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Chapter 6 discusses the representation of memory in trauma narratives. Accounts of victims of childhood trauma are contrasted with the testimony of Holocaust survivors. I argue that that the distinctive qualities of trauma narratives can also be understood as differences in the culturally constructed landscapes of memory that shapes the distance and effort to remember affectively charged and socially defined events. Landscapes of memory draw from implicit models of memory that influence what can be recalled and warranted as accurate. Trauma narratives involve cultural models and metaphors of personal and historical memory. For them to function as personal and collective history, there must be public places for them to be told, acknowledged, and retold. The political recognition of collective identity and history can help create such a place. Individuals’ stories, in turn, can serve as testimony to ground collective history and call for further moral and political response. Understanding the personal, social, and political meanings of trauma in theory and practice requires tracing the systemic loops that link memory, symptom, and response with a landscape of cultural affordances.
Chapter 3 illustrates the poetics of illness experience by examining clinical conversations during a psychiatric assessment of a patient. Patients’ narratives in clinical contexts are often fragmentary and contradictory, reflecting their ongoing struggle to make sense of inchoate experience and position themselves in ways that elicit care and concern. Metaphors of illness experience open up narrative possibilities, but may be blocked by conflicting agendas or cross-purposes of clinician and patient. In place of an overarching integrative narrative are interruption, miscommunication, and mutual subversion. Focusing on narratives, with close attention to the speakers’ rhetorical aims, can identify situations of tension and misunderstanding, which can be clarified through cognitive and social analysis tracing the models and metaphors used in clinical exchanges to their personal meaning and embodiment and outward into the social world where they function as part of discursive systems that organize institutions and confer power. Close attention to metaphor in lived experience, social interaction, and cultural performance can yield an account of the dynamics of clinical conversations.
Chapter 1 provides an overview of the central argument of the book. Medical anthropology, psychology, and psychiatry must steer a course between realism and constructivism, integrating the useful features of both perspectives. Metaphor theory and 4-E cognitive science provide ways of integrating cognitive and socio-cultural processes. Metaphor production and comprehension involves cognitive and emotional processes embodied and enacted through rhetoric and social discourse. These practices constitute a hermeneutic circle that can be traced from body to person to social world and back. They show how symbols and things live in the same world. This work has implications for understanding the ways illness experience and healing practices are embedded in larger systems of knowledge/power. The metaphors that arise in individuals’ struggles to make sense of their predicaments and to heal from affliction are borrowed from everyday concepts of mind and body, as well as the political language of power, resistance, and dissent. Every metaphor lends power to a particular view of the world. We must judge the value of metaphors on their moral, political, aesthetic, and pragmatic implications.
Chapter 10 returns to broader issues of the cultural politics of metaphor, examining the tensions between ethics and aesthetics in illness experience and healing. While the focus on language allows us to mobilize the richness of literature to explore illness experience, in doing so we may inadvertently downplay the material circumstances that determine health disparities and inequities. Against this apparent opposition, I argue that attention to the aesthetics of language and the creative functions of imagination and poeisis can help us understand the mechanisms of suffering and affliction and devise forms of healing that better respond to the needs of individuals within and across diverse cultures and contexts. Every choice of metaphor draws from and points toward a form of life. The critique of metaphors that begins with an appreciation of the qualities they confer on experience, and then moves out into the social world to identify ways that systems and structures are configured, rationalized, and maintained. A critical poetics of illness and healing can contribute to efforts to improve our institutions and achieve greater equity not only by recognizing and respecting difference and diversity but also by engaging with the particulars of each person’s experience.
Chapter 2 explores the developmental psychology of metaphor and its significance for illness experience. While semiotics of medicine implies a simple link between physiological processes and symptom reports, illness experience is articulated through metaphors that are grounded in bodily experience, social interaction, discourse, and cultural practices. Bodily grounding of metaphor is based on sensorimotor equivalences, as seen early in development in synesthesia and cross-modal analogies. Social grounding resides in the pragmatics of language in which context and goals depend on social roles, norms, and cultural meaning. Despite this, metaphors allow for creative play by requiring only piecemeal correspondences to the world through ostension. The meaning of metaphors is then found not in representation but in presentation. Clinical examples illustrate a patient on dialysis refusing a blood transfusion and a woman with medically unexplained floating sensations, showing how a semantics of metaphor can clarify the tensions between the essential irrationality of illness experience and the biomedical presumption of rationality in normative accounts of illness cognition and behavior.
Chapter 9 explores the origins of healing authority and its experiential grounding. Sociological accounts of authority usually refer to institutional power. Many elementary systems of medicine connect healers’ own initiatory illness and affliction to their knowledge and power. This connection is explicit in the Greek myth of Asklepios and was taken up by others in terms of the archetype of the wounded-healer. This ethos of the wounded-healer reflects a relational structure present in the dynamics of the clinical encounter. Healers’ relationship to their own wounds not only conveys symbolic power but can evoke specific psychological and interpersonal dynamics that may contribute to the effectiveness of treatment. In this symbolic logic of healing, the healer’s own wounds become sources of wisdom when they are confronted rather than denied. The ways this attitude may be learned and embodied are illustrated by a series of dreams with images of wounding and healing during psychiatric training. This ethos has implications for understanding the epistemic authority of healers, the training of clinicians, and addressing basic issues in intercultural health care.
Chapter 7 explores some ways in which metaphors trauma shape the experience of the self and temporality through examples from refugees and Holocaust survivors. A key function of narrative is organizing the experience of time. Narratives of the self have consequences for the experience time. The discussion distinguishes two meta-narratives of the self in terms of their implicit root metaphors and associated temporalities: the adamantine self, characterized by endurance, integrity, coherence, autonomy, self-definition, self-determination, and self-control; and the relational self, characterized by flexibility, fluidity, sensitivity to context, multivocality, interdependence, and responsiveness. These models of the self are associated with different ideologies and forms of social life that shape trauma memory and experience. They also influence the ways that trauma experience is narrated through personal and collective stories. This occurs in settings that require an attentive listener. The ethics of storytelling has an essential counterpart in the ethics of listening, which involves particular forms of temporality and ways of participating in a cultural community.
Chapter 5 focuses on the narrative shaping of the sense of self and of the process of transforming it in psychotherapy. We can advance our understanding of the sources of rhetorical power of metaphor through some version of the constructs of myth and archetype. Myth stands for the overarching narrative structures of the self and other produced and lent authority by cultural tradition. Archetype stands not for preformed ideas or images, but for the bodily or existentially given in meaning. Metaphor links the narratives of myth and bodily experience through imaginative constructions and enactments that allow movement in sensory-affective quality space. Examples from contemporary psychotherapy illustrate how healing metaphors can transform sense of self and personhood. While this approach is most obviously applicable to psychotherapy and other talking cures, which use language to reconfigure experience, it captures a discursive level of sense-making that is an important part of all forms of symbolic healing, whether during ritual actions, as part of the prior construction of expectations, or in subsequent interpretation of outcomes.
Chapter 4 shows how the embodied and enacted psychophysiology of metaphor can explain mechanisms of symbolic healing. Recent research on placebo responding and predictive processing or active inference theories in computational neuroscience suggest models for the physiology effects of placebos, imagery, and imaginative enactments. Examples drawn from traditional shamanistic practices illustrate how healing metaphors and images map bodily physiology, cognition, and experience onto metaphoric landscapes or myths. Movement in these landscapes or along an arc then gives rise to corresponding changes in physiology, cognitive, and social relationships or position, which make use of the dynamics of sensory and affective meaning, including processes of abreaction or catharsis and aesthetic distance. Healing rituals involve a hierarchy of cognitive processes that are structured metaphorically, which reaches down to physiological processes and outward to social interactions. Its multiple levels can operate in tandem to reinforce or subvert processes. This leads to a view of symbolic action and healing ritual as involving multiple parallel levels of causality and communication.
Chapter 8 considers the politics and poetics of alterity or otherness. Others confront us with experiences that may be radically unfamiliar, strange, and unsettling. This may be compounded by illness, trauma, and cultural difference. With empathy and imagination, we can gain an understanding of another’s experience, see their perspective, and build a picture of their predicament. The imaginative spaces and places in their stories offer us a way into another’s lifeworld—even when that world is profoundly different from our own. Narrative medicine provides a pedagogy of empathic understanding through literature. While much of this work employs story, lyric poetry offers another mode of articulating illness experience that may be closer to patients’ emotionally charged, confused efforts to make sense of experiences that do not fit cultural models or templates. The work of the poets Paul Celan and Edouard Glissant sheds light on the power of language to bridge disparate worlds and on the ethical stance needed when empathy fails. A poetics of alterity has implications for efforts to understand individuals’ illness experience and grounding an ethics of care.