Abstract
Starting from the premise that people are essentially narrative beings, I argue that the onset of severe mental illness compromises the narrative enterprise of being able to construct one's Self and one's relationships in meaningful and coherent ways. This is due to both the curtailment of opportunities for narrative engagement and the dispossession of those whose narratives do not conform to the current conceptualization of narrative and narrativity. In these circumstances, supporting the narrative enterprise is an ethical endeavour that requires that we examine not only which narratives we construct, but also how we construct them. This requires a re-thinking of what might constitute narrative and how we might facilitate or enhance the narrativity of people with severe mental illness. Following this, I suggest four means to support the narrativity of people with severe mental illness: through maintaining narrative continuity, maintaining narrative agency, countering master narratives and attention to small stories.
Over the last 15 years or so there has been an exponential rise in the interest shown in narrative as a theory and a method across the disciplines. Narrative is, however, a somewhat nebulous term and its use is neither always clear nor consistent. For some, narrative provides a unique insight into the world and our experience of it [1]. On this view, narratives are more or less accurate representations of ‘what really happened’ and our understandings of that reality (i.e. data for subsequent analysis). Focus on such ‘representational narratives’ is an approach found in the works of writers such as Cortazzi [2] and Riessman [3], key authors and proponents of narrative analysis. For others, narrative forms reality, it is the world. Authors advocating such ‘constitutive narratives’ would include Bruner [4], [5], Polkinghorne [6] and Barone [7].
In the present paper, I shall examine what ethics might look like with regard to people with severe mental illness if we start from the position of constitutive narrativity. To do this, we need to explore a number of general areas before we move to the specifics of severe mental illness – if indeed such impairment makes any significant difference to our narrative-based ethics.
In essence my argument is as follows:
This is a somewhat ambitious project to be attempted in the confines of a single paper, but an outline of a different way of thinking is presented here for reflection and debate.
Narrative and the Self
The view that we are narrative beings is well-argued by authors such as MacIntyre [8], Bruner [4], [5] and Taylor [9]. For these authors, among others, not only do we exist in a story-telling world, but our very Selves are constituted by the stories we and others tell about ourselves. Our experience (of both the world and ourselves) is not reality put into narrative form but rather our narrative form made real. In other words, we are our stories.1 In these stories, we constitute ourselves as people in accordance with concepts of ourselves [10]. These self-concepts are not static [10] and our identity is a combination of historical narrative and literary fiction [11]. The importance of narrative in the construction of identity is recognized in psychiatry and psychology [12–15] though, as yet, the problem of the narrative identity of those who cease to be narrative agents (as currently understood in narrative theory) has not been addressed.
Lives, like stories, have a trajectory through time. What comes before affects and to some extent determines what happens next. This trajectory gives lives, and stories, a narrative coherence [9] without which the story-line would give way to a mere assemblage of unrelated, episodic events. Maintaining this sense of coherence is an overarching feature of a life-project and productive of wellbeing [16] and (arguably) its loss is a feature of mental ill-health such as in schizophrenia [17] or posttraumatic stress disorder [18].
The issue of narrative coherence is not, however, simply an individual matter. Although it is generally true that we are the main protagonists of our own stories, we also feature more or less weightily in the stories of other people. Our narratives of them and their narratives of us are accompaniments to the primary narrative and primary narrator. These accompaniments may maintain, challenge, move forward, disrupt, strengthen or hinder the stories of the primary narrator [19]. In other words, narrative coherence is a function of the web of narratives of which we are all part.
Severe mental illness and the compromising of the narrative enterprise
Severe mental illness poses three distinct challenges to the narrative enterprise. The first of these is the challenge to narrative agency – the ability and opportunity to author one's own narrative. Because of cognitive difficulties or loss of language, individuals may lose the ability to construct and articulate a coherent narrative (in terms of tellability, tellership, linearity and moral stance) [20]. Similarly, the individual's interactions with others may be restricted by a condition that results in decreased opportunities to launch and maintain narratives [20].
The second challenge to the narrative enterprise is that posed by the response of others to narratives that do not fit the expected narrative norms and are, thus, classified as inadequate narratives or not even recognized as narratives at all.
The supposed loss of narrativity on the part of people with severe mental illness is perceived from outside as a loss of the self and a function of the particular mental illness [14], [21], rather than the inability of current narrative theory to encompass the experiences of madness:
… generally speaking it [madness] is characterized variously by fragmentation, amorphousness, entropy, chaos, silence, senselessness. … Such being-states do not fit well with narrative's drive to organize and arrange experience: whether the author is describing his or her experience from within madness, or from a position ostensibly situated outside it, there would appear to be a disjunction between the content to be narrated and the possibilities inhering in conventional narrative forms. [22]
The third challenge to the narrative enterprise lies in the mobilization of meta-narratives on the part of others as a means to understand, contain or manage the challenge posed by the narratively dispossessed. Nelson [19] argues that master narratives – stories that serve as summaries of socially shared understandings, are often archetypal, consisting of stock plots and readily recognizable character types, and we use them not only to make sense of our experience but also to justify what we do. [19]
Narrative ethics
Narrative ethics, like narrative analysis, is interpreted in a number of ways. For some, narrative ethics is little more than using narrative as means of eliciting information on which to make decisions formulated within another ethical framework [23–25]. For others, narrative ethics is an ethical framework in and of itself, counterpoised against other ethical frameworks [26]. This is the stance I shall adopt, but I shall develop and deepen a formulation of ethics that positions me alongside authors such as Newton [27], thus:
The fact that narrative ethics can be construed in two directions at once – on the one hand, as attributing to narrative discourse some kind of ethical status, and on the other, as referring to the way ethical discourse often depends on narrative structures – makes this reciprocity between narrative and ethics appear even more essential, more grammatical, so to speak, and less the accident of coinage. (p.8)
Furthermore,
… narrative ethics implies simply narrative as ethics: the ethical consequences of narrating a story and fictionalising person, and the reciprocal claims binding teller, listener, witness, and reader in that process. [27], p.11]
In this view ethics:
… signifies recursive, contingent, and interactive dramas of encounter and recognition, the sort which prose fiction both crystallizes and recirculates in acts of interpretive engagement. [27], p.12]2
Narrative ethics is, thus, concrete, personal and situated. It is, essentially, concerned with the stories we tell and how we tell them and ‘since the vicissitudes of narrative situations do not easily submit to prescriptive or procedural norms of rationality’ ethics is not ‘a set of meta-theoretical ideas or pre-existing moral norms’ [27]. Rather, it is a moral response to the appeal of the other. This is the ethics that Illich refers to when he says that, we are creatures that find our perfection only by establishing a relationship, and that relationship may appear arbitrary from everybody else's point of view, because I do it in response to a call and not a category. [28]
Ethical narratives
If we are entrusted to be co-authors of a person's story, as I believe we are in the care of people with severe mental illness, then it follows that we should endeavour to author the story in the best way possible. As a first step to developing a more comprehensive theory of narrative probity in relation to the care of people with severe mental illness, I want here to suggest four aspects of narrative that might form a basis on which to (co-)author a narrative for and with a vulnerable Other:
Maintaining narrative continuity
By paying attention to the context and embodiment of the protagonist and to the significant others in the story, it is possible to establish a backdrop against which to evaluate the narrative. Does the story emerge from this backdrop in a way that does not disrupt one's belief or does the story jar with the backdrop, a disruptive episode that does not appear to link with past or future? Do the choices and actions of the protagonist make sense against this backdrop? Do these choices and actions cohere with what we know of the protagonist? Is the narrative internally coherent in terms of its themes and the means used to relate events together? [3], [29]. In other words, is the historical continuity of backdrop, story and protagonist maintained?
This element of narrative probity draws upon such debates around advance directives or Ulysses contracts concerning the issue of whether selfhood is maintained, changed or lost during severe mental illness [30]. A narrative approach, however, allows for both change and continuity, as a person's identity is seen to be formed in stories that create some form of meaningful whole out of different phases in one's life. Consequently, this period of my life might seem totally out of step with what has gone before and I might be acting very differently from how I did before, but I am still a narrated and narrating Self [14] attempting (however, poorly during crisis) to integrate past and future events into my life story [30].
In order that the Self is not lost during episodes of severe mental illness, we need to provide ways and means for individuals to accommodate such episodes into their narrative and their narrating. There are a number of means by which narrative continuity can be facilitated in the face of severe mental illness: the Ulysses contract, the life history and the values history are but examples. The Ulysses contract maintains continuity by not implying:
…that one phase of life (a clear period) is more important than another one (a period of crisis). It rather entails the claim that the various phases should be taken seriously, and should be related to one another. [30]
The second challenge posed to narrative continuity by mental illness is to formulate and maintain a trajectory that emerges from the backdrop. In the Netherlands, for example, some attempt has been made to provide an environment that facilitates such narrative continuity. Hogeway, caters for people with dementia on the basis of seven different lifestyles that are, in turn, based on a detailed study of cultural patterns and practices across the Netherlands [35]. Each group within Hogeway, has its own pattern of daily life and activities which reflect what, for them, are the ordinary, everyday lives which individuals would have lived when in the community. (p.450) Emphasis is placed on establishing the type of work they did, their religious beliefs, their social class, their cultural patterns and practices, their hobbies and interests, and on finding ways to facilitate activities which help to keep them anchored in reality. (p.450)
Maintaining narrative agency
If we are narrative beings and the primary narrative of our life is the one we construct for ourselves in relationship with others, then the maintenance of narrative agency takes on major importance. Narrative agency in this sense consists of two inter-related ideas: the ability and opportunity to construct one's own narrative; and the contribution one makes to the narratives of others.
Ability to construct one's own narrative
The importance of constructing one's own narrative is familiar territory in psychiatry and psychotherapy [13], [36]. Such activities are vitally important, but the issue of the narrative agency of people with mental illness goes deeper and prompts a reconsideration of what we think of as narrative and narrative identity [14], [21], [22].
Narrative, as it is generally conceptualized, is, among other things, fundamentally chronological (i.e. there is a progression of events through time) and relies on language for its articulation, even when the language abilities of narrators are limited in some way [37], [38].
Such a conceptualization of narrative, I would argue, restricts the possibility for narrative agency among certain individuals and groups of people. This is a serious matter, given that I wish to argue we are narrative beings despite the seeming loss of the ability to construct one's Self and to relate to Others. One way of addressing this issue is to reframe our understanding of narrative so as to include those who are currently dispossessed. This reframing would require that we give up, or at least loosen our hold upon, an insistence that all narratives should have a recognizably chronological basis. Although this might seem to cut us adrift from the fundamental basis for understanding narrative, the skill required would be to discern how stories relate to other stories rather than to chronology. Narrative, thus, becomes related primarily to meaning rather than time. Thus, the chronologically fragmented stories or repetition of stories by a person with mental illness may be understood as unaddressed, misunderstood, recurring meaning rather than merely as a result of the impact of the impairment. To understand the story we need to relate it to other stories this person has told and stories that have been told about this person. In so doing, we are realizing or enacting the sort of narrative competence that Montello refers to when discussing the benefits of engaging with literary narratives [39]: ‘joining one story with another, accurately to observe and make sense out of the chaos of suffering and loss’ (p.194). In this way, we can build up a narrative map both with and for the person with severe mental illness, a map that may have little immediate meaning or use for that individual but is essential for us in understanding the landscape of that person's experience. In a quote referring to people with dementia but that could easily be applied to those with severe mental illness Moore and Davis state that the person:
may be able to present only fragments of a performance story. The more a nurse knows about narrative components or the different sections of a story, the more easily he or she can identify and follow up on a story fragment offered.… [40]
Similarly, in order to include people with limited linguistic expression in the narrative enterprise it will be necessary to find ways of eliciting and constructing narratives making appropriate accommodation for the limited linguistic ability of the person [41]. Moore and Davis [40] report that normally aging speakers use four narrative strategies to help the listener follow the story:
Estimating the listener's probably expectations for what the story will be about and how it will be told, alerting the listener to any unusual features; Signalling the beginning of the narrative, providing some initial context; Monitoring when the listener may need clarification or further detail; and Keeping the story on track and bringing it to an appropriate end.
People with mental illness may lack the narrative capacity to use these strategies and so it may be necessary for others to piece together narrative fragments into a meaningful whole. This ‘narrative quilting’ has been applied to the care of people with dementia [40] and it would seem an appropriate method to transfer to the care of those with other mental illness.
A further way of maintaining narrative agency for people with mental illness is to look to interpreting other symbolic means of expression in a narrative fashion. Although it is recognized that non-discursive forms of expression such as dance, opera, drama, music and art have a power to cope with diversity of experience [21], I want to suggest that the skill required is to be able to read these non-discursive expressions narratively. Dance, for example, can articulate a story as much as it can be a channel for self-expression. This is, of course, a familiar and common approach in the arts. Movement and artistic expression can also be a means of telling a story – if we as readers are sensitive enough to the narrative features of such media. Similarly, observational techniques can provide us with some insight into the journey of individuals in context throughout the day. Although the process of giving narrative form to these channels of self-expression is predominantly in the hands of caregivers, these means of communication and observation, coupled with the notion of narrative quilting (see earlier) and attention to small stories (see later) would seem to be means of facilitating narrative agency for people with severe mental illness.
Contributing to the narrative of others
If we are narrative beings it follows that we shall relate to others in and through narrative. This raises the issue of how others contribute to our own narratives. Although this obviously includes stories others tell about us (and thus how we respond to those narratives), there is another equally important way that others can contribute to our narratives, namely how we ‘read’ the narrative of another.
In the Vineyard of the Text, Illich [42] makes a distinction between monastic and scholastic reading. Monastic reading, Illich says, was an embodied activity that required the reader to incorporate the reading into one's own life. The text was something that was approached as having something to say directly to one's own experience and existence (What does this text say to my life?). Over the course of history, around the twelfth century, monastic reading was replaced by what Illich calls scholastic reading. This form of reading, brought about by physical changes in the text such as spaces, paragraphs, punctuation and so on, came to focus on what the text itself was saying and, thus, the text became an object in its own right and a subject of debate (What is this text saying? Or, What is the correct reading of this text?).
I want to suggest that a monastic approach to reading the text of another's life restores some degree of narrative agency to that person and thus displays more narrative probity than a scholastic reading that distances the other's narrative. In answering the question, ‘What does this narrative say to and about my own life?’, we are opening the door for others to contribute meaningfully and deeply to the construction of our life narratives.
It is my contention that we have a tendency to approach people with severe mental illness, because of their vulnerability and dependency, as recipients of our care, service and narrative constructions rather than contributors to our own narrative constructions. In approaching a person with severe mental illness, in this way, we are curtailing one aspect of his or her narrative agency and thus one aspect of the Self. Furthermore, we are constraining our own development by limiting the range and nature of the narratives that we allow to affect us [39]. For Ricoeur [43], the reading of the text is a vital element in the narrative process:
… the process of composition, of configuration, is not completed in the text but in the reader and, under this condition, makes possible the reconfiguration of life by narrative. I should say, more precisely: the sense or the significance of a narrative stems from the intersection of the world of the text and the world of the reader. The act of reading thus becomes the critical moment of the entire analysis. On it rests the narrative's capacity to transfigure the experience of the reader. (p.26)
Countering master narratives
To challenge disabling master narratives, counterstories that are individual, enabling and meaningful need to be both constructed and realized. This is not only the case in terms of the master narratives, mobilized by the diagnosis of mental illness (e.g. the master narratives of schizophrenia, bipolar disorder, dementia or depression), that depict madness as ‘Other’, but is also true of the master narrative of narrative theory that seeks to exclude ‘fragmentation, amorphousness, entropy, chaos, silence, senselessness’ by imposing coherence [22].
In the realm of dementia, the conceptual work of Kitwood [44] has gone quite some way in challenging the master narrative of dementia as an inevitable decline into senescence and the ‘new culture’ of person-centred care is an attempt to make the conceptualization concrete. The stock plots of decline, rooted in the biomedical model of dementia and poor prognosis, are gradually being challenged by stories arising from psychosocial [44], disability [45], [46] and citizenship [47] models of dementia. With regard to mental illness, the work of the antipsychiatrists such as Laing [48], Cooper [49] and Szasz [50], and more recently, movements such as the Hearing Voices Network [51], [52] have sought to stretch or dissolve the rigid formulations of the narratives of mental illness constructed and imposed by Western biomedical orthodoxy. In addition to the challenge posed by such conceptual work, autopathographies of those experiencing madness [53–55] seek to claim a space in which to be heard. In so doing, such autopathographies challenge both the imposition of the master narratives of the particular diagnosis by what they say and the master narrative of narrative by how they say it.
Attention to small stories
One other aspect of our current approach to narrative generally that may actually serve to dispossess people with severe mental illness is the tendency to focus on longer rather than shorter narratives. Concern with life history, for example, while essential for understanding the individual and the backdrop from which the current narrative emerges may, in its focus on the historical narrative construction of Self, fail to recognize the identity work that goes on in the here and now, both expressed and performed in what Bamberg [56] calls ‘small stories’. In other words, past narratives may take precedence over current narratives even when the primary figure has forgotten the past and is functioning primarily in the present. In relying on past narratives, therefore, we may be both missing current ones and denying the individual the opportunity to engage in identity work in the present.
In contrast to life histories that attempt to organize lives into coherent and consistent narratives over long periods of time, small stories are situated in chit-chat and are fundamental to the ongoing construction of local identities [56]. These small stories, unlike longer autobiographical accounts, are not oriented toward coherency, authenticity and consistency, but privilege the fleeting and fragmented as contributing to the performance of identity in everyday interactions [56]. A focus on small stories may, then, be highly appropriate in the care of people with severe mental illness as such stories may resonate more closely with those for whom experience is fragmented in this way, and, perhaps, as Bamberg [57] has argued, to the experience of people in general. The skill required, therefore, is the ability to recognize these small stories, in all their complexity, collecting them in different times and settings so that we can learn to understand how they contribute to the development and maintenance of the Self.
Conclusions
Narrative, it seems, is essential in maintaining and creating our sense of Self. As narrative beings we construct our own lives in narrative fashion and accompany others in the construction of their narratives. The maintenance of narrative integrity and agency is, at root, an ethical activity as it is fundamentally concerned with how we live our lives in relationship with others. People with mental illness may, however, be regarded as having lost both narrative integrity, on account of a loss of coherence and consistency, and narrative agency, because of a loss of the ability to author their own narratives. When we are called upon to accompany others in the (co-)construction of their narratives, we need to focus upon both the narrative that is constructed and how the narrative is constructed. The first requires that we understand narrative ethics, the second that we commit ourselves to (co-)authoring ethical narratives.
The loss of narrative integrity and agency for people with mental illness results not only from the mental disorder and the decreased opportunity for narration, but also from how narrative is currently conceptualized. To restore narrative integrity and agency to people with mental illness, we need to find ways in which people can narrativize their lives. This could involve living in environments that extend their narrative context and their ways of expressing narrativity in the face of their difficulties communicating caused by a variety of mental illnesses. In terms of narrative theory we need to re-conceptualize the nature and role of narrative so as to avoid dispossessing those whose narratives do not conform to current views of what narrative is. In practice and in theory, a narrative approach is fundamentally supportive of a person-centred approach to psychiatric care.
Footnotes
1For an opposing view of narrative, see Strawson, G., Against narrativity. Ratio, 2004; XVII (4, December):428–452.
2Newton, of course, is writing about the ethics of narrative fiction, but this should not rule invalid the transposition of this form of narrative ethics to the realm of health care as it is well established that the interplay between literature and medicine is beneficial to the moral and professional development of health-care practitioners (see Charon, R. and Montello, M., Literature and medicine: an on-line guide. Annals of Internal Medicine, 1998; 128 (11):959–962). Indeed, given the somewhat imprecise boundaries between real life and fiction and the narrative nature of life (see later), developing a real-life ethics from the lessons of prose fiction seems entirely reasonable.