Defining narrative

In their discussion of what they term ‘the problem of reality’, Robert Scholes, James Phelan and Robert Kellogg have argued that “Meaning, in a work of narrative art, is a function of the relationship between two worlds: the fictional world created by the author and the ‘real’ world, the apprehendable universe. When we say we ‘understand’ a narrative we mean that we have found a satisfactory relationship or set of relationships between these two worlds” (p.82).8 This is the basic framework within which this article seeks to shed fresh light on how narrative works from a medical humanities perspective. When we draw meaning from narrative, we assimilate our own experiences with the ones being described to us. But I want to take this concept further to assert that even when no narrative is apparent—in metaphor, phenomenology and photography to use Woods's examples—through reception of the medium, the recipient will make meaning by using narrative. The narratee will form a story, however loosely based on truth or fact, to make sense of what they see, hear, experience, etc.

One of the main difficulties with this line of reasoning is that the parameters of what does and does not constitute narrative are not clearly defined in current narrative studies scholarship. In her essay “Toward a definition of narrative”, however, Marie-Laure Ryan has put forward three potential domains for consideration: discourse, story and use (p.24).9 For the purposes of this essay, I am most concerned with the aspects of story and use because these are the areas most applicable to the medical encounter: what is the story and how can that story be used to provide good healthcare for the patient? As Brody has pointed out, “not only is the telling of stories a specific sort of act, it is an act that has important implications for the very organization of human knowledge and of other human actions” (p.23).10 How narrative is constructed has been considered central to how humans understand one other and themselves by cognitive scientists such as Mark Turner (pp.4–5).11 Unsurprisingly, then, in the view of some medical humanities scholars, narrative is also fundamental to understanding the medical encounter. For doctors and other health professionals, Arthur Kleinman has argued, “witnessing and helping to order that experience [of illness] can be of therapeutic value [to patients]” (p.xii).12 So, in this case, for example, ordering experience means creating a narrative that can help the health professional to understand the patient's situation and enable the patient to feel heard and cared for. There is a difficulty with this theory in that—in practice—the doctor's attempts to help order the experience of illness may be restrictive and damaging for a patient who is unable to get their story across as they would like. Nevertheless, no matter what the patient does or does not say, the health professional will (and is required to) make a judgement on the patient's condition and treatment. A narrative will take shape in the mind of the healthcare professional that will enable them to make this judgement, although of course we cannot know precisely the extent to which it is driven by or reflected in the patient's account of what has happened to them and why. Clearly this view of the narrative exchange between a patient and their health professional is deeply problematic; there will be multiple and potentially conflicting narratives forming not to mention the ethical implications of autonomy and justice. Potentially, the medical encounter could be a site of trauma in itself in these terms.

In ‘Beyond the wounded storyteller: rethinking narrativity, illness and embodied self-experience’, Woods explores the extent to which we are ‘narrative selves’ and whether narrative is the best way to respond to illness. Here, she finds that in the medical humanities there is a tendency to identify narrative by its relationship with meaning, culture or identity. It is, therefore, not designed to encompass diverse perspectives of human experience; in the medical humanities “a person's narrative is often held to be coextensive with their subjective experience, their psychological health and indeed their very humanity” (p.114).13 In other work where she discusses this topic, she refers specifically to the dangers of ‘overinflating that counts as narrative’ which she believes “risks mistaking a specific form of primarily linguistic expression for the master-trope of subjective experience” (p.74).5 In her discussion of the need to be more attentive to genre rather than conflating different types of narrative, Woods further criticises the ways in which some authors “collapse distinctions between different narrative forms and contexts” (p.74).5 In this, she seemingly refuses multiple narrative possibilities in her assessment of how we express ourselves in the world. Moreover, her suggested alternatives to narrative (phenomenology, metaphor and photography) may well create as equally a rigid taxonomy as the one she is attempting to challenge. Perhaps, instead, it is the multiplicity—this expandability—of our understanding of narrative and its uses that makes it most pertinent and valuable to the medical humanities, itself a diverse and vibrant field of enquiry. Moreover, it is my contention that in our engagement with any creative expression of human feeling or experience, we employ a way of narrativising to make sense of phenomenological events what we see/hear/taste/smell/touch. Therefore, narrative—and I mean by that the weaving of story to make meaning—is a primary and necessary part of analysing creative output, whether that creative output is considered narrative-based or not. The privileging of meaning in a simplistic or linear sense is problematic particularly in the light of literary and artistic movements that have revolutionised the way we understand and use nonlinear narrative such as postmodernism and surrealism. However, this acknowledgement is not to suggest that meaning is redundant or narrative is not present or at work in these art forms. Rather, they challenge our ability to narrativise as a recipient of language, metaphor, imagery, rhetoric but they do not negate it. Indeed, in these expressions of art and literature and through this mode of communication, the human capacity and facility to find meaning and to myth-make even in the most difficult of situations becomes most clear.

Referring to Paul Macneill's work, Woods raises an interesting and important point about artists such as Stelarc and Orlan who, in her words, want to suggest ways of “exploring the discontinuities and disruptions of embodied self-experience” (p.76).5 These artists, she argues, “resist the principle comforts of narrative—continuity, closure and containment—in the pursuit of the paradoxical, the ambiguous and undecidable” (p.76).5 Yet, Woods's reference to the ‘comforts of narrative’ seems a rather narrow interpretation of what ‘narrative’ itself might be. Not all narrative has to have ‘continuity, closure and containment’. Significant movements in literature and in critical studies such as postmodernism, poststructuralism, New Historicism and reader-response theory, to name but a few, have brought about fresh understandings of self, identity and narrative perspective in their use of and engagement with linearity and chronology. Indeed, by its very definition, one could argue that stories of illness in particular reject the ‘comforts of narrative’. So often, illness narratives exhibit emotional responses to feelings of confusion, silence, denial, disgust, shame and anger that deny that idea of ‘continuity, closure and containment’ to which Woods alludes. Yet, the listener, reader or witness to the story must find a way to make sense of what he or she hears or sees. Reader-response theory is particularly relevant here because in a medical humanities context this is where narrative response becomes central to an understanding of another's illness and suffering. When Louise Rosenblatt introduced reader-response theory in 1938, she referred to the processes readers use to create meaning and experience.14 Rosenblatt proposed that analysis takes place through the reader's emotions, hopes and fears, experiences and knowledge, rendering each interpretation subjective and unique. Woods is right to suggest that ‘language is not the only medium for communicating matters of medicine, health and illness’ but she does not acknowledge that in order to make sense of how illness is communicated and what it means, narrative ordering and a (perhaps predominantly internal) linguistic framing is required. A photograph, for example, is clearly a visual medium and does not require language in and of itself to convey a message. Once we seek to make sense of and communicate the meaning that we find within it, however, we require narrative. I do not know how metaphor can exist without the linguistic apparatus that carries it. Even the quote that Woods uses from Kirmayer to exemplify her point discusses metaphors as the ‘building blocks of narrative’ that serve as ‘narrative opportunities’ to ‘drive the story onward’ (p.76).5 Given that Woods too acknowledges that non-narrative forms ‘intersect with or contribute to narrative’ but do not take storytelling as the starting point, her argument suggests that it is necessary to expand rather than limit the boundaries of narrative? Like photography, phenomenology, too, requires a narrative carrier; and although this may be conveyed through body language, sign language, linguistic language, music, film or philosophy, experience nonetheless requires narrative ordering by the receiver/responder to make sense of it. Although Havi Carel has argued that “[p]henomenology can be used to order and describe the experiences of illness and provide a robust account of the embodied nature of illness” (p.100),15 she neglects to note that phenomenology is not a pure form of expression. The assertion that it can be used to ‘order and describe’ experience strikes me as a process that employs narrative structures to make story and, ultimately, meaning.

What is speakable, what is expressible: illness narratives and their limits

Writing in defence of narrative as a means of valuable expression, Lisa Diedrich has argued that although there is failure in death, although death itself is inexpressible because it, like pain, is beyond comprehension or expression, we strive—through narrative—to recognise suffering, to explore new boundaries of loss and pain, to navigate ways of being in the world. Narrative, for Diedrich, is therapy because it demands interpretation: In the face of death, one fails. One confronts that which is impossible. One faces failure and impossibility as well as death. And yet, in illness narratives one ‘pays attention to suffering.’ And yet, one attends to loss. And yet, one negotiates new terrains of embodiment and of language, of intersubjectivity and of utter aloneness. Through narrative, one moves out into the world and at the same time deeper into oneself. Failure cannot be overcome or compensated for, but it can be treated in and through narrative. (p.81)16

In terms of the interpretation and interpretability of illness, this is a useful way of employing narrative in medical humanities contexts. Medicine can use narrative to ‘treat’ (in all the ways in which that term might be used helpfully) the failures that occur to make sense of patients’ stories. Narrative engagement in these terms can heal.

Modern popular culture bespeaks an overwhelming willingness and need to tell our stories of illness through various narrative outlets. As the history of literature has become more and more about the individual, so has this branch of writing become ever more centred on the personal experience of living and dying with disease, illness and bodily disorder so that “by the end of the twentieth century, illness and disability narratives were established as literary genres” (p.2).17 Brody has helpfully argued that “we can best understand what it means to be sick by attending carefully to the stories people tell about sickness” (p.28).10 Stories, he argues, are both complex and inherently flawed pieces of meaning-making. He observes that stories are required to be seemingly paradoxically both straightforward and complicated because, as J. Hillis Miller has shown, “each storytelling is a retelling, making the story into a sign, but neither a perfectly straight line nor an infinitely convoluted line can serve as a sign” (p.32).10 The literary critic and narratologist, H. Porter Abbott, has suggested that “human beings have a cognitive bias toward the clarity of linear narrative in the construction of knowledge” (p.143).18 But despite this, Abbott's ‘cognitive bias’ for ‘linear narrative’ (my emphasis), which has been seen as the privileged form of narrative in medical humanities scholarship, captures the complex stories that make up our belief systems about who we are, where we have come from and what life and death might mean. Although Brody, too, has reservations about the sense of linearity of this form of narrative, it is nevertheless, for him, meaning-making. Moreover, receiving and responding to the articulation of the subjective experience of feeling, emotion, pain, suffering, fear and anxiety are key to our making sense of the world. Simply put, no matter how inconsistent and imperfect, no matter how convoluted or truth-devoid our stories of illness are, it is the way in which we engage with them—the stories around stories that we form—that enable us to shape the world in the way that we do.

Conclusion: beyond narrative?

An alternative viewpoint, however, lies in a well-known television interview that took place in the mid-1990s. In 1994, Melvyn Bragg famously televised an interview with Dennis Potter as he was dying of pancreatic cancer. Best known for his television series The Singing Detective (1986), Potter had been writing screenplays for the BBC since 1965 and was a much-loved and well-renowned writer. In the opening section of the interview, Bragg questions Potter about his cancer, essentially starting the interview at the end of Potter's life. In his response to the question ‘How did you, and when did you, find out that you'd got this cancer?’, Potter begins to narrate a new way of seeing the world as a dying person: Below my window in Ross […] the blossom is out in full now … it's a plum tree, it looks like apple blossom but it's white, and looking at it, instead of saying ‘Oh that's nice blossom’ … last week looking at it through the window when I'm writing, I see it is the whitest, frothiest, blossomest blossom that there ever could be, and I can see it. Things are both more trivial than they ever were, and more important than they ever were, and the difference between the trivial and the important doesn't seem to matter. But the newness of everything is absolutely wondrous, and if people could see that, you know. There's no way of telling you, you have to experience it, but the glory of it, if you like, the comfort of it, the reassurance … not that I'm interested in reassuring people, bugger that. The fact is, if you see the present tense, boy do you see it! And boy can you celebrate it.

For Potter, the experience of dying is not easily narratable (“[t]here's no way of telling you, you have to experience it”) and yet the desire to try to capture it persists; he goes on attempting to define it by describing ‘the glory of it’, ‘the comfort of it’, ‘the reassurance’ it brings him. The use of these nouns—‘glory’, ‘comfort’ and ‘reassurance’—is telling: clearly designed to bring about a sense of succour and consolation both for him and for his audience (the witnesses of his dying), Potter refuses the impossibility of relating his experience of illness. Instead, he opens the possibilities of meaning up to those who see and hear his story. As the interpreters of Potter's death narrative, for example, we might see the natural imagery that he uses to describe seeing the blossom as representative of both life and death. The blossom captures the transitory and temporary nature of life and the inevitability of death and decay. It is beautiful but its beauty is fleeting.

What we have in the above passage from the interview are examples of the three so-called non-narrative forms of communication that Woods puts forward as alternatives to narrative: metaphor, phenomenology and photography (in this case, film). These forms of expression may or may not be categorised as narrative in and of themselves. However, the only way we can become effective interpreters of another human being's plight, as I have attempted to show in the short piece of critical analysis of this passage above, is through narrative engagement. It is only through narrative that we gain access to Potter's world and get a sense of what he is experiencing. We become effective witnesses to his predicament, valuable listeners of his story.

Although this is essentially a failure narrative (Potter will not survive his cancer and does not pretend that he will), the message in the Potter–Bragg interview might be perceived as uplifting because he has a constructive and affirmative attitude to dying. For him, the process brings fresh perspective of the world: he sees with new eyes that which—without the knowledge of impending death—he had long taken for granted. Perhaps—looked at in this way—his is one of the plethora of ‘triumph narratives’ of modern times after all. He suggests that the dying are given privileged access to a better way of seeing the world, very different from the one he perceived as a non-terminally ill person: ‘you have to experience it’ he tells us, it is not something he can fully describe through language. The interview gives Potter a way of expressing what he is going through, although the limits—and the illimitability too (his viewer can make of it what they wish)—of that expression are evident. Perhaps the lesson to be learned from Potter's interview is that we need to embrace the seeming limitations of narrative. He says he cannot articulate what he sees and feels and yet, watching the interview, there is clearly an affective element that is transferred to his audience, to say nothing of his communication of wonder. What Potter shares is his imaginative response to the dying process, one in which his viewer-listener participates both as (most probably) a non-dying person and as a witness to his suffering. It is the way in which we interpret Potter's words that provides narrative agency that gives his experience meaning and significance. Listening and responding (rearticulation, analysis and understanding) are key to Potter's voice being heard, his experience being validated, his life—and death—having significance in the world.

Given the rise of the autobiographical illness narrative over the last 20 years, the emerging provocation to the medical humanities is both surprising and—one might have thought—unnecessary. In recent years, some narratologists have understood life-writing to pose important questions about the relationship between self and identity. Paul John Eakin has argued that “when it comes to autobiography narrative and identity are so intimately linked that each constantly and properly gravitates into the conceptual field of the other.” He concludes, ‘narrative is not merely an appropriate form for the expression of identity; it is an identity content’ (p.100).23 As Woods has pointed out, the movement against narrativity that philosophers such as Galen Strawson and Crispin Sartwell have begun represents a resistance towards the seeming obligation to ‘find life meaningful’ (p.76).5 But where exactly does this get us? We do not, of course, have to find life meaningful, however thought-provoking as this argument is, I wonder what this kind of philosophical approach really achieves.

It is clear that narrative is both problematic and requires problematisation to be useful to our thinking in this discipline. This essay does not seek to provide answers, necessarily, but to reassess the placing of narrativity in our emergent field of enquiry. Narrative is a constructed artifice, no matter who is doing the constructing or why; it does not exist outside and beyond the human and it does not accurately reflect events, but on the other hand perhaps it does so as much as anything else. It is, of course, a contested and contestable way of mediating the world, one fraught with complexity and intricacy. The boundaries of narrativity, then, should be expanded to include those forms of expression that Woods refers to as non-narrative because even (and sometimes especially) non-verbal expression requires language and narrative ordering in the construction of expression and in the process of meaning-making. Each time we make an effort to produce an expression of suffering, we demand a cognitive engagement that requires the ordering information into narrative. We seek out communication; we desire the transmission of an idea. This is narrativity and it takes a myriad of forms.