Finding One’s Voice: Recovering from Trauma

Vivian Owusu, a stunning twenty-one-year-old African woman who grew up in Ghana, was about to walk out of the university counseling center when I went to the waiting room to get her for our initial appointment. Her first psychiatric provider had retired a year after meeting her and her next one took a different job six months later, so I was her third psychiatrist in less than a year. Vivian had not shown for her first two appointments with me and now, due to a double-booking error that was my fault, I was thirty minutes late. I apologized and asked if she had time to stay and meet with me. I could see her anger and agitation. “I suppose.” Irritated but still poised, Vivian followed me down the hall to my office. What an unfortunate beginning, I thought, feeling harried. We had been short-staff ed for months and I had been squeezing patients in as best I could, feeling like I wasn’t doing my best work. Vivian settled herself upright on my couch and looked at me coolly. She had big dark eyes, flawless brown skin, beautifully braided hair, a button nose, and a hostile expression. In response to my questions, she told me she was a junior, pre-law. She hadn’t slept for three or four days. Depression had been plaguing her and she had been having thoughts of killing herself. Her expression of hostility briefly showed a trace of sadness. “I don’t trust people,” she said. “I take things personally and I get annoyed.” She often felt emotionally volatile and easily got upset with people if she felt they were rejecting her. I had skimmed her medical record prior to the appointment and saw that she had had multiple emergency contacts with our clinicians and two psychiatric hospitalizations, the second five months earlier. She said she wasn’t having suicidal thoughts currently and would call us if she did. What she wanted from me was a refill of medicines she was taking to help with the depression and anxiety.

Collaborating in Choosing Treatment Options: Medicine and Other Psychiatric Resources

In practicing narratively, the doctor and patient can examine together what the doctor’s kit of psychiatry might have to offer in light of the values and preferences of the person seeking consultation, which authorizes the patient as the arbiter of what is helpful and what is not. Narrative psychiatry holds the perspective that while the doctor may have specialized knowledge about treatments, the patient is the expert on his or her life, and medicine or other treatments can be evaluated according to the values and preferences of the patient. In its nuanced approach to effective collaboration, narrative psychiatry offers ways to more fully manifest the intentions of the mental health recovery movement. This chapter will show how to collaborate with patients in considering and choosing among psychiatric resources such as psychotropic medications. In doing so, it will touch on the range of competing discourses about psychiatric treatments that may be influencing our patients and us. The story we have come to hold about who the patient is and what the problem is determines the therapeutic options we consider. All the skills described in the previous chapters—emotional attunement; developing a rich portrait of who the person is separate from the problem; clarifying the patient’s vision for his or her life; creating an externalized, experience-near description of the problem and its effects; and cultivating a narrative of how the person is resisting the problem and how that is linked to personal hopes and values—are prerequisites for being able to collaboratively consider which resources might best meet the patient’s needs. From our initial consultation on, we cultivate very different stories about the patient and the problem depending on the questions we ask—or don’t ask. Creating narratives that articulate our patients’ personal experiences of their problems and that honor their resiliencies, skills, and preferences sets the stage for considering treatments that will be most effective and life enhancing. When we have a collaborative therapeutic stance, we can look side by side with our patients at the wealth of treatment options that might be helpful and weigh the pros and cons together.

What Is Narrative Psychiatry?

Narrative psychiatry brings the muscle and agility of narrative theory and the spirit of compassion and social justice to the practice of psychiatry. What makes narrative psychiatry different from psychiatry-as-usual? Rather than focusing only on finding the source of the problem, narrative psychiatry also focuses on finding sources of strength and meaning. The result is compassionate, powerful healing. Narrative psychiatry combines narrative and biological understandings of human suffering and well-being. It begins with compassionate connection with patients, understanding that we live our lives in relationships and connect with one another through the stories we tell. It relishes discovering untold but inspiring stories of a person’s resiliency and skill in resisting mental health challenges while dismantling narratives that fuel problems. It examines what the doctor’s kit of psychiatry has to offer in light of the values and preferences of the person seeking consultation, authorizing the patient as the arbiter of what is helpful and what is not. Psychiatry as a field is seeking a more positive and patient-centered approach, which narrative psychiatry exemplifies. In his address at the American Psychiatric Association’s annual meeting on May 6, 2012, President-Elect Dilip Jeste, M.D., said that “ ‘positive psychiatry’—a psychiatry that aims not just to reduce psychiatric symptoms but to help patients grow and flourish—is the future.” Likewise, in 2012 the U.S. Substance Abuse and Mental Health Services Administration called for a focus on “recovery” that includes collaborative and culturally sensitive care that seeks to honor the patient’s values, self-determination, and preferred relationships and to foster not just the absence of symptoms, but also well-being. Narrative approaches to psychiatry, psychotherapy, and medicine have been burgeoning in the last decade, inspired by the wave of narrative theory that has progressively suffused philosophy, anthropology, literature, and the arts over the last fifty years. Training programs and courses teaching narrative approaches to mental health treatment and to medicine are flourishing.

Finding Lost Stories of Love: Remembering Love and Legacy amid Loss

“‘I have no son Danny,’” Daniel said, with bitterness. “That’s what my father said to me when he was near death. Thirteen years ago, I go to see him in the hospital, and he’s there in the bed with tubes coming out of him. I go up to him and he says, ‘Who’s that?’ and I say, ‘It’s your son, Danny’, and he says, ‘Danny who? I have no son Danny.’” Daniel’s face bore traces of sadness and anger. “Just before he died he denied me.” Daniel Francis O’Conner, a spirited man of sixty-seven, sat perched in the middle of the couch in my bright, airy private-practice office. He had the time and resources to engage in weekly, open-ended psychotherapy with me. With a short white beard, sparkling blue eyes, a quick smile that lit up his whole face, and a readiness to laugh at himself and the world, Daniel had an equal readiness to hold himself and the world to high standards of generosity, morality, and justice. I looked forward to our meetings, in which Daniel moved from one story of his life to another with eloquence, grit, irony and humor like a true seanachaí , an Irish storyteller. A lifelong resident of Holyoke, a tough little city in Massachusetts known for its historic mills and factories, Daniel shared the feisty passion of its Irish-immigrant residents. He was married to his beloved wife, Molly, and they had two grown children, Brigid, age 30, and James, 25. A published poet who was newly retired from thirty-two years as an awardwinning high school English teacher and long retired from boxing, Daniel was exploring a new career as a psychotherapist. He had met me at a workshop on narrative psychiatry that I had given at The Family Institute of Cambridge (the one in which I had presented my work with Elena, from chapter 5), and wanted to work with me, with hopes of taking stock of what his legacy might be as he prepared to enter his seventies.

Cultivating Stories of Strength and Meaning and Deconstructing Damaging Discourses: The Course of Treatment

Listening for narratives of strength and meaning that have not yet been told but are implicit in the patient’s experience is key to the art of narrative psychiatry. In any conversation, there are many openings for finding exceptions to the activities and effects of problems. Each exception to the problem is a seed that can be cultivated into a narrative by fleshing it out with detail, linking it to other exceptions over time, and articulating the meanings that these exceptions have for the person. This new narrative offers fertile ground for freshly imagining what might be possible in the future. It sustains valued aspects of identity and points the way toward freedom from the problem. At the same time that we are nurturing nascent stories of skill and resilience, we are also listening for narratives that fuel problems, so that they may be examined, dismantled, and replaced with narratives that support well-being. Stories that fuel problems come from many sources. For example, someone who is dealing with depression may be influenced by a family story of being the “problem child,” a local story that derides those who seek mental health treatment, and a wider cultural story that narrowly defines a successful life in terms of money. These narratives can be named and closely examined in light of the patient’s own values, allowing the patient more choice over which narratives are taken up and which are set aside. Narrative psychiatry continuously attends to the patient’s social context. Often, the people who consult with us are living under the influence of cultural discourses that make negative claims about their worthiness, seek to limit their prospects, and engage them in processes of self-scrutiny that lead to anxiety or despair. By discourses I mean narratives and practices that share a common value. These discourses include those that privilege or denigrate people on the basis of their race, gender, gender preference, sexual preference, body type, financial status, education, health, or ability. Narrative psychiatry attends to issues of power—of privilege and oppression—and deconstructs the operations of power as they influence someone’s life.

Conclusion

Narrative psychiatry is the North Star that guides me in my work. Whether I am conducting fifteen-minute appointments at a community mental health center, weekly psychotherapy in my private practice, or a college student’s first psychiatric consultation, the principles and practices of narrative psychiatry offer me direction and support. In every psychiatric context in which I practice, I seek to enhance my patients’ awareness of their strengths and values and assist them in taking steps toward their vision of well-being in the context of a collaborative and compassionate therapeutic relationship. It’s time to bring greater humanity back into the day-to-day practice of psychiatry. Just as primary care practitioners are seeking to attend more fully to their patients’ stories and lives, so, too, can we in psychiatry, especially in contexts such as med checks and hospital rounds. Narrative psychiatry offers the person-centered, recovery-oriented care and “positive psychiatry” that the leaders in our field are calling for. What narrative psychiatry needs to move forward is to train more narrative practitioners and to conduct more research to establish a stronger empirical foundation. Case-based, qualitative evidence of the efficacy of narrative approaches to mental health treatment is rich, such as that presented in this book and in two decades of articles and books published by White, Epston, Madsen, Freedman, Combs, Russell, Gaddis, Kronbichter, Maisel, Ncube, Speedy, and many others. Quantitative studies that have been completed to date, such as Lynette Vromans and Robert Schweitzer’s study of narrative treatment of major depression, and Mim Weber, Kierrynn Davis, and Lisa McPhie’s study of narrative treatment of eating disorders, while supporting efficacy, are limited by small sample sizes. Exciting research studies are currently underway. John Stillman has developed a narrative trauma treatment manual expressly for the purpose of defining core narrative therapy principles and practices so that their efficacy can be researched. He and Christopher Erbe have completed a pilot study demonstrating the reliability of scales used by observers rating whether therapy sessions were consistent with the practices described by the manual; that is, whether the treatment was actually narrative.

Finding Happiness: Rising from Despair and Turning Away from Anxiety

“Anxiety is ruining my life,” Addie Markiewicz had said to me at her first appointment at age sixteen. Now, four years later, she entered my office, dropped her backpack on the floor, plopped down comfortably on the couch, picked up one of my blue throw pillows and began fiddling with the zipper. A junior in college, Addie had long, dark hair, blue eyes, fair skin, wholesome good looks, and a dry, at times mischievous sense of humor. In our weekly sessions, she could be alternately reticent and forthcoming. A gifted student with lots of friends, she volunteered at a daycare facility for children with special needs and was a respected and beloved babysitter for several families in the area. She had helped to form an advocacy group at her college for students who were dealing with mental health challenges. She had a loving relationship with her parents, whom she called her “best friends,” and her life had been free of any major trauma; on the contrary, her childhood had been characterized by a loving, supportive family and a close-knit community of which she was a cherished member, many of whom shared her Polish American heritage. For the first three years of our work together, I met with Addie for twenty minutes every week or two and she also met with a psychotherapist. After he moved out of the area, I became her primary psychotherapist, meeting with her weekly for fifty minutes. She had made great strides in overcoming profound despair, an ongoing sense of unreality, severe anxiety, and unwanted compulsive urges that had dogged her since she was twelve, but at times one or more of these problems flared up again, and we were still chipping away at them, working toward a fuller recovery. From our first appointment, she had identified a problem of feeling an overwhelming urge to spend hours and hours on her homework until it was flawless, accompanied by a keen anxiety lest there were any mistakes.

Externalizing and Unpacking the Problem:Understanding Symptoms and Suffering

Seeing the problem as separate from the person is a stance that informs narrative psychiatry. This stance gives us firm footing in responding to our patients with respect and empathy and frees us to nimbly and creatively work with them to mitigate the unwanted effects of problems in their lives. We don’t blame patients for their problems. Rather, we align with them side-by-side to look out at the problem together and see what can be done about it. What this means is seeing problems as separate from our patients’ identities; that is, as outside of what they value and who they are striving to be. In doing so, we see both the problem and the person more clearly. Externalizing the problem in this way is a therapeutic practice that is one of our most powerful narrative interventions. It shifts the psychological landscape in which we are working. Patients often experience their problems as all encompassing. By externalizing the problem, it becomes circumscribed and we can more easily unpack it: characterize it, determine its boundaries, discover how it is impinging on a person’s life, expose the ways in which it operates, and discern what supports it and what weakens it. Separating the problem from the person makes it easier to see how patients are succeeding in living their lives in ways that they find satisfying and how they have freed themselves from the influence of the problem. We can more easily discover areas of the patient’s life in which the problem is not operating or is powerless, and we can more readily discover strengths and resources that a patient can draw on to overcome the problem. Not seeing problems as integral to who patients are provides immediate relief from negative identity conclusions, which are often piled on top of other unwanted effects of problems. These discoveries are energizing, inspire hope, and point the way toward effective treatment. The practice of externalization was developed by Michael White as a way to objectify problems instead of objectifying people.

Starting with Stories of Success: The Initial Psychiatric Consultation

If compassionate connection is the heart of narrative psychiatry, then eliciting healing stories is its soul. In narrative psychiatry, we begin seeking stories of strength and meaning from the very first appointment. As we listen to the story a patient brings to us, we also listen for the untold stories implicit in their narrative that may support their well-being. Fleshing out these stories, making them alive with detail, vivid with language and compelling with plot, strengthens them and gives them purchase to eclipse a disempowering, problem-dominated story. What we can know about a patient depends on what we are listening for. The openings for story development that we hear and the questions we ask in the first appointment lead to the cocreation of the narrative of the patient’s life that informs our understanding of the problem and our treatment options. By eliciting narratives that lead to a more nuanced, colorful, and balanced portrait of the patient and a more contextualized view of the problem, we can understand the nature of the problem and the patient with more depth, clarity and subtlety. Tall and thin with a short spiky haircut, and carrying a canvas messenger bag, Amanda Riley spoke earnestly when she first came in to see me for treatment of depression. A sophomore in college, she was mired in a story of how she was making bad decisions and wasn’t living her life right. Amanda had been referred to me by a psychotherapist at the college counseling service where I consulted due to concerns about panic attacks and depressed mood. The hope was that I would be able to help Amanda clarify the nature of the problem and determine if medication might be helpful, a typical workaday situation for many psychiatrists in today’s world. So how would a narrative psychiatrist approach his or her first meeting with Amanda? At the start of my initial conversation with Amanda, I asked her what year of school she was in and what she was studying. She told me she was a sophomore in college, majoring in Chinese and art.

Connecting with Compassion: The Therapeutic Relationship

Compassionate connection is the heart of narrative psychiatry. As humans, we live our lives in relationships. Who we are and what we feel—the very development of our nervous systems—arises through our connection and emotional resonance with others. The quality of that attunement determines what is possible for us to feel and to know of ourselves. The meanings we give our experiences and feelings—the stories we tell about who we are—arise in relationships. Every story has a teller and an audience, and the nature of that audience determines what kind of story it is possible to tell. Telling an emotionally moving story in a way that is healing requires an empathically attuned listener. For all these reasons, connecting with our patients is our first priority. Creating a therapeutic alliance with our patients begins with emotional attunement and is strengthened by transparency and collaboration. That is, in narrative psychiatry, we are open with our patients about our thought processes and we work with them in a side-by-side stance to look together at the problems they are facing, the values and strengths they can develop, and the treatment resources they can choose to draw upon. Addressing the impact on patients’ lives of racial, cultural, sexual, gender, and other identities and narratives with sensitivity to issues of privilege and oppression also builds trust. Attending thoughtfully to issues of power in the doctor-patient relationship serves to empower patients as partners in the treatment process. Supporting patients in developing empathic communities of support outside of therapy expands opportunities for healing connections in patients’ lives. Let’s look at how we can put these ideas into practice, starting with developing emotional attunement. Empathic emotional attunement is connection at its core, and from infancy on, experiencing another’s empathic attunement is soothing to us, body and soul. It is, in itself, healing. Becoming emotionally attuned with someone means listening with your whole being. It is attending not only to what you see and hear, but also what you feel in your gut and in your heart in being with the other person, and responding compassionately from that place.