The idea of narrative is becoming recognized as basic to understanding humans and culture. Philosopher Alisdair MacIntyre writes, "[W]e all live out narratives in our lives" and "we understand our own lives in terms of the narratives that we live out." (MacIntyre, 1981) . The default mode of the brain according to Washington University neuroscientist Raichle is to make up stories. It is what we do easiest. It is what burns the least amount of glucose. It is, according to neuroscientists and artificial intelligence experts Shank and Abelson, the template for human memory. We humans actually think more in terms of verbs than in nouns. When we see something, we want a story about it. We want to know what it does or what it can be used for.
What is narrative? The shortest narrative consists of two action clauses and an orienting clause. I like to tell a short story that one of our clients told. She said, "One time I killed my boyfriend, but then he came back to live and tried to kill me. That was when we were living in Georgia and I was dealing coke." This short story tells so much. It conveys the essence of a character, of a human being positioning herself to be seen in a certain light. It contains values and emotions. It conveys a richness of understanding far beyond its mere words. It is a work of social art, complexly rich and detailed.
University of Auckland Professor Brian Boyd argues that our big brains arose to do story. Brain evolved to do story because story worked. Story worked because it is the most efficient way to store massive social information as illustrated above. Each of us can, apparently, know about 500 other people. The amount of information we need to negotiate relationships with these others is massive. We retain it in the form of stories.
Thus, narrative medicine means an understanding of health and disease for humans, that is grounded in the stories humans live out in their lives and the stories that we understand about our lives which give our lives meaning and purpose. Whatever we do only makes sense in the context of being grounded in a story or two. When you recognize that I have a belief, that belief only makes sense if I tell about the experiences that led me to form that belief. This belief rests upon experiences that led to certain conclusions that are stored in a narrative template.
Probably you wonder why this excites me so much! I would answer, "because it bridges my indigenous parts with my non-indigenous parts. In growing up, I learned that everything that mattered was a story. If my grandparents had something important to tell me, they would tell me a story. I was expected to interpret the story, to make sense of the story and to grasp what they wanted me to know. I learned that "all there is, is story". In Lakota, our personhood is the synthesis or integration of a swarm of stories that surround us called the nagy. These stories consist of all the stories that form us or that we have told or are enacting as we move about in the world. This nagy also consists of all the tellers of those stories. We are forever embedded in each other's nagy's.
To bring that into the practice of medicine, it means that illness is embedded in the stories we are performing and that are performing us. There is a biological story about how we are organisms who are born, live, wear out, and die. Our lives are finite. Within that finitude, however, are multiple social stories which interact with the "how long do I have to live story". Another story tells us that some events within our lives appear to be random, meaning that I can't make sense of them. I can't place them within a story. However, if I find the stories that people are telling and that are told about them, often their illnesses are illuminated in some way. The illnesses make more sense.
David B. Morris of the University of Virginia, writes that narrative is above all a form of knowledge (Morris, 2005) . In this view, narrative knowledge complements and differs from traditional "logicoscientific" knowledge (Charon, 2001) . For Charon, narrative knowledge is less of a product than a tool. It is "what one uses to understand the meaning and significance of stories through cognitive, symbolic, and affective means." Its identifiable properties -- beginnings, middles, endings, characters, conflicts, and turning points -- for Morris are more descriptive than definitive.
Narrative comes from the Latin word, narrare, which means "to tell" and refers to various forms of telling. Philosopher Richard Kearney writes that, "[N]o matter how distinct in style, voice, or plot, every story shares the common function of someone telling something to someone about something" (Kearney, 2002) . For Morris, these tellings include the gamut from fragments of discourse to ancient formulaic epic poems like the Iliad or The Odyssey to cryptic post-modern novels. Other scholars go further than Charon to argue that all knowledge, even the conventional declarative knowledge of modern medicine is narrative because all knowledge is embedded in theory which is a story about how the world is supposed to work. These stories have characters in the form of biological entities or molecules, they have plot in the sense of operations that take place upon these entities (enzymatic reactions, flows of ions, passage of molecules across membranes). They have implicit values such as preserving the life of the organism. Even mathematical proofs can be seen as narratives. Some neuroscientists see human identity and the operation of human consciousness as narrative (Fireman, McVay, & Flanigan, 2003) .
Narrative is not strictly verbal. It is visual, bodily, kinetic, musical, and mixtures of all these. Choreographed dances are stories, such as American Spring as are musicals like Oklahoma. For Morris, stories also hold the negative, what cannot be told, the gaps, silences, and what cannot be said. Stories always contain a matrix of choices -- what is valued, what is marginalized, and what is excluded. Within medicine, narrative reminds us that illness is always caught up in stories involving families, jobs, cultures, and meanings and is not limited to the simply biological rendering, which we call "the natural history of the disease". Indeed, I suggest that illness is without natural history because it is always affected by human affairs -- by people's search for meaning and happiness, by the relationships in which they find themselves, and by the broader stories of culture. Biology is not an island unaffected by the sea in which it swins.
BibliographyCharon, R. (2001). Narrative Medicine: a model for empathy, reflection, profession, trust. JAMA, 286, 1897-1902.
Fireman, G. D., McVay, T. D., & Flanigan, O. J. (2003). Narrative and Consciousness: Literature, Psychology, and the Brain. Oxford: Oxford University Press.
Kearney, R. (2002). On Stories. New York City: Routledge.
MacIntyre, A. (1981). After Virtue: A Study in Moral Theory. South Bend, Indiana, U.S.A.: University of Notre Dame Press.
Morris, D. B. (2005). Success Stories: Narrative, Pain, and the Limits of Storylessness. In D. B. Carr, J. B. Loeser, & D. B. Morris, Narrative, Pain, and Suffering (Vol. 34, pp. 269-285). Seattle, Wash8ington, USA: Intertnational Association for the Study of Pain Press.
