Why Do the Stories Psychiatrists Tell Their Patients Matter?

Philip Thomas, MD
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Why do stories matter? Why is it that what a psychiatrist says to a patient about their experiences can have such a powerful effect – for good or for ill? This is something that has puzzled me for many years. It still does. This piece is an attempt to open up some of the important issues that lie beneath these questions.

As is often the case I find philosophy to be a really useful tool in teasing out some of the issues, and so we start with not one story, but two. These are factitious stories – a thought experiment. Philosophers have relied on thought experiments for thousands of years to help them to examine aspects of reality, the world we see before us, in order to understand more clearly what may or may not be going on underneath. Please don’t be put off by the philosophy. Read the stories and then see what you think!

Jackie

Jackie starts to hear voices. She is very upset by them because they say very unpleasant things to her. She goes to see a psychiatrist. She talks to the psychiatrist who asks her a few questions. At the end of the interview Jackie asks ‘Why do I hear voices?’. The doctor tells her that the voices are a symptom of schizophrenia. They are caused by a disorder of the brain, an overactivity of the dopamine system. She says that this imbalance can be rectified by neuroleptic drugs, which reduce the overactivity in the brain’s dopamine systems. If she takes the medication her voices will go away and she will feel better.

Jackie listens carefully to the psychiatrist and decides to follow her advice. She goes home and takes the medication. A few weeks later the voices have more or less disappeared, and she is feeling better.

Jill

Jill starts to hear voices. She is very upset by them because they say very unpleasant things to her. She goes to see a psychiatrist. She talks to the psychiatrist who asks her a few questions. At the end of the interview Jill asks ‘Why do I hear voices?’. The doctor tells Jill she isn’t sure, and she needs to spend more time to get to know about her, so they arrange to meet a week or so later.

In the meantime she gives Jill a prescription for a small dose of neuroleptic medication, telling her it may help her to feel less distressed by the voices. The next time they meet Jill is feeling a little better. The voices are still there but she isn’t as upset by them.  The psychiatrist has set an hour aside so they can talk.

During the course of their conversation it emerges that although the voices started to trouble Jill only recently, this was because they started saying unpleasant things to her. In fact she had been hearing voices for many years since the age of six when something terrible had happened to her involving a family ‘friend’. The voices comforted her, telling her it wasn’t her fault, and that she wasn’t to blame for what had happened to her.

The tone of the voices changed dramatically a few weeks before she saw the doctor. Her ex-boyfriend had attempted to rape her. She was devastated, and the next day her voices began to accuse her and to blame her for what had taken place. She began to feel a little easier as she told the doctor, even though the voices were still angry with her and scolded her for speaking about them.

A few weeks later she stopped the medication, and was seeing the psychiatrist regularly to talk about what had happened to her and her voices. She was keeping a journal and was halfway through writing out her life story. Although her voices hadn’t completely gone away, she was coping with them much better and able to carry on with her life.

 

These two women were given quite different stories by their doctors. Jackie’s voices were interpreted as a symptom of schizophrenia, a brain disorder that required her to take medication. Jill’s voices were interpreted in terms of trauma. She was encouraged to talk about her experiences and her life, and then write about them.

What perhaps is much less obvious, and the issue that I want to draw attention to, are the moral implications of these two stories. What I mean by that is the way that these stories have remarkably different outcomes as far as the possibilities for action, or agency of the two women are concerned. In other words when we are troubled, the sort of stories that are presented to us, and whose strands we may pick up and weave into our lives, open up or close down future possibilities for us. In order to show how that is possible, I want to introduce a little philosophy.

 

One of the most significant developments in the humanities and social sciences over the last forty years or so has been the so-called ‘narrative turn’. This refers to the idea that we can think about ourselves and our lives as stories or narratives. This originated in literary theory but it has had a profound influence on philosophy, anthropology, cultural studies, sociology and psychology. Its impact has also been felt in medicine and psychotherapy too, although not, until very recently, in psychiatry (but see Brad Lewis’s, 2011, Narrative Psychiatry).

A number of philosophers have played an important role in developing the idea of narrative identity – the view that we can think of ourselves in terms of the stories we tell about ourselves, but the figure whose ideas stand behind a great deal of this work is the German philosopher Martin Heidegger. Although for some he is a controversial figure (he had a dubious relationship with National Socialism in Nazi Germany) his major work Being and Time (Heidegger, 1962) is widely regarded as one of the most important philosophical texts of the twentieth century. Heidegger’s ideas had a major impact on the work of R. D. Laing (1960). Being and Time  contains the key insight that our being, or existence, is fundamentally historical in nature.This opens up the possibility of thinking about human lives in narrative terms.

The argument is that if human being is temporal, that is to say if it is fundamentally grounded in our experience of time, then we may also think of being as narrative. Like a good story we can think of a human life as having a beginning, a middle and an end, enfolded by a plot.

This doesn’t mean to say that a human life can be summarised or captured as an ordered, flowing story. At the heart of the philosophical notion of narrative identity is the view that we live our lives tentatively, contingently, reflexively and pre-reflectively. Most of the time we live our lives pre-reflectively; we simply don’t step back from our engagement with the world and think of ourselves as stories.

Throughout our existence our lives are work in progress, great unfinished stories. Our narratives only come to an end when we die, and even then the story is not complete. We leave behind loose threads which others try to tie up after we’ve gone, as they continue to tell and re-tell stories if they remember us. What matters as far as narrative identity is concerned is our struggle to impose some sort of order on our inchoate and emergent experiences.

Narrative, or telling a story about ourselves, is a powerful way of doing this. It assists us in our search for meaning and our attempts to understand our experiences. MacIntyre (1981) argues that human action is only understandable in so far as it is embedded in an historical context. It follows from this that history, human action and meaning must be related. How does this happen?

Jeremy Holmes (2000), a psychiatrist and psychotherapist helps us to understand the importance of narrative in understanding the links between history, action and meaning. He uses distinction between intentional and non-intentional causality (Bolton and Hill, 1996). The former is associated with human agency, whereas the latter rests outside the realm of human life in science and the natural world.

We can understand the significance of this if we consider the example of Jackie, who hears voices, and who is told that her voices are a symptom of schizophrenia, a disorder of the brain brought about by overactivity of dopamine systems. This biomedical view of madness is based in non-intentional causality. The voices heard by Jackie are seen to arise out of circumstances and events in the natural word in the her brain, and over which she had no control. Thus her voices arise as a consequence of non-intentional causality, and in this view there is no possibility of understanding the significance of her voices through her life story.

The consequences of this are even more important. It places her future entirely in the hands of the experts, doctors and psychiatrists who hold the knowledge and mastery, or so it seems, over the physically causal events in her brain. Thus in the story of how she copes with her voices, Jackie is relegated to a bit-part, a walk-on role in the clinic once every six months or so for a routine check-up. The real hero in this piece is her doctor. This is precisely how Arthur Frank describes the relationship between patient and doctor in the restitution narrative (Frank, 1995), although he is describing what happens in narratives of physical illness.

In contrast, by talking about her experiences with her psychiatrist, Jill came to the conclusion that her voices originated in painful and traumatic events in her past. The recent sexual attack reinvoked a sense of powerlessness, horror and anger that she must have felt since the age of six, and which her long-standing voices had guarded her against. Through this insight, which is validated by her psychiatrist, not only does she have a different story about her voices, but a story that has the potential to put her in a very different relationship to them.

She is able to see that her voices have arisen in response to human actions and intentions, terrible things done to her by other people. In other words her voices arise out of intentional causality. This means that is possible to understand the original action, the voices, and the person’s struggle to cope with and make sense of them, in moral terms. Something terrible has happened to this woman, and we can see her struggle as an act of courage.

In truth the distinction between intentional and non-intentional causality isn’t as clear cut as I have presented it here. Jeremy Holmes points out that even in medical conditions that have clear-cut genetic causes (i.e. that arise through non-intentional causality) like a child born with Down’s syndrome, stories remain important in understanding how the family copes, the love they have for the child and the ambiguities of their own feelings about the situation they find themselves in. Intentional causality – the things that happen and arise as a consequence of the decisions we make as human beings – is fundamentally moral in nature.

This is why narrative is so important in psychiatric practice. If we are able to help a  person who hears voices to find the story that suits them best, possibilities for action open up for them. For some people the right story might just be ‘schizophrenia’, the metaphor of dopamine overactivity and neuroleptic medication, but for many, probably the majority, this is an unhelpful, disempowering narrative.

In Jill’s case the story she negotiated with the doctor helped her to release her anger over the injustice she felt because of what had happened to her. She was able to channel her anger and despair constructively for herself and for others like her by becoming politically active in a women’s group, in much the same way described by Susan Brison (2002) in her powerful account of her search for meaning after a devastating sexual attack. Jill continued to hear voices, but she understood their meaning and significance in her life story, and in solidarity with women who had similar experiences her voices no longer troubled her.

Being human means having to face and make choices and decisions to do things, or not to do things. The decisions we make have implications for others as well as ourselves, some good, some bad. Even when we have to face up to an event over which we had no control such as a natural disaster that results in death and destruction, how we face up to it is still to some extent in our own hands, and thus subject to intentional agency. We may have no control over the event, but the path we tread subsequently is in part determined by decisions we make. Narrative and agency are central to understanding the meaning and significance of suffering. This is why the stories psychiatrists tell their patients are so important.

 

References

Bolton, D. & Hill J. (1996 ) Mind, meaning and mental disorder. Oxford: Oxford University Press.

Brison, S. (2002) Aftermath: Violence and the Remaking of the Self. Princeton, Princeton University Press.

Frank, A. (1995) The Wounded Storyteller: Body, Illness and Ethics. Chicago, University of Chicago Press.

Heidegger, M. (1962) Being and Time. (trans. J. Macquarrie & E. Robinson). Oxford, Basil Blackwell.

Holmes, J. (2000) Narrative in psychiatry and psychotherapy: the evidence? Journal of Medical Ethics: Medical Humanities. 26, 92 – 96.

Laing, R. (1960) The Divided Self. London, Tavistock.

Lewis, B. (2011) Narrative Psychiatry: How Stories Can Shape Clinical Practice Baltimore, The Johns Hopkins University Press.

MacIntyre, A. (1981) After Virtue. Notre Dame, University of Notre Dame Press.

 

13 COMMENTS

  1. Heidegger, Wittgenstein , Vygotsky, Szasz, Laing, Kurt/Mark Vonnegut, the patient may have read all these things so when the psychiatrists expounds a theory the wise detained patient will keep quiet. The psychiatrist doesn’t know his patients previous reading list. The psychiatrist doesn’t know if the patient actually believes or takes account of anything they say or is merely humouring them. A confounding factor although perhaps not in the examples above.

    Perhaps it’s just as easy to overestimate the importance of our conversations as it is to overestimate the importance of medication.

    Interesting thought experiments though. I enjoy them for what its worth.

  2. Yes, the psychiatrist’s interpretation of the patient’s world does indeed matter. Patients are all too vulnerable to the opinion of the “expert.”

    For example, Dr. Thomas, here is your colleague in Critical Psychiatry, Duncan Double, doing his best to assert antidepressant withdrawal syndrome is a psychological phenomenon, rather than iatrogenic neurological dysfunction http://criticalpsychiatry.blogspot.co.uk/2012/09/what-does-it-mean-to-say-that.html and http://criticalpsychiatry.blogspot.co.uk/2013/01/the-challenge-of-reducing-and-stopping.html (read all comments on the two blog posts).

    This is in opposition to what patients say about their symptomology. For many case studies, see http://tinyurl.com/3o4k3j5

    As long as psychiatrists refuse to see their patients are truly injured by too-fast tapering, and instead blame the patient for the symptoms, those injuries will continue.

    There are hundreds of thousands of posts all over the Web about how doctors try to impose their version of reality on patients suffering from withdrawal symptoms. The result is a loss of trust in the expertise of even otherwise sympathetic psychiatrists. What you want to believe is true is simply not true.

    I understand Critical Psychiatry’s position is that withdrawal syndrome is a psychological or psychosomatic phenomenon. Duncan Double refers to the opinions of other DOCTORS to support this argument, rather than referring to actual patient experience.

    I suggest you and your colleagues in Critical Psychiatry listen more closely to what patients have to say about this issue. You might call this user-led research (http://bjp.rcpsych.org/content/180/1/1.full).

  3. Dear Philip, I appreciate your acknowledgement of the importance of the stories psychiatrists tell their patients. Also the gentle nudges from commenters that what may be most important is how skillfully supporters encourage the human being before them to tell their own story. To unfold it, perhaps by shining new more and less helpful perspectives on the story telling, maybe with a few “writers prompts.”

    Ultimately, if psychiatrists, therapists, family, clergy, friends, can compassionately and patiently ask “Tell me your story,” perhaps that is the most important narrative of all.

    I think that is what you were implying anyway.

    I’d love to also add the concept of ethnography and thick description (Claude Levi-Strauss) which places highest value on those with lived experience,; postmodernism, which really helps explore the nonlinear nature of narratives and, I think, rightly challenges the implication that history follows a linear path or time conventions; and the wisdom of the East which allows us to drop stories when they are not helpful, regardless how how entrenched they seem (historically, generationally, culturally).

    So many rich things to consider when we look at life as stories we tell ourselves and each other.

    Thank you again!

  4. “Jeremy Holmes points out that even in medical conditions that have clear-cut genetic causes (i.e. that arise through non-intentional causality) like a child born with Down’s syndrome, stories remain important in understanding how the family copes, the love they have for the child and the ambiguities of their own feelings about the situation they find themselves in. Intentional causality – the things that happen and arise as a consequence of the decisions we make as human beings – is fundamentally moral in nature.”

    How we as a society allocate resources to address emotional/mental distress is “fundamentally moral in nature”. It was never as scientific as our western minds would like to presume that it is.

    I went to psychiatry believing that their “medicines” could help me to feel and function better. As Whitaker’s careful research shows this is overwhelmingly a calculated myth perpetuated by economic interests. My meds were nothing more than psychoactive drugs that numbed and distracted me from the real issues in my life.

    Necessary life skills of character and fortitude cannot be found in a patented capsule of outlandish chemical makeup– no matter how many stories psychiatrists want to tell about their life-saving cures.

    Psychiatry could help people by stopping the lies about brain diseases, chemical imbalances, meds that are “like insulin for diabetes”, and the supposed lifelong chronic nature of severe mental illness.

    If they wanted to help a person find an alternative narrative based in the reality of their circumstances, that would be a bonus.

  5. I am a therapist myself. One reason that Jackie and Jill were told different stories is because they had two very different disorders. Jackie was clearly schizophrenic, Jill was a maybe, until it was revealed that she had been hearing voices since childhood. Schizophrenia at that age is very rare. It’s no surprise that Jill’s problems were trauma-induced, which calls for a totally different treatment regimen.

    • This is not the way I understood what the author is talking about. One psychiatrist couldn’t take the time to listen and was basically interested in peddling the pills. The second psychiatrist was actually helpful in walking with the woman on the Journey of healing because she was willing to invest some time and listen to what her person was actually saying to her. The first psychiatrist already had his or her mind set on what the agenda was going to be. The second psychiatrist was willing to find out something about the person she was working with before she was willing to make any decisions about what was happening.

    • I think you are missing the point. Jackie was “clearly schizophrenic” (as you put it) because her clinician chose to VIEW her that way, and the data he reported reflect his assumptions about the situation. It is quite possible and maybe even likely that if the second clinician had talked to Jackie, s/he would have discovered a similarly compelling story. But #1 never bothered to ask her about the reason for or meaning of her voices, while #2 was interested in Jill’s story rather than telling her his view of what was wrong.

      It’s also almost certain that if Jill had gone to clinician #1, she would have been diagnosed with schizophrenia and “treated” accordingly, without #1 finding out anything about her history or the possible reasons/meanings behind her symptoms. #1 would never have asked about her story.

      The point is, the conclusion that is reached is dramatically impacted by the questions that are asked, and those questions are a function of the professional biases of the clinician – they don’t necessarily have anything at all to do with the client.

      Case in point: I was called to the hospital to do an involuntary treatment evaluation on a 17 year old, developmentally delayed girl. She was intellectually about 6 years old. She was diagnosed with bipolar disorder, based on mood swings and aggression, which she clearly did demonstrate. However, a 20-minute phone call with her mom revealed that she has been relatively well behaved and happy until a couple years ago, at which point she was raped. She reported that the girl became withdrawn and depressed for about a year, at which point, she disclosed the rape. It was only after this disclosure that she began to be aggressive and “moody.”

      She did fit the criteria for “bipolar disorder.” But I had her diagnosis changed to “PTSD,” since the “bipolar” symptoms clearly only arose in the context of a severe traumatic event. Was the first clinician wrong, or was I? There’s no way to say. The first clinician used a very narrow set of questions focused on symptoms, and told the story that this girl’s brain was malfunctioning, because that’s what s/he was looking for. I asked broader questions based on the idea that her behavior had a cause and a meaning, because that’s what I believe is important. You could say I was as biased as the first clinician, but my bias was to support more of a sense of agency for the client, because that’s what I observe to be the most helpful way to intervene.

      To me, diagnoses are not right or wrong. They are either helpful or unhelpful. Mostly, I think they are unhelpful, because they take power away from the client. I used them because I had to, and I tried to use the ones I felt were the most helpful in getting them the support they needed, and if not that, the ones that did the least harm. I think you and your clients might benefit from thinking about diagnoses in that way. The client’s story is much more important and relevant than the label we choose put on them ever can be.

      —- Steve

  6. I will throw my two cents in: I found the article to be fascinating, it tells an interesting tale about the importance of a narrative approach versus non-narrative (medical model.) I agree with this concept totally. I also, as others have said before me, am skeptical of this philosophy because the focus seems to drift from consumer to “Dr.” The emphasis MUST be on client-centeredness, Carl Rogers believed and not psychiatrist-centeredness. Every word out of a psychiatrist’s mouth is very important because they hold power – to prescribe, to dictate diagnosis, etc. Does every person have a narrative, yes they do. I believe that LISTENING to a narrative is what is essential. I had a psychiatrist who saved my life. Somehow he knew what was happening to me but his genius was to listen and help ME figure it all out, it took time, but he knew he couldn’t give me immediate answers or else I would never have experienced real change that leads to healing. I believe that psychiatrists must beware of the power that they hold. How do you create an environment to allow for narrative, when it is a 15 minute session?
    Finally, I have to comment on intellectualism. I grew up in a family of two psychologists, had various cousins at universities, etc., etc. all with high intellectual credentials. My family’s book collection rivaled that of the local library. They could all quote any brilliant mind of any century, etc, etc. But they couldn’t relate to another human being, not at all. I am an intellectual myself, I found your references fascinating and I am not trying to insult your intellectual approach, but I always remember the lessons, I learned growing up, that analyzing something is useful, but the job of the therapist is to help the patient, to “walk the walk” so to speak.