“Tell it slant:” poetic musings on identity

I hated labels anyway. People didn’t fit in slots–prostitute, housewife, saint–like sorting the mail. We were so mutable, fluid with fear and desire, ideals and angles, changeable as water.  Janet Fitch, White Oleander

The acclaimed poem, Where I’m From, by Kentucky poet laureate George Ella Lyon has become a popular poetry writing exercise. It is well-known in schools, creative writing classes, contests and writing forums.

The poem is a beautiful evocation of childhood with a strong sense of place and belonging. It speaks to people in diverse circumstances and provides a template to express one’s uniqueness and experiences. As Lyon writes, “the list form is simple and familiar, and the question of where you are from reaches deep.”

Here’s a poem based on the Where I’m From template by Melanie Poonai, the 15-year-old winner of Foyle Young Poets of the Year Award in 2007:

Where I’m From

I am from a life filled with colour,
From the chocolate brown that is my skin.
I am from the sunshine yellow of my mother’s laugh,
From the red and white of my brother’s favourite football shirt.
I am from the crisp new white pages of a book,
From the miserable grey of the street I live on.
I am from green, pink and yellow; My garden in summer filled
with flowers,
From the terrifying black of the nightmares that haunt me.
I am from the ginger orange of my buried cat,
From the blue and gold of my ever-short school tie.
I am from the dark oak of my grandmother’s coffin,
From the golden “Aum” pendant around my neck.
I am from every pink scar etched into my body,
From the red, orange and brown of a hot curry.
I am from every identical colour of the twins I love,
From the blue and green of a hospital ward.
I am from all that has happened,
And all that will be.

Since introduced to the poem at a Toronto Writer’s Collective training workshop, I have used it as a writing prompt in many contexts: from healthcare settings to a youth shelter to a program for street-involved people to a forum for academics and educators.

I’ve had many opportunities to write to it myself and every time the end product is different. I am always surprised at what emerges. While there are certain phrases and images that keep surfacing as a recurring thread, new things emerge every time I do the exercise that leave me wondering where they’ve come from.

I’ve been thinking about what gives this poem its power and resonance. Is it the openness and universality of its subject? Or the simple structure and repetition that opens a door for writers of all skill levels? Is it the possibility of writing about the “self” without divulging too much, or boxing us in to restrictive categories?

While the autobiographical nature of the piece is often emphasized (and Lyon has written about its roots in her childhood), the poem allows for accounts of the self at a literal level, a metaphoric level, or both. It can capture the emotional tone of “where we’re from” without relying on concrete information about the past. It offers opportunities to write about things that may otherwise feel too exposing or too raw.

While Lyons rooted the poem in her own experience, the poem allows us to create a story about the past through fragments and glimpses — a story that can change and evolve with every telling. It is this ambiguity and flexibility that bestows a sense of psychological safety and freedom not possible in explicitly autobiographical pieces that construct identity as unchanging and solid.

In an era of increasing complexity about notions of identity and the pressure to place labels on our experience, this kind of writing offers another way to express and re-create ourselves. As Emily Dickinson so beautifully wrote, “tell all the truth but tell it slant.”


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One story begets another: personal narratives by a father and daughter

untitledI have been preparing a presentation for an upcoming conference on the medical humanities essay A Patient Examines his Doctor by literary critic and writer Anatole Broyard.

While working on my dissertation a few years ago, Broyard’s writings on illness were on my radar but I had not delved into his essays. I was inspired to re-visit his collection of essays, Intoxicated by my Illness, after listening to a talk by a physician about the lessons she learned from Broyard’s reflections on his relationship with his physician. Having now read the essays several times, I am beginning to see Broyard’s work as a literary guide on compassionate care. In mining his experiences in the “foreign country of illness” – in particular, his feelings of  isolation and alienation — Broyard examines “what sort of doctor he wants to have, and to talk to, and be with.”

With Broyard’s ideas in my mind, I happened across a very different but equally compelling story. It is the backstory of Broyard’s own life — a complex legacy of race, identity and family secrets. While well-known as a writer and literary critic during his lifetime, Broyard became a subject of controversy after his death when it became public that he was of Creole ancestry and had concealed his racial identity to everyone except his wife and a few close friends. His story was explored by Black theorist Henry Louis Gates Jr. in an article for The New Yorker in 1996 entitled, The Passing of Anatole Broyard and the controversy reached across the border into Canada through an article by Robert Fulford in the Globe and Mail.

Demonstrating the veracity of Arthur Frank’s contention that stories beget more stories, an intergenerational narrative of race and identify was born when, several years after his death, Broyard’s daughter wrote her own memoir, One Drop: My Father’s Hidden Life – A Story of Race and Family Secrets. In this book, Bliss Broyard struggles to make sense of her father’s decision to keep his background an “open secret” and explores the conflicting emotions and troubled losses he left behind.

While she is not able to completely reconcile her father’s actions, she comes to appreciate his decision within the context of prevailing cultural narratives of race and ethnicity that shaped her father’s life and might have led to such a decision. Responding to the question of what this newfound ancestry means to her, she challenges our assumptions about identity saying, “I may never be able to answer the question What am I? Yet the fault lies not in me but with the question itself.” (For more insights read her New York Times interview.)

In resisting the rigidity of identity categories, personal narrative allows us to explore the intricacies of personal history, family dynamics and identity. Whether it is using one’s story to map the unfamiliar and frightening terrain of serious illness or as a vehicle to explore the troubled legacy of race, inequality and loss, memoirs do not lend themselves to easy endings and simplistic analyses. This makes memoir an invaluable resource for thinking about identity — and for constructing personal stories that are generative for ourselves and others.

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“How Are You?” Personal Reflections on a Healthcare Visit

While working on my PhD dissertation a few years ago I became intrigued by the idea of liminality. In cultural anthropology, liminality (from the Latin līmen, meaning “a threshold”) is the ambiguity or disorientation that occurs in the in-between or transitional phase of social rituals.

Healthcare researchers have begun to use the concept to explore the experience of living with illness and chronic disease. For my research, I explored the spaces I move through at the hospital through the lens of liminality to help me make sense of interactions between practitioners and patients.

Recently I had an experience as a patient that made me think again about liminality in healthcare settings. I arrived for an appointment to get the results of an ultrasound. As I sat in the waiting room, I became aware, once again, that worry and anxiety are constant companions in hospital waiting rooms. I watched the other patients and tried to imagine their stories.

In time, a woman called my name and asked me to follow her to the exam room to meet the doctor. She had no uniform to indicate her role. She did not introduce herself by name or position, and the small ID badge around her neck was impossible to read as we walked. As we proceeded down the hall, she asked me how I was. I responded with a courteous but brief “fine,” assuming this was polite banter to fill the time as we made our way to the exam room.

She glanced at my chart and asked whether I was there to get test results. I said yes, and then she asked again: “How are you?” Our interaction suddenly seemed unclear and I was confused about how to respond. Was this more than social chit-chat? Why was she asking again? Did she expect me to say more about how I was feeling? I mumbled something once more about being fine; at this point we reached the exam room and she left me to wait for the doctor.

Our brief interaction left me unsettled. I wondered who she was — a nurse, a medical resident, or perhaps, a secretary? If she was the clinic nurse I wondered why a skilled professional was spending her valuable time escorting patients to exam rooms. If her role was to identify patient concerns before they see the doctor, this was never explained.

It got me thinking about the impact a seemingly innocent question such as “how are you?” might have in the context of a health care visit. While we use this question in daily life as a greeting ritual, social lubricant, or invitation for further conversation, it takes on a more complex meaning during a clinical encounter. In these moments patients are vulnerable and  focused on their health status — hoping that things truly are fine. In an oncology waiting room, for example, patients and their families might be trying to hold back a flood of worries and anxieties that accompany a frightening diagnosis or the prospect of invasive treatments.

I think a few things would be helpful in those ambiguous moments. The first is for health care professionals to introduce themselves and tell patients what their role is. The woman who escorted me could have said, “Hi, my name is Maureen and I’m the nurse who works with Dr. G. I check in with patients before he arrives to ask if they have any concerns.” That would provide context on who she is and what she is there to do. It seemed to me that the offer of extra support is something patients and families visiting the clinic that day might really need.

This got me thinking about the #hellomynameis campaign in the UK, started by doctor and cancer patient Kate Granger. The campaign emphasizes the role of simple introductions when providing care. Following her own experiences in the hospital Granger writes,

It felt incredibly wrong that such a basic step in communication was missing. I firmly believe it is not just about common courtesy, but it runs much deeper. Introductions are about making a human connection between one human being who is suffering and vulnerable, and another human being who wishes to help. They begin therapeutic relationships and can instantly build trust in difficult circumstances. In my mind #hellomynameis is the first rung on the ladder to providing truly person-centred, compassionate care.

As healthcare providers and therapists, we should remember that hallways and waiting rooms are in-between zones – they exist between the “public” spaces outside the hospital and the “private” spaces inside. When I greet a patient in the waiting room now, I try not to ask “How are you?” as I assume the patient might find my inquiry confusing: Is she making polite chit-chat or is she starting the counselling session? I hope that chatting about the weather or their journey to the hospital provides a more neutral way to transition from the outside to the inside.

In thinking about my recent clinic visit, I realized that I also experienced a moment of grace. As the doctor entered the exam room, his hand still on the doorknob, he sidestepped social niceties and announced immediately, “The test looks fine. Everything is good.” In doing so, he brought a welcome and abrupt end to the anxiety I was feeling and smoothed the way to other conversation – that could include social pleasantries and discussing the specifics of my situation. At the end of the visit, after releasing me from the need for further medical surveillance, the doctor said, “We’re here if you need anything in the future” which made me feel both acknowledged and cared for.

This experience reminded me, on a personal level, that healthcare settings are full of in-between spaces and ambiguous interactions. One of our jobs, as practitioners, is to pay attention to these transitional zones and try to navigate them as gracefully as possible.

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A Kindness Curriculum for Healthcare Providers?

I’ve spent the last few weeks working on a grant proposal to support compassion in healthcare. I’ve been reading and thinking a lot about compassion – both what it looks like and how to teach it. I’ve also been musing about the idea of kindness. Could something so old-fashioned and prosaic hold promise for improving care in the increasingly high-tech universe of medicine?

In an article, “On kindness,” medical educator John Launer reflects on the big impact of small acts of kindness on people dealing with illness or vulnerability. Like Launer, I teach communication skills to healthcare providers. As he points out, those of us who teach these skills spend a lot of time talking about listening, non-verbal cues, and empathy. While these are all important, we tend to focus on behavioural strategies, and less on human values. We rarely use terms like “wisdom” or “kindness” in our curriculum. He raises an interesting question: How would being explicit about those values change how we think about giving and receiving care? He also highlights the importance of institutional kindness – creating an environment that encourages and values such actions.

Around the same time that I came across Launer’s article, I found Laura Pinger and Lisa Flook’s What if schools taught kindness for twice a week for 20 minutes. This article is about a school-based program that taught kindergarten students about kindness. They used stories and practices to help the kids cultivate mindfulness, regulate their emotions, and pay attention to the needs of others. They focused on both extending help to others and acknowledging the kindness extended by other people. They posted a “kindness garden” on the classroom wall to make visible acts of friendship between the kids. “The idea is that friendship is like a seed — it needs to be nurtured and taken care of in order to grow.”

Pinger and Flook reinforce the idea that even small changes create a ripple effect. Fundamentally, the school-based program emphasizes the quality of attention we turn towards others in moments of distress or need:

For example, what quality of attention do we bring when we interact with our kids? Do we give them our full attention — eye contact, kneeling down to speak with them, asking questions — or are we distracted? By modeling behavior, and through our interactions, we show them what it’s like to be seen and heard and to be compassionate with others.

All of this made me think about the Roots of Empathy (ROE) program I taught several years ago to a group of Grade 6 students who were struggling with life challenges and limited resources. In the ROE program, an infant and their parent visit a classroom every few weeks. The ROE instructor encourages students to observe the baby’s development and name the baby’s feelings. In this context, the baby is the “teacher,” and the instructor uses the children’s ideas to help them reflect on their own feelings and those of others.

I can still remember the kid’s excitement when the baby and her mother arrived in the classroom, and how they rushed to greet and try to help them. All of the kids wanted to touch the baby and be close to her. Even the most disengaged or “difficult” students were drawn to the baby and seemed to respond to our lessons on empathy. While the program couldn’t begin to resolve all the issues these kids faced, it gave them the message that small acts of kindness make a difference.

When I mentioned this blog posting to someone recently they remarked, “Kindness in healthcare is a rare thing. The whole environment doesn’t really lend itself to acts of kindness.” It made me think about the value of kindness in healthcare settings, and how the environment might actively discourage it. What quality of attention do we bring to our interactions with patients? Are we distracted? Do we give them our full attention — even during our brief moments of contact?

While it’s hard to argue against kindness for its own sake, there are higher stakes for healthcare. James Rody, MD, the Director of the Center for Compassion and Altruism from Stanford University, writes about the relationship between kindness and healing:

It is amazing what difference a physician’s attitude can have on a patient. A positive emotional state allows one to more fully connect, decreases anxiety and leads to a faster recovery. There is even evidence that when a patient listens to less than a minute of compassionate communication from a physician they feel less anxious. Researchers have mapped reduced anxiety and increased positive emotion to biological and immunological responses in the body.

Rody believes that kindness isn’t just good for patients.  He draws from emerging neuroscience research that acts of kindness stimulates the reward circuits in our brains, so giving and receiving kindness has a positive effect on healthcare providers as well.

While there’s a big gap between kindergarten students and health care providers, I’m wondering if the lessons we need to learn are not that different. Maybe we need to  institute “kindness gardens” on the walls of our hospitals to remind us of the importance of small acts of kindness towards others and hope they will grow.

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“Sock Drawer Stories” – PTSD and Frontline Providers

Painting of a woman looking at the viewer Brian Goldman is a veteran ER physician who hosts a weekly show on CBC Radio called White Coat, Black Art. During each episode, he describes — and illuminates — the health care system from “my side of the gurney.”

A few weeks ago, I listened to Goldman’s powerful piece about incidences of post-traumatic stress disorder (PTSD) among frontline/emergency responders called Sock Drawer Stories: Portraits of Hope and Healing. One of the paramedics he interviewed described the impact of witnessing daily traumas as “dirty socks.” The metaphoric sock drawer is the place they “stuff in all the experiences until it is ready to spill over.”

Inspired by the idea of the sock drawer, and struggling with PTSD herself, visual artist and paramedic Teresa Coulter created a series of striking portraits of her colleagues to raise awareness about PTSD among first responders.  (To view the portraits see the artist’s website at:  http://www.teresacoulter.com).

For Coulter, these “intimate, vulnerable” portraits are a way of acknowledging the emotional toll of dealing with trauma day in and day out. The portraits are an attempt to “crack open” the isolation and stigma of first responders with PTSD.

While PTSD is often ignored within the professional community, the process of painting also opens up a space for dialogue between herself and her portrait subjects. The ensuing dialog provides a place for the first responders’ stories “to land.” In doing so, the painting transforms their stories as her “brush is writing their story differently.”

Since hearing the show, I’ve been thinking about the cumulative effects of witnessing difficult situations on other members of the helping professions such as therapists, counselors, psychologists, nurses and physicians. There are many names for this problem in the literature: secondary stress, vicarious trauma, compassion fatigue and (ultimately) burnout.

While this is an important issue and deserves our attention, I don’t particularly like this language. The idea of “burning out” implies that our compassion is limited; and once it’s depleted, it’s gone. These images don’t offer much hope.

I’m more interested in how we cultivate an ability to bear witness to extreme distress without permanently depleting our resources. It’s not to deny the emotional impact, but rather to try and engage in new conversations focused on promoting resiliency and well-being. I like to think about compassion, for example, as a renewable resource.

I’ve been thinking about this issue from within the field of narrative healthcare, and am  reminded of Arthur Frank’s work on the impact of stories in the world. Viewing stories primarily as “social actors,” the central question he poses is, “What can we do with the stories we hear?” And this brings me to one of the questions I’ve returned to many times over the years: “What do we do, as therapists, with the stories we hear?”

In the book Stories We’ve Heard, Stories We’ve Told: Life-Changing Narratives in Therapy and Everyday Life, Jeffrey Kottler describes therapists, doctors and clergy as the designated “story listeners” of modern culture, whose job it is to hold the painful or unresolved narratives that others often don’t want to hear.

This resonates with the cultural analysis of illness stories, which suggests that people can’t make sense of illness or disability stories that don’t have a positive resolution. We want a clear trajectory and a neat or happy ending. It is those unresolved “chaos” stories that are the hardest to hear.

This dynamic often leaves frontline providers (and therapists) with nowhere to put the stories they’ve heard or the events they’ve witnessed. The metaphoric sock drawer just gets fuller. As one of the paramedics Goldman interviewed, it’s not useful (or fair) to burden your family or friends with the terrible things you’ve seen. Even sharing with colleagues can sometimes feel like burdening them with disturbing details.

So who will listen, and where should one put the stories? I think the need to make visible the stories we carry partially explains the growing field of narrative medicine and the rise of reflective writing by healthcare providers and therapists. The arts are creative containers for these stories – and powerful outlets for expressing what we hold onto.

Unlike the sock drawer that keeps things hidden and in the dark, the arts allow these stories to emerge into the light where they can stimulate deeper conversations.

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Improvisation in Practice – lessons from music class?

This past year I participated in a weekly class called The Art & Practice of Relational Improvisation: a drumming journey into the wild and beautiful unknown facilitated by drumming teacher and expressive arts therapist Shara Claire. During our small group sessions my fellow students and I learned two kinds of skills: technical (e.g., hand drum techniques, timing and rhythm) and the more elusive, but equally important, communication skills that enabled us to play as a cohesive unit. We were practicing listening to ourselves, and to each other.

Throughout our journey together, we struggled to hone the art of having musical conversations. With no score to follow, we drew on what we had learned and practiced — and made up the rest as we went along. There were moments of uncertainty, self-doubt and discomfort, as well as many moments of laughter, connection and creativity.

My self confidence and musical skills slowly grew, but the lessons I learned extended far beyond the walls of the drumming studio. Throughout this journey, I’ve been thinking more and more about improvisation in relation to my life outside the drumming class and, in particular, to my work as a social worker and educator.

As many before me have noted, clinical encounters are acts of “relational improvisation” as they are comprised of unfolding dialogues into often unknown territory. We can’t know where the conversation will go as we try to negotiate meaning together.

While these interactions happen without the safety net of a script, clinicians do not arrive empty-handed: we draw on our experience, knowledge and practice skills to forge connections with (virtual) strangers – or patients – who are coping with life crises, illness, or loss.

This improvisational dynamic resonates powerfully with musicians as well. As Kenneth Sharpe points out in his discussion of jazz music and moral improvisation in healthcare, practitioners

are not just “making it up,” any more than a good jazz musician is making up music. Moral medical practice starts with ethical guidelines and professional norms. But these rarely tell precisely what to do… Good improvisation is not making something out of nothing, but making something out of previous experience, practice, and knowledge.

In the blog post how-jazz-helps-doctors-listen, violinist and medical educator Stephen Nachmanovitch underscores the importance of “presence” in both musical and clinical encounters. What he says applies to jazz musicians playing in an ensemble as well as front line practitioners and therapists facing a client or patient:

In real medicine, you view the person [the patient] as unique. You use your training, but you don’t allow your training to blind you to the actual person sitting in front of you [or alongside you in a band]. In this way, you pass beyond competence to presence. To do anything artistically, you have to acquire technique, but you create through your technique, not with it.

On a more personal level, relational drumming class taught me a lot about where the edges of my own comfort zone are in relation to risk-taking, vulnerability, and venturing into the unknown. It taught me how hard it is to be in relationship with others when our “internalized voices” (the sometimes negative stories we tell ourselves about ourselves and others) threaten to drown out what’s in front of us, and reduce our ability to respond to what is unfolding at that moment.

Drumming class also taught me about the importance of “showing up” and sticking with it – especially when things go off track because of faulty listening or poor communication. I  learned it’s about making a contribution that will serve the larger group (i.e. think about the needs of the “circle” or the community), and it’s about geting back on track when you misstep.

As Frank Barrett points out in his book, Yes to the Mess: Surprising Leadership Lessons from Jazz, one of the best ways to cultivate an “improvisational mindset” is to remain open to possibility in the midst of unpredictable change, and to think of mistakes as resources for further growth.  Jazz musician Stefan Harris echoes this idea beautifully in his TED talk on the spirit of improvisation:

In jazz, every mistake is an opportunity… many actions are perceived as mistakes only because we don’t react to them appropriately. Mistakes only come from lack of awareness and attention… jazz is about the science of listening.

Being in an improvisational class provides a perfect opportunity to think about the balance between personal self expression and the needs of the larger group. As a student of relational improvisation I learned something about the delicate (and always shifting) balance between finding one’s own voice and honoring the voices of others. Relational improvisation is about cultivating the courage to express one’s self, but it’s not only about self expression; it’s also about leaving room for the contributions of others. These attempts to create collaborative conversations are as tricky in relational improv class as they are in clinical and therapeutic encounters!

In his discussion of communication in the clinical encounter, medical educator Paul Haidet points out that improvisational practices are the foundation of collaborative clinical relationships; and that the skills learned in musical improvisation can be a powerful resource for learning to engage patients in collaborative conversations. Paying attention, adapting, and being comfortable with not knowing are necessary (while often neglected) skills for managing day-to-day practice:

Patient-centered care demands leaving space for patients to organize their unique narratives. Figuring out when and how to interrupt, to slow down, to be silent, to change the subject — these are the kinds of improvisation a jazz player makes all the time.

Paying attention to those dynamics in drumming class gave me some ‘ah ha’ moments about how I negotiate those tensions in my social work practice. I thought about how much space I’m comfortable leaving in difficult and delicate conversations, how I feel when I don’t know how to respond to something, what situations prompt me to become  more directive (and less collaborative), what I decide to focus on and amplify when someone has many issues – and what I decide to leave behind.

One of the main things I carry away from my lessons in relational improvisation is that our practice is richer, and more interesting, when we create something together. This brings me to key principles in theatre improvisation — shared responsibility, cooperation, and communication. The notion of “yes, and” captures this open and collaborative spirit. As described in 10-principles-of-improv-and-why-you-should-care:

“Yes, and” means that we accept everything that happens as an offer, as a gift. It is our job to bring our unique perspective to bear, and build off of whatever is given to us.

‘Building off whatever is given to us’ seems a powerful metaphor for practice. While not ignoring the skills and knowledge that practitioners bring to clinical encounters, it acknowledges the unpredictable nature of the process and firmly locates our attention in what we construct together. It also acknowledges the interpersonal sensitivity and creativity we need to cultivate in ourselves and beginning practitioners.

While it may be difficult to teach these skills from a textbook, we can deepen students’ relational sensibilities through the narrative methods of close reading and reflective writing, by demonstrating and role modelling effective communication  in clinical encounters, and by valuing the role of practice wisdom in professional training.

As my year of relational drumming brought home to me first hand, there is a role for theatrical and musical improvisation in the training of practitioners. It is those hands-on experiences that foster the elusive, but invaluable, skills required for relational-centred care.




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Lessons on empathy from a medical actor

Empathy is a lot more nuanced and complex than people sometimes assume. There are many theories about what empathy is, what it looks like and how to foster it.

Brené Brown’s work on empathy, including the The Power of Empathy video and her TED talk, has brought this topic to a larger audience, and encourages people to think about empathy in the context of their own relationships.

There is also increasing attention (and lively debates) on teaching students in the healthcare professions communication skills, and, in particular, how to foster empathy in future healthcare providers.

I gained a new perspective on this topic from Leslie Jamison‘s collection of essays The Empathy Exams. This book is based partly on her experiences as a standardized patient (SP for short).

As an SP, Jamison is a medical actor who plays the role of patients in the service of training future clinicians. SPs are given a script that outlines the patient’s back story. A student clinician might be assessed on whether they “voiced empathy” for a patient’s concern.

As an educator, I’ve worked with SPs to teach students counselling skills. I have also worked with SPs while learning to be a facilitator for the Institute for Healthcare Communication. SPs are well-trained in the art of communication. Perhaps the most valuable part of working with an SP is the immediate feedback they offer about how they felt during your conversation.

The line between fiction and reality is blurred in these interactions. It’s a kind of willing suspension of disbelief — both parties agree to play their part as the story unfolds in unpredictable ways. Jamison describes an encounter with a medical student saying:

We make small talk about the rural Iowa farm town I’m supposed to be from. We each understand the other is inventing this small talk, and we agree to respond to each other’s inventions as genuine exposures of personality. We’re holding the fiction between us like a jump rope.

What her stories illustrate is that there are no generic checklists or easy formulas that do justice to the messiness and complexity of empathy. As Jamison suggests, empathy is about “reading” a person and their situation. Sometimes empathy means expressing words of concern. Sometimes it means being calm and reassuring. Sometimes it means being together in silence. As she suggests, respect and tentativeness can be unexpected forms of empathy.

Other students seem to understand that empathy is always perched precariously between gift and invasion. They won’t even press the stethoscope to my skin without asking if it’s okay. They need permission. Their humility is a kind of compassion in its own right. Humility means they ask questions, and questions mean they get answers… Empathy isn’t just remembering to say “that must be really hard” – it’s figuring out how to bring difficulty into the light so it can be seen at all.

Empathy isn’t just listening, it’s asking the questions whose answers need to be listened to. Empathy requires inquiry as much as imagination. Empathy requires knowing you know nothing. Empathy means acknowledging a horizon of context that extends perpetually beyond what you can see…

In the end, it is the humility of the students that moves her the most. It is their willingness to acknowledge they don’t know. I think that’s one of the most surprising, but valuable, lessons from her journey as a medical actor.

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Writing and the body: what’s the connection?

In 1667, when philosopher Baruch Spinoza proclaimed “no one has yet determined what the body can do,” he was, perhaps, heralding recent attention to the body in social science, education and therapy practices. The critical issue for these fields is the presence and role of the physical body in disciplines that have traditionally privileged the mind. In short, people are asking, “what about the body?”

On May 2, 2015 at a Taos Institute event in Santa Fe, I facilitated a workshop on the theme of writing as an “embodied practice.” As I prepared, I started thinking about the physicality of the writing process and became really curious about the possible connections between writing and our bodies.

On one level writing has always been a physical act — whether inscribing pictographs on stone tablets, moving a pen across paper, or striking a keyboard. But there are other, often unrecognized, dimensions of writing as an embodied practice.

Right after I agreed to do this workshop, I came across Julia Cameron’s reflections on writing and the body in The Right to Write. I was so glad to see a section, entitled ‘The Body of Experience’, devoted to the physicality of writing. Despite popular cultural notions of writing as an often disembodied or intellectual act, Cameron suggests writing is a deeply physical experience.

Using body-based metaphors to describe the writing process, Cameron explores the connection between writing and walking. Encouraging us to see writing as more than the act of putting words on a page, she reminds us that the early British nature poets were “great walkers” and many contemporary writers incorporate walking into their routines. Suggesting that the movement and rhythm of walking helps work out writing problems, she writes:

When I have a tangled plot line, I walk to sort it out. I walk and I mull. I am not exactly ‘thinking’ about my writing as I walk, but the question is there, posed by my mind to my body.” Joyce Carol Oates has also declared, “the structural problems I set for myself in writing, in a long, snarled, frustrating and sometimes despairing morning of work… I can usually unsnarl by running in the afternoon.

This resonated for me as I recalled many instances of working through writing problems and ideas by walking while writing my dissertation. In fact, I often mulled over ways to construct my writing while walking to or from work (scribbling in my notebook on the subway or walking down the street), and would later translate these ideas to the computer screen later. It seemed as if I was “writing” my thesis even when I wasn’t sitting at the keyboard and, perhaps more importantly, the movement and rhythm of walking may have facilitated that. It was as if the act of walking brought into focus the ideas I was grappling with, and allowed me to translate my ideas into text.

In the blog Deep Down in the Classroom: Writing Pedagogy and Practice,  Christine Giancatarino suggests that writers have “embodied wisdom” or bodily knowledge comparable to the muscle memories of actors, musicians and athletes:

Ask an athlete to write about how he maintains his pace in a marathon, or how she deflects a shot on the hockey field. If she verbalizes her response, her answer will be from the experience of doing it, or attempting to do it, not from being told how to do it. She will speak from a bodily knowing because her bodymind (her muscles, bones, nervous system, brain, mind) knows.

In an interview on writing, embodiment and voice, narrative medicine scholar Sayantani DasGupta describes the urge to write as an “embodied necessity,” feeling like it comes from the “guts and bones.” In a similar theme, writer Jill Solway says that “when I’m writing, it’s never coming from my head through my hand. It’s coming from some other place into, in the best of all possible worlds, my heart and then my hand.”

Of course, it may not be necessary (or even useful) to define too precisely what that “other place” is. And my intention here is not to perpetuate a false dichotomy between body and mind.

I do wonder, however, if highlighting writing as an embodied practice helps us acknowledge the presence of the writer in his or her writing in more significant ways. I wonder if seeing writing as a process we do with our body, can help us remember that what we write is rooted (in some way) in who we are and our experience in the world.

Viewing writing as an embodied activity acknowledges that we are always writing from a particular time and place. As writers, it might help us enhance our own bodily awareness when we write. It might heighten our understanding of how who we are shapes the meaning of what we write — for both ourselves and readers.

In the end the process of writing also produces something tangible and physical — it is this “finished product” that gives us the opportunity to translate our writing into another kind of embodied act — that of reading and/or performing our writing. And it is these acts that allow us to connect most powerfully with others; it is in the act of reading and being listened to that we create a sense of shared community.

As Anderson and MacCurdy point out in Writing & Healing: Toward an Informed Practice, writing allows us to tell our stories, to listen to what our stories tell us, and to hear and be heard by others. When we create this kind of space for both speaking and listening, we invite new connections.

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‘Listening with our pens’

One of my virtual mentors in the field of narrative medicine is Sayantani DasGupta. I’ve never met her, but her work has shaped my thinking about the critical role of narrative in healthcare.

DasGupta is interested in the role of stories in healthcare and spends much of her time as a professor of medical humanities teaching clinicians-to-be how to listen. Here are some resources where you can find more of her writing and reflections:

Her blog Stories are Good Medicine:

What I do is teach my students to listen by writing stories. I have them do listener response – writing in reaction to a poem or story we read in class…So yes, I’m training people to be better doctors by teaching them how to be writers.

The TED talk Narrative Humility highlights her philosophy of listening  — how stories can be “little boats that help us navigate the treacherous waters of illness.” Emphasizing that illness and healthcare is fundamentally a storied process, she is interested in how we learn to attend respectfully to the stories of others by paying attention to our own assumptions and “inner workings.”

‘Narrative humility’,  a close cousin to cultural humility, calls for a new kind of relational space where we are called upon to respect “that which we do not know.” She asks challenging, but necessary, questions about the culture of hierarchy in healthcare and the dangers of teaching communication skills through reductionist strategies – what she aptly calls “faking our humanity.”

Her essay, The Kingdom of the Sick: narrative medicine helps caregivers and patients find meaning in illness, addresses the issue of how we “train to listen.” She writes about teaching as a form of witnessing, as teachers and students walk a “narrative pilgrimage” together to explore stories of illness and disability.

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Welcome to my blog

This blog is an exploration of narrative approaches to healthcare, social work, teaching and social science inquiry. My name is Karen Gold and I am a social worker, educator, and narrative medicine facilitator.

I have been working in healthcare as a clinical social worker and educator for over twenty years and I my interest in narrative approaches to clinical practice and therapy dates back to the late 1990s when I began studying narrative therapy. Then in 2008 I read Rita Charon’s Narrative Medicine: Honoring the Stories of Illness which inspired me to focus my work in the area of ‘narrative medicine’. Her intertwining of literature, narrative theory and medicine felt like a close philosophical cousin to my earlier interests in narrative practice approaches.

A couple of years later I entered a PhD program which allowed me to focus my work on relational practices and healthcare narrative. I spent my time immersed in reading about auto-ethnography, arts-based social science, social constructionist inquiry, poetry and short stories by healthcare practitioners – and thinking about the relationship between narrative and relational moments in everyday practice.

While working on my dissertation, I did workshops at the Taos Institute as well as training at Columbia University’s Program in Narrative Medicine. These were highlights of my process, as I had the opportunity to immerse myself in relational and constructionist inquiry, the hands-on methods of narrative medicine pedagogy (close reading and reflective writing) as well as meet folks from different disciplines and areas of practice brought together by our interest in collaborative practices and/or narrative medicine.

My focus in all of this has been to promote better communication, empathy and compassionate care. I’m interested in how narrative helps us understand illness from the perspective of patients and families, as well as how narrative gives us a unique window into the professional identity and everyday experience of clinicians. I’m especially interested in how stories can help us recover important moments and conversations (what narrative therapist Michael White might have called the ‘absent but implicit’).

I currently integrate narrative approaches in my work as an educator (using reading, reflective writing and reader’s theatre to promote understanding of ethics and relationships in healthcare practice) and facilitate a hospital-based writing group to provide a space to reflect on practice and share our writing with colleagues. I am also a volunteer facilitator for the Toronto Writer’s Collective which is based on the Amherst Writing method and aims to bring creative writing opportunities to often marginalized voices throughout our city.


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