In his book Sapiens: A brief history of humankind [1], Yuval Noah Harari states and points out when in our Sapiens human species, cousin of chimpanzees, the Cognitive Revolution occurred, so that the Sapiens could become stronger than tiers, big animals and Neanderthal humankind: around 70.000 years ago. The Cognitive Revolution would have been followed by the Agricultural Revolution 10.000 years ago, by the Scientific Revolution 500 years ago, and by the Industrial Revolution, 200 years ago.
Before exploring how the Cognitive Revolution occurred, let me tell the reader that Sapiens is a masterpiece, if someone wants to learn empathy and collaboration, crossing through the 466 pages of the history of our species, with the facts, our fallacy in decision making, our genial ideas, our beliefs, and the subtle balance or unbalancing between the individual, the society and the environment.
Seventy thousand years ago the Cognitive Revolution started: guess on what it was based? Language, quite an easy answer for scholars, teachers, or fans of narrative and storytelling. Neuroscientists, together with archaeologists, did prove that language shaped the identity of the Sapiens and of the world before Harari wrote this book. However, he adds a unique point of view which is really an eye-opener to understand why Sapiens won and Neanderthal extinguished: the latter had a factual language, based on true events: Today I saw a lion and we have to be careful. This was the Neanderthal language: deeds, real facts, chronicles. The Sapiens, which at that time (70.000 years ago) were still hunter-collectors as the Neanderthal ones, had this kind of language: Today I saw a lion: it said to me that if we are going to hunt for him the whole spirit of the savannah will seek for revenge: however, if we sacrifice him, and kill him giving a tribute to the savannah and its gods, we might be praised. On top of the real event “the seen lion” the Sapiens had and still has the imaginative power: she/he created a story, a myth, with a meta-objective which was going far beyond the sole killing of the lion. This story implies a matter of possible war with the savannah and its Gods. We might be praised, the Sapiens added this fantastic concept, but also of the possibility, the “may be”. And in fact, Sapiens left Africa, since the tiers were too dangerous and went to other lands… But this another story.
Flexibility and imagination are the two engines which brought Sapiens to make the Neanderthal disappear and to end up until now, thinking to be ruler of the world, according to the cognitive revolution: stories and myths, related to real facts were the fuel of the hunter-collectors to control bigger societies, and are still here as a sociological need. Harari goes on across millenniums, centuries and brings us to our contemporaneity with a critical evaluation of what the Sapiens did, but with one strong statement: the tipping point was the Cognitive Revolution, the skill of narrating and creating stories.
What have these to do with Medical Humanities and Narrative Medicine? Chronicles of facts are requested to take care of a patient, however, in the spoken and written narratives, we collect “factions”, a neologism created from real events, “facts” woven together with fictitious thoughts, conversations, things, “fictions”. In sciences and medical studies, we have been told to rely only on real facts, I saw a lion today, and discard other stories, The gods of the savannah, since we do not believe in their existence. However, this is very often just a point of view, that of the “Neanderthal ones”: if we want to be Sapiens good carers we have to accept the “faction” stories, which might occur during the visit, in the clinical setting, at-home care, or wherever that patient decides to give to us the pathography, that is the story of his/her illness.
If Harari stresses out the point that myth was there for social control, personally I think that illness, ageing, but also birth and death put us in a fragile and vulnerable situation, fosters existential questions, and therefore we seek comfort in imagination and fantasy with spirituality issues (from Gods to quantum physics and energetic levels…). It’s an individual inner drive, not only a story that we absorb by the external “media of communication”. It’s through an inner silence which brings us not only to the clue of awareness but also to fantastic realms of our individuality in interaction with the others. Patients, since they live with illness experience, despite the reductionist approach which calls the disease with a technical name, they might encounter the courage to “fight the lion” with the allied Gods: someone calls it storytelling, belief, mind attitude, or placebo, but this works in terms of patient’s outcomes, as we will read. Let’s make clear that we should not forget that the disease is there: so if “the lion is there” in patients’ mind, we have to choose what to do: escaping, if yes, how to escape, taming the lion, or killing it or many other possibilities. The disease is there, and brings pain to patients’ body, but what make someone experiencing the pathway of care is the language, which mirrors the mindset of how people address the disease [2].
Too many often the reductionist providers of care could not see and even do not want to face the individual need of the factions, better only relating to facts, and even more, judging the patients as ignorant, liars and confusing people. What about if the carers could finetune with the patient’s factions, that is to understand the symbolic language used in conjunction with the facts?
We could distinguish two levels of fictions, a first one, probably, looks like a more ethical one according to our western dogma of clinical intervention, which is related to the mirroring of the language used by the patient.
Let’s invent a possible dialogue between a patient and a doctor using the faction genre:
This disease is a lion, the patient states,
Yes, we have a lion in your body,
What can we do?,
Making it dormant, and taming, we cannot definitely kill it, because there is no adequate weapon, since your body is the land where the lion lives, and also the land will be devastated by the blasters,
Taming process, with what? With whom? How long it will take?, the patient asks.
With me by your side, together with the team, with particular therapeutic options, with the things you cherish the most, and it will be a long process, since you have to learn a new style of life; living with this tamed dormant big cat inside you, it will become not dangerous…
This could be a sort of alignment between the carer and the patient. The metaphor is the fil rouge where, in this linguistic equation, the name disease is replaced by lion, which has to be transformed at the end of the dialogue in a safe enough dormant big cat. There is no lie, just a short storytelling which embellishes, gives meaning, and provides solutions to the events.
To make possible such an encounter, it is important to master the language and the listening art: the carer should add another language to her/his technical jargon, the symbolic, fictional one. It is demonstrated that when we listen to a foreign language, our brain is more focused on the details of the words of the speaker because we fear to lose the meaning of what is told and it is a challenging conversation [3]. This is a good tip for being able to really listen, imaging (again, once more the validity of imagination of the Sapiens) that we are listening to somebody who does not speak our native language.
Eventually, the second level is to remove the real therapeutic options for the illness and to leave only the storytelling: one could say, this is not ethical. Right, we have to fix the boundaries to use only words. In 2014, researchers in Canada [4] did an outcome research study about the role of communication in the treatment of patients with chronic back pain. Half the patients in the study received mild electrical stimulation from physical therapists, and half received sham stimulation (all the equipment is set up, but the electrical current is never activated). Sham treatment — placebo — worked reasonably well: these patients experienced a 25 percent reduction in their levels of pain. The patients who got the real stimulation did even better, since their pain levels decreased by 46 percent.
However, there was a sub study even more interesting: each of these groups was further divided in half. One half experienced only limited conversation from the therapist (staying on the “disease” of facts). With the other half, the health care provider asked open-ended questions and listened attentively to the answers (biography and pathography). They expressed empathy about the patients’ situation and offered words of encouragement (i.e. we will tame the lion) about getting better. Patients who underwent placebo treatment but had therapists who actively communicated reported a 55 percent decrease in their pain. Communication alone was more effective than treatment alone. The patients who got both electrical stimulation and a good conversation were the clear winners, with a 77 percent reduction of pain.
In an editorial on the New York Time, a doctor writes:
Frequently my patients ask if a multivitamin will give them more energy. In the past, I would say no, because there are no significant scientific studies to demonstrate this, and also because in the absence of a vitamin deficiency there’s not much for a basic multivitamin pill to do. Now I take a different approach. I say something along the lines of “Many of my patients find that they have more energy when they take a multivitamin.” I’m not lying, because many have indeed said so. Without fail, there are always a few patients who come back at the next visit and swear they feel much better. Some argue that it is unethical to promote placebos to patients. But increasingly, many say it would be unethical not to give placebos a try in situations where patients are not getting relief from traditional means (and where it would not cause harm or replace a necessary treatment). [5]
Storytelling works for Sapiens, sometimes it is not enough to counteract a severe condition but sometimes with very subjective conditions as pain it produces positive health outcomes. Factions works if integrated also with other good therapeutic options. As Ofri wrote, there are “Factions” of doctors (note the polysemic word), those pro placebos stories, those against placebo stories. Again, it depends on the severity of the patients, on her/his contextual environment, on the creeds and beliefs and mindset. Not only of the cured one but also of the doctors and carers since we are all, we like it or not, Sapiens apes behind the roles even now after 70.000 years.
And for the lovers of fiction, I end up with the words of Tyrion Lannister in the closure of Games of Thrones – I don’t know if the screenwriters had read Harari’s History of Sapiens, even if it looks like:
What unites people?, Tyrion asked. Armies? Gold? Flags? No. It’s stories, he said. There’s nothing in the world more powerful than a good story. Nothing can stop it. No enemy can defeat it.
As Jean-Do, affected by the locked-in syndrome, a quadriplegia that causes the inability to speak, so that the patient communicates with other through coded messages by blinking the eyes, in his cult memoir [6], dictated through the blinking process, says:
I will stop to complain: two things are still there, memory and imagination.
And with this imagination, he starts his interior dialogue that softens the hardship of his condition: storytelling, in this case, becomes a wonderful strategy for personal coping and nor for political social control.
[1] Yuval Noah Harari, Sapiens- A Brief History of Humankind, Penguin Random House UK, 2011
[2] Maria Giulia Marini, The languages of care in narrative medicine, Springer, 2019
[3] Alejandro Pérez, Guillaume Dumas, Melek Karadag, Jon Andoni Duñabeitia, Differential brain-to-brain entrainment while speaking and listening in native and foreign languages, Cortex, 2018
[4] Fuentes J1, Armijo-Olivo S, Funabashi M, Miciak M, Dick B, Warren S, Rashiq S, Magee DJ, Gross DP, Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Phys Ther. 2014 Apr;94(4):477-89
[5] Danielle Ofri, The Conversation Placebo, Ney York Time, Jan. 19, 2017
[6] Jean Dominique Bauby, the Diving Bell and the Butterfly, Paperback 1998
