Narrative and the Cultural Construction of Illness and Healing. Mattingly, Cheryl, and Garro, Linda C. Berkeley: University of California Press, 2000. ix + 279 pp. Paperback, $17.95.
Narrative—defined broadly as an account of events that are somehow connected by the narrator—is an ubiquitous part of biomedicine. Case conferences, grand rounds, and clinical sessions are occasions for narrative construction and deconstruction. Patients routinely narrate their illnesses and experiences to their doctors, relatives, and acquaintances. And medical researchers construct narratives’ discovery for their readers. Narrative is not something particular to biomedicine. Jerome Brunner once described narrative as a fundamental, pan-human mode of thought, and there is much evidence of a penchant for narrative-making by practitioners and patients engaged with indigenous medical systems. Cultural anthropologists have been interested in telling and collecting narrative accounts from the earliest days of their discipline, and it should be no surprise to learn that medical anthropologists have developed a special interest in this subject. For them, narratives are two things at once. Narratives are an object of inquiry. How are medical narratives constructed in a given society? To what ends are they customarily employed? With what effects? And narratives are a tool in the ethnographer’s kit—a methodology for eliciting useful information from informants and a vehicle for communicating the complex substance of their research to readers.
Interest in medical narrative accelerated during the 1980s. The editors of Narrative and the Cultural Construction of Illness and Healing believe that this “narrative turn” was part of a more general intellectual change affecting anthropology. Anthropologists had previously analogized societies to machines and organisms but were inclined now to think about social life and relations “in terms of constructions, performances, enactments, contestations, plots, and counterplots. Narrative fits within this family of dramaturgical terms, which emphasize action, motive, event, and process as the key ingredients of social life” (p. 17). The narrative turn coincided with an effort—exemplified by Arthur Kleinman’s The Illness Narratives: Suffering, Healing, and the Human Condition (1988)—to refocus the attention of medical anthropologists, shifting them from an earlier concern with disease and illness (i.e., a dichotomy that is based on the ontology of biomedicine) to an “anthropology of suffering” (a perspective that transforms biomedicine into an object of inquiry rather than a lens for viewing sickness).
Narrative is a core element of this medical anthropology because it provides access to patients’ life worlds, and connects their suffering to the webs of meanings, cultural conventions, and social relations within which it (suffering) unfolds. Thus, suffering is neither spontaneous, nor a solitary activity, nor static. The construction of suffering is fluid and collective, it relies on cultural templates, and it emerges from the interplay of multiple narratives of the “same” illness. The emergent meanings and realities, like the narratives in which they are embedded, are not simply produced. They are typically negotiated, contested, and sometimes resisted.
These themes run throughout most of the essays in Narrative and the Cultural Construction of Illness and Healing. Several articles focus on the role of narrative in reestablishing a coherent sense of self and life in the wake of serious sickness (Linda Hunt on cancer in Mexico), chronicity (Linda Garro on diabetes among Native Americans), and stigma (Catherine Riessman on infertility in India). Two essays consider the role played by autobiographic and other forms of narrative in the training of physicians (Byron and Mary-Jo Good) and, more specifically, psychiatrists (Donald Pollock). An essay by Cheryl Mattingly examines what happens to patients (viewed from a phenomenological perspective) during efficacious “healing dramas” associated with forms of psychotherapy.
The book’s final essays are sceptical about unqualified assumptions about the coherence and efficacy of medical narratives, e.g., identifying narratives’ “ways of making sense of ongoing situations and guides for future action” (p. 17). An essay by Ole Dreier (a Danish psychotherapist) argues that therapists would do better if, instead of co-constructing narratives with patients, they concentrated on the social practices and arrangements that are responsible for producing and shaping conduct across diverse social contexts. Laurence Kirmayer (a Canadian psychiatrist) criticizes medical anthropologists who rely on literary analogies in writing about medical narrative. According to him, the analogies tend to obscure essential features of clinical encounters, by underplaying the fragmentary quality of clinical narratives and ignoring patients’ bodily experiences:
In the clinical encounter, we find narratives that are broken by the intrusions of symptoms, the incomprehensibility of illness, the inattention of powerful interlocutors (like physicians), or the debilitating effects of illness on creative and integrative cognitive functions. In chronic illness, coherent narratives emerge, but in acute illness we often have a situation where narratives have not yet been constructed or where multiple tentative accounts coexist and compete (p. 171).
In her essay, Uni Wikan contests the centrality of narrative in current anthropology. She rejects the most common justification for the narrative turn and argues that stories do not offer privileged access to the patient’s experience. Important elements of the patient’s lived predicament go unsaid and are sometimes unsayable. The anthropologist’s current preoccupation with narrative effectively shields her from this uncomfortable reality.
In brief, Narrative and the Cultural Construction of Illness and Healing is a comprehensive and provocative guide to recent developments in the ethnography of medical narrative. For readers who are unfamiliar with narrative analysis or the history of the “narrative turn” in medical anthropology, the introductory chapter provides a comprehensive and informative overview of the salient literature and key concepts.
Allan Young, Ph.D.
Professor of Anthropology