Diagnosis Narratives and the Healing Ritual in Western Medicine

James Peter Meza, James Meza

• Publisher: Routledge
• Year: 2018
• Topic: Social Sciences
• eBook ISBN:
  9781351804981
• Subtopic: Anthropology
• Index: Social Sciences

The dominance of "illness narratives" in narrative healing studies has tended to mean that the focus centers around the healing of the individual. Meza proposes that this emphasis is misplaced and the true focus of cultural healing should lie in managing the disruption of disease and death (cultural or biological) to the individual's relationship with society. By explicating narrative theory through the lens of cognitive anthropology, Meza reframes the epistemology of narrative and healing, moving it from relativism to a philosophical perspective of pragmatic realism. Using a novel combination of narrative theory and cognitive anthropology to represent the ethnographic data, Meza's ethnography is a valuable contribution in a field where ethnographic records related to medical clinical encounters are scarce. The book will be of interest to scholars of medical anthropology and those interested in narrative history and narrative medicine.

Part I
Methods

1 Fieldwork methods

Science is asking important questions; research is answering those questions. Anthropologists are scientists who explore, discover, understand, and describe culture. In this chapter, I report the intellectual and pragmatic components of how I accomplished those tasks for this research project.

Epistemology matters

Narrative theory is ubiquitous and informs many disciplines; it means different things to different people. The “self” is a highly contested construct. Living in a post-modern world, an in-depth reading of narrative and healing reveals a cacophony of opinions. To critically appraise this body of literature, I was advised to study philosophy because “it will help you think.” I took the advice to heart (Cahoone 2010; Goldman 2006; Kasser 2006; Robinson 2004).

Qualitative writers often do not declare their epistemology, leaving the reader without a frame of reference to view claims by researchers (Cohen and Crabtree 2008). I believe that while we may never achieve a full understanding of reality, we can approximate it ever more closely through scientific endeavors. I adhere to an epistemological philosophy of pragmatic realism.¹ Bruno Latour opens his book with a challenge from another, “Do you believe in reality?” and answers, “But of course!” (Latour 1999). He was writing to extricate us from the “Science Wars” of post-modernism. Latour and I share a mutual epistemological perspective. Anthropological writing on healing in Western medicine relies predominantly on narrative theory, most often written from a relativist perspective. Although I can accept the value of contributions written from a relativist perspective, I believe they share only one perspective, leaving me the burden to integrate their work with that of others.

The seminal text that applied narrative theory to narrative healing was The Illness Narratives: Suffering, Healing and the Human Condition by Arthur Kleinman. Published in 1988, this text marked the beginning of “a narrative turn” in anthropological thought. With this text, the Harvard Friday Morning Narrative Group launched a landslide of narrative studies related to healing. Common to most all of these writings is an epistemological framework of relativism. Kleinman takes the semiotic nature of what people say about their illness as both a reflection of reality in medical practice as well as our cultural framework. Critiques of illness narratives point out that patients present themselves as social actors persuading themselves and the doctor to a potentially biased narrative, a form of relativism. Narrative and healing studies flourished, and Cheryl Mattingly and Linda Garro summarized the orthodox versions of narrative healing quite well (Mattingly and Garro 2000).

As a pragmatic realist, I am unwilling to accept everything written from a relativist perspective. While work written from that perspective contains partial truths, it remains incomplete and risks describing reified constructs. Phenomenological descriptions may not withstand the scientific imperative to replicate findings. My pragmatic realism resonates with the theoretical foundation of this ethnography.

Theory matters

Ethnography needs a theoretical foundation. My first task before starting fieldwork was to explicate my theoretical framework. Theory determines what questions can be asked, guides data collection, and organizes data for analysis. Because of prior training, I was initially attracted to psychoanalysis as a possible theoretical frame (Ewing 1990; Murphy and Murphy 2004). Yet, one of the primary reasons to do ethnography is to advance theory, and that is not possible with psychoanalysis – it only provides an organizing principle for ethnographic data. I next explored narrative theory because of the metonymically dominant phrase “narrative healing” in the anthropological canon. I was disillusioned with its relativism, something it shares with psychoanalysis (Rudnytsky and Charon 2008). Having confessed my dissatisfaction with relativist narrative theory, I used highly selective foundational theorists and generated an integrated theoretical frame for this work that combines narrative theory and cognitive anthropology. I present a rather parsimonious theoretical perspective that connects the vast body of anthropological work on healing to the current study while preserving my scientific pragmatism. I hope the reader appreciates how my ethnographic data and the theoretical frame I explicate support each other. For me, working with theory put a fresh perspective on narrative theory, which I had experienced as rather stale. I do not attempt to present a comprehensive review of narrative theory. This book is about healing, not narrative theory.

My favorite summary of narrative theory was written by Cheryl Mattingly (Mattingly 1998). If a reader wants a succinct summary of narrative theory, I recommend that text. I discuss theory to accomplish this research project because theory is part of the anthropological method of discovery.

The research question

The research question, “What is healing?” has occupied the past twenty years of my career. Physicians use the word “healing” often when reflecting on the practice of medicine, but there is no “meat on the bones” from a scientific perspective. Rather, when doctors talk about “healing,” they usually appeal to the humanities.

Healing is a construct; it is not something observable under a microscope. I maintain that it is observable in cultural practices. The research question that guided this project was to clarify the domain analysis for “healing” to defend against the criticism that healing is a reified construct. For many years, I explored psychology, which claims to describe healing. I can only say that I exhausted psychological explanations of healing as insufficient or inadequate to define the construct despite years of training, teaching, and practicing with access to that discipline (Dossey 2001; Frattaroli 2001; Herman 1992; Jung 2006 [1957]; Maslow 1999; Whitfield 1987). As an anthropologist, I observed the social practices and interactions that shape healing relationships, relationships that connect the individual to our cultural world. Social practices can be observed and therefore have a greater scientific claim to define a construct in the real world.

The ethnographer as data collection instrument

“When it’s done right, participant observation turns field workers into instruments of data collection and data analysis” (Bernard 2002: 324). This statement implies participant observation can be done incorrectly and result in inaccurate data. The validity of this research depends on my qualifications to do participant observation. Raymond Madden voices a common methodological concern: reflexivity, or the ability to prevent writing oneself into the data unknowingly (Madden 2013 [2010]: 2). Prior to any formal anthropological training, I came equipped with “reflexivity,” a necessary skill for ethnographers. I spent six years becoming a certified Balint leader, a group process based on psychoanalytic principles; two of those years were spent with individual supervision (American Balint Society). During that time, I practiced the cognitive skills to monitor two, three, or four things simultaneously in real time. A Balint leader must observe the speech, symbolic attributes of speech, body language or proxemics, emotions, shared emotions, and group dynamics, all for discerning the “story” of the case as the group participants re-enact it. Psychoanalytic frameworks have the added benefit of leaving no doubt about distinguishing self from other. That is definitional of transference and countertransference. Distinguishing self from other is required to do anthropological work. Ethnographers must also monitor multiple social spaces and levels of analysis simultaneously. Figure 1.1 is a metaphor for the reflexivity required.

Figure 1.1 Self-portrait of ethnographer

Figure 1.1 demonstrates the distance from my retina to my hand, the distance from the camera to the mirror as recorded on the screen of the camera, the distance from my retina to the image on the camera screen, and the distance from my retina to the mirror – all these observations occurred simultaneously. Ethnography requires awareness of multiple perspectives simultaneously.

Early in my anthropological training, a mentor handed me a journal article co-authored by Arthur Kleinman (Smilkstein et al. 1981). The implication was that my biomedical training prevented me from becoming a legitimate anthropologist or social scientist. Although I said nothing at the time, I had read that article contemporaneously upon publication and the biopsychosocial model was part of my training from my youth (Engel 1977; Engel 1996). I have spent thirty years listening, pondering the meaning, and struggling to understand patients and their stories. Yet, respected anthropologists told me I would never be able to see cultural information because “You think like a doctor.” In fact, this fascination with the duality of being both an anthropologist and a master clinician has been a matter of persistent curiosity since the day I first met an anthropologist; the fascination continues until today. I was always in the marked category. Professors would stop mid-sentence and say, “Oh, you’re that student.” Other anthropologists used my medical background as a challenge to the validity of my anthropological work because of my assumed bias toward defending biomedicine. Nancy Chen describes similar complexities of being a Chinese American working as an ethnographer in China (Chen 2003: 5). Long ago, I decided this was much more of a reflection of the culture of academia than anything to do with my work or me. Actually, my pragmatic realism allows me to accept simultaneously both biomedical and sociocultural perspectives about reality. I understand science is a cultural production (Canguilhem 1991 [1978]; Latour 1999; Lewontin 1992 [1991]).

Perhaps I can best illustrate with an example that predates this research. “Grand Rounds” is a medical education tradition (one might say ritual), where an intern, the least senior doctor, presents to the entire department a difficult case seen on the hospital wards that week. There ensues an exhaustive discussion of the every possible diagnosis and the audience challenges the presenter with questions of all sorts. Why were certain tests ordered or not ordered, physical exam findings, and book knowledge of rare diseases are all part of the enactment. The intern usually spends enormous time and effort preparing for this spectacle because the chair of the department attends, as well as most of the senior faculty who did not even participate in caring for the patient. Of course no matter how prepared, the process “teaches” by pointing out mistakes (Brancati 1989). The stated goal is to “prove” the correct diagnosis.

I was present for many such conferences. As a doctor, I typically could discern the actual diagnosis within five to ten minutes by juggling the positive and negative space of the diagnosis as a cognitive construct (Edwards 1979). The remaining fifty minutes rely on a system of diagnosis referred to in the medical community as an “exhaustive” diagnostic approach; I was typically bored throughout that part – again, a symptom of my pragmatism. As an anthropologist, I watched who was allowed to speak and when, the cultural capital of superior medical knowledge and how that “knowledge” determined the “reality” of facts, the delicate balance of demonstrating competence while fearing humiliation in a social setting, administrative and cultural power structures and how they interacted within the case discussion. I witnessed what Pierre Bourdieu and Jean-Claude Passeron called Reproduction in Education, Society and Culture (Bourdieu and Passeron 1990 [1970]). On one notable occasion, my diagnosis differed from a powerful faculty physician who had originally trained as a surgeon. As such, his knowledge of anatomy was unquestioned. He deployed that knowledge by reviewing x-rays to support his diagnosis. Although the entire department agreed with his diagnosis, after the conference I walked down the hall to the radiology department and they confirmed that my interpretation was correct; this meant twenty-five other people had a different impression of that diagnostic “reality” based on cultural practices. During such episodes, I am fully a clinician and fully an anthropologist.

The methodologically important part of that example is that I am aware of when I “cognitively code-switch” from doctor to anthropologist. I approached this research purely as an anthropologist. I rarely comment on something from a doctor’s perspective, but I always declare when I do that. This is ethnography.

Just as anthropologists have questioned my veracity because of medical training, doctors question my veracity if I try to explain the sociocultural aspects of behaviors in a clinical setting. Mary Douglas would call me dirt. Oh well. My eclectic lifelong learning agenda has exposed me to many disciplines other than medicine and anthropology. I love statistics. Others comment that I am odd, but I can “see” statistical distributions in social settings; I can estimate the probability of events in my head and recognize when social behaviors are not randomly distributed. I have studied health law, accounting, human resource management, psychology, economics, psychometrics, art history, evidence-based medicine, and other intellectual pursuits. None of these disciplines has a unique window on reality. Although the jargon varies, many constructs have a common core underlying how people understand the world.

Ethnographer as social actor

Throughout the course of fieldwork, I was vigilant to monitor my position as a social actor. I knew I needed to guard against informants perceiving me as having medical knowledge. An anthropologist must start with the assumption that they know nothing and ask those in the culture under study to teach them. It is more difficult to function as an anthropologist in “one’s own culture.” It is much easier to compare the other to the culture of origin while studying an unfamiliar culture.

I was quite successful at being perceived as “uninformed” by always taking the “power down” position when gathering data. My informants treated me as a medical student, a family medicine physician learning urology, a PhD student, an interloper or voyeur, a pet, an uninitiated observer, or the object of teasing. I was usually ignored, remediated, teased, taught, or given gifts of insight. Unexpectedly, I encountered occasional fear about collecting “evaluative” data, which hospital administrators could misuse. I was diligent about reinforcing the non-evaluative nature of anthropology as a social science. Those in the field rarely excluded me from participation; the only two occasions I recall were a VIP patient and a matter of litigation. I helped in the daily tasks consistent with my “novice level” of experience. On one occasion, I drove around town to retrieve a cell phone for one of the faculty physicians so that the clinic could st...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Figures
• Preface
• Acknowledgments
• Part I Methods
• Part II The diagnosis narratives
• Part III Ritual healing in Western medicine
• Part IV The body politic
• Part V Narrative studies on healing reconsidered
• Appendices
• Index