Povl E. B.

DepartmeWhangarJensen@N

© 2011 Th

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Why should psychiatrists learn about narrative therapy?

Povl E. B. Jensen

Australian and New Zealand Journal of Psychiatry 2011; 45:709–711

DOI: 10.3109/00048674.2011.589370

In the presence of acute mental illness a patient ’ s sense

of competence and identity is particularly fragile and vul-

nerable, perhaps even more so in a multicultural setting

like New Zealand or Australia (with patients and psy-

chiatrists of very different cultural backgrounds). I am

concerned that the ways we presently practise for instance

diagnostic interview and risk management may act to fur-

ther destabilize rather than support the patient. The use of

a narrative therapy approach may offer a different oppor-

tunity for engaging with the patient and an improved

foundation for patient – psychiatrist collaboration.

It was almost by coincidence I went to an annual confer-

ence 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 cer-

tainly 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

scientifi c 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 fur-

ther developed it with contributions from all over the

world).

Jensen, Consultant Psychiatrist

nt of Mental Health, Puriri House, Private Bag 9742, ei Hospital, Whangarei 0148, New Zealand. Email: Povl.

orthlanddhb.org.nz

e Royal Australian and New Zealand College of Psychiatrists

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 diagno-

sis PTSD, BPAD, or schizophrenia) and, equally impor-

tant, 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 inter-

cepted the digger-operator who was excavating the latest

and so far biggest soil-slip which threatened to under-

mine 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 sta-

bilize 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 dan-

gling high in the air.

I think that we unfortunately often practise psychiatry

along similar lines despite good insight and good inten-

tions. 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 bewil-

derment, helplessness and not least a fear that one ’ s sense

710 EDITORIAL

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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 fi ghting to preserve integrity, dignity, sometimes

his or her life. Further down the track, so to speak, we

have also encountered otherwise intelligent and compe-

tent 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 diag-

nostic 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 diag-

nosis, a formulation and a treatment plan, in keeping with

established good medical practice. However, the psychi-

atric 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 fi le 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 fi rst 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 fi rst 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 infl uenced 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 exten-

sive introduction to NT, but it is my hope that by using

my road-works metaphor I can illustrate the potential ben-

efi t 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

fl oor, 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 pre-

clude offering full scientifi c information) and by attempt-

ing to rescue and document evidence of competence,

courage, achievement and values, alongside the excava-

tions for pathology, we may offer crucial support to the

patient ’ s struggle to maintain or recover a sense of com-

petence and identity. It may also enhance the patient ’ s

experience of having been heard and having his/her con-

cerns 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 work-

ing in Australia and New Zealand once took the Hippo-

cratic Oath, and we dedicated our work to ‘ the good of

the patient ’ . In reality the psychiatric fi les 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

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sometimes we have made the real person cease to exist

on fi le (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 con-

sultation 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 fi rst 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 rela-

tionship, and in the process have reduced the person ’ s

experience of isolation.

It is also worth noting that the patient is likely to appre-

ciate, sometimes even value, the completed assessment

document.

I am in no way arguing that we should distance our-

selves 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 desir-

able 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 psy-

chiatrist will ‘ manage ’ the patient, not how the patient

wishes to manage his or her life).

I fi rmly 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 ques-

tionable 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 disqualify-

ing 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

fi nd that NT may be a helpful alternative to pharmaco-

therapy 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 confl ict 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 becom-

ing a doctor in the fi rst 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 confl ict

resolution [5].

A great selection of NT articles is available free online

through Epston ’ s homepage (welcome to narrativeap-

proaches.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 fi rst two chapters of Morgan’s book [6]

“What is Narrative Therapy?”

Declaration of interest : The author reports no confl ict of

interest. The author alone is responsible for the content

and writing of the paper.

References

White M, Epston D. 1. Narrative means to therapeutic ends . New

York, Norton, 1990.

White M. 2. Maps of narrative practice . New York, Norton, 2007:

40.

Hatcher S. Risk management in mental health: applying lessons 3.

from commercial aviation. Australasian Psychiatry 2010; 18:4 – 6.

Hedtke L, Winslade J. 4. Re-membering lives, conversations with the dying and the bereaved . New York, Baywood, 2004.

Winslade J, Monk G. 5. Narrative mediation, a new approach to con-fl ict resolution . Jossy-Bass, 2001.

Morgan A. 6. What is narrative therapy? Adelaide, Dulwich Centre,

2000.