cossart Dec 9, 2016 at 9:12

Context is key and we all interpret what we see, and hear (or don’t hear). All in the clinical context have a narrative and all need a voice. Our personal beliefs, experience, emotions and way of seeing the world will influence our interpretation. Doctors need to be educated to understand this. This can be done.
1. Dariusz Galasinski Dec 9, 2016 at 12:51
  
  I agree. It probably can be done. The problem is that I am yet to meet a doctor who, apart from making faces to suggest intensive listening, actually talked to me about ‘my narrative’. In fact, my narrative is to provide a context in which to order the tests which immediately become the ‘real evidence’.

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