Abstract
I was delighted to read the editorial by Povl Jensen on ‘Why psychiatrists should learn about narrative therapy’ [1] for several reasons, beginning with the simple one that it was a breath of fresh air in attitude, content and style. Importantly it also raised fundamental concerns about the way we interact with patients, and framed the solution to a pervasive but potentially undermining approach as a respectful, creative and collaborative engagement with the patient.
However, while I find narrative therapy profoundly useful, it is not the only answer. Jensen is describing a process at the core of many contemporary psychologies and psychotherapies of self and trauma, where empathic engagement requires both respect and validation but also the effort he describes to find language that is meaningful to the patient and resonates with their experience. He raises the issue that data collection in the conventional psychiatric interview may be an invalidating and ‘excavating’ experience, but notes that we do still need the data. In a more ‘narrative’ style interview, we can discover together a metaphor for the patient's predicament that offers a better shared understanding and fosters the rapport essential to both better data acquisition and the building of a therapeutic alliance. As Jensen suggests, it may also begin treatment by being quintessentially therapeutic. This approach is described well in the conversation model of psychodynamic engagement with the patient, which allows the treatment of patients with illnesses that have undermined the sense of self such as borderline personality disorder, but is also a useful approach to the patient presenting in distress or crisis [2]. It helps avoid the ‘interrogation’ that patients can experience as persecutory [3].
In teaching trainees in our network, colleagues and I find that this task of combining the science of the data-gathering practitioner with the art of engagement is a challenging one for the trainee, but satisfying, as Jensen suggests. It brings a meaningful connection as well as good clinical results. I would also add that our other medical colleagues, that Jensen mentions, actually look to us for guidance on medical communication and we should perhaps take some leadership by championing an approach to history gathering and alliance-formation rather than allowing a reduced version of our craft to be the norm.