叙事循证医学与癌症治疗

循证医学在临床中的推广应用虽已取得了一些成绩,但其仅关注于疾病诊疗的技术层面的局限性也逐渐突显。叙事医学是近年来新发展起来的,在心理和社会层面给予患者更多人文关怀的新医学模式。叙事循证医学是叙事医学和循证医学两种理念和方法的相互渗透与有机融合,是有别于前两者的一体化了的新体系。叙事循证医学的实践需要遵循“叙事的循证化和循证的叙事化”两个原则。在此原则指导下的癌症治疗旨在针对癌症患者的“病痛”,利用多学科团队、新诊疗途径和疗愈判定指数,使患者在生理、心理、社会诸多层面均得到疗愈。     

叙事医学在临床研究中的应用进展

叙事医学的概念自问世以来,在国内外均得到快速发展。对采用叙事医学进行干预的临床研究进行综述,以期为广大临床医护工作者开展有关叙事医学的临床对照研究提供参考。现有叙事医学涉足的领域包括了叙事医学教育、叙事医学文学、叙事医学临床实践等方面,在叙事医学临床实践方面集中在叙事病历、叙事故事的建立,并通过叙事干预实现其医疗目的。叙事医学干预不同于传统的医学干预,将叙事医学作为干预措施进行的对照研究相对有限。     

Utilizing Narrative Methodology in Trauma Treatment with Haitian Earthquake Survivors

An earthquake devastated Haiti in January 2010, killing than over 230,000 and displacing millions. Following this disaster, a culturally specific narrative model was developed for leaders (i.e., teachers, clergy, etc.) to treat trauma symptomatology among Haitians. The Haitian local leaders (n=85) were treated with the narrative model. Data were collected and analyzed, and the results were significant. The leaders’ trauma symptoms decreased following treatment. Following the narrative treatment, they were trained to utilize the model. Recommendations for future research and limitations of the study are discussed.     

叙事医学中时间性的意义和临床价值

人类通过叙事展现自我,建构历史,叙事寓于时间之中,人的存在也与时间休戚相关。时间、叙事和医学,三者之间有着密切的联系,时间性是医学的五大叙事特征之一。在叙事和诊疗的过程中,叙事者和医生都需要厘清特定事件的逻辑,在时间序列中解释因果关系,寻求解决方案,文学和医学由此有了极强的共通性。叙事医学提醒医务人员关注时间性,并提供了许多具体的方法和案例,来提升医务人员对诊疗时机的把握能力,学会理解患者在医院时空中时间之流的体验,据此培养他们的共情能力,提高诊疗水平,并在积极的反思中,完成自我的成长和救赎。

     

叙事哀伤照护赋能围产期临床人文关爱实践

安宁疗护和哀伤辅导是叙事医学的重要维度。以中国叙事医学理念为框架,围绕一则死胎家庭的围产期叙事照护及叙事哀伤辅导案例,阐述围产期丧失造成的哀伤剥夺如何导致失胎/失婴家庭成员陷入严重的创伤叙事闭锁和心身失调状态,进而阐明如何通过强化多学科团队的协同作用,通过产科医护人员的叙事照护,引领丧子家庭走出至暗时刻,重新回归正常的生命叙事进程。叙事性的哀伤支持是最佳的哀伤支持方式,唯有重视围产期叙事生态,积极开展有效的叙事照护,增强生育体验与生育信心,才能对抗生育率下降的社会危机。

     

Narrative Derivatives of Alpha Elements: Clinical Implications

The author considers both the psychoanalytic field and the ways in which the characters of a psychoanalytic session can be understood. He then develops one of Bion's ideas, the dream in the waking state, by isolating the derivatives of such dreams or rather the alpha elements they consist of. The author implies a theory of technique which takes account of all the signals "the bi-personal field" gives the analyst about the functioning of the analytic couple by means of "narrative derivatives". This enables continual changes to be made in interpretation     

叙事病历临床应用的可能路径

在对叙事医学教育工具“平行病历”相关的文献进行梳理的基础上,概括出国内外研究的主要特征;指出临床实践中推行平行病历困境的症结,并明确提出应使用叙事病历概念,应讨论的主体是叙事书写,应强调中国本土叙事医学临床实践经验等主张。以安宁疗护领域的“对话体”叙事病历运用为例,提出拓展病历书写的多重可能性和人文容纳力的理解。致力于对病历开展反思性研究,旨在推动医学界将病历作为叙事医学教育临床转化的重要起点;通过提供个案和可供遵循的路径,助力形成相对完善的教育体系,并提出构建具有中国主体性叙事医学框架的可能。

     

叙事医学在医学教育与临床实践中的五个关键词

叙事医学是新时代医学人文的落地工具,以医护患三大主体的叙事素养提升以及多维度生命和谐健康关系构建为中心议题。围绕叙事医学强调的叙事素养、关系构建、身份认同、主体间性和视域融合五个关键词,全方位阐释这一医学教育和实践新模式。叙事素养是实现和谐关系构建、医护职业和患者身份认同、主体思维模式和视域差异融合的综合体现,由关注力、再现力、互纳力和反思力四个方面能力构成。叙事素养以叙事性文本细读训练为内化手段,以叙事性反思写作为检验工具。     

Using a Narrative Metaphor: Implications for Theory and Clinical Practice

The evolution of family therapy from a cybernetic metaphor to a narrative metaphor has led us to think differently about therapy, about clients, and about ourselves as therapists. In this article we pursue how this different way of thinking has informed a theoretical understanding of a narrative therapy approach and consequently has opened space for different ways of working clinically. We begin by tracing the evolution to narrative; we consider the implications of social constructionism and its political effects; and we complete the discussion by focusing on narrative theory. We then show how the clinical work follows logically and is coherent with the theoretical considerations. We describe, and illustrate with clinical examples, an innovative approach to working with couples and families with adolescents. In this work we pay attention to the larger cultural stories, including gender constructions, and to personal stories that persons have created to make meaning out of their experience as they interact with one another in a reciprocal meaning-making process. Interventions focus on externalizing the problem narrative that is influencing the client(s), mapping the effects of the problem pattern and/or the totalizing view persons might have of others, and creating space for client(s) to notice preferred actions and intentions. Finally, we close the loop by asking questions of ourselves and others about the effects of working from a narrative metaphor.     

Narrative and Clinical Change in Cognitive-Behavior Therapy: A Comparison of Two Recovered Cases

Psychotherapy research suggests that therapeutic change is associated with the emergence and development of innovative moments (IMs)—that is, exceptions to the problematic self-narrative that brought the client to therapy. This study compares two recovered cases of major depression, according to symptom measures, that presented contrasting profiles of evolution of IMs: one typical of successful therapy (Barbara), and another typical of unsuccessful therapy (Claudia). The core conflictual relationship theme (CCRT) was used to study narrative change independently of the innovative moments coding system (IMCS). The results suggest a high congruence between the IMCS and the CCRT profiles. Although Barbara presented changes in the IMCS and the CCRT in a similar way, Claudia's self-narratives (IMs and CCRT), despite symptom change, did not change. The results are discussed, considering the importance of narrative changes in recovery from depression and the maintenance of therapeutic gains.     

Narrative identity in schizophrenia

This study examined narrative identity in a group of 81 patients with schizophrenia and 50 healthy controls through the recall of self-defining memories. The results indicated that patients’ narratives were less coherent and elaborate than those of controls. Schizophrenia patients were severely impaired in the ability to make connections with the self and extract meaning from their memories, which significantly correlated with illness duration. In agreement with earlier research, patients exhibited an early reminiscence bump. Moreover, the period of the reminiscence bump, which is highly relevant for identity development, was characterized by fewer achievements and more life-threatening event experiences, compared with controls. A negative correlation was found between negative symptoms, number of self-event connections and specificity of narratives. Our results suggest that schizophrenia patients have difficulties to organize and extract meaning from their past experiences in order to create coherent personal narratives.     

Anesthesia Awareness: Narrative Review of Psychological Sequelae,Treatment, and Incidence

Awareness during general anesthesia occurs when patients recall events or sensations during their surgeries, although the patients should have been unconscious at the time. Anesthesiologists are cognizant of this phenomenon, but few discussions occur outside the discipline. This narrative review summarizes the patient recollections, psychological sequelae, treatment and follow-up of psychological consequences, as well as incidence and etiology of awareness during general anesthesia. Recalled memories include noises, conversations, images, mental processes, feelings of pain and/or paralysis. Psychological consequences include anxiety, flashbacks, and posttraumatic stress disorder diagnosis. Limited discussion for therapeutic treatment after an anesthesia awareness experience exists. The incidence of anesthesia awareness ranges from 0.1 to 0.2% (e.g., 1–2/1000 patients). Increased recognition of awareness during general anesthesia within the psychological/counseling community, with additional research focusing on optimal therapeutic treatment, will improve the care of these patients.