0
Topics in Practice Management |

Using a Narrative Approach to Enhance Clinical Care for Patients With AsthmaUsing a Narrative Approach FREE TO VIEW

Helen Owton, PhD, CPsychol; Jacquelyn Allen-Collinson, PhD; A. Niroshan Siriwardena, MBBS, MMedSci, PhD
Author and Funding Information

From The Open University (Dr Owton), Milton Keynes; and the University of Lincoln (Drs Allen-Collinson and Siriwardena), Lincoln, England.

CORRESPONDENCE TO: Helen Owton, PhD, CPsychol, The Open University, Childhood, Youth, and Sport, Walton Hall, Milton Keynes, MK7 6AA, England; e-mail: h.owton@open.ac.uk


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(1):288-293. doi:10.1378/chest.14-2630
Text Size: A A A
Published online

There are currently > 230 million people in the world with asthma, and asthma attacks result in the hospitalization of someone every 7 min. The National Heart, Lung, and Blood Institute outlines four components of clinical practice guidelines for the diagnosis and management of asthma, which tend to take a biomedical focus: (1) measures of assessment and monitoring, obtained by objective tests, physical examination, patient history, and patient report, to diagnose and assess the characteristics and severity of asthma and to monitor whether asthma control is achieved and maintained; (2) education for a partnership in asthma care; (3) control of environmental factors and comorbid conditions that affect asthma; and (4) pharmacologic therapy. Many national guidelines include providing patients with asthma with (1) written action plans, (2) inhaler technique training, and (3) structured annual reviews. Although current guidelines help improve clinical processes of care for asthma, there is also a need to improve self-care of asthma by empowering individuals to take more control of their condition. There is a growing appreciation that a narrative approach with patients with asthma, which focuses on the illness experience and aims to enhance patient-clinician understanding, might improve self-care. We explore how a framework for clinicians to listen to patients’ stories, developed from research on individuals with asthma, might enhance communication, improve patient-clinician relationship, and foster better patient self-care. The article closes with the implications of this approach for clinical practice and future research.

Figures in this Article

It is estimated that there are 235 million people in the world with asthma,1 yet asthma is underdiagnosed and undertreated, constituting a global health challenge. Asthma creates a substantial burden for individuals and families and has the potential to greatly limit people’s activities throughout their lifetime. International research suggests that poor asthma self-care is responsible for exacerbating asthma symptoms, contributing to asthma attacks and also to deaths from asthma2 and asthma-related conditions.3,4

The myriad symptoms of asthma, including cough, wheeze, chest tightness, and breathlessness, are caused by airways inflammation.5 The National Heart, Lung, and Blood Institute6 outlines four components of clinical practice guidelines for the diagnosis and management of asthma: (1) measures of assessment and monitoring, to assess the characteristics and severity of asthma and to monitor whether asthma control is being achieved and maintained; (2) education for a partnership in asthma care; (3) control of environmental factors and comorbid conditions; and (4) pharmacologic therapy. Many national guidelines7 include providing patients with asthma with (1) written action plans, (2) inhaler technique training, and (3) structured annual reviews. Given high numbers of hospitalizations from asthma attacks and the risk of a fatal asthma attack, the primary goal in most clinical practice with patients with asthma is to try to ascertain ways to control the symptoms of asthma with the use of medication.6

The use of guidelines and a biomedical, clinician-centered approach to management of asthma can improve clinical care, but to improve outcomes further there is also a need to improve self-care for asthma. The call for a narrative turn in medicine8 might improve clinicians’ understanding of the complex storied aspects of clinical work in patients with asthma, thereby helping patients improve self-care.

Asthma clinicians usually spend time to ensure that patients are accurately diagnosed, they are trained and assessed on their inhaler technique, peak flow is measured, and patients are given the correct treatment and the best care possible, which often results in improved outcomes for patients. To further enhance treatment and patient care, a narrative approach highlights the importance of actively listening to stories about patients’ asthma. Empirical evidence of the benefits of narrative medicine is encouraging.9 In relation to patients with asthma specifically, Hatem and Rider10 cite clinical studies that show significant improvement in lung functions when patients draw on narrative to convey their personal experiences.9

Doctors and patients often draw upon different types of stories. Doctors’ stories are interpreted through a specific narrative frame, one contoured by a biomedical framework. Similarly, patient stories might depend heavily on repetition of what it is that physicians say.11 Within this narrative, patients play a defined role, one that many ill people are willing to fit into without question, and almost all do so when required.12 Clinicians can, however, help challenge rigid narrative roles by asking open-ended questions: “How can I help you today?” and “What seems to be the problem?” Patients’ responses to these questions often involve recounting a story about what the problem is, when their problems began, and discussions of symptoms, suffering, and health beliefs. Importantly, doctors then need to pay close analytic attention to these stories.

Although the medical re-authoring of a patient’s story is not necessarily problematic in itself, patient stories and doctor stories often do not work well together,13 which might potentially lead to patients becoming angry and rejecting medical narratives of their illness because of the (often) dehumanizing focus of medical narratives.8 In refusing to be reduced to “clinical material” in the construction of the medical text, patients are asserting their voices.12

Advocates of the narrative approach in health-care settings8,12,1422 argue for a move beyond mechanical understandings of the body and a return to the lived illness experience as a way effectively to bridge the gap between patient and clinician. Indeed, when exploring stories of sickness,23 the idea is that a good story is central in what clinicians refer to as the placebo effect because it provides (1) an explanation consistent with the person’s worldview, (2) a connection to a community of practitioners and concerned others who share this worldview, and (3) a sense of mastery and control over the experience.

Clinicians might, therefore, also enhance their clinical practice by being aware—through the lens of narrative theory—of different narratives that patients with asthma may tell, because the more stories they know about, the greater the potential for helping people write action plans,7 which may assist them in the process of restorying their lives.22 With narrative competency, clinicians may enhance their ability to understand their patients’ experience of illness more fully.8,24

Teaching trainees the skills of close reading and listening to patient narratives means that these medical trainees are transferring the basic skills of clinical attention, by which doctors, nurses, and allied health and social care professionals might competently absorb information that their patients and colleagues have to impart.14,24 This can enhance the way bodies, selves, and storylines are listened to and then responded to, ethically and dutifully, and means that clinicians stay with the emotional and personal complexities of illness.8,14 When clinicians develop narrative competency they have the capacity to acknowledge, interpret, and make meaning of illness stories.24 Although a narrative approach appears to be a relatively new phenomenon in medicine, much was historically learned about conditions through personal narratives.

Personal narratives of asthma experiences have traditionally informed medical practitioners for many centuries. In the 12th century, for example, a comprehensive account was written in Arabic by Moshe ben Maimon (Maimonides, 1138-1204).25 Thus, up until the 16th century, various observers of the disease (eg, Galen, 129-199 ad) contributed to a treatise on the prevention, diagnosis, and treatment of asthma.26 It was in the 17th century that asthma was viewed as a condition in its own right, in part, due to the pivotal piece of work in 1698 by John Floyer (1649-1734), an English physician who published work on the symptoms, causes, and treatment of asthma. It was Floyer’s treatise that constituted a central point of reference for subsequent authors and for clinical practice.27 These early medical texts included accounts of the author’s own pain and suffering and continued to shape clinical initiatives and medical writing.27 Additionally, Hyde Salter (1823-1871) wrote one of the most influential 19th century texts on asthma in 1860, based on his own account of the disease as well as those of his patients.27 Subsequently, however, clinical reliance on personal observations and accounts of individuals started to recede.27 Although during the early 1800s asthma was rarely mentioned in medical literature, during the 19th and 20th centuries, personal narratives of disease and the sense of identity and meaning often previously shared by doctor and patient were increasingly marginalized and are noted as increasingly lacking.28,29

Medical understandings of, and treatments for, asthma have often shifted dramatically across time, whereas the physical manifestations, existential impact, descriptive language, and symbolic significance of asthma have remained comparatively constant.26 Therefore, a narrative approach might enhance understanding and help practitioners identify how best to assist patients with asthma.

The diagnosis of asthma can constitute a rupturing and threatening event, disrupting the routine processes of a person’s life; this is what is referred to as a disrupted body project.30 As individuals engage in the task of constructing past events through personal narratives, they also start the dynamic process of (re)claiming identities and (re)constructing their own lives.30 The metaphor of narrative wreckage seems to characterize such experiences.12 The problem when this occurs is that people are left needing a new map for their lives and a need to restory the self.12,21,22 Predictive testing for asthma conditions may provide patients with an opportunity to know one’s fate, at least to some degree, but patients may also encounter psychologic and emotional difficulties in receiving this information.12

A narrative approach was used to investigate breathlessness in chronic obstructive pulmonary disease, and the importance of trust apparent in patients’ narratives was highlighted.31 A narrative approach informs health personnel about the patient’s experiences and the relationship between patient and caregiver.31 Indeed, narrative approaches are becoming a promising combination for clinicians by enhancing their clinical practice and as a dynamic technique for motivating and supporting health behavior change.31 In an extensive review,32 a number of studies, reviews, and meta-analyses examined the impact of narrative vs statistical evidence on persuasion, perceived usefulness, and self-efficacy, asserting that narrative communication could be an effective tool for promoting health behavior change. How best to use narrative approaches in health-care settings remains currently of great research interest. The use of a research-based typology is explored in the next section in relation to patients with asthma.

An asthma identity typology or model was developed33 based on three ideal types: conformers, contesters, and creators. It is important to note that the ideal type never seeks to claim validity in terms of a reproduction of, or a direct correspondence with, social reality.34 It is important to stress the fluidity and context dependency of the types; people do not always fit neatly in the typology and may be a mixture depending on the circumstances.12 Furthermore, they may cross the categories depending upon time/context. At certain times, people may change from one dominant aspect to another, for example, during the period of winter, when asthma may flare up in some patients. There is not scope in this article to go into detail about typology, which is addressed elsewhere.33 Nonetheless, a discussion on metaphors may assist in the understanding of working with patients with asthma as a way to develop a written action plan and, fundamentally, to develop an understanding of the patient’s lived experience of illness.

The human body serves as a rich source of metaphorical thought and language. In research,33 most participants who spoke of an asthma attack appeared to experience panic, fear, and anxiety, particularly when they could not get the air out. Some used visceral metaphors, particularly highlighting the tightness and choking nature of asthma. Conversely, those who spoke of episodes or slow onsets of asthma or bronchoconstriction seemed to experience fewer feelings of anxiety, panic, and fear. The way participants speak metaphorically about their asthma may well have implications for the way they manage their asthma.35 An exploration of metaphors in individuals’ narratives of asthma may provide clinicians with a key indicator of how patients are living and coping with asthma.36 For example, talk of beating it, overcoming asthma, fighting it, struggling, contesting, battling, fixing it, asthma attacks, or curing it might highlight the way the individual is fighting asthma. The metaphor of fighting illness, not lying down to it, and overcoming adversity, is pervasive in many accounts of illness in western society. Fighting illness is a way of talking about it, which is strongly culturally approved.36 Metaphors help us to understand how humans make and shape meaning.37 One study38 in particular found that narratives of self-reliance and comeback strategies were coping mechanisms for young people (11-16 years) in managing chronic illness.

Furthermore, the tone of a personal narrative is perhaps the most pervasive feature.39 The tone is conveyed both in the content of the story as well as the form or manner in which it is told; it is both the whats and the hows.40 For example, the tone could be optimistic (hopeful that things will improve), progressive (moving forward), pessimistic (things perceived in a negative light), or regressive (deterioration or decline).

Helping individuals to talk about their asthma, asthma attack, or asthma episode might assist health-care practitioners to understand how a patient is handling their condition and indeed how the narrative may be helping or hindering positive health-care behaviors. Crucially, this might enable an alternative narrative map to be offered—one that the patient might previously have been unaware of and that could have direct and powerful health benefits. Conversation analysis of doctor-patient consultations is providing insights into the effects of narratives on patients and clinicians.41

Clinicians can facilitate ways in which narratives are listened to by adopting a patient-centered consulting style rather than the traditional biomedical approach that focuses on eliciting answers from patients to questions posed by practitioners. A patient-centered approach, in contrast, involves active listening (rather than silence) from the practitioner, to enable patients to tell their story. It involves both patient and practitioner actively contributing to develop the story in a way that is helpful for the patient and crucially involves understanding the wider context in which patient, practitioner, and environment all contribute to the story. Patients contribute through their personal experience of the complexity of their illness, bringing to the consultation their health beliefs and context and communicating their own agenda. Doctors contribute a range of consultation skills. Both are affected by current mood and environmental factors such as the time available. Importantly, this perspective involves exchanging information, agreeing on a problem formulation, and sharing decisions about treatment depending on the needs of the patient and the nature of the problem (see also Fig 1).42

Figure Jump LinkFigure 1 –  Patient-centered consulting. (Adapted with permission from Siriwardena and Norfolk.42)Grahic Jump Location

This approach requires skills and learning from both patient and practitioner, but particularly from the practitioner. Such skills, extensively described in the clinical consultation literature, include giving patients time (the golden minute) to tell their story, nonverbal encouragement (eg, nodding), and verbal prompts (eg, echoing) and responding to cues. Understanding the patient’s story involves listening to their beliefs and concerns about their health, eliciting from where these beliefs have arisen (eg, previous experience, other professionals, relatives, friends, and the media), and what the patient expects from the consultation. This approach provides opportunities to respond to patients’ needs and, when required, to modify and reshape those patient stories that are unhelpful—or potentially even harmful—to those that encourage better prevention behaviors, health promotion, self-care, and help-seeking for asthma.43

Such an approach is particularly important in the care of asthma, because concordance with treatment is often poor.44 To improve concordance, doctors and patients need to understand each other’s beliefs about asthma and its causes and treatment. They need to agree on a formulation of the illness that enables patients to maximize their function, better understand treatments, and enact lifestyle and self-care measures while reducing the burden of care.45

Narratives may be hampered by a range of factors, even when practitioners are open to, familiar with, or trained in the narrative approach. An obvious barrier is pressure of time, but more subtle hindrances include failing to pick up cues or adopting a doctor-centered agenda by behaviors such as a rigid adherence to assumptions of causation, inappropriate psychologizing of symptoms, dwelling on negative emotions, providing overly detailed explanations, or giving thinly disguised advice.42

This short review has considered the potential of narrative approaches in dealing with patients with asthma in clinical practice. Patients might be very sensitive to and strongly affected by patient-doctor power dynamics, and doctors’ active listening to patient stories may facilitate more democratic medical encounters. This allows practitioners to communicate more effectively with patients and to tailor advice and treatments more specifically to their individual needs. Much still remains to be researched in relation to narrative approaches to promoting health-related behaviors,32 including how this particular approach might work in combination with other approaches (eg, visual methodologies) or interventions. Narrative communication may be one of the most basic forms of human interaction; it may also be one of the most powerful ways to establish and develop trusting patient-practitioner relationships, leading to enhanced asthma care, self-care, and well-being.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Chronic respiratory diseases: asthma. 2014. World Health Organization website. http://www.who.int/respiratory/asthma/en/. Accessed August 6, 2014.
 
Royal College of Physicians. Why Asthma Still Kills. The National Review of Asthma Deaths (NRAD). London, England: Royal College of Physicians; 2014.
 
Asthma management and prevention: a practical guide for public health officials and health care professionals. 2009. Global Initiative for Asthma website. www.ginasthma.org/guidelines-gina-report-global-strategy-for-asthma.html. Accessed October 11, 2013.
 
Denford S, Campbell JL, Frost J, Greaves CJ. Processes of change in an asthma self-care intervention. Qual Health Res. 2013;23(10):1419-1429. [CrossRef] [PubMed]
 
McArdle W, Katch F, Katch V. Exercise Physiology: Energy, Nutrition, and Human Performance. Philadelphia, PA: Lippincott Williams & Williams; 2007.
 
The four components of asthma management. 2007. National Heart, Lung and Bood Institute website. http://www.nhlbi.nih.gov/files/docs/guidelines/04_sec3_comp.pdf. Accessed August 6, 2014.
 
Quality standard for asthma. 2013. National Institute for Health and Clinical Excellence website. http://guidance.nice.org.uk/QS25. Accessed September 25, 2013.
 
Lewis B. Narrative Psychiatry: How Stories Can Shape Clinical Practice. Baltimore, MD: The Johns Hopkins University Press; 2011.
 
Sakalys JA. Restoring the patient’s voice. The therapeutics of illness narratives. J Holist Nurs. 2003;21(3):228-241. [CrossRef] [PubMed]
 
Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Educ Couns. 2004;54(3):251-253. [CrossRef] [PubMed]
 
Verghese A. The physician as storyteller. Ann Intern Med. 2001;135(11):1012-1017. [CrossRef] [PubMed]
 
Frank AM. The Wounded Storyteller: Body, Illness, and Ethics. Chicago, IL: University of Chicago Press; 1995.
 
Hunter KM. Doctor’s Stories: The Narrative Structure of Medical Knowledge. Princeton, NJ: Princeton University Press; 1991.
 
Charon R. Narrative Medicine: Honoring the Stories of Illness. Oxford, England: Oxford University Press; 2006.
 
Charmaz K. Struggling for a self: identity levels of the chronically ill.. In:Roth J, Conrad P., eds. Research in the Sociology of Health Care: The Experience and Management of Chronic Illness. Greenwich, CT: JAI Press; 1987:283-321.
 
Charmaz K. Good Days, Bad Days: The Self in Chronic Illness and Time. New Brunswisk, NJ: Rutgers University Press; 1991.
 
Kleinman A. The Illness Narratives: Suffering, Healing and the Human Condition. New York, NY: Basic Books; 1988.
 
McAdams D. The Stories We Live by: Personal Myths and the Making of the Self. New York, NY: Morrow; 1993.
 
Sparkes AC, Smith B. Disrupted selves & narrative reconstructions.. In:Sparkes AC, Silvennoinen M., eds. Talking Bodies: Men’s Narratives of the Body and Sport. Jyvaskyla, Finland: SoPhi; 1999.
 
Sparkes AC, Smith B. Men, sport, spinal cord injury and narrative time. Qual Res. 2003;3(3):295-320. [CrossRef]
 
Smith B, Sparkes AC. Men, sport, spinal cord injury, and narratives of hope. Soc Sci Med. 2005;61(5):1095-1105. [CrossRef] [PubMed]
 
Carless D, Douglas K. Narrative, identity and mental health: how men with serious mental illness re-story their lives through sport and exercise. Psychology of Sport and Exercise. 2008;9(5):576-594. [CrossRef]
 
Brody H. Stories of Sickness. Oxford, England: Oxford University Press; 2003.
 
Charon R. What to do with stories: the sciences of narrative medicine. Can Fam Physician. 2007;53(8):1265-1267. [PubMed]
 
Gregersen PK. The historical catalyst to cure asthma.. In:Brown E., ed. Asthma: Social and Psychological Factors and Psychosomatic Syndromes. Basel, Switzerland: Karger Publishers; 2003.
 
Jackson M. Asthma: A Biography. Oxford, England: Oxford University Press; 2005.
 
Jackson M. Asthma, illness, and identity. Lancet. 2008;372(9643):1030-1031. [CrossRef] [PubMed]
 
Netuveli G, Hurwitz B, Sheikh A. Lineages of language and the diagnosis of asthma. J R Soc Med. 2007;100(1):19-24. [CrossRef] [PubMed]
 
Sparkes AC. Telling Tales in Sport and Physical Activity. Champaign, IL: Human Kinetics; 2002.
 
Sparkes AC. Reflections on the socially constructed physical self.. In:Fox KR., ed. The Physical Self: From Motivation to Well-Being. Champaign, IL: Human Kinetics; 1997:83-110.
 
Kvangarsnes M, Torheim H, Hole T, Öhlund LS. Narratives of breathlessness in chronic obstructive pulmonary disease. J Clin Nurs. 2013;22(21-22):3062-3070. [CrossRef] [PubMed]
 
Hinyard LJ, Kreuter MW. Using narrative communication as a tool for health behavior change: a conceptual, theoretical, and empirical overview. Health Educ Behav. 2007;34(5):777-792. [CrossRef] [PubMed]
 
Owton H, Allen-Collinson A. Conformers, contesters, creators: vignettes of asthma identities and sporting embodiment [published online ahead of print September 15, 2014]. International Review of Sociology of Sport. doi:10.1177/1012690214548494.
 
Calhoun C, Gerteis J, Moody J, Pfaff S, Virk I. Part V: the sociological theory of Max Weber.. In:Calhoun C, Gerteis J, Moody J, Pfaff S, Virk I., eds. Classical Sociological Theory.3rd edition. Chichester, England: Wiley-Blackwell; 2012:265-338.
 
Sharma VP. Anxiety and stress can aggravate asthma symptoms. Mind Publications website. 2001. http://www.mindpub.com/art376.htm. Accessed February 7, 2011.
 
Owton H. Integrating multiple representations: fighting asthma. Qual Inq. 2013;19(8):600-603. [CrossRef]
 
Lakoff G, Johnsen M. Metaphors We Live By. Chicago, IL: The University of Chicago Press; 2003.
 
Gabe J, Bury M, Ramsay R. Living with asthma: the experiences of young people at home and at school. Soc Sci Med. 2002;55(9):1619-1633. [CrossRef] [PubMed]
 
Crossley M. Narrative psychology, trauma, and the study of self/identity. Theory Psychol. 2000;10(4):527-546. [CrossRef]
 
Riessman C. Narrative analysis.. In:Milnes K, Roberts B, Horrocks C., eds. Narrative, Memory & Everyday Life. Huddersfield, England: University of Huddersfield; 2005:1-7.
 
Heritage J, Maynard DW. Communication in Medical Care. Interaction Between Primary Care Physicians and Patients. Cambridge, England: Cambridge University Press; 2006.
 
Siriwardena AN, Norfolk T. The enigma of patient centredness, the therapeutic relationship and outcomes of the clinical encounter. Qual Prim Care. 2007;15:1-4.
 
Launer JMN. Narrative-Based Primary Care: A Practical Guide. Abingdon, England: Radcliffe Medical Press; 2002.
 
Horne R. Compliance, adherence, and concordance: implications for asthma treatment. Chest. 2006;130(1_suppl):65S-72S. [CrossRef] [PubMed]
 
Gallacher K, May CR, Montori VM, Mair FS. Understanding patients’ experiences of treatment burden in chronic heart failure using normalization process theory. Ann Fam Med. 2011;9(3):235-243. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Patient-centered consulting. (Adapted with permission from Siriwardena and Norfolk.42)Grahic Jump Location

Tables

References

Chronic respiratory diseases: asthma. 2014. World Health Organization website. http://www.who.int/respiratory/asthma/en/. Accessed August 6, 2014.
 
Royal College of Physicians. Why Asthma Still Kills. The National Review of Asthma Deaths (NRAD). London, England: Royal College of Physicians; 2014.
 
Asthma management and prevention: a practical guide for public health officials and health care professionals. 2009. Global Initiative for Asthma website. www.ginasthma.org/guidelines-gina-report-global-strategy-for-asthma.html. Accessed October 11, 2013.
 
Denford S, Campbell JL, Frost J, Greaves CJ. Processes of change in an asthma self-care intervention. Qual Health Res. 2013;23(10):1419-1429. [CrossRef] [PubMed]
 
McArdle W, Katch F, Katch V. Exercise Physiology: Energy, Nutrition, and Human Performance. Philadelphia, PA: Lippincott Williams & Williams; 2007.
 
The four components of asthma management. 2007. National Heart, Lung and Bood Institute website. http://www.nhlbi.nih.gov/files/docs/guidelines/04_sec3_comp.pdf. Accessed August 6, 2014.
 
Quality standard for asthma. 2013. National Institute for Health and Clinical Excellence website. http://guidance.nice.org.uk/QS25. Accessed September 25, 2013.
 
Lewis B. Narrative Psychiatry: How Stories Can Shape Clinical Practice. Baltimore, MD: The Johns Hopkins University Press; 2011.
 
Sakalys JA. Restoring the patient’s voice. The therapeutics of illness narratives. J Holist Nurs. 2003;21(3):228-241. [CrossRef] [PubMed]
 
Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Educ Couns. 2004;54(3):251-253. [CrossRef] [PubMed]
 
Verghese A. The physician as storyteller. Ann Intern Med. 2001;135(11):1012-1017. [CrossRef] [PubMed]
 
Frank AM. The Wounded Storyteller: Body, Illness, and Ethics. Chicago, IL: University of Chicago Press; 1995.
 
Hunter KM. Doctor’s Stories: The Narrative Structure of Medical Knowledge. Princeton, NJ: Princeton University Press; 1991.
 
Charon R. Narrative Medicine: Honoring the Stories of Illness. Oxford, England: Oxford University Press; 2006.
 
Charmaz K. Struggling for a self: identity levels of the chronically ill.. In:Roth J, Conrad P., eds. Research in the Sociology of Health Care: The Experience and Management of Chronic Illness. Greenwich, CT: JAI Press; 1987:283-321.
 
Charmaz K. Good Days, Bad Days: The Self in Chronic Illness and Time. New Brunswisk, NJ: Rutgers University Press; 1991.
 
Kleinman A. The Illness Narratives: Suffering, Healing and the Human Condition. New York, NY: Basic Books; 1988.
 
McAdams D. The Stories We Live by: Personal Myths and the Making of the Self. New York, NY: Morrow; 1993.
 
Sparkes AC, Smith B. Disrupted selves & narrative reconstructions.. In:Sparkes AC, Silvennoinen M., eds. Talking Bodies: Men’s Narratives of the Body and Sport. Jyvaskyla, Finland: SoPhi; 1999.
 
Sparkes AC, Smith B. Men, sport, spinal cord injury and narrative time. Qual Res. 2003;3(3):295-320. [CrossRef]
 
Smith B, Sparkes AC. Men, sport, spinal cord injury, and narratives of hope. Soc Sci Med. 2005;61(5):1095-1105. [CrossRef] [PubMed]
 
Carless D, Douglas K. Narrative, identity and mental health: how men with serious mental illness re-story their lives through sport and exercise. Psychology of Sport and Exercise. 2008;9(5):576-594. [CrossRef]
 
Brody H. Stories of Sickness. Oxford, England: Oxford University Press; 2003.
 
Charon R. What to do with stories: the sciences of narrative medicine. Can Fam Physician. 2007;53(8):1265-1267. [PubMed]
 
Gregersen PK. The historical catalyst to cure asthma.. In:Brown E., ed. Asthma: Social and Psychological Factors and Psychosomatic Syndromes. Basel, Switzerland: Karger Publishers; 2003.
 
Jackson M. Asthma: A Biography. Oxford, England: Oxford University Press; 2005.
 
Jackson M. Asthma, illness, and identity. Lancet. 2008;372(9643):1030-1031. [CrossRef] [PubMed]
 
Netuveli G, Hurwitz B, Sheikh A. Lineages of language and the diagnosis of asthma. J R Soc Med. 2007;100(1):19-24. [CrossRef] [PubMed]
 
Sparkes AC. Telling Tales in Sport and Physical Activity. Champaign, IL: Human Kinetics; 2002.
 
Sparkes AC. Reflections on the socially constructed physical self.. In:Fox KR., ed. The Physical Self: From Motivation to Well-Being. Champaign, IL: Human Kinetics; 1997:83-110.
 
Kvangarsnes M, Torheim H, Hole T, Öhlund LS. Narratives of breathlessness in chronic obstructive pulmonary disease. J Clin Nurs. 2013;22(21-22):3062-3070. [CrossRef] [PubMed]
 
Hinyard LJ, Kreuter MW. Using narrative communication as a tool for health behavior change: a conceptual, theoretical, and empirical overview. Health Educ Behav. 2007;34(5):777-792. [CrossRef] [PubMed]
 
Owton H, Allen-Collinson A. Conformers, contesters, creators: vignettes of asthma identities and sporting embodiment [published online ahead of print September 15, 2014]. International Review of Sociology of Sport. doi:10.1177/1012690214548494.
 
Calhoun C, Gerteis J, Moody J, Pfaff S, Virk I. Part V: the sociological theory of Max Weber.. In:Calhoun C, Gerteis J, Moody J, Pfaff S, Virk I., eds. Classical Sociological Theory.3rd edition. Chichester, England: Wiley-Blackwell; 2012:265-338.
 
Sharma VP. Anxiety and stress can aggravate asthma symptoms. Mind Publications website. 2001. http://www.mindpub.com/art376.htm. Accessed February 7, 2011.
 
Owton H. Integrating multiple representations: fighting asthma. Qual Inq. 2013;19(8):600-603. [CrossRef]
 
Lakoff G, Johnsen M. Metaphors We Live By. Chicago, IL: The University of Chicago Press; 2003.
 
Gabe J, Bury M, Ramsay R. Living with asthma: the experiences of young people at home and at school. Soc Sci Med. 2002;55(9):1619-1633. [CrossRef] [PubMed]
 
Crossley M. Narrative psychology, trauma, and the study of self/identity. Theory Psychol. 2000;10(4):527-546. [CrossRef]
 
Riessman C. Narrative analysis.. In:Milnes K, Roberts B, Horrocks C., eds. Narrative, Memory & Everyday Life. Huddersfield, England: University of Huddersfield; 2005:1-7.
 
Heritage J, Maynard DW. Communication in Medical Care. Interaction Between Primary Care Physicians and Patients. Cambridge, England: Cambridge University Press; 2006.
 
Siriwardena AN, Norfolk T. The enigma of patient centredness, the therapeutic relationship and outcomes of the clinical encounter. Qual Prim Care. 2007;15:1-4.
 
Launer JMN. Narrative-Based Primary Care: A Practical Guide. Abingdon, England: Radcliffe Medical Press; 2002.
 
Horne R. Compliance, adherence, and concordance: implications for asthma treatment. Chest. 2006;130(1_suppl):65S-72S. [CrossRef] [PubMed]
 
Gallacher K, May CR, Montori VM, Mair FS. Understanding patients’ experiences of treatment burden in chronic heart failure using normalization process theory. Ann Fam Med. 2011;9(3):235-243. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543