We began our workshop/worship in Warburton by singing and calling in the spirits of the land and its original people. Then we did an introduction process in which each person says what they are called, where they come from, and introduces one of their ancestors to the other person in one quick sentence or so. I learned that sentences are not quick in Australia and people have much to say and tell. Introductions took over two hours. People were starved for the opportunity to tell their stories and to be heard. After lunch we continued with the theme of hearing the silenced voices, one that is apropos to Australia in which aboriginal people were silenced to ourselves in which we silence the voices within that we don't like or don't appreciate. In the post-lunch exercise, much as what we did in the Hearing Voices conference, the goal was to meet one or more of our voices that we have silenced and to remove the gag and allow them to talk and be heard. This turned out to be powerful, too. So many of our voices have been silenced by the dominant culture, which is one of greed and individuality. The voices of sustainability and cooperation have been drowned out by the sounds of greed and what Thomas King, the Canadian aboriginal writer, has called the "Ferenghi laws of acquisition (see his collection of stories called A Short History of Indians in Canada". The Ferenghi are from Star Trek and primarily represent the "all for me, and none for you" point of view. Allowing the silenced voices to speak is a powerful process.
I went on to talk about the ways in which the mind is a model of the larger social world. Just as we have marginalized indigenous people in the broader social world, we have marginalized the indigenous voices within us in the social world of our minds. We need to allow them to be heard. Here comes dialogical self theory again, which was the topic of my keynote address at the Hearing Voices conference. Dialogical self theory sees the mind as a collection of voices all of which are speaking at once trying to be heard. Therapy consists of imposing a kind of order of politeness and respect in which all the voices can be heard and can dialogue with each other. Richter (author of integraring Existentialism and Narrative Therapy) has written about the many me's within us. Each "me" manages one of my relationships and carries voices, experiences, and stories for negotiating that relationship. Some "me's" are more appropriate for some contexts than others. Social skill consists of knowing which me's to bring out for any given encounter.
Relevant to this is Marius Romme, Professor of Social Psychiatry at the University of Limburg in Maastricht, The Netherlands, who is credited as being one of the European founders of the Hearing Voices movement, though in my talks, I was quick to add that what Romme proposed has been practiced and believed by aboriginal elders for centuries, perhaps even 43,000 years. Romme was practicing psychiatry in The Netherlands when one of his patients, Patsy Haagan, said "You believe in a God no one can see, so why don't you believe in the voices which I at least can definitely hear and which are real to me." Romme thought about her proposition and found that he could agree with it. Why not? He accepted the ontological reality of Patsy's voices (just as indigenous elders do). He invited other voice hearers to talk together about their experiences but found that although they could talk they didn't really help each other. So, he and Patsy appeared on Dutch TV and invited others who heard voices to call into the program. Four hundred, fifty viewers who heard voices phoned. Of these, 150 people said they coped without the assistance of psychiatry; indeed some said they were happy to hear voices. Romme asked, "Could perhaps the techniques used by those who coped well with the voices be used by those who didn't?" A conference was organized to encourage broader discussion, similar to the conference we had in Melbourne. From this Healing Voices groups formed around the world. Ron Coleman, who spoke at the Conference, founded the first one in England 25 years ago.
My proposition was that narrative medicine has much to offer the Hearing Voices movement just as does dialogical self theory and therapy. Rita Charon, MD, PhD, one of the leaders in the world narrative medicine movement wrote that narrative medicine is "Medicine practiced with narrative competence, that is, the ability to acknowledge, absorb, interpret, and act on the stories and plights of others." (Charon R. Welcome and introduction. Presented at: Narrative Medicine: a colloquium; May 2, 2003; Columbia University, New York, NY). As doctors/, we act on the narratives presented to us daily by patients, their families, and other health care team members. This is what Romme did. He accepted the story brought to him by Patsy Haagan and worked within that story. The late Canadian family physician, Miriam Divinsky wrote that, "[Stories] help us see other ways of doing things that might free us from self-reproach or shame". Hearing and telling stories is comforting and bonds people together." This is what people had found at the Hearing Voices conference and what we found at the Warburton workshop. Coming together in circle to tell and hear our stories with each other creates relief and builds community. Within the Lakota concept of nagi, once we hear another's stories they are forever a part of us.
In Warburton, I spoke about the nagi, which is the swarm surrounding us of all the stories that have ever been told about us, by us, and by those who have influenced us coupled with a part of the spirit of the teller of that story. Nagi is what forms and shapes us and makes us who and what we are. It is our legacy. Once we tell or hear a story that story becomes forever a part of the listeners nagi. Miriam Divinsky further wrote that "Stories offer insight, understanding, and new perspectives".They educate us and they feed our imaginations." (Divinsky M. Stories for life. Introduction to narrative medicine. Can Fam Physician 2007;53:203-5 (Eng), 209-11 (Fr)) Through story
(1) we structure and interpret our life experiences;
(2) we create a coherent life story;
(3) we construct, display and reinforce our sense of self;
(4) and we manage this self in relation to others in our social worlds.
As I said in Melbourne, story is the default mode of our brains. It is our best way to store and manage information. The narrative structure is ubiquitous in human experience and emerges, according to the Scottish developmental psychologist, Colwyn Trevarthan, even in the early exchanges between mother and infant. In these interactions, infants engage in stories without words or with words supplied by their mothers. We have the task of creating a coherent life story, often with the help of our family and friends. Through the use of narrative structures, we invent an "I" to integrate our many me's. In fact, we know at least one part of the brain located in the mesial pre-frontal cortex which eliminates our ability to tell a coherent "I" story if it is rendered dysfunction by stroke or other damage. We use story to run countless simulations about what might happen if we behaved in particular ways in future encounters with others. I gave an example of this in which I asked everyone to remember a time in which he or she had an argument with their spouse or partner and had to leave home for work or another errand before the argument was resolved. "All the way home," I said, "you are running various "what if"." scenarios in your mind, rehearsing the discussion that will take place when you arrive home. Depending upon the outcomes of these various simulations, you decide whether to stop for Chinese take-out, flowers, chocolates, or perhaps a drink at the pub." Everyone could relate to this.
Then I defined a narrative unit (following the work of Labov) as one containing at least 2 Complicating Action clauses where the verbs are in the past or historic present tense, and where we can infer an order to the clauses. There are also one or more Orientation clauses setting out who was involved in the events, when and where the events took place, and giving other necessary background information. I used an example of a short narrative from one of our clients who comes to our complicated minds group. Mandy said, "Then there was the time when I killed my boyfriend, except that he didn't die, and there he was at my back, trying to strangle me again." This actually has three Action clauses. True to the requirement for an Orientation clause (which can be implicit in the conversation), Mandy added, "That was when we lived in Georgia and I was dealing coke and he was really jealous, but then we broke up and now we're best friends. I know all his girlfriends and all his kids." I asked everyone if they could feel Mandy's charm as a person from the story and everyone could. This occurs because we recognize the other aspect of a narrative -- the affective strand of meaning where narrators reveal their feelings about the events they are accounting. This justifies the telling and shows the kind of person the speaker claims to be: "narrative is a presentation of the self, and the evaluative component in particular establishes the kind of self that is presented". This illustrates the narrative competence of the speaker in putting together a multi-voice, multi-faceted story in accessible language.
Next I moved onto illnesses, discussing how narrative competence allows us to Use the different perspectives of storytelling to create a complete picture of the illness and its meaning to the patient.
The narrative of an illness needs to not only give the patient a voice, but also to re-present the dialogue between patient and caregivers, inclusive of the voice of the caregiver or health professional. I gave the example of the story of the first encounter with the illness being named. Mandy said, Linda: We fought for 6 hours that day because I fought back. At one point I was slamming his head into my knee. I went to the hospital and that's when I found out I was pregnant. That"s when they diagnosed me." To her credit, Mandy had received every psychiatric diagnosis available from someone. This is how she came to have a "complicated mind". Mandy also told habitual stories that illustrate usual activities. For example, she said, " I get so angry, I mean he would wake me up for no reason, and he knows I can never get to sleep and so I have a 3 hour panic attack because he needs $5, right now, so I would lock him in the basement. I would just get so sad. I would take all my pills, whatever I had around. I'd still do it but my son put me right, he said he didn't want to be without me. They would call me from the other side, my best friend, my son's father. And he was really good looking." Mandy was talking about her usual activity of taking all the pills at hand when she was upset. She was however, entertaining a counter story during her time she had been in the Complicated Minds group -- that her son loved her and would miss her and needed her to stop overdosing on pills. People also have "reported speech" narratives in which they describe important conversations with others. Mandy said, "The doctors don't want to hear what I tell them. They get really nervous when I come in the office. I made one of them brownies but it doesn't help." Mandy's experiences with physicians were generally negative. She made them uncomfortable and recognized it. These stories are important. During our interactions with health professions decisions are made about the management of the illness and the health practitioners story about the illness is transmitted to the patient. Interactions between patients and health care professionals thus play a major role in the social construction of illness narratives. We rely upon physicians to tell us what we have and why we have it. This generates "because narratives" in which we explain ourselves, often in reference and comparison to others, which are called narratives of comparison with others.
We completed the workshop in Warburton with examples and exercises of people telling each other stories and listening for the smaller narrative units comprising the story, thereby recognizing points of potential intervention. Then we went across the street to the Polish Jester for a wonderful Polish meal of pickled vegetables, smoked herring, and stuffed cabbage. I fell asleep immediately upon returning to Karith.