Why Should Psychiatrists Learn about Narrative Therapy?

In the presence of acute mental illness a patient's sense of competence and identity is particularly fragile and vulnerable, perhaps even more so in a multicultural setting like New Zealand or Australia (with patients and psychiatrists of very different cultural backgrounds). I am concerned that the ways we presently practise for instance diagnostic interview and risk management may act to further destabilize rather than support the patient. The use of a narrative therapy approach may offer a different opportunity for engaging with the patient and an improved foundation for patient–psychiatrist collaboration.

It was almost by coincidence I went to an annual conference in narrative therapy three and a half years ago, but it profoundly changed my ways of thinking about my work as a psychiatrist. At an age of near sixty when I should quietly begin to slip into retirement, and when I was certainly hanging out for it, I was given a lease of professional life greater than I had ever experienced before.

Now, I do not suggest that you get started on narrative therapy (NT) just because you are getting old (but I would strongly recommend it if you are becoming disillusioned in your work).

I do not expect you to just take my word for NT being the most exciting, accessible, culturally respectful and versatile therapy available, because there is virtually no scientific evidence base to back such claims.

Neither do I suggest that you have a serious look just because it had its birth place here ‘down-under’, (Michael White from Adelaide and David Epston from Auckland in unique collaboration [1], and over some 30 years further developed it with contributions from all over the world).

What I hope will arouse your interest and get you started is that NT offers a quite different way of thinking about our relationships with our patients (be the diagnosis PTSD, BPAD, or schizophrenia) and, equally important, offers some simple but brilliant tools and/or guidelines to assist the enhancement of the life of both the patient and the psychiatrist.

To best illustrate what I am on about I will use the example of the road works which are taking place along our farm as I write this (I am writing from home, not an ancient mental health farm-hospital). A road-drain has for years been discharging water across a paddock and the roadside bank causing occasional slips to the bank. The council will every couple of years turn up with a digger and excavate the slip setting it up for another slip (because the drain is still there). Three weeks ago I intercepted the digger-operator who was excavating the latest and so far biggest soil-slip which threatened to undermine our farm fence. I pleaded with him to delay further excavation till such time that they at the same time could stabilize the bank with rocks. To my surprise both the digger-operator and the council-manager I later spoke to entirely agreed with my argument. However, it was their preference to proceed with the excavating and then stabilize with big rocks later, as soon as possible. Well, two weeks later after a bit of rain, before any rocks had been put in, the bank slipped again and our farm fence is dangling high in the air.

I think that we unfortunately often practise psychiatry along similar lines despite good insight and good intentions. At the same time I believe that the fact that we mostly achieve remarkably good outcomes speaks highly about the skills and the caring qualities of my fellow psychiatrists.

From time to time I have come across patient accounts in psychiatric journals that describe experience of bewilderment, helplessness and not least a fear that one's sense of self and identity is slipping away, in the presence of acute mental illness and/or hospital admission. We have all witnessed the distress on numerous occasions; the patient fighting to preserve integrity, dignity, sometimes his or her life. Further down the track, so to speak, we have also encountered otherwise intelligent and competent patients who continue to reject the diagnosis and the well considered and evidence-based treatments we offer.

As I have been working with a NT perspective in recent years I have become increasingly doubtful that the standard psychiatric diagnostic interview as we know it is ideally suited to meet the immediate needs of some of our patients and I wonder if there may not be occasions when it causes damage to rapport with consequences for the ongoing working relationship and ‘compliance’ (if you consider our use of language such as ‘compliance’ or ‘non-compliance’, it cannot be surprising that some patients will feel demeaned).

The diagnostic psychiatric interview as we teach it to registrars in training does focus on an excavation of diagnostic features, and exploration of patient history for trauma, suffering, incompetence (personal or family), genetic vulnerability, drug use and criminal activity, etc.

This is done for the purpose of putting together a diagnosis, a formulation and a treatment plan, in keeping with established good medical practice. However, the psychiatric patient is not presenting with pneumonia or kidney failure but with a condition that has a particular ability to destabilize a person's sense of competence and identity (even if grandiose delusions perhaps for some have offered a temporary alternative identity).

I fear that the diagnostic interview may undermine this further, unless we somehow manage to ‘put something back in, in place of the material we dig out’. Likewise, I am concerned about how the steadily increasing size of the patient file with its weight of documented illness, failure and incompetence, may undermine the patient's (and the psychiatrist's) hope for a better future.

I believe, and it is so far my experience, that by using a more NT approach and strategy when we first connect with a patient it is possible, as we start our excavations, to ‘put something back in’ at the same time, to stabilize things a bit.

One of the most widely known and most basic tools or strategies in NT when you first meet a patient is to support the patient in the negotiation of an ‘experience-near’ description of the presenting problem for which they are seeking help. As White puts it [2]: ‘an experience-near description of the problem is one that uses the language of the people seeking therapy and that is based on their understanding of life (developed in the culture of their family or community and influenced by their immediate history).’ As part of negotiating this experience-near description of the issues, we may also invite the patient to consider a metaphor that may assist the description. Metaphors are used extensively in NT to give name to things such as the presenting problem, personal attributes or concepts of value, because it may assist in making complexities more visible, simple and not least, personal. The metaphor also stimulates the imagination and may offer a new perspective.

It is beyond the scope of this article to offer an extensive introduction to NT, but it is my hope that by using my road-works metaphor I can illustrate the potential benefit of using an experience-near metaphor in the process of conceptualizing and ideally communicating complex ideas.

I have for some time had the notion that I would like to write this article but felt daunted by the task of how to transfer a potential avalanche of ideas to paper and further to an interested reader without losing it all on the floor, or down the drain. The fact that the road-works digger was back on our road this morning along with a heavy rain warning caused a surge of anxiety for the wellbeing of my farm, but it also gave me a metaphor which not only set the writing in motion but also helped stabilize my focus.

By attempting to use and acknowledge the patient's words and metaphors (rather than insisting on teaching the patient our professional language (this does not preclude offering full scientific information) and by attempting to rescue and document evidence of competence, courage, achievement and values, alongside the excavations for pathology, we may offer crucial support to the patient's struggle to maintain or recover a sense of competence and identity. It may also enhance the patient's experience of having been heard and having his/her concerns acknowledged, and it will give the psychiatrist a far better and more inspiring understanding of the patient's realities.

I am concerned that in recent years management-driven treatment practices often overrule evidence-based or best-practice-based treatments and patients become dehumanized as collections of diagnostic features and ‘risks’.

I presume that the vast majority of psychiatrists working in Australia and New Zealand once took the Hippocratic Oath, and we dedicated our work to ‘the good of the patient’. In reality the psychiatric files on many patients contain very little or nothing about the patient as a person and the treatment may have an overwhelming concern about ‘risk management’ to the point that the person's identity is described by the perceived risks. This is not to deny that some patients indeed represent serious risk to self and or others, but how can we offer ourselves as doctors working for the good of the patient when sometimes we have made the real person cease to exist on file (I acknowledge that for some patients illness has just about erased what the person used to be).

In contrast, by actively searching for values, evidence of competence and achievement during the patient consultation and perhaps identifying some of the people who gave hope to the patient along the way (rather than just naming the perpetrators), one may sometimes add 10 to 20 minutes to the standard diagnostic assessment and/or one may not get all the details first time around. But in doing so we may have given the patient valuable support (stabilized the road slip a bit), treatment may already be underway, and valuable information and knowledge may have come to light (which the standard interview failed to unearth). Last but not least, by making that extra effort to acknowledge the patient's reality, hopes and wishes we may have achieved a better foundation for a working relationship, and in the process have reduced the person's experience of isolation.

It is also worth noting that the patient is likely to appreciate, sometimes even value, the completed assessment document.

I am in no way arguing that we should distance ourselves from practising good medicine alongside our colleagues in other specialities, but I am proposing that our patient population is very different, mainly because sense of identity and competence is far more challenged by a mental disorder than by the average medical or surgical condition. Further, while the desirable outcome for most medical and surgical conditions will be relatively obvious in most cases, this is far less clear in the realm of mental health and requires a strong patient representation when the management plan is worked out (I guess it has been long taken for granted that ‘management plan’ refers to how the psychiatrist will ‘manage’ the patient, not how the patient wishes to manage his or her life).

I firmly believe we need to practise good medicine, to make diagnosis, to research, etc., but we need to pay attention to the unique vulnerability of our mental health patient population, and the dehumanizing onslaught of tick-boxes and risk-management practices (with questionable evidence base [3]).

Use of NT in psychiatry will not make compulsory treatment or hospitalizations obsolete, but it may ease some of the associated distress and potentially disqualifying impact on patients.

It is my proposal that narrative therapy is much more than just another psychotherapy (and contrary to common belief it is not ‘something about telling stories’). Amongst many possibilities it offers a very different opportunity for engagement and collaboration between patient and psychiatrist.

In my practice in general adult community psychiatry I find that NT may be a helpful alternative to pharmacotherapy for some patients, but for most (the majority of my patients are in some pharmacotherapy) the NT is a valuable part of the overall treatment and something I will attempt to use in some shape or form with all my patients.

It may offer a challenge to the standard diagnostic interview as it is practised during registrar training and exam practice, but to the best of my knowledge it does not conflict with other RANZCP guidelines.

It has not been my ambition that this article should portray narrative therapy, but in case some of the above has in some way resonated with you and should you desire to re-connect with some of your reasons for becoming a doctor in the first place, then do have a closer look at NT. There is a large collection of NT books covering a wide range of topics from working with the dying and bereaved [4] to business mediation and conflict resolution [5].

A great selection of NT articles is available free online through Epston's homepage (welcome to narrativeapproaches.com) and more can be accessed free on line from the Narrative Therapy Library and Bookshop on the Dulwich Centre homepage (www.dulwichcentre.com.au) including the first two chapters of Morgan's book [6] “What is Narrative Therapy?”