Family Practice Vol. 18, No. 4, 425-429
© Oxford University Press 2001
Unravelling empowering internal voices—a case study on the interactive use of illness diaries
Division for General Practice, Department of Public Health and Primary Health Care, University of Bergen, Norway.
Stensland P and Malterud K. Unravelling empowering internal voices—a case study on the interactive use of illness diaries. Family Practice 2001; 18: 425–429.
Received 13 June 2000; Accepted 12 March 2001.
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Abstract |
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Background. The article is part of a study of an illness diary method for improving clinical communication with patients suffering from long-standing illness without clinical findings.
Objective. The aim of this study was to demonstrate how patient empowering can be approached through a process of shared insight in a personal illness description.
Methods. This was a single case study from three encounters with a 48-year-old woman suffering from headache, who participated in the illness diary study. Theoretical sampling was used to select the presented case from the sample. The material comprises sections of notes and transcripts from audiotapes.
Results. During the encounters, the medical dialogue is changed to include the patient's internal dialogues on her illness and her ways of coping. Her body language is approached and met, and its empowering potential is explored in the dialogue.
Conclusion. The reflective practitioner may contribute to transform a consultation from repetitive patterns to a dialogue based on the patient's own coping resources.
Keywords. Case study, clinical method, diary, general practice, psychosomatic.
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Introduction |
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The surprises of clinical practice support inquisitiveness, but also introduce an element of unpredictability. Reports on medical practice may describe the doctor's actions as if they were based solely on textbook knowledge, though clinical decisions also rely on experience and clinical judgement.1 In general practice, a great proportion of the clinical problems do not fit the standard descriptions.2 An uneasiness concerning what to do with these problems may be transformed into negative attitudes in the doctor towards patients with more or less unexplained disorders.
The context wherein medical theory is implemented in clinical practice is a meeting between persons. The symptom is presented as a personally voiced description of a bodily perception. The interpretation is shaped by the listener's associations and experience. By looking more closely at the thinking processes involved in symptom presentation,3 this article intends to introduce a fresh approach to the clinical dialogue.
The core of this study is to demonstrate how patient empowering can be approached through a process of shared insight in a personal illness description.
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Methods |
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The authors previously have presented the development of4 and the clinical experience with5 an illness diary method for improving clinical communication with patients suffering from long-standing illness without clinical findings. This was an action research study in the first author's (PS) own practice.6
This article presents a single case study from one patient who participated in the illness diary study. Theoretical sampling7 was used to select the presented case from the sample, looking for a case which could illustrate interaction related to the thinking processes involved in the sharing of insight.
The encounters were audiotaped and transcribed.5 A slightly modified verbatim transcription was utilized. The doctor took field notes from all encounters. The field notes also comprised the doctor's own reflections as participator in the interaction.
Below, we present excerpts from PS's encounters with Anna J, a 48-year-old married woman, who had been suffering from headache since her youth. Two adult daughters had moved away from home. She was working full time in a shop. The headache had been diagnosed by a neurologist and her GP as a combined migraine and neck pain. She had consulted PS for 4 years, but only twice to discuss how to handle her headache. The material comprises sections of notes and transcripts from three encounters: the first dialogue when she presented with deterioration of her problem and was introduced to the illness diary, a dialogue 4 weeks later based on her written material and a conversation (evaluation meeting) 4 months later when a clinical supervisor participated.
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Results |
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The first consultation
Anna said that she had a relapse of serious headache. She had been taking ~20 ergotamine/meprobamate tablets in the last month. The pain reappeared whenever she was not working, was tired or wanted to relax. She said:
"These days, I get this banging pain from anything, from being a bit tired, from walking with my dog, even from sitting down at home. I even wake up at night. This is really scary!"
As her doctor, PS performed a clinical examination, finding tense neck muscles. Anna was sitting restlessly, talking in a rapid and tense manner, and laughing frequently. After the examination, Anna talked less rapidly and gave her doctor the impression of listening more carefully.
PS considered what to do. These complaints were presented in a new way. What was the significance of the new presentation? Might this be a new medical disorder? Should she have a renewed hospital evaluation? What more might Anna have to tell about her situation?
PS said that he believed that the problem still was a combined migraine and muscle headache, but that he was not sure. He therefore suggested that Anna made an illness diary on the strength of her headache, its localization, accompanying symptoms, situations where it occurred and medication. Thus more information might be gathered on the medical problem in the context of her life. She accepted the idea of making notes for a month.
The next consultation—4 weeks later
D(octor): "All right, a month has passed and you have made a note four times . . . (reads, murmurs) . . . headache rather strong."
A(nna): "It's kind of strange when writing this down . . ."
D: "You have taken fewer tablets than you used to, seven tabs in a month, that's less than half of what you used to take previously . . ."
The doctor thought: How come there has been a change? Nothing is prescribed—no treatment given. Anna's notes were quite sparse, but she had numerous notes on situations where illness occurred.
A: "Maybe it means something that I have been working so much this latest year . . . but . . . from January I've been working only every other week . . . that's in a way better for me . . . And . . . here (points at her notes), Friday the other week, I had 12 women visiting for supper . . . and then you know there is a bit of stress. I manage to recover from that now . . . I go to bed and get some rest in time . . ."
D: "This means that you are rather happy with the situation?"
A: "If this is a tablet consumption I can stay with, and I don't die tomorrow and my fingers won't fall off . . . then I guess it's ok" (laughs).
Anna said that she hoped that she could improve even more.
D: "Do you think that is possible? To do even better?"
A: "Yes, . . . if I'm conscious about what I'm doing . . . the human mind is kind of strange . . . it has something to do with something in here (points at her chest) . . . here is something telling me: You can make it!"
Anna said that she knew her strength as a something situated in her chest. PS thought that this might be a new way of talking about her suffering, to communicate with her personal strength. Anna said that she wanted to go on herself to see how this strong voice helped her.
Evaluation meeting—4 months later
Anna had not consulted any doctor since the last consultation and she said that she had even less headache than before. We were talking about writing an illness diary:
D: "When you had written this down, and you got an overview, what did you think?"
A: ". . . When writing this, concerning one's head and me so on . . . you get kind of more conscious . . . at least you reflect more, of everything . . . at least I think I in a way have got more hold of myself now."
D: "When putting this in writing, I remember that you got quite surprised . . . because then it was not as bad as you had expected?"
A: "Maybe it was stubbornness . . . I would try to show you . . . I am sure I'm so subconscious that there is something telling me: hey, hey, beware, now you're supposed to give yourself away . . . Here somewhere . . . even if I went to you and said that I used too many tablets . . . here somewhere far behind is a small black one that says that now you've got to pull yourself together, now we've got to do something so that he doesn't believe that . . . this seems to sound illogical . . .
Anna seemed to be uneasy, taking breaks, breathing shallowly and sitting in a corner of the chair.
D: "When this headache comes, you feel it is overwhelming you, and you sit down in your chair . . ."
A: (laughs)
D: "What is actually whirling around in your head just then?"
A: (immediately, as if the answer was already on her tongue) "Now again!"
D: "Now again!?"
A: "Yes, whatever I'm doing, nothing seems to help and I think I've done so much now to avoid this headache, so I figured that I had deserved . . . Simple minded me . . . I thought that when I at some time was getting into menopause, I was going to become a new and better person. But that is not taking place."
S(upervisor): "‘I had deserved something else’ . . . another voice appeared. What is it saying?"
A: "Well, the thing is that I feel this headache is a bother, a huge nuisance. I don't think that I deserve to have this headache."
S: "So, when one voice is saying—oh shit—the other is saying: Anna deserves more . . . Would it be totally ridiculous to ask what this voice says in addition?"
A: "But finding this voice? . . . I would fear not being able to handle that."
S: "That voice, ‘you deserve more’, if that voice should come from a person, who might that be?"
A: (rapidly) "You know, the first thought is my grand-dad. I don't know why, but it's got to be him."
Anna started telling about her warm and nice grandfather, breathing fast and eagerly.
S: "What I'm saying is within the frame that you in a way are acting as co-researcher. And then the question is: Do you think it might be an idea to make small notes on how these voices talk?"
A: "Yes . . . because I also have another voice, a small black one, and it is more pronounced than the good one, I surely feel that . . . the black one is there all the time, reminding me of my lack of self-confidence and saying things like ‘you won't manage that’ . . . I think he . . . no I mean (laughs) it is much easier to find than the good one. Because, the black is always nagging me . . . but I guess that's because one is fighting more with the black one, because the black is trying to destroy while the good is . . . I think the black one is so much easier to see."
S: "How has it been to work on this?"
A: "I was calmed down in a way, because when I came the first time . . . I had great sleep disturbances because of . . . my fingers and my pill abuse . . . I woke up at night and had lost the sense of touch in my fingertips . . . and that's all gone. Here you see how strange one can be."
Reflection
A patient well known to her GP presented with a deterioration of her well-known complaint. PS, as her doctor, chose not to refer her elsewhere, but to introduce a communication tool. He hoped to make a significant change in the medical dialogue on the complaint, giving more emphasis to the patient's own ideas by collecting information through an illness diary. The dialogue, revealing the patient's ideas, gave the doctor an insight into a new language of personal, bodily experience based on the woman's self-talk or internal dialogues. This took the doctor by surprise; a previously dull dialogue pattern was broken as the new elements of unpredictability appeared. The new language of thinking processes offered the doctor an approach to communicate with the patient's personal strength. In this way, the doctor became involved in an empowering dialogue by clarifying the patient's coping strategies. The pauses and hesitations of the patient indicate how the doctor is invited into a private field of conversation. The dialogue presupposes a trustful relationship and a favourable atmosphere taking place.
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Discussion |
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A bodily language for personal ideas—internal voices
Naming is giving personal meaning to experiences.8 By choosing expressions such as "a banging, scary headache", Anna makes the doctor alert. The personal description of the experience is developed further by her internal voices. "You won't manage that" and "you can make it" are competing voices that contribute to Anna's illness and to her coping.
Vygotski, the Russian psycholinguist, argues that people create meaning by exploring their experiences through their personal language in internal dialogues.3 He studied language development in children and described how they perform ‘egocentric speech’ during activity, as a means of thinking and problem solving. He meant that egocentric speech was the predecessor of ‘internal speech’ which accompanies thinking in older children and adults. The development of conceptual thinking presupposes the use of words and language. Thinking is not only expressed in words, but emerges through them.3 Internal dialogues may be seen as a meeting point between symbolic language and pre-verbal thinking. They are part of the unsaid premises that accompany and interact with speech.
Internal speech prepares dialogue and sharing of meaning with others. Exploration of ideas takes place by a dialogue between internal voices or by involving other persons in open dialogue.
Whose metaphors?
Metaphors are important components of language.9 Illness metaphors provide pictures or models of meaning, giving colour back to the patient's symptom experience. In medical dialogues on body complaints, the professional's metaphors may dominate the patient's own language.10,11 Internal voices may give access to the patient's own linguistic metaphors. Such voices may be volatile and may need attention not to evaporate before they are even noted. Making notes from the content of these emerging voices may keep the personal metaphor in mind, to enhance self-awareness and reflection on the situation. Anna's case shows how the writing procedure of preparing a diary may make patients aware of their own reflection and acknowledge internal voices as legitimate metaphors defining the linguistic frames of the clinical dialogue.
Anna showed both a bright voice of personal strength and a male, black voice of blame. Both are accessible, but need to be invited to be expressed. There is not only one illness narrative, but several options. The internal voice metaphor is emphasizing the potential of alternative modes of talking about illness experience. Being ill may be expressed in a repetitive narrative blocking alternative voices from providing coping narratives. If these coping narratives are requested, they may be found to co-exist with the negative voice.
Anna showed how this dialogue may stimulate curiosity, as she explores the content of the message "I had deserved more". The dialogue made her more conscious about her strength, personalized as a ‘something’ inside her chest.
Sharing the illness narrative
An encounter gives an opportunity to express, hear and see the message of the internal voice. Anna could see how her words fell by watching the doctor's face, showing her what kind of statement this was. Were we touched? Did she manage to express herself? The specific meaning of her words in spoken language was shown through and by the articulation of her message, when she was showing more than what she could say. Her respiration, intonation and gestures constituted a language that conveyed a surplus of information. The medical examination had changed the relationship between the doctor and Anna in the first consultation, giving the doctor an impression of being heard better. The articulation of some words (now again! I had deserved . . .) were seen to touch Anna, as words are forming the speaker as much as they are informing the listener.12 The doctor heard through both ear and eye listening, and was actively contributing to develop the self-image of the speaker, encouraging or discouraging what might be said.
Sharing the written material from an illness diary adds to this interaction. The illness diary anchors the medical dialogue in the patient's experience and may assist the doctor to hear what the patient is trying to say, before he starts interpreting from his own world of images.4,13 This opens up a possibility for the patient to attend to resource-oriented voices in a field where the negative monologues have been predominant.
To emphasize the participants' mutual contributions in the development of a personal medical dialogue is to acknowledge an interpretive approach to the patient– doctor encounter.14
The reflecting practitioner
Reflection is an activity of any professional practice. Schön has described the complexity of practice as the challenge of adding relevance to theory application.8 When setting the problem, the practitioner grasps the presented dilemma and defines what type of decision is to be made. The interpretation of a presented problem is a process of redefining. By framing information in theoretical and contextual knowledge, and naming it to make sense in relation to previous professional experience, the practitioner reconstructs the problem.
Anna's case started with her presentation of a scary pain, leading to the doctor's ambiguous questioning of what to do next. He felt that the illness narrative needed more light, in this case by the patient's contribution in writing.
Many of our professional actions are spontaneous and intuitive, knowing is in action as a tacit knowing.8 With experience, knowing-in-action becomes automated and the professional may run the risk of selective inattentiveness, sorting out phenomena that do not fit a pre-set picture of the situation. In Anna's case, the doctor's selective inattentiveness might be lack of curiosity to search for her understanding of the pain.
Attending to the surprises and divergent situations of professional practice calls for a more active evaluation. According to Schön, this reflection-in-action is the assessing and hypothesis-generating activity coming to mind, or going on, while you are doing it, a certain dimension of inarticulate premise of clinical knowledge.
Is it possible to transform a situation of selective inattentiveness to a setting of reflection-in-action? The use of illness diaries has been demonstrated5 to support and stimulate the doctor's patience and interest in what this special patient has got to say now, by making today's encounter less predictable than it used to be. In the wording of Schön, the tacit frame ruling the doctor– patient encounter is made visible to the professional.
"I also have another voice"
Living with illness signifies a way of being in the world. Articulating the stories of internal voices can introduce alternative opportunities on how to proceed from a spot that seemed to be stuck. Coping may thus be understood as a search for ways to proceed by entering one's own language account of resources.
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Acknowledgments |
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Professor Tom Andersen, University of Troms
, was clinical supervisor and has followed the project with creative and valuable advice. The Norwegian Medical Association's Fund for Quality Improvement has supported and made the project possible. |
References |
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