Photo by Yoshiki Nakano
CHLOE WALKER: Could you start by telling us a bit about your personal path to the study of healing and Narrative Medicine?
DR. LEWIS MEHL‑MADRONA: Well, I was born in southeastern Kentucky, and apparently I told my mother I was going to go to Stanford Medical School when I was three years old. I don’t remember that, though. I was raised in a Cherokee family, with my grandparents and my mother. This was in the ‘50’s, and my mother was sort of trying to assimilate. And eventually I did go to Stanford Medical School. Afterward, I went to finish residency in family medicine, geriatrics, and psychiatry, and at some point I figured out that the narrative movement was just like Indian stuff. That the storytelling that went on in communities and on reservations that I received during my childhood was being called, “narrative medicine,” or “narrative psychotherapy” or “narrative practice,” “dispersive practice” and “biological theory” in Europe and Australia, and to a lesser extent, North America.
at some point I figured out that the narrative movement was just like Indian stuff.
So, that was how I got interested in narrative medicine specifically, but long before that, I was captivated by how stories “encharacter” us and embody us. How we’re embodied in stories that then set our expectations for what will happen to us, and how we’ll respond to adversity, stress, other people, bears, moose, beavers, or anything else we might encounter.
CW: Absolutely, I know I tell myself some scary stories about what I might expect if I come upon a bear. That opens up an interesting conversation about the role that narrative plays in the formation of our identities. I would love to hear your thoughts on how narratives shape the understanding that we have of our past, who we are now, and who we might be in the future.
LM: You know I think it might have been Arthur Kleinman who came up with the term identity narrative. And it seems consistent that we have a story that we would tell other people in response to the question, "Who are you?" In environments in which people are meeting for the first time, especially with the expectation that they’ll get to know each other, like first dates, early-dating, and after-hours work gatherings, if you listen to what they’re talking about, everyone is really asking and answering the question, “Who are you?”
They’re either telling the story about who they perceive themselves to be or crafting it for the audience who’s listening. So all of us are, I think, improv artists and we’ve got these stock stories that we use. We change them to suit the audience and color them a little differently, spin them a little differently because we like audience reaction. We like people to cheer or to sympathize and go, "Aw – poor you." We like them to clap. But we have to tell a story, our story, in a way that matches the audience.
All of us are, I think, improv artists and we’ve got these stock stories that we use.
I think we have a number of identity narratives that we're accustomed to telling. And people with rigid narratives often get diagnosed with some kind of psychiatric illness because they can’t tell a different story to a different audience. Some audiences, the police, for instance, don’t want to hear the same stories that you might tell to your best friend. You might get in trouble for that. So I think to be honest and identify our own narratives is really important because it explains to us what is the meaning of my life, why am I here on this earth, what am I supposed to be doing with my life, and who is my lineage? Where do I come from and where am I going? These are the questions for which the pursuit gives us fulfillment or meaning or purpose and even tells us how to behave. It’s shown in some studies that people who have meaning and purpose tend to be healthier, so I think this identity narrative is pretty important.
CW: Yes, and narrative medicine is about exactly that -- the importance of these narratives as they relate to healing and well-being. We know that these stories matter, so what’s stopping doctors from working with these stories? What barriers do you see standing in the way of doctors embracing practices that would incorporate listening to these narratives?
LM: Well, there isn’t much interest in narrative work in our clinical environment. The enemy is just how we get paid and the training we have to do in relation to getting paid. One of our challenges right now that I’m working with is getting the residents to understand what’s been taught – the Lake Wobegon Effect, which was clearly named by some guy who must have really liked Garrison Keilor a lot. In Lake Wobegon, everyone is beautiful, handsome, and smart, and the idea is that doctors develop treatments based on the idea that every patient is above average.
An example of this is a patient recently who had mildly high blood pressure. It was well-controlled by just one medication, and the patient works out every day and otherwise looks really healthy. My resident wanted to put him on a statin because statins are supposed to be good for everybody to prevent heart disease. So I ask, “What’s his cholesterol?” And it’s 121, which is pretty good. So I show this Lake Wobegon paper to the resident. If the patient takes a statin which makes him weak, which often happens because they interfere with the function of mitochondria in muscles, well, then the patient stops working out so much, and then you’ve actually increased his cardiac risk and not decreased it.
CW: So the Lake Wobegon Effect is the unrealistic assumption that a patient will experience the benefits and not side-effects?
LM: Yes, but you need to understand the whole context of the person’s life in treatment. Not just because you read a study that everybody’s getting on the bandwagon with, which says everybody should be on statins and then we’ll have fewer heart attacks. That’s not been proven for everyone; it’s been shown in studies of the 20 percent of at-risk people. And this is the perspective that I think narrative medicine can bring us. It’s asking what’s the full story of your life? What do you do that’s important to you? Another example is another patient who smokes. I asked him, “Who are you when you smoke?” He looks to me, and he says, “Johnny Depp.” So I’m not going to get him to stop smoking until I come up with a better character for him to be than Johnny Depp with a lit cigarette hanging out of his mouth. So in that sense, we’re naming the story and one of the characters in the story, and that has a tremendous impact on quality of care.
One study showed that doctors interrupt a patient after 18 seconds of listening, and the patient never gets to finish the story.
CW: That’s so fascinating, and I think it touches on something that so many experiencing pain or trauma often feel in a clinical setting. They struggle with not feeling heard by doctors. They want to be perceived as more than a set of symptoms, and that really seems to compound their experience of being ill and feeling ill.
LM: Yeah, building narrative competency for physicians means teaching them how to listen to the person’s story in a nonjudgmental, non-interpretive way until the story is done. And then to work with that story in a respectful way. Because, typically, doctors don’t do that. One study showed that doctors interrupt a patient after 18 seconds of listening, and the patient never gets to finish the story. In that same study, they found that if doctors could extend the amount of listening to 24 seconds, they cut down what are called “doorknob complaints” by 37 percent. A doorknob complaint would be saying to the doctor, as his hand is on the doorknob, “Oh, by the way, I have chest pain and shortness of breath every time I walk around the room.”
So, I think, listening needs to be a focus. But we’re struggling with how to do that. We want to do it, and we want to teach the residents to do it, we acknowledge that it’s valuable, but how to do it is the question that we don’t have an answer to yet. I think part of it is the capitalistic system. But there is some hope, because Medicare is talking about moving to a reimbursement plan in which a particular practice is given a group of patients, and they would get paid a flat rate to take care of them. It’s a lot like the Chinese system.
we know a lot about how to keep people out of the hospital, we just don’t have the time to do it, and nobody will pay us to do it.
If that happens, then we’ll completely transform our system because then it’s propelled by how to keep patients healthier, because sick care is expensive [as opposed to having as many patients come through in a day as possible]. And so a lot of things that seem crazy now would make tremendous sense in a system like that. Because we know a lot about how to keep people out of the hospital, we just don’t have the time to do it, and nobody will pay us to do it.
CW: That makes a lot of sense because it would alter the incentive systems for doctors. In your book, Narrative Medicine, you discuss the motivations of Western doctors and one of your positions struck me. You write that a Western doctor is focused with increasing life length, as opposed to increasing quality of life. I was really taken with that, and I’m curious, in your ideal vision of the world, what is a doctor’s job? What are the ideal objectives that a doctor or medical practitioner should have?
LM: You know, that’s a good question. I would come at it from a Native American perspective and say that I think doctors fundamentally need to address health and disease from all perspectives, to be interdisciplinary, and to work with other healthcare providers, including traditional elders, to accomplish those goals. The more conventional medicine perspective, and I’ve encountered plenty of physicians who think this way, is that the doctor’s job is to diagnose you and give you a pill, and if you want to get that other fluffy stuff, well, go find it. Or they’ll refer you to psychiatry, and then that person can find it for you. So clearly, there’s a continuum of what people believe medicine should be doing.
When I started medical school, what was popular was the bio-psycho-social model. So we were looking at social therapies for all kinds of diseases, but that didn’t last because it wasn’t as profitable as drugs. So if we were a country with national health insurance, these ideas are amazingly cost-effective long term. But for short-term capitalism, they’re not. Under short-term capitalism, you just give them a pill, you know? And get them out the door.
I once worked at a hospital where they passed a rule that said that patients needed to be seen for 15 minutes. And I was, like, “Well, I can’t get all my work done with someone in 15 minutes.” And they said, “Oh, actually we didn’t mean you. We were trying to go after the guys who only see their patients for five minutes.” How can you know anything after five minutes with someone? But that’s sort of where our healthcare is right now.
CW: With that in mind, do you have any advice for current medical students who might feel a similar dissatisfaction with the Western emphasis on diagnostics and technical procedures?
LM: Yeah, I think it helps to have another community to spend time with so as to offset the propaganda and the brainwashing that goes on. But it’s a complicated question because a number of us have a strong belief that peoples’ life stories and the stories they have about their illness and about how they can get better or can’t get better are incredibly important parts of their medical history. But the difficulty we have is the system of checked boxes that Medicare, Medicaid and insurance companies came up with for determining how we get paid. You get paid by how many boxes you can check on the chart, and it’s pitting this against getting the story.
how do we get practicing doctors and residents who are going to become practicing doctors interested in taking the time to also talk stories with people and know people’s stories?
So, really, the question is, how do we get practicing doctors and residents who are going to become practicing doctors interested in taking the time to also talk stories with people and know people’s stories? A lot of us think there would be much better care if we could do that or would do that. I think we’re making inroads. We’re talking about interrelation; we’re talking about coming up with a managed residency program to make that happen [here at the University of Maine]. We’ve already got an Art in Medicine track that’s been approved, so you can get an MFA at the same time you do your residency. I think we’re going to be the only one in the country.
CW: That’s fantastic to hear. Another way you’re encouraging this shift is through your non-profit organization, Coyote Institute, which offers workshops and trainings for healthcare professionals to become more versed in these narrative practices. On the site, you describe the Coyote’s job as intervening in systems that have become too rigid and inflexible. In what ways do you think the Coyote Institute can most powerfully intervene in today’s medical landscape? What is the programming that you see Coyote Institute providing that’s most important right now?
LM: Well, we do a lot of narrative medicine training, and we also do a lot of training for the value of indigenous medicine in North America and what conventional medicine can learn from indigenous medicine. So, for instance, I’m giving a talk at a big psychotherapist conference in a few months about something called Who I See. It’s this idea that you can look at the world from the perspective of indigenous knowledge and you can look at it from the mostly scientific perspective, and one doesn’t negate the other. They’re just two eyes in which we look at the same phenomena. So we teach things like that, and we do training on narratives on healing and storytelling. We’ve contributed to some research, and we’ve contributed to some studies as well. We also support indigenous ceremonies.
you can look at the world from the perspective of indigenous knowledge, and you can look at it from the mostly scientific perspective, and one doesn’t negate the other.
CW: In your mind, what are the most significant aspects of medical care that indigenous cultures prioritize in their treatments that modern, Western medicine disregards?
LM: So, the idea that community is the unit, the basic unit, of study for health and disease instead of individuals. I think that is really important. I think it’s something like 80 percent of illness is socially determined, according to a study from York University. And if we all believed that, we’d probably implement national health insurance, because we would believe that we’re all responsible for each other’s illnesses, which is often a traditional value in Native American culture.
we’re all responsible for each other’s illnesses
The idea that the person who is sick is the canary in the social mineshaft. That they’re letting everybody know that there’s disharmony and imbalance in the community and that we need to address the community. And certainly, you can see that here in Maine, with our runaway opiate problem, because it totally parallels our lack of employment problem, so the towns that have the least employment have the highest of opiate abuse, and on down the line.
So, thinking in terms of community instead of individuals. And also recognizing that it’s important to come together with other people when you’re sick, as opposed to going off on your own and getting well. That connectedness is probably more important than privacy when you’re ill. These are some ideas that I think would transform conventional medicine if we could think that way.
connectedness is probably more important than privacy when you’re ill.
Also, the indigenous idea that illness is simultaneously physical, mental, spiritual, communal. You know, that there’s no such thing as a simple physical illness or a simple mental illness, and it’s all interconnected, and that we have to address all levels of disharmony and not just the obvious one from our cultural landscape.
What’s interesting about traditional Native American culture is that spirituality is part of everything, whereas in the conventional world, it’s off by the side, and it’s called “pastoral care.” So, that’s pretty off-putting for Native American patients, to feel like not only is their religion barred from coming into the hospital for the most part, but that the spirituality has no relationship to whether or not they get well, which is pretty much the standard party line for medicine. Which is interesting because 80 percent of doctors, in one study, believe in spiritual beings, and believe that spiritual factors are important for people to get well. It’s just not accepted as part of the practice of medicine.
The indigenous idea that illness is simultaneously physical, mental, spiritual, communal [would transform conventional medicine].
CW: I know, in addition to working as a doctor and an educator, you offer healing intensives as well. What practices do you draw from, and what might one of these healing intensives look like for an individual?
LM: We talk about it as education for self-healing, because we don’t want to get into the trap of the doctor-patient relationship because we’re doing things that are not necessarily doctor-y. We’re using narrative approaches with dialogical therapies. We’re looking for the stories that describe your life or the stories you’re enacting, and we’re looking for the characters who live within your swarm. In Lakota, it’s called a nagi, which is all the stories that swarm around your body, making you who you are. And a little bit of the essence, the divine essence of the person, or the being who told that story. So, we’re trying to make a map of your nagi.
we’re looking for the characters who live within your swarm.
And we do some Cherokee bodywork and reiki, and ceremony. We’re trying to address the physical, emotional, mental, spiritual, and communal. It’s hard to address community because people usually come by themselves, but we can at least bring their attention to who their community is, and question how they relate to it, and how they could change those relationships to be more fulfilling and sustaining.
CW: Moving outside of a clinical setting or healing-intensive or any medical office, how can we, as individuals, incorporate these traditional concepts, or tenets of narrative medicine, as an everyday practice? What can we do as listeners or simply members of a community to help give more support and offer more empathy to one another?
LM: Well, a couple of things come to mind. One is to create healing circles for each other, in which people come together at regular intervals for the purpose of healing for each other. It’s pretty simple and wonderful to have a place to be nurtured and not have to pay for it. Just to know it’s always there for you, however often you come.
Some people even do book groups together. Discussing a book together inevitably leads to people sharing their personal stories. Another possibility is a talking circle, which is a mechanism of communication in which someone starts the circle with a stick, and whoever starts it poses a question, or tells their issue, or tells a story, or whatever they’re going to do. Then, the stick passes around the circle, and the idea is to eliminate direct communication – to be able to hear people without micro-expressions, judgment, interpretation, or interruption. Whoever holds the stick talks as long as they went, and then it just keeps going around until whoever started the circle feels resolved. In the more ancient world, these circles could go on for days, and often did, if it was a matter of political decision making.
CW: Those all sound like helpful and easily implemented practices. In particular, the idea of moving away from a dialogue is fascinating to me, because in most contexts we talk about the value of dialogue. It’s interesting to think about how the obligation to interpret, respond, or interact with someone telling a story might actually take away from that story living on its own.
LM: Right, and I think the typical way people converse in modern society squelches the minority and the softer voices. It also quickly educates people to what’s acceptable to talk about and what isn’t from other people’s micro-expressions. It was developed in a culture that had taboos about who could talk to who under what circumstances.
the idea is to eliminate direct communication – to be able to hear people without micro-expressions, judgment, interpretation, or interruption.
In the talking circle, all those barriers are removed, though I haven’t seen them work very well when there’s a power gradient. If your boss comes to the circle, that might not be so good. I’ve seen it work very well with the social class gradient because people just accept everyone, but ideally, when in a circle, there’s some safety that if you say something, your boss is not going to retaliate the next Monday. It’s sort of a given in indigenous cultures, but maybe not so much in contemporary American mainstream culture. I mean, there are communities where people regularly hold this ceremony together, even outside of the reservation. I’m not sure how narrative it is, though it is an enactment of a narrative.
Quakers have something similar to the talking circle, and I think the way Quakers do it is when you feel moved by the spirits to say something useful to someone else, you stand up and say it. Otherwise, you keep quiet and sit down. So they struggle with whether what they’re about to say is useful or not to someone else, which is interesting.
In my grandfather’s time, he was Cherokee, and they would have these sorts of circles. They would offer what we now call cigars, but they call them talking sticks or prayer sticks. They would all light up a cigar that they’d grown, typically from their own tobacco, and say prayers, and then they would just wait for guidance. If someone heard something, they would stand up and say, “I heard such and such,” and then sit down. It was a similar thing; no one reacted. The idea was that if it mattered enough, people would say it; it didn’t require a reaction. It would just become obvious.
CW: We’re always looking for tangible solutions to give to those who might not have medical resources or proximity to some of these different options, so dispersing these ideas feels incredibly valuable.
LM: Yeah, I think people have been conditioned to think that they can only get help from experts, and oftentimes, the help we get from our peers, friends, or family can be a lot better.
I remember teaching a charity body work class in Australia. It was toward the end that we were doing what we call a "healing free for all," where there are four tables out, and everybody wanders around working on anyone who’s on a table. I got the most incredible massage from this guy, and after we were done, I said, “Where did you learn to do that?” He said, “I don’t know, I’m an accountant. It’s the first time I’ve ever done that.” It showed that spirits are moving toward him and guiding him, and he was just really open to whatever happened, and so something magical happened.
We don’t always need a professional or an expert.
I think I’ve seen magical things happen in people’s living rooms, just doing healing circles or talking circles. It’s because we really are healing for each other. We don’t always need a professional or an expert. In fact, sometimes that alienates us further to think, “Well, I have no friends at all. All I can do is talk to these professionals who wouldn’t talk to me if I didn’t pay them.” That, I think, can make a huge difference.
CW: Kind of a hypothetical question, but in your vision of a healthier world, how would you see healing and pain fitting into the macro picture of day-to-day life? We at ENDPAIN see pain as pretty integral to the human experience, and it’s about finding functional ways of dealing with pain and trauma and living with it and moving through it. What might a world that functioned in that way look like to you?
LM: I think we would go back to living in small groups or tribes, and we would help each other. We probably wouldn’t have to work quite as hard to meet the bills, and we would help each other more and contribute to each other’s stories more. We’d have communal meals, maybe storytelling in the evening for children and adults, and adult children grappling with the idea that if one suffers, it’s because of the many. It’s because of an imbalance among the many. How do we many contribute to healing the one?
We need to be more connected to each other, maybe through the growing of food.
I suspect we have to reverse the isolating trends of modern society in order to get very far, that we have to come together more than we are. We need to be more connected to each other, maybe through the growing of food. Community gardens might be a start to get people connected. Sometimes, co-op housing works, and sometimes it’s dismal. I think we would keep exploring how can we have a community that feels like a community in the sense of the word. What are the structures that allow us to support each other?
some people are buying apartment buildings together and living in them as a community.
The Communist experiment didn’t work, and the Capitalist experiment sure isn’t working very well. I don’t know what the answer is, but I suspect that deeper study of indigenous people here in the US or in Australia or wherever, New Zealand, could teach us how people can live together in community. What we do with that, I don’t know. I mean, how far do we go? I don’t know. I mean, some people are buying apartment buildings together and living in them as a community. Other people are doing that with farms.
CW: I think what you say rings so true because as the size of our community expands, we can’t really think of the community as our “unit” without losing sight of ourselves. We very often hear politics and medicine being discussed together, but it’s about what responsibility the government has to play in medicine, not how politics and social structures inherently affect our health and well-being and how we think about both.
LM: Right. Well, I think that’s a mistake of conventional mainstream society–to avoid the spiritual and political. The political is huge. It’s about the social determinants of health flow from the political, so who has employment and who doesn’t, who has housing and who doesn’t, who has food and who doesn’t. I mean, those are hugely political questions that we try to avoid, for the most part.
I think that’s a mistake of conventional mainstream society–to avoid the spiritual and political.
Even as we speak, on Standing Rock Reservation it’s all about water, and water is hugely important for health. If your water is destroyed, how will you live? How will you be healthy? The present policy says that Indians get a perpetual lease on their land from the government, but they don’t own it, and if the government wants to do something different with it, like give it to a pipeline company, they can do that, and they don’t have to ask. It’s a political action that directly relates to health. The World Health Organization has firmly stated that the most important element in health is good plumbing, clean water and getting waste to where it is safe. And I suspect people came together as a result. The demonstrations are largely about community, sharing meaning and purpose, and feeling like much better human beings as a result.
As a society, we’ve taken a stance that it’s all about individuals.
As a society, we’ve taken a stance that it’s all about individuals. So, what happens to me is of no bearing to you down the line, but if the problem is something global like pollution, it’s happening to all of us. And it’s not going to change until we all come together to change it, whether it's pesticides in the food, or GMOs, or whatever we’re concerned with today. The killing of all the butterflies with roundup. I mean, who doesn’t love butterflies? They make us happy, and they’re almost gone.
CW: With all of this in mind–the personal, the communal, the political, the butterflies–do you have any self-care practices that help you get through the day?
We sing to the sun every morning and say a little prayer.
LM: Well, I exercise in the mornings. I think that’s really important. We sing to the sun every morning and say a little prayer. I set my alarm to try to take deep breaths every hour because at work, we forget to breathe, and that seems bad. I go to ceremonies. Singing, praying, meditating. Those are some of the things that I do, and try to do with other people. I just try to be with other people.
FURTHER READING BY DR. LEWIS MEHL-MADRONA