from Chapter 3

The Maps That Define Our Reality

I remember thinking once that everything could be figured out, that formulas would be discovered to explain it all, that there were pristine and independent truths that transcended all cultures and stories. The person discovering those truths would certainly win prizes. Historically, in medicine, we have been driving toward certainty like Hannibal through the Alps or Patton into Italy, waging war with the darkness of ignorance, believing we can triumph. But what if health is a matter of equilibrium? What if disease and misfortune are related to disharmony? What if nature is pliable and plastic and molds to our intent and wishes? What if intent really does change material processes? What if it is all just story, and some stories no longer fit as well as they once did?

Narrative medicine helps us understand that everything we assume to be true about the world is just a story. The idea is simple--that it’s all story and that we, as a culture, create our stories. This is not in a negative sense, as in lying or confabulation, but in the most positive sense as a creative act of meaning-making in which we produce a story or map that makes sense of our world and, to the extent it matches our environment, allows us to survive in that world. It even allows us to alter our world and even our physiology. What’s different about the story of the person who is diagnosed with schizophrenia, for example, is the mismatch of his story with the environment. We can evaluate stories on the basis of how well they fit their context and environment.

Narrative medicine argues against the natural history of disease concept with its narrow focus on biological cause and effect. It claims instead that disease is embedded in a person, family, locality, and culture, and can only be understood through the many stories told that include the person and the illness. We cannot see an illness independent of the stories we tell about it. We cannot treat an illness without telling a story. We cannot position ourselves as healers or as experts, without telling stories. We cannot explain anything without telling stories.

For example, a mother brought her five-week-old daughter to the family medicine clinic for an urgent visit. Over the past two weeks she had already been seen several times in the office and once in pediatric emergency. The child had been without bowel movements for the past ten days, was sleeping poorly, and was fussy and irritable. She vomited after nursing. For the past 36 hours she had had projectile vomiting.

Most of us with conventional medical training would approach this child similarly because we share a certain story about health and disease. Our story focuses upon the mechanical things that can go wrong and become life threatening. After the x-ray, ultrasound, and blood and urine tests all came back normal, I made the intuitive leap that this mother and child could benefit from a simple prescription for chamomile and peppermint tea. I told the mother the story of Peter Rabbit and how his mother had given him chamomile and peppermint to calm his stomach and make him sleep after his antics in Mr. Macgregor’s garden. “If it worked for Peter Rabbit, it will probably work for your child,” I said, with some humor. She smiled and agreed with a nod. Then we discussed how to prepare and administer the tea. I asked her to return the next day in case my story wasn’t as good a map for this territory as I had hoped.

When they returned, mom stated with pleasure that the tea “had worked.” The baby’s bowels moved, the vomiting stopped, the child slept for six hours straight, and the irritation and fussiness resolved. Was it the tea or was it the story tied to the tea, or both? Was it, perhaps, the relaxation of the mother that was added to this brew when she was reassured that nothing terrible was happening? Did we heal the mother sufficiently for her to heal her child? We don’t know.

Mainstream medicine teaches physicians to be skeptical about evidence that cannot be explained by a physical process. A key notion behind the narrative approach is that we need to create a guiding story, a map that works and is pleasing, even as we recognize that the map is not the territory. Consider this story John Briggs told in a lecture at Massey University in New Zealand. During World War II, a platoon of soldiers was lost in the Alps. They had no idea where to go. Their lieutenant found a map in the bottom of his pack. The soldiers examined the map, compared it to their terrain, and struck out in a verified direction, heading for safety. When they arrived, their Captain looked at the map. Without knowing it, they had a map of the Pyrenees Mountains in Spain--nowhere near their position in France. Nevertheless, the map had worked. It had helped them find their way back. Maps do not have to be correct to work.

The story shows that we need a map, regardless of its accuracy or point-to-point correspondence with our surroundings. We need structure to orient our perception or we are lost in what has been called pre-narrative awareness, or pure sensation without interpretation. This kind of experience presents as the confusion of psychosis, when the map has vanished and experience is overwhelming. The map interprets our experience in such a way that we can take action. The soldiers took the action of walking out of their position, following the map. Regardless of the accuracy of the map, it led them to take action, without which they would have surely died. It gave them the needed certainty to act.