John Launer on narrative based medicine
In the last ten years there’s been a revolution in the thinking in many diverse field of learning. The revolution has come about through a variety of influences: feminism, anti-racism, cultural studies, social sciences, post modernist thought. It is a move away from ‘normative’ ways of understanding people to ‘narrative’ ones; away from the idea that exploring reality is like peeling away the layers of an onion, looking for the inner meaning concealed at the centre, and towards a different kind of metaphor: seeing reality more like a tapestry of language that is continually being woven. The concept underlying this revolution can be summarised as follows: we construct our view of reality by telling stories.
This revolution has had a particular influence in the world of mental health care, where a whole range of professions - including psychologists, psychotherapists and even some psychiatrists - have started to move away from being authoritative and certain about their view of mental problems, and have started to see their role more as collaborators in helping people to develop different stories about themselves. They have increasingly been working from the principle that if we can change our stories, we can change our view of reality.
For several years a group of us at the Tavistock Clinic have been exploring whether such ideas might make sense in primary care. Since 1995 we have been teaching a multidisciplinary course to GPs, practice nurses, health visitor and other primary care professionals. What we have discovered is that approach can be useful not just to encounters where there are apparent mental health problems, but all medical encounters. Indeed, medicine itself or its various elements can all be seen as a set of cultural stories that we offer to people to see if they fit. It can also be used as a way of understanding wider systems such as practices, teams, etc.
Using a narrative paradigm for primary care: the pros
- Offers clinicians a respectable intellectual framework no longer rooted in eighteenth century mind/body dualism
- Leads them to question some of the apparently solid certainties of science and of medicine.
- Helps them to become more aware of their social and political roles and to examine the power relations in their encounters with patients and teams.
- Enriches their work by drawing their attention to the variety of cultures and beliefs with which they come into contact.
- Allows them to let go of a constant sense of responsibility for other people’s problems, and to acquire a greater sense of the possibilities open to their patients.
Using a narrative paradigm for primary care: the cons
- Patients come to primary care because they want to meet experts who can offer conventional medical explanations for their problems. A narrative approach must provide a way of asking intelligent questions about medical knowledge without disqualifying that knowledge.
- Professionals have to do things: to stick needles into people, dispense drugs, carry out minor operations, prevent illness, monitor risk and do a host of other business. Patients expect them to be technical experts. A narrative approach cannot exclude action, nor can it be a licence for ignoring the normal tasks of primary care.
- Most people in primary care have to work under tremendous pressure of time and workload. They face demands from health service managers and politicians, as well as resource shortages. Narrative ideas and skills will not be helpful if they open up a ‘Pandora’s box’ that people do not have skills or resources to cope with. They will be most useful if they help people become more effective in ten minutes than if they lead people to attempt the impossible or run even later.
- The biggest challenge in taking a narrative approach is knowing when to stop. Disease, disability, deprivation and death are not stories. Narrative ideas can help people question their own convictions, but no-one should play postmodernist games with patients’ lives.
The seven C’s.
We have found that the most useful conceptual framework for communicating the essence of a narrative based approach are what we call the seven C’s. These are seven core concepts that all have a background of substantial theory and discussion in psychology and the therapies.
- Conversations.
Conversations don’t just describe reality, they create it. In primary care, they can be seen as interventions in their own right. We teach the skills for ‘conversations inviting change’: exploring connections, differences, new options, new realities. One of the great advantages of such conversations in family medicine is that they don’t have to have beginnings or endings: ‘ultra brief, ultra long therapy’.
- Curiosity.
This is the common factor that turns conversations from chatter into therapy. It should be friendly not nosy. Curiosity invites patients to reframe/reconstruct their stories. An essential aspect of curiosity is neutrality (to people, to blame, to interpretations, to facts.) Curiosity should also extend to yourself. How can you stop being bored, angry, impatient?
- Contexts.
This is what it is most effective to be curious about. Important contexts are families (geneograms), workplaces, history, geography, community, faith, belief systems, values. These are what people want to talk about and make conversations come alive. Attention to contexts also means thinking about your own, including the constraints of time, what patients expect of you and what medicine and society expect of you.
- Circularity.
Life seen as an endless and infinite dance of interactions. Think of the Krebs cycle, but in three dimensions and over time. A sense of circularity gets away from fixed ideas of cause and effect, unchangeable problems, over-concrete diagnoses. You can encourage this sense by (a) “circular questions” (b) following feedback (circling between yourself and patients) (c) tracking interactions (circling between patients and their family members).
- Co-construction.
What you are looking for is a better reality than the present one, which means a story (a form of words) that makes better sense for people of what they are going through. It may or may not incorporate a medical story, It may even change what they are going through.
- Caution.
Extend your skills and adventurousness but don’t be unrealistic about your own resources, or cover up for the lack of others. Don’t upset patients or get scared.
- Care.
Without which nothing else works.
Conversations inviting change: a framework for exploring and developing narratives
The most useful technical framework we have come across for narrative-based primary care is based on the idea of ‘interventive interviewing’. This was an idea first developed by the Milan Team of family therapists in the 1980s. They examined their own consultations to discover what seemed most effective in bringing about change.
They discovered that what didn’t seem to work were:
- advice
- looking for solutions
- telling people what is ‘really’ going on
What they found did work were consultations made up entirely of questions that make people think. They suggested that therapy worked not by ‘finding the right answer’ but by inviting people to think about themselves in different ways by the judicious use of questions. Their ideas were developed by the Canadian psychologist Karl Tomm, who came up with the phrase ‘interventive interviewing’, although we now prefer the more user-friendly term, conversations inviting change.
Tomm suggests that interviewers should move between:
Linear questions.
Most typical medical ‘clerking’ questions fall into this category. These are investigative questions about facts (‘When did it start?’). They are oriented towards the interviewer’s need to fit things into an existing framework of explanation, with little or no effect on the interviewee.
Strategic questions.
Many medical questions also fall into this category too. These are leading questions designed to nudge people in particular directions (‘Why don’t you try telling your husband?’). If the relationship is a traditional one they may work, but if not the effect may be constraining and oppositional.
Circular questions.
This term has given rise to a lot of muddle. Some people have misunderstood these as ‘questions that just go round in circles’ – the opposite of the truth! Family therapists have also created confusion by using them in particular ways e.g. to cover any questions that closely follow the patient’s feedback or any questions that move around different members of the family in turn or questions that ask one person to comment on relationships between others. However, the most useful definition is probably: any question that draws attention to the way the world operates according to circular rather than linear principles. (‘How do you respond when your wife says she’s feeling panicky?’) The therapist’s intention is therefore to introduce a descriptive rather than explanatory world view, and the effect on patients is often to help them feel liberated from stigma and blame.
Reflective questions.
These are a particular kind of circular question, aimed at inviting people to think about familiar experiences in new contexts. (‘If you suddenly stopped feeling depressed, would that make life more difficult for anybody?’) The intention of the therapist here is to perturb people a bit by challenging them to consider the unfamiliar. The effect on patients may be to confuse them, but good reflective questions can help them move into new and more constructive narratives about themselves.
The Milan team, Tomm and their followers also proposed two other central principles for interviewing:
- tracking language (picking up the exact words that patients use)
- following feedback (asking questions based on what the patient has just said, not the ideas you previously had in your head)
Finally…
You can’t teach ‘conversations inviting change’ by learning lists of questions, or by following guidelines and protocols about when to move from one type of question to another. Like all good practice, interventive interviewing works best when you’ve completely forgotten you’re doing it, and you couldn’t even tell others what kind of question you have just asked. On our courses, we find the best way to teach it is in the context of clinical supervision i.e. with one person interviewing another about a case that’s bugging him or her, with an observer watching and a tutor helping out. The feedback we get is that people who learn the skills like this in the context of mutual supervision then find it easier to apply in consultations with individuals, couples or families, and in training.
