Narrative-Based Addiction Medicine in an Evidenced-Based World (Jonathan J. Kopel and Bill White)
In 1976, Dr. Thomasina Borkman penned a now-classic paper depicting two ways of knowing: professional knowledge and experiential knowledge. In distinguishing the two, she noted the following: “In contrast to professional information, experiential knowledge is (1) pragmatic rather than theoretical or scientific, (2) oriented to here-and-now action rather than to the long-term development and systematic accumulation of knowledge, and (3) holistic and total rather than segmented.” The tension between these two ways of knowing is evident throughout the history of addiction treatment and recovery and within the relationship between academically trained addiction professionals and helpers credentialed by personal addiction recovery experience. While the categories of professional and experiential knowledge are not mutually exclusive, the tensions between the two have heightened in both primary medicine and addiction medicine.
Within primary health care, evidenced-based medicine (EBM) remains the primary methodology for examining the efficacy of medical treatments. EBM was originally developed to counter the rise in harmful or ineffective treatments being disseminated within the medical field. EBM is based on a rigorous analysis of the risk, costs, and side effects of any proposed treatments through randomized trials and meta-analytic studies. Although EBM has dramatically improved treatment outcomes, it fails to reflect the full spectrum of factors involved in the care and healing of patients. Each patient has a unique personality, culture, ethnicity, history, social standing, and religious background, which EBM cannot analyze quantitatively, but which are critical to providing optimal care and addressing the full spectrum of physical, emotional, and spiritual needs of the patient. In light of EBM’s limitations, many physicians have adopted narrative-based medicine (NBM) within their clinical practice and research.
Unlike EBM, NBM focuses on examining the intertwining narratives found between physician-patient relationships and society. As Ian McWhinney explains, “It is not easy for us to attend to our patients’ experience. To do so requires us to step out of our usual way of attending to a person’s illness. We are trained to see illness as a set of signs and symptoms defining a disease state – as a case of diabetes or peptic ulcer or schizophrenia. The patient, on the other hand, sees illness in terms of its effects on his or her life. The physician therefore must learn to see illness as it is lived through, before it has been categorized and interpreted in scientific terms”. Rather than being viewed as a statistic or disease entity, each patient within the NBM is understood and encountered through the lens of their personal journey and narrative. In the framework of NBM, the physician aims to utilize the narratives of themselves and their patients to address the relational and psychological dimensions involved in both treatment and healing.
Similar trends are evident in addiction medicine and the larger arena of addiction treatment. There is, on the one hand, a growing emphasis on evidence-based practices and competency-based training of addiction treatment practitioners. On the other hand, there is a growing recovery advocacy movement that seeks to reconnect acute care models of addiction treatment to the larger and more enduring lived experience of personal and family recovery. The latter is being supported, in part, by the re-integration of people with lived experience of recovery as “wounded healers” within the clinical world of addiction treatment. The result is an effort to identify and replicate scientifically-validated methods of treatment that have measurable effects on recovery outcomes and parallel efforts to help patients weave such supports into larger narratives that have personal and cultural salience.
What is occurring in primary health care and addiction treatment is a blending of professional knowledge and experiential knowledge. Such a synthesis can counter the limitations of each way of knowing and holds great promise within the future of both primary medicine and addiction medicine. This shift will require shifting the service relationship from an expert model to a sustained recovery partnership.
About the Authors: Jonathan Kopel is an M.D./Ph.D. student at the Texas Tech University Health Sciences Center (TTUHSC); Bill White is author of Slaying the Dragon: The History of Addiction Treatment and Recovery in America.
Borkman, T. (1976). Experiential knowledge: A new concept for the analysis of self-help groups. Social Service Review, 50(3), 445-456.
McWhinney, I. (1997). A Textbook of Family Medicine. 2 ed. New York: Oxford Univeristy Press.