Week 4: Living Beneath The Bell Jar of Depression and Mental Illness

*Excerpt from Sylvia Plath, The Bell Jar (pgs 112-244)

*Colleen Farrell, Systole and Diastole, Strength and Openness

*Rebecca Grossman-Kahn, Beyond the Rubble of Lake Street—Minds in Crisis in a City in Crisis

**CQ Assessment Due.

We jumped into two poems by Sylvia Plath: Lady Lazarus and Tulips. Pairs of students explicated each poem and then shared their conversations. We talked about what was different about poetry as a genre as compared with the quasi-autobiographical work of Plath in The Bell Jar and the narrative essay style of Dr. Farrell. We talked about some concepts that help guide psychiatry, such as the DSM-V (and some of its limitations), stigma, how we define normal vs. abnormal, functional impairment/subjective distress.

We watched the following video as we transitioned to thinking about mental health inequities:

We then discussed widespread mental health inequities and cultural considerations for trying to decrease these inequities amongst different patient populations: Black/AA, Native and Indigenous, Latinx/Hispanic, Asian American/Pacific Islander, Arab/Middle Eastern, Multiracial communities. In groups of 2-3 each, students each studied one of these patient populations and shared their findings with the larger group.

For the second half of class, we had the honor of guest speaker Dr. Rebecca Grossman-Kahn joining us virtually to speak about her NEJM piece “Beyond the Rubble of Lake St– Minds in Crisis in a City in Crisis” and narrative medicine in psychiatry. We had a great conversation and covered a lot of ground. Topics discussed included the following:

-how we communicate mental illness to patients

-how we collaborate with families to better understand when patient narratives might not provide the whole picture

-the art of practicing psychiatry with an attention to narrative

-how we make decisions about when to limit or take away a patient’s autonomy (i.e. through involuntary commitment for mental health)

-how we address health inequity and social justice at the bedside and through the medical system.

My Week 4 lesson plan and slides are included below:

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Week 3: Diagnosing Illness Narratives

*Part III Chapter 6: Close Reading from Rita Charon, Narrative Medicine (pgs 107-130)

*Arthur Frank, The Wounded Storyteller (pgs xi-xiii, 75-84, 97-102, 115-119)

How do Frank’s 3 types of illness narratives help us and in what ways might this framework limit our understanding of illness narratives? What stories do people tell through social media about illness and how does society receive these stories? Give an example of what common responses to illness narratives might suggest about societal understandings of health inequity. OR Create a narrative about illness that uses common elements outlined in Frank’s illness narrative categories.

Our class began discussing questions posed by Ann Jurecic: “Where did [illness narratives] come from? Why are we so interested in reading them now? Why are so many people interested in writing them now?” In groups, we tackled the illness narrative worksheet, each group focusing on a single category of Frank’s types of illness narrative. I asked for students to focus on examples in popular media, ie. film and art. We then discussed the benefits of this narrative typology and the limitations of this framework, unraveling some of the caveats that must be kept in mind when thinking about these categories. I shared brief slides about the evolution of medicine and narrative, patient- and family-centered care, and examples of using illness narrative types to inform communication strategies and in research.

Some highlights of our conversation include:

-Categorizing types of illness narrative is most helpful for the listener. Importantly, Frank’s illness narrative types are not distinct categories but rather can overlap. How people narrate illness is a dynamic process and different illness narrative types can be expressed at any given moment.

-Understanding how people narrate their experiences with illness can help us to better meet them where they are and provide patient- and family-centered care.

We explored the question of whether “survivor” falls under a restitution narrative vs. a quest narrative (answer: lots of caveats to consider!). The idea of knowing how to respond when a narrative contains elements of chaos and restitution/quest was explored, and the idea of how to best meet patients where they are with how we communicate. We also talked about how knowledge of these narrative types could impact clinical care. Class ended with an engaging creative writing prompt about personifying disease!

My Week 3 lesson plan, worksheet, and slides are included below:

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Week 2: Foundations of Narrative Medicine and Health Inequity

After intros and an overview of the syllabus and course schedule, I acknowledged the recent death of Tyre Nichols in our city of Memphis. Prior to class, it was difficult to anticipate what this conversation would look like with students that I had not met yet, but I wanted to make space for grappling with yet another incidence of police brutality in our nation.

The students launched into a discussion about the readings and specifically the AMA table about key principles and associated terminology (see below).

*Watch Empathy: The Human Connection to Patient Care.

*Read Part II of Rita Charon, Narrative Medicine: Honoring the Stories of Illness (pgs 65-104).

*Read AMA Advancing Health Equity: Guide to Language, Narrative and Concepts Intro, Part 1: Health equity language, and Part 2: Why narratives matter (pgs 4-27).

Some highlights of our conversation include:

-Person-first language. i.e. the impact of “underserved communities” vs. “communities that have been underserved by/with limited access to ____”

-Difference between when people choose to identify with certain words vs. when labels are imposed on them by others (i.e. victim, survivor)

-Does altering language affect clinical care and/or outcomes? Does raising awareness about the importance of person-first language actually alter patient-provider relationships?

We discussed ways that people are “made vulnerable” and about what is meant by the idea that “we need to change the narrative,” and we closed with a reflective writing exercise about experiences with healthcare.

My Week 2 lesson plan and slides are included below:

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Week 1: E-Introductions due to MLK Day

Since we observed MLK day and did not meet in person for our first day of class, Week 1 included completing the following readings and reflective writing assignment. Each student introduced themselves, reflected on the following prompt, and responded to a classmate’s post on our online discussion board. Haikus were the most popular creative writing form!

January 16 – MLK Day, No Class. E-introductions.

*Watch Pecha Kucha on Narrative Medicine

*Start Cultural Intelligence Assessment (due 2/6)

*Part I from Rita Charon, Narrative Medicine: Honoring the Stories of Illness (pgs 1-62)

Prompt:

Write a brief introduction to self. Who are you? Why are you taking this class? What do you hope to learn about this semester? What are you hoping to do in the future?

AND

Choose one of the three writing exercises introduced in the pecha kucha. Write a brief letter, a haiku, or a 55 word poem sharing something on your mind related to health (examples include reflecting on current events or media related to medicine, personal or professional experiences in medical settings, creating a work of fiction, thoughts related to the readings).

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From Clinic to the Classroom: Teaching about Narrative Medicine and Health Inequity at Rhodes College

After a hiatus during medical training (med school, residency, first year fellowship), I am excited to be back in the classroom teaching about narrative medicine and health inequity at Rhodes College this semester! The course is designed for post-baccalaureate Health Equity students and advanced undergraduate students, and I will share my teaching materials here, just like old times. I look forward to teaching alongside my clinical duties as a combined fellow in pediatric hematology/oncology and hospice and palliative medicine.

HLEQ 430 introduces the field of Narrative Medicine and the role of narrative in raising awareness of health inequity. Illness narratives illuminate patient experiences with social determinants of health, and clinician narratives provide insight into healthcare perspectives on inequity. Through a close study of medical narratives, we will delve into systems of health inequality, implicit bias, systemic racism and sexism, narrative ethics, death and dying, mental illness, disability, and more. Students will have the opportunity to engage with narrative medicine theory and discourse as well as to create their own forms of narrative. This course is designed for individuals interested in health equity, medicine, nursing, public health, medical anthropology, clinical psychology, other health-related fields to gain an interdisciplinary understanding and humanistic perspective of medicine through the lens of narrative.

Course requirements will include weekly readings and reflections, class participation, a mid-term narrative analysis paper, and a final project of narrative creation.

Image courtesy of Tara Winstead.

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[Cancer Knowledge Network] World Cancer Day 2017

This article is also available at the Cancer Knowledge Network. Republished in honor of Childhood Cancer Awareness Month this September.

I could never have anticipated how much the field of oncology would excite me. As a teenager, I chose to volunteer with pediatric oncology patients on a whim. I found myself fascinated, and deeply humbled by the psycho-social challenges that these young patients and their families face. I found my way to medicine, and I wondered whether the medical field of oncology would be similarly intriguing to me.

It was. It was exciting for me to understand the patient population I cared so deeply about on an even more intimate level, as I began to make sense of the medical language and decision-making that so impacts these lives. As a medical student, I have had the privilege of caring for patients with a variety of cancers. I have helped care for patients with gynecologic cancers such as ovarian cancer, medically manage adult and pediatric cancers like leukemias and lymphomas, as well as surgically remove cancers like breast cancer and metastasized melanoma.

As I reflect on all my patients over this past year, my fondest memories come from caring for oncology patients. In the face of such a serious and devastating disease like cancer, I feel as though my relationships with patients were even more meaningful. I am grateful to have found a field that not only allows but encourages me to develop such intimate relationships while I care for people.

World Cancer Day is yet another opportunity for us to remember that cancer, like the human race, is inherently diverse. While we strive to find “the cure for cancer,” we must all remember how different each type of cancer is, as well as the great variety in how these cancers inhabit different bodies. Perhaps most importantly, cancer also affects each individual in a unique and unpredictable way. This month is a chance to appreciate the breadth and depth of all that people go through with cancer.

To me, World Cancer Day is a reminder that while we’ve made incredible progress over the years, we have so far to go. I am excited by the HPV vaccine, and the opportunities that we have for early cancer screening. I am encouraged by the Cancer Moonshot initiative and other efforts to fund further research. I look forward to increased awareness, as more people understand the harms of smoking and take steps toward cessation.

With this new year, I am realizing just how much I have learned about the biological disease of cancer, the clinical management and, most important to me, the challenges that people with cancer can face throughout and because of their treatments. With each new year, more people are diagnosed with cancer, but more people are also dedicating themselves to the cause of cancer. I look forward to seeing what this new year will hold.

 

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[Cancer Knowledge Network] What September Means to Me

This article is also available at the Cancer Knowledge Network.

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Painting wooden figures is an all-time favorite craft for kids at C.S. Mott Children’s Hospital. Five years ago, a little boy with no hair sat beside me, splotching gobs of glittery paint atop a dragon made of wood. I don’t remember the boy’s name, but I remember his face, his kind eyes. When his mom came to get him from the playroom after he had been discharged, he turned to me. “This is for you,” he said. And before I could respond, he had bolted out of the playroom and was halfway down the hall, his left arm reaching up with little fingers curled tight around his mother’s hand.

I will never forget how moving it was for me, how touched I was by his altruism. This little boy, genuinely selfless, didn’t think twice about giving me his carefully crafted creation. He wanted a complete stranger to have it. Children like him inspire me.

September may be half over, but not a day has gone by that I haven’t thought about Childhood Cancer Awareness Month. Throughout my journey in medicine, although childhood cancer has been a cause that I’ve been passionate about for many years now, I have tried to keep an open mind about my career selection. But I’m the kind of person who has always known what I’ve wanted. This is who I am, and this is what I am about. I am determined, now more than ever before, to pursue a career in pediatric oncology and palliative care. I want nothing more than to dedicate myself to improving the lives of these children and their families in any way that I can.

But September is not about me. September is about all the children around the world diagnosed with cancer. All the loving parents devastated by the news. The siblings struggling to understand. The families that suffer so deeply. September is just one month, and 30 days is not nearly enough.

Let’s face it. It’s not ok. It’s not ok that so many children, instead of starting school this September, are being diagnosed with cancer. So many children are spending their days in and out of hospitals instead of in classrooms and outside playing tag at recess.

September reminds me just how important the cause of childhood cancer is to me, and how important it should be to all of us. Childhood Cancer Awareness Month celebrates the great strides that we have made in caring for children with cancer, and at the same time looks ahead at the great challenges that remain. This month calls for reflection, about how the landscapes of awareness, research, policy, and clinical care have all evolved with time. And, how much farther we still have to go.

The dragon sits atop my bookshelf. It reminds me every day of the little boy who taught me how to be selfless, who showed me the meaning of altruism even if he didn’t know what the word means.

So many of these young patients and their families have touched me over the years. I hope that I can someday return the favor, that I can touch the lives of those affected by childhood cancer with my own version of “glittery dragons.”

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[Cancer Knowledge Network] Talking to your Child about Death and More

This article is also available at the Cancer Knowledge Network.

“What is cancer?”

“Something you can die from,” an adolescent in remission once told me.

He later described his treatment to me, saying, “if it weren’t for the treatment, I would’ve been….” His voice trailed off as he swiped a finger across his neck and made a krrr sound. “It’s true,” he concluded, nodding.

This teen, in this moment, chose to express himself outside of words. He had been comfortable defining cancer explicitly in relation to “death” before, so why did his words falter now? I remember being taken aback by this symbolic beheading, an action fraught with connotations of cancer as both violent but also punitive. I wondered how many other children associated cancer with death, how many felt as though they were receiving a death sentence when diagnosed.

In a world where cancer is one of the leading causes of death for adults, it’s no wonder why many people instinctively associate cancer with dying. With cancer as a disease commonly in the spotlight in society—with Cancer Moonshot and other awareness efforts towards prevention, treatment, and cure ever-present in the media—I worry that many kids have fears of death earlier on that often go unaddressed. A fear of death can be held by any young person with cancer, even those with highly treatable forms.

With these high cure rates for some childhood cancers, I can understand why discussions about dying may not immediately enter into the picture. I feel like conversations about death and dying often happen late in the course of treatment, sometimes as they should. That being said, I think it’s important for children to feel comfortable voicing any concerns that they may have about what it means to have cancer as a young person.

This conversation illustrated to me the importance of understanding a child’s fears upon diagnosis and throughout the course of treatment. Another teen I spoke with defined cancer as “[s]omething… that… makes you special…” I asked her how, and she proceeded to explain “cause…I don’t know. Cause, you get to meet a lot of people with that and not a lot of people are able to do that.” To her, cancer was something that she valued. She appreciated the people that she was able to meet because of her cancer. Her perspective on cancer was less antagonistic and more thankful for the good that had come out of her diagnosis.

This, to me, is one of the reasons that palliative care and child life support early in a child’s cancer diagnosis can be especially instrumental. These specialists devote a great deal of attention to a patient’s understanding and ability to cope with a cancer diagnosis. Since cancer can mean something entirely different to each and every individual, taking the time to focus on a patient’s perspective on cancer can improve a young person’s quality of life and enhance healing.

Simply asking can make all the difference: What does having cancer mean to you? How do you feel about your cancer treatments? What worries you about the future? From open-ended discussions to coping activities, palliative care and child life specialists are equipped with tools to delve into the psychosocial complexities of a cancer diagnosis, be it a fear of death or a new perspective on life. But these are questions any provider can ask; anyone can express an interest in the many ways cancer permeates into one’s life. By asking, we can show youth that we care.

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Judith Hannan: Missing Voices in Narrative Medicine

It is my honor to feature this blog post by Judith Hannan, author of Motherhood Exaggerated and The Write Prescription: Telling Your Story to Live With and Beyond Illness.

Recently, I participated in a Narrative Medicine workshop at Columbia University. This mini-version of the groundbreaking Masters in Narrative Medicine program created by Dr. Rita Charon posits that the literary arts—close reading, close listening, and writing—are a necessary adjunct to the medical arts to ensure compassionate, ethical, and high quality health care. Academics spoke about gathering and interpreting patient narratives, doctors led us in analyzing stories, and writers and film specialists examined work depicting the intersection of life and medicine. Missing was the voice of the patient unfiltered through the view of the doctor, professor, or writer.

I felt this absence again in Andrew Solomon’s otherwise excellent article in the April 26, 2016 issue of The Guardian. The title of his piece is “Literature about medicine may be all that can save us: A new generation of doctor writers is investigating the mysteries of the medical profession, exploring the vital intersection between science and art.” Is Solomon saying that only narratives by doctors have a place within the practice of medicine? And who is us? Is it medical professionals, patients, the general population? Are patient narratives being co-opted by the very people trying so hard to bring dimensionality to the people they are healing?

I am not a medical professional. I am a writer and teacher who focuses on stories of physical or mental illness from the point-of-view of the patient, caregiver, or family member. Writing my memoir, Motherhood Exaggerated, is what allowed me to understand how I had become transformed as a mother during my then eight-year-old daughter’s treatment for cancer and her early years of survival. For readers, the book gave them permission to tell their own stories. They brought me their tales like presents which heretofore had no one to unwrap them. It was then that I realized that the field of narrative medicine either had to expand to include the patient/caregiver voice or we need to create a new field—maybe narrative healing—not just to embrace but to elevate the value of these stories.

In a June 29, 2010 New York Times article, Dr. Abigail Zuger asked whether memoirs of illness should be held to the same standard as other writing. “Perhaps,” she said, “these books serve a different purpose from the usual book for the writer and the reader.” My second book, The Write Prescription: Telling Your Story to Live With and Beyond Illness, is a response to Zuger’s question. Personal reflection and intimate prompts help writers enter into their stories where they will find healing, not by moving on from the trauma that has occurred in their lives, but by discovering how to move with it. Unlike Zuger, though, I think all writers should tell their stories well, not for the purposes of publication or to attract more readers, but because better writing will result in greater insight and transformation. It is the difference between a recitation of what happened and placing those events within the larger context of a life, between cliché and a unique voice, between venting and discovering, between momentary catharsis and more lasting change.

Aspiring toward literary excellence will mean that the genre of illness narrative will broaden in appeal. Like any good book, the reader will both find a piece of him or herself as well as acquire a larger view of what it means to be human. And it will give control to the person whose story it is to tell. In “Fraying at the Edges,” (New York Times, May 1, 2016) N.R. Kleinfield creates an exquisite portrait of Geri Taylor during the years immediately after her diagnosis of Alzheimer’s disease. As Taylor talks about how so many services emphasize the caregiver and the later stages of the disease, she expresses a similar desire for control. “We don’t want to be done to, we want to do.”

This is an important message for anyone in the healing profession. Yes, doctors should continue drawing out the stories of their patients’ lives, they should continue writing and sharing their own humanity. But patient narratives have their own place. Their readership should extend beyond those who have had similar experiences to include the general population as well as those within the medical field.

If you want to contribute toward the language of medicine, the best way to approach your story is in small bites; trying to tell everything at once is too daunting and will prevent you from looking closely. Receiving a diagnosis can make you feel like you are no longer the same person. To remain in touch with the entire range of who you are, bring all your senses into your writing. Be aware not only of what is happening to you and inside of you, but what is going on around you. Read what you have written aloud to yourself. Writing gives us that tiny bit of distance that allows us to confront emotions, events, and fears that we might flinch from if we were speaking. Reading what you have written will help you recognize the feelings and discovery you have made.

You don’t need a special place to write or, particularly when you are starting out, a large amount of time. Here is a prompt you can do in ten or fifteen minutes.

NAMING AN ILLNESS

     My meditation teacher tells me that, whenever negative forces or thoughts arise, I should give them a name as a way of neutralizing them. It’s easier to talk to people than to feelings and talking can reduce the sting. Grief, for example, is an impenetrable block; Greta, though, is a woman with a soft voice, long hair shading her eyes, a slight limp; she is more comfortable in water than on land. I can lean into Greta to hear her speak, brush the hair from her eyes, take her hand and guide her to the rocking waters of the sea.

Anxiety is the character I meet most often. Her name is Sybil. She greets me with a stutter. I have known her for over forty years and she has changed. Her body is still made up of the same sharp angles. Her feet still pace as if they never need sleep, my heartbeat mirroring their uneven rhythm. She still takes me by the arm, whispers in my ear of things only her silver eyes can see. But it no longer takes as much strength for me to loosen her grip. Her hair, once black, spiky, and uncombed is now nearly white and contained by a headband. I used to Sibyl welcome; she loves a strong cup of Irish breakfast tea. These days I’m more inclined to stroke her long fingers, straightening and lengthening them before they can turn into claws.

Siddhartha Mukherjee, in The Emperor of All Maladies: A Biography of Cancer, says, “To name an illness is to describe a certain condition of suffering—a literary act before it becomes a medical one.”  The true literary act, though, is in the renaming of the illness, to give it a moniker that is uniquely yours. It is a way to address your illness in familiar terms and to communicate with others in a form they can understand.

Writing Prompt

Write about your illness, or that of someone for whom you are caring, as if it were a person. Give it a name. What does it look like—height, hair and eye color, skin tone, clothes, hands?  Describe its mannerisms, habits, and moods. Give it a voice. Talk to it. How, if at all, has naming your illness influenced your relationship to it?

 

03252014_LWC_Judi_Hannan_0470_Final 4x4.jpgJudith Hannan is the author of Motherhood Exaggerated (CavanKerry Press, 2012), her memoir of discovery and transformation during her daughter’s cancer treatment and her transition into survival. Her essays have appeared in such publications as Woman’s DayOpera NewsThe Huffington PostThe Healing MuseZYZZYVATwins Magazine, and The Martha’s Vineyard Gazette. She teaches writing about personal experience to homeless mothers and at-risk adolescents as well as to medical students, and is a judge of the annual essay contest sponsored by the Arnold P. Gold Foundation for Humanism-in-Medicine. She served as Director of Development of the 92nd Street Y and then for the Children’s Museum of Manhattan. She now serves on the board of the Museum, Jody Oberfelder Dance Projects, as well as on three boards affiliated with the Mt. Sinai Medical Center in New York—the Adolescent Health Center (where she now serves as President of the Advisory Board), the Children’s Center Foundation, and Global Health. She lives in New York.

 

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An open invitation for guest blog posts on illness narratives

When I first started this blog, I was excited to seize the domain illnessnarratives.com. Now several years later, however, I’ve realized that the focus of my writing here has evolved, and I’ve felt uncomfortable about how many of my posts have been about me and my writing rather than on illness narratives in general. This blog has been alive throughout a good chunk of my journey towards a career in medicine, from my undergraduate to my medical school education. It’s been challenging to find my direction, to balance sharing my own personal writing accomplishments and experiences with my thoughts on illness narratives that I encounter

To that end, I’d like to try something new. I’ve always felt it strange that I was the only voice in a blog that aspired to comprehensively survey the landscape of illness narratives.

This is an open invitation to anyone interested in writing a guest blog post. Here are some examples of what I’m hoping for, but I would welcome a post about anything that interests you related to illness narratives:

  • Review of an illness narrative, be it literature, film, music, or any other media
  • An illness narrative of your own
  • Thoughts about illness narratives as a genre
  • Ideas about the ethics of writing about illness
  • Any other interest you would like to explore!

Your blog post could be as short or as long as you like. It could be anywhere from a paragraph to a few pages; whatever works for you. All you have to do is email it to tkpaul@umich.edu, and I’ll get back to you as soon as I can. It’s that simple. Please don’t hesitate to let me know if you have any questions at all; this will be a learning process for me.

I’m hoping that this might change things up a bit, and that I’ll be able to breathe some life back into this website. Because it’s summer, the world is anew, and it’s time.

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