Narrative, identity and the therapeutic encounter

Summary This article explores the place of narrative in the constitution of selfhood, and through this lens examines its multifaceted role in the clinical encounter. It begins by explaining and critically evaluating the recent view advocated by Schachtman and others that narrative is wholly constitutive of the self. On this view, the role played by narrative is not merely a descriptive one, but serves more fundamentally as the ontological substrate upon which identity is invariably built and sustained. Understood as such, this capacity may distinctively modulate the meanings, motivations, and attitudes individuals adopt in reaction to and in anticipation of happenings in their lives. Acts of self-narrative can serve not only to describe meaningful facts about a person's life, but may also serve to reflexively influence the very states of affairs that they aim to describe. After assessing the theoretical attraction of this view, counter-evidence to this theory is adduced from clinical neuropsychiatric cases wherein lapses of narrative, such as those observed in dementia, dissociative identity disorder, autism and amnestic syndromes, do not entail wholesale losses of selfhood. Analyses of cases such as these reveal that there is more than narrative that is constitutive of selfhood and identity, and further raises the question of whether the absence of conveyed self-narrative ought to be interpreted as evidence of a failure of this capacity versus as evidence that an agent simply is no longer is motivated to express it. Rather than a monotonic construct, it is argued that narrative is one of a cadre of crisscrossing capacities sharing some family resemblance and with characteristically open texture that variably combine to produce selves with no single common denominator, but rather with dynamic clusters of commonalities. Six other symbiotic dimensions are identified that contribute to an intact scaffolding of selfhood, and disturbances within each of which might lead to distinctive pathologies. In particular, the capacities for self-other representation; diachronic unity; synchronic unity; consciousness (in particular, awareness); ecologic embededdness; and cognitive unity are explained and evaluated, along with pathologies that may arise in the setting of disturbances of each. It is contended that avenues of research studying the neural substrates corresponding to these different dimensions of selfhoold, as well as how these varied neuronal systems coalesce to produce a phenomenologically integrated and unified self is much needed. Further clarity with respect to these issues can shed further light on how particular brain lesions may differentially affect elaborations of selfhood. Such research could foreseeably include functional neuroimaging studies, non-invasive brain modulation (e.g., transcranial magnetic stimulation; transcranial direct current stimulation), and targeted neuropsychological testing of individuals with apparent disruptions of self stratified according to the different dimensions elucidated to aid in uncovering the enigmatic neuroanatomy and neurophysiology of selfhood. The cross-disciplinary nature of each of these avenues underscores the profound importance of deep and sustained collaborations among philosophers, ethicists, clinicians and researchers to optimize and advance approaches to the pathologies of the mind and the self. Neuroethical upshots of the account of selfhood developed are discussed, including implications for treatment of individuals with neurodegenerative conditions wherein the self itself is called into question, for the foundation and function living wills, and for approaches to pain management in individuals with disorders of consciousness. While narrative, when elicited, can provide a vital window into patient experience, lapses of narrative may be just as central to the psychoanalysis of the self and to the therapeutic encounter. What is not, and cannot be spoken, is often as vital as the narrative itself.