Conversations Inviting Change: Narrative-Based Practice in Healthcare

John Launer reflects on the emergence of the ‘Conversations Inviting Change’ narrative medicine training programme

Interest in narratives within healthcare goes back a long way, but most people reckon that the identifiable field of narrative medicine coalesced at the beginning of the 21st century with the publication of two books. The first was a collection of essays, entitled Narrative-Based Medicine: Dialogue and Discourse in Clinical Practice (1998), edited by Greenhalgh and Hurwitz, two academic GPs from London. This collection included contributions from interdisciplinary scholars, healthcare professionals, patients and carers from around the world and showed how much could be learned from exploring narratives of health and illness experiences. A few years later, Rita Charon, a physician and literary scholar from Columbia University, published a book with a similar title, Narrative Medicine: Honoring the Stories of Illness (2006), with its theoretical roots in literary theory.

Although these works differ in their approaches, they both aspired to apply narrative ideas to every aspect of medical practice. They shared the same aims: namely, to act as a counterbalance to evidence-based medicine and to restore humanity to the practice of medicine (Jones and Tansey, 2015). Accounts of narrative medicine and critiques of it have generally tended to focus on what has been called the ‘Columbia approach’ – specifically, on the use of the close reading of texts (Woods, 2011) and on practitioner writing. At the same time, other expressions of narrative medicine have continued to emerge in the UK, Europe and elsewhere. Some varieties of narrative medicine have focused specifically on the application of narrative ideas and skills from the social sciences to real-life encounters in healthcare. This is where my own interests lie.

I was one of the chapter authors in Greenhalgh and Hurwitz‘s (1998) book and have been preoccupied for a long time with the question of how clinicians in healthcare can navigate the uncertain territory between biomedical science and a search for meaning through witnessing stories and inquiring into them. My professional training is both as a doctor in general practice and as a family therapist. At the time I wrote my chapter, I was already involved in a project to train GPs and others in primary care how to practice within a changing world where the authority of doctors was no longer taken for granted and where patients might have divergent views of the world based on differences of gender, generation, social class, culture, religious and political beliefs, or other factors (Launer and Lindsey, 1996). The teaching methods we used and the skills we taught on our course for using in everyday healthcare already drew on the narrative tradition within family therapy (White, 2007). In particular, these methods emphasised how therapists might be conscious and reflexive in relation to power within the consultation. Once narrative medicine emerged as a field, we began to graft these ideas onto our narrative medicine approach.

Like the Columbia approach, our work has developed enormously both in scale and scope over the years. However, our approach has taken quite a different form. We describe what we teach as a form of ‘narrative-based practice’, or more simply ‘narrative practice’ (Launer, 2018; Launer and Wohlmann, 2023). We have given it the name ‘Conversations Inviting Change’. We run activities ranging from one-day introductory workshops to supervision groups lasting a year or more. Additionally, we run training courses, which are accredited by the Association of Narrative Medicine Practice in Healthcare (ANPH). We’ve delivered training widely around the UK and Europe, as well as internationally including the United States and Japan, reaching many thousands of practitioners overall. Since the COVID-19 pandemic started, we’ve worked online as well as in live groups. We now have a team of around 30 trainers.

We teach ‘Conversations Inviting Change’ with a mixture of theoretical input and peer supervision groups. We generally teach about ten to twenty people at a time, dividing them into smaller groups of four or five people for supervision practice. In any practice session, we invite one person to give a spoken account of a  clinical case or professional encounter that’s causing them distress or has raised a dilemma for them. Someone else in the group acts as their peer supervisor, interviewing them about the narrative as they speak. Other members of the small group then act as observers, while a tutor is present in each small group as a coach. The tutor may pause the conversation to invite the group to offer comments, suggest hypotheses about the narrative, or propose questions for the supervisor to ask next. There are some similarities in our approach to Balint groups – reflective spaces for case discussion that are widely used in medical training (Balint et al, 1993). However, we emphasise precise attentiveness to language, and the need for the supervisor to be minutely responsive to the other persons self-expression from moment to moment, without having any predetermined goals in mind.

We commonly receive feedback from course participants that it’s unprecedented for them to receive such focused attention on a dilemma in their working lives. Specifically, they notice that we do not attempt to tell them what to do during supervision. Participants are frequently surprised how the process of someone witnessing their narrative and inquiring into this more in the manner of an ethnographer than a conventional health professional can help them to find their own way towards a resolution. Course participants taking on the role of peer supervisor often describe how difficult they find it to restrain their usual interviewing behaviour – like trying to nudge the narrator in certain directions –  but they too are surprised to discover how narratives contain their own momentum for significant and self-motivated shifts if allowed to flow freely, with questions driven by curiosity rather than the desire to maintain power and control. Most people report gaining the ability to transfer these skills and experiences to encounters with patients and colleagues, lessening their sense of burden from the assumed obligation to fix everyone else’s problems, and developing their capacity to allow agency to others (Bullock et al, 2011).

Teachers of medical humanities, including narrative medicine, are usually aware of a tension between intellectual integrity and practical utility (Launer, 2023). On the one hand, academic teachers rightly strive to transmit ideas that may be highly sophisticated, nuanced and profoundly challenging to the comfortable certainties that often seem to possess the world of healthcare. On the other hand, departments and institutions training healthcare professionals may insist that disciplines should only find a place on the curriculum if they offer demonstrable improvements as judged by conventional parameters, including professional performance and clinical outcomes. Narrative practice, in the form of ‘Conversations Inviting Change’, is an attempt to bridge that gap through testing the ideals of narrative medicine against the complex and sometimes messy realities of everyday healthcare, in every healthcare conversation, and from moment to moment. It effectively translates narrative medicine from the academy to the clinic. By doing so, we hope to transform clinicians into narrative practitioners.

About the Author

John Launer is a medical educator with a background as a GP and family therapist. He is honorary president of the Association for Narrative Practice in Healthcare. John holds honorary posts at University College London and the Tavistock and Portman NHS Trust. He is a columnist for the British Medical Journal. You can follow John on Twitter/X at @johnlauner.

References

Balint, Enid, Michael Courtenay, Andrew Elder, Sally Hull S, and Paul Julian. 1993. The Doctor, the Patient and the Group: Balint Revisited. London: Routledge.

Bullock, Alison, Lynn Monrouxe, and Christine Atwell. 2011. Evaluation of the London Deanery Training Course: Supervision Skills for Clinical Teachers. Cardiff School of Social Sciences Working Paper Series. Working Paper 141. Cardiff: University of Cardiff School of Social Sciences.

Charon, Rita. 2006. Narrative Medicine: Honoring the Stories of Illness. Oxford: Oxford University Press.

Greenhalgh, Trisha, and Brian Hurwitz  (eds.) 1998. Narrative Based Medicine: Discourse and Dialogue in Clinical Practice. London: BMJ Books.

Jones, Emma, and Elizabeth Tansey (eds.) 2015. The Development of Narrative Practices in Medicine c.1960–c.2000. Wellcome Witnesses to Contemporary Medicine (vol. 52). London: Queen Mary, University of London.

Launer, John. 2018. Narrative-Based Practice in Health and Social Care: Conversations Inviting Change. Abingdon: Routledge.

Launer, John, and Caroline Lindsey. 1997. Training for Systemic General Practice: A New Approach from the Tavistock Clinic. British Journal of General Practice 47(420): 543-456.

Launer, John and Anita Wohlmann. 2023. Narrative medicine, narrative practice and the creation of meaning. The Lancet 401(10371): 98-99.

White, Michael. 2007. Maps of Narrative Practice. New York: W. W. Norton & Company.

Woods Angela. 2011. The Limits of Narrative: Provocations for the Medical Humanities. Medical Humanities 37(2): 73-78.

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