Our starting point for our discussion of the ethics of caring might seem an obvious one—that caring is essentially a relationship between two or more people—but the obvious will only take us so far with regard to the basis of caring and what a ‘caring relationship’ consists of. It is these sorts of issues that we will address here and, in so doing, we will attempt to address some of the challenges of postmodern thinking to our view of self and ethics.
Much of current healthcare ethics can be seen as part, albeit a very minor part, of the project of modernity that, amongst other things, seeks to establish universal morality. To see that this is so, we need only look at principlism as an ethical framework in healthcare. The fact that Principles of Biomedical Ethics is now in its sixth edition (Beauchamp and Childress, 2008) is testimony to the impact and importance of this approach and the claims of its supporters that the principles are universal, simple, accessible, and culturally neutral, embrace a common set of moral commitments, cluster together a common set of moral issues, and generate a common moral language (Gillon, 1994).
Postmodernism contests such universalist assertions and has had tremendous significance in contemporary thought through its unsettling and disruption of tightly held modernist ideas. Moving away from structured theory and methodology, postmodernism is characterized by multiplicities—of interpretation, beliefs, narratives, attitudes, and so on. In terms of ethics, this involves opposing a collective and prescriptive ethics in favour of a more flexible, contextual approach.
In his book Postmodern Ethics, Bauman (1993) charts the implications of such an ethics. With Levinas, he identifies relationality as the particular beginning for ethics, that relationship being between the Self and another who is radically different and thus fundamentally unknowable, the other. He notes that:
Given the ambiguous impact of the societal efforts at ethical legislation, one must assume that moral responsibility—being for the other before one can be with the other—is the first reality of the self, a starting point rather than a product of society.
(Bauman, 1993: 13)
For Bauman, a postmodern ethics embraces the ambivalence that marks all moral encounters, and calls for a restored sense of the Self’s responsibility to the other. This is not an appeal to moral relativism, but instead an emphasis on responsibility as the basis of social relationality.
From this starting point, we will attempt to outline of an ethics of caring. In order to make this argument we will need to lay some philosophical foundations, for which we will draw on the work of Levinas regarding the relationship of the Self and the other and the work of Deleuze and Guattari on arborescence—thinking that is hierarchical, linear, and centred—and rhizomatics—thinking that is horizontal, nonlinear, and decentred (see Deleuze, Guattari, and Personhood). In laying these foundations we will argue that Levinas’s philosophy is ideally suited to the practice of medicine and the rhizomatics of Deleuze and Guattari relevant to our pursuit of person-centred caring.
Having presented our philosophical framework, we will turn to how caring as an approach, demeanour, a habit of mind, and an orientation to the world and others might manifest itself. We shall argue that a narrative approach to care is suited to this orientation in that it can accommodate Levinas’s notion of alterity—namely the radical difference of the other, a difference that cannot be subsumed into the Self—and Deleuze and Guattari’s lines of flight—that is, ways of escaping from or challenging standardization—through the idea of personhood as a process of becoming. As such, a narrative approach to care expresses a commitment to and solidarity with the other, as found in some of the writings on personalism. This returns us to a consideration of ethics as based on contextualized relationships, moral imagination, fluidity, personal commitment, and solidarity with the other.
All of this is risky stuff as, we shall argue, it implies the giving up of established frameworks of ethical reasoning, taking direct and personal responsibility for navigating the frequently choppy waters of individual lives, and being willing to take risks on the basis of story. We believe, however, that this is both the ethical and the caring way to travel.
Over the years, a number of authors have undertaken concept analyses of ‘caring’ (McCance et al., 1997; Sourial, 1997; Brilowski and Wendler, 2005). While each of these has a slightly different focus, there seems to be some general agreement that caring involves: a moral stance; being in relationship; presence or genuine engagement with the other; and an appreciation and acceptance of the individuality of the other and his or her lived experience.
These features of caring are resonant, unsurprisingly, with Noddings’ work on the ethics of care/feminist ethics (Noddings, 1984) but also with the ethical framework of personalism (see, e.g., Schotsmans, 1999). Both of these approaches have something important to offer our understanding of caring, but, equally, both have limitations that result in being only able to take us so far. Noddings, we think rightly, stresses the relational nature of caring, its focus on concreteness, uniqueness, and communication. But for Noddings, caring is primarily a one-way process: the one caring and the cared-for, with the only person benefiting from the relationship being the cared-for (Hassan, 2008). Furthermore, Noddings argues that the one caring does so out of a sense of duty or that caring is a natural trait, implying that failure to care is thus a failure of either or both. These dual problems are, as Hassan (2008) has identified, potentially harmful to the one caring. The former may prompt one to sacrifice one’s own sense of morality to that of the other, an abandonment of Self in some respects; the latter may result in a negative self-perception if one fails to care. On the other hand, drawing on the work of Levinas (1961) allows us to utilize the insights of the ethics of care—concreteness, uniqueness, and communication—while avoiding, if we are careful, the dangers suggested by Hassan.
The strengths of personalism lie in its focus on human dignity, uniqueness, and solidarity (Schotsmans, 1999). These three facets of ethical behaviour foreground the role of the social in the nature of caring, both by indicating how the social influences and maintains the uniqueness of individuals and in placing this interaction within a wider social context. This sociality does not emphasize inherent capacity as some authors do (Harris, 1985; Brock, 1993), but the relationship between the Self and the others, what Schotsmans (1999) calls solidary responsibility. In taking this approach, Schotsmans endeavours to provide a philosophical foundation for personalism—a framework with which generally we agree. The personalism of Schotsmans, however, is, we believe, limited by its reliance on universalist norms as framing its teleological approach—an approach resonant with Aristotle’s notion of human flourishing—and an incipient utilitarianism. In seeking to address these limitations, we will draw on Deleuze and Guattari’s notions of rhizomatics and becoming (Deleuze and Guattari, 1987).
Levinas, the Self, and the Other
Current healthcare ethics tends to fall into what in Levinasian terms is called a totalizing discourse, that is, a discourse that seeks to frame that aspect of life with which it is concerned in a certain way, using concepts, policies, procedures, and so on that undermine, marginalize, or exclude alternative ways of thinking about the matter in hand. Healthcare ethics currently places primacy on medical knowledge and the concomitant application of a priori principles, often found in the ethical framework of principlism, especially those principles developed and promoted in the series of editions of Beauchamp and Childress’ Principles of Biomedical Ethics (2008). This approach is limited, however, as it promotes a version of autonomy limited by methodological individualism, of the patient in healthcare encounters, rather than recognizing the personhood of that same individual, a personhood, moreover, that is both dialogical and social.
Levinas offers an approach to ethics that is distinctly different to that of the predominant models of principlism and scientific knowledge (Levinas, 1961). Discontent with much of western philosophy’s negative attitudes toward the other, Levinas identified a uniquely ethical relationship between the Self (or, for our purposes, the healthcare provider) and the other (again, the patient). This relationship is marked by difference and a recognition that the other cannot be reduced to the Self as both entities are completely separate. This radical difference is what Levinas terms alterity.
Levinas conceives of the Self as a unique, but not fixed, entity that experiences the world with pleasure and interest (Davis, 1996: 43). It assumes itself to be both powerful and free—that is, until it comes into contact with the other. Faced with the other, this egoistic spontaneity is called into question as the Self is no longer in unique possession of the world. The encounter with the other disrupts the egoistic power and freedom of the Self and forces certain unavoidable decisions upon the Self. On the one hand, the Self can attempt to impose itself onto the other, by insisting on the correctness, applicability, and acceptance of its worldview, interpretations, concepts, definitions, beliefs, attitudes, and behaviours. This, according to Levinas, would constitute an act of violence: ‘To reduce the other who calls me as a unique self in the face-to-face to a set of a priori moral principles is a violence to her alterity’ (Robbins, 2000). Alternatively, the Self can respond with a sense of responsibility and obligation toward the other in all his or her otherness (Schotsmans, 1999).
This encounter with the other is a far more fraught experience than might initially be thought, for it is in this encounter that the Self’s presumptions of the world are seriously challenged. The Self must come to terms with the complete separateness of the other, and this, for Levinas, is the site of ethics: ‘The strangeness of the other, his irreducibility to the I, to my thoughts and my possessions, is precisely accomplished as a calling into question of my spontaneity, as ethics’ (Levinas, quoted in Davis, 1996: 36). To describe it another way, the ethical experience with the other involves looking into the vulnerability that characterises the other’s Face with our prior assumptions of our own power, and realizing that the call of the vulnerable other, as it is expressed in the Face, is ultimately a plea ‘Do not kill me’ (Benso, 1996; Schotsmans, 1999).
Our encounter with the Face provides us with the opportunity to become truly human, as it is in this encounter that the good of the Self and the good of the other coincide. Sokolowski articulates this with regard to medicine thus:
in the important arts, and specifically in the art of medicine, the goodness of the art will help shape the character of the person who practices it, because it will form him into someone who seeks the good of another as his own good. It will help the physician to be excellent not just as a doctor but as a human being.
(Sokolowski, 1989: 269)
Furthermore, given the uniqueness of the ethical encounter—that is, the encounter between this unique Self and this unique other, at this time, in this place and under these circumstances—the Self and the other are opened up to a multiplicity of possibilities. This multiplicity is what Deleuze and Guattari (1983) call ‘lines of flight’ (see Deleuze, Guattari, and Personhood), in which human beings are not tied to fixed patterns of being, but are free to construct and reconstruct themselves in accordance with desire and in response to their circumstances. This can occur over the entire trajectory of a person’s life; therefore, ‘becoming’ is a never-ending task, one that is continually stimulated when the Self meets the other, and vice versa. It is this notion of personhood as processual, fluid, and dynamic that we explore in the next section.
Deleuze, Guattari, and Personhood
In the previous section we have tried to set the foundations for a framework for an ethics of caring, drawing on a number of concept analyses of caring and the work of Levinas. These two lines of thought converge in their respective concern for the uniqueness of the other and the nature of the relationship between the Self and the other. We want now to add to this a generative or dynamic dimension through grafting on the notion of becoming, as found in the work of Deleuze and Guattari (1987), which is interesting in two respects. First, by calling into question the modernist western ways of thinking and knowing, they call into question some of modernity’s taken-for-granted certainties and thus open up the possibility of thinking and knowing differently; and, second, by emphasizing difference and becoming, they call into question the repetition of personhood inherent within much of current patient-centred care. These two challenges can be explored using the contrasting metaphors of the tree and the rhizome.
Deleuze and Guattari use the term arborescent or arboreal (that is, tree-like) to refer to western ways of thinking, acting, and knowing that have emerged since the Enlightenment. Such structures of thought are linear, hierarchical/vertical, fixed, and deeply rooted. In this light, late modern personhood is seen as the result of the process stemming from the discovery of the individual in the eleventh and twelfth centuries (Morris, 1987), and emerging from the Enlightenment possessive individualism of Locke and Hume to a humanistic conceptualization of personhood as individual self-ownership, rooted in that individual’s history and personality, consistent, and internally and externally coherent, and framed within a sociolegal discourse of rights and citizenship. This conceptualization allows authors such as Radden (1996) and Dembo (2010) to argue that mental illness disrupts or interferes with personhood or dissolves it entirely (see also Lysaker and Lysaker, 2002), and it is the basis for much current psychiatric practice that charts mental illness along chronological lines, commencing with assessment and diagnosis, through treatment, to cure, remission, or management, dependent upon the prognosis. In Deleuzo–Guattarian terms, this can be seen as a form of territorialization, that is, the colonization of the Self in schizophrenia by a discourse that demands unity, order, coherence, hierarchy, and linearity. For Deleuze and Guattari, the Self is constructed within three strata: organism, significance, and subjectification. The first points to the necessity to be organized as a body, the second to being interpreted through hierarchical language, and the third to the requirement to become a clearly identifiable, singular Self (see Markula (2006) for a discussion of these strata). Davidson and Shahar echo this arborescent tendency on the part of psychiatric discourse when they write:
to the degree to which current psychiatric practice identifies, isolates, accentuates, and consolidates deficit and dysfunction, it compounds the loss of self brought about by the illness. It reduces a person who is struggling with an illness to nothing more than ‘a mental patient’
(Davidson and Shahar, 2007: 244)
The Self that serves as the benchmark for assessing such deficits ‘is characterized as some inherently “rational”, “stable”, “unified”, “self-determining”, and “transcendent” “thing” that is able to represent “reality” “as it is in itself”’ (Roberts, 2006: 192)—an arborescent self.
In contrast, rhizomes are nonlinear, horizontal, noncentred, anarchic, and nomadic. Rhizomes are defined by their connections rather than their roots and spread horizontally across time and space. Unlike trees, rhizomes do not have a defining form—they can take any shape or direction and nodes can be connected to any other nodes. Transposing this image to how personhood might be conceived, we have an image that is one of multiplicity:
This vision—the narrative self as a postmodern story—is related to the postmodern idea that the self has no stable core but is multiple, multivoiced, discontinuous, and fragmented … From this viewpoint, the self is not something that is inherently given, is fixed, or has one core. On the contrary, the self can be compared with ‘a buzzing beehive so agile and inconsistent, we can barely keep track of it’ (Rosseel, 2001).
(Sermijn et al., 2008: 637)
This Self defies subjectification, that is, the requirement for a clearly defined, singular identity (Markula, 2006). Furthermore, personhood can be seen as a process of becoming through connectedness. It does not rest at or in any particular node of the rhizome but travels the spaces between such nodes. As such, personhood can be seen as being in a state of permanent becoming, as nodes are added to the rhizome and new pathways navigated.
This notion of becoming is also central to the work of Deleuze and Guattari who argue that rhizomes are the outcome of struggle between ‘lines of articulation’ and ‘lines of flight’. Lines of articulation seek to establish unity, coherence, and stability through the setting of rules, establishing explanations, ordering and categorizing, and defining centre–periphery relations. The processes of articulation establish personhood through framing individuals as conforming to the demands and expectations of ordered classifications, such as ‘heterosexual parent’, ‘good employee’, and ‘effective manager’, or, for our purposes here, the ‘person with capacity or insight’, or ‘compliant, co-operative patient’, or even ‘person with schizophrenia, borderline personality disorder, or depression’. For example, we see these articulations in much of the writing on personhood and dementia, where ‘personhood’ is attributable only to those who have capacity, self-awareness, and a sense of future interests. Witness Brock:
I believe that the severely demented, while of course remaining members of the human species, approach more closely the condition of animals than normal humans in their psychological capacities. In some respects the severely demented are even worse off than animals such as dogs and horses, who have a capacity for integrated and goal directed behaviour that the severely demented substantially lack. The dementia that destroys memory in the severely demented destroys their psychological capacities to forge links across time that establish a sense of personal identity across time. Hence, they lack personhood.
(Brock, 1993: 372–3)
We want to suggest that in psychiatric care, one such ‘line of articulation’ is that of ‘person-centred care’ (see, e.g., Department of Health, 2005; Cox et al., 2006). Taking Kitwood’s (1997) notion of person-centred dementia care as an example, we see a focus on the ‘person behind the dementia’ and a range of practices that have arisen to protect and maintain that person from the ravages of dementia—life history, reminiscence, psychotherapy, maintaining previous relationships, interests, and activities, and so on. These activities, and the philosophy of person-centred care generally, posit an arborescent personhood prior to the dementia, a personhood or identity that is in some (unarticulated) way related to memory, relationships, and past behaviours, that can be, through skilful management, protected and maintained. In so doing, such care seeks to establish, or more accurately reproduce, the unity, coherence, and stability of the personhood that it posits as being behind the dementia. This notion, we believe, can also be found in the psychiatric literature when it is argued that mental illness interferes with and/or detracts from personhood (see, e.g., Dembo, 2010), a unified identity, or authorial subject (Radden, 1996, 2003), or undermines the agency that is required for the unity of the autonomous person (Kennett and Matthews, 2004), a thesis again dependent on the positing of a desirable, unified personhood.
This notion of reproduction, or perseveration in Deleuzian terminology, is important as it suggests that the ‘reality’ of the person behind the condition or illness can be reproduced through a series of technologies, whether these be pharmaceutical, psychotherapeutic, or sociocultural. This reproduction of personhood is then taken for the reality of personhood—that the personhood produced through person-centred care is taken as being that original personhood that the condition or illness threatened to obliterate. Just as the map of the Empire in Borges’ On Exactitude in Science (1960) sought to replicate the world point for point, person-centred care seeks to replicate an individual’s personhood prior to the onset of the condition. This replication, of course, is, to use Baudrillard’s term, hyperreal, an image without the substance or qualities of the original:
It is no longer a question of imitation, nor of reduplication, nor even of parody. It is rather a question of substituting signs of the real for the real itself; that is, an operation to deter every real process by its operational double, a meta-stable, programmatic, perfect descriptive machine which provides all the signs of the real and short-circuits all its vicissitudes. Never again will the real have to be produced.
(Baudrillard, 1983: 170)
The illusion that person-centred care creates through its attempts at replication is then taken as a manifestation of the real—personhood is that which person-centred care maintains and protects. As Cypher and Higgs (2001) say: ‘the boundary between artificiality and reality will become so thin that the artificial will become the centre of moral value. ’ Person-centred care thus becomes an exercise in the management of living—embedding an individual within a series of networks focused on maintaining an illusory ‘person’ behind the dementia.
Lines of flight, on the other hand, seek to make connections across borders, disrupt established lines of articulation, dissemble unity and coherence, and thus open up possibilities for becoming ‘other’ and for multiplicities (becoming variegated others). We can see these lines of flight reflected in developments such as: queer theory, which contests essentialist and heteronormative categories of identity, asserting that identity is multiplicitous and ever-changing, never reducible to a fixed essence (Butler, 1989); crip theory, which transforms ‘the substantive, material uses to which queer/disabled existence has been put by a system of compulsory able-bodiedness …[and] imagining bodies and desires otherwise’ (McRuer, 2006: 32); or the experimentations of Australian performance artist Stelarc, who challenges notions of fixedness in arborescent thinking by breaking down traditional conceptualizations of the unity and stability of the body through performances such as his third, mechanical arm project or the grafting of a third ear onto his arm (Gibson and Smith, 2005).
Lines of flight, or rhizomatics, focuses on multiplicities, and in terms of personhood this means seeing personhood as a process of becoming through association with, and relationship to, the world and Others (see Goodley (2007) for a discussion of rhizomatic parenthood). Personhood is thus fluid, contingent, and dynamic, a process or performative act made real (or unreal) in each and every interaction.
It is at this point that we want to revisit the notion of caring and to offer a framework for an ethics of caring, cast in the light of Levinas and Deleuze and Guattari. We here outline certain features, explicating their relevance for the professional–patient relationship.
Caring is a relationship framed within the obligatory response to the vulnerability of the other. This is more than a ‘duty of care’ as it involves the ontological Self, not simply the professional Self. Caring is also a unique and personal response—the encounter being between this Self and this other at this time and in this place. Universalist concepts, principles, or codes of practice cannot substitute for the uniqueness of this ethical encounter. This response is predicated on a ‘generous impulse’ toward the other, which is in turn based upon a desire not to fulfill the Self’s own lack, but on the continual difference of the other (Clifton-Soderstrom, 2003: 452). This generous impulse toward the other can be said to express itself in three distinct ways: (1) to help people live as well as they can; (2) to enable them to become who they may become without ‘fixing’ their identities into preconceived notions; and (3) to respect, maintain, and promote personhood.
Fundamentally, caring involves acknowledgement of the primacy of alterity, or the radical difference of the other. The emphasis of the relationship is not on knowing the other and so pulling them into the Self, but on maintaining the other’s alterity while ethically responding to them in a way that upholds their humanity. Greenwood (2007) notes, ‘This relational approach to providing care is based on the recognition that people involved in all aspects of health care are ‘other’ and separate from the assumptions and pre-conceptions that are made by those that make and implement health policy’ (p. 224). This focus on alterity rejects the imposition of predetermined concepts, definitions, expectations, and trajectories. To treat a patient solely within imposed medical categories is to do that person violence, as it does not acknowledge the radical alterity of the other.
This recognition and acceptance of alterity, and the willingness to engage and work with it, is, we suggest, an expression of Schotsmans’ (1999) solidary responsibility toward the other. This is accomplished by accepting that the encounter is not founded on knowing the other, as this is impossible due to the other being completely separate and unable to be ‘subsumed under the confines of knowledge’ (Clifton-Soderstrom, 2003: .450). Solidarity therefore upholds the difference of the other while at the same time indicating support of and commitment to the other’s needs.
The caring relationship demands certain virtues and attitudes on the part of the practitioner: humility in admitting the other’s separate existence, compassion, and the willingness to accompany the patient through his or her troubles. As Lavoie et al. point out:
Goodness and compassion are not without echo in the current practice of care, where appropriate. In the presence of the patient’s suffering, it means welcoming the other and showing sensitiveness towards his or her suffering. Is this not what a “caring” attitude is all about?
Caring for the practitioner means more than administering to specific needs: it entails interacting with the other with empathy and due concern for his or her emotional and mental as well as physical welfare.
Caring involves aiding the other in his or her line of flight and helping the other find a way to live well and meaningfully. Thus caring involves the appropriate expression of that line of flight and this might include nonorthodox, nontraditional ways of relating to and treating the other. As Clifton-Soderstrom (2003) comments, ‘The need for patient voices is a response to modern medicine’s imposition of scientific language on illness experiences which universalizes persons into general categories before understanding their specificity’ (p. 459). The voice embedded in the patient’s Face allows his or her narrative to come to life and to influence the shape of the healthcare provider’s responsibility. This gives patients an important role in their own medical experience, bringing them into a meaningful discourse with their illness and with the people who are attempting to help them.
Finally, caring requires the realization that the good of the practitioner and the good of the patient are inextricably linked. Though the caring relationship is asymmetrical, with one person responsible for administering certain types of care, this does not mean that one person is in a higher position than the other or that they should expect any privileges. Levinas dismisses any expectations of reciprocity within this relationship. There remains, however, a persistent power in the other’s Face contained within the other’s injunction to the Self to act in a nonviolent way. The other is both higher than the Self and in a fragile position, and the Self must concede both when it answers the other’s call. This thus makes the Self more sensitive and careful in his or her response, with the unlooked for benefit of influencing the Self’s humanity and encouraging his or her own personal becoming. This also fosters the two-way nature of the professional–patient relationship, with the good for both emerging in communication with the other.
The call of the other and the subsequent moral response of the Self displays an insistence on relationality as necessary to the ethical encounter. In this encounter, neither Self nor other are privileged more so than the other entity. Instead, the two communicate with each other in positions of equality but irreducible separateness (Davis, 1996: 42) through a dialogical call and response scenario. In this way, the relationship between Self and other crucially respects each other in a supportive, nonviolent approach. The emphasis of the relationship is not on knowing the other and so pulling the other into the Self, but on maintaining the other’s alterity while ethically responding to him or her in a way that upholds his/her humanity. As Greenwood (2007) notes, ‘This relational approach to providing care is based on the recognition that people involved in all aspects of health care are “other” and separate from the assumptions and pre-conceptions that are made by those that make and implement health policy’ (p. 224). The weakness and vulnerability of the other may be recognized in the patient’s Face as a call to responsible and sensitive action on the part of the psychiatrist or carer. Treating the person in this way rather than systematically addressing symptoms and disease acknowledges the separateness of the other without doing the other violence of subsuming him or her into the knowledge categories of the medical establishment.
Crucially, we shall see in what follows that narrative is not merely limited to the individual patient. It may be used as an actual practice of caring, with its main features supporting personhood and encouraging ethical responses to the other. No two narratives will ever be the same, and narrative care in a clinical setting focuses on the uniqueness of the other, understanding the contingency inherent in the nature of the other. This aspect of contingency denies any rigid categorization in terms of logicoscientific thinking, exactly in line with Levinas’s philosophy of ethics. Knowing the other falls less into medical knowing than it does in knowing as a form of compassionate response dedicated to accompanying patients in their journey. Part of the responsibility of the psychiatrist in this role of accompaniment is to support patients in their line of flight or path of becoming, rather than, once again, ‘fixing’ them into certain options. Narrative opens up possibilities of becoming and presents alternative futures that may not have been explicit prior to the clinical encounter.
Narrative usually follows a particular trajectory (although this is not to discount narratives of people with mental illness, which perhaps are fragmented or show less awareness of chronological time or the trajectory of a person’s life) involving mindfulness of a person’s past, present, and future.
Levinas, therefore, provides a useful way to understand the vulnerability of the patient as other. The Face of the patient assumes primacy and ensures that the patient’s voice is heard in the clinical encounter through his or her expression in narrative. This also challenges predominant medical models built on scientific knowledge rather than ethics, as ethics moves to the forefront of the clinical encounter rather than impersonal diagnosis and treatment regimens. Personhood is restored to the patient, and both psychiatrist and patient may experience the endless possibilities of becoming in their relationality with one another. In effect, this is what Kopp (1976) writes about regarding the therapeutic relationship—that the patient should be personally important to the therapist.
Discussing caring in the light of the philosophies of Levinas and Delueze and Guattari raises a number of challenges to our notions of ethics and personhood, which in turn raise questions as to how such challenges might be addressed in practice. It is all well and good to philosophize about lines of flight, the Face, alterity, and so on, but when one is faced, often literally, with someone who is suffering and is seeking help, what response is adequate to the task set for us by serious consideration of Levinas and Delueze and Guattari? Even if we were able to identify the best course of action, would it be, in Levinasian terms, an adequate response to the Face that demands an infinite response? Unsurprisingly, we do not have the answer to such questions but would offer the following as one way of responding: through what is becoming known as ‘narrative care’.
Narrative as a lens through which to see the world and a tool with which to act in the world, we think, allows us to respect and act in accord with the broad outlines of Levinasian and Deleuzo–Guattarian thought, which we have attempted to articulate earlier. In particular, narrative has the following five features.
First, the strong, if not necessary and inextricable, relationship between narrative and the Self (see, e.g., MacIntyre, 1981; Bruner, 1987; Taylor, 1989; Ricouer, 1991; Schechtman, 1996) brings together both a concern for a workable method and a concern for personhood. Unlike other ethical frameworks such as principlism, narrative links action with a sense of Self and character and is thus very much in line with Levinas’s description of the meeting of Self and other.
Second, narrative is concrete and unique and can accommodate considerable degrees of alterity, both in content and form—witness, for example, the range of subject matter, genres, and form in literature, ranging from the very highly structured works of Poe to the meanderings of Tristram Shandy. Postmodern narratives, in particular, can embrace heterogeneity, nonlinearly organized time, and causality and space that is in motion and lacks a central point (Sermijn et al., 2008).
Third, narrative is concerned with meanings as much as, if not more than, historical fact. Indeed, authors such as Spence (1982) argue that narrative encapsulates its own truth that may or may not be consistent with what is thought to be historical truth. This does not relegate narrative to a subordinate position, however; it merely indicates the need to be sensitive to the relationship between the two. Thus narrative care is not, as Jack Coulehan says, ‘about getting more accurate biomedical information’ (quoted in Engel et al., 2008: 242), but about ensuring that whatever diagnosis, prognosis, or treatment is given is in accord with the meaning system of the patient, and that there may be a trade-off between narrative and historical truth in the pursuit of enabling patients to live well, avoiding fixing their identity, and respecting personhood.
Fourth, narratives are contingent and fluid, flexible, and dynamic. There is nothing inherent within a story that has to be that way, stories can always be rewritten. This allows for the possibility of more positive stories to be told, as, for example, in the practice of narrative therapy (White and Epston, 1990; Freedman and Combs, 1996).
Finally, in the process of coconstruction or coauthoring of narrative, one expresses solidarity with the other. The process of coconstruction pays close attention to the meanings, intentions, desires, goals, beliefs, background, thoughts, and actions of the individual seeking help. The narrative practitioner seeks to work within the individual’s narrative framework to construct a mutually acceptable, credible, and ultimately liveable narrative. This is not to abandon one’s own morality in favour of that of the other, to become ‘a passive listener to her ethical appeals and then a slave to her arbitrary bidding’ (Diedrich et al, 2003: 48)—the danger identified by Hassan in Noddings’ ethics of care (Hassan, 2008)—but to ensure that one uses one’s own knowledge, skills, insights, and morality in the service of the other. In this way, both the Self and the other are cared for.
Narrative Care in Psychiatry
Narrative approaches have flourished in numerous disciplines over the past few years and we think that psychiatry should be no exception to this narrative turn. Lewis (2011a) states that ‘Narrative work in psychiatry provides an opportunity to put science in perspective and keep empathic and meaningful connections with patients at the center of psychiatric education, research, and practice’ (pp. 489–90) and ‘helps psychiatry self-correct from the pernicious side-effects of biological psychiatry without falling into a morass of anti-psychiatry and without throwing away the bioscience baby with the bathwater’ (p. 493). It is important for Lewis (2011b), however, that, despite clear affiliations with the uses of narrative in other fields such as medicine, psychotherapy, literary theory, sociology, and anthropology, psychiatry ultimately demands an understanding of narrative, coextensive with its own pursuits, goals, and needs. For this purpose, Lewis distinguishes between narrative care as both a specific approach and a sort of meta-approach for psychiatry which utilizes a variety of existing psychiatric models, including biopsychiatry, cognitive behaviour, and humanist, from an overarching perspective of narrative. We would like to outline general features that characterize narrative care before detailing its specific relevance for psychiatry.
Narrative care contains certain emphases that remain consistent despite its particular uses in various fields. It centres on the uniqueness of the patient’s story, recognizing the value of this narrative for the patient and for the clinical encounter. The patient’s narrative is radically different from any other, underscoring the patient’s position as the vulnerable other Levinas describes. According such respect to the patient’s story consequently means foregrounding the patient as a separate but entirely equal person. It restores his or her individual humanity in a medical model which often treats disease rather than the subjective experience of illness undergone by the patient. For example, one author (C.B.) once worked with a man, let us call him K, who, a number of years previously, had been diagnosed with schizophrenia. One major factor, according to K, in this diagnosis was that K had reported hearing voices. Following diagnosis, K was prescribed medication and, as a result, in K’s words ‘the voices went away’. Without the voices, however, K felt so lonely that he attempted to commit suicide by jumping out of his apartment window, several storeys up. K was badly hurt physically, and was left with a severe limp and a useless right arm. K stopped taking the prescribed medication and his voices returned. While now physically disabled, K was happier because he now had company. In this case, K’s voices played a role and carried a subjective import far beyond that which could have been understood by interpreting the voices symptomatologically. In listening to, and making accommodation for, the individual’s experience, narrative care seeks to treats the whole person. This does not prevent the practitioner giving due attention to biological matters, but appreciates the personal and social aspects that inform a patient’s story and his or her individual experience of illness.
Narrative care seeks to prevent what Freeman (2011) terms narrative foreclosure, identifying four aspects of such foreclosure that negatively impact upon the individual:
1. Dead ends—where the future is already locked into certain possibilities, with no apparent way of breaking out; such a viewpoint is influenced by prevailing cultural ideas about one’s storyline.
2. The point of no return—a point where one must decide whether one can continue in one’s story the way one has been.
3. Irrevocability—a sense of impossibility in changing or repairing what has been done, that it is too late.
4. Existential despair—or complete despair at the troubles of one’s life, there seems to be no possibility of reopening one’s narrative, and that the end and/or death is imminent.
Each of these may have implications for psychiatric practice. For patients diagnosed with mental illness, the future may seem a dead end in that the prevailing cultural narratives of mental illness overwhelm and take over the individual’s own sense of narrative. The future is bound up within the diagnosis of mental illness, and no narrative outside of this seems possible. Points of no return might be reached, for example, at diagnosis or hospitalization where reassessments of one’s story might be required through being faced with being ‘mentally ill’. Once someone is so diagnosed he or she might think it impossible to conceive his or her experience except in psychiatric terms: see, for example, the irrevocability that some of Cohen’s research participants seemed to experience having been hospitalized (Cohen, 2008). Finally, is the despair where people might see themselves as always being ‘mentally ill’, their troubles or experience of mental illness seemingly having closed down all possibilities, for example, in terms of regular employment, relationships, and sense of Self.
While narrative care can help prevent foreclosure, it can also contribute positively to three essential aspects of the clinical encounter.
First, narrative care enhances the physician–patient relationship by recognizing that the professional is deeply involved in the story told by the patient as attentive listener, active interpreter, and coauthor of new life meanings. The professional, ethically obligated to respond in a caring way to the call of the other, is thus not to be seen as an impartial distributor of medical knowledge but as vital (in both the sense of essential and imparting life) to the patient’s narrative of illness. In this way, narrative approaches to care strengthen the professional–patient relationship through mutual communication, recognizing that relationality is the hallmark of the clinical encounter.
Second, improving the patient–physician relationship reduces the isolation of the patient, demonstrates the profound desire to care and heal on the part of the physician, and restores the equality of the patient in the diagnosis and treatment process. There is a growing body of research that identifies these aspects as promoting patient satisfaction, overall health and wellbeing, and adherence to treatment (Engel et al., 2008).
Third, narrative care can accommodate different models of mental illness, allowing the physician and the patient to configure these in the way best suited to the individual. As Lewis says:
there are many ways to tell the story of psychic difficulties and differences. There is not just one right way and many other wrong ones. All these modules of mental illness involve a process of story telling and story retelling. Each provides an alternative understanding of our past and our present and each suggests different routes forward. These different routes include different meanings, different practices, different rituals, different communities, different locations, different side-effects, different costs, etc.
(Lewis, 2011a: 492)
The possibility for different narratives allows for the possibility of different futures, or, in Deleuzian terms, ‘lines of flight’, whether this be expressed in the language of patienthood, mental illness, mental distress/mental health difficulties, mental health survivor, system survivor or Mad Pride, or some stable or fluctuating configuration of any or all of these. Narrative care can also accommodate the rhizomatic Self in that it allows for multiplicity, that is, different narrative Selves across time and place, without confining oneself through the imposition of, or insistence on, an artificial linearity, consistency, univocality, continuity, and cohesiveness (Sermijn et al., 2008).
Narrative in Practice
Having argued for the relevance of narrative care to the ethical practice of psychiatry in general, we want now, albeit very briefly, to state how narrative care might be applied in practice. We accept that the following subsections are rather brief, but this is only in part a function of the word limits imposed upon us. More significantly, our argument is that narrative care does not and should not make any proscriptive demands upon practice in the sense of determining what is the ethical thing to do in any given circumstance. Rather, narrative upholds the uniqueness of the individual clinical encounter, the encounter between this Self and this other, at this time, in this place, and under these circumstances. All we can do here is indicate how two aspects of psychiatric practice, diagnosis and treatment, might be amenable to and benefit from being viewed through a narrative lens.
The process and impact of diagnosis should not be underestimated. The traditional process of psychiatric diagnosis with its focus on deficits has the potential for totalizing judgement (e.g. the person with schizophrenia becomes a schizophrenic) and normative judgements of ‘normal’ or ‘abnormal’ behaviour, both of which may story people according to those deficits and behaviours, precluding acknowledgement of talents and energies that most people demonstrate as individuals (Carrey, 2007). The process of algorithmic dialogue, the form of questioning that calls for patient responses that can be fitted into a decision tree for the purposes of diagnosis and prescription (Hall and Powell, 2011), limits our understanding of the individual and limits the possibilities for the ethical encounter by territorializing the life experience of the patient on the basis of medical discourse. This reduction of the patient’s experience to a DSM diagnostic category ‘renders a DSM-based narrative non-comprehensive’ (Tekin, 2011: 371) and thus limited in usefulness. Narrative, on the other hand, offers ‘elements to the reader that strain against the container of a particular diagnosis’ and ‘holds hidden in its own shadow multiple alternative interpretations, and a trace marker for larger narratives with their own multiple histories, vocabularies, writers, and audiences’ (Wood, 2004: 196). Narrative, by its very nature, resists, or at least contains within itself, the possibility of resisting biomedical territorialization.
Further, a narrative approach views the diagnostic consultation as an opportunity to develop a relationship with the other:
What I was listening for and reading for were diagnostic clues to help identify a biological or emotional source of the patient’s symptoms, autobiographical background to help me understand who it was who bore these symptoms, and grounds for personal connections between the two of us sitting in that little room.
(Charon, 2006: 4)
In forming a comprehensive understanding and a personal connection, the physician is able to frame his or her contribution to the patient’s narrative in ways that fit with the patient’s experience and meaning system. Cohen (2008) indicates how the meanings of psychiatric diagnoses among mental health service users may vary from those of professionals and how these meanings take on different significance when framed with hospital or community-based treatment regimes. Narrative as a meaning-making activity imposes on the physician an obligation to understand how any diagnostic process or label might impact on the patient’s life and self-understanding. Little and Hoskins (2004) state that ‘practitioners cannot fully understand or fully appreciate the narratives of girls struggling with such a diagnosis [anorexia] without examining the context in which they are embedded’, and, we suggest, it is that context that will determine how any such diagnosis is understood and incorporated into the ongoing narrative and meaning system of the individual, with all that implies for acceptance, compliance, the physician–patient relationship, and so on.
The potential impact that a diagnosis has on the self-concept of the patient makes diagnosis a highly ethical issue. Little and Hoskins (2004) state that ‘the DSM-IV constructs what it means to be an anorexic girl’ (p. 87) and Tekin writes that on the basis of a diagnosis of major depressive disorder a person may
redefine her past experiences based on the descriptive framework established by the diagnostic schema, reassess the psychological and historical facts of her life in the light of the theory underlying her diagnosis, start to re-evaluate certain events of her past as earlier symptoms of her mental disorder, and so on … The alteration in the subject’s autobiographical narrative may generate changes in her future plans, hopes, desires, anticipations, expectations, habits, as well as her relationships with others.
(Tekin, 2011: 365)
Thus diagnosis must be seen in the context of past, present, and future—that any diagnostic category is not simply a descriptive label but a formative actor in the life of the patient. The purpose of diagnosis, in this way of thinking, is to help patients live well, as understood within their line of flight, rather than being an inappropriate articulation of experience.
Narrative has similarly strong possibilities for an ethics of treatment. The inherent flexibility of narrative offers sound opportunities for integration of a variety of treatment approaches in psychiatric practice. As noted in the section Narrative Care in Psychiatry, Lewis (2011b) identifies two particular methods for implementing narrative in psychiatry: as a meta-approach in which the psychiatrist may draw on the existing range of treatment models within a narrative overview, and as a specific approach.
He advocates using the metanarrative approach to identify which psychiatric model would be most suitable for patients, arguing that narrative psychiatry increases treatment options by allowing the patient’s voice to be heard so that any course of treatment fits with the patient’s values, personal experiences, and narrative trajectories. Such treatment could be within the conventional biopsychiatric model, including the administration of psychopharmacological drugs, or more alternative therapies and self-coping strategies. What narrative realizes is that the use of medication has effects beyond that of merely managing biological processes. Rather, ‘medications have chemical and symbolic effects, and the symbolic effects are just as critical as the chemical ones for human satisfaction, adherence, and outcome’ (Lewis, 2011: 492). Narrative psychiatry does not have to abandon the use of medication. Instead, it frames such use within the larger story of the patient:
Beyond medications, the larger implication of narrative psychiatry is that there are many ways to tell the story of psychic difficulties and differences. There is not just one right way and many other wrong ones … Each provides an alternative understanding of our past and our present and each suggests different routes forward.
(Lewis, 2011a: 492)
Narrative care, therefore, does not privilege one treatment model over another—there is no ‘best’ way to go—and acknowledges that the multiplicity inherent in people’s stories and identities may not respond well to a single model of psychiatry. Treatment may be adjusted at any time as it seeks to fit the person’s values, narrative trajectory, and needs. As such, this view of narrative psychiatry underscores our premise that an ethics of caring privileges, respects, and supports the other while providing help in whatever way possible.
Adaptability and fluidity mark this narrative approach to treatment: it does not impose on the patient any fixed routine or set of expectations, enabling greater freedom for patients in their personal process of becoming. Importantly, it does not impose external medical narratives upon individuals, but allows them to articulate and develop their own. For example, participants in Cohen’s research (Cohen, 2008) indicated a range of self-coping strategies that were meaningful to them—ranging from walking and relaxation techniques to religious practices, poetry, and illegal drugs.
Similarly, narrative can be used as a therapeutic tool by helping patients learn to reinterpret and reauthor their own stories. New, more empowering meanings can be produced by the patient and therapist together in this process of reauthoring personal narratives (see, e.g., White and Epston, 1990).
Such a conceptualization of narrative care in either of its meta- or specific manifestations resonates with what has become known as the recovery movement. This movement also campaigns against ‘one dimensional medical model approaches’ (Lewis, 2011b: 153), and focuses on lived experience. Participation in alternative therapies agrees with such an emphasis, as does solidarity with the wider recovery community. The patient’s experiences and needs take primacy, with patients taking greater control in the shaping of their own treatment. These individuals recognize that mental illness comprises more than bodily symptoms, and seek to incorporate approaches that appreciate the connection between body and mind (Cohen, 2008). The overall treatment goal for people in the recovery movement centres on both wellness and wellbeing, and gives due consideration to mental health, biological, social, and economic factors.
We have attempted in this chapter to outline what an ethics of caring might look like when taking account of the challenges of postmodernism and the works of Levinas and Deleuze and Guattari. We have argued that caring is primarily an ethical relationship based on the encounter between the Self and the other, taking into account the radical alterity of the other. Caring, in this way of thinking, is thus expressed by attention to and solidarity with the uniqueness of the other and the directions of their lines of flight. One way of attending to and expressing solidary responsibility toward the other is, we have suggested, to take seriously the opportunities provided by the development of narrative care. Lewis (2011b) argues that using narrative tools aids in countering the biological turn that has occurred in psychiatry in the last three decades, and narrative psychiatry restores empathy and personal connection to the clinical encounter, enabling humanity to be seen more clearly instead of merely as a set of biological processes (pp. 64–65). As already noted, this reduces the isolation of the patient, strengthens the professional–patient relationship, increases diagnostic accuracy, and improves treatment outcomes. It promotes moral imagination and ethical response on the part of the professional, and responsibility for one’s own illness stories and meaning-making for the patient. Narrative care gives psychiatrists a new set of conceptual, practical, and, above all, ethical tools—including a new language with which to understand the construction of narratives, expanded definitions of caring, and emphasis on compassion, dialogue, and mutuality—for their ongoing face-to-face encounters with their patients.
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