Narratives in Hand Therapy ^∗

Statement of the Problem: The Illness Experience

Clinicians and patients do not always use the same end points to define the patient’s recovery as a success. Clinicians may include in their definitions of success measures of reductions in disease and impairment, whereas patients tend to measure their success in terms of recovery of function.¹ Given the strong correlation between disability and mood, stress, and beliefs and the usually more limited correlation with disease or impairment,² a patient’s physical problem, such as a hand injury, cannot be separated from the personal experiences that give the problem its meaning. The meaning a problem or injury embodies for a patient is idiosyncratic, circumstantial, and personal. The illness experience can help explain how a person’s diagnosis affects his or her life.³^,⁴^,⁵ Narrative medicine helps therapists treat the illness experience, not just the disease. This involves listening empathetically, trying to imagine how the situation feels to the patient and also how it changes the patient’s life and story.⁶

Narrative Example of the Illness Experience

Introduction to Narrative Medicine

Dr. Rita Charon’s appreciation that a substantial portion of medicine involves the exchange of stories motivated her to earn a PhD studying narrative in English literature while she was active in her primary care practice. Finding that her improved understanding of narrative helped her better connect with her patients, she developed this aspect of her practice and coined the term “narrative medicine.” Absorbing and interpreting the patient’s story and being able to retell that story and give it form and meaning helped her and her patients realize the complexity of the illness experience, creating new possibilities for healing.⁷ The narrative approach asks health providers to absorb, interpret, recognize, and be moved by patients’ stories.

Operationally, narrative medicine looks like casual conversation between the provider and patient. The provider uses communication techniques that elicit personal and meaningful information from the patient. Both the patient and the provider are engaged in the exchange with the provider listening actively, reflecting, maintaining eye contact, avoiding interruptions, and asking open-ended questions.⁸ Patients feel listened-to by being given opportunities to convey personal and emotional aspects of their illness.

When we listen to patients’ stories, we collaborate with them and can empower them to create new life stories. In other words, providers who facilitate the unfolding of patients’ stories ⁶ help them to become authors of their lives, which restores or enhances a sense of control.⁹ To do this requires engagement with the patient. In other words, just listening is not enough; the therapist must also be engaged in the interaction.¹⁰

Another aspect of the practice of narrative medicine is the process of reflection. Charon ¹⁰ describes the “reflective space” that leads to a fresh or clearer version of the meaning of one’s story. When therapists state the patients’ narrative back to the patient, they show that they are listening and reflecting.

The narrative fallacy occurs when we create a story that confirms our flawed interpretation of a circumstance.¹¹ When patients’ stories are reinforcing their illness, pain, or disability, therapists can help develop a more accurate, adaptive, and enabling story. For example, a patient who is having trouble performing range of motion soon after tenolysis for fear of hindering healing may do better when encouraged to adopt the more accurate and adaptive narrative of performing range of motion to remodel soft tissue and prevent adhesions.

Emotional Labor

Practicing narrative medicine is not easy. It requires emotional labor. Emotional labor occurs when clinicians regulate the emotions they display to convey a desired professional image.¹² Narrative medicine helps physicians (and therapists) become more supportive as colleagues, enhancing self-reflection that fosters greater sensitivity to the complexity of peoples’ lives. In this way, narrative medicine promotes a sense of physician (and therapist) society, where individual patient stories matter.¹⁰

Regulating one’s emotional display while looking sincere can be challenging at times, such as when a patient’s ideas about the injury are very dissimilar to the clinicians. Understanding the importance and strength of one’s intuition can help depersonalize these disagreements and keep the relationship from becoming adversarial. It is not that the patient lacks respect for your views as the expert, it is just that—right or wrong—they value and respect their own intuition and gut feelings more than your expert advice.

Narrative Example of Emotional Labor

Jack’s Story

An active 60-year-old male executive sustained a radial collateral ligament injury to his right dominant small finger proximal interphalangeal joint while bicycling, which was one of his favorite activities.

Therapist Reflection

This patient loved to ride his bicycle. When discussing his progress and the typical timeline for recovery, he was shocked to learn that it could take longer than 2 weeks for him to recover from his injury. He could not accept this and demanded that he recover normal range of motion and resolution of all symptoms in 2 weeks’ time.

Solution

The therapist helped him explore other activities to do temporarily while recovering, which helped him occupy his time more effectively, and the hand team provided enthusiasm and encouragement for his progress.

Narrative Message

This patient was used to being in charge in all aspects of his life, and he was going stir-crazy not being able to perform his usual high-demand athletic activities.

Procedural Reasoning versus Interactive Reasoning

Narrative medicine emphasizes interactive over procedural reasoning. Procedural reasoning is where an expert uses structured actions (procedural knowledge) to accomplish goals. Procedural reasoning is used to decide what treatment to use at what frequency or intensity.¹³^,¹⁴ There is a certain comfort in having procedures and rules for care but when providers use only procedural reasoning, evaluation and treatment may resemble a cookbook approach. By comparison, when providers collaborate with patients to understand their unique needs, it is called interactive reasoning.¹³^,¹⁵ Interactive reasoning looks like a social interaction but is actually a purposeful process that helps the therapist understand the patient while also building rapport.¹³ Interactive reasoning uses the patient interaction to bring to light and amplify information that is relevant to recovery.⁴ This is facilitated when the therapist elicits the patient’s story and appreciates the patient’s emotional tone and nonverbal communication.⁶ By eliciting and restating the patient’s narrative, both the patient and therapist come to a better understanding of how the patient makes sense of his or her illness experience.¹⁴^,¹⁶ This insight can create new opportunities for addressing the illness.