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Exploring group-based life review with family physicians : constructing narratives of experience and… Pearson, Hilary Mary 2005

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EXPLORING GROUP-BASED LIFE REVIEW WITH FAMILY PHYSICIANS: CONSTRUCTING NARRATIVES OF EXPERIENCE AND MEANING by HILARY MARY PEARSON B.A. (Honours), University of Manchester, 1971 M.A., University of British Columbia, 1986 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY in THE FACULTY OF GRADUATE STUDIES (Curriculum and Instruction) THE UNIVERSITY OF BRITISH COLUMBIA March 2005 © Hilary Mary Pearson, 2005 ii ABSTRACT This narrative research study was inspired by a desire to expand professional development opportunities for family physicians in Canada. Research points to increasing numbers of physicians who are unable or unwilling to continue practicing because of the overwhelming stress experienced in their work. Self-care, disclosure of personal difficulties, collegiality and help-seeking have not traditionally been fostered in medical culture and difficulties are often denied or go unnoticed until they reach a critical point. Recognizing that the current medical practice environment places the morale and sustainability of many physicians in jeopardy has underscored the importance of developing a range of initiatives to support physicians in their work and reduce professional isolation. Group-based life review is a semi-structured process designed to combine individual reflection and writing about one's experiences with sharing life stories in a small group context. It has the potential to promote self-awareness, interpersonal learning and a sense of connection and mutual support among group members. The purpose of this inquiry was to create an understanding of the multiple meanings that six family physicians made about their participation in a seven-week professional development program grounded in group-based life review. The goal of the inquiry was to gain an understanding from the participants diverse perspectives that could shed light on the viability of using group-based life review with family doctors as a means to enhance well-being and sustainability and illuminate the potential benefits and drawbacks of this approach within the context of their personal experiences and professional culture. A reflexive collaborative narrative research methodology combined with participant inquiry was used to investigate the research question and to co-construct an in-depth understanding of how each of the participants experienced joining with colleagues in the life review program. The six narratives presented in this document provide a multi-focal perspective of the experience of participating in the program and contribute to understanding the viability and effectiveness of life review as one possible means to promote well-being, collegiality and sustainability among family doctors. The doctor's stories also illuminate some of the ways in which current medical discourses impact professional development opportunities for family physicians and raise issues and questions that merit further attention by both practitioners and researchers who are seeking to develop effective initiatives to support family doctors. The narratives and thematic results that were generated in this exploratory inquiry indicate that the life review program was experienced as an effective way to promote self-care, mutual support, a sense of community and enhanced sustainability among family physicians. iii TABLE OF CONTENTS A B S T R A C T T A B L E OF C O N T E N T S LIST OF T A B L E S LIST OF F I G U R E S A C K N O W L E D G E M E N T S C H A P T E R 1 1 Introduction 1 Rationale for the Inquiry 1 The Purpose of the Study 3 Locating the Researcher 4 Developing Interest in Researching with Family Doctors 5 Preparing to Re-search: Two Professional Development Initiatives 8 First initiative. 9 Second initiative. 11 The Research Dilemma 12 C H A P T E R 2 15 Review of Relevant Literature 15 Introduction to the Literature Review 15 Self-reflection and Biographical Learning in Adult Education 15 Mezirow: Transformative Learning 17 Randall: Life-As-Story 19 Creating Safe Spaces for Sharing Stories 24 Group-Based Life Review 28 The Constructs of Vicarious Traumatic Stress and Burnout 32 Distress Among Physicians. 34 Reluctance to seek help or disclose personal distress. 34 Emotional and interpersonal disconnection. 36 Mistakes and moral decisions. 38 Impact of the current health care system. 40 Doctor's narratives. 41 Family Physicians 43 Characteristics of family practice and the importance of self-knowledge. 43 Scope of practice. 45 The context and sustainability of family medicine. 48 Strengthening collegiality and self-care. 53 Balint groups. 55 The Accelerated Recovery Program for Compassion Fatigue. 55 Effective Emotional Management. 56 Summary of the Literature Review 57 C H A P T E R 3 59 Locating the Research Methodology 59 Introduction 59 Epistemological Assumptions of Constructivism 59 and Social Constructionism Narrative Epistemology 60 Rationale for Using Narrative Inquiry 62 Narrative as a Research Process 64 Articulating Narrative Understanding 66 Reflexivity in Narrative Research 68 iv C H A P T E R 4 71 A Reflexive Collaborative Narrative Method 71 The Research Journal 72 Selection of Participants 73 Inviting Participation 73 Setting the Stage: Preliminary Conversations 74 The Life Review Program for Family Physicians 76 First Research Conversations 78 The Transcription Process 80 Reflexive Listening and Interpretive Readings 82 Writing the Initial Narratives 83 Second Research Conversations: Revisiting the Stories 83 Criteria for Legitimacy: Evaluating the Worth of the Study 85 Resonance. 86 Consensual validity. 86 Persuasiveness. 86 Pragmatic use. 87 Independent Peer Review 87 Internal peer review. 88 External peer review. 88 Thematic Analysis 89 Table 1: Conceptual Grouping of Themes 90 C H A P T E R 5 91 Findings 91 Doctor's Stories 92 Eric's Story 92 Robin's Story 106 Kate's Story 119 Vanessa's Story 135 Ray's Story 149 Chantal's Story 162 Themes 174 Theme 1: Struggling with Constraints to Self-care 174 and Professional Support 1A: Lack of time for self-reflection and connection. 174 1B: The need to create non-stigmatizing 175 collegial support groups. Theme 2: Experimenting Safely with Self-disclosure among Colleagues 176 2A: Concerns about professional norms. 176 2B: Personal control about the degree of self-disclosure. 177 2C: Witnessing others hsk self-disclosure. 177 Theme 3: Expert Group Facilitation. 178 Theme 4: Isolation, Relationship, and Collegial Support 180 Theme 5: Normalizing Concerns and Frustrations 181 Theme 6: Affirming Vocational Commitment and Esteem 182 Theme 7: Sharing the Burden of Painful Events and 183 Witnessing Trauma. Theme 8: Sharing the Distress of Potential or Perceived Mistakes 186 Theme 9: Personal and Interpersonal Learning 187 9A: Integrating life experiences and expanding 187 self-understanding. 9B: Learning from other's experiences and life stories. 188 9C: Keeping a journal amplified personal learning. 189 Theme 10: Promoting Professional Sustainability and Self-care. 190 V C H A P T E R 6 192 Discussion 192 Introduction 192 Time in Context 192 Building Relationships and Creating Community 194 Group Facilitation 196 Sharing the Burdens of Care 198 Living with Uncertainty and Ambiguity 200 Theoretical Considerations 201 Implications for Research 202 Implications for Practice 204 Conclusion 206 R E F E R E N C E S 207 A P P E N D I X E S 224 Appendix A - Poem 224 Appendix B - Four Principles of Family Medicine 226 Appendix C - Participant Information Letter 228 Appendix D - Consent Form 229 Appendix E - Group Process 232 Appendix E1 - Group Guidelines 232 Appendix E 2 -Guidelines for Writing 233 Appendix E 3 - Joumalling 234 Appendix E4- Group Agreement 235 Appendix E 5 - Branching into Medicine 236 Appendix F - Life Review Themes 237 Appendix F 1 - Branching Points 237 Appendix F 2- Family 238 Appendix F 3- Career 239 Appendix F4- Stress and Distress 240 Appendix F 5- Meaning in Life 242 Appendix G - Initial Research Interviews 244 Appendix H - Transcription Key 245 LIST OF TABLES Table 1: Conceptual Grouping of Themes vii LIST OF FIGURES Figure 1 Randall; Story of My Life Figure 2 Randall; Storying Life Cycle 22 23 VIII ACKNOWLEDGEMENTS First and foremost, I want to express my gratitude to the six family doctors who chose to participate with me in this inquiry. I feel deeply fortunate and privileged to have met you, shared stories with you, and been inspired by you on this research journey. It is an honour to know you and I cannot thank you enough for your trust and generosity. I have been blessed with a supervisory committee that is second to none. I want especially to thank my research supervisor Dr. Marv Westwood for the mentorship and unfaltering support he has given me over many years. Without your wisdom, encouragement, unstinting availability, and care I would not be here. Your steadying hand and belief in me has kept me going when I stumbled and doubted myself. I deeply appreciate your passionate interest in my work and the laughter, learning, and celebration of life that we have shared. I thank Dr. Maria Arvay for being a role model and guide on this narrative research quest. Your willingness to share not only your vast knowledge and unending curiosity but also the warmth of your heart is gift that I appreciate beyond words. Dr. Betty Calam, I thank you for sharing your professional expertise, insight, and unwavering support. I feel blessed to have shared this journey with Dr. David Kuhl. David, I warmly thank you for teaching me about the world of medicine, inspiring me with your vision, and for both challenging and encouraging me to trust and voice my truths. It is a joy to know you and work with you. I am grateful to Dr. Eva Knell for conversations, questions and laughter that we have shared. I thank Christine Hay for providing expert and very welcome assistance with transcription. I could not have done this project without the steadfast support of family and friends. I am thankful for their ongoing love and presence in my life. Finally, my husband David has stood beside me with patience, love, courage and conviction as I have moved through this process. Thank you does not express what I feel in my heart. 1 CHAPTER 1 Introduction This narrative research study was inspired by a desire to expand professional development opportunities for family physicians in Canada and contribute to the future development of initiatives that can effectively enhance well-being, collegiality and sustainability among family doctors. Many authors who have conducted research on family practice medicine have drawn attention to the importance of enhancing the sustainability of family doctors (Cassell, 1997; Hale & Hudson, 1999; Sotile & Sotile, 2002; West, 2001). They report problems with recruitment in family practice medicine and increasing numbers of doctors who are unable or unwilling to continue practicing because of the overwhelming stress experienced in their work (Hale & Hudson, 1999; Holland, 1995; Myers, 2003; West, 2001). Based upon my experiences of working with family doctors prior to this study, evidence about the need to expand the range of resources available to support physicians in their work, and my familiarity with group-based life review, I decided that there was definite merit to exploring the efficacy and viability of using a group-based life review model (which I describe in detail in Chapter 3) as one possible way to enhance sustainability and collegiality among family physicians. As part of this study, a life review program for family doctors was designed and piloted with six physicians. By engaging in a collaborative research relationship with the participants in this study I sought to create a rich, in-depth understanding of the unique and complex meanings that the doctors constructed about their experiences in the life review program. in the context of an identified need to expand professional development opportunities for family physicians, the results of this collaborative narrative inquiry offer a multi-focal understanding of the experience of participating in the life review program and provide insightful contributions about the viability of using this approach to enhance personal well-being and mutual support among family doctors. The doctors' stories also illuminate some of ways in which current medical discourses impact professional development opportunities for family physicians and raise issues and questions that merit further attention by both practitioners and researchers who are seeking to develop effective initiatives to support family doctors. In this chapter I provide the rationale for this inquiry and the purpose of the study. I then briefly outline my approach to engaging in this narrative inquiry and describe two initiatives that led me to want to explore the process of group-based life review with family doctors and construct an understanding of how they experienced being in a life review program. Rationale for the Inquiry Researchers underline the importance of self-awareness, social support and the ability to talk about distressing events for people who, like physicians, work in professions where they are called upon to witness suffering in other's lives (Arvay, 1998; Catherall, 1999; Figley, 1999; Levine, 1997). Unfortunately, self-disclosure, self-care, and collegiality have not traditionally been 2 fostered in the medical culture and relatively little literature exists on the subject of the internal stress experienced by doctors (Cassell, 1997; Frank, 1995; Hale & Hudson, 1999; Sinclair, 1997; West, 2001). Traditional medical training, attitudes and expectations all too often result in a professional stance of coping alone, maintaining interpersonal distance, and isolation. Many doctors remain legitimately cautious about disclosing personal distress in this professional climate for fear of being judged weak or incompetent and stigmatized for needing support. In such circumstances, "the professional environment is a good place to become and remain ill" (Kaufmann, as cited in Sullivan, 2004b, p. 1). Difficulties are often denied or go unnoticed until problems reach a critical point (Montgomery Hunter, 1991; Myers, 2003; Sotile & Sotile, 2002). Without opportunities for collegial connection, doctors also miss out on occasions to proactively revitalize themselves by sharing the satisfactions, frustrations, personal meaning, anxieties and joys that they experience in their work (Remen, 2000, 2001). In the editorial report of the Canadian Medical Association (CMA) Guide to Physician Health and Well-Being (2003) Dr. Michael Myers calls for sweeping reform of the culture of medical practice. This, he says, is needed to reduce suffering, isolation, lost productivity due to illness, and to counteract the traditional stigma attached to seeking help. He describes this stigma as reinforcing denial of symptoms, delaying help-seeking, driving self-medicating and noncompliance with treatment, augmenting suffering and exclusion, and killing doctors through self-neglect and suicide. There is evidence that the current medical practice environment is exacerbating what is already a critical situation and places the health, well-being, and sustainability of physicians and their families at even greater risk. A large scale survey carried out by the C M A reported a serious decline in physician morale (Sullivan & Buske, 1998) and almost half of the respondents (46%) to the C M A s 2003 Physician Resource Questionnaire reported that they were experiencing an advanced stage of burnout. Remen (2001) suggests that people who are interested in the well-being of physicians need to expand their concerns about the care of impaired physicians to the care of all physicians, given the unprecedented numbers of doctors who are dropping out or seeking early retirement. The initial report of the National Physician Survey (Sullivan, 2004b) confirms the difficulties that many Canadians are experiencing in obtaining access to family doctors and medical specialists and indicates that 60% of family physicians in Canada are currently either having to limit the number of new patients they see or are not accepting new patients at all. In recognition of these concerns the C M A has launched a number of initiatives such as the National Centre for Physician Health and Well-being, the Canadian Physician Health Network and the C M A Guide to Physician Health and Well-being. Despite such initiatives, Myers (2004) draws attention to a current lack of available resources to sustain physicians in their work and the need to develop a broad range of preventative and remedial interventions that can respond to the 3 varied needs of doctors and their families and mitigate the traditional avoidance of seeking support. The reasons for conducting this study are grounded in this documented need to expand resources to support physicians in their work and explore ways to proactively promote their well-being and sustainability. My review of the literature revealed that there is currently a shortage of group-based programs designed to enhance self-awareness, provide family doctors with an opportunity to share both the joys and burdens of being general practitioners, and encourage a climate of mutual support. A s I shall discuss in Chapter 3, a considerable body of literature in the field of adult education and group counselling points to the value of biographical learning and the potential for transformative interpersonal learning that can occur when people are given opportunities for authentic self-reflection and re-storying in the safety of a cohesive group climate. Group-based life review is designed to combine individual reflection and writing about one's experiences with sharing life stories in a group context. It has the potential to promote individual self-awareness, interpersonal learning and intimate connection among group members. At the same time, it is a semi-structured process that allows participants to self-disclose at their own pace and retain a high degree of personal choice and control over their level of engagement. Sotile and Sotile (2002) contend that many physicians would welcome opportunities for informal counselling and workshops "that are respectful of the medical culture" (p. xix). Based on my familiarity with using a group-based life review model and previous opportunities to work with family doctors I decided to explore the viability of this approach as a possible means to enhance well-being and collegiality among family physicians. Previous research studies on life review (Birren & Deutchman, 1991; Kuhl, 2002; McClean, 2001; Shaw, 1999; Silver, 1995; Westwood, Black & McClean, 2002; Westwood & Kuhl, 2002) indicate that the model appears to have natural therapeutic and integrative potential. To date, no research has been published to understand how family physicians would experience participating in a group-based life review program. The Purpose of the Study Given the rationale presented for this study that highlights the levels of stress among doctors, the isolation and reluctance of physicians to seek help and the lack of resources available to support physicians in their work, the research question being asked in this study is the following: What meanings do family physicians construct about their participation in a group-based life review program? The purpose of the study was to create an understanding of the multiple meanings that six family physicians made about their participation in a seven-week professional development program grounded in the life review method. Through a reflexive narrative research process and presence as a participant-inquirer during the program, I engaged in a collaborative relationship with the participants in this study so that we could co-create an in-4 depth and multi-focal understanding of the meanings they constructed about the experience of joining with colleagues in life review. The goal of the inquiry was not to draw conclusive truths about the value of life review or in a traditional sense to generalize the findings to family doctors as a whole. It was to gain an understanding from the participant's diverse perspectives that could shed light on the viability of using group-based life review with family doctors as a means to enhance well-being and sustainability, illuminate the potential benefits and drawbacks of this approach within the context of their personal experiences and professional culture, and contribute insights and new questions to ongoing discourses about how to effectively enhance well-being, collegiality, and sustainability among family physicians. Locating the Researcher We all, novice and experienced researchers alike, come to inquiry with views, attitudes, and ways of thinking about inquiry. These histories, these personal narratives of inquiry, may coincide with or cross a boundary to varying degrees with the actual inquiries we undertake. Almost all of us - it is almost unimaginable that we could not - come to narrative inquiries with various versions of formalistic and reductionistic histories of inquiry. To the extent that this is true, we are forever struggling with personal tensions as we pursue narrative inquiry. ...narrative inquirers need to reconstruct their own narrative of inquiry histories and to be alert to possible tensions between those narrative histories and the narrative research they undertake. (Clandinin & Connelly, 2000, p. 46) I did not come to this research from a naive or a neutral stance. As a counselling psychology professional I have intentionally sought to be entrusted with and intertwined in other people's life stories. A s we co-create and re-member their personal experiences in the quest for new, fulfilling or at least bearable stories, my own story is inevitably changed and re-membered. Influenced as I am by the epistemologies of constructivism, social constructionism and narrative, I embrace a relational, contextual, dynamic, and narratively co-constructed view of selves. During my initial training and work as a counsellor, I specialized in working with women from a feminist perspective. This illuminated the need for me to consider how power dynamics and current social and cultural discourses can constrain or expand both the relative opportunities we have for telling our stories, and the ways in which we tell them. In following years, I pursued additional theoretical and clinical training and experience in couples, family and group counselling. This work, together with my experiences in the community college system where I meet many new immigrants to Canada and people from a broad diversity of cultural backgrounds, has sensitized me further to the fact that the stories we tell others (and that we tell ourselves about our selves) are inevitably constructed and re-constructed according to the audiences and 5 contexts in which we find ourselves. The relative degrees of safety, freedom and acceptance that we experience in any situated interpersonal encounter will undoubtedly affect what we choose (both consciously and unconsciously) to reveal of our complex selves and reciprocally how others receive and interpret what we tell or show them. Our constructions and representations of "selves" are interpersonally co-created, negotiated and dynamically re-constructed according to our purposes at any particular time, the audiences we are addressing (including our own internal audience) and the discourses that are available to us. Charmaz and Mitchell (1997) note that researchers rarely tell beginning tales about the uncertainty or awkwardness that is often the starting point of any meaningful investigation: Beginnings are reconstructed at the end, in appendices and footnotes. In retrospect, what we did becomes what we should have done. Our temperate voices tell measured tales of just means and ordered findings. No false starts are in these stories - no confusion, trepidation, quandary, infatuation, or terror, (p. 209) However, from the perspective of constructivist and narrative inquiry, the self of the researcher cannot be disengaged from the research process. Authors are called upon to be both adequately self-aware and adequately self-exposing to allow readers to understand the writer's interpretive positioning (Arvay, 1998, 2003; Clandinin & Connelly, 2000; Reinharz, 1997; Richardson, 1997, 2000). Steier (1991) challenges researchers to allow processes of self-reflexivity to enter into research activities and to consider "how can we create ways of relating research stories that allow the tellers (us) and our constructing processes not to be eliminated from the tale?" (p. 167). Based on the belief that I need to include myself in the research in a sufficiently transparent way, I will risk telling a beginning tale. I therefore begin by revealing some of the trepidation and passion that infused my desire to engage in this research study and describe two initiatives that informed my desire to explore group-based life review with family doctors. Developing Interest in Researching with Family Doctors Seven or eight years ago, I was part of a team from the Counselling Psychology Department at my university who were involved in helping residents 1 in Psychiatry to learn about using a client-centered counselling model in their practice. During our work together, the students talked about the difficulty they were having "switching gears." Their years of medical training had underlined the importance of rapid assessment and intervention. If they took too long diagnosing a medical problem or became distracted by generalities, they were negatively evaluated. The residents reflected on the struggles they had initially had with this approach and their desire, as beginning medical students, to connect with their patients and spend time talking with them. Now, 1 Doctors who undergo a period of advanced training in a medical specialty after graduation from medical school and licensing to practice medicine. 6 ironically, when they were very accustomed to the fast paced diagnose-prescribe model, they were being asked to suspend problem solving, build a therapeutic relationship and focus more holistically on the experiences of their client. For myself our work together brought into focus what Kenyon and Randall (1997) point out: In any given educational program we are schooled in particular principles, theories and methods, "we are literally discipline-d into a particular way of interpreting both our world and ourselves" (p. 108). After several years of medical training, the residents I worked with had been discipline-d toward an ethics of intervention just as I, as a counselling psychology student, had been discipline-d toward an ethics of relationship. The ability to cross boundaries and integrate perspectives in a way that is personally and professionally meaningful is not necessarily easy. As Weston (2001) notes: The task of isolating a biomedical cause of a patient's suffering is worlds apart from the task of understanding a patient's experience of being ill. The first demands the ability to sift through the patient's personal story of illness, discard all that makes the patient's narrative unique, find what is universal, and discover the disease. The second requires physicians to "steep" themselves in the experiences of their patients in a very personal way, to understand their patients' feelings and individual frames of reference, (p. 2) I became increasingly conscious of the importance of the degree to which doctors could both diagnose the disease and simultaneously steep themselves in the experiences of their patients over the next several years as I accompanied my aging parents through various health crises. I knew the comfort that Berger and Mohr (1967) refer to in telling an ailing parent that the doctor was coming, implying that all would be well, or at least better, with the reassurance of his presence. W e may be feeling panicky but he would not. Throughout my father's last illness and death I experienced how much his sense of being seen, being truly witnessed, by the multiplicity of medical professionals he encountered meant to him and to myself, as his daughter. When he felt seen he was reassured, confident, at ease. When the encounters were distant, formal, impersonal, he became anxious and vulnerable, and so did I. I noticed the toll on my Dad's caregivers. Early one morning, a young resident came to take my father for yet another test but he kept addressing him by the wrong name. I insisted on checking with him several times about the name, concerned that Dad would unnecessarily go through a test destined for another patient. The resident was finally able to reassure me that he did have the right person (my father). He was simply exhausted after more than 24 hours of being on call. It had been a busy night with multiple crises. He apologized for seeming muddled and appearing rushed. 7 A s I journeyed with my Dad through his illness, I reflected on my experiences of working with faculty and students in Health Sciences programs at the Community College where I am a counsellor. Through my involvement in co-teaching communication skills training for students and co-leading some professional development workshops for faculty, I had gained some knowledge about health care culture and I had developed a profound respect for the demands involved in combining care and cure. At times I stood in awe of the challenges presented to students as they embarked on careers in health care. They were expected to rapidly and effectively learn a whole range of communications skills competencies alongside the medical procedures required by their chosen professions. Many students sensed that after graduating, the challenges they would face in the world of work would be no less. How would they find ways to provide deeply empathic care at the fast pace demanded by our current systems? How would they find ways to prevent themselves from burning out, or from becoming disillusioned if workloads and time pressures prevented them from truly connecting with patients? Both my father and mother had been hospitalized previously. However, my Dad's final illness was the first time that I became deeply aware of the complexities of health care in a large / teaching hospital. A s we navigated our way through the comings and goings, I was grateful for knowing that our family doctor was only a phone call away. He was one source of stability and constancy in a shifting sea of changing caregivers. One person who knew my father as more than just a patient, a disease, or a dis-eased elderly man. Inevitably, the family doctor was our first port of call when a problem arose and just as frequently the last. The person we turned to for follow up and for help with pulling all the pieces together when things became confusing. Although through marriage I had joined a family in which both my father-in-law and brother-in-law were family doctors, I began to realize how little I knew about what it was like to be a general practitioner. I knew they worked long hours, saw many different patients in a day and frequently had weekends and nights interrupted when they were on call. I knew that they bore witness to the whole range of traumas, joys, suffering, births and deaths that entered their patient's lives. More than this, I did not know. The ethics of patient confidentiality and what I have come to think of as the required stoicism of medical culture, left little room for them to speak about their felt experiencing of being a family doctor. And respecting the cultural norms that I had grown up with, both in general and in particular around doctors, I respected their privacy and did not ask. What was it that drew me to want to learn more about the worlds of family doctors? The re-cognition of the central role that the doctor played in our lives during my father's illness, that our current family doctor continues to hold for us? What I have read, heard, and experienced about the crisis in health care in Canada? Conversations with family doctors as our paths intersected in various workshops and meetings? Perhaps some sense of social and professional responsibility to contribute to supporting colleagues in allied health care professions? Maybe it 8 was a greater awareness of my own vulnerability as I moved into a period in my life when I began to experience the deaths of friends and relations? Perhaps partly it was realizing that I, like many others, hold somewhat conflicted and shifting expectations of how I want doctors to be with me when I am in the role of patient: Warm, compassionate and human on the one hand, yet fast to pinpoint a solution to my various problems, calm in the face of tragedies and consistently available. Probably all of these threads (and others that I have yet to uncover) intertwined to draw me toward this research project. In the last four or five years I have had a number of opportunities to engage with groups of family practice residents and family doctors in a variety of training and professional development initiatives. A s I began to learn with them and to gain some insights into the world of doctoring, I became increasingly aware of the paradoxical dilemma between responsibility and response-ability that I was encountering. I realized, more than ever, the depth of responsibility that we, as individuals and as a society, ask our doctors to bear. A s Arthur Frank (1995) says: "The weight modernity places on its heroes (being the beginning and end of all things - having to settle the task of the universe) - physicians feel this weight" (p. 153). At the same time, as an outsider to their professional culture, I sensed that I was moving into a world that encouraged them (almost required them in many instances) to silence much of their felt experiencing of being doctors. I contrasted what I was learning about their professional training experiences and cultural norms with my own experiences of becoming and being a counsellor. Our perspectives on voicing personal experiences and actively seeking peer support had been shaped very differently. In my work as a counselling professional over the last 17 years, I have personally learned about the joys and burdens of working in a caring profession and the risks that I, and others, run of experiencing vicarious traumatic stress. Research and practice stress that it is important for those who experience trauma and those who work with trauma to have opportunities to share their experiences and have them witnessed and validated. By the very nature of their work, physicians experience traumatic events, either directly or in witnessing the suffering of their patients. However, as Montgomery Hunter (1991) points out, although medicine is filled with stories, the untold stories of medical care are often those of the physicians. Preparing to Re-search: Two Professional Development Initiatives As part of preparing to engage in this research, I co-led two professional development initiatives which included elements of group-based life review. These were neither designed nor intended to be research studies, but rather to engage in learning with family doctors and familiarize myself somewhat with their culture. I will highlight what I learned from these initiatives while protecting the identities and individual experiences of the participants and co-leaders. 9 First initiative. The first initiative involved working with members of an inner city, front line health care team. This group of professionals wanted to address the impacts of vicarious traumatic stress on their functioning as individuals and team members, enhance their resiliency and both celebrate and re-generate the joys of caring. The majority of the participants in the program were family doctors. In initial meetings to discuss the goals and viability of the program, we dialogued about what would be appropriate to share. How would the personal and professional connect as they engaged in collaborative group work? How could they be separated? How would the cultural and ethical norms about what could be voiced in medical care impact their level of engagement? Would they be comfortable, even able, to share experiences and self disclose when, for most of them, their medical training and work culture underscored the importance of confidentiality and coping alone? How would the group work affect their day-to-day working relationships, both among themselves and with other team members who would not be participating? These issues remained alive as we worked together to build and maintain a climate of safety and support that is necessary for effective group work and essential when working with trauma or vicarious traumatic stress. Eight of the eleven people who had initially indicated an interest in the initiative participated in the program. One person was unable to continue after the first session because of prior commitments. Two others chose to discontinue after the first two months citing other priorities in their lives and preferring to pursue the self-care strategies they already had in place for themselves. We met as a group for 12 sessions, of approximately 3 to 4 hours each, over a period of 6 months. Anecdotal reports given at the evaluation meeting that was held two months after our last session, suggested that collaboratively re-storying and re-enacting critical life events had enhanced their ability to integrate traumatic experiences and given them an increased sense of resiliency and sustainability with regard to their professional work. Several members spoke to becoming aware of the degree to which they had shut down their emotions prior to the group work. They talked of how their professional training and culture endorsed a stance of coping alone, maintaining composure ("detached concern"), and an appearance of being confidently in control. The cumulative impacts of bearing witness to multiple traumas in their work with an extremely vulnerable population of inner city patients were compounded by their expectations of handling things alone and a perceived sense of little support from health care administrators. The slide toward emotional numbing and withdrawal was not difficult in these circumstances. Learning that others in the group shared similar feelings in the face of difficult encounters with patients or the death of a patient with whom they had built caring relationships normalized their experiences, led to a greater sense of collegiality and significantly reduced feelings of isolation. Collaboratively exploring practical ways to effectively handle challenging situations and 10 debriefing with colleagues in a time-efficient way both validated the depth of knowledge and skills that were present in the group and opened up new perspectives and novel ways of trying things in the future. Many reported that as a result of the group sharing they were reaching out for support in ways they had not previously thought possible. A number of the participants spoke to an increased sense of aliveness and joy, both in their personal and professional lives. They felt that the sense of connection they had experienced in the group and the strategies they had developed (both for self-care and for supporting one another) were spilling over positively into the workplace as a whole and into their personal lives. We discussed, as we had on a number of occasions during our work together, the relative benefits, challenges and disadvantages of engaging in this kind of collaborative re-storying with colleagues with whom one works on a daily basis. We looked at how the goals of building personal and professional resiliency and enhancing team cohesion can both intersect and be dissonant. For example, some participants expressed that because they had wanted as many colleagues as possible to join the group, they had initially put subtle pressure on people who were ambivalent to join or stay in the group. However through their own experiences of having members choose to leave the group, they realized how important it was to experience a sense of constancy and shared commitment to the group process. Overwhelmingly, participants believed that the collaborative group work had a significantly positive effect on their goal of alleviating the impacts of vicarious traumatic stress and increased their resiliency and professional sustainability. They had two main recommendations with regard to future initiatives of this kind: First, to emphasize in initial meetings that the personal and professional are deeply interconnected and, in many ways, are inseparable when one engages in therapeutic group work. This, they felt, would allow people who are unaccustomed to self-disclosure to judge their readiness and commitment to this kind of process. Second, to make professional development opportunities of this kind more readily available to health care professionals. A s I mentioned earlier, the majority of the participants were family doctors and several proposed that we consider offering groups for family physicians across the city. For myself, being invited into their stories increased my knowledge and understanding of the health care culture and the complexities involved in working in this field. It was also an intensely emotional experience. I was inspired by their commitment to provide care for patients who are perhaps among the least advantaged and most desperate in our Canadian society. At times I was awe struck by their heartfelt desire to actively bear witness to the multiple traumas in their patient's lives and the humility and humanity with which they did this. At other times I feared for their well being as I recognized the systemic levels of trauma they were consistently exposed to and as I, in my turn, bore witness to their suffering and the suffering (through their stories) of their patients. 11 The period during which we worked together as a group was co- incidentally the period in which the disappearance of women from the down town eastside of Vancouver was becoming more prominent in the news. A number of these women were patients of the front line health care team we were working with. W e struggled with the enormity of this tragedy and our sense of horror, disbelief, anger and helplessness. W e sat together in a circle of profound grief, drew strength from the sacred space of human and spiritual connection that we had created among ourselves and, at the closing of one session, moved in a huddled group toward the elevators that would signal separating for the night and returning to our own lives outside of the group. At other times in the group, we shared laughter and learning and celebrated working in professions where we are privileged to witness healing moments and accompany people (including ourselves) on journeys of self-discovery and self-affirmation. In addition to reflecting on what I was learning with them and on my practice as a group facilitator, I was naturally spiraled into reflecting more deeply on my own journey. To question how experiences of traumatic events in my own life, experiences of witnessing trauma in the lives of my clients, and choosing to work with professionals who experience vicarious traumatic stress impact me. To reflect on the extent to which I am personally practicing what I preach in terms of self-care and retaining personal and professional resiliency. The disappearance of so many women in the down town eastside, some of whom I came to k/now through our group work, impacted me deeply. Continual conversations and peer supervision with my co-leader, discussions with the supervisor of the initiative and my research supervisors, attending a memorial service with friends, and being encouraged to language my experiences in poetry in an inspiring class at the University (Appendix A) helped me to both sediment the learning I was engaged in and alleviate the potentials of experiencing not only secondary, but possibly tertiary traumatic stress reactions. Second initiative. In the second initiative, I worked as part of a team to enhance the abilities of family physicians to work with patients experiencing post-traumatic stress response (PTSR). The group program included both didactic and experiential elements. As part of the training, we introduced the concept of life review. Once there was a strong climate of safety and trust in the group, we invited the participants to share, in ways that felt comfortable for them, a significant branching point in their lives. W e introduced this both as a way to enhance their own self-awareness and resiliency and as a means to further understand what it might be like for patients who were experiencing P T S R to share their stories. The impact of listening to the doctors' stories was for myself, and others in the group, very moving. What follows are some of the words spoken by participants about the meanings of this collaborative re-storying for themselves: 12 Doctor W: "The group restored my faith in humanity. I feel better about seeing my patients" Doctor X: "I was going to work. I had stopped connecting. I felt privileged to hear the stories. I've always felt, as a family doctor, the sense of being privileged to connect with people's lives, have patients share with me. I had lost the sense of being privileged - had gone to a place where I had closed off. I got reconnected." Doctor Y: "The process allowed me to tell my own story and to know others. This is the first time with doctors that I've been able to get so low - so deep. Deep enough to know that I'm not alone. Always before I've felt that I was alone. I always thought I was the one who had the worst story. I reached a level where I shared my insecurities with others who were honest. I felt that you understood the deep anxiety I feel at times". Doctor Z:" This allowed me to trust what I've always known about doctors - a feeling of deep respect and affection. Deep down, what I've felt doctors should be - we are. This will affect the way I worship at the church of medicine. Why can we not do this with each other? The religion of medicine is alienating. We need to have a forum. What is, or has been historically, the support system? My faith is being restored with regard to the system." The Research Dilemma Many authors have underscored the benefits that connection, peer relationships, supportive witnessing and small group member-to-member learning bring to healing trauma, preventing or ameliorating secondary traumatic stress reactions and enhancing well-being (Catherall, 1999; Flannery, 1990; Herman, 1997; McCann & Pearlman, 1990; Stamm, 1999; Yalom, 1985). My experiences as a co-leader in group-based life review and trauma repair work using group-based therapeutic enactment have shown me first hand the benefits of being able to share stories in the safety of a supportive group climate. What emerges frequently, in my experience, is a sense of healing and connection/re-connection that extends beyond any one individual in the group and often beyond the boundaries of the group into an increased sense of community. Herman (1997) speaks eloquently to this issue of connecting with a sense of human commonality: Traumatic events destroy the sustaining bonds between individual and community. Those who have survived learn that their sense of self, of worth, of humanity, depends upon a feeling of connection to others ... Trauma isolates; the group re-creates a sense of belonging. Trauma shames and stigmatizes; the group bears witness and affirms. Trauma degrades the victim; the group exalts her. Trauma dehumanizes the victim; the group restores her humanity. Repeatedly in the testimony of survivors there comes a moment when a sense of connection is restored by another person's unaffected display of generosity. Something in herself that the victim believes to be irretrievably destroyed - faith, 13 decency, courage - is reawakened by an example of common altruism. Mirrored in the actions of others, the survivor recognizes and reclaims a lost part of herself. At that moment, the survivor begins to rejoin the human commonality, (p. 214) I resonated deeply with the words spoken by Dr. Z; "Why can we not do this with each other?" and re-cognized that the seeds of my research interests had sprouted into a passionate desire to puzzle through this question with family doctors. Why could they not do this with each other? The need to do this was palpable in the two groups that I had co-facilitated and I had a beginning sense of both the difficulties and significance of sharing stories among colleagues. Could other family doctors share stories with each other? If they did, which ones would they share? How would they tell their stories? Would sharing stories among doctors be restor(y)ative, as it seemed to be in the case of Dr. Z, or might it be discomforting and cause angst? How would doctors experience participation in a structured group program of self-reflection and collaborative re-storying about various themes in their personal and professional lives? How would they voice the meanings of such an experience? How would I be able to adequately co-construct with them the experience of our co-participation in a life review program? How could I adequately re-present the meanings of their/my/our experiences? Anecdotal evidence and my experiences in the two groups led me to believe that group-based life review could be one way in which family doctors could engage in self-reflection, share stories, create spaces for collegial support and in doing so, potentially enhance their personal and professional sustainability. And yet, I remained cautious. I was very conscious that self-disclosure has not been traditionally fostered in medical culture and that as West (2001) says, "Medicine is a profession where it can be safer to pretend that all is well, even when palpably it is not" (p. 204). McWhinney (1996) stresses the importance of self-knowledge if doctors are to be healers as well as competent technologists. However, he notes that "self-knowledge is neglected in medical education, perhaps because the path to this knowledge is so long and hard" (p. 436). He wonders whether it is preposterous to ever imagine that medicine could become a self-reflective discipline. Was it preposterous for me to think that family doctors would join with me in this research project? Literature in the field of adult education emphasized the value of self-reflection and biographical learning (Brady, 1990; Birren & Cochran, 2001; Kenyon & Randall, 1997; Mezirow, 1991). Previous research studies on group-based life review indicated a number of potential benefits that participants may experience in the life review process. However, group-based life review had not previously been researched with groups of family doctors, or to the best of my knowledge with any homogenous groups of physicians. I dwelled among self doubt, trepidation and passion for several months, wondering if my desires were off base, wandering into exploring other avenues of researching, alternately sitting 14 on and falling off a knife edge of anxiety. Each time I turned away from my questions, I felt a need to re-turn and listen to the whisperings of my heart. Thankfully, as the process unfolded, my research committee supported me as wise companions and challenged me to pay attention to my passions. I returned to reading the word of James Hollis (2001): "When something is of us, it is for us, it sets off a tuning fork inside us ... The resonance within us cannot be willed; it happens. No amount of willing will make it happen. But resonance is the surest guide to finding our own right path" (p. 61). It was time to start the research journey that is storied in the pages of this text and risk asking the questions. 15 CHAPTER 2 Review of Relevant Literature Introduction to the Literature Review Group-based life review was originally conceived within the discipline of adult education. I therefore start by reviewing the place of self-reflection and biographical learning in the context of recent developments in the theory and practice of adult education. In doing so, I have chosen to focus on the theoretical propositions of Mezirow and Randall that I find helpful in informing my understanding of life review processes. I then highlight issues from counselling theory and practice relevant to creating climates that facilitate sharing stories. I also describe in detail the approach to group-based life review that formed the foundation for the personal and professional development program for family doctors that is the focus of this research study. Following this I concentrate on three main content areas related to medical practice: (a) an exploration of the impacts that exposure to suffering and professional expectations can have on physicians in the context of literature on secondary traumatic stress, burnout and distress among physicians; (b) the literature on the context of family medicine and family physicians; and (c) I conclude by considering the degree to which three existing group-based models address opportunities for collegial support among family doctors. Self-reflection and Biographical Learning in Adult Education Sokol and Cranton (1998) note that Habermas's (1971) delineation of three kinds of knowledge (namely, instrumental, communicative and emancipatory knowledge) has become a common framework for understanding learning. Instrumental knowledge is concerned with causal laws, technical knowledge and hypothesis testing. Communicative knowledge includes our practical interests, understanding of others and the social norms of the world we live in. Emancipatory knowledge is the freedom and sense of empowerment that comes from critical self-reflection which engenders greater self-awareness and ability to integrate our experiences. Much formal education has traditionally focused on instrumental knowledge and reflected what Friere (1970) described as a "banking model" of teaching (instructors deposit information into the supposedly empty vaults of student' minds) or Ortony (1979) referred to as a "conduit model" (pre-packaged knowledge is transmitted from experts via teachers to students who are subsequently tested in various ways to demonstrate that they have learned the preordained information). Mezirow (1994) noted that most adult education has been devoted to descriptions of how to facilitate instrumental learning and similarly, professional development programs, particularly in fields where there is rapid technological change, tend to focus on instrumental learning. Given this context, it is not so surprising to learn that self knowledge and self-reflexivity have been neglected in medical education (McWhinney, 1996). 16 The conviction that storytelling can be intrinsically empowering has been advanced by both feminism and popular education movements. This has had a significant influence on present-day adult education and has led to the development of a number of "story-ing" approaches that are currently used within adult education and other disciplines (Randall, 1995). Increasingly in the last two decades authors in the field of adult education have underscored the value of what Alheit (1992) terms "biographical learning" - the potential for an increased sense of authenticity, aliveness and agency that comes from reflection on our own lived experiences (Atkinson, 1995; Brady, 1990; Howard, 1989; Kenyon & Randall, 1997, Mezirow, 1978, 1991). There is now wide acknowledgement of narrative as a primary way in which human beings make sense of their experience and of the emancipatory potential of reflecting on and sharing the stories of our lives. A s Brady (1990) says: Is this not our destiny as human beings to learn, to grow, to come to know ourselves and the meanings of our life in the deepest, richest, most textured way possible? If we do not know the self, what can we know? If we cannot learn from reflection upon our own lived experiences, from what can we learn? (p. 51) Similarly, Newman (1994) notes that reflection has been given increasing importance in the field of adult education "and a lot of us in adult education have come to see one of our major roles as that of helping learners reflect on and learn from their experiences" (p. 236). Newman (1994) charts the changing meanings given to reflection over the years and the relationships between reflection and action in various models. I will briefly summarize his review: • In the liberal education tradition reflection really meant the same as pondering. Learners would listen to a teacher, or read, and then find time to think things over hoping to reach deeper understandings or finer appreciations. Reflection happened in repose. Action, as a result of such reflection, may take place later. • In the 1960's, a whole range of psychotherapeutic techniques that encouraged self-disclosure were incorporated into adult education. Reflection became a more emotionally charged and less orderly activity as a result. • In the early 1970's Paulo Friere politicized reflection. Reflection and action are inseparable; both are contained in praxis. Learners act both on themselves and their worlds, changing their own consciousness and the ways they engage with other people and institutions. • In the 1970's and 1980's Donald Schon was interested in practitioners who could think on their feet and adjust their practice accordingly. He named this process reflection-in-action. Action and reflection coincide but remain separate concepts. Reflection is a way of monitoring and adjusting action. • In 1985, Boud, Keogh and Walker developed a model which suggested a chronological sequence of experience, reflection, then outcomes. Later on, Boud and Walker (1992) 17 revised the model to give greater emphasis to the roles of reflection both prior to and during learning experiences. However they view reflection as by definition detached from experiencing. We cannot, they conclude, be fully immersed in an experience and at the same time be reflecting on our actions. • In the 1990's models of reflection tend to focus on linking reflection with reasoning. Reflection becomes more a set of mental activities to be performed or part of a definition of the competencies required to be successful in the workforce. Newman views the move to seeing reflection as a competency based in reasoning as stripping away other important elements of reflection such as reverie, flights of fancy, insight and intuition. He views Mezirow's (1991,1994) transformative learning model as significant in preventing a domestication of the potentially emancipatory activity of reflection: Mezirow's perspective transformation contains within it a form of reflection that is of another order altogether. Perspective transformation involves achieving a form of meta-reflection in which, if successful, we do not only see the world and ourselves more clearly, we see ourselves seeing the world. We perceive our perceptions. We are aware of awareness. (Newman, 1994, p. 239) Mezirow: Transformative Learning Mezirow (1991, 1994) framed his theory of transformative or emancipatory learning within Habermas's (1984) writings on communicative action and views transformative learning as central to adult education. At the core of transformative learning is a process of critical self-reflection, which allows us to see how our present is enveloped by our past and possibly shapes our future. In emancipatory learning we come to see our reality more inclusively, to understand it more closely, and to integrate our experiences better. Dramatic personal and social change becomes possible when we become aware of the way that both our psychological and our cultural assumptions have created or contributed to our dependence on outside forces that we have regarded as unchangeable (Mezirow, 1991, p. 88). The underlying assumptions of Transformative Learning Theory (1991, 1994) are constructivist. The theory is based on the premise that we all have perspectives derived from our experiences, expectations, assumptions and values. We create meaning (and therefore learning) out of what has happened in our lives. According to Mezirow (1994) our meaning structures (or frames of reference) are two-dimensional. Meaning perspectives or habits of mind are "broad sets of predispositions resulting from psychocultural assumptions which determine the horizons of our expectations" (p. 223). Such habits of mind include intentions, emotions and cognitions and act as filters through which we interpret the meanings of experiences. Meaning perspectives include sociolinguistic codes (e.g. social norms, cultural principles or rules and language games), 18 psychological codes (e.g. personality traits, repressed parental prohibitions and emotional response patterns), epistemic codes (e.g. learning styles and sensory learning preferences) and moral codes (conscience and moral norms). Meaning schemes "are specific manifestations of our meaning perspectives" (Mezirow, 1994, p. 223) and are comprised of things such as beliefs, opinions, judgments and feelings which are related to a specific interpretation. Transformative learners reflect upon and question their perspectives; they open up new ways of looking at and integrating their experience and act based on new perspectives. Mezirow (1991) contends that the most significant learning (transformation of meaning perspectives) can occur suddenly as the result of a major life event or may occur in increments as the result of changes in meaning schemes. Engaging in critical reflection and discourse will not always result in transformative learning and individual or social action. Mezirow (1994) identifies four processes of intentional adult learning: 1) refining or elaborating meaning schemes; 2) learning new meaning schemes; 3) transforming meaning schemes; and 4) transforming meaning perspectives. He outlines eleven phases that can contribute to perspective transformation: 1. A disorienting dilemma 2. Self-examination with feelings of fear, anger, guilt or shame 3. A critical assessment of assumptions 4. Recognition that one's discontent and the process of transformation are shared and others have negotiated a similar change 5. Exploration of options for new roles, relationships and actions 6. Planning a course of action 7. Acquiring knowledge and skills for implementing one's plans 8. Provisionally trying out new roles 9. Renegotiating relationships and negotiating new relationships 10. Building competence and self-confidence in new roles and relationships 11. A reintegration into one's life on the basis of conditions dictated by one's new perspective. Mezirow (1997) notes that establishing a sense of solidarity among participants is essential to effective discourse and educators must pay attention to establishing democratic, safe and collaborative learning climates. The implementation of these ideal conditions within the context of adult education implies a conscious effort by the educator to establish and enforce norms in the learning situation which neutralize or significantly reduce the influence of power, the win-lose dialogue, and the hegemony of instrumental rationality found elsewhere in society ... The educator is seen as a collaborative learner, and tries to work his or herself out of the job of facilitator to become a collaborative learner, contributing her experience to arriving at a best consensual judgment. 19 Ideally (and this is characteristic of adult education), the relation of educator to learner is one of subject-to-subject, a peer relationship, rather than one of subject-to-object, not uncommon in the education of children, (p. 171) Shaw (1999) draws attention to four issues that were raised at the first national conference on transformative learning that took place in 1998: • A need to pay more attention to power structures and how these impact dialogue, communication and the process of emancipatory learning. •-• A need to consider more fully to how different cultural contexts affect transformative learning processes. • A need to recognize different ways of learning and knowing such as intuitive, emotional and spiritual knowing and possible gender differences in learning styles. • A need to consider the issue of whether transformational learning emphasizes individual rather than societal transformation and how this relates to issues of social action. Notwithstanding some of the criticisms that can be made of transformative learning theory (or indeed any attempt to create a comprehensive model of adult learning), Mezirow's model is a valuable lens through which to consider life review because it does contextualize the act of reflection (Newman, 1994). Mezirow (1996, 1998) points out that there is significant diversity in the ways various cultures delimit who has a voice, the forms that discourse and learning may take, how the validity of beliefs are claimed and maintained and the extent to which individuals and groups are allowed to act on critically reflective insights. He notes that in attempting to develop an evolving and comprehensive model of adult learning, his aim is not to engage in specific cultural critiques, but to provide a framework for studying learning in different cultures and understanding how different cultural contexts affect how adults learn within them. Randall: Life-As-Story Randall (1995) explores the metaphor of life-as-story and the expansion of this metaphor to include the possibility that we author ourselves into being, making sense of the events of our lives to the extent that we incorporate them into our unfolding novel. Randall (1995) contends that any examination of the life-as-story metaphor is coincidentally an examination of the mysteries of learning, "that entire active process whereby consciously or otherwise, we are forever trying to 'make meaning' out of our existence and 'make something' out of our lives" (p. 8). He notes that while much has been written about learning from psychological, sociological, economic and political perspectives, little has been written about the poetics of learning. Randall draws attention to three issues related to adult education and adult learning that merit an inquiry into the poetics of self-creation and learning. First, in adult education and other fields there has been a significant increase in various approaches rooted in the story model. The conviction that storytelling is intrinsically empowering, which was put forward initially by feminist and popular education movements, has become well entrenched in many circles and has led to a 20 proliferation of storytelling. In this context, evaluation of what story and storying is can at minimum alleviate "the fuzzying effects of the enthusiasm with which talk of story is so often accompanied" (p. 5). Second, it is imperative to consider the construction of people's stories, stories which are not only about the past, but the present and future as well, given what we know through research about the impacts of past experiences, personal baggage and self concept on how, what and why adults learn. Additionally, the type of qualitative method often used in adult education research requires particular attention to critical reflection on the part of researchers. Third, there has been a shift away from predominantly psychodynamic models of personality toward a constructivist view which allows for an appreciation of peoples' active participation in the process of their own becoming and draws attention to the complex hermeneutical processes by which they are continually reconstructing their worlds and themselves. If it is a question of not only having a story but being a story, then Randall wonders among other things what the implications are for seeing the self at once as the main character in one's story, the principal reader of that story and the story teller? Questions such as these are not merely intriguing, Randall suggests, but potentially of vital importance in understanding more about the art of living and what can be inferred about the art of telling - and living our stories. "The way we story our lives directly affects the way we understand ourselves; the way we understand ourselves directly affects the way we act; and the way we act directly affects the way the world is" (p. 9). Randall (1995) provides a thought provoking and very wide ranging perspective on the art of living. I will not attempt to provide a summation of his work but rather point to two models (Figures 1 & 2) that I found useful in considering the complexity of the process of storying and re-storying our lives. He proposes viewing the concept of life-as-story in relation to one or another or combinations among four possible levels of self-awareness: existence, experience, expression, and impression. "Existence - the outside story": In objective terms, the outside story encompasses all the minutiae of our existence in time and space. It is the level of what actually "happened" in the past, the sum total of everything we have done, said, thought or felt in all the various dimensions of our lives; verbal, emotional, intellectual, interpersonal, conscious, unconscious, behavioural, physical, biochemical, and molecular. Where our whole story begins is a matter of debate because in some ways it is inseparable from the whole story of the cosmos: in temporal terms, our stories were underway in the bodies and minds of our parents before our birth; the physical boundaries between ourselves and everyone and everything else are difficult to delineate; we breath in and out, we eat and excrete as we regenerate the molecules of our bodies; in socio-psychological terms we are a part of all that we have met. The whole story is never available to us in its entirety because of its multi-dimensionality and vastness and because we are inside it; asleep, 21 unconscious, unaware for probably a third of it. We can only apprehend this outside story partially and imperfectly through theories, senses, memories, and imagination. "Experience - the inside story": The inside story is what we make of our outside story. It is what we create in our hearts, minds and bodies about our experiences in the sense of everything we have somehow or another taken inside and constructed meaning from. The inside story is selective. Although it is based in the outside story, it is not a representation of it. It is our individual, unique interpretation and re-interpretation of what we know, think, feel, remember, believe and hope about ourselves. Multi-directional and many-leveled, it is not simply a storying of the past or present, but is also filled with projections about the future. As Randall (1995) says, "if the inside story is our experience, it is also our expectation; if it takes in our learning, it takes in our yearning as well. It is what we 'make up' about the past and future both" (p. 53). "Expression - the inside-out story": The inside-out story is what we present or project to the world. It is what we communicate both in telling and showing ourselves to others be that through words, expressions, possessions, actions or involvements. Our inside-out stories are ambiguously and problematically related to the inside stories. What we tell or show of ourselves by one means of expression (our words for example) may be belied by another (our facial expression). How we perform our inside-out stories is shaped by the contexts, relationships and cultures within which we move and the variety of inside-out stories we perform are continually interacting and evolving. Even the act of attempting to express our inside story will change it as we move from felt experiencing to voicing or writing the inside-out story. "Impression - the outside-in story": The outside-in story is what is made of us by others -what is "told" of us, or "read" into our lives by people who encounter us in any way. These outside-in stories are not static snapshots of who we are at some point in time. Inevitably they include hypotheses about where we have come from, who we have "been" in the past, and where we are going in the future. Sometimes people may seem to be able to "read" us better than we can ourselves. Often, the "readings" others make of us will feel very different from our own versions of ourselves, and seem to be simplified or skewed sketches of who we experience ourselves to be. "Rather than detailed narrative portraits, they are the un-filled-in outlines; "storyotypes", we might say; like stereotypes, only more historical, more tensed, and more inventive, for they entail reading into our lives not merely a hypothetical present but also a possible future and past" (p. 57). The storyotypes people create (whether positive or negative) will directly determine how they treat us, indirectly affect the opportunities provided to us, and will strongly impact the story we tell ourselves. In diagramming this theoretical proposition (Figure 1), Randall emphasizes that there are no precise boundaries between the levels of existence, experience, expression and impression. They are inextricably entwined and the interplay among them is what constitutes the mystery of being and complexity of interpersonal relationships. "Somehow, woven together in one web, 22 swirling about me as one world, all of them are 'my life', all of them are 'my self, and all of them are 'my story'" (Randall, 1995, p. 61) Figure 1 The Story of My Life The Outside Story Adopting three of the main perspectives at work in the telling of literary stories (the narrator, the protagonist and the reader) Randall proposes a tentative schema for considering the complexities and subtleties involved in researching storying styles and the process of self-storying (Figure 2). In making distinctions between these three modes of being (basically talking, doing and thinking), Randall 's goal is not to categorize people or suggest that in life these modes are either neatly contained or separate. He offers the schema as a beginning way of playing with possibilities and exploring questions. Although visually limited to a circle in the diagram, Randall envisages a spiraling cycle of self-storying: one in which we move from a primarily protagonist mode, immersed in the doing of our life-story; to a primarily narrator mode, voicing the story of our lives to others and to ourselves; to a primarily reader mode, where we ask what kind of story it is and consider it in the light of the larger stories around us that have co-constructed our own. Re-entering the protagonist mode, we would then do so in a more self-aware way. W e would, Randall suggests, have bridged the gap between "having" and "being" our story. Reading our story and questioning its composition in a critically reflective way allows us in effect to re-story it: "Thus, we have come out on the other side of it, ready not only to live it in a new and more author-itative manner, but also to take it and read it at a whole new level: one on which we might be open to re-storying our souls all over again" (Randall, 1995, p. 321). 23 Figure 2 Starving Life Cycle PROTAGONIST Level of Experience Of course, the cycle described above is idealized. Many factors can disrupt or interrupt our self-storying, prevent us from voicing our stories or disallow the space and means for critical reflection and re-storying. Retelling and re-constructing our lives on several levels at once is more easily said than done and the resistance to doing so may come not just from others but also from ourselves (Kenyon & Randall, 1997; Mahoney, 2003). A s Mahoney (2003) points out: We are neither prisoners of our pasts nor free to choose any future. W e are, however, vigilant protectors of what we hold "close to" our hearts - our view of reality, our sense of ourselves, our values, and our sense of control. When we are asked to change these, as we often are in our development, the challenge to change may feel overwhelming (p. 3). Eakin (1999) describes a theoretical modeling of the self provided by Neisser (1988). Neisser's five selves include the ecological self; the interpersonal self; the extended self; the private self, and the conceptual self. Eakin expresses being drawn to this model because it avoids the traditional and restricting mind/body split; it presents the possibility of a plurality of selves, none of which are privileged; it acknowledges the formative role of conceptual models (social roles, personal traits, theories about body and mind, self and subject) in the development of individuals' self-concepts, and it extends the developmental history of selfhood to pre-linguistic and pre-symbolic registers rather than assuming, as many have, that selfhood begins with the acquisition of language. I am drawn to Randall's modeling for very similar reasons and 24 experienced it as a useful lens through which I could reflect on the process of group-based life review and the complexities of inviting, co-constructing and re-presenting the doctors' stories of their experiences in the life review program. Randall (1995). proposes that the calling of educators, those interested in the drawing out (e-ducing) and nurturing (edu-care) of fellow human beings is to create spaces for the mutual birthing of stories: It is to provide each other a safe, hospitable space in which we can tell ourselves and read ourselves as much as we need. It is to help us re-story ourselves in such a way that the one story will more integrally embrace the many; that we will be able to tell, at least to ourselves, more of the stories we have hitherto left untold (especially those of the self-sabotaging kind); that we will be able to identify, to critique, and to discern among the many master-stories that vie for our allegiance in the world at large; and that we will be allowed a more self-conscious defense against the 'storyotyping' of both others and ourselves, (pp. 353-354) Creating Safe Spaces for Sharing Stories How can we meet the challenges of being present to stories and creating safe places to invite collaborative re-storying? I reflect on Moore's (1996) words: The people who come to me, like myself in my own life, are wobbling, and I know it will do no good for me to loose my grip and wobble with them... I can't presume to know how to help anyone. What I have learned as a therapist, something I didn't know before I began this work, is that each person is a mystery never to be fully understood. The so-called problems people bring to therapy aren't problems at all; they're mysteries, and the response to a mystery should be entirely different from that to a problem. A mystery is something not to be solved, but only to be honored, appreciated, contemplated, and revered, (pp. 181-182) I have found that part of the answer to the challenge of creating at least relatively unwobbly spaces where we can begin to unfold the mysteries (and perhaps the missed-stories) of our own and other's lives resides in the words of Carl Rogers: "So if a theory is to be held at all it seems to me that it should be held tentatively, lightly, flexibly in a way which is freely open to change, and should be laid aside in the moment of encounter itself (Rogers & Stevens, 1967, p. 187). What I have taken from these words into my own work as a counsellor is the challenge to enter into the ambiguous, unfolding, liminal spaces between theory and practice, self and other. It would be ethically unconscionable for me to invite others to share their stories and their struggles with me without having a solid grounding in theories that inform my professional practice and enhance my ability to co-create ethical and hospitable climates. Equally, in encountering others in therapeutic settings, I need to be reflexive and ensure that my theoretical perspectives are not limiting my openness to the uniqueness of their lives. Having knowledge about various theoretical 25 perspectives and integrating these within a constructive perspective (Mahoney, 2003) allows me to be both grounded and spontaneously responsive to the needs of clients and the nuances of the relationship we are creating together. Like existential theories, a constructive approach emphasizes the importance of human relatedness and sees therapy as a collaborative and evolving journey between the client and the therapist (Mahoney, 2003; Yalom, 2002). The goal is to offer an authentic human relationship, remain open to how our own ways of being will be touched and possibly transformed in the process, and create contexts in which clients can risk exploring their lives in personally meaningful ways and experiment with possibilities for living more fully (Mahoney, 2003). I find the words of Yalom (2002) inspiring as principles to inform my own practice: At its very core, the flow of therapy should be spontaneous, forever following unanticipated riverbeds ... Therapists must convey to the patient that their paramount task is to build a relationship together that will itself become the agent of change. Above all, the therapist must be prepared to go wherever the patient goes, do all that is necessary to continue building trust and safety in the relationship. I try to tailor the therapy for each patient, to find the best way to work, and I consider the process of shaping the therapy not the groundwork or prelude but the essence of the work ... One needs technique in learning to play the piano but eventually, if one wants to make music, one must transcend learned technique and trust one's spontaneous moves, (pp. 34-35) Building a climate of interpersonal safety and trust becomes an even more complex, dynamic and multidimensional process when we engage in group work. Kline (2003) points out that theories designed for individual counselling do not adequately address the complexities for group interaction and how such interactions can be used to benefit group members. Much has been written on the theory and practice of group counselling and therapy (Corey, 2000; Edelson & Berg, 1999; Ormont, 1992; Yalom, 1985, 1998). My intention is not to attempt to provide a comprehensive review of this literature or to explain differences among the variety of theoretical approaches. My goal is simply to highlight several issues that I see as an important framework for effective work with groups. Yalom (1985, 1998) has brought some clarity to understanding how group work can be helpful to clients. In his work, Yalom conducted a comprehensive investigation of many different approaches to group psychotherapy. His goal was to look beyond the form, techniques, and specialized language of various schools of group therapy to distill a framework for considering the basic healing factors that group therapy can offer. Yalom (1985, 1998) describes eleven factors that contribute to therapeutic change, while stressing that these factors are interdependent and do not occur or function separately. The therapeutic factors he proposes are the following: instillation of hope; universality; imparting information; altruism; corrective recapitulation of the 26 primary family group; development of socializing techniques; imitative behaviour; catharsis; existential factors; group cohesiveness; and interpersonal learning. I agree with Yalom (1985) that in therapeutic group work, it is to a large extent the group that is the agent of change. The group therapist's job is to be actively engaged in the creation and maintenance of a supportive group climate: Who provides support, universality, advice, interpersonal feedback, testing, learning, opportunities for altruism, and hope? Obviously, the other members of the group! Thus to a large extent, it is the group that is the agent of change... Thus, if it is the group members who, in their interaction, set into motion the many therapeutic factors, then it is the group therapist's task to create a group culture maximally conducive to effective group interaction, (pp. 115-116) Yalom (1998) contends that "group cohesiveness and interpersonal learning are of greater power and complexity than any of the other factors examined thus far" (p. 24). Of group cohesiveness, he says: It is essential to note that group cohesiveness is more than a potent therapeutic force in its own right. Perhaps even more important, it is a necessary precondition for the other therapeutic factors to function optimally. When, in individual therapy, we say that it is the relationship that heals, we do not mean that love or loving acceptance is enough; we mean that an ideal therapist-patient relationship creates conditions in which the necessary risk taking, catharsis, and intrapersonal and interpersonal exploration may unfold. It is the same for group therapy: cohesiveness is necessary for other group therapeutic factors to appear, (p: 27) Yalom (1998) speaks of how difficult it has been to pin down a precise definition of a variable such as group cohesiveness. It involves overlapping dimensions; on the one hand it is the group phenomenon (the degree of "groupness" or "we-ness" that the members feel), on the other hand are the individual member's various and fluctuating degrees of attraction to the group. Broadly speaking, cohesiveness may be defined as all the shifting forces acting and interacting on all the members to remain in the group. It reflects the "condition of members feeling warmth and comfort in the group, feeling they belong, valuing the group and feeling, in turn, that they are valued and unconditionally accepted and supported by other members" (Yalom, 1998, p. 26). I have found a useful framework for addressing the complexities of group cohesiveness in the model proposed by Schutz (1958) and pragmatically translated in the work of Borgen, Pollard, Amundson, and Westwood (1989). Schutz posited that group members have three basic personal needs: the need for inclusion; the need for control; and the need for intimacy/trust. Each of these must be met as they arise, co-mingle and evolve during the life of the group. Borgen et al. define these three basic needs in the following way: 27 "Inclusion" relates to group member's needs to have a sense of belonging to the group. Assessing what is expected of themselves and others and figuring out how much they want to invest in the group, how much they 'fit in', how they will perform in the group and what that will be like for them. "Control" refers to the needs that individual members experience in terms of influencing the group. How much can they control what happens in the group and to what degree can the group influence what happens to them in this context? "Intimacy/Trust" relates to individual member's needs to feel close to and in a secure, safe relationship with the other participants. To what degree are they accepted as unique individuals and freer to express themselves authentically? To what extent do they experience others in the same way? Borgen et al. (1989) stress that these needs are not independent of each other and are not dealt with by the group or individual members in some kind of systematic or prescribed way. However, the authors provide a useful framework for considering how the needs of the group members evolve and re-cycle through various stages of group growth: In the "initial stage" of the group, members will be most concerned about issues of inclusion as they (often warily) feel their way into the group. In the "transition stage", members will often struggle with issues of control and decision making as they try to secure their position in the group. Interpersonal conflicts and struggles with the group facilitator often arise in this process. Groups that successfully navigate these struggles develop an adequate sense of shared control and shared responsibility and a sense of cohesiveness and accomplishment arises. In the "working stage" of group growth, the concerns and needs of the members centre on issues of developing intimacy and trust among themselves. Developing interpersonal trust allows for greater appreciation of individual difference and more authentic communication among the participants. Members feel secure and psychologically safe enough to self disclose and provide feedback to others. The productivity of the group increases, as do opportunities for significant interpersonal learning and creative spontaneity. Finally the group moves into the "termination stage." Group members may experience grief reactions as they think about losing the connections they have built among themselves, the support and challenge that the group has provided them. At this stage group facilitators need to provide adequate time for these emotions to be expressed so that members have an adequate sense of closure and readiness to make the transition out of the group. There are, of course, many different types of groups; educational, psycho-educational, support, and therapeutic to name only a few, innumerable reasons why people engage in group work (voluntarily and involuntarily) and equally varied goals or purposes. A s I shall subsequently describe, a life review group is most closely described as a semi-structured learning group that has a psycho-educational emphasis. Attention is given to the intra and inter-personal psychological needs of the group members to create a facilitative group climate for both individual 28 and interpersonal learning. Many authors have written about the qualities and skills that are needed to be an effective group facilitator. It is beyond the scope of this brief overview to provide details about these here, but clearly, responding adequately to the needs of group members at any point in time, deterring forces that threaten cohesiveness and fostering interpersonal learning requires a range of competencies, flexibility, spontaneity and reflexivity on the part of the facilitator. Every member in a group is a unique, mysterious individual and equally, each group is unique. The journeys we take with them as a "fellow traveler" (to adopt Yalom's 2002 term) are mysterious, challenging, sometimes daunting, often inspiring and inevitably fascinating. Group-Based Life Review The process of group-based life review is designed to provide a personal and interpersonal opportunity for reflecting on, re-storying, re-presenting, re-integrating and potentially re-authoring the meaning of one's life stories. In its original form, Butler (1963) initiated life review as a way to allow people nearing the end of life to revisit memories and deal with conflicts in need of resolution. The original model did not involve group work or the suggestion of themes by a facilitator or therapist but relied more on free-flowing memories. The approach to life review that I am proposing to research with family doctors is a semi-structured, group-based model known as Guided Autobiography (Birren, 1987; Birren & Birren, 1996; Birren & Cochran, 2001; Birren & Deutchman, 1991). Guided Autobiography expands individual approaches to reviewing experiences and emotions over a life course by placing it within a group context and using a series of evocative themes to promote reflection. For the sake of simplicity, and because the term life review is, I believe, more readily understood by potential participants, I shall continue to use the terminology of "life review" or "group-based life review" when referring to the Guided Autobiography model. This life review approach has been widely used and researched (Birren & Deutchman, 1991; Kenyon & Randall, 1997; Silver, 1995) and appears to have natural therapeutic and integrative potential. Birren and Deutchman (1991) summarize the benefits from twenty-two life review studies. Some of the positive outcomes of life review included a sense of increased personal power and importance; recognition of past adaptive strategies and application to current needs and problems; reconciliation with the past and resolution of past resentments and negative feelings; resurgence of interest in past activities or hobbies; development of friendships with other group members; greater sense of meaning and purpose in life; increased role clarity, self-esteem and self-understanding; and ability to face the nearing end of life with a feeling that one has contributed to the world. The model was originally researched with older adults in residential care facilities and in more recent years has been successfully used with older adults facing job loss (Rife, 1998), veterans from WWII and the Korean war (Molinari & Williams, 1995), Canadian WWII and 29 Peacekeeping veterans (Gervais, 2001; Westwood et al., 2002), terminally ill patients (Kuhl, 2002; Westwood & Kuhl, 2002), and beginning counsellors (McLean, 2001). The distinguishing feature of the process is the semi-structured format. A set of core themes and guiding questions are used to foster self exploration (through personal reflection and writing) and sharing (telling one's story and listening to others' stories) in small groups of five to eight people. The following nine core themes were chosen as reflecting key life and existential issues (de Vries, Birren & Deutchman, 1995): History of the major branching points in my life; family history; career or major life work; the role of money in my life; health and body image; loves and hates; sexual identity, sex roles, and sexual experience; experiences with and ideas about death and dying, and other losses; influences, beliefs and values that provide meaning in my life. The opportunity to view one's life story through the perspectives of the various themes has been described by Birren and Deutchman (1991) as akin to shining a light through a nine-sided prism. Just as the light is refracted differently depending on the side of the prism it is shone into, so each theme provides a different angle for re-viewing one's life stories. Themes can be used flexibly to fit with the make-up and time frame of the group program, and specific themes may be developed to reflect the interests of group members. In keeping with the non-invasive ethic of the process, members may always choose not to address a particular theme (Kenyon & Randall, 1997). Structured group activities can enhance a sense of psychological safety for group members because each structured situation provides a focus and a container for the level of activity that participants choose to engage in (Borgen et al., 1989). The way a group member chooses to be during any particular activity is bounded by the structure of that situation and does not have open-ended implications or consequences for the process as a whole. In life review, while the various themes are inextricably interwoven in the complexity of individual life stories, each theme/session is also an entity within itself. Group members are free to adjust their level of disclosure according to their degree of comfort with the theme and their personal sense of safety and interpersonal trust. The life review process always begins with an introductory session to clarify the facilitator's role, group expectations and goals, and the structure of the process. This first session is geared towards reducing the natural anxieties that will often arise in meeting other members for the first time and entering into the process. Knowing about life review is different than actually beginning to experience it, question how interpersonally comfortable and accepted one will be in the group, and wonder about the level of personal disclosure and emotionality that may be evoked. Establishing group agreements, guidelines for giving and receiving feedback, and providing structured activities that allow members to begin to get to know each other and engage in non-threatening self-disclosure provides the foundation for building a safe and cohesive group climate. 30 Following the introductory session, participants are invited to spend time personally reflecting on the theme that has been selected for the subsequent meeting. They are asked to write about how the theme relates to their life and encouraged to do this in their own individual way. To increase a sense of being able to write freely and spontaneously, members are reminded that they are not required to show what they have written to any one else, will be invited to share only what they choose to disclose, and should plan to share up to a maximum of two typewritten or four handwritten pages with the group. The reflecting and writing time that participants engage in outside of the group meetings is an integral part of the process and serves a two-fold function. It not only provides an opportunity to enhance introspection, integration and personal meaning-making, it also increases the personal control that individuals have over what they will subsequently share. As participants review what they have written, they have time to quietly reflect on their personal comfort about disclosing parts of the story that may include affectively charged material and decide which parts of their writing they want to share with the group, and what they prefer to keep private. Birren and Birren (2001) recommend increasing the flexibility of life review for use with populations who are less comfortable with writing. I have personally found that there are great benefits in encouraging participants to use whatever modalities are most conducive to their own styles of personal reflection and story telling. Allowing people to use multiple ways of language-ing their experiences (for example drawings, objects, photographs) not only ensures that writing is not experienced as a barrier to participating but also allows participants to create a personally resonant exploration and voicing of their stories. Participants share their stories verbally in the group in a nonjudgmental atmosphere. At the end of telling their story, each participant can choose to hear from others in the group how listening to the story impacted them personally and, as noted earlier, guidelines are established to enhance the effectiveness of both giving and receiving feedback. Hearing from others can offer the speaker new perspectives on his or her experiences and enhance the realization of both unique and common experiences. However, as de Vries et al. (1995) emphasize, life review is distinct from group therapy and does not actively seek to promote change in individual member's emotional, cognitive, or behavioural responses. The purpose of life review is to provide a learning climate within which people can increase self-awareness, integrate and make meaning of their life experiences to date, and begin to think about future hopes and intentions. Sharing life stories in a safe, small group context gives individuals the chance to recall events, and feeling about those events, that may have been forgotten or perhaps suppressed because they were experienced as unacceptable at the time. Being able to compare and contrast one's own experiences with those of the other group members can help participants to feel accepted, acceptable and self accepting (Birren & Deutchman, 1991; de Vries et al., 1995; Brown-Shaw, Westwood & de Vries, 1999). Sometimes an individual may join a life review group 31 carrying what they feel is a shameful secret, only to find that disclosure of the secret is met with acceptance, little surprise and similar revelations on the part of others (Birren & Cochran, 2001; Birren & Deutchman, 1991). The process of critical reflection and interactive sharing may lead to new insights, the resolution of past issues, affirmation of the journey that is unfolding, or bring to light issues that merit further exploration. Brown-Shaw et al. (1999) noted that life review sometimes results in a deepened awareness of issues that remain unresolved and challenging. In this way, it can serve as a self-diagnostic tool that allows people to consider whether, or how, they wish to address difficulties that may be preventing them from living life as fully as they wish. According to Kenyon and Randall (1997), group-based life review can provide a means for engaging in transformative learning: The point in this first stage is not to analyze our lifestory, simply to express it as fully as we can. But even this is transformative. Getting ourselves out of ourselves, turning our inside text inside-out (on paper or in the ears of another), inevitably changes us. "We are simply more than we were before" (Winquist, 1980, p. 60). Going thus intentionally from experience to expression, we expand, we evolve. Like the chambered nautilus, we step outside of the same old story. No longer thus so stuck in particular interpretations of who we are, we open to the possibility that one life (our life) can have more than one version. W e become - to ourselves - a different person, for the entire exercise both empties and fills. On the one hand, it begins to purge us, even exorcise us, of the more troubling, less looked-at corners of our lives, of the stories we have habitually left untold... Finally, it can increase our personal power, not the potential power of the story left untold, but the actual power that every story, once aired, injects into the world, (p. 128) The group leader's role is to ensure that each group member receives equal time to express themselves and that no judgmental remarks or interpretations interfere with an atmosphere of mutual respect. From my own experience in being a participant and leader in life review groups, I have found that the therapeutic benefits of the process are enhanced significantly when group leaders have a solid theoretical foundation and expertise in group facilitation and can ensure that issues of inclusion, control and intimacy are maintained at optimal levels (Dimock, 1976; Borgen et al., 1989). Life review welcomes the presence of the whole person, including the pain and suffering people have experienced as well as their joys and triumphs (Birren & Cochran, 2001). Leaders need to be aware that sometimes life review may involve a group member describing a traumatic event from their own life story. Given the prevalence of trauma in our society, it is not unlikely that life review may lead to remembering either direct exposure to violence and victimization, or to 32 witnessing the traumatic suffering of others. Recovery from trauma cannot occur in isolation. It requires safety, re-membering, mourning the losses, and the possibility of reconnecting to life and community (Herman, 1997). Working with people who have been traumatized requires specialized training and, as noted previously, life review is not group therapy. However, if leaders are prepared to handle the disclosure of traumatic memories during the process, life review can provide fertile ground in which participants can both share and integrate distressing memories into their broader lives. Westwood and McLean (in press) recommend that facilitators have an understanding of trauma recovery processes, the ability to act in preventative, and, if necessary, remedial ways to reduce the risk of re-traumatization, and knowledge about sources of referral to other helping professionals if extreme reactions to traumatic memories arise. A therapeutic life review process is one in which there is a natural and incremental deepening of the level of disclosure among participants reflective of, and embedded within, an increasing sense of cohesion, mutual trust and personal safety (Birren & Cochran, 2001; Birren & Deutchman, 1991; Westwood & McLean, in press). When effectively facilitated, life review can confirm not only a sense of one's uniqueness and worth as an individual, it can also promote intimate connection with other people, an awareness of commonalities, and sense of community (Birren & Cochran, 2001). In summary, there are two features of life review that make it a preferred method for helping family doctors to share their stories: First, life review is framed within an educational approach. Although it can have a naturally therapeutic and integrative potential and has increasingly been used in counselling psychology, it was not designed to be a formal group therapy (Birren & Birren, 1996). This, I believe, may make it accessible and acceptable to a broader audience of participants some of whom who may shy away from therapy models for fear of stigmatization or because they view therapy as solely focused on repair or problem solution. Second, the structured format of life review allows participants who may be un-used to disclosing personal feelings or distressing experiences to move into the process in a gentle way, a way that endorses a sense of personal control around self-disclosure and is respectful of the medical culture (Sotile & Sotile, 2002). The Constructs of Vicarious Traumatic Stress and Burnout Vicarious traumatization was first coined by McCann and Pearlman (1990) to describe a phenomenon experienced by trauma therapists working with survivors of traumatic life events. The term "vicarious trauma" may be applicable to this study because it describes experiences of being overwhelmed by witnessing the trauma of others. Doctors are not immune to the effects of witnessing the trauma of others, their patients. Pearlman and Saakvitne(1995) describe vicarious trauma among therapists or other health care providers as: A transformation in the therapist's (or other trauma worker's) inner experience resulting from empathic engagement with clients' trauma mate r ia l . . . . These effects are 33 cumulative and permanent, and evident in both a therapist's professional and personal life. (p. 151) Figley (1999) defines vicarious traumatic stress (which is alternately referred to as secondary traumatic stress or compassion fatigue) as "the natural, consequent behaviours and emotions resulting from knowledge about a traumatizing event experience by a significant other. It is the stress resulting from helping or wanting to help a traumatized or suffering person" (p. 10). All health care personnel who engage empathically with people who are in severe distress are vulnerable to experiencing secondary traumatic stress reactions (Figley, 1999; Herman, 1997; McCann & Pearlman, 1990). In describing conceptual frameworks for understanding vicarious traumatic stress, Arvay (1998) notes that according to Pearlman and Saakvitne (1995) exposure to trauma can damage us on six levels: • Disruptions in our central beliefs about the world and spirituality: W e may start to question our beliefs that the world is a benign place, that justice and trustworthiness exist, that our life is meaningful, that hope is possible. • Disruption in self-capacities: Our ability to maintain a positive sense of ourselves, modulate strong affect and maintain a sense of connectedness with others can be disturbed. The results of this can include a sense of isolation, disconnection, hypersensitivity and increased self-criticism. • Disruption in interpersonal relationships: W e may start to withdraw socially, feel alienated, become indifferent to activities we previously enjoyed and lose our ability to maintain intimate relationships. • Disruption in ego resources: Meeting our own psychological needs and negotiating appropriate boundaries in our personal and professional lives may become impaired. • Disruption in memory: W e may start to experience intrusive thoughts or images, re-experiencing the traumatic material we have witnessed as if it were our own. Burnout is a different concept from vicarious traumatization. The construct of burnout was explicated by Maslach (1976) and the Maslach Burnout Inventory (Maslach & Jackson, 1981) is currently the most widely used instrument to measure burnout. Burnout is a prolonged response to chronic emotional and interpersonal stresses at work and is defined as comprising emotional exhaustion, feelings of depersonalization, and a low sense of personal accomplishment at work. In their research on vicarious traumatic stress among mental health professionals, Pearlman and Saakvitne, (1995) concluded that vicarious trauma (VT) is a distinct phenomenon from the construct of burnout. In the experience of VT, they found that individuals were almost always experiencing burnout. However, individuals experiencing burnout do not necessarily have symptoms of vicarious trauma (e.g., intrusive imagery, avoidance behaviours, feelings of numbing 34 out, hypervigilance, and disruptions to core beliefs). Sotile and Sotile (2002) have further described burnout as: . . . a state of physical, emotional, and mental exhaustion that results from intense involvement with people over long periods of time in situations that are emotionally demanding . . . burnout tends to be job related and situation specific, rather than pervasive. Burnout is not the same as being generally overstressed, and it differs from depression in that it is the final stage in the breakdown of coping reserves specifically relative to work' (pp. 4-5). While the two concepts are different, there is commonality in the symptoms people may experience. In reviewing the vast literature on burnout, Sotile and Sotile (2002) summarize seven symptom clusters that identify burnout: distressed affective states such as depressed mood and emotional exhaustion; poor concentration; more frequent physical symptoms of stress such as headaches or sleep disturbances; diminished work performance; loss of motivation for work; interpersonal distress in various forms such as irritability, dehumanization or indifference; organizational distress, low morale, job dissatisfaction, absenteeism or job turnover. Distress Among Physicians. Becoming a physician invites direct exposure to human suffering. Hale and Hudson (1999) say that in all fields of medicine "doctors are required to transform the shocking into the mundane; and, in doing so to contain the unacknowledged anxieties their patients project on to them" (p. 221). Scaer (2001) points out that accumulation of traumatic life experiences leads to a state of increasing vulnerability and decreased resiliency to further trauma exposure. During their professional career many doctors are at risk of experiencing vicarious traumatic stress reactions and burnout because of the consistency with which they are exposed to suffering. Despite this, medical schools provide little training in traumatic stress (Bills, 1999). Reluctance to seek help or disclose personal distress. Reaching out to others is considered to be an important element in both preventing and recovering from vicarious traumatic stress. However, the experience of trauma can often lead to a sense of isolation and many professionals who view themselves as caregivers are resistant to seeking help for themselves (Gentry, Baranowsky & Dunning, 2002). Maoz, Rabinowitz, Herz and Katz (1992) note that doctors find it especially difficult to seek help for themselves. Sinclair (1997) suggests some possible reasons for this: Several features of the medical habitus may be at work to account for such high rates of many sorts of mental illness . . . among members of the profession that itself treats illness . . . the underlying importance of not complaining or "whinging" . . . the distaste for the low-status segment of Psychiatry; unwillingness to examine, or unawareness of, internal mental events ... perhaps the most 35 important feature ... is the great difficulty doctors have in reversing their medical status and becoming a patient, (p. 319) Unfortunately, the stress and suffering experienced by individual doctors may go undetected, even by themselves, until it reaches a critical point. A s Montgomery Hunter (1991) notes, doctors who are constantly either dulled by routine or assailed by death (and the sense of failure that this can lead to) "easily become hardened to suffering, not the least their own" (p. 141). Hale and Hudson (1999) list seven self-protective defense mechanisms that doctors typically employ in trying to cope with the anxieties of repeated exposure to traumatic material: denial of unwelcome feelings such as anxiety; becoming workaholic; intellectualizing or 'medicalising' personal problems to make them seem controllable; becoming hypochondriacal; escaping into eroticized experiences to confirm being alive and vibrant in the face of depression and physical decay; using black humour to transform what is terrifying, disgusting or sad into hilarity; and acting out which can include becoming medically overactive (e.g. over prescribing), taking addictive drugs or using alcohol excessively, engaging in risky behaviours (e.g., driving too fast) or committing suicide. While some of these defenses may provide a semblance, or perception of coping, they are disturbing when considered in terms of research on trauma and trauma recovery. Fighting against, hiding from or denying painful feelings generally makes things worse: "The more feelings need to be avoided, the more energy is spent on keeping them at bay - energy that should have been used for feeling alive and open to new experiences" (Scaer, 2001, p. xiv). Vicarious traumatic stress and burnout have been linked to high rates of suicide, depression, alcoholism and substance abuse among physicians (Holland, 1995; Preven, 1981; Reiser & Rosen, 1984; West, 2001). Hale and Hudson (1999) note that doctors have high rates of suicide compared to other professionals. When doctors are unable to continue working in ways that are personally and professionally satisfying, effective and sustainable, the impacts of this are felt in their professional, personal and family relationships (Hilfiker, 1985; Holland, 1995; McBride & Metcalfe, 1995; Rout, 1996; Rout & Rout, 2000; Sotile & Sotile, 2002; West, 2001). Self-disclosure has not been traditionally fostered in the profession (Becker, Geer, Hughes & Strauss, 1961; Hilfiker, 1985; Holland, 1995; Maoz et al., 1992). Frank (1995) notes that the culture of medicine has "little space for personal becoming" (p. 158). West (2001), among others, draws attention to the implicit value in the medical culture of getting on with the physical business of doctoring and pushing the subjective and the psychological to the margins. A culture of silence surrounds mental health issues in a professional culture "in which the private and the public have been kept firmly and unhealthily separate" (West, 2001, p. 206). The costs of living with this mask of professionalism can be significant for some physicians. As Reiser and Rosen (1984) note: 3 6 Our profession is littered with casualties: doctors who are addicted, alcoholic, and divorced or else deeply depressed, disillusioned, and alone. For rare individuals, the apparent opportunity to deny all emotion may seem a welcome relief, but it is a dangerous denial and one most of us do not welcome anyhow. For the vast majority of us, being in touch with our feelings and coming to peace with them is essential to our well-being. There is good evidence that patients are much more vulnerable to disease if they are not in touch with their feelings. W e believe that doctors too are at greater risk and for the same reason. W e cannot continue to treat ourselves, much less our patients, like insensate machines, (p. 85) Cassel l (1997) notes that "the medical environment is not very kind to its workers" (p. 181). Physicians are uncomfortable acknowledging emotional distress in either colleagues or residents. Those in need of help receive little support from their peers and little encouragement to seek psychotherapeutic assistance in a climate where emotion is traditionally unwelcome and systematically suppressed. In describing a service for doctors in need of psychological services in the United Kingdom (U.K.), Hale and Hudson (1999) draw attention to the added fears of stigmatization experienced by doctors who are referred to counselling services (usually by their consultant or clinical tutor) as compared to those who self refer: The position of the referred doctor is rarely simple. One doctor may become the focus and scapegoat for a troubled unit or hospital. In effect, doctors may come for therapy on their own firm's behalf. Often it takes a crisis, sometimes a crisis with legal implications, for the need - whether individual or collective - to be recognized. For the doctors on whom such pressures play, there is the reasonable fear of being labeled sick, mad, or inadequate - the weak link in a macho team. Small wonder that many doctors, junior or senior, can regard seeking psychological help as tantamount to professional suicide, (p. 228) Furthermore, Hale and Hudson (1999) note intercultural issues complicate help seeking behaviours. Doctors practicing in the U.K. but who were trained abroad are generally wary of seeking psychological help and those that were referred to their services were "seized with thoughts of fear and rejection" (p. 228). Both Sinclair (1997) and West (2001) speak of the gendered and racial constraints that have been persistent in the medical world and muddled with questions about standards. Emotional and interpersonal disconnection. Given physician's proclivity to hide or deny the extent of internal emotional stress it is not surprising, in view of recent research on trauma, to see how readily relationships with others and with their own sense of being a compassionate and caring person can be undermined in the work of doctoring. Reduced ability to sustain compassionate relationships has been linked to iatrogenic 37 suffering for patients (Kuhl, 1999, 2002), a loss of meaning and validation of their place as healers for the physicians (Bills, 1999; McBride & Metcalfe, 1995), more dissatisfying, fractious and draining encounters with patients (Hilfiker, 1985; Holland, 1995; Maoz et al., 1992; Sotile & Sotile, 2002), and as a primary ingredient in patients pursuing malpractice suits (Cassell, 1997). After more than 30 years of studying stress and trauma, Levine in his book Waking The Tiger (1997) describes the importance of learning to move fluidly between instinct, emotion and rational thought to resolve and heal traumatic experiences and maintain a sense of connectedness in the world: Without a clear connection to our instincts and feelings we cannot feel our sense of connection and sense of belonging to this earth, to a family, to anything else. Herein lie the roots of trauma. Disconnection from our felt sense of belonging leaves our emotions floundering in a vacuum of loneliness. It leaves our rational minds to create fantasies based on disconnection rather than connection. These fantasies compel us to compete, make war, distrust one another, and undermine our natural respect for life. If we do not sense our connection with all things, then it is easier to destroy or ignore these things. Human beings are naturally cooperative and loving. W e enjoy working together. However without fully integrated brains, we cannot know this about ourselves, (p. 266) It is now recognized that trauma is a psychophysical experience that affects the entire body-mind-spirit of a person's being (Rothschild, 2000). Traumatic memories tend to be stored in an emotional or somatic context that traumatized individuals may not be able to readily access or place in a verbal context (Scaer, 2001). Trauma is not "talked" into us and cannot be talked out of us (Dayton, 1994). Nevertheless, while talking alone may not heal trauma, verbal therapies and interactions have an important place in initiating the process of healing and helping traumatized individuals to begin the vital process of integrating traumatic memories into an embodied narrative (Rothschild, 2000; Scaer, 2001): Integrated trauma therapy must consider, consist of, and utilize tools for identifying, understanding, and treating trauma's effects on both mind and body. Language is necessary for both. The somatic disturbances of trauma require language to make sense of them, comprehend their meaning, extract their message, and resolve their impact. When healing trauma, it is crucial to give attention to both body and mind; you can't have one without the other. (Rothschild, 2000, p. xiv) Researchers have stressed that people who work in the field of trauma must have a solid professional support network and an ability to pay attention to their own evolving needs if they want to continue to provide care and lead productive lives (Catherall, 1995,1999; Cerney, 1995; Munroe, 1999; Pearlman, 1999; Zinn, 1988). Research has shown that being able to verbally 38 express one's distress can have significantly positive effects on the functioning of the immune system (McFarlane & van der Kolk, 1996) and that gaining information and education about traumatic stress symptoms alters the body's stress response and promotes healing (Scaer, 2001). An inability to express emotional concerns limits opportunities for intimacy and invites disconnection thus leaving doctors much more vulnerable to being "toppled into depression, .alcohol and drug abuse, or suicide" (Holland, 1995, p. 29). Concurrently, the unwillingness of doctors to openly speak about the stress they are experiencing (and see this as a sign of strength rather than weakness), prevents them from receiving broader societal understanding and a more comprehensive realization of the needs for increased systemic support and human resources (Holland, 1995). However for doctors, disclosing feelings of uncertainty, experiences of helplessness in the face of unfixable suffering or sharing the fear of making mistakes all carry with them the anxiety of being judged as incompetent or accused of malpractice (Hilfiker, 1985; Holland, 1995; Sinclair, 1997). Mistakes and moral decisions. Sotile and Sotile (2002) report the metaphor that Leape (1994) used to describe the fear experienced by doctors of making mistakes; like test pilots, errors are seen as a failure of character, the result of negligence or not trying hard enough. They report from literature that approximately one third of physicians in the U . S A are, in the course of their lives, subjected to a medical malpractice suit and that the support of colleagues which is so much needed at times like this is often not forthcoming. Clarke (1996) notes similar trends in Canada; malpractice suits tripled in the fifteen years prior to 1996 and the amount of award quadrupled; twice as many suits against doctors were successful compared to fifteen years earlier; and in 1994, doctors were on average spending $200 million annually on insurance for claims of injury alone. A s Holland (1995) comments, for many doctors "the threat of litigation hangs like gathering clouds" (p. 24). Uncertainty is a fundamental aspect of medical practice. In diagnosing (identifying or labeling the disease), making a prognosis (forecasting how the illness may unfold over time) and deciding on a course of treatment, doctors must continually make decisions in situations that lack clarity. In reviewing literature on the issue of medical mistakes and how they are variously handled both interpersonally and through formal mechanisms, Clarke (1996) concludes that medical practice is inevitable error-ridden. Medical work "inherently encapsulates a degree of uncertainty. Yet it usually results in, even requires action" (p. 297). Hilfiker (1985) points out that although mistakes are inevitable they are not well received in the culture of medicine or society at large; doctors suffer their mistakes in silence and the emotional consequences are significant: The medical profession seems to have no place for its mistakes. Indeed one would almost think that mistakes were sins. And if the medical profession has no place for mistakes, neither does society. The number of malpractice suits filed 39 each year is symptomatic of this. In what other profession are practitioners regularly sued for hundreds of thousands of dollars because of misjudgments? . . . . The drastic consequences of our mistakes, the repeated opportunities to make them, the uncertainty about our culpability, and the professional denial that mistakes happen all work to create an intolerable dilemma for the physician. W e see the horror of our mistakes, yet we cannot deal with their enormous emotional impact. Perhaps the only way to face our guilt is through confession, restitution and absolution. Yet within the structure of modern medicine there is no place for such spiritual healing . . . Little wonder that we are defensive about our judgments, that we blame the patient or the previous physician when things go wrong, that we yell at nurses for their mistakes, that we have such high rates of alcoholism, drug addiction and suicide. At some point, we must all bring medical mistakes out of the closet. This will be difficult as long as both the profession and society continue to project their desires for perfection onto the doctor. (1985, pp. 85-86) Doctors, Clarke (1996) notes, are continually called upon to make moral decisions. Even the choice of a label for a particular dis-ease can be a moral act, such as choosing to see drug addiction as an illness rather than a weakness of character. Citing previous work, Clarke identifies eight types of situations where doctors are frequently called upon to make moral decisions among conflicting demands: • Deciding between the needs of one patient versus a group of patients. For example adequate care of one patient may require the relative neglect of others or the use of experimental drugs may result in death for an individual patient but benefit others in advancing knowledge. • Making choices about the allocation of time, resources and skills among individual patients. • Choices between the present and future interests of patients. • Meeting the expected needs of the patient versus the patient's family. • The conflict of being unable to help a patient when one expects oneself to be a healer. • Conflicts between service to the patient and service to the state or other organizations. • Dilemmas in balancing the advancement of one's career with the interests of patients. For example deciding to stay in a rural practice because the community needs a doctor versus moving to a more lucrative urban setting. • Conflicts between the doctor's role as doctor and other roles such as wife, husband, father, mother, religious person and so on. 40 Impact of the current health care system. Sotile and Sotile (2002) point to the pressures of being a physician in this day and age. Medical professionals have always led busy, pressured lives, however, traditionally they enjoyed high levels of control, autonomy and prestige and typically, most doctors were men who had the support of a stay-at-home spouse. Based on their research, they note that the typical medical family today has changed dramatically in both its form and function. Doctors are currently faced with demands to work faster, take on excessive workloads, keep pace with rapidly developing technologies in their field skills and constantly adjust to changes that are out of their control. In Canada, the current health care climate is unsettled and demoralizing for many working in the area. High workloads, lack of resources and for many, a sense of not feeling adequately valued or recompensed is further complicated by a less deferential and more litigious culture. A large-scale survey of 3,520 physicians carried out by the Canadian Medical Association (CMA) indicated a serious decline in physician morale (Sullivan & Buske, 1998): "Canada's physicians appear to be a stressed-out, fed-up and cranky lot as the close of the century approaches... Never have so many physicians worked so much for so little income and so little gratitude" (p. 525). The C M A report indicated that 62% experienced heavy workloads, 55% claimed to have difficulty balancing professional and personal lives, and 43% had concerns about decreases in income. In addition to facing comprehensive technological, political and economic changes along with significant forces of bureaucratization and corporatization, the prestige of medicine has diminished and doctors are currently experiencing unprecedented levels of criticism (Halvorsen, 1999). As one of the respondent's to the C M A survey wrote: The answers to these questions do not convey my very real sense of despair and exhaustion. I believe that most physicians unconsciously contracted with society to pursue their profession to the utmost of their ability and energy, to keep up their skills and to do whatever was needed to promote patient care. In return, we expected respect, the equipment to do the job and freedom from financial anxieties. All 3 of these expectations have been abrogated, yet we continue to fulfill our side of the contract in confusion, disbelief and a sense of betrayal. (Sullivan & Buske, 1998, p. 528). Murphy (1999) noted that the ongoing restructuring of health care has been designed to address management needs (e.g. increased efficiencies and cost containment) and has largely ignored human and organizational elements. The key factor of the well-being of workers is "conspicuous in its absence" (p. 159). Restructuring, Murphy says, generally focuses on "hardware issues" (e.g. length of patient stay, speed of admission) and health care workers have little input into the redesign; they are expected to fit in as best they can. In advocating for a change in this model, Murphy points to results of the largest ever patient satisfaction survey 41 which involved over a million patients across 545 hospitals and 44 states in the U.S.A. The 10 factors that correlated most highly with patient satisfaction had nothing to do with hardware issues, they were all interpersonal factors such as the friendliness of nurses, sensitivity and attention paid to personal needs, cheerfulness of the staff and demonstrated concern for privacy. The dramatic changes that have occurred in the health care system and the perception of medicine in the broader culture leaves many young doctors feeling dispirited as they see what lies ahead of them: It must surely be significant that today's young doctors seem to qualify and leave their medical schools dispirited by what they have come to know about the conditions in which medicine is now practiced. The reduced numbers who elect to continue in their hospital jobs and so become fully registered doctors are often, quite frankly depressed by their work, by the relentless hours, by their sense of working in isolation (or with colleagues who never seem to stop running), by an increasing number of patients who seem to view their relationship with their doctor as something that the doctor offers and in which that they themselves play only a passive part, by a growing view that administrators and politicians seem to stand over and against them, rather than alongside, and by increasing restrictions on their freedom to speak out about any concerns they may have for the service they are striving to provide. Without doubt, bureaucratic restrictions are growing year by year, with little to show in the way of improved doctor/patient relationships (the heart of medicine), but rather in dissatisfaction and increasing pressure: (Holland, 1995, pp. 150-151) Sotile and Sotile (2002) describe physicians as feeling "double-crossed" because the spoken and implied psychological contracts they had on entering medicine (e.g. esteem, autonomy, appropriate financial recompense, appreciation for their efforts, supportive dealings with colleagues and harmonious relationships with patients) have been violated. Experiencing being double-crossed, they argue, leads to lowered morale, increased stress and loss of trust for the physician and spills over into their relationships with others and frequently results in a virulent, negative emotional chain reaction: For many physicians, the strained relationships and loss of support that result from mismanagement of their emotions proves to be the final ingredient in a recipe for stress, dissatisfaction, and burnout. High demand/low control is bad enough; high demand/low control/low support can be deadly. (Sotile & Sotile, 2002, p. xv) Doctor's narratives. In this climate of uncertainty, Montgomery Hunter (1991) speaks to the "psychic refreshment" and "moral encouragement" that narratives about the experience of being a doctor can offer to others in the profession: 42 ... being a physician is hard work. These narratives about doctoring, especially in a time of change, are valuable for representing the subjective experience of physicians meeting difficult patients, puzzling or frightening patients, patients who may sue ... such reports "from the trenches" tell us something never included in the medical case history: the physician's thoughts and feelings about the medical encounter, (p. 163) However, as Montgomery Hunter also points out, the untold stories of medical care are often those of the doctors and Holland (1995) comments that it is "remarkable how little literature there is on this subject of internal stress in doctors" (p. 29). While some biographical, autobiographical and fiction writing does speak to the experiences of being a doctor (Berger & Mohr, 1967; Hilfiker, 1985), in general, the opportunities that exist for doctors to either voice or read about the experiences of being a doctor are quite restricted. In reviewing studies of the experience of being a doctor, Kleinman (1988) concluded that the majority of them are principally external accounts. The voice of the healer, the story of what it is like to be a healer is often missing: Practitioners often feel that these externalist academic accounts for all their analytical power, leave something out that is of vital salience for them: namely, the internal, felt experience of doctoring, the story of what it is like to be a healer. Physicians have turned to fiction and essay to convey this inner world of the c l i n i c ian . . . . We know more about the patient than the healer. W e do not possess an adequate scientific language to capture the essence of the doctor's experience. What the doctor feels is most at stake - what is most relevant to practice - often slips through our crude analytical grids, (p. 210) The tension between what stories doctors can tell, what stories we can hear, and what remains unnamed is great. Slaby and Glickman (1987) pick up the same theme that Berger and Mohr (1967) bring to our attention in their evocative story of the life of John Sassal l , a country doctor in England. How much do we want our doctors to be our equals? How much can we hear of their struggles? We all want physicians to be sensitive, warm human beings. We also want them to be professional; they must function in spite of the realities of our tragedies. W e cannot expect them to be both to their fullest. Professionalism is to a degree, a mask. In professionalism's finest form, physicians who don the mask are forever aware that they are wearing it. They may hold it with tremulous hands, but they know its necessity. They must weigh data objectively, make rapid decisions, and confront problems in a manner inspiring confidence during our most dreaded crises ... and even our moments of death, (p. 165) 43 Rudolph and Stamm (1999) suggest that enhancing the personal satisfaction and professional effectiveness of front line health care providers is fundamental to the well being of our society as a whole. Given what we currently know about preventing and alleviating the impacts of exposure to suffering and the extent of distress being experienced by significant numbers of physicians, it is troubling to learn how few opportunities doctors appear to have for sharing either the burdens or the joys they experience in their work. Doctors' stories and narratives about doctoring appear to be circumscribed by societal expectations of physicians, medical culture, and the ways in which we currently "story" medicine. While the above factors relate to all health care workers but especially physicians, family doctors face a unique set of circumstances because of the nature of their practice. The following details the particular stresses on family physicians. Family Physicians2 Characteristics of family practice and the importance of self-knowledge. In underlining the importance of the patient-caregiver relationship, authors have highlighted the need for interdisciplinary models that can augment required training in medical science and technology with a human science perspective that focuses on understanding individual experience and the co-creation of meaning. The importance of developing such a "transformed clinical method" (McWhinney, 1975) is particularly relevant in family practice medicine. As Cassel l (1997) says, family practice medicine is "based on the centrality of the patient rather than on an organ system or disease, as in the case with specialism. It is addressed to both the sick and the well" (p. 4). One of the main differences between family medicine and other medical branches is the duration of the doctor-patient relationship over extended periods of time. Polliack (1992) comments that family doctors are involved in both treating disease and caring for people who are ill or dis-eased. The dividing lines between curing and caring, between medical and social issues and between problems of health and problems of living are never very clear. More than any other type of doctor, family physicians work at the undefined interfaces. Nor can they deny this role, for the core of family medicine lies not only in the technical competence of the doctor but also in a comprehensive approach to the needs and expectations of others. (1992, p. xii) Family practice focuses on the human components of medicine and the therapeutic benefits of the doctor-patient relationship. The self of the doctor is seen as fundamental in 21 will continue to use the terms family doctor, family physician and family practice medicine as they reflect the most commonly used terminology in Canada at this time. Equivalent terms in the literature are general practitioner (GP), general practice, primary care physician, primary care practice. 44 general practice (Cassell, 1997; McWhinney, 1996). In family medicine "it is the being of the physician, not just the doing, that counts. Physicians are not merely bearers of knowledge and skills, vitally important as those are, but are themselves the instruments of care" (Cassell, 1997, p. 7). The College of Family Physicians of Canada (2003) defines the role of the family physician based on the following four principles of family medicine (See Appendix B for full text): 1. The family physician must be a skilled clinician. 2. Family Medicine is a community-based discipline. 3. The family physician in a resource to defined practice population. 4. The doctor/patient relationship is central to the role of the family physician. Harrison (2001) allows us to understand the fullness of what this means by reviewing the definitions provided by Willis (1995) and Heath (1995). According to Willis, generalists can best be defined in terms of what they do not do; anything that a patient brings to a family physician is of interest. Heath's definition is similar; "All aspects of human existence are legitimate concerns of the general practitioner provided that they are presented by the patient. This means that the general practitioner is obliged to deal with the complexity of each individual patient and should never be content to respond to a patient by saying 'That's not my business or my problem'" (Heath, as cited in Harrison, 2001, p. 67). Holland (1995) sees family doctoring as fertile ground in which to understand the stress experienced by care-givers because of the exceptional circumstances created by their professional field: Frequently understandings develop as a result of studying extreme situations. It is as if the exceptional serves to force the main issues out into the open. Family practice is just such an extreme. A doctor's responsibility is unusual in that it extends across the twenty four hours of each day, as well as covering the physical, social, psychological and clinical areas of caring for adults. Once other professions had continuous responsibilities but now I can only think of one other role in life that is close to this total care, and that is parenting. However, parents care for their own children, and do not have the pressure of clinical responsibility, (p. 6-7) Given that the ability to build therapeutic relationships is a core aspect of family medicine then McWhinney (1996) suggests that self-knowledge on the part of the healer is essential, even if the path to such knowledge is hard: How can we expect our patients to grow in self-knowledge if we lack self-knowledge ourselves? Yet how difficult the pursuit of this knowledge is; how much easier to live a life of comfortable self-deception. To confront with complete honesty our own inner selves is a painful thing. For physicians it is particularly 45 difficult; it is all too easy for us to see ourselves as members of an elite, successful in a highly competitive field, the objects of awe and admiration . . .We cannot begin to know others until we know ourselves. W e cannot grow and change as physicians until we have removed our defenses and faced up to our shortcomings, (p. 81) Other writers (Hilfiker, 1985; Holland, 1995; Maoz et al., 1992; West, 2001) draw attention to the necessity for family doctors to gain self-knowledge in terms of their ability to sustain their own well-being. Family doctors are entwined in the physical, psychological and social lives of their patients. Alongside curing disease or preserving life stands the importance of witnessing and relieving suffering. The majority of elderly patients, those with chronic diseases, and most dying people are cared for by family physicians (Cassell, 1997; Holland, 1995; Latimer, 1995). A s Weston (2001) points out, connecting with dying patients in a deeply personal way and providing continuity of care requires courage: One example, which illustrates the distinctiveness of family medicine, is the care of dying patients. Deliberately involving oneself in the last stages of another person's life, investing time and energy to become attached to someone who will soon die, is a daring and courageous act. Physicians, deprived of their "bag of tricks", have no cure to offer. Their knowledge of drugs and available support services may ease their patients' suffering, but, more than anything else, it is their attentive concern and love that are helpful to the patient, (p. 1) Having the ability to connect deeply and empathically with clients/patients is paradoxically one of the qualities that can render people in helping professions most vulnerable to experiencing vicarious traumatic stress (Carmel & Glick, 1996). So the very qualities that foster a healing relationship are a risk for those who are not provided with effective means of support. Maoz et al. (1992) capture this dilemma: Doctors working with the same population over a long period become very involved with their patients, especially when dealing with emotional and social problems. Professional detachment, a dubious asset at the best of times, but an effective defense for doctors, becomes weakened in family medicine. This makes doctors more emotionally vulnerable to patients' problems but allows the opportunity to treat the patients by harnessing the emotional response, (p. 43) Scope of practice. A s we have seen, painful feelings such as uncertainty, anxiety, helplessness, frustration and isolation are often part and parcel of working in a profession that calls on us to help others to heal their suffering. For family practitioners, the nature of their work can increase the difficulties experienced by other physicians (Hilfiker, 1985; Holland, 1995; West, 2001). 46 The broad scope of their practice adds significantly to the levels of uncertainty that family doctors can experience. Because family medicine specializes in treating the whole person in their social contexts, the range of issues that people bring to them is immense. Often these are not, strictly speaking, medical problems but the whole gamut of their social, psychological and interpersonal difficulties. Often, for a variety of reasons, family doctors feel obligated to assist with these problems even if they could be better handled elsewhere (Clarke, 1996; Hilfiker, 1985; Holland 1995). The depth of the doctor-patient relationship, the reluctance of patients to speak to strangers, financial constraints, lack of community resources and the doctor's desire, commitment and sense of professional obligation to help all weigh upon the family practitioner. Holland (1995) speaks to how easily family doctors can become overwhelmed by the scope of their practice and the ideals of their profession. He notes that "doctors frequently have a distrust or uncertainty about referral to professionals in other disciplines who are not qualified doctors" (p. 69). Given that a large percentage of a family doctor's patients are presenting with and/or experiencing psychological difficulties, the reluctance of physicians to refer to counselling and psychotherapy services and their confusion about the qualifications and functions of people working in these professions adds to their own levels of responsibility, workload and ultimately stress. Added to this is the astonishing rate of advances in medical knowledge and technologies that doctors are expected to understand and integrate and which no one person can ever reasonably expect to do. Reiser and Rosen (1984) describe how most doctors handle this: What most doctors do to solve the dilemma is to draw a box around an area of relative "expertise" into which they then withdraw. They put a perimeter around the huge and momentous total picture. Where the doctor draws his box depends on many factors. Some draw it around molecules. Others draw it around an organ system. A s one very sincere and successful academic physician expressed it, "I'm a liver man." A few brave souls try to draw larger boxes and speak of themselves as generalists or family practitioners. Clearly the fear - an eminently understandable one - is that the larger one draws the box, the greater the risk that one's knowledge base will be vitiated and ultimately prove faulty, (p. 34) Family physicians draw very large boxes. They are at risk of buying in to idealized conceptions of their role, being all things to all people, being expected and expecting themselves to fix things across the whole spectrum of patient needs. Both self and patient-imposed expectations about availability can lead family doctors to "put patients not only first, but also second, third and fourth until they themselves, as well as their families, are relegated right off the bottom of the priority list" (Holland, 1995, p. 38). When doctors do this and neglect their own self-care and needs for self-preservation, the inevitable result, Holland (1995) suggests, will be exhaustion, a sense of failure and potentially a vicious cycle of increasing dependency on the part 47 of the doctor's patients. Hilfiker (1985) is eloquent in describing his own experience of struggling with limits in a profession where accessibility is one of its defining tenets: It is, of course, foolish to suppose that I could have responded to everyone's need. There seemed, however, to be no personally acceptable way of defining what the limits of my response should b e . . . . The feeling grew and grew that I had to protect myself from other people's needs, that they would tear me apart if I didn't take care of myself first. While my soul called for a life of service, my emotions called out for the life of a hermit, (p. 42) Working in a scope of practice that seemingly has no clear boundaries, Holland (1995) encourages doctors to reflect on and define reasonable and re-negotiable boundaries for themselves - to consider how being responsible and Holland's term "response-able" need to be combined: "If the patient is to be encouraged to be response-able for himself, then the responsible thing for the response-able doctor to do, is to encourage, enable and challenge the patient to develop the condition of being response-able for themselves" (p. 122). Drawing boundaries is not a simple issue, particularly for doctors working in smaller communities. The joys and rewards of knowing patients intimately and understanding/living within the social contexts of their lives makes it hard for doctors to draw lines between being personal friends and medical friends (Berger & Mohr, 1967; Holland, 1995). Conversations with family doctors who have worked in small communities have sensitized me to what it is like to hear the sounds of ambulance sirens in a small community, wonder which of the people you know is in trouble, prepare yourself to meet them and their families in the emergency ward and find the fortitude to operate on people with whom you have sustained relationships. Others have spoken of the difficulties of even trying to go shopping at the local supermarket without patients wanting to connect and ask advice about their health concerns. The joys and the stresses of being a family doctor, along with the expectations (both on the part of patients and physicians) are intricately braided and it takes time, reflection, support and courage to unravel and re-weave them in a ways that are personally sustainable and satisfying. Family doctors usually see diseases early in their evolution and often alone in making critical decisions. Doctors working in larger hospital environments can consult with and share responsibility with consultants and teams. They can admit patients for continuous observation. Family doctors are often much more isolated physically and in sharing professional responsibilities (Hilfiker, 1985; Maoz et al., 1992). They have to decide (sometimes over the telephone when they are on call and dealing not only with their own but also, in shared practices, with colleagues' patients that they do not know) what is the best course to take. In a more litigious culture and in the face of derision from colleagues if they over refer to emergency services, family doctors walk a very fine and lonely line. 48 Feelings of helplessness and frustration are also exacerbated by their commitment to dealing with patients over continuous periods of time. Family doctors sit in the extended suffering of chronic illness and death. They are obliged to deal with intractable problems and seemingly intractable patients week after week. A number of the physicians I have spoken with introduced me to what they referred to as the 80/20 rule of patient care, the common experience that "a relatively small number of people produce work out of all proportion to their number and medical conditions" (Holland, 1995, p. 50). Several authors point out how easily family doctors can feel trapped in what seem to be ineffectual, stagnant relationships with particular patients. Unused as they are to openly discussing feelings, unsure of how to proceed without seeming to blame the client or themselves and caught by their commitment to providing continuity of care, some doctors can reach the point where they dread or resent the expected next visit from a particular patient, yet do not feel they have the means or the right to discuss this with the patient and, if needed, refer them to another practitioner. Based on my own work with family doctors, I have seen some of them caught between their ideals of service and the reality of working with demeaning, offensive or outright abusive patients. Holland (1995) speaks of the importance of a doctor knowing "he does have the choice and freedom to accept or reject the patient who is now in front of him for care" (p. 53) and that in certain situations, termination of the relationship is sensible, freeing and ultimately interpersonally respectful. The context and sustainability of family medicine. Family doctors, like others in health care professions, are currently under pressure to take on ever increasing workloads. The rising costs of running a family practice, increased paperwork, the pressure to see yet more patients in a day and trying to help patients navigate and tolerate the increased complexities of the health care system, all compromise the very thing that is at the heart of family medicine, the doctor-patient relationship (Holland, 1995; West, 2001). One of the main joys of being a family physician is the opportunity to build rewarding and sustained relationships with clients (Berger & Mohr, 1967; Cassel l , 1997; Hilfiker, 1985; Holland, 1995; Maoz et al., 1992; van Zwanenberg, 2001). Media are quick to point out how patients suffer when doctors have to limit the amount of time they give to individual patients but we hear little about how being hurried and overburdened impacts doctors well-being (Sotile & Sotile, 2002). An excerpt from one of the Canadian doctors who responded to the C M A 1998 survey captures their current dilemmas: I have practiced in a remote area for 21 years and handle up to 180 births per year with no back up ... I see 50 patients or more each day (no choice) and have nothing to show for it except total and absolute exhaustion. I'm writing this at 2230 hours after [seeing] 48 patients, 3 ER calls, surgery until 2200 hours, and now charting until midnight. (Sullivan & Buske, 1998, p. 525) 49 Some writers draw attention to the fact that family medicine is seen to be less prestigious than other specialties and has struggled to carve out recognition as a separate discipline, either claiming specialist status or defining family medicine as opposite and complementary to specialist areas (Harrison, 2001). Family practice can be more onerous, or at least more unpredictable, in terms of time commitment and potentially both more and less challenging. In the seminal study by Becker et al. (1961), many of the students began to question their goal of becoming a family doctor as they approached graduation. They felt that the breadth of knowledge and skills that were needed to be a good family doctor was overwhelming and that the typically heavy workloads in family practice would prevent them from doing a good enough job for their patients. Many of the soon-to-be graduating students started to see specialization as a way of containing the breadth of knowledge required, enabling them to control workloads more easily and provide a better chance of providing good care. Advances in medical technology have moved medicine away from its traditional grounding in an ethics of care and compassion towards an ethics of intervention in which "the caring aspects of the healing relationship have come to be neglected, and even denigrated" (Pellegrino, 1985, p. 8). Many patients today gather health information for themselves from sources such as the internet. They are both more aware and more assertive about their rights and more knowledgeable about the increasing array of specialized and alternative health services that are available today (Clarke, 1996; Harrison, 2001). Maoz et al. (1992) remark that some patients view family doctors as gatekeepers to specialist referrals and treat them as if they were traffic policemen. However, if family doctors are seen as having referred unnecessarily or sent too many patients to emergency services "they may face the justifiable derision of colleagues as the patient is sent home with a diagnosis of indigestion and a sarcastic letter. Status in the eyes of colleagues is important" (p. 43). Authors point out that medicine is a hierarchical culture and that although collegiality is vital, it is not generally taught or honoured in either training or practice. The culture is engrained with a basic competitiveness that makes cooperation among doctors difficult and often results in poor communication (Maoz et al., 1992; Greenberg, 1990). Cassel l (1997) sees that as part of cost cutting measures, there is increasing and detrimental pressure placed on family doctors to act as gatekeepers: At a time when money speaks so loudly, primary care has come to be seen by many as a kind of medicine with financial, social, and organizational advantages, and with little regard to it as a kind of medicine in its own right.... Some other defining characteristics that have been discussed are that primary care physicians are first-contact doctors, that they may act as gatekeepers - in aiding the more rationale use of resources - and that they are not specialists or are not functioning as specialists, (p. 4) 50 The whole issue of gatekeeping is a thorny one. Pellegrino and Thomasma (1988) define three ways in which family physicians can act as gatekeepers: • "Traditional" gatekeeping is in line with the traditional responsibility of practicing rational medicine and what they call beneficence-in-trust. The physician uses only those tests and treatments that are beneficial and effective for the patient - this they say is the proper exercise of gatekeeping - morally imperative and economically sound. • "Negative" gatekeeping usually occurs in some kind of pre-payment system in which the physician strives to limit the use of health care services. This kind of gatekeeping is morally dubious because the physician can be caught in role conflicts - on the one hand the responsibility to be an advocate for their patient and on the other serving as guardian of societal resources. • "Positive" gatekeeping occurs when physicians encourage the use of health care facilities for personal or corporate profit - this they denote as morally reprehensible. A s I noted earlier, the current health care climate in Canada is demoralizing for many physicians. The efforts to contain health care costs place bureaucratic restraints on what family doctors are allowed to do for their patients and undermines their professional expertise and ethical commitment to providing the best care they can. Many are being forced into the unenviable position of being reluctant negative gatekeepers with resultant strains on their emotional well-being, their relationships with patients and their energy levels as they try to fight or circumvent situations that they experience as ethically unacceptable. As Donovan (2000) says: The guiding principle for the physician is no longer the patient's best interest and values but maximization of therapeutic benefit under budgetary constraints ... Attention to patient needs is further diverted by payment systems such as capitation, which - through incentives, withholds and payment limits - forces the physician to act as a double agent for the organization and all its enrollees as well as for his or her patient, (p. 20) A recent article in the Vancouver Sun (Wednesday, March 5, 2003) drew attention to the significant decline in the number of medical students who are choosing to enter family medicine. In an era of rapid technological expansion and increased specialization we may be confronting both the end of family medicine as we know it, or at the very least, increasing difficulties in finding a family doctor. West (2001) reports similar problems in the UK. In addition to rising rates of stress, clinical depression, alcoholism and suicide among doctors there is "accumulating evidence of declining morale, increased turnover and intense problems of recruitment and retention, especially among G P s in the inner city" (p. 5). Harrison (2001) summarizes the changes occurring in both patient's expectations and the reality of general practice in today's culture: the reality of today's practice is far from the ideals of the constantly available personal doctor who provides comprehensive care; people are more 51 interested in speed of access to services than they are in continuity of care or a personal relationship with "their" doctor and will access what they want in a variety of ways; and G P ' s today demand realistic workloads and the opportunity to have lives outside of medicine, neither of which their traditional job description provides for. Moving into partnerships has for many doctors been seen as a way to alleviate the stress of being constantly available, be able to find greater balance in work and family life and share financial costs. While this can work well in many instances, doctors may experience partnership situations as less effective and efficient (with regard to sharing patients and having less intimate knowledge of their concerns) and as not truly solving the debilitating effects of being on call. Being on call involves disturbance to sleep patterns and results in tiredness and a reduction of recreational time. The disruption of sleep patterns that is endemic to medical practice does not end with on call duty time and can continue even years after doctors have stopped practicing. While sharing on call duties with partners may reduce the number of evenings or weekends that a doctor is on call, during those times when she or he is covering for the group practice the demands and responsibilities are increased because they are looking after their colleagues' patients as well as their own (Holland, 1995). Even if the on call time is relatively quiet, the emotional readiness and physical preparedness it requires can be draining in ways that are difficult for other people who have not experienced it to understand (Hilfiker, 1985). Medical partnerships can also be a major source of interpersonal stress (Harrison, 2001; Holland, 1995; West, 2001). A s we have seen, the culture of medicine has traditionally engendered competitiveness among doctors and fear that sharing personal feelings of inadequacy or stress would lead to them being a target of shaming or blaming. Conflicts over perceived workload inequities or about shared decision making is difficult in climates where people are unused to talking about their feelings and do not have a strong tradition of inter-collegial trust. Fear that the distress being experienced by one member of the team will become contagious can further prevent doctors from supporting one another adequately (Holland, 1995; West, 2001). What could be a major source of professional support and stress reduction becomes the reverse: It is as if the doctor's partners are all striving to prevent the distress of medical work from further insinuating itself into their lives ... In an attempt to hold back the flood, they react by ignoring it in their colleagues, as if denying it will somehow make the other's stress go away. It is a vain attempt to stop work's tentacles from spreading from doctor to doctor, or into the doctor's home, but unfortunately such behaviour only serves to distance them from the person who is stressed, making his situation worse ... Without feelings being considered and received by his colleagues, the doctor finds himself shutting off in his turn from the feelings of family and patients alike. Often he will then be horrified at himself, 52 believing - and concerned - that he is losing his humanity. (Holland, 1995, p. 149) Harrison (2001) finds that the tension of trying to balance general, primary care with the need to maintain currency and expertise leaves family doctors today questioning whether to go for "breadth" (the more traditional view of offering open ended and accessible services) or to opt for "depth" (sub-specialization, limited availability and a more restricted place in a primary practice team). He exposes the disparities between the rhetoric of family practice (comprehensive, all inclusive, unendingly available service) with the realities of family practice in current social, economic and political climates and concludes by wondering what remains at the heart of general practice. Whether, in fact, in this context, the generalist can survive. Other authors note the growing prominence and need for family medicine in solving current health care issues (Cassel. 1997; McWhinney, 1996; West, 2001)). A s a society we are experiencing a growing diversity of social and health care needs (Clarke, 1996), a growing mismatch between high technology medicine and the health care needs of large groups of the population (Cassell, 1997) and increasingly complex ethical decisions about care (Pellegrino, 1985). Family practitioners need to fill the gap left by the impersonality of modern science and some believe that the concept of the physician as healer, as well as scientist, is poised to rise again like the phoenix (West, 2001). The complex structure of contemporary medical care adds to the difficulty of providing sustained ethical care. Unfortunately, the "trust relationship" required for so momentous a decision as, let us say, a no-code order is becoming ever more difficult in contemporary medical care. Team care, multiple consultations, rotations of house staff, institutionalization, stress at the moment of decision - all complicate the relationship. In public and teaching hospitals there is often no one with a sustained relationship with the patient who can serve as a personal physician in the delicate process of making moral choices. This is an intolerable impediment to ethical patient care in the complicated nexus of today's clinical decisions and the reconstruction that medical ethics will demand. (Pellegrino, 1985, pp. 26-27) Without an ability to respond to care in a more holistic manner, both patients and health care providers can become stranded in a wasteland between cure and death (Gadow, 1998; Scudder, 1990). Family doctors are the "lynchpins of the health-care system" (West, 2001, p. 204). As Nuland (1994) says: Between the lines of this book lies an unspoken plea for the resurrection of the family doctor. Each one of us needs a guide who knows us as well as he knows the pathways by which we can approach death ...The clinical objectivity that should enter into our decisions must come from a doctor familiar with our values and the lives we have led and not just from the virtual stranger whose 53 superspecialized biomedical skills we have called upon. At such times, it is not the kindness of strangers we need but the understanding of a long time medical friend. In whatever way our health care system is reorganized, good judgment demands that this simple truth be appreciated, (pp. 266-267) Strengthening collegiality and self-care. Despite the needs for interdependency and collegiality medicine remains a hierarchical culture. In reflecting on Robert Frost's poem The Silken Tent, Reiser and Rosen (1984) provide both a plea and a warning: Instead of quarreling with each other from the safety of our theoretical boxes, we must begin to appreciate that medicine as a human experience involves all of us at ail levels of the systems hierarchy, embracing "everything on earth the compass round". Each of us, with our own legitimate expertise, must begin to realize that we are all strands linked by a silken tent, a tent woven from the fabric our own shared humanness. This is a very simple notion, yet one that is heeded too rarely. To medical students, we would say: A s you dig your way through the mountains of facts, beware of those who burrow their own little holes in those mountains and then growl at approaching strangers. W e are all miners, (p. 35) Reiser and Rosen (1984) close their book with the contention that medicine "is a human experience, propelled forward by science but guided by love" (p. 170) and offer a 'desiderata' (which I will highlight) to young men and women entering medicine: • Remember that being a doctor is a privilege • Remember you are free • Empathize with the plight of your fellow professionals • Remember why you decided to become a doctor • Remember medical school does not last forever • Forgive yourself • Accept ambiguity and personal limitations • And, physician, heal thyself. In 1984 Reiser and Rosen stated that we must "nurture the needs, hopes, and sensitivities of the promising young men and women who have elected to adopt this unique, stressful, beautiful, and perilous career. W e must encourage introspection, healthy relationships, play, openness, and joyous, creative expression. W e must spawn a generation of doctors who are not afraid to love" (p. 175). It is sobering to be reading almost twenty years later in the literature how much work remains to be done if we are to accomplish this goal. Many doctors continue to be legitimately fearful about expressing their feelings or telling their stories despite the importance of this for their own well-being and enhancement of the doctor-patient relationship. For family practitioners this is further compounded by their relative 54 status in the medical hierarchy and the current predominance of the science as opposed to the art, or he/art, of medicine (Cassell, 1997; West, 2001). In looking at the in-depth experience of family doctors who work in inner-city contexts in England, West (2001) confronts the systemic difficulties that family doctors experience in giving voice to their experiences: The difficulty is that doctors have been taught to distrust their personal stories in the name of big science. Such science can be a normalizing truth that tends to disqualify, limit, deny or contain other personal stories (White & Epston, 1990). G P ' s are on the edge of the profession and its hierarchies of power and knowledge. Science has provided the discursive and bureaucratic base through which the medical profession has rationalized its privileged status in society but it has tended to marginalize other ways of knowing. What is suggested here is that doctors must find some means to weave more authentic and experientially inclusive stories, using subjective/autobiographical understandings and psychological insights, alongside the science, (p. 208) How can we assist family doctors to weave the more experientially inclusive stories that West (2001) and many others see as critical to enhancing the well-being of family physicians? In a recent study group meeting that he facilitates for a number of students like myself who are interested in engaging in research with physicians, Dr. David Kuhl (personal communication, July 15, 2003) challenged me to look again at how we turn the desiderata offered by Reiser and Rosen (1984) into a reality. How do we work toward having a fifth principle added to the characteristics of family practice medicine? Currently, the principles that guide family practice inform doctors that they are responsible for and embedded within the context of treating the whole patient, providing comprehensive care, continuity of treatment and availability. There is, despite everything we know from research and practice, no principle that directs or commends, requires or commands, or simply allows for family doctors to take care of themselves. For myself, the challenge of adding a principle of self-care to the defining characteristics of family practice seems to be caught in something of a chicken and egg dilemma. Several authors have commented that the importance of self-care for family physicians will never be fully recognized until doctors are willing to lift the shrouds of silence and speak openly among themselves and with others not only about external pressures, but also, the significant personal and emotional stresses they experience in their work. However, to what extent will doctors be able or willing to engage in such conversations and self-disclosure without a guiding principle or cultural endorsement of the validity of self-care, the legitimacy of emotions and the importance of both seeking and receiving support? Before such necessary conversations can be brought into wider social discourse, it is likely that they will need to become more familiar and common place among family doctors. Numerous times in my readings authors refer to the importance of collegiality and some of them 55 speak personally to the benefits they have received in joining with peers in conversations and groups to reflect on the challenges of being a doctor. In considering how we may be able to expand on opportunities for mutual support among family physicians, I will briefly review some existing group-based models that are described in the literature. Balint groups. Balint groups have been recognized and endorsed for a number of years as one way for family physicians to create a collaborative learning space and gain peer support. However, the focus of such groups remains largely on the doctor-patient relationship. Although Balint groups in mainland Europe have become more open to addressing the interplay of personal and professional issues (West, 2001), the more personal needs and experiences of the doctors remain a somewhat secondary issue - ones to be addressed individually outside of the group -and the main objective continues to be the improvement of doctors' skills in terms of the doctor/patient relationship (Balint, 1957; Maoz et al., 1992; West, 2001). Traditionally membership in Balint groups has been voluntary. In some countries (for example, the U.S.A. and Israel) Balint group seminars have been introduced as either compulsory or strongly recommended electives in family medicine residency programs. Maoz et al. (1992) note that this change "has sometimes caused much resistance among the residents and made it difficult to discuss cases for which doctors feel personally responsible and about people who would be their patients for a long time" (p. 128). The designated focus of Balint groups (i.e. the doctor/patient relationship) does not address the legitimate concerns that doctors experience about disclosing feeling of uncertainty, inadequacy or mental distress among colleagues (West, 2001). A s West concludes: ... even when G P s engage in Balint groups and consider, in depth, the emotional dynamics of the work, issues surrounding the interplay of personal and professional identities tend to be omitted from the conversation, even when crucial to the performance of the role. This is partly for fear of what others might think or say. (West, 2001, p. 144) The Accelerated Recovery Program for Compassion Fatigue. In the field of trauma research, treatment models that have been developed to address vicarious traumatic stress (Catherall, 1999; Gentry et al., 2002; Pearlman, 1999) are generally focused on working with those who are already experiencing vicarious traumatic stress reactions and do not combine both prevention and treatment. For example, Gentry et al. (2002) recently developed the Accelerated Recovery Program for Compassion Fatigue (ARP) "a five (5) session model for the treatment of the deleterious effects of compassion fatigue (CF) in the lives of professionals who encounter trauma secondarily through their work" (p. 128). Originally developed as a standardized individual treatment model the program has been expanded into train-the-trainer and small and large group workshop 56 formats. The authors recognize the "unique challenges of a professional asking for help" (p. 129) and the importance of connection with others to help compassion fatigued professionals on what they call "the road back home": Developing a personal "therapeutic community" is also mandatory in the prevention of C F . Breaking isolation and constriction can often provide immediate lessening of the problems associated with C F . The professional will be challenged to identify and develop underutilized resources for support, nurturance, and enrichment, (p. 131) While the A R P model shows promise (Gentry et al., 2002), it does not address how to draw professionals into a supportive community of colleagues before the onset of vicarious traumatic stress reactions. Nor are the bases for creating a supportive community of colleagues built into the program. A s in many individual approaches, participants are encouraged and challenged to build and maintain support outside of the treatment program. Family doctors may experience significant difficulty in finding the time, opportunities and resources to single handedly build a supportive network in the current culture of medical care. Effective Emotional Management. After more than 25 years working as counsellors and consultants in the medical field, and researching stress, burnout and resiliency among physicians, Sotile and Sotile (2002) have developed a model for stress-hardiness that they call Effective Emotional Management (EEM). They describe this model as moving beyond traditional approaches by incorporating the two essential and interrelated components of stress management, personality-based coping patterns and relationship dynamics. Sotile and Sotile (2002) contend that if physicians learn E E M skills they can both avoid or eliminate the negative consequences of emotional mismanagement and gain greater collaboration with colleagues, increased cooperation from patients, and affection with loved ones. They also point out that E E M makes good business sense in terms of decreasing negative interpersonal interactions and positively affecting morale, teamwork and productivity in the medical workplace. The E E M model is presented in detail in their recent book entitled The Resilient Physician (2002) in which they draw on a comprehensive review of relevant literature to describe stress and stress resilience among physicians. Throughout the book they include a number of inventories that can be used to assess individual coping styles and interpersonal dynamics and offer a broad range of advice and strategies to address various issues including: balancing work and family life; understanding and managing relationships in the medical workplace; anger management; negotiating conflict; the disruptive physician; listening and communication skills; coping with change; understanding and managing the stress of medical training; and, making your workplace a positive interpersonal culture. 57 Sotile and Sotile (2002) suggest that their book can either be used by individual physicians to enhance their personal well-being and stress resilience or applied in a group work formats by medical teams. Sotile and Sotile (2002) note that "collegiality and collaboration serve as the cornerstones of a stress-resilient medical organization" (p. 295). They present a developmental schema for considering the challenges that may impede the creation and maintenance of a collaborative work climate; offer strategies for addressing common problems; and outline a day long sample curriculum for staff and physicians who want to work toward building a positive workplace culture. The E E M model offers a breadth of ideas and strategies that will undoubtedly prove valuable to those who learn and apply them. It appears to have good potential for assisting with team building and conflict resolution among people who are committed to creating positive climates in the shared workplace. However the model is not designed to create a climate of collegial support among physicians, either those who work together or in different locations. Sotile and Sotile (2002) recommend that physicians attempt to build this kind of collegiality outside of workshop or workplace settings: We have found it to be of particular value for medical colleagues to periodically interact with each other in settings other than work. Herein lies the team-building value of staging yearly practice retreats, office holiday celebrations, or casual social affairs that bring your families together. Seeing a colleague in new contexts expands your perceptions of that individual; you now see him or her not only as a physician-colleague but as a person - someone who has a spouse, children, interests, and abilities outside of medicine, even a sense of humor. Such experiences serve to build traditions that will deepen your collegial relationships and mature your organization, (p. 315) In conclusion, while all three of these approaches are valuable in terms of the purposes for which they were designed, none of them intentionally address the need for building climates of support among family physicians or address how in joining together in cohesive groups doctors could provide the necessary therapeutic conditions for being the prime agents of change in terms of their well being and right to self-care. Summary of the Literature Review The literature provided evidence of the significant degree of distress that exists among physicians and the risks that doctors can run of experiencing burnout and vicarious traumatic stress if they do not have adequate emotional support. It pointed to features in the medical culture that inhibit doctors from disclosing personal distress or seeking help and to the fact that self-care has never been fully addressed within this professional context. The literature described the exceptional circumstances that family doctors face and indicated how the current complexities, structure and climate of the health care system further compromise professional satisfaction and 58 sustainability. It confirmed the need to expand resources to promote well-being and sustainability among physicians and revealed that there is currently a lack of group-based initiatives designed to provide family doctors with opportunities for collegial connection and building a climate of mutual support. Literature pointed to the benefits of biographical learning and the possibility that exists for emancipatory learning when people are provided with opportunities for critical self-reflection and re-storying their experiences in a safe, democratic, and cohesive group environment. Prior research indicated that a group-based life review process has the potential to promote self-awareness, personal and interpersonal learning, and connection among group members. Given evidence in the literature, the significance of this study was to examine whether a group-based life review program could provide a meaningful way for family doctors to share their experiences, create mutual support, and address issues of self-care and sustainability. 59 CHAPTER 3 Locating the Research Methodology Introduction This inquiry is grounded in the working assumptions of constructivism, social constructionism, and narrative epistemologies. I begin this chapter by highlighting aspects of these epistemologies so that readers can more fully understand how I am situating the investigation. I then provide the rationale for adopting a collaborative narrative methodology to explore the research question being asked in this study. I conclude by considering the process of narrative research and draw attention to issues related to articulating narrative understanding and the importance of reflexivity in narrative research. Epistemological Assumptions of Constructivism and Social Constructionism What distinguishes constructivism from other epistemological orientations is the emphasis placed on the selective, generative and organizational nature of human perception, memory and understanding. A s Spivey (1997) notes: "Constructivists view people as constructive agents and view the phenomenon of interest (meaning or knowledge) as built instead of passively 'received' by people whose ways of knowing, understanding, and valuing influence what is known, seen, understood, and valued" (p. 3). To know is to construct. Constructivists contend that there is no such thing as a single "truth" or objectifiable "reality". Knowing and understanding are fluid, partial and context dependent - influenced by individual, relational, temporal and sociohistorical factors (Arvay, 2002a, 2003; Burr, 1995; Gergen, 1999). Because "reality" is seen as socially constructed and context dependent, multiple versions of reality exist at any point in time and in principle, the forms of our descriptions and understandings are boundless (Mahoney, 1991; Gergen, 1999). Knowledge is not viewed as something that we either have (or do not have) or as something waiting to be discovered, but "as something that people do together" (Burr, 1995, p. 8). Shotter (1986) describes this as a practical knowing , " . . . a 'knowing from' (a knowing from within a situation that takes into account, and is accountable in, the situation in which it is known). Rather than having to do with finding, with discovering something already existing but hidden from us, it is a form of knowing to do with making, with bringing into existence something that is as yet only intimated or implied in what is currently in existence" (p. 213).). As Gergen (1999) explains "Truth" is replaced by situated, locally negotiated "truths". The adequacy or acceptability of any truth telling is dependent upon the willingness of others to support our view of things within a particular culture. Social constructionism places a primary emphasis on discourse, the performative aspects of language practices and how such discourses function within social relationships. Language is viewed as creating, rather than mirroring reality (Arvay, 2002a; Burr, 1995; Denzin, 1997; Gergen, 60 1999). While recognizing the varied viewpoints and dialogues that exist within constructivist and social constructivist epistemologies, Gergen (1999) proposes four working assumptions that I experience as useful foundations for my proposed research: 1. For any situation, there exist a potentially unlimited number of descriptions and interpretations. Language (not only spoken or written words but all varied forms of representation) do not mirror, picture or capture an independent world. In principle therefore (although not in practice) no one description or interpretation can be ruled as superior or more truthful than another. 2. Language and all other forms of representation gain meaning from the ways they are used within relationships or contexts. Meanings are co-constructed in relationship and our quest for a sense of assuredness or grounded reality can only be achieved through relationship. Furthermore, the relationships and discourse practices operating among human beings are contextualized within the surroundings they inhabit, and are culturally, historically and socially relative. 3. A s we engage in co-constructing our experience in language practices, we constitute social life and participate in creating our future because language is a critical element of action. The process of maintaining viable connections and traditions, transforming social life and building new futures depends upon our capacity and willingness to generate meaning together to engage in "generative discourses, that is, ways of talking and writing (and otherwise representing) that simultaneously challenge existing traditions of understanding, and offer new possibilities for action" (p. 49). 4. Reflection on our forms of understanding is vital to our future well-being. Because the generation of what we consider to be reasonable or valuable is always from within a certain tradition, we are typically blind to alternatives that lie outside of our adopted framework. The ability to engage in generative discourses requires reflexivity - an ability to place our own viewpoints into question, listen to alternative viewpoints and grapple with the complexities of multiple perspectives and framings of reality. From a social constructionist view, then, there is no one "sel f but a plurality of selves that we construct and negotiate with others given the discourses that are currently available to us. Our constructions and representations of ourselves are influenced (circumscribed to lesser and greater extents) by language systems, cultural and social arrangements and patterns. However, we are open to change as active agents engaged in what Shotter (1999) refers to as "joint action": a dynamic, reciprocal process of co-constructing ourselves and others. Narrative Epistemology Narratives are both a product and a process (Polkinghorne, 1988). They fill our personal, social and cultural environments in a multiplicity of forms and a central premise of narrative epistemology is the universality of narrative (Arvay, 2002b). Roland Barthes (as cited in 61 Polkinghorne, 1988) claims "the narrative is present at all times, in all places, in all societies; the history of narrative begins with the history of mankind; there does not exist, and never has existed, a people without narratives" (p. 14). A narrative epistemology assumes that we make ourselves, and others, known through the stories that we construct (Bruner, 1986; Cochran, 1985; Cochran & Laub, 1994; Denzin, 1997; Kenyon & Randall, 1997; Mishler, 1999; Polkinghorne, 1988; Sarbin, 1986). Narrative is the primary way in which people structure and make meaning of their experiences. As Arvay (2002b) states: How and what we tell in our stories becomes a means by which we make meaning. In our storytelling, we not only create a narrative, we are constructing ourselves or, as Theodore Sarbin (1986) claims, we are always involved in the activity of self-narration: the "I" construes the story in which the "me" will be shown as one of the main characters, or actors, (p. 208) Through its narratives, a culture provides models of identity and agency to its members and it is through our own narratives that we construct a version, or rather versions, of ourselves in the world (Bruner, 1996). We do not simply absorb or follow various cultural plots in storying our lives. Depending upon the contexts in which we find ourselves, we actively construct and re-construct ourselves as we select, adapt, adopt or resist the discourses that are available to us at any particular time. Mishler (1999) notes that, "We express, display, make claims for who we are - and who we would like to be - in the stories we tell and how we tell them. In sum, we perform our identities" (p. 19). Such performances, however, are not simply private matters - our stories are subject to negotiation, social sanctioning and/or perceived cultural legitimacy (Bruner, 1991; Burr, 1995). However, story telling and story construction provide endless opportunities for re-authoring our lives and revising and reinterpreting the life accounts we have previously constructed (Bruner & Weisser, 1991; Richardson, 1997). Narrative provides a way of interconnecting and signifying seemingly disconnected events or activities. It is a means for linking past to present and to potential futures. At the level of individual lives, narrative provides a lens through which we can negotiate the evolving meaning of our life and achieve a sense of wholeness (Polkinghorne, 1988; Richardson, 1990). Narratives allow for an illumination and reconciliation between the expected and exceptional and provide information about the subjective experience of the storyteller and the intentions, feelings, beliefs, and values that inform the action or events they are describing (Arvay, 2002b; Bruner, 1991; Clandinin & Connelly, 2000; Polkinghorne, 1988; Riessman, 1993; Sarbin, 1986). A s Randall (1995) succinctly notes, "the way we story our lives directly affects the way we understand ourselves; the way we understand ourselves directly affects the way we act; and the way we act directly affects the way the world is" (p. 9). Bruner (2001) suggests that autobiography (in Western culture) serves two main functions: On the one hand, telling our stories serves as an act of entrenchment in which we 62 present ourselves to others (and to ourselves) in a way that is culturally comprehensible. On the other hand, we don't just tell any old story. W e tend to tell those that we consider worthy of telling, ones that are interesting and that in some sense mark the individuality and exceptionality of our lives. To meet the criterion of tellability, stories must violate canonical expectancy but do so in a way that is culturally comprehensible. This complex then "involves not only the construction of self, but also a construction of one's culture" (Ibid p. 35). Arvay (2002b) provides a succinct description of the nexus between constructivism, social constructionism and narrative: All claim that the self has agency, lives within multiple "realities", is relational and contextually bound, is a process or a life unfolding, operates within self systems or cultural systems, and makes meaning by contrasting differences both dialogically and through human activity, often at a tacit level of awareness. The most important feature that all three share is the understanding that humans construct the meaning of their lives through language practices (p. 209). Rationale for Using Narrative Inquiry Narrative inquiry does not provide a detailed road map to a precise or pre-conceived destination or solution to a problem. Rather it opens doorways to multiple meanings, suggests ways to create and dwell in spaces of collaborative meaning making and encourages us to develop an expanded orientation toward our questions and "create new understandings and the possibilities for new realities" (Hoskins, 2002, p. 242). In this study I was seeking to enter into a space of dialogically structured meaning making with the participants so that we could strive to create a rich understanding of their experiences in the life review program. Polkinghorne (1988) suggests that researchers are generally faced with four problems when they attempt to study meaning: • Meaning making is not a static activity and it is therefore hard to grasp. • Each of us has direct access to only one realm of meaning - our own. Studying meaning requires the use of linguistic data which is always contextually situated and linguistic statements lose much information when treated in isolation. • Analyzing linguistic data relies on using hermeneutic reasoning which does not lend itself to the production of certain and necessary conclusions. • The complex recursive and relational patterns among various levels of abstraction, awareness and control make meaning a difficult area to investigate. Research into meaning making is not well suited to methods that use quantified data or have as a goal predicting or controlling behavior, "instead, it provides a kind of knowledge that individuals and groups can use to increase the power and control they have over their own actions" (Polkinghorne, 1988, p. 10). Shorter (1999) describes explaining and explanation as belonging to the realm of physical sciences where the goal is traditionally to get things right. 63 Human action that is mediated by meaning is generally regarded as the realm of interpretation rather than causal explanation. A s Bruner (1996) states, "Explanation does not exhaust interpretation, nor does interpretation exhaust explanation ... But the two are fundamentally different, and play different roles in the search for knowledge" (p. 112). He goes on to stress that being interpretive does not imply being anti-empirical, anti-experimental or anti-quantitative. It simply means that we have to take into account the triad of perspective, discourse and context and try to make sense of what people tell us in the light of this triad before we begin explaining things. Research methods must always be selected to best fit the research question. Lieblich, Tuval-Mashiach, and Zilber (1998) suggest that when researchers are addressing real-life problems "it may be advisable to approach people whose lives are relevant to the issue in an open manner, exploring their subjective, inner experience on the matter at hand" (p. 5). These authors point out that along with the interest that psychology has in being able to predict and control the behavior of humans and animals, the mission of psychology is to explore and understand the inner world of individuals. One of the most direct ways to learn about this inner world is through the personal narratives that people construct and tell about their lives and experienced reality. A number of authors have pointed out that the majority of studies on the experience of being a doctor are external accounts (Holland, 1995; Kleinman, 1998; Montgomery Hunter, 1991). In this exploratory study, it was crucial to create an understanding from the doctors' own perspectives and use a methodology that would allow myself and other readers to leam from the voices of the six doctors in the life review program. The purpose of group-based life review is not to explain ourselves (either ourselves or others) as some kind of finished product, but rather to provide an opportunity to create new ways of understanding what we know and choose to k/now about ourselves. It is a process that inherently recognizes that our life stories can be seen as open and unending. "They are, as Bakhtin (1981) put it, 'unfinalizable', for life always opens up more options ('real' and 'fictional' ones), includes more meanings, more identities, evokes more interpretations than even the number of all possible life stories could express" (Brockmeir & Carbaugh, 2001, p. 8). A collaborative narrative methodology provided the most appropriate means for reflecting the dynamic, fluid and dialogical nature of constructing and re-constructing understanding that is inherent in the life review process itself, and in the process of re-searching, co-constructing and interpreting the meanings of the participant's experiences. Narratives reflect not only our individual experiences in the world but also the social and cultural discourses within which we are embedded (Bruner, 1991, 1996; Burr, 1995; Mishler, 1999). The process of studying and interpreting personal narratives can illuminate the personal, interpersonal and socio-cultural conditions that delimit how individuals dialogically re-construct 64 and re-present the meanings of their experiences. In this way, stories created through a collaborative narrative research process can provide useful information about the ways in which current medical discourses may constrain or expand certain kinds of professional development opportunities and initiatives for family physicians. It is through narratives that cultures provide models of identity and agency to their members. Potentially, if the research narratives are experienced as resonant, they may speak to other family doctors who read them and open spaces for self-reflection and giving voice to their own experiences. Narratives can serve as teaching tales with the power to transform practice (Arvay 1998, 2002b; Bruner, 1996; Hoskins, 2002). As Hoskins (2002) says: "Understanding how people construct their lives and are also constrained by certain discourses allows for a deepened understanding of the complexities of negotiating identities in a postmodern context" (p. 237). Narrative as a Research Process Based on their own research experiences, Lieblich et al. (1998) suggest that conflicts and contradictions are part and parcel of doing narrative research because life stories and their readings are as complex and multi-layered as human identity. However, the open-ended, unpredictable and emergent nature of narrative research does not imply an "anything goes" approach. These authors contend that interpretive decisions should not be "wild" - they require justification. Researchers "are responsible for providing a systematic and coherent rationale for their choice of methods as well as a clear exposition of the selected processes that have produced their results" (p. 2). Denzin (1997) distinguishes between the analysis of narrative and narrative analysis as two approaches to narrative research. The analysis of narrative moves from stories to common elements. Stories are collected and subsequently analyzed through concepts from existing theories or inductively through the materials themselves. Narrative analysis moves from elements to stories. Events and experiences are collected and synthesized into a story or stories by means of a plot line. In the present study, I initially engaged in narrative analysis, co-constructing the participants' experiences in the life review program and re-presenting these in a story form. Following this I then moved into a process, a narrative analysis, exploring where there were common themes among the stories and also noting where there were distinct or singular elements. In the face of a complex variety of approaches to narrative research Mishler (1995) says that researchers must make decisions about the main purpose of the study and the primary focus of the analysis. Is the researcher more interested in the facts of the story and the succession of happenings or in how the story is constructed and represented? In reflecting on these questions I found the typology described by Lieblich et al. (1998) to be particularly helpful. These authors propose four different perspectives or interpretive lenses through which to look at stories: From the "holistic-content" perspective, focus is placed on the entire story and its content taking 65. account of both explicit and implicit meaning; the "holistic-form" quadrant focuses on the formal aspects of the entire story (rather than the content) and considers aspects such as plot structure over time and the metaphors used; a "categorical-content" perspective focuses on analyzing the content of specific parts of the story irrespective of the content of the whole story - word or other story segments are counted and placed in categories that the researcher defines as relevant to the research question; the "categorical-form" quadrant focuses on the morphological and discourse levels of sections of the story by counting and categorizing characteristics of the language and style used. The authors clarify that the quadrants are not exclusive and that synthesis between form and content analysis can prove very fruitful. Of these four perspectives, I decided that taking a holistic view of both the content and form of the stories would serve as a useful and layered interpretive framework for understanding the research narratives and illuminating the process of meaning construction. Recognizing the situational limitations and dialogically co-constructed nature of knowing, implies that there cannot be a separation of the investigator from the investigated (Arvay, 1998; 2002b; Greene, 1994; Schwandt, 1999; Smith, 1989). When researchers are following an experimental positivist research paradigm, they position themselves as neutral observers and generally write themselves out of the research text. In seeking to verify pre-established hypotheses, the legitimacy of the research is judged according to traditional criteria such as rigor, validity and reliability. A s Lincoln and Guba (2000) explain, the researcher in this model retains control of the research process and is presumed to be an objective, "distant scientist'. However, when we enter into constructivist narrative research, control of knowledge generation is shared between the participants and the inquirer. From this perspective, the researcher assumes the position of a "passionate participant" whose purpose is to facilitate the generation of multivoice reconstructions. Establishing the authenticity and trustworthiness of narrative research relies in part on "individual reconstructions coalescing around consensus" (Lincoln & Guba, 2000, p. 170). In this study, I positioned myself as a participant-inquirer for the purpose of inviting and co-constructing stories about the doctors' varied experiences in the life review program. The narratives that are presented in this text are collaborative documents that were mutually constructed in research conversations. There are no set standardized rules or criteria for evaluating the worth of narrative research findings (Riessman (1993). Authors suggest a variety of alternative criteria to evaluate legitimacy (Clandinin & Connelly, 2000; Lincoln & Guba, 2000; Lieblich et al., 1998). Given this complexity it is my responsibility as the researcher to provide readers with a sufficiently detailed and transparent understanding of the methodology that I followed in this inquiry and select criteria that allows others to assess the quality of the study. In this inquiry, I chose four criteria to evaluate the worth of the study: resonance, consensual validity, persuasiveness, and pragmatic use. These will be described and discussed in Chapter 4. 66 In the remainder of this Chapter, I will now turn to discussing two key issues that I needed to address as I engaged in narrative inquiry. Articulating Narrative Understanding From a constructivist narrative perspective, understanding is a practical and unavoidable experience of being in and of the world (Schwandt, 1999, 2000; Shotter 2002). Understanding is both lived and living. It emerges dialogically "in the space between the living, bodily expressions of one individual and the spontaneous bodily responses to them by another" (Shotter, 2002, p. 296) in what Shotter refers to as a complexly intertwined "third space". Shotter (2002) contends that understanding the nature of such spaces can only be studied from within the practices in which they are created: Thus to investigate Their nature, their structure, the calls they can exert on us, what is possible for us within them and what is not, we need some utterly new methods of investigation, quite different from the "onlooker" methods inherited from the natural sciences. Instead of dealing with regularities and repetitions, as in modernist inquiries, we must deal with quite specific "once-occurent events of Being" (Bakhtin, 1993, p. 2), occurring in the quite distinct and specific realities of understanding emerging between us in the many different relationships in which we become involved, (p. 299) In this study, entering into Snorter's "third space" invited both myself (as a participant inquirer) and the participants to be open to space-moments of learning and re-cognize that meaning-making is emergent, dynamic, relational and context sensitive. In rejecting the traditional mind/body split, postmodern narrative epistemology challenges the view that thought and language can be understood as independent and disconnected from bodily experience or that the history of selfhood begins only with the acquisition of language (Arvay, 2002b; Eakin, 1999; Mahoney, 1991; Polkinghorne, 1988; Shotter, 2002). W e are invited to re-embody experience and meaning and to recognize that long before anything emerges in our conscious mental experiences "we can find in the very structure of our responsive bodily activities the precursors or prototypes for what we shall later talk of in mental or cognitive terms" (Shotter, 2002). As Mahoney (1991) puts it, "Feeling literally illuminates and energizes activity" (p. 176). In exploring the contributions made by Merleau-Ponty to understanding language, Abram (1996) notes that "Communicative meaning is always, in its depths, affective; it remains rooted in the sensual dimension of experience, born of the body's native capacity to resonate with other bodies and with the landscape as a whole" (pp. 74-75). We learn the sounds and gestures of our native languages bodily. In dialogue we respond not only, or even primarily, to the spoken words of another, but to the multi-layered and embodied experience of the encounter: gestures, movement, rhythm and tone of the sounds of speech, felt sense of the shifting emotional climate 67 and responsiveness between us, and our experiences of the environment in which we are encountering another. Shotter (2002) provides a quotation from Merleau-Ponty to express this: "... in my experience of others ... I inevitably grasp my body as a spontaneity which teaches me what I could not know in any other way except through if (p. 289). In my training and work as a professional counsellor I have learned the importance of paying attention to not only the words that are expressed in trying to reach mutual understandings, but the importance of taking into account all the varied ways in which we are interpersonally experiencing and expressing an embodied encounter. Paying attention to the multiple ways in which meaning is interpersonally communicated allows for both an expanded ability to explore and interpret implied knowledge and also enhances a more authentic and collaborative way to dialogue about the relationship that we are interpersonally experiencing and negotiating. Neumann (1998) reminds narrative researchers in their encounter with those they are researching, "empathic knowing, whatever its limits, is as much about the present moment (of the telling) as it is of the past experience (of that which is told), however enwrapped in the past the present moment may be." (p. 437). Both during my participation in the life review program and subsequent research conversations, I sought to remain both experientially and reflexively attuned to my own embodied experiences, my interpretations of what was expressed bodily by others (in gestures, voice tone, silences and emotional expressiveness), and my sense of the situated and evolving emotional climate. A narrative approach to inquiry advocates pluralism, subjectivity and relativism. There is no single true perspective on a topic, no correct interpretation or right way to read a text. Meaning is fluid, partial and situated and as Riessman (1993) says, "we are interpreting and creating texts at every juncture ... our narratives about others' narratives are our worldly creations. There is no 'view from no where' (Nagel, 1986), and what might have seemed nowhere in the past is likely to be somewhere in the present or future ... All we have is talk and texts that represent reality partially, selectively, and imperfectly" (p. 15). From a narrative perspective, understanding is interpretation because we are continually taking something as something and "to understand is always to understand differently" (Schwandt, 2000, p. 195). Citing Gadamer, Schwandt (2000) describes understanding as a risk and an adventure which can be dangerous but "is also capable of contributing in a special way to the broadening of our human experiences, our self-knowledge, and our horizon, for everything understanding mediates is mediated along with ourselves" (p. 196). From this perspective, researchers are required to question who they should be toward and with the participants in a study. It necessitates engaging reflexively with one's own biases and "acknowledging the ongoing liminal experience of living between familiarity and strangeness" (Schwandt, 2000, p. 207). To seek understanding requires a willingness to risk confusion about ourselves and the other person 68 we are seeking to understand. It demands that we engage in genuine conversations that challenge our own self-understanding and stance in the world. Clearly, any research grounded in these assumptions has to acknowledge that there can be no one, or final, interpretation of experiences. Any interpretation is a re-interpretation. Any text that is produced is entangled in other texts. It is a construction from certain perspectives and situates both authors and readers within particular discourses or ideologies (Denzin, 1997). The core of postmodernism is doubt (Richardson, 2000). It suspects all claims to truth or authoritative knowledge as serving particular interests. Taken to its extreme, radical relativism implies that "even the doubt must be doubted. There is no center that can hold" (Gergen, 1999, p. 30). And yet, as Richardson (2000) says, "a postmodern position does allow us to know 'something' without claiming to know everything. Having a partial, local, historical knowledge is still knowing. In some ways, 'knowing' is easier, however, because postmodernism recognizes the situational limitations of the knower" (p. 928). The goal then of constructivist and narrative research is not to uncover the truth of a phenomenon but rather to articulate an understanding, a reading of events and experiences that may be useful. The understandings that were collaboratively created during this study and that I, as the researcher, have translated into this current document are inevitably like snapshots in an album of photographs. They provide images of an experience taken from a particular angle and revealing a certain expression and play of light and shadow. However, by their very nature of being still photographs, they can only illusively encapsulate what was, and is, the fluidity and evolving process of living. Bal (1997) provides a useful description of the tension that exists in constructing narrative texts:" . . . a text is a finite, structured whole composed of language signs. The finite ensemble of signs does not mean that the text itself is finite, for its meanings, effects, functions, and background are not. It only means that there is a first and a last word to be identified; a first and a last image of a film; a frame of a painting, even if these boundaries, as we will see, are not watertight" (p. 5). Reflexivity in Narrative Research Research conversations are complex, dynamic, contextual interactions. Arvay (2003) emphasizes that narrative researchers face multiple questions about interpretation, re-presentation and voice in constructing a research text and notes that these concerns "are fundamentally about reflexivity. Reflexivity from a narrative perspective problematizes the researcher's process and examines how power relations are attended to both within the research relationship and in the construction of the research narratives" (p. 257). Reflexivity can be understood as a turning back of one's experience upon oneself while recognizing that "the self to which this bending back refers, and the experience upon which the process is predicated, must also be understood as socially constructed" (Steier, 1991, p. 3). He goes on to explain that if we allow for multiple perspectives and acknowledge that the self to 69 which we are referring may be different as a result of it's own self-pointing, then the reflexive looping back may unfold as a spiral. Steier (1991) offers the suggestion of seeing research as translation. This forces a de-privileging of the researcher's viewpoint and requires that we recognize that conversations are historical, interactive and contextually situated with no one voice representing the way it really was: Paradoxically, seeing research as translation allows that, as we reflexively understand our research to be about ourselves, we open up greater (rather than fewer), degrees of freedom for the voices of the others. It allows us to begin to question where our own categories do not fit, and where we have created 'false notes' out of good music" (p. 177). Clandinin and Connelly (2000) propose that if researchers are to truly inquire and interpret narratively they cannot pre-determine the course of the analysis because narrative analysis is relational and the boundaries are interactively permeable. A s these authors point out: Narrative inquiry always has a purpose, though the purpose may shift, and always has focus, though focus may blur and move. Narrative inquiry boundaries expand and contract, and wherever they are at any point in time, they are permeable, not osmotically permeable with things tending to move only in one way but interactively permeable. Researchers' personal, private, and professional lives flow across the boundaries into the research site; likewise, though often not with the same intensity, participants' lives flow the other way. (Ibid. p. 115) Clandinin and Connelly (2000) contend that the researcher's experience is always a dual one - being part of the experience itself yet also remaining the inquirer experiencing the experience. Tensions around relational intimacy and reflective distance are always alive in narrative research from the initial creation of field texts through to the construction of research texts. The authors suggest that researchers situate themselves within a three-dimensional research inquiry space that includes temporal continuity (past, present, future), personal and social interaction, and situated context. Within this space the inquiry and the inquirer can move in any of four directions: inward, toward internal conditions such as feelings, hopes, values; outward, to existential conditions in the environment; backward, to past experiences; and forward to present and future conditions. They see research into human experience as experiencing it simultaneously in these four ways and to ask questions pointing in the four directions. Working within the three-dimensional space, we work not only with our participants but also with ourselves as researchers. Both Behar (1996) and Clandinin and Connelly (2000) challenge researchers to recognize that they are vulnerable, embodied, complicit observers who cannot hide behind the presentation of an idealized, inquiring self. Narrative researchers need to 70 be willing to enter the anxiety, ambiguity and ambivalence of the research process without a pre-determined map so that mutual, relational, respectful learning can evolve and hopefully lead toward the creation of texts "that, when well done, offer readers a place to imagine their own uses and applications (Clandinin & Connelly, 2000, p. 42). From the inception of this inquiry and throughout the process, I kept a research journal in which I recorded extensive field notes and personal reflections. I found this invaluable in helping me to work within the three-dimensional space that Clandinin and Connelly (2000) recommend. It encouraged me to stay reflexively aware of how my own experiences and ways of making meaning were shaping my perceptions. It also allowed me to explore how interpersonal issues of intimacy, distance, authority and authorization were entwined and negotiated as we participated in the life review program and collaboratively constructed the meanings of their experiences in the research narratives. A s I struggled with how I could authentically address these issues, I decided to adopt Arvay's reflexive collaborative narrative method as the foundation for my approach to this exploratory inquiry. Arvay (1998, 2002b, 2003) developed the method as a way to put the heart back into constructivist research and move more consciously toward interactional and dialogical forms of research practice and representation. In the following chapter, I outline the epistemological foundations of the method and describe in detail the procedures that were followed in this study. 71 CHAPTER 4 A Reflexive Collaborative Narrative Method This research study was designed to explore the meanings that family doctors construct about their participation in a group-based life review program and to co-create an understanding and re-presentation of their experiences through individual and shared reflections, research conversations, and collaborative interpretations. In this study, adopting a collaborative narrative method provided a way to both inter-stand the meanings that participants constructed about their experiences in the life review program and to critically explore how cultural discourses were at play in the stories and in how we interpersonally negotiated the construction, interpretation and representation of the research narratives. According to Arvay's (2003) method, research conversations are designed to invite stories. The complexity of inviting stories requires entering into the third space (Shotter, 2002), trusting that meaning-making activities will emerge dialogically, and envisioning the co-investigators not as respondents or informants but as co-actors in the research performance. I am in agreement with the epistemological basis and assumptions of the method (Arvay 1998, 2002b): • Knowledge is local, partial and socially co-constructed through dialogue. • Meaning is constituted through language and human beings create their identities through the stories that they tell (to themselves and others) about their experiences. Stories provide both coherence and continuity to our lives and reveal our intentions and purposes. • Human beings are meaning makers. W e impose meaning on our own constructions and those of others. Understanding an other is inevitably an act of interpretation. • Cultural stories within which we are embedded influence what we tell to whom, and under what circumstances. • Research texts are human constructions written by people who have a situated and vested interest in the research. Therefore narrative researchers should include themselves in the text in ways that allow readers to gain a better understanding of how interpretations were constructed. • Reading research texts is an interpretive process. There is no single or universal way to respond to a textual account. • Researchers should strive to create non-hierarchical, collaborative research relationships with participants and be conscious of power differentials that exist within research relationships. 72 Arvay (2003) outlines seven stages in the research process: (1) setting the stage: a reflexive preliminary interview, (2) the performance: a collaborative research conversation designed to invite stories, (3) the transcription process, (4) four collaborative interpretive readings of the transcript, (5) the collaborative, interpretive interview, (6) writing stories, (7) sharing the stories. Inviting participants to engage in collaboratively interpreting and discussing the interview transcripts makes heavy demands on the time and involvement of co-investigators. The current research study was designed to understand the experiences of participants in a group-based intervention. Prior to the two research conversations that we held, the participants in this inquiry had dedicated significant amounts of time to attending the life review group meetings and reflecting and writing prior to each meeting. It was not feasible to ask them to put in additional hours to collaboratively interpret the research transcripts according to Arvay's (1998) original research design. Arvay (2002b) suggests that when time is an issue, researchers can accomplish narrative analysis through the four interpretive readings without the participation of the co-investigators. In doing so, they need to remain reflexively cautious that the stories do not become their sole interpretation of participants' lived experiences. The method has been successfully adapted in this way by Black (2003) and Smitton (2003). The research procedures that were followed in this inquiry will now be addressed in detail. The Research Journal The first step in conducting research of this nature was to begin by keeping a self-reflexive research journal. The journal provided a means for recording descriptive field notes and things that struck me as interesting or puzzling. It allowed me to express the emotional responses that were evoked in hearing others' life stories and reflecting on, and sharing, parts of my own. . During the sometimes unsettling, sometimes exhilarating journey of being a researcher, it was the place where I could keep track of my shifting perceptions, develop self-awareness, reflect on methodological conundrums, pose myself new questions and see where I needed to seek both further clarification and support to push through blocks. When it came to writing the interpretative narratives my research journal was a resource for re-membering the context of our interactions during the life review group and research conversations and a record of the thoughts, feelings and intuitions I had at various times. It was a road map of how the research process had unfolded. Most importantly, it allowed me to juxtapose ways that I had interpreted experiences in my journal during the life review process with the meanings that participants shared with me during our research conversations. In varied ways, reflexive joumaling helped me to remain open and curious about our multiple perspectives and strive as Fine, Weis, Weseen and Wong (2000) recommend, "to come clean 'at the hyphen' 73 meaning that we interrogate in our writings who we are as we co-produce the narratives we presume to 'collect'" (p. 123). Selection of Participants The participants were a self-selected group who voluntarily chose to join the inquiry. The selection of participants for this case study followed a purposeful, and more specifically, a critical case sampling approach (Creswell, 1998; Merriam, 1998). I was seeking participants who had the knowledge and experiences required to adequately respond to the research question and the time and willingness to participate in the inquiry (Morse, 1994). Selection of participants was based on three primary considerations. First, participants had to be family practice physicians, doctors who were qualified to work in Canada as general practitioners. Second, the participants had to have practiced in Canada as family doctors for a minimum of six years so that they had sufficient experience to address the research question. Third, the participants needed to be available to attend the group-based life review program and research interviews and be able to commit the time required outside of these meetings to participate fully in the study. The group size was limited to six participants to ensure that there was adequate time in the group meetings for participants to share their stories. It was hoped that there would be diversity among the participants in terms of age, gender, and type of family practice. However, because participation was voluntary and self-selecting, no criteria were put in place to limit participation on the basis of gender, age, or location and type of family practice. A s the group meetings and research interviews were held in Vancouver, British Columbia (BC), it was assumed that most of the participants would currently reside and work in the Greater Vancouver area or in parts of B.C. that are within easy travel distances from the city. It was also assumed that language barriers would not preclude the participation of family doctors for whom English is not a first language. Being licensed to practice family medicine in British Columbia, Canada requires fluency in the English language above the levels needed to participate meaningfully in a life review program and research interviews that would be conducted in English. Inviting Participation Participants were initially invited to join the study through word of mouth. A letter of invitation was prepared (Appendix C) that was distributed by the facilitator of the group-based life review program using his professional networks. The life review facilitator is himself a family physician and also has an interdisciplinary doctoral degree with a focus in counselling psychology. Daniel (a pseudonym that will be used for the purposes of this study) seeks to combine his knowledge and skills in medicine and counselling psychology in his work as a researcher, service provider and educator. He has established expertise in leading in-service and professional development initiatives for physicians and other health care providers, and a broad network of professional contacts within health care. 74 In addition, Daniel and I delivered an oral presentation during Family Practice Rounds at a major hospital in Greater Vancouver. W e spoke briefly to the project, invited participation, and distributed the letter of invitation to doctors who expressed interest in learning more about the study. During the oral presentation, Daniel recommended that where doctors were in shared practices, it would be preferable to have only one doctor from each group practice volunteer for the study. This was done in an effort to expand diversity and also to take into account interpersonal sensitivities that might heighten the anxiety of engaging in a process of self-disclosure with one's immediate work colleagues. Family doctors who indicated a desire to learn more about the study were telephoned so that we could discuss the research process in more detail, review the criteria for participation, and consider whether they wanted and were able to join the research project. Of the eleven doctors who expressed an initial interest in joining the study, three realized that prior personal and professional commitments would conflict with the time frame of the study; one did not meet the criteria for selection, having only been in practice for two years; one doctor knew that her office partner planned to join the group and based on our recommendation in the oral presentation, felt that her colleague should have the first opportunity to join. Following our telephone conversations, six family physicians (four women and two men) indicated a strong interest in joining the project and introductory conversations were scheduled with five people. For one volunteer, one of the pre-scheduled meeting dates created a conflict with on-going commitments. After some juggling and co-ordination among schedules I was able to find another date that would work for everyone and scheduled an introductory meeting with the sixth volunteer. Subsequently, another physician who had heard about the study from a friend contacted Daniel to express interest in volunteering for the study. However, by that time we had reached the maximum number of participants for the life review group. Setting the Stage: Preliminary Conversations Kvale (1996) provides two contrasting metaphors to illustrate different theoretical approaches to research interviewing. In more traditional interview approaches, the interviewer is like a miner attempting to "dig nuggets of data or meanings out of a subject's pure experiences, unpolluted by leading questions" (p. 3). Conversely, the interviewer as a traveler wanders through the landscape with local inhabitants, enters into conversation with them and asks questions that invite subjects to tell their own stories about the world they live in. Meaning is not something that exists in a static or finished form waiting to be discovered. Meaning making is a fluid, dynamic, emergent, relational and context sensitive process. In any situation there will always exist a multiplicity of meanings that we create and dialogically negotiate as we language and embody our experiences within relationships. The traveler metaphor is clearly more compatible with my own theoretical orientation and intention in this collaborative inquiry to invite stories through 75 conversation (Arvay, 1998, 2002b, 2003). I have therefore chosen to follow Arvay's (1998) lead and prefer to speak of research conversations rather than interviews in recognition of my assumptions about the relationship between discourse and meaning (Mishler, 1986). Preliminary conversations lasting approximately one hour were held with each of the six potential participants in the study. The participants decided the locations where these conversations were held and the times that would fit best with their schedules. Four of the conversations took place in the doctors' offices, one was held in my home, and the sixth at a coffee shop that we both frequented and enjoyed. One of the conversations had to be rescheduled at the last minute. A s I was arriving for our meeting at the end of evening office hours, the physician received an urgent call to attend a delivery. By this point in the research, I was already conscious of these busy doctor's lives, the unpredictability with which they had to contend when they were on call, and the need for us to take into account that responding to patients' needs took priority over scheduled meetings. The purpose of the interview was to begin developing rapport; share the reasons why I was interested in the research topic; facilitate dialogue about the research process, time commitment involved, and the roles and responsibilities that both I, and the participant, would have in this inquiry. My intention was to be transparent about my values regarding life review, my personal experiences with the model, my views about collaborative research relationships, and the philosophical values in which the research design is grounded. The preliminary conversations provided an opportunity for the participants to raise questions or concerns and talk about their initial reasons for joining the study and what they hoped to gain from participating in a life review group with colleagues. It was also the time when we began to get to know each other outside of the "researcher" and "participant" roles. As each conversation progressed, it flowed beyond the boundaries of focusing on the study into a reciprocal sharing of parts of our professional and personal lives that connected us as people and laid the foundations for our research relationship. Towards the end of each conversation we took time to review the consent form (Appendix D) together and dialogued about ethical issues such as confidentiality, the potential risks and benefits of being part of the study, and the right to withdraw from the study at any point. I suggested leaving the consent form with each participant for a week so that they could reflect on their decision about joining. In every case, the participants choose to sign the consent form at the end of the meeting stating that they felt certain about their desire to join the study and that their questions and concerns had been addressed in our conversation. The six doctors who participated in the study were all practicing family physicians in the Greater Vancouver area. Their ages ranged from 39 to 59. Two of the six had been in practice for approximately 15 years and four had practiced for 25 years or more. While all were currently practicing as family doctors in an urban setting, between them the participants brought a wealth 76 of diverse experiences as doctors: teaching and mentoring residents; experience in rural practice; working overseas in a developing country; involvement in medical research; and experience in specialty clinics focused on working with specific illnesses or client populations. The Life Review Program for Family Physicians There were a total of eight participants in the life review group; the six family doctors, Daniel as the group facilitator, and myself. Thanks to a major hospital, we were able to hold our meetings in a spacious and private conference room in an office building. During the life review meetings I positioned myself as a participant-inquirer, witnessing the life review process and responding to the stories that were shared. Being present as a participant-inquirer during the group meetings and reflexively journaling my experiences provided both a foundation for establishing collaborative peer relationships with the participants, and greatly enhanced my capacity to understand and construct with them the narratives of their experiences. Participating in the group allowed me hear and experience the emotional impact of the stories that were shared, and in responding to them share parts of my own life experiences. It allowed me to be part of the spontaneous conversations that emerged during our break times and as we gathered together each evening. Being present at both an experiential and reflexive level was important in both helping to illuminate how the lenses I was wearing were colouring my perceptions and in challenging me to extend my choice of lenses (Arvay, 2002b; Steier, 1991; Peshkin, 2001). Daniel and I had considerable experience working together as co-leaders of groups prior to this inquiry. A s the researcher in this study, ethical guidelines precluded me from assuming the role of co-leader. However, I was actively engaged in assisting Daniel with the logistics of the group process, in preparing for each meeting, and in dialoguing about how the process had unfolded after each session. Our collaborative planning and debriefing conversations allowed us to explore the intersections between the research component of the study and the group process, including the shift in our relationship from working as co-leaders to being leader and researcher. Dialogues with Daniel and my research committee helped me to struggle reflexively with what sometimes felt like the uncharted waters of participant inquiry and explore the tensions of living among the multiple "I" positions that are an inevitable part of collaborative inquiry (Clandinin & Connelly, 2000; Reinharz, 1997). Before the start of the research inquiry, I designed the life review program for family physicians in collaboration with Daniel and my research supervisor. The structure of the program followed the original life review design (Birren & Deutchman, 1991). As Birren and Cochran (2001) suggest I adapted the number and focus of the original themes and created themes and sensitizing questions that would be responsive to this particular group context. In addition to writing on the various themes, I invited the participants to keep a personal journal of anecdotes or notes to themselves about their experiences during the process. This is 77 not part of the original life review model. I included it as a way of possibly enhancing the group members' reflections and learning during the life review process and expanding the re-collections of the experience that we would share in the research conversations. The original design of the group-based life review program called for six sessions of approximately ZV2 hours duration. These sessions were scheduled in the evening at more or less regular intervals over a period of seven weeks. By the time we had reached the third group meeting, it became clear to Daniel and myself that six sessions would not be enough to provide adequate time for both the rich sharing that was occurring on the various themes and appropriate time for group closure. When this issue was brought to the group, the decision was made to add a seventh meeting that would that would allow for closure, and (at the participants' request) an opportunity to provide feedback about the structure and process of the group and thoughts about future directions. In some life review groups, participants value the opportunity to have a follow-up meeting several weeks after the process has ended. When the participants in the group knew that this was a possibility, they were unanimous in their desire to schedule a follow up meeting and this was held eleven weeks after the final session. The first meeting was dedicated to building an initial sense of inclusion and personal control among the group members following the model developed by Borgen et al. (1989). We reviewed the structure and purpose of life review and the guidelines that I had prepared about group process, writing on the themes and journaling their life review experiences (Appendix E). A s a group we collaboratively established group agreements to promote confidentiality, respectful communication and a non-judgmental group climate. The draft group agreement (Appendix E 4) was expanded upon to establish how we could most effectively address the issue that a number of the doctors would be on call during the sessions. The participants were reminded that in keeping with the principle of confidentially inherent in life review, no audio or videotaping would occur during the meetings and that they were not required to show me what they wrote on the various themes or in their journals as part of the research process. I believed it was important to respect the confidentiality of the stories they chose share in the group and their personal writing, and only include in the research narratives what they chose to share with me in the collaborative research interviews following the program. The first meeting was also a time to engage in several introductory activities that allowed the participants to get to know each other and become oriented to the process by sharing a branching point in their lives related to becoming a family physician with one other group member (Appendix E 5). The meeting closed with reviewing the theme that participants would prepare for the second session. The following five sessions followed a similar format, with the exception of the second session which began by inviting participants to speak to their learning goals and what they hoped 78 to personally gain from participating in the program. After a short introductory activity to allow members to reconnect with the group and speak to any issues that they needed to bring forward or put to one side so that they could be fully present, the group members shared and responded to the stories that they had individually prepared. The sessions ended with reviewing the theme for the following week and a brief closing activity. Each meeting focused on a different theme (Appendix F), in the following order: • The major branching points in your life. • Your family. • Your career as a family physician. • Your experiences with stress, distress and bearing witness to the suffering of others. • The meaning of your life, and your aspirations and life goals. The final (seventh) session provided the opportunity for the participants to speak to what they had either personally or professionally gained from their participation, provide Daniel and myself with feedback about the program, and share ideas that they felt could make the program more effective and responsive to the needs of family doctors. A closing activity ensured that all of us had time to acknowledge the work we had done together and express our feelings about the group coming to an end. A follow up meeting was held almost three months after the final session. It was an opportunity to reconnect, reflect on our work together, and explore what the participants were carrying forward from their learning and experiences in the program. First Research Conversations Individual research conversations lasting from 114 to 2 hours were scheduled with each participant in the three weeks following the final group session. With the participants' permission, our conversation was audio taped for subsequent transcription. Three of the conversations took place at participants' homes at their request and three in a small office adjacent to the conference room where the group had been held. Initially, when I spoke to the group about my desire to create an understanding of the co-researcher's experiences through a collaborative conversational interaction, I realized that some of the participants were a little confused. They expressed being more used to traditional structured interviews in which they would be expected to respond to a series of pre-established or guiding questions. I consulted with Daniel and my committee members about my dilemma of not wanting to direct or de-limit the interviews and yet sensing that some participants were concerned about trying to second-guess what would be expected of them. To alleviate potential anxiety, I decided to prepare a short handout (Appendix G) in which I suggested we could start our conversations with taking a chronological view on how their experiences had unfolded over time in the group. As physicians are very used to taking patient's life histories, Daniel thought this may provide a familiar and comfortable way of framing the research conversations. 79 As Arvay (2002b) points out, inviting stories is a complex act and requires more than interviewing skills: "It is about entering the 'third space" by being present to it and trusting that the process will unfold - a leap of faith that meaning making activity will unfold dialogically" (p. 213). When I thought about wanting to co-create and maintain collaborative research relationships, I was conscious that trying to hold a stance of reciprocity within the framework of "doing research" is a complex issue. As researchers we need to question ourselves about who we are speaking for, and to, and for what purpose and be willing to ask ourselves who is claiming that the research relationship is collaborative and to what ends (Arvay, 2003; Haraway 1991; Fein et al. 2000; Harrison, MacGibbon & Morton 2001; Richardson, 1990). I began each conversation with a "starter statement" as a way of both inviting stories and encouraging choice about how participants wanted to begin: As I said in the shod handout, I'm hoping that today we can have a conversation about your experiences in the group. I don't have a set series of questions and there isn't any right or wrong way of doing this together. One way I'd suggested in the handout is to start by tracking back to the beginning, to your initial decision to join the group if that makes sense for you. Or you may prefer to begin by speaking more globally about your experiences. It's whatever feels right, or fits for you. In several instances, as we began to talk, I was very conscious of the inescapable power differentials that appear to be inherent in any research interview situation, no matter how collaborative one's wants to be. Following my starter statement, one participant said, "Why don't you choose how to start." Another commented, "I thought I'd like to start by going back to the beginning, if that's O K with you?" Initially, there were comments such as, "I don't know if this is interesting?" or "I don't know if this is the kind of thing you're expecting?' Quite quickly however, these kinds of statements receded as we flowed into a more natural, conversational dialogue. Five of the six participants brought their personal journals with them to the interviews. To varying degrees, they would pause to leaf back through them, reflect on what they had written, and sometimes either summarize their writings or directly quote from their journal. At the start of one conversation, a participant asked what we would do about the tape recorder when she wanted to pause and take time to reflexively review her journal writings. Would we turn it off, so that there wasn't a long silence? I responded that we would just leave it running; take the quiet time needed for her to read her journal as we would if we were talking without recording our conversation, and reassured her that I had extra tapes with me so we could take all the time we needed. Kvale (1996) reminds us that the original Latin meaning of conversation is "a wandering together with" and that interviews are literally inter-views. Voice is not something that we discover but something that we create together. In constructing the other, we are likewise reconstructed (Lincoln, 1997). During each research conversation I was actively engaged in an emerging, 80 interactive dialogue. I consciously used the skills of active listening, empathic reflection, paraphrasing and clarifying to reach a mutual understanding of what the participants were telling me and to express an openness and desire to hear whatever they chose to share. Although the focus of each conversation was on the participant's experiences in life review, we wandered into other avenues as we wove together an understanding and interactively explored the meanings of being in this program. I responded authentically to questions the participants asked me about my own recollections or feelings and, occasionally, I offered an anecdote from my own life that resonated with experiences they were describing. The conversations were evocative and at times emotional. We shared laughter, surprise, frustration, joy and some tears. When painful emotions emerged during the conversations, I responded empathically and tried to create a welcoming and safe space to honour the expression of feelings. I deliberately withheld from probing or using counselling skills such as advanced empathy to engage in exploring the issues more deeply. Kvale (1996) points out that research interviews are distinct from therapeutic conversations that people have requested, and "it may be unethical to attempt to instigate new self-interpretations or emotional changes" (p. 156). I was however conscious, as I had been during the group sessions, of the multiple positions I was balancing and the tension I sometimes experienced between my counsellor/group facilitator 'selves' and the less known positioning as a participant-inquirer. I was interested in understanding how my presence in the group as a researcher and non-doctor may have impacted the life review process and also the significance of the group facilitator being himself a family doctor. In the first interview, the participant spoke spontaneously about these issues. I decided, following this conversation, that I would explore this gap in my understanding with the other five participants and raise these questions myself if they did not emerge naturally as we talked. Following each research conversation, I reflected on the interview and recorded my recollections and feelings in my journal. I made notes about both the context and content of the conversation. I recorded my perceptions of the feeling tone between us, and expressions of emotion. I recalled what was said in body language or, in several cases, brief enactments to illustrate part of a story. I wrote about what had struck me as significant, the emotional impact of listening to what was shared, and comments and questions to myself about my sense of my own performance. I then reflexively listened twice to the audiotape of the conversation and wrote further notes, insights, and questions, in my journal. The Transcription Process Transcription is always incomplete, partial and selective and can never hope to reproduce the living research conversations (Mishler, 1986). A s we move from a multi-dimensional, contextualized, embodied conversation to an attempt to re-construct that through 81 transcription, the best that we can hope to achieve is a degree of verisimilitude (Denzin, 1995; Reissman, 1993). Moreover, as many authors point out, the process of transcribing is inherently interpretive and theory laden (Arvay, 2002b; Clandinin & Connelly, 2000; Kvale, 1996; Lapadat & Lindsay, 1999; Mishler, 1986; Riessman, 1993). I fully transcribed the first research conversation myself so that I could both immerse myself in the process and develop a schema (Appendix H) for recording features such as the length of pauses, interruptions and where there was overlapping speech (Arvay, 1998, 2002b; Black, 2003). Initially, I transcribed the audiotape of our conversation as a rough draft, recording all aspects of the speech produced including pauses, silences, repetitions, incomplete words, over-talk, and affective expressions (such as laughs, tears, shouts). I noted any parts of the speech that were inaudible or difficult to hear clearly and environmental sounds (e.g. pages of a journal being flipped through, a telephone ringing). I was pleased that I had followed Dr. Arvay's advice to take two tape recorders to each interview as certain passages that were muddy on one recording were sometimes more clearly audible on the second tape. I subsequently chose to have draft transcriptions of the remaining conversations completed by a person who is skilled and experienced in doing this kind of work. W e discussed the intent of verbatim transcription and I familiarized her with the schema I had developed. Once each rough draft was prepared, I went through the transcription process a second time. This allowed me to check for accuracy; interpolate the notes I had made in my journal about things such as body language, movement, and contextual features; and attempt to reflect on paper my interpretations of voice tone and emotional expressions. Naturally, the audiotapes of our research conversations in this study were only a partial representation of what happened in the interviews. In carefully constructing the transcripts my goal was not to imagine or pretend that it was possible to recreate in textual form the experience that unfolded between myself and each participant during our conversations. Because transcription is inherently interpretive, what the process provided was a way to be reflective about the numerous decisions I was making and consider how my assumptions and rhetorical purposes were shaping the construction (Lapadat & Lindsay, 1999). A s I went through the drafts that the transcriber had prepared, it was fascinating to see how interpretive processes were at play (especially when words were spoken softly) and the degree to which transcripts become decontextualied representations (Kvale, 1996). For example, on one first draft the transcriber heard, "There's not a lot of illness in my practice." After re-listening carefully to the audiotape and re-situating these words within the context of our conversation and what this person had described during the life review sessions, the sentence was re-transcribed as, "There's a lot of mental illness in my practice." In a similar situation, what was initially recorded as, "Many losses of patience," became "Many losses of patients" when interpreted within the context of the participant's story. 82 Reflexive Listening and Interpretive Readings In keeping with the holistic form and content approaches described by Riessman (1993), I decided to work with the whole text as a way of understanding the interplay between the parts and the whole. As I reflected on the transcripts, I returned frequently to listening to the audiotapes. While I had used devices such as a bold font to indicate emphasis and noted affective expressions in the transcripts, the words on the page remained flat. Listening repeatedly to the audiotapes was, for myself, an essential way of re-embodying our conversation, enlivening the text, and exploring the meaning of voice tone, inflection, silences, and significantly repeated words or metaphors. It helped me to identify narrative episodes that I would then mark in the text, be attuned to how stories and themes circled within others, and notice how our voices converged, diverged and sometimes merged as the dialogue unfolded. I used the four interpretive readings described by Arvay (1998, 2002b, 2003) as a way to enter more deeply into exploring each text from different interpretive perspectives. The first reading was for content, accuracy and a sense of the storyline. The second reading was to locate the participant in the story, to engage in an empathic interpretation of how the participants were presenting and positioning themselves in the interactive dialogue and choice of stories that they shared. The third reading was for the research question, to explore the meanings that were expressed or implied about their participation in the life review program and the constructive feedback they provided about the group process and facilitation. The final reading was a critical reading to interpret the influence of culture and social context in the stories that were shared. In this reading I was seeking to understand how issues related to socialization processes and the context of medical culture how medical discourses were woven into their stories. I used four different coloured markers to highlight in the margin parts of the text that spoke to these different readings: green for the self of the narrator; yellow for the research question; pink for feedback and future recommendations; blue for the cultural context. Having completed the four interpretations, it was interesting to see that while a few parts of each text were marked by a single colour, in most instances what emerged in the margins of the text was a braid of three or four colours as the interpretive threads co-mingled and intertwined throughout the dialogue. As I listened to the audiotapes and reflected on the transcripts from these different interpretive angles, I frequently returned to re-reading my personal research journal. Juxtaposing my recollections with the transcribed conversations allowed me to dwell more deeply within the experiences they were describing; it illuminated where my earlier perceptions about various events were expanded or shifted as a result of our research conversations; and it helped me to stay in touch with how my own experiences and ways of understanding were shaping the process of interpreting the texts. 83 Writing the Initial Narratives Authors point out that narrative researchers are confronted with moral and ethical questions as they think about how they will represent their research participants and consider who is protected, and who is not, in the narratives they present to readers (Arvay, 1998; Denzin, 1997; Fine et al., 2000; Richardson, 1990; Steier, 1991). In moving from transcription to representation, I became very aware of some of the dilemmas I was personally facing as a participant inquirer. Confidentiality is an important part of my professional code of ethics and practice as a counsellor and the stories that were shared in the group program were held in confidence among us. For several weeks I felt very conflicted about what to include and exclude in the initial narratives. I struggled with feeling very protective about the personal stories that were shared in our research conversations and wanting, at some level, to treat these with the same degree of confidentiality as those that had been shared in the group. At the same time I was committed to representing the understandings we had constructed during our dialogues with as much narrative truth as possible. Struggling with this issue brought more clearly into focus the need to respect what the participants had chosen to share with me and avoid limiting the richness of their stories by being overly cautious. We had agreed that pseudonyms would be used in the narratives and changes made to any specific names of places or people to ensure anonymity for the participants and others. Five of the six participants chose their own pseudonym and the sixth person invited me to choose one for her. The participants also knew that once I had written an initial narrative it would be sent to them for editorial review and that we would meet to discuss any deletions, additions or changes that they felt were necessary. In constructing the narratives I wanted to create texts that could invite readers to engage with the participants stories. After debating how I could privilege the voices of the participants in an authentic and respectful way, I chose to write the narratives as first person accounts and use this literary device to retain the vitality of their experiences (Arvay, 1998, 2002b, 2003). I framed each narrative as a conversational recounting of the participant's experiences in the group-based program. I decided that this approach allowed me to more accurately reflect their individual styles of re-storying their experiences and, although my voice is not represented in the text, I want the reader to understand that the narratives were a collaborative process of constructing meaning. The narratives presented in this text are evolving stories filled with complexity and future possibilities (Mishler, 1999). Second Research Conversations: Revisiting the Stories Once the initial narratives were written and reviewed by my doctoral advisor, I contacted each of the participants to set a time when we could meet to discuss their individual narrative. I reminded them that the purpose of this second conversation was to explore their impressions of reading the story, the degree to which they felt it resonated with their experiences, and changes that they felt were needed to add to the clarity and accuracy of my interpretation. I arranged to 84 deliver a copy of the narrative to them ahead of the meeting so that they could have adequate time to digest and reflect on the narrative before we talked about it. I included a brief cover letter asking them to read the narrative for accuracy and note any places in the text where they felt the story needed to be expanded or changed in some way. I also invited them to make a note of any new or different insights that may have come to mind since our research conversation that they would like to be incorporated into a revised narrative. The meetings were scheduled for times and locations that best suited each participant: two conversations took place in the participant's homes; two in the doctor's offices; one at the location where we had held our group meetings; and one at my home. Three of the conversations were relatively brief, ranging from 25 to 35 minutes, and three were longer, lasting between 1 to VA hours. The participants' responses to the narratives were very positive. All of them commented that they resonated with their narratives. Some expressed surprise at seeing how much they had said and commented that it was affirming to read the story. The six participants responded with some of the following statements: "There isn't anything I want to add or change in the story. It reflects my experiences very fully." "My initial reaction was, 'Did I say all this?' I liked what I said. This story captures my experience, feelings and beliefs in a comprehensive and integrated way. I really resonate with this story." "The story captures the essence of my experience. I certainly see myself in the story. I believe in the things I'm saying here." "For me the story is re