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CFP: Pain and its Paradoxes

11 Jul, 17 | by amcfarlane

BMJ Medical Humanities will host a special issue on PAIN in June 2018! We want you to be part of it!

Title: Pain and its Paradoxes
Abstract Deadline: August 1, 2017
Final Submission Deadline: October 1, 2017 (publication date June 2018)

Pain is almost certainly the most common illness experience on the planet. Yet, it is frequently treated poorly, and those who experience pain often endure skepticism, doubt, and stigma for their condition. In most places around the world, pain closely tracks social power structures, which means that marginalized groups are both more likely to experience pain, and are more likely to have it regarded dubiously and treated inadequately.

Moreover, while pain is a near-universal part of the human condition, it remains difficult to define and conceptualize. As Emily Dickinson famously noted, pain has an element of blank. And while pain and suffering are often experienced together, they remain distinct phenomena: some people in pain do not suffer, and some people who suffer state that they are not in pain. Pain is an essential pathway to redemption for many, and for others it exists only as a devastating, hollowing experience that defies meaning. In short, the paradoxes of pain are multiple, varied, and slippery. While pain has not escaped scholarly attention in the medical and health humanities over the last decade, current and inequitable burdens of global pain alone justify sustained focus and analysis. Accordingly, the Special Issue of Medical Humanities on “Pain and its Paradoxes” aims to integrate critical and rigorous scholarship (peer reviewed) addressing the lived experiences of pain, past, present, and future. Specifically, we invite manuscripts on subjects including but not limited to

  • The nature and concept of pain;
  • The history of pain;
  • The phenomenology of pain;
  • Narratives of pain;
  • The relationship between pain and suffering;
  • Pain as an emotional experience (including the history of pain as emotional experience);
  • Pain and anxiety;
  • Pain and sympathy;
  • Pain and grief;
  • Pain and inequalities (race, gender, class, age, disability status, etc.);
  • Pain and disability;
  • Pain and stigma;
  • Pain and pharmaceuticals, including but not limited to opioids

The editors are especially interested in manuscripts considering pain from non-Western contexts.

Interested contributors should send an abstract to EIC Brandy Schillace (bls10@case.edu) and Guest Editor Daniel Goldberg (daniel.goldberg@ucdenver.edu) no later than August 1, 2017. Final submissions should be submitted to the BMJ Medical Humanities online ScholarOne system, choosing the category Special Issue: Pain and it’s Paradoxes by October 1, 2017. All contributions will be subject to rigorous peer review.

Storytelling, Suffering, and Silence: The Landscape of Trauma in Afghanistan and Nepal

4 Jul, 17 | by amcfarlane

Dr Ayesha Ahmad, Global Health Humanities Editor, has been travelling in Afghanistan and Nepal and meeting women who’s lived experience is a conflict of chronic gender-based violence. Her initiatives are to integrate storytelling into mental health trauma interventions globally in contexts of war, oppression of women’s speech, violence towards women and girls, and writing against the backdrop of rich story-telling traditions.

As I write from the heights of Nepal, my vision is engulfed by a globe of surrounding mountains. They stand majestic and solemn into the sky. Carved deep into the mountain hearts are the trails and tracks of their wanderers’ journeys and within them are the graves of the stories that they told. At dawn, the story rose, and at dusk, the story faded.

Peacefulness betrays the legacies that we could find. The stories in the mountains are resting. This is a beautiful silence. There is a freedom in their untouched and unheard voices. Because they lay with the mystery of the mountain’s strength and existence; there is a landscape of stories and a landscape of mountains.

I came here to hold the stories that cannot rest, the stories that are suspended in a silenced captivity in hidden spaces of suffering.

The tragedy of a story is when the storyteller is no longer writing the story that she is living with within her.

The stories I was graciously given were from a women’s safe house, a vast juxtaposition to the wide and open world that her ancestors believed in. Now on her horizon there is no distance to seek, no land to explore, no story being told.

One month ago, I was writing beneath a different mountain in the heart of Afghanistan, but the stories echo, timeless and boundary-less.

It is a strange role to be receiving the telling of a story. I feel an extreme privilege to be surrounded by a story that has not been opened before. When a person gifts their story, it is a journey of exploration. Finding the story of the self creates a landscape, and to bear witness is to discover an unexplored territory, a place within a person’s world that has not been seen before.

The stories that were being shared with me were secrets, secrets in the mountains just like the mountains themselves contained secrets, journeys that no longer held paths to their destination, spaces of pure untouched land.

The tragedy of the story, though, is in its silencing. The stories were like bodies that fell from hidden mass graves, their sufferings and the deaths that buried them deep in silence were marked by injustice, brutality, violence, and isolation.

Even in the speaking of the story, the words that were falling heavy into the air were betrayed by a wounded silence. The story-teller must bear their self to tell their story, but in the diminishing of their identity as a human being, I could feel their burdens, the weight of a wish to be held as a person in their worlds. Underneath these moments where the women became their own storytellers, they were story-sufferers, suffocated by a silenced self and voice.

During the telling of their story, time felt different. Time did not pass by. There was a suspension of the time that had been lost from their lives because of violence; those moments that placed them in the grave whilst still alive and stole their breath away.

Their story became our journey. They travelled with me, we became wanderers through a language that was not ours. We wanted to speak of beauty, of dreams, of hope, but the narrative that had been sewn into their skin told a more sombre tale. Still, we continued, we took each step together through this tough terrain and we found a path through as she held her words like a fence that guided us to a space where she could kneel and touch the ground, and find her land of freedom.

I will carry their words, such precious cargo, from these mountains, cradles and graves, from the women, the silenced storytellers of Afghanistan and Nepal to the front-lines for justice.

There is silence in the mountains. Yet, silence comes from somewhere, from the winds and the valleys across their distance. Silence sounds beautiful when the silence is part of freedom, but being silenced means solitude and stagnancy. A story that cannot travel is a mountain that does not reach the sun.

The suffering of the silenced mountain story-tellers continues; there is silence, but not the absence of a voice or words, there are shadows but not the absence of self, and there are the graves of untold stories, but the mountain and her story-tellers exist together and the stories will wait their time to be told.

Film Activism: Science, Art and Social Reform

30 Jun, 17 | by amcfarlane

Our Screening Room editor, Khalid Ali (Khalid.ali@bsuh.nhs.uk), interviews film director and producer James Redford.

Activism is defined as ‘efforts to promote or direct social, political, economic and/or environmental reform to make improvements in society’. James Redford, documentary filmmaker, producer, and humanitarian uses documentary filmmaking to truly earn the title of a ‘film activist’. I met him in London in May 2017 where he was promoting his latest documentary Resilience: The Biology of Stress and the Science of Hope.

Reflecting on his inspirations for the film, James explains: ‘Resilience contains disturbing information about the adverse health effects of difficult childhood experiences. If I had not encountered something we can do to offset those experiences, I would not have made that film. I would be only displaying the medical basis for bad news. We must understand the biological risks for children exposed to emotional, physical and sexual abuse, neglect, violence or mental illness in their homes.  However, if you provide that child with even one caring, responsible, consistent adult who shows them what it means to be in a loyal, stable relationship with an adult – such as a religious leader, an extended family member, an educator, a social worker, a volunteer, or a police officer with the right training – you can minimize the toxic effects of a bad environment. And that applies globally; qualities of love, compassion, care and connectivity are universal.  In the fall of 2016, I visited The Navaho Nation, an indigenous Native American nation within the USA; I observed how their religious and cultural values reduce the risk of ill health attributed to centuries of oppression and genocide.  In their religion there is an appreciation of healing through family and community gatherings and rituals that supports the mental health of the individual. Chanting religious traditions can have the same healing effect as someone with training in care and compassion. I also showed the film in Columbia, Kazakhstan, New Zealand and now in the UK, and every time I am amazed by the overwhelmingly positive reception due to its universal message’.

When I asked Mr Redford about the conception of Resilience, he stated: ‘The story began in 2012 when I made another film, The Big Picture: Rethinking Dyslexia, in collaboration with Karen Pritzker, a notable philanthropist in the USA who supports many social causes.

Karen was working with educationalists on how to support children with dyslexia but had also known about the little-known Adverse Childhood Experiences (ACES) Theory. The science was there for 15 years, but not widely known. I read the study after she sent it to me, and along with her daughter, producer Dana Schwartz, decided to make the film. The first film we made addressing the ACEs study was Paper Tigers.

It was based on the true story of a high school principal in Walla Walla Washington who employs creative methods in supporting troubled children using the principles of ACES. A year spent at the school with the at-risk teens reveals just how far patience and compassion can go in setting kids on a healthier course.’

James Redford’s interest in using film to explore important medical issues has a personal dimension. After a childhood autoimmune illness caused liver failure, James received two liver transplants in 1993. That experience led him to making The Kindness of Strangers, an interwoven story of real-life organ donors and transplant recipients. James (who prefers to be called Jamie) reflects on his self-discovery journey in hospital wards: ‘I had to go through a lot of mental and psychological tests before the transplant operation. I came to know that having the support of close family relationships was shown to reduce failure rates in transplants. That was my first realization that there is a link between what was happening in someone’s immediate family environment and its effect on someone’s physical health. In America, in the 90s, there was a myth that transplantation medicine was a mysterious world where dark things happen, people were kidnapped, and organs were taken without their consent. I acknowledge that there are black markets for organ donation, but at the same time there is also altruism in its purest form: families who, at the time of losing a loved one, find it in themselves to consent to donate the organs of that deceased loved one. I believe that human beings have it in themselves to do beautiful, charitable things. I am alive because of it. The Kindness of Strangers was embraced by doctors, health care professionals, social workers and recognized organizations. Surviving that personal journey of illness, and recovery was the inception of the James Redford Institute for Transplant Awareness.’

The Big Picture: Rethinking Dyslexia film was another story anchored in James’ personal experience. ‘My son Dylan, who is now a successful artist at 25, was diagnosed with dyslexia at a young age – he was struggling at school as his handwriting and reading did not reflect his intellect or intelligence, so he was often labelled as lazy. Luckily my wife, a life-long educator, knew how to secure the right help for him. Karen Pritzker’s daughter, Allison Schwart, is also dyslexic, and both she and Dylan agreed to discuss on camera how and where to get support and which techniques are most helpful. Assistive technology such as dragon speech, speech recognition software, and autocorrect are terrific and now widely available. Dyslexia is not a moral or character flaw- science proves that underlying anatomical brain differences are the reason for the symptoms of dyslexia. It is important to disseminate these films and show them widely in schools.’

James’ work also reveals a passion for environmental issues. ‘I grew up in a home with parents who were active environmentalists. My father, actor/director/producer Robert Redford, has been a passionate advocate for environmental protection for over five decades. After the box-office success of Butch Cassidy and the Sundance Kid my parents bought a small family resort in the Rocky Mountains of Utah to protect the land from being developed into condominium units. At the time the land had been overgrazed by sheep and the native predators – wolf, coyote, and mountain lion – had been poisoned off the land. Under the protection of my parents, the natural landscape recovered to its original glory. I produced HBO’s Mann V. Ford, a documentary that chronicles a Native American community that was poisoned by the paint waste from the Ford Motor Company. I also directed HBO’s Toxic Hot Seat, a film that looks at the efforts of the United States chemical industry to hide the health risk of chemical flame retardants.’

In order to honor my father’s environmental legacy and to pursue my own, the two of us founded The Redford Centre, a non-profit environmental media company that has been active for 10 years now in accelerating better and healthier environments for all.

In partnership with the Redford Center, I am now completing HBO’s Happening: a Clean Energy Revolution. President Trump’s decision to break our nation’s promise to support the Paris Climate Accord in no way reflects what is happening in America with clean energy. The clean energy economy is booming at the same rate of growth we saw with radio, TV, and the Internet, and I’m hoping that the film will do its part to accelerate that growth even further. With climate change, every second counts.’

Jamie summarizes his mission eloquently: ‘My films and stories discuss problems as well as offer solutions. Through my company KPJR films and The Redford Center, I have the privilege of offering hope and solutions to some of our most vexing social, environmental, and health challenges. Through film we can bring about change, we can fix things – or at least try to do them better.’

Book Review: No Apparent Distress

27 Jun, 17 | by amcfarlane

No Apparent Distress: A Doctor’s Coming-of-Age on the Front Lines of American Medicine by Rachel Pearson, New York: W.W. Norton, 2017, 272 pages, £21.99.

Reviewed by John Coulehan, Stony Brook University, NY

Was there a time before memoirs of medical training became a popular genre of nonfiction?  It’s difficult now to imagine a time before aspiring young physician-writers frequently turned their attention to the slings and arrows of outrageous—but also often sublime—medical education. Intern by Doctor X, one of the earliest first-hand accounts of  hospital training, appeared in 1965. Its lurid description of life in a teaching hospital forced the author to remain anonymous, but the book was eagerly consumed by the public, whose appetite for these stories has grown and multiplied over the ensuing decades. Soon additional memoirs began to appear, and a new genre, the medical bildungsroman, was born. Today Amazon and Barnes & Noble offer dozens of books featuring the personal stories of young physicians. Some of these, like Danielle Ofri’s Singular Intimacies or Atul Gawande’s Complications, are first rate literature; others are merely workmanlike. Some focus mostly on the writer’s internal struggle or character formation; others are explicit in their critique of depersonalization, overuse of technology, or injustice in American medical care.

The plots of medical bildungsromans are pretty standard: an idealistic student enters the maelstrom of medical school or residency training, overcomes obstacles, gains practical wisdom and survives, determined to become an altruistic and humane physician, despite external constraints, like deficiencies in the health care system. Some physician-writers are able to combine these generic ingredients into compelling and provocative stories. To do so requires freshness of insight, a talent for vivid storytelling, and a distinctive voice.

Rachel Pearson’s No Apparent Distress displays all of these qualities in good measure. Dr. Pearson graduated from the University of Texas at Galveston in a combined MD-PhD program, with her PhD in Medical Humanities . The book’s title is an ironic reflection on the traditional medical shorthand, “The patient is in no apparent distress,” or shorter still, the chart entry, “NAD.” As Dr. Pearson makes apparent, there is in fact a great deal of distress among students, physicians, patients, and in the American health care system as a whole.

Aside from the author herself, the book’s  most significant character is St. Vincent House, the site of a student-run free clinic for indigent and uninsured patients. Over 25% of Texans were uninsured in 2008. For those in Galveston, St. Vincent’s (with the motto, “All Are Welcome Here”) was virtually the only available safety net. Rachel began working in the clinic  from her first days in Galveston and continued throughout medical school, eventually serving as a student director. Thus, much of No Apparent Distress is devoted to her education at St. Vincent, which included in-depth learning about the social and cultural context of medicine, and the glaring inequities in American health care. The publisher’s flyer describes No Apparent Distress as “a searing indictment of America’s health care system.” I would not call the book “searing.” Yet, it’s compassionate and hopeful stories of struggling patients teach the reader much more about injustice than searing rhetoric could.

Take the example of Mrs. Klein, who appeared at St. Vincent’s with a large abdominal mass that had been growing for three years.  Dr. Pearson recounts her difficult, but successful, attempt to enlist faculty volunteers to biopsy the mass, interpret the slides, and eventually obtain coverage for Mrs. Klein in Galveston’s indigent care program, allowing her to undergo surgery. Although this entire process required eight months, it was doubly successful because the mass turned out to be benign. Meanwhile, the author describes her experience with the “luxury medicine” that took place nearby, a month long rotation with Doctor Houston whose internal medicine practice featured cosmetic Botox injections, laser hair removal, and “electrode” treatment for diabetic foot pain. This contrast between uninsured and luxury medicine highlights the irony of “no apparent distress.”

Another major theme of the book is uncertainty and error as experienced by a physician-in-training. Like many physicians, Dr. Pearson vividly  remembers her first significant medical error. When evaluating a St. Vincent’s patient, she forgot to report abnormal urinalysis findings to her preceptor. This, in turn, led to an incorrect diagnosis. Several months later the patient was found to be suffering from terminal kidney cancer. The author agonizes over her personal responsibility for the delay in his diagnosis (as I think most conscientious students and physicians would), even though it’s difficult to see how a single urinalysis result would have made a difference to the outcome.

Dr. Pearson relates a number of other instances of hesitation, error, awkwardness, and confusion as she progresses through medical school. As I noted earlier, these are all standard student responses, as are the array of hostile, difficult, engaging, and grateful patients. What makes No Apparent Distress stand out is the author’s ability to bring her feelings and these characters to life. She also has a distinctive voice, an attractive mixture of naiveté, passion, sharpness, and common sense that hooks the reader and makes him keep turning pages. Finally, this memoir is unusual in its focus on efforts to care for the uninsured patient as an integral part of medical education.

No Apparent Distress carries the subtitle, “A Doctor’s Coming-of-Age on the Front Lines of American Medicine.”  This is unfortunate because it evokes the hackneyed war metaphor that the author strongly condemns as contributing to the inhumanity of contemporary American health care. Fighting, battles, front lines—we need less of this violence and more of the caring that Dr. Pearson actually prescribes. So forget the subtitle, but read the book, which is a notable contribution to the medical bildungsroman.

Book Review: Balint Matters

20 Jun, 17 | by amcfarlane

Balint Matters: Psychosomatics and the Art of Assessment by Jonathan Sklar, London: Karnac, 2017, 254 pages, £27.99.

Reviewed by Dr Neil Vickers.

Michael Balint is mentioned in medical humanities circles as a revered ancestor, much as one might talk about William Empson as a significant figure in the history of English literary criticism. Everyone knows they’re important but surprisingly few people read either writer today or even know why they should. (An important exception is Josie Billington’s superb Is Literature Healthy? – reviewed here – which devotes a chapter to Balint.) Empson did theory before Theory, and Balint did narrative medicine before Narrative Medicine. Both men were at least as interesting as what came after them and yet both have become unduly sepia-tinted with the passage of time. Part of the reason for this fading in Balint’s case has to do with the fact that his clinical examples are firmly rooted in the sociological reality of the 1940s and 50s. The world Balint describes is hidebound by class. As a psychoanalytically-minded medical humanist, I occasionally press a copy of Balint’s classic, The Doctor, the Patient and the Illness (1957) on M.Sc students, but always with the caveat about his antiquated case material. ‘Someone should update it,’ I whisper, as they saunter out of the room.

Now someone has updated it. In his new book, Balint Matters, Jonathan Sklar, psychiatrist, psychoanalyst and leader of Balint groups (as well as a leading scholar of Ferenczi’s thinking) has produced a masterly summary of the Balint technique, along with a history of Michael Balint’s contribution to the theory of the doctor-patient relationship in collaboration with his wife, Enid. The second half of the book, entitled ‘Assessment’, which I won’t discuss here could be published as a volume in its own right. Assessing a patient for psychodynamic treatment is a topic on which surprisingly little has been written.

Michael Balint was born Mihály Bergsmann in Budapest in 1896. His parents were descendants of German-Jewish families who had been in Hungary for only two or three generations. (This German-Jewish world of Leopoldstadt is described in a wonderful series of autobiographical interviews that Georg Lukacs gave towards the end of his life, published as Gelebtes Denken). In 1916, young Mihály took the momentous decision to abandon Judaism in the hope of eluding the anti-Semitism that was still rife in Austro-Hungary and changed his name to Bálint (which means ‘Valentine’ in Magyar). He first came into contact with psychoanalytic ideas while a medical student in Budapest. His fellow-medical student and first wife, Alice Szekely-Kovacs, was one of Sándor Ferenczi’s analytic patients. Balint himself held off from having analysis with Ferenczi at first, and following the overthrow of the Hungarian Soviet Republic (which had bestowed a public professorship of psychoanalysis on Ferenczi, a world first) Michael and Alice fled to Berlin in 1919 to train as analysts at the Berlin Psychoanalytic Institute, where both had analysis with Hans Sachs, and where Michael did a PhD in chemistry and physics. The couple went back to Budapest in 1924 and became patients, colleagues and friends of Ferenczi. Balint became Ferenczi’s literary executor and the chief exponent of his thinking in the international psychoanalytic movement for decades. If the rediscovery of Ferenczi has reinforced the air of ‘always the bridesmaid, never the bride’ hanging over Balint, so has the explosion of interest in Winnicott, with whom he has so much in common.

Balint’s main contributions lie in two areas: psychosomatics, understood holistically as the study of the relationship between mental and physical disturbances; and the uses of therapeutic regression, which he explored in his other great book, The Basic Fault (1967). Sklar’s concern is with the first and specifically with the work Balint developed at the Tavistock Clinic in the 1940s and 50s with his third wife, Enid (Alice having died shortly after they arrived in England, to escape the Anschluss). Balint focused his attention on how the doctor’s attitudes and approach affected the course of an illness, and suggested that ‘the most frequently used drug in general practice was the doctor himself, i.e. it was not only the bottle of medicine or the box of pills that mattered, but the way the doctor gave them to his patient—in fact, the whole atmosphere in which the drug was given and taken.’

Sklar offers a number of clinical vignettes from Balint groups he has facilitated, describing how this works in practice. These case histories for me formed the heart of the book. I won’t spoil the reader’s pleasure by describing too many of them but among those that stood out for me was the case of a 70-year-old woman who was addicted to dihydrocodeine, a strong opioid analgesic. The woman had complained of a pain in the hip but a scan revealed only minor osteoarthritis. Her condition never seemed to improve. She made occasional visits to a cousin who lived far away and would ask her doctor for a bumper supply of painkillers to get her through. Then, much against the patient’s will, her daughter visited the GP and told her that her mother never went to see a cousin, and that the story was just a ruse to get more prescription opioids. The GP was appalled to realise that in the course of the previous year she had prescribed more than 3,000 dihydrocodeine tablets to this woman. In discussion with the group, the GP realised she knew nothing about her patient’s history. With a bit of help from Sklar, the group discussion included the following ideas: 1) the patient had an addictive relationship to the doctor; 2) the doctor felt depressed on behalf of the patient; 3) the doctor was unconsciously acting as a container for aspects of her patient’s mind, perhaps playing the part of a distant depressed mother, who gave her daughter ‘the wrong medicine.’ Feeling, noticing and understanding these projections didn’t cure the patient but they did give her doctor more freedom in the way she related to her. Addiction could now be seen as a way of representing early childhood deprivation.

Balint groups have also been used with psychiatrists. Sklar is fascinating on the attempts by some trainees to use Balint groups as a covert form of personal analysis. This arises not least because of the peculiar pressures of working with severely disturbed patients. The kinds of problems many of the trainee psychiatrists brought had to do with the ways in which they were made to carry aspects of their patients’ mental disturbances. Again, to pull out just one example, Sklar describes the case of a young psychiatrist, Dr L, overwhelmed by the suicide of a male patient who had been admitted at his mother’s request, shortly after the latter’s recent remarriage. Dr L bitterly regretted not administering ECT. Perhaps it would have saved him? She was also worried about the effect of the suicide on the other patients on the ward where the man was being treated. The nurses had suggested that a community ward meeting should be convened to break the news. The group listened to Dr L’s anxieties and asked for information about the patient’s history. It turned out that his biological father had killed himself by electrocution. Sklar asked how the ward meeting had gone. It had been fine for the most part though a psychotic woman had to be removed. This woman had told the meeting she was the angel of death and that there would be more deaths. Somewhat to the group’s surprise, Sklar observed that the psychotic woman had voiced what was in effect Dr L’s own worst fear about herself. Here was an instance of the need to listen to the very mad, as barometers of the most split-off emotions in the room. The psychotic woman had been excluded because she was voicing the emotions that were most unacceptable to the group. Dr L then remembered that her patient had killed himself on his mother’s birthday and that her recent marriage was to an electrician. These snippets, combined with the knowledge of the patient’s father’s suicide, shed new light on the hopes she had placed in ECT. They amounted to a re-enactment of the patient’s deep upset over his father’s suicide and at the same time offered a means to shut out and ignore the meaning of the mother’s marriage to an electrician. As a result of this meeting, Dr L softened down her until-then vigorously-asserted opinions about psychiatry’s exclusively organic basis.

For me, the most moving chapter in the book describes Sklar’s work in the early 2000s at a hospital in an unnamed city in South Africa. In 2007, it was estimated that nearly 6 million South Africans had HIV or AIDS, or 12 per cent of the population. This was overwhelming to the medical professions attempting to offer treatment at a time when antiretrovirals were beyond most people’s reach. Thabo Mbeki’s refusal to believe that HIV had anything to do with AIDS licensed widespread denial of the natural history of the disease and its behavioural causes. Of course, the doctors knew how AIDS was commonly transmitted but the overwhelming nature of the incidence of the disease and the need to shield families from stigma meant that patients were often treated as if they were just medically irrelevant dying people. The doctors for whom Sklar acted as a Balint facilitator told him of their anger at the way AIDS patients were treated as undeserving and subhuman. But they also described the primitive fears the disease evoked in the workplace. The whole practice of medicine was at risk of becoming warped by the cultural phantasies surrounding it.

Sklar’s book deserves to be read by anyone who wants to know how to listen to patients with an analytic ear, how to understand the dilemmas of clinical practice analytically, or why psychoanalysis still has so much to offer physical medicine. As his title makes clear, Balint matters, particularly in an environment where doctors and patients are urged to forget about the whole person and focus instead on gross symptoms and quick fixes. As a result of his endeavours, it should be easy for most readers to imagine a Balintian response to many clinical dilemmas. It is even possible that this brilliant exposition of Balint’s thought will initiate a new phase in the reception of this underrated and very fertile thinker, and bring about further extensions of the Balint model of the kind Sklar himself has achieved here.

Book Review: Eros and Illness

13 Jun, 17 | by amcfarlane

Eros and Illness by David B. Morris, Cambridge: Harvard University Press, 2017, 368 pages, £31.95.

Review by George Derk, PhD (gtd2gu@virginia.edu)

With the provocative pairing in the title of his new book, David Morris sets himself the task of dramatically altering the perceived relation between these two terms. As he contends, there exists less of an opposition and more of an affinity between them than we are usually willing to admit. At times, they even seem like bedfellows rather than rivals: “eros and illness both usually send us under the bedcovers” (27). Professor Emeritus of English at the University of Virginia, Morris began his academic career focusing on eighteenth-century literature before turning his attention to the medical humanities. In some ways this new book is a follow-up to and an elaboration of a couple of his previous ones, including The Culture of Pain (1991) and Illness and Culture in the Postmodern Age (1998), but at least one significant difference sets this recent work apart from the rest. Morris draws from his personal experience as caregiver for his wife, Ruth, after she was diagnosed with early-onset Alzheimer’s. It is this model of care, where provider and patient are the most intimate of partners, that allows Morris to explore the neglected dimension of eros in illness.

Morris begins by developing a capacious interpretation of eros, one that cannot be reduced to sexual activity nor to the Roman equivalent of Cupid. He instead derives his understanding of the concept from both the French philosopher Georges Bataille and the Canadian poet Anne Carson, and while he carefully stipulates that eros resists any easy definition, the word that comes closest to naming it is desire. He proceeds with a thorough examination of desire in the context of health care—or what he calls “medical eros”—mostly through illness narratives and doctors’ memoirs. He occasionally supplements these primary texts with analysis of literature and the other arts, as when he discusses the waiting involved in caregiving as akin to the waiting depicted in Samuel Beckett’s most famous play, or as when he finds an affirmation of eros in a series of nude portraits that Amedeo Modigliani painted while suffering from a terminal illness in wartime Paris. What he eventually uncovers amounts to an alternative medical genealogy, a recovery of the ancient figure of Asklepios as the embodiment of the obscured tradition of eros in Western health care. For Morris, the dominant stature of the other ancient healer, Hippocrates, and what he represents—biomedicine, or what Morris terms “medical logos”—has resulted in a reduction of the pluralism of healing practices, inhibiting the effectiveness of treatment for chronic illness.

From a certain angle, the book falls into a recognizable pattern of decrying how science-based, data-driven medicine has lost sight of its core humanistic principles, which I suspect would prompt many health care professionals to respond that the realities and demands of the job only allow for so much empathy and compassion. However familiar Morris’s argument may sound, the frequency with which medical logos runs up against its own limits warrants reiteration. If medical eros seems like some New-Agey solution to the problems of modern health care, it does a lot more good than some of the other reactions, such as over-treatment, that occur when doctors confront uncertainty or a lack of options. Perhaps the more insightful and original contribution of this book, though, is less its appeal to humanize medicine and more its belief that anyone can learn how to care for those who fall ill. Indeed, as Morris suggests with his own transformation from English professor to fulltime caregiver, the innate capacity to provide humane care stems from the eros that one already bestows onto his or her loved ones. The relative absence of Ruth’s story further underscores that this book chronicles the experience of illness not from the perspective of the patient but from that of the caregiver, although at times the boundary blurs. Morris himself becomes a patient after suffering a heart attack, which he attributes to the stress of providing care and which he takes as an example of a “supradyadic effect,” or how one’s health is interdependent on the health of those in one’s social network.

The book, overall, reads like part Bildungsroman of a caregiver and part philosophical treatise on the nature of caregiving. Morris strives to preserve the desire that drew him to Ruth in the first place and sustained them through three decades of marriage. In the face of regret at not recognizing Ruth’s symptoms earlier, guilt for his irritability towards Ruth’s increasing debility, and, most of all, anguish at the terrible inverse logic of dementia (“she was fading emotionally, just when I felt in greatest need of her ordinarily loving expressiveness”), Morris maintains that eros doesn’t necessarily have to evaporate altogether and may actually serve as the greatest resource when medical logos has no answers (39). Along with the personal experiences that he relates, the case for eros is strongest when grounded in specific instances wherein biomedicine finds itself ill-equipped. Morris’s inclusion of the writings from people with non-normative identities—such as the African-American, lesbian poet Audre Lorde who claims in The Cancer Journals (1980) that the “love of women healed me”—proves particularly effective in this regard. Dwelling on the accounts from those at the margins testifies to the potential of medical eros to help remedy the imbalance of treatment for underserved communities. In addition to the benefits made available by eros, the cost of not acknowledging its contributions equates to an egregious oversight. Morris cites an estimate by the American Association of Retired Persons that within the U.S. 36-38 million family caregivers provide $350 billion (approximately £270 billion) in unpaid labor annually.

Yet counterexamples exist to raise questions about this book’s insistence, in its more unrestrained moments, on championing eros as a possible panacea. The anti-psychiatry movement, which Morris overlooks, would seem to embody many of the characteristics of medical eros. For all the necessary reforms that it has lead to, it has arguably been too successful in undermining biomedical treatments for psychiatric ailments. While the dismantling of mental health care results more directly from draconian cuts to funding than from this particular movement, the U.S. continues to live with the legacy of an impaired system of psychiatric care. That said, Morris anticipates an objection such as this by advocating for a balance between eros and logos. His goal, as he states it, is for biomedicine “to recognize eros and to deal with it—the good and the ill—mindfully” (13).

The principal testament to eros that Morris offers may ultimately be the fact that he managed to write this book. While caring for Ruth, Morris admits to feeling drained of his normal passion for writing: “I could write, but writing lacked all pleasure, joy, and desire” (251). As the examples curated by Morris attest to again and again, illness throws eros into disarray. One of the more telling instances in the book involves the poet Jane Kenyon, suffering from end-stage leukemia, who is reminded by her husband that the bed she lies on is the same site of their countless sessions of lovemaking over the years. This is the type of recognition that Morris prescribes, an awareness of how a bed, as object and symbol, stands for the underlying bridge between eros and illness. The challenge of the latter consists of finding new ways to realize the former. The strength of Eros and Illness resides in how Morris models the counteracting of illness by eros through his writing, eloquently giving voice to Ruth, who lost hers, and rediscovering his own in turn.

After the Storm: Liberation and Hope in Later Life

6 Jun, 17 | by amcfarlane

After the Storm (Kore-eda Hirokazu, Japan 2016), in UK Cinemas from 2nd June 2017

Reviewed by Khalid Ali, Screening Room editor

Japan is well known for its relatively traditional social structures, a predetermined life course that heavily influences career choices. Kore-eda Hirokazu’s latest film After the Storm explores those paradigms through the story of Ryota (Hiroshi Abe), a hapless man in his late 40’s who won a major award for The Empty Table, a novel he wrote as a child. However, his adult life is plagued with failure; he is divorced, falling behind on paying his son’s school fees, and abuses his day job as a private detective by blackmailing his clients. Still, his worst enemy seems to be a gambling addiction; a trait he inherited from his recently-deceased father. In contrast, his elderly mother, Yoshiko (Kirin Kiki), is a feisty, strong woman who is trying to get her son’s life back together by scheming to bring him closer to his wife and son. Yoshiko is the perfect model of ‘successful ageing’; she is not a victim of loneliness or social isolation, in spite of being a widow living alone in a council flat. She spends her time listening to music in weekly classes and practises Tai-chi in neighbourhood group sessions; in short she is content with her own company, wisely commenting, ‘Making new friends with people of my age only means more funerals’.  The contrast between the positive life-approach the old woman adopts, and her son’s self-destructive behaviour and bitterness, is remarkable.  The inter-generational bond between Yoshiko and her grandson, Shingo (Taiyo Yoshizawa), is another factor in Yoshiko’s well-being until a typhoon brings the family members together under one roof to candidly face their hidden secrets and prejudices.

Continuing his fascination with ‘father-son relationships’ which was a prominent theme in Like Father, Like Son, Hirokazu delves deeper into negative personality traits such as gambling, contemplating whether inheritance or environmental factors play a more prominent role in the vertical propagation of addictive and compulsive behaviours. Ryota’s father was a pathological gambler who taught his son the rules of buying winning lottery tickets, and Ryota is following in his father’s footsteps by doing the same with his son Shingo as a bonding exercise.

Full of astute observations on ageing, the film upholds family values; having a role in the upbringing of grandchildren is an important dimension contributing to well-being in later life. A study comparing older Japanese and American people showed that personal growth and positive relations with others were highly rated amongst older Japanese people as important factors in psychological well-being. (1)

When asked whether the character of Yoshiko is representative of old people in Japan, Hirokazu states: ‘I try not to think about such big themes when I am making movies. It’s just that the grandmother is a fairly accurate portrayal of my own mother. I wasn’t consciously making her happy, but I was trying to show how she dealt with her “unfulfilled dreams” by “loving the present/now”, and how that was different from the protagonist, Ryota, in dealing with his aborted dreams. I don’t think the elderly people in Japan are happy. When I visit European countries, I always feel that old people there seem so much happier’.

In spite of its focus on positive trends in old age, After the Storm does not shy away from exploring darker subjects such as financial abuse of old people by their close relatives in Ryota’s scams to embezzle money from his mother. Hirokazu thinks that some older people are resourceful enough to deal with such issues in talking about Yoshiko: ‘Knowing she has been lied to, she still goes along with it; that is how she deals with her son. Life is more complicated than simply labelling people as “black or white”. As a director I do not have bad characters, and others who are very critical of them.  I make sure that there are other characters in the story that understand the motivations of the “bad ones”. I think of human beings’ short comings in gradual steps when writing their traits for the screen, so that the audience can warm up to them through a flaw they can relate to. The filmmaker’s position is not to forgive someone’s flaws or empathise with them blindly, but also to be able to laugh at them from a distance.’

After the Storm is a beautiful gem that shines a light on the factors that make some people happy and content; Yoshiko does not dwell on her bereavement; she even breathes a sigh of relief being liberated from her gambling deceased husband.  Her perpetual sense of hope and positivity brought to my mind Emily Dickson’s poem ‘Hope’:

‘Hope’ is the thing with feathers-

That perches in the soul-

And sings the tune without the words-

And never stops- at all….

Address for correspondence: Khalid.ali@bsuh.nhs.uk

Reference

  1. Kaasawa M, Curhan KB, Markus HR, et al. Cultural perspectives on aging and well-being: A comparison of Japan and the USA. Int J Aging Hum Dev 2011; 73 (1): 73-98.

Does Narrative Medicine Have a Place at the Frontline of Medicine?

30 May, 17 | by amcfarlane

This guest blog post is by Liam Dwyer, a postgraduate medical student at Trinity College, Dublin, where medical training encompasses medicine and health as well as humanities, provoking students to conceptualise medicine differently; not simply as a clinical science, but with a more holistic perspective. Here he explores the role of narrative medicine, both in medical training and its practicality in a clinical setting.

While medicine has always encompassed a narrative form, it is only in the past two decades that the study of humanities has begun to eclipse medical training (1–5). It represents a means of developing a skill in interpretive, relational and reflective areas otherwise difficult to teach (6). As espoused by Dr. Rita Charon, it ‘enlarged the evidence available on which to base our clinical actions and the grounds for our therapeutic affiliation’ (7), yet whether its basis represents clinical idealism rather than clinical realism entails further inquiries into the nature of such skills.

It cannot be denied that narrative medicine is met with some opposition. It stems from realistic concerns about the management of time, especially in terms of accessibility for patients. In the current situation, even large university hospitals have systems of managing the multiply-injured patient comparing poorly to international standards (8). Morris et al. reports the rooted dubiety of clinicians about narrative medicine. ‘”What you say about narrative is very interesting,” He has heard repeatedly. “Thanks so much for coming. But I have seven minutes per patient.” End of story’ (9). Furthermore, many patients, especially those who are well-informed, prefer a ‘no-nonsense’ physician who holds the answer (9). Narrative infers an expurgation of professional distance and authority.  A clinician conveying such intimacy may step over the line between paternalism and patient-centred care (10).

A significant discussion surrounding narrative medicine was Dr. Charon’s 2001 article in JAMA, asserting that narrative medicine is a form of knowledge, in terms of being a source and an instrument (11). As a source, it represents something clinically relevant to numerical data of an arterial blood gas. As an instrument, requiring skillful technique for its implementation, like a scalpel (9). Dr. Charon wants certified professional competence and medical training in narrative, advocating ways of thinking about knowledge that are bound to inspire resistance. A biomedicine potentially reformed by narrative medicine is right to see its menacing identity and power. Unlike biomedicine, narrative medicine entirely depends on the concept of inter-subjectivity (9). For narrative medicine to warrant space in JAMA, it needs to accentuate its claim to knowledge, which in the last few years, it has achieved to some extent (12–16). Physicians are beginning to accept the value of what’s absent by the accredited biomedical narrative forms (12–16). Not only medicine but also nursing, law, religious studies, and government have recognized the value of narrative knowledge (11,17).

Medical narrative forms have been established for exploring novel styles of interactions with patients (18). Even clinical trials have begun to be formulated around narrative medicine (19). Numerous teaching programmes have recently been created to enhance narrative competency, such as those at Columbia or  King’s College London, with experts in the area of narratology demonstrating its therapeutic role for patients (9). Authors such as Bury proposed that illness of any kind is a disruption, an adjournment of an on-going life (20,21). When an individual faces an illness, they need to adapt their life story. In this milieu, narrative provides a voice to that disruption (20). Anatole Broyard, a prominent writer for the New York Times, delineated the story of his illness, affirming ‘storytelling seems to be a natural reaction to illness. People bleed stories, and I’ve become a blood bank of them’ (20,22).

Narrative medicine aids doctors in appreciating styles of thought and interaction in medicine that go beyond disease-framed, chronological history-taking (5,23,24). They have been shown to play a key role in making diagnostic assumptions and developing care pathways (25), especially in comprehending the story of those with cancer (26), acute coronary syndrome (ACS), and those with other chronic diseases (25,27). Recently, Gargiulo et al. investigated the psychosocial and organizational aspects of the patient’s journey whilst undergoing hematopoietic stem cell transplantation (HSCT) through various narrative interviews (25). Psychological issues (‘I met many people who are now dead, each person is unique… unfortunately that’s life…’), and clinical issues (‘you might get infected… you might have stomach ache, backache. I had to take many pills every day. I could not eat… I lost 22kg… ‘) were highlighted, leading to more effective care plans for the patients (25).

Yet for narrative medicine to be implemented at the frontline of medicine, its idealistic expectations must be re-evaluated. A number of problems relating to Charon’s way of thinking have been raised. Angela Wood’s essay contests the rationale of the concept of narrative self through her discussion and use of Galen Strawson’s seminal ‘Against Narrativity’ (28,29). It asserts that storytelling is not the sole or most valuable method by which to highlight an individual’s suffering. It calls for the reassessment of the role of the narratee in the narrative process permitting scholars to re-evaluate what it is we do with stories of illness (29).  Also, to think on methods in which narrative may be employed to understand illness and suffering in medical humanities contexts.  Narrativity should be broadened to encompass forms of expression as even non-verbal expression needs language and narrative ordering in the development of expression. In each effort made to elicit an expression of suffering, we demand a cognitive engagement that requires the ordering information into narrative (29). As eloquently put by McKechnie, ‘We seek out communication; we desire the transmission of an idea. This is narrativity and it takes a myriad of forms’ (29). Furthermore, Dr Charon’s development of the parallel chart (30) is a practical and essential part of medical training, designed to increase the student’s capacity for effective clinical work. However, to employ parallel charts in an acute clinical context is far from practical. This method asks doctors, in addition to maintaining traditional records on their patients’ progress, to monitor the emotional toll of the hospital experience. As the healthcare environment speeds up, practice will also speed up, and therefore inter-professional healthcare teams will need a more powerful framework to achieve empathetic and effective collaborative relationships.

Narrative medicine is a promising addition to the current training strategies to prepare medical students for effective performance as resident physicians and practising clinicians, but its effective implementation in an acute setting is a challenging feat. Indeed, resistance to narrative medicine does exist, both with patients and physicians, and will not dissipate. Narrative medicine has gained enough traction that the present time seems appropriate to confront its internal differences. This self-assessment assures not just clarification of its principles, but also of the benefits that extend beyond improved patient care for doctors.

References

  1. Bell SK, Krupat E, Fazio SB, Roberts DH, Schwartzstein RM. ‘Longitudinal pedagogy: a successful response to the fragmentation of the third-year medical student clerkship experience’, Academic Medicine 2008; 83(5): 467–75.
  2. Krupat E, Pelletier S, Alexander EK, Hirsh D, Ogur B, Schwartzstein R. ‘Can changes in the principal clinical year prevent the erosion of students’ patient-centered beliefs?’ Academic Medicine 2009; 84(5): 582–6.
  3. Branch Jr. WT, Kern D, Haidet P, Weissmann P, Gracey CF, Mitchell G, et al. ‘Teaching the Human Dimensions of Care in Clinical Settings’. JAMA. 2001;286(9):1067–74.
  4. Karnieli-Miller O, Vu TR, Holtman MC, Clyman SG, Inui TS. ‘Medical students’ professionalism narratives: a window on the informal and hidden curriculum’. Academic Medicine 2010; 85(1): 124–33.
  5. Hurwitz B, Charon R. ‘A narrative future for health care‘. Lancet. 2015; 381(9881): 1886–7.
  6. Arntfield SL, Slesar K, Dickson J, Charon R. ‘Patient education and counseling: narrative medicine as a means of training medical students toward residency competencies’. Patient Education and Counseling. 2013; 91(3): 280–6.
  7. Charon R. ‘Narrative medicine in the international education of physicians’. La Presse Médicale. 2013; 42(1): 3–5.
  8. Medicine E. ‘An Integrated Trauma System for Ireland’. Irish Association for Emergency Medicine. 2014;(December).
  9. Morris DB. ‘Narrative medicines: challenge and resistance’. The Permanente Journal. 2008;12(1):88–96.
  10. Tauber AI. ‘Patient Autonomy and the Ethics of Responsibility’. New England Journal of Medicine. 2008; 36(1): 148–9.
  11. Charon R. Narrative medicine: A Model for Empathy, Reflection, Profession & Trust. JAMA. 2001;286(15):1897–902.
  12. Zachariae R, Pedersen CG, Jensen AB, Ehrnrooth E, Rossen PB, von der Maase H. ‘Association of perceived physician communication style with patient satisfaction, distress, cancer-related self-efficacy, and perceived control over the disease’. British Journal of Cancer. 2003; 88(5): 658–65.
  13. Hojat M, Louis DZ, Markham FW, Wender R, Rabinowitz C, Gonnella JS. ‘Physicians’ empathy and clinical outcomes for diabetic patients’. Academic Medicine. 2011; 86(3): 359–64.
  14. Soo S, Kaplowitz KS, Johnston M V. ‘The Effects of Physician Empathy on Patient Satisfaction and Compliance’. Evaluation and the Health Professions. 2004; 27(3): 237–51.
  15. Davies K. ‘The information-seeking behaviour of doctors: A review of the evidence’. Health Information and Libraries Journal. 2007;24(2):78–94.
  16. Charon R, Hermann N, Devlin MJ. ‘Close Reading and Creative Writing in Clinical Education: Teaching Attention, Representation, and Affiliation’. Academic Medicine. 2016; 91(3): 345–50.
  17. Swenson MM, Sims SL. ‘Toward a narrative-centered curriculum for nurse practitioners’. Journal of Nursing Education. 2000; 39(3): 109–15.
  18. Murphy JW. ‘Primary Health Care and Narrative Medicine’. The Permanente Journal. 2015; 19(4): 90–4.
  19. Robert Lawrence M. ‘Impact of Early Implementation of Narrative Medicine Techniques on Patient Centered Attitudes of Medical Students’. 2017. ClinicalTrials.gov Identifier: NCT03041571.
  20. Fioretti C, Mazzocco K, Riva S, Oliveri S, Masiero M, Pravettoni G. ‘Research studies on patients’ illness experience using the Narrative Medicine approach: a systematic review’. BMJ Open. 2016; 6(7):e011220.
  21. Bury M. ‘Chronic illness as biographical disruption’. Sociology of Health and Illness. 1982;4(2):167–82.
  22. Broyard A. ‘Intoxicated by my Illness’. Intoxicated By My Illness and Other Writings on Life and Death. 1990: 3–68.
  23. Loudon M. ‘Doctors’ stories: the narrative structure of medical knowledge’. Medical History. 1993: 211–2.
  24. Greenhalgh T. Narrative based medicine: narrative based medicine in an evidence based world. British Medical Journal. 1999; 318(7179): 323–5.
  25. Gargiulo G, Sansone V, Rea T, Artioli G, Botti S, Continisio GI, et al. ‘Narrative Based Medicine as a tool for needs assessment of patients undergoing hematopoietic stem cell transplantation’. 2017; 88(7): 18–24.
  26. Copelli P, Foà C, Devincenzi F, Fanfoni R, Prandi R, Puddu M, et al. ‘The degree of coincidence between the needs of cancer patients and the answers in the statutes of associations and dedicated health services’. Assistenza Infermieristica e Ricerca. 2011;30(1):24–33.
  27. Apostoleris NH. ‘Review of integrating narrative medicine and evidence-based medicine: The everyday social practice of healing’. Families, Systems, & Health. 2012; 30(1): 82–3.
  28. Strawson G. ‘Against Narrativity’. Ratio. 2004; XVII(December): 428–52.
  29. McKechnie CC. ‘Anxieties of communication: the limits of narrative in the medical humanities‘. BMJ Medical Humanities. 2014; 119–24.
  30. Weiss S, Midelfort L. ‘Narrative Medicine: Honoring the Stories of Illness’. JAMA. 2006; 296: 2622–3.

Death By Suicide: The Beginning After the End

23 May, 17 | by amcfarlane

The Levelling, directed by Hope Dickson Leach

On general release in UK cinemas now

Review by Professor Robert Abrams, Weill Cornell Medical College, New York

Even before you view The Levelling, a film written and directed by Hope Dickson Leach, its title gives off a disquieting aura; you feel you are about to enter the maelstrom of a fearsomely destructive force. And so you are. The word “levelling” itself connotes complete destruction or possibly rageful retribution. One can only hope that there might also be a corresponding coda of reconstruction and healing.  The viewer of this film is ultimately witness to both: a saga of suffering known to clinicians as complicated grief, and its protracted resolution, of which some of the details will be outlined here.  But the viewer’s worst fears are realized at the beginning, in the primal mayhem of a drunken party that plays along with the opening credits.

In the next scene a young woman, Clover Catto (Ellie Kendrick), is returning home to the family dairy farm from University for the funeral of Harry (Joe Blakemore), her younger brother. Harry shot himself to death, even though their father Aubrey (David Troughton) insists it was an accident after a night of drinking. Aubrey is indeed a difficult man, described with considerable understatement as “not an easy father.” He is neglectful of animals and indifferent to people, especially it seems, to his daughter. Whenever confrontation with emotion becomes unavoidable, he recoils: “You have to get up, get out of bed, and milk the bloody cows.”

Determined to understand what happened, Clover surveys the flood-ruined wreck of a farmhouse in search of memories. She blames her ostrich-like father for her brother’s unexplained changes of personality, but Aubrey is inured to any suggestion of feeling or loss.

At least in one way her father had got it right. Clover is not a good fit for farm life. She cannot abide the killing of animals or cruelty; she cannot eat them, either; a commercial cattle farm is no place for a person with these sensibilities, even for one training to be a veterinarian. No respect for any form of life and no emotional attachments, whether human or bovine, are allowed in Aubrey’s world.

Father and daughter have been divided, one might say imprisoned, by a mutual feeling of abandonment and injustice. But Aubrey is still the most important man in Clover’s life, hate becoming psychologically equivalent to love once the algebraic negatives are removed. In the Catto family’s no-communication bubble, Clover had hoped for nothing as keenly as to be loved by her father; her father had privately yearned for her to be the one to initiate a rapprochement, had wanted Clover to want to return home, to support her troubled, probably mentally ill brother, and to shore up Aubrey himself as well.

What is the relevance of this film for readers of Medical Humanities? The Levelling deals with a conundrum seen often enough in clinical practice—and also in life: the consequences of suicidal death for the living. Death by suicide entails a double death, exactly as described by the clergywoman-therapist in the film, encompassing both the death of the person and the death of the “person you thought you knew.”  Healing is necessarily intricate, and it is accurately and sensitively presented in this otherwise disturbing film.  The Levelling can be summed up as a chilling depiction of what psychiatrists now consider to be “complicated grief.”  Complicated grief is a syndrome of greater severity, complexity and persistence than ordinary grief.  It is a condition in which the circumstances of the death interfere drastically with mourning.  Thus the survivors must deal first, before anything else, with the traumatic aspects of loss, with shock, anger, and their own sense of injury; this principle applies to the aftermath of a suicide or to any premature or unnatural death. Acknowledging the traumatic aspects of the event itself and then the personal meaning of the death is a foundational precondition for any meaningful process of bereavement.  For now, the clergywoman-therapist tells Clover, “This is about you.”

The melancholic beauty of the music in The Levelling and the camera’s focus on an untidy farm are fitting backdrops to a messy, circuitous and wrenching emotional path to healing from complicated grief. The brilliance of the film lies in its measured manner, the way we slowly become privy to the source of the characters’ anger and sorrow, their journey from death and destruction to a long-delayed but never-too-late recognition of their love for each other. “Levelling” in the end implies a new beginning on an even playing field.

Address for correspondence: rabrams1717@gmail.com

New Editor for Medical Humanities

18 May, 17 | by amcfarlane

BMJ, a leading medical knowledge provider, is pleased to announce Brandy Schillace PhD as the new editor of Medical Humanities.

Dr Schillace is Senior Research Associate and Public Engagement Fellow for the Dittrick Museum of Medical History, College of Arts and Sciences, at Case Western Reserve University, US. For ten years, she managed the medical anthropology journal, Culture, Medicine, and Psychiatry, and edited its first medical humanities special issue. An accomplished medical humanities scholar, speaker and author, she continues to serve as chief editor of the medical humanities and review blog MedHum | DailyDose. Her recent books include the co-edited collection UNNATURAL REPRODUCTIONS, on “monstrous” birth across time and genre (Cambria), DEATH’S SUMMER COAT, exploring cultural approaches to death and dying (E&T UK, Pegasus US), and CLOCKWORK FUTURES, a social history of technology and the “steampunk” aesthetics of invention (Pegasus, US). In all her work, Dr Schillace seeks to uncover the human stories at the centre of science and medicine.

Dr Schillace will take over as editor from Deborah Bowman from 1 July 2017. Welcome to Dr Shillace and thank you to Professor Bowman for all of her excellent work on the journal.

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