By Marshall Scott
It won’t surprise anyone that I peruse medical journals for entertainment. I don’t claim to understand everything I read; but I still find fun in it.
And sometimes I find something that particularly catches my interest. During one such session not long ago, I actually found two. One was this title for a research study: “Culturally Appropriate Storytelling to Improve Blood Pressure” (Annals of Internal Medicine, 2011; 154:77-84). The second was another study with a title apparently similar, but subtly different: “Effect of Preventive Messages Tailored to Family History on Health Behaviors: the Family Healthware Impact Trial” (Annals of Family Medicine, 2011; 9:3-11).
Now, in my business both storytelling and family history are important things. So, I was certainly interested as I read the articles. As I said, the titles seem alike. However, there are differences, and the differences are important.
In “Storytelling,” a team was looking for a way to provide both information and encouragement for changes in behavior for African Americans with hypertension. African Americans are more likely to have high blood pressure, less likely to get it under control, and more likely to have serious complications. The team thought of storytelling.
Now, at first blush storytelling might seem well outside the frame of reference of modern allopathic medicine. However, for more than a decade now some medical schools have offered courses in narrative medicine. There is some appreciation that we understand ourselves and our lives, not only in light of facts, but also in light of the stories within which those facts have meaning.
So, they began with a number of focus groups made up of African Americans living with high blood pressure. From participants in those focus groups they selected a number that told their stories well. They recorded them telling their stories, and put the stories on a DVD, along with additional information on hypertension. They then provided DVDs to African American patients with hypertension. Study patients (both those with controlled and uncontrolled hypertension) received study DVD’s. Patients in the control group (whose hypertension was also not controlled) received a DVD with basic health information. Investigators hoped that study patients whose hypertension wasn’t yet controlled would show improvement, and that patients who hypertension was controlled would sustain their existing control and behaviors.
And it worked. It didn’t make a big difference for the patients whose hypertension was already controlled. However, for those for whom hypertension wasn’t controlled, those who watched the DVD had a significant improvement (lower average numbers) in their systolic blood pressure (the first number in blood pressure) over the control group at three months. In fact, the patients were followed for nine months; and while the average pressures for all patients went up between three and nine months, there was still a significant difference for those who had watched the study DVD.
What made the difference? Well, the investigators suggest (and I agree) that personal stories about living with high blood pressure were more powerful than a straight lecture, and especially when the person telling the story looked and sounded like them. As a result, they were more likely to embrace and maintain the lifestyle changes that led to better control of blood pressure.
The second study seemed to suggest the same point and yet had different results. The article “Family History” reports on the Family Healthware Impact Trial. Family Healthware is a software program developed by the Center for Disease Control (CDC) as an interactive tool to allow patients to record information on family history for six common diseases and for related health behaviors. When the user has completed his or her entries, the software generates a health risk assessment for the various diseases based on family history. It also provides health messages and suggestions for healthy behaviors. The thought was that because these health messages were customized and based on the patient’s individual family history the patients would find them easier to adopt and maintain. They selected 2,364 subjects in the control group, and 1,422 in the control group, and followed them for a series of good health behaviors (smoking cessation, eating more fruits and vegetables, getting more exercise, taking aspirin daily, tracking their blood pressure, and getting cholesterol and glucose checked regularly). Study subjects received the report with risk assessments and health messages connected to their individual family histories. Control subjects received a set of standard health messages, not individually tailored.
Surprisingly, investigators did not see the results they had hoped for. Study patients did show increases in eating fruits and vegetables, and in getting exercise; but for the other health behaviors results were small to insignificant. For most of the behaviors, the fact that the recommendations were based specifically on patients’ family histories didn’t seem to make much difference.
As I read the article, I realized that there was a significant difference between the studies. In the first study communication with the patients was not only customized, but specifically reflective of their community, and, really, of their own lives. In the second the messages were customized the family history, but were not specifically reflective of the patients’ communities. They were the standard medical messages, and not personal stories. While the messages in “Family History” were arguably just as useful, the stories in “Storytelling” were more meaningful, in that they were more related in their expression to the lives and experiences of patients.
Now, this is one of those moments where we notice the differences in how we see the world. In modern medicine, “if it didn’t get documented, it didn’t get done;” and if it hasn’t been documented in a formal research study, it can’t be approved. For the rest of us, and especially for those of us in the church, the reaction is likely to be, “Well, duh!” Our most important information is rooted in story – specifically, in the story of what God has done for us. Moreover, as any person in the pew can tell you, it is shared more effectively in story than it is in simple discourse.
Fact is, this is at the center of our lives as Christians. We are committed to receiving and passing on the Gospel; and since we receive it in and through story, we are committed to passing on the story, and not just the principles and conclusions that we derive from the story. Even in passing on the principles and conclusions, it is in story that we find them meaningful. That makes it important that we find ways to pass on the story that are culturally relevant for those we pass on to. I have said over the years that central to the task of theology is translation of the truths of the faith into a language understood by those we seek to reach. That is simply another way of saying that as we pass on the faith, we do best to do so in ways that are, as the study says, “culturally relevant.”
We know, really, how this affects our evangelism. From the first efforts at translating the Scriptures in to a language understood by the people – arguably, we could go back to the Septuagint, and even farther – we have been making our efforts to share the story in ways that are culturally relevant. At times in our history we have not only identified new languages, but even created alphabets for the purpose (Cyril and Methodius come to mind). We wrestle with it within our congregations (how shall we teach our children?): in our communities (what will reach Gen X or Gen Y?): and across the Body of Christ (as one example, just what do we all think about the Chinese Three Self Christian Movement?).
At the same time, it also raises some anxiety: is there a point where cultural relevance begins to dilute, even pollute, the faith we seek to convey? How many times did European missionaries feel that they had not only to translate the language of the faith, but also to make faux Europeans of the evangelized? How well otherwise do the stories we receive translate? How well do our stories, the experiences in which we find the meaning of the faith confirmed, translate? I have noted that one of my favorite books is Martin Palmers’ The Jesus Sutras: Rediscovering the Lost Scrolls of Taoist Christianity. In that work he translates a number of documents, produced by Chinese Christians over a couple of centuries. By the later of those documents, the effort is clear to translate the stories not only into Chinese characters, but into Chinese terms. When the stone stele of the Religion of Light, produced in 781 CE, speaks of Jesus in much the same terms as a bodhisattva, is that a culturally relevant meaning, or is it a step too far?
By the same token, we know just how central this anxiety is in our current Anglican difficulties. Each side finds points at which the other side addresses and embraces the culture; and each side asks whether the other has gone too far. I have written before here at the Café of one cultural difference – whether one lives in an individualist or a “communalist” culture – that I think makes our communication difficult. Another is between those who feel that what God wants us to know is conveyed in the contents of Scripture; and those who feel that God also wants us to know what we learn through scientific study, and to wrestle with how both can be meaningful in our lives. This difference is critical because the details of what we learn through scientific study also shape the stories that we use to make meaning. In the case in point, we do have different understandings of what it means to be human when some of us want to quote only Scripture, and some of us also want to include information from medicine, anthropology, and psychology.
In that case, it can be tempting to try to turn again to specific tenets, to distill from the received stories concepts that transcend the limits of our languages and our stories. That, too, has been an ongoing process, from Augustine to Aquinas to Tillich. Yet even then we discover that cultural relevance lurks in the wings. Each academic theologian is working with a philosophical language that reflects its own time and shapes its future – in my examples, Neo Platonic to Aristotelian to Existentialist forms. As much as some might try to see them as more pure and more abstract, each theologian and the language the theologian seeks to use is shaped not only by concepts, but by cultures and the stories through which those cultures make and find meaning.
And with each generation we discover it anew, or at least we think we do. We discover that our efforts to abstract concepts and convey them by discourse – as in, for example, modern allopathic medicine –don’t help people live in the way that we might hope. In a very real sense they aren’t meaningful, because they don’t relate to our experiences and our perceptions. We return again to stories and storytelling. It is how we make meaning in our lives. It is how we connect our past with our place in the world now, and how we shape our hopes for the future. Critically for us, it is how we live in Christ. It is how “the faith once delivered to the saints” becomes our faith. It is how we discover that faith can live in our own lives. It is how we pass on the faith we have received to those who come after. It is how we know what Christ has done for us, and is doing in us; and how we know that he will be with us even to the end of the ages.
The Rev. Marshall Scott is a hospital chaplain in the Diocese of West Missouri. A past president of the Assembly of Episcopal Healthcare Chaplains, and an associate of the Order of the Holy Cross, he keeps the blog Episcopal Chaplain at the Bedside.