Sot. Sci. Med. Vol. 38, No. 6. pp.

171-774, 1994
ElsevierScienceLtd
Pergamon Printedin Great Britain
0277-9536194$6.00 + 0.00

INTRODUCTION

CHERYL MATTINGLY’ and LINDA C. GARRO*

‘Department of Occupational Therapy, University of Illinois at Chicago, Chicago, IL 60680, U.S.A.
and ‘Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada

Contemporary interest in narrative within many
fields, including medicine, has been accompanied by
an intensified preoccupation with narrative as a mode
of thinking. Narrative thinking is often contrasted
with what are variously called abstract, propositional
or scientific modes of thought, for narrative logic
operates rather differently than categorical thinking
[l-5]. It does not “ascend to the abstract” to borrow
a phrase from Bruner [l] but is grounded in particu-
lars. More specifically, it is grounded in the particu-
lars of human action. In Gennette’s [6] memorable
expression, narrative is a “monstrously elaborated
verb.” Narrative is used when we want to understand
concrete events that require relating an inner world of
desire and motive to an outer world of observable
actions and states of affairs.
Narrative offers what is perhaps our most funda-
mental way to understand life in time. Through
narrative we try to make sense of how things have
come to pass and how our actions and the actions of
others have helped shape our history; we try to
understand who we are becoming by reference to
where we have been.
The ‘eventness’ of narrative form is only one of its
defining features. Equally important is its image-rich
quality, its capacity to describe a world through the
evocation of sensory images, to interweave even
contradictory pictures and symbols and thus offer
contradictory explanations in the very same story. It
is not surprising that Ricoeur [7] defines narrative as
an “extended metaphor.” Like metaphor, a narrative
juxtaposes disparate elements that belong together
not by categorical similarity but because they contrib-
ute to the plot. Also like metaphor, narrative offers
a way to contemplate the ineffable, the abstract, by
way of the concrete.
This collection of papers addresses how narrative
offers a way to think about illness, sometimes from
the perspective of the patient, sometimes from the
healer’s point of view, sometimes from the collective
vantage point of a social group. Several papers
address the relationship between an individual under-
standing and a cultural understanding of an illness, as
revealed in the stories people tell. Taken together,
these papers consider how narrative offers a logic for
explaining illness, provides metaphors for under-
standing the experience of illness and places illness
and healing within human time. A number of ques-
tions are explored. What kind of representation of
illness or healing does narrative offer? How does it
differ from other ways of representing illness experi-
ence and the process of healing? Do we see disease,
distress, and disability differently when we hear sto-
ries about them? How do narrative accounts of illness
and healing shape the way illness is understood?
Some observations about narrative representations
of illness and healing recur across this group of
papers. Narratives provide a powerful means for
communicating and giving meaning to experience.
Creating a narrative is an active, constructive process.
Narratives are not limited to reconstructions of the
past, but are used to express one’s present under-
standings of a disorder and may anticipate the future
as well. Social and cultural context informs and forms
narratives. Reflections on social roles, probable
causes, assessments of alternative ways for respond-
ing to illness, and moral commentaries are among
those aspects that may be included.
While each of the papers takes a somewhat differ-
ent approach to the representation of experience
about illness and healing through narrative, there are
many complementarities. We turn now to review
these areas of overlap and divergence.
Three of the papers (Farmer; Garro; Mathews,
Lannin and Mitchell) concern the relationship be-
tween narrative and shared cultural understandings.
While grounding their studies in the illness experi-
ences of individual sufferers, these authors transcend
the particular histories and life circumstances to
representations of shared cultural models. These
authors tend to focus on the reconstruction of past
experience. However, reference to the past is used to
frame the present and anticipations of the future are
implicit in these narratives. Current theorizing about
cultural models in cognitive anthropology provides a
backdrop for their findings.
Drawing on interviews recounting experiences with
chronic jaw problems known as TMJ, Garro exam-
ines how individual reconstructions are situated or
contrasted within shared cultural models of illness,
mind, and body. Narratives provide a vehicle for
confronting the contradictions between an individ-
ual’s experience and expectations based on shared
cultural models, for example, the contrast between

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772 Introduction

one’s history and the model of how an illness should Although there were other sources contributing to the
unfold. Seeking care for a malfunctioning body is emerging discourse on AIDS, Farmer implicates ill-
commonly associated with the discovery of a cause, ness stories as the medium through which shared
a diagnosis, and usually, a treatment, but not in these representations became elaborated and took form.
narratives. When care is sought but events do not Purported characteristics of AIDS were evaluated
transpire as expected, individuals often are also con- within the context of specific narratives. Illness mean-
fronted with cultural models of illness based on the ings emerged and became established through the
mind-body dichotomy and the resulting implications generation and discussion of illness stories. In the
of doubt about the legitimacy of one’s suffering. development of a cultural model, these reflections on
Individuals must also deal with an afflicted body and the illness experiences of known individuals became
the responses to their bodies are framed with refer- interwoven with existing interpretive frameworks,
ence to cultural models as well. Thus, narratives do such as shared understandings about tuberculosis.
more than convey the effect of illness on individual and compatible information from outside sources.
lives. In narratives, the presentation and interpret- Narrative is thus credited with a key role in the
ation of experience is guided and shaped by shared community transition from striking dissensus to con-
cultural understandings. sensus about AIDS. By drawing attention to the
Narrative allows us not only to tell what happens, contribution of narrative in the formation of cultural
but to impart how an event takes on meaning for models, Farmer challenges us to think in new ways
us--to convey the ‘double landscape’ of inner and about the relationship between cultural models and
outer worlds. Although not addressed by Garro, an narrative.
example of this from her paper is a very short account Mention of narrative or literary theory is absent
from one woman about a doctor who looked at the from these three papers. The remaining papers in this
narrator as though she were “nuts” when she dis- collection (Mattingly; Jackson; B. Good and M.
closed that she was receiving treatment for TMJ. Good; Hunt; M. Good et al.) focus more explicitly on
Narratives are also highly metaphorical accounts, narrative as offering a plot structure, or multiple plot
laden with connotative images. To use the same structures, for understanding the nature of the illness
example, this account imparts a vivid image of sudden and for placing the illness within a possible future of
marginalization, the withdrawal of support from a social action. These papers draw upon theories of plot
trusted doctor, a doctor trusted in part because he has and theories of reader response to consider how
supported and believed in her. narrative shapes the future as well as the past.
In recent years, there has been a growing interest Mattingly observed interactions between an occu-
in metaphor and imagery by cognitive anthropolo- pational therapist and a brain-injured patient. Her
gists as can be seen in Mathews, Lannin and paper examines story making---the creation of narra-
Mitchell’s paper on narratives of southern black tive within clinical time-rather than story telling.
women with advanced breast cancer. The vivid im- She looks at therapeutic interaction as the formation
agery and metaphorical entailments present in how and negotiation of a therapeutic plot. arguing that
these women talk about lumps and their appropriate occupational therapists actively try to create certain
treatment is part of an indigenous model of health kinds of clinical plots, to make certain kinds of
emphasizing balance in the blood. Although this was therapeutic stories come true and to persuade patients
not the only explanatory framework present in these to become partners in this therapeutic story making.
narratives, it was the one with which these women Mattingly’s paper provides an introduction to nar-
were most conversant. Popular American notions rative theory and suggests areas of converging interest
about cancer and biomedical understandings rep- with medical anthropology. Her paper introduces
resented other sources of knowledge. The principal themes present in the remaining papers, particularly:
concern of this paper is how these women draw upon (a) the role of narrative in prefiguring expectations
these three different, and often conflicting, models in about the future; (b) narrative as a social and pcrsua-
their narratives. While the individual accounts were sive tool for convincing others (and onesclfl about the
highly variable, Mathews, Lannin and Mitchell view salience of particular illness or healing stories; and (c)
narrative as a window on the processes, including narrative as a way to understand present experience
their cognitive implications, involved in adapting which is strongly marked by the possible, by an only
personal experience to pre-existing explanalory partially revealed future.
frameworks. Two of the papers (B. Good and M. Good; Jack-
Farmer poses a different question, namely, how do son) converge on the active, sense-seeking dimension
these shared cultural models come to be established of narratives. These authors emphasize the fluidity
in the first place? While he is specifically concerned and multiple interpretations of narratives told in the
with the emergence of an explanatory framework for present and their mediating role between past and
AIDS in Haiti, his observations may illuminate simi- future. They reveal an ambiguity of narrative reading
lar processes for other new illnesses, for example, the that allows a number of possible future outcomes to
relatively recent appearance of maturity onset dia- be envisioned, While in Jackson’s research with
betes in many areas where it did not previously exist. chronic pain patients, this fluidity was relatively rare,
 Introduction 173

B. Good and M. Good found it to be common among which thwarts the central biomedical narrative, the
the Turkish epilepsy stories they heard. Both of these war on cancer cells that the physician is trying to
papers examine how telling stories about illness offers wage. Physicians also use narrative to assert pro-
an opportunity to read that experience through a fessional power with patients by painting alternative
number of different interpretive lenses. These two narrative scenarios in an effort to persuade patients
papers also highlight the centrality of narrative point to comply with recommended treatments. In contrast
of view in structuring the meaning of the text. to the papers by Jackson and B. Good and M. Good
Jackson’s paper explores how narrative ambiguity where multiple perspectives frame potentialities, the
is introduced when the narrator assumes different narrative frames in Hunt’s paper serve to limit inter-
personas in the course of a single interview. She pretive possibilities, but in so doing, allow physicians
connects a particular narrative form which she calls to maintain an open vision of their clinical work,
a “shifting persona narrative” to the structure of both present and future.
treatment. In the chronic pain facility where she The form and content of therapeutic narratives as
carried out her ethnographic study, staff members shaped by cultural context is explored by M. Good
used a confrontational treatment approach, one that et al. Illuminated by an intriguing comparative per-
tended to oppose the view of the staff person against spective from Japan, this paper centers on American
that of the patient. While she found that most of her oncologists and the distinctive narrative strategies
interviewees’ narratives were built around a single involved in plotting time horizons for their patients.
consistent voice, a significant minority of those inter- In contrast to the narrative projections of the occu-
viewed told stories that allowed a consideration of a pational therapist observed by Mattingly which are
number of contradictory explanations of pain. She oriented to the patient’s possible future, the oncolo-
argues that this contradiction was manifested gists studied by M. Good et al. strive to create an
through the adoption of multiple perspectives. Her experience of immediacy, of living in and for the
paper illustrates how shifts in point of view can occur present. Conveyed through contrasting metaphors,
within a single story producing what appear to be these narratives instill hope without encouraging false
contradictory interpretations of the illness experience expectations by placing therapeutic activities within a
in a way that allows the narrator to keep open an meaningful context oriented toward the present while
array of potential readings. blurring endings and leaving the future ambiguous.
B. Good and M. Good highlight one particular While the biomedical subplot may become more
aspect of the Turkish narratives they elicited, the explicit when death approaches and treatment is no
‘subjunctivizing’ capacity of these narratives to hold longer an option; in other instances, therapeutic
the ending in suspense. Many of those they inter- actions may continue with endings remaining incon-
viewed were deeply invested in maintaining an open- clusive or absent from the narrative. In America, the
ness toward the future, in continuing care seeking and construction of an ending resulting in death requires
hoping for positive outcomes of the illness. They told oncologists to make a pivotal and often difficult shift
stories that left the ending unfixed. In analyzing these in their narratives.
narratives, B. Good and M. Good draw from reader The contributors to this collection bring diverse
response theory, particularly the work of Iser [8]. This perspectives to an understanding of narrative rep-
paper examines narrators as both tellers and readers resentations of illness and healing. By emphasizing
of their own illness stories, blurring the boundaries different aspects of illness experience and its represen-
between telling a story and living one out. The stories tation through narrative, these papers attest to the
contained in this paper are in an important sense multiple ways in which narrative both conveys and
unfinished, for they concern illness experiences that creates meaning. As a group, these papers show how
are still unfolding. narrative offers a distinctive way to think about
The final two papers (Hunt; M. Good et al.) both illness and healing. Impacting on both individual and
raise the issue of professional power in creating cultural representations, narrative provides a means
clinical meaning. Coincidentally, both deal with on- for exploring how constructions of the concrete and
cologists, but in settings which differ markedly in the personal are grounded in culture, as well as how
terms of access to biomedical technology and fiscal individual accounts of illness transform or create
resources for treatment. In a context characterized by shared knowledge. Narratives also provide an avenue
technological and financial constraint, Hunt shows for linking, albeit sometimes tentatively, an inner
how physicians draw upon multiple and disparate ideational and emotional world with an external
narrative plots to explain outcome in particular cases. phenomenal world of actions and circumstances. And
Especially when illness course does not conform to while narrative is central to reflections on and con-
the biomedical plot, Hunt shows how alternative structions of past experience, it is equally important
narrative frames, foregrounding attributes of econ- in configuring present and future experience.
omic context or perceived patient characteristics, are
used as a means of exculpation and justification for
Acknowledgements-Most of the papers in this collection
the physician’s actions. It is the patient or the necess- were originally presented at the 1990 American Anthropo
ary reliance on less effective or inadequate treatments, logical Association Meetings held in New Orleans at a
174 Introduction

session jointly invited by the Society for Cultural Anthro- 2 Bruner J. Acfs of Meaning. Harvard University Press,
pology and the Society for Psychological Anthropology. Cambridge, MA, 1990.
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provoking comments on the papers. Bringing together this Knowledge. Manchester University Press, Manchester,
collection was a collaborative effort. The work on this paper 1984.
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order of authorship simply alternated on the two parts. Cornell University Press, Ithaca, New York, 1980.
7. Ricoeur P. Time and Narrafiue, Vol 1. University of
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