Narratives of Psychiatric Illnesses

Distress and stress are common across cultures, societies, and countries, but their identification and management vary tremendously. Cultures dictate what is acceptable as normal and what is abnormal or deviant. In the practice of clinical psychiatry, the threshold for normal and abnormal changes is often determined according to changes in social norms and political ideologies. Laws, as set by politicians, decide whose liberty is taken away and who is forced to receive treatment against their wishes. Furthermore, individual consultations, when an individual falls ill, are determined by resources allocated to services and types of healthcare systems. In many public healthcare systems, clinicians may need more time to explore patient’s needs.

Mental illnesses exist across all countries, though rates of various psychiatric disorders may vary tremendously even within the same country. When people fall ill, they may need to be looked after, and their care partners may require education, help, and support. The clinicians are trained to reach clinical diagnoses and prescribe therapeutic interventions accordingly. Eisenberg, ¹ pointed out that disease deals with the recognition of pathology, and that is what clinicians are trained to do. When a patient’s distress and symptoms start to affect others or their social functioning, their disease turns into illness. Thus, individuals in distress are more interested in managing and getting their social functioning back. This dysfunction, along with explanatory models of illness, encourages individuals and their care partners to seek appropriate help. If their explanatory models are supernatural or natural, they may seek help from religious or folk healers. Another advantage that folk healers have is that they follow patient narratives, whereas allopathic clinicians often focus on symptoms. In these changing times, with the advent of AI and protocols, it is crucial that we look at the role narratives play in the management of an illness, be it physical or psychiatric, or a mixture of the two.

Within the concept of disease, Carel ² sees medical approaches as naturalistic. This is seen as a broad spectrum of views focusing on physical facts which can be used to explain the human world. The medical observations are supposed to be objective, objectifying, and neutral. However, no amount of professional training and values are completely bias-free as unconscious biases related to a number of micro-identities, such as age, gender, religion, sexual orientation, etc., come into play while reaching diagnoses. The AI and protocols are supposed to eliminate these biases, but additional factors, such as socioeconomic status, educational status, etc., also creep in. By virtue of medical professionalism, clinicians, especially psychiatrists, need to be empathic and also professionally distanced, which enables them to follow and deal with a set of symptoms so that they can reach a clinical diagnosis within the prevalent classificatory and diagnostic system they are following. However, patients do not fit into neat and prevalent diagnostic categories, especially in psychiatry, and do not behave like their diagnostic categories.

So why are narratives important?

Narratives by patients and their care partners are at the core of clinical engagement, but in many settings, this does not happen because of a lack of time and resources. In the clinical practice of psychiatry, patient narratives are at the heart of reaching a diagnosis and measuring the effectiveness of therapeutic interventions and interactions. Kleinman ³ described illness narratives, arguing that bearing the distinction between illness and disease in mind, the clinician must reconfigure the patient’s culturally shaped “illness problems” (experiences of symptoms and suffering) and technical “disease problems” (anatomical or physiological changes). The story told by the patient (but also their care partners) gives substance to their experience of distress (if any), and these narratives include metaphors, explanatory models, and pathways into care so that the clinician is in a position to explore and understand the patient experiences and expectations of the therapeutic encounter.

Lewis ⁴ notes that the study of narratives is becoming increasingly important in the humanities and social sciences. It also becomes significantly relevant in medicine, including the practice of clinical psychiatry. In a subsequent piece, Lewis ⁵ notes that the withdrawal of NIMH support for the Diagnostic and Statistical Manual meant that psychiatry is well placed to use this instability for self-reflection and a deeper understanding of the meanings that psychiatric practice holds dear. Furthermore, such narrative approaches lead to multiple processes of psychiatric meaning-making ways to tell the story of mental health problems faced by patients and their direct and indirect impact on care partners. Narratives can be helpful in bringing together bio-psycho-socio-spiritual models. In addition, narratives allow both self-reflection and managing ambiguity by the clinician and the patient. Narratives have been used in psychotherapy ⁴ and family therapies. ⁶ Narratives may not fit into diagnostic categories, but they can give a clue to the priorities the patients may have in the context of their social functioning.

Anecdotal clinical observation suggests that most patients can live with their symptoms provided they have a degree of social functioning, including a degree of financial stability, housing, employment, and social support, including personal relationships. Carel ² urges a shift back to phenomenology and narratives. These two go hand in hand. Whereas phenomenology is seen as the first-person lived experience with emphasis on individuals with distress placed on their functioning in the context of their external physical environment, narratives expand on that, and that is how patients and their care partners may understand their experiences. These approaches shift the spotlight onto illness rather than disease and allow a better recognition and partnership between the patient and the clinician. ² This focus on the lived experience makes the shift to a better and closer understanding of body or mind dysfunction along with a better understanding of the disruption of functioning, habits, capacities, and actions of the person who is ill. In many cultural settings, regrettably, the teaching of phenomenology has virtually disappeared, giving way to reductive diagnostic questionnaires and algorithms. Thus, an understanding of the impact on the patient gets lost. Explanatory models, as highlighted by Kleinman, ⁷ are a key component of the illness narratives and may well differ from not only the clinician treating them but also their care partners. These are likely to be strongly influenced by cultural values, social, educational, and economic status, etc. As the explanatory models may vary, resulting dissonance can have a major impact on therapeutic engagement. Patient and illness narratives can help overcome some of this dissonance and improve therapeutic engagement.

Normativist approaches to illness focus on culturally defined and culturally explained norms indicating what is socially (and culturally) acceptable and what is then identified and classified as deviant. As mentioned earlier, especially in psychiatry, various behaviors can be seen as abnormal with varying impacts upon the physical and sociocultural worlds as well as the functioning of the distressed individual. The Cartesian mind-body dualism and dogma, which are widely prevalent and accepted in allopathic medicine and cultures, can create problems when patients from cultures that do not follow the dichotomy present to clinics. Cultural values, habits, behaviors, and worldviews influence help-seeking and engagement.

All illness narratives can help us understand phenomena the patient may be experiencing and also help us explore coping strategies. Such explorations can help us better understand patient experiences and their explanatory models, which will facilitate better engagement. Health and illness are not opposing parts of the spectrum, and our thinking in diagnosis and management needs to change, and narratives may help us achieve this shift.

As Carel ² urges clinicians, a degree of adaptability and creativity in the illness needs deeper exploration and proper recognition. Clinicians must understand the experience of illness alienation with the patient, and potential misunderstandings can be avoided. A clear understanding of what patients are going through can help generate empathy and provide the right situational context to make the right decisions in the clinical context. Often, the argument is made that clinicians need more time to explore narratives. However, if psychiatry is to survive and thrive, we must take our gaze back to phenomenology and explore narratives. The explanations about lack of training and lack of time need to be put aside to ensure that patients get the best service they need and deserve. Exploring and understanding patient narratives and lived experiences can make us better clinicians.