education & training The use of literary analysis in advanced communication

Narrative medicine is a well established academic field and has been shown to increase clinical skill and improve the therapeutic relationship of those who study its principles ([Banks et al , 1995][1]; [Jones, 1999][2]). Literary analysis is a convenient means of fostering advanced communication

Narrative medicine is a well established academic field and has been shown to increase clinical skill and improve the therapeutic relationship of those who study its principles (Banks et al, 1995;Jones, 1999). Literary analysis is a convenient means of fostering advanced communication skills. Moreover, the skills gained from such an education are highly applicable to everyday psychiatric practice. The evidence for the efficacy of narrative medicine is well established, and on this basis a strong argument can be made for its inclusion as a compulsory part of the current MRCPsych course.

Background
Several months ago I was lucky enough to attend a lecture given by the neurologist Oliver Sachs at King's College, London, which focused on his interest in patient narratives and included many anecdotes from his years of practice. It was highly amusing and interesting on two levels. The first was the emphasis Sachs placed on the patient's history or so-called narrative structure and its central importance in understanding the internal ruminations of its bearer. The second was a reminder to myself of a course I was fortunate enough to participate in while an undergraduate at the University of Manchester School of Medicine.
A list of possible study modules, especially medical ones, usually includes the most banal choices, however hidden among my undergraduate options was the intriguing title 'Tolstoy and the art of patient perspectives'. None of my friends had the faintest idea what this was about, and the title was so peculiar that most steered clear of the course. I telephoned the doctor running the course and he explained to me that through analysis of literature, students could gain a greater sensitivity of the subtleties of language, which would, in turn, lead to a greater appreciation of patient narratives and histories. I was hooked and have been ever since. Which is why Sachs's lecture was so resonant. What I learned in that 3week course at medical school changed my perception of language and still endures in the way I practise today.
Narrative medicine is not a new concept. Many readers will be familiar with its broad principles, but it is unlikely that they will have studied its theory formally or applied its concepts since its inclusion in undergraduate or postgraduate courses in Britain remains rare.
In the USA the story is very different. Narrative medicine is well represented in most medical departments and has been an academic subject in its own right for around 30 years. In 1994 around one-third of American medical schools taught literature to undergraduates and since then the number has grown substantially (Banks et al, 1995). Its benefit has been demonstrated in many studies and is now seen as a convenient means of enhancing communication skills (Charon, 2001). Because very few British medical graduates will have experienced any tuition of this sort, my experience remains fairly rare. I wish to demonstrate in this article how narrative medicine can be extremely useful and how the principles can be readily added to the curriculum.

Personal experience
In those 3 weeks at medical school, along with the course tutor Dr Tim Dowling, and another student, I read and analysed a series of stories and poetry and discussed the texts after every piece had been digested. The initial and most important was Tolstoy's short story The Death of Ivan Ilyich. This gives a detailed account of a man's insidious slide towards death. Along the way we are presented with the physical and mental anguish that accompanies his demise, and the story forces us to reflect on our own perception of what death constitutes and the emotional maelstrom it creates.
The course also included poetry by T. S. Eliot, W. B. Yeats and Sylvia Plath, all of whom display a profound sense of the human condition and demonstrate a remarkable understanding of the intricacies of both verbal and non-verbal communication. These texts were analysed and discussed, with particular emphasis placed on the themes, content, metaphor and imagery employed as vehicles for emotional resonance. The basic premise of the course was to allow the student to gain an appreciation of literature and therefore a familiarity with and skill when dealing with narrative structures. These skills could then be transferred to everyday clinical practice. There were three main elements to the approach as taught by Dr Dowling: narrative appreciation, substitute experience and narrative as a therapeutic tool.

Narrative appreciation: honing language sensitivity
Narrative appreciation involves becoming highly accustomed to the structure and nuances of a piece of writing. The very act of systematically analysing and digesting The Death of Ivan Ilyich or The Bell Jar by Sylvia Plath will equip the reader with an ability to tease out important features, phrases and subtle meanings of speech or writing. The flexibility and idiosyncrasy of language is frequently encountered in clinical practice and any development in the appreciation or interpretation of such language will immensely aid the understanding of particular narratives.

Substitute experience
Most people will have very little understanding of what it is like to suffer the stress of a hereditary brain disorder or having to undergo electroconvulsive therapy. However, literature allows the reader to access a vast repository of experience. Many writers demonstrate such a profound understanding of the vicissitudes of disease that their writing could be used as verbatim case studies. For example Plath's The Bell Jar is an intense account of the mental illness suffered by the lead character Esther and the experience she undergoes while being treated for intractable depression. (The story parallels Plath's own life closely.) As well as being highly emotive, the prose supplies an experience by proxy, delivered through the eyes of an accomplished communicator. Moreover, Esther's fear, inner turmoil and disorientation are all laid bare, which gives one some sense of her condition. The following extract gives a sense of her predicament: 'Whenever I sat on the deck of a ship or at a street cafe¤ in Paris or Bangkok, I would be sitting under the same glass bell jar, stewing in my own sour air' (Plath,1963).
Plath chose the image of a bell jar because it is enclosed and alienating, forming a barrier between Esther and the rest of the world. Its use also suggests she has no control over her circumstances. Patients seen in clinic every day will also use personal analogy to describe their own symptoms.
Many works of literature paint such extraordinary and 'realistic' descriptions of emotional experience that keen observers can find within them a lifetime of human psychology. For this reason they are essential teaching resources.

Narrative therapy
It has long been known that the very act of expressing one's anxieties has a positive effect on the mind (Banks et al, 1995). It seems that the divulgence of personal experience forms a vent, releasing anxiety and stress, and acting almost like a pressure valve (Panichelli et al, 2005).
An enhanced ability to allow the divulgence of personal history is an area that has been underdeveloped in mainstream clinical practice, perhaps because of time constraints or possible ignorance. Reading and appreciating well-written literature can help one to explore the universal traits of the human condition and allow one to focus on the cathartic elements of patient history by developing an understanding of the patient's perspective. It cannot be stressed enough that it is this sensitivity which allows the patient to share their burden (Curbow et al, 1999). It follows from this observation that having a greater understanding and ability to appreciate their 'story' will be more rewarding in therapeutic terms. Many studies have continually demonstrated that patient satisfaction stems from the practitioner understanding the patient's anxieties and most importantly demonstrating this (Arborelius & Fossum, 2004).

Discussion
My undergraduate study module 'Tolstoy and the art of patient perspectives' was successful in melding together two ostensibly unrelated subjects and demonstrating how they can be used together and taught effectively to enhance clinical practice. One must not forget that literature is not the only means of developing a keen sensitivity to human emotional states; music and fine art are both as important. However, literature provides the most applicable and expedient means of fostering enhanced sensitivity to patient communication because of its verisimilitude.
Some previous articles reviewing narrative medicine have advocated the introduction of a dedicated reading list but have not made a case for tuition in analytical skills (Beveridge, 2003). It must be emphasised that the mere reading of books is not sufficient. A degree of formal analysis must be employed to allow reflection on the themes, structure, content, nuance, imagery etc, which infuse not only literature but all speech in general and provide intricate clues to the emotional state of an individual. These analytical skills cannot be mastered by reading alone. Initially such techniques could be taught in a discussion group, with the basic analytical skills being refined through future exposure to literature and patient narrative in tandem. It is this process of analysis and therefore transferable skill that is paramount.
Those best placed to provide this tuition would be well versed in the process of literary analysis. A truly multidisciplinary approach incorporating members of the English faculty would be preferable. This model is used to great effect in the USA, with 'literary scholars' participating in discussion groups (Banks et al, 1995). Those providing the tuition would not require any esoteric knowledge of medicine. As argued above, the principles of analysis can be applied as readily to a consultation as to a poem by T. S. Eliot.
The current MRCPsych course could easily accommodate a short series of illustrative lectures and discussions equipping students with the required analytical skills. No formal examinations would be required, emphasis should be placed on enjoyment of the material itself. The process, if practised over time, would become 'unconscious', enriching the consultation but not interrupting its flow. It is hoped that in time the tuition would be disseminated among other colleagues and undergraduate students, eventually becoming ubiquitous and a necessity for best clinical practice.
The arguments above demonstrate that the principles of literary analysis can be used as an adjunct to diagnosis and therapy in everyday clinical practice. Furthermore, I would argue that the addition of arts courses to the syllabuses of medical schools is not something to be considered an extravagance or exotic extra but an essential aspect of the future direction of medicine (Charon, 2001). Evidence from the USA and the UK shows that 'literary medicine' courses can be taught easily (Calman et al, 1988) and with good cost-benefit parameters (Banks et al, 1995). The inclusion of such teaching in the MRCPsych course is long overdue and would enhance patient-doctor interaction immensely.
Psychiatry more than any other specialty is at the interface between art and science. This is why the College should be the first to acknowledge the potential benefit of narrative medicine and should endeavour to take the lead with the addition of a dedicated course in literary medicine to the MRCPsych programme.

Declaration of interest
None.