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Applications of narrative theory and therapy to the practice of family medicine

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This article presents narrative theory and therapy as an approach with significant potential for providing family physicians with additional tools to assist them in dealing with difficult clinician-patient encounters. We first define narrative therapy, then briefly describe its theoretical assumptions in relation to psychosocial concepts already familiar to family physicians. Important aspects of narrative therapy are examined, including the unique role of questioning in the narrative process; understanding and helping patients change their problem-saturated stories; renaming and externalizing the patient problem; and the use of rituals, documents, and audience in recognizing and reinforcing patient change. The article concludes with thoughts about how narrative approaches can contribute to more-healing doctor-patient relationships.
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96
February 2002
Family Medicine
Narrative therapy is a form of psychotherapy, pioneered
in Australia and New Zealand in the 1980s,
1
that em-
phasizes the importance of story and language in the
development and expression of interpersonal and
intrapersonal problems.
2
It uses therapeutic question-
ing to help clients recognize and reflect on the discrep-
ant but positive elements of their current problem-
saturated stories and to empower them to reformulate a
more-preferred life direction.
Clinical experiences with family practice residents
and their patients have convinced us that narrative ap-
proaches have much to offer the specialty of family
practice. In particular, patients who we label as
noncompliant, difficult, somatizing, self-defeating, de-
pressed, or anxious
3,4
can benefit from the incorpora-
tion of narrative elements into their encounters with
physicians.
In this article, we use the case study of a patient who
initially was not able to comply with treatment recom-
mendations for diabetes to illustrate basic concepts and
techniques of narrative therapy that have application to
the practice of family medicine.
Narrative theory stresses above all the importance of
language in shaping people’s realities. It is important,
therefore, to make a contextual point about the language
used in this article. Narrative therapists do not like to
refer to themselves as therapists, and they rarely call
the people who consult with them patients or even cli-
ents. This is because therapist-client language contains
many assumptions about authority, power, and exper-
tise that narrative therapists wish to question. We sus-
pect that narrative therapists might have similar, even
stronger, feelings about the terms doctor and patient,
which are heavily freighted with symbolism and ex-
pectation. Nevertheless, for the sake of clarity, this ar-
ticle will continue to refer to doctors and patients as a
shorthand for roles deeply ingrained in the social fab-
ric. We hope that readers will begin to ask themselves
questions about what these labels convey both nega-
tively and positively about the individuals who assume
them.
Theoretical Framework
The basis of narrative therapy is social construction-
ism
5
or the idea that the way people experience them-
selves and their situation is “constructed” through cul-
turally mediated social interactions. Through story and
language, cultures send powerful messages to their
members about the meaning of important concepts that
sustain the culture, including gender, race, class, and,
Special Article
Applications of Narrative Theory and Therapy
to the Practice of Family Medicine
Johanna Shapiro, PhD; Valerie Ross, MS
From the Department of Family Medicine, University of California-Irvine
(Dr Shapiro); and the Department of Family Medicine, University of Wash-
ington (Ms Ross).
This article presents narrative theory and therapy as an approach with significant potential for provid-
ing family physicians with additional tools to assist them in dealing with difficult clinician-patient
encounters. We first define narrative therapy, then briefly describe its theoretical assumptions in rela-
tion to psychosocial concepts already familiar to family physicians. Important aspects of narrative
therapy are examined, including the unique role of questioning in the narrative process; understanding
and helping patients change their problem-saturated stories; renaming and externalizing the patient
problem; and the use of rituals, documents, and audience in recognizing and reinforcing patient change.
The article concludes with thoughts about how narrative approaches can contribute to more-healing
doctor-patient relationships.
(Fam Med 2002;34(2):96-100.)
97Vol. 34, No. 2
of course, health.
6
For example, the psychiatrist/anthro-
pologist Arthur Kleinman distinguished between dis-
ease and illness by defining the latter as “how the sick
person and the members of the family and wider social
network perceive, live with, and respond to symptoms
and disability;”
7
in other words, what a disease means
to the patient and family. Kleinman realized that such
meaning is made or constructed on the basis of per-
sonal beliefs about health and illness that are strongly
influenced by cultural norms and standards. Narrative
ideas offer a useful framework to help patients and phy-
sicians access this process of meaning construction and,
in cases of dysfunctional meaning, work to change it.
8
The Patient
Mr A was a 51-year-old white male with adult onset
diabetes mellitus and secondary complications, seen by
a third-year family practice resident, Dr B, in a univer-
sity-based outpatient clinic. Initially relying on a dis-
ease model, the physician tried to manage Mr A through
a treatment plan of blood sugar monitoring, medica-
tion, diet, and exercise. The patient, however, seemed
to ignore the physician’s recommendations. Dr B de-
scribed the patient as chronically noncompliant and in
denial, and Dr B was frustrated by his care. In particu-
lar, Dr B complained of being “tired of telling him what
to do” with so little result. An initial narrative-based
intervention invited Dr B to switch from making direc-
tive statements to Mr A to asking him questions—lots
of questions.
Questioning: the Basic Tool of Narrative Therapy
Physicians use questions to identify the chief com-
plaint, clarify pertinent symptomatology, elicit the his-
tory of present illness, and formulate a differential di-
agnosis. This type of questioning seeks specific answers
and generates information used to corroborate or modify
the physician’s conclusions. The format of this ques-
tioning tends to privilege the knowledge of the doctor
over that of the patient, by inferring that the patient can
offer either right or wrong responses, relevant or tan-
gential data.
Narrative questioning has the intent of uncovering
meaning and generating experience rather than creat-
ing information.
9
This type of questioning emphasizes
patients making their own interpretations of events and
formulating their own insights. The result is a process
in which patient self-discovery and understanding are
central, and the physician’s role is facilitator and ally.
Narrative therapists use different kinds of questions to
achieve these effects (Table 1). For example, questions
are used to invite people to see their stories from dif-
ferent perspectives and to understand how they are in-
fluenced by sociocultural factors. Other questions ask
patients to envision different, more-hopeful outcomes
for themselves, to probe the significance of rare but
hopeful events in their lives, and help them recognize
that they are constantly making choices for or against a
particular problem-saturated story.
The Problem-saturated Story
10
Narrative therapy involves working with people who
are stuck in problem-saturated stories that they tell
themselves, and that society has told them, about who
they are and what their lives signify. These stories have
become “disabling”
11
in the sense that the individuals
feel they have lost control of their stories and are un-
able to change their meaning. For example, one day,
Mr A told us, “Everybody knows you have to be very
compulsive to control diabetes, like Mary Tyler Moore.
I’m not that kind of person, so I’m sunk. This “story”
is based on prevalent beliefs within both the culture of
medicine and the larger society about “good” and “bad”
diabetic patients. It may not be the story the teller wants
to tell but is perceived as the only story available.
Renaming the Problem
Technical medical language emphasizes pathologi-
cal processes and deficits and often makes it difficult
for patients to accept more preferred or desirable sto-
ries about themselves.
12
Noncompliance, for example,
is a term rooted in the medical model of disease that
has been criticized as pejorative, coercive, and
disempowering.
13
Narrative therapists encourage the use
of patient, rather than medical, descriptions of the prob-
lem. When the patient creates a personalized “working
label” for his/her problem, he/she gains power and con-
trol. For example, rather than view himself as
noncompliant, Mr A preferred to talk about his attitude
of not caring.
Externalizing the Problem
1,8-10,14
A major premise of narrative therapy is that the per-
son is not the problem; the problem is the problem. A
narrative approach advocates externalizing the patients
problem by locating it outside the individual and within
the culture. Working as a narrative physician, Dr B be-
gan to wonder which aspects of her patient’s world and
belief system had encouraged this problem of not car-
ing. Specifically, she asked, “Where did the idea that
you have to be like Mary Tyler Moore to control diabe-
tes come from?” Questions such as this help patients
realize that what they conceive of as their problem is
tightly woven into the social and cultural fabric. In the
case of Mr A, we learned that societally supported views
about how men should handle illness (being “macho,
“ignoring,and “not being compulsive” about sickness)
influenced his not-caring responses. Through a series
of such questions, Mr A (and Dr B) began to think of
not caring not as some kind of personality flaw at the
core of his being but as a problem that existed outside
himself and was created in part by societal expecta-
tions and pressures about gender roles.
Special Article
98
February 2002
Family Medicine
When faced with seemingly intractable patient prob-
lems such as noncompliance, physicians may feel, as
did Dr B, that patient and disease are in league against
them. Externalizing helps reset this boundary by creat-
ing an alliance of doctor and patient on one side versus
the problem on the other.
15
If physician and patient can
become paired against a challenging but ultimately
beatable problem, the patient-physician coalition has a
better chance of remaining intact.
A common concern about externalizing is that such
an approach will cause patients to take less responsi-
bility for their problems. Paradoxically, narrative thera-
pists insist that just the reverse occurs. When people
are freed from self-blame and guilt, they are more likely
to take responsibility for the effects the problem has on
their lives and more likely to assume a position of re-
sistance and overcoming toward a problem they view
as something distinct from themselves. At one point,
Mr A confided with a conspiratorial grin, This not
caring thinks it’s smarter ‘n me. But I can out-trick it.
Exploring the Effects of the Problem
1,8,9
By asking questions not about the cause of the prob-
lem but about the influences or effects it has on the
patient’s life, it is possible for the patient to clearly iden-
tify the problem story. For our patient, some of these
reverberations of the problem included frequent doctor
visits, pain, hospitalizations, and neuropathies, as well
as a sense of hopelessness and failure. Sometimes it is
helpful to ask patients, “What will happen if the prob-
lem were to continue on its present course?” The pa-
tient can even provide a name for the plot of the prob-
lem story.
9
As Mr A put it, “Unless I start paying atten-
tion to this darn thing, my story will be called ‘How to
Let Diabetes Kill You.
Table 1
Types of Narrative Questions
Term Purpose Example
DECONSTRUCTIVE Show how stories are constructed; situate narratives Who told you “real men” don’t pay attention to their health?
in larger systems
RENAMING Support patient efficacy by sharing authorship What would you call this problem of not paying attention to
and expertise with patient your diabetes?
PERSPECTIVE Explore other people’s views of patient Does everyone agree that you’re not capable of managing
diabetes, or does someone have a different idea?
OPENING SPACE Allow hopeful thoughts, actions to surface and be Are there ever times when not caring doesn’t control you?
explored; highlight patient efficacy regarding problem Tell me about these.
HYPOTHETICAL Stimulate patient’s imagination to envision different, Suppose a miracle happened and not caring was solved,
(MIRACLE) more hopeful futures how would your life be different?
PREFERENCE Check to make sure that exceptional moments How did you feel when you got the trucking job? Is this
are actually preferred to the problem story; something you really want?
establish patient preferences
STORY DEVELOPMENT Explore and linger on elements of the preferred story Tell me more about how you were able to resist that fast
food? What exactly happened?
REDESCRIPTION Help patient recognize preferred qualities in themselves What does it say about you as a person that you were able to
and probe implications for identity test your blood sugars daily last week?
BIFURCATION Encourage patient to align him/herself against the problem Is the event you’re describing on the side of not caring or
against not caring?
STOPPER Refocus patient when he/she seems to be getting stuck Which story are you telling now?
in old story
AUDIENCE Identify supportive witnesses to the new or developing story Who in your life would be least surprised that you are able
to make this change?
Many different authors have created questions and question types that assist the main tenets of narrative therapy: deconstruction, externalizing, and restorying.
White and Epston’s
1
work laid wide-ranging groundwork; Freedman and Combs
9
also provide extensive examples. This table suggests a few types of
questions that were helpful in the case at hand.
99Vol. 34, No. 2
It is equally important to explore the effects of the
patient on the problem. In other words, in what areas
does the patient have influence over the problem? In
what ways can the patient still stand up to the prob-
lem? Here is an example of a typical patient-effects
question asked by Dr B: “Can you tell us about a time
when you have been stronger than not caring?at which
point Mr A recalled occasions when he had chosen to
follow his diabetic diet. Such questions help make vis-
ible the positive ways the patient may be acting or plan-
ning on acting in relation to the problem.
Searching for Hopeful Exceptions
to the Problem
1,9,10
The overarching goal of narrative therapy is to help
the patient replace the problem-saturated story by con-
structing a preferred story.
16
The building blocks for
this new story are found in the discovery of hopeful
moments, thoughts, or events that do not fit with the
problem story. For Mr A, holding a job, beating co-
caine, and wanting to see his 2-year-old son grow up
were examples of such occurrences that, when discussed
with the physician, reflected back to Mr A possibilities
of hope and transformation.
Patients are often dismissive of these sometimes
small and initially uncharacteristic glimmers. At one
point, Mr A told us, Anybody can have thoughts about
wanting to change. The narrative physician can play
an important role by questioning this perception. In-
stead of ignoring such hopeful moments, Dr B chose to
focus intently on them. “Wait a moment! Are you tell-
ing me you’ve been thinking about tackling your dia-
betes? How did you manage to do that? How did that
make you feel? How is that in line with what you want
from your life?” Lingering over such occurrences, and
asking the patient to reflect on their details, helps them
grow in importance and power.
Patient Preference
8
Because it is easy to become impatient about identi-
fying hopeful moments and building a preferred story,
narrative physicians should remember two cardinal
rules: (1) don’t try to convince the patient to rewrite
his/her story and (2) stay behind the patient.
14
A narra-
tive approach does not involve physician persuasion or
coercion. Rather, it encourages the patient to find his/
her own voice and to make choices about how he/she
wants to live. Opposing the patient’s viewpoint simply
results in an escalation of defensiveness and resistance.
Narrative therapists also caution that rather than be-
coming cheerleaders for patient change, their role is to
stay behind the patient’s progress, recognize it, empha-
size it, but always ensure that it is being pursued and
desired by the patient. With Mr A, Dr B learned to
switch from praise (“That’s great you’ve started to eat
more regular meals.) to respectful interest in the be-
havior (“How were you able to come up with a more
organized schedule for eating?”). In this model, rein-
forcement takes a back seat to understanding how suc-
cessful change occurs, is in line with Mr As values,
and supports the image he has of himself.
Ritual
8-10
Although narrative therapy relies primarily on ques-
tioning and listening in the search for preferred mean-
ings, it also uses other techniques that have relevance
to a family practice setting. Note-taking stresses the
incorporation of exact patient language, a willingness
to share these observations with the patient, and en-
couragement of the patient to take his/her own notes
during a session, implying that the patient’s observa-
tions are as valid and important as the physician’s.
8
Letter writing from physician to patient is another pow-
erful technique to summarize key points of a session
and, with the advent of e-mail, not excessively time-
consuming. Documents, such as certificates, awards,
and diplomas specifically created to commemorate sig-
nificant patient developments, are also meaningful.
When Mr As blood sugars started regularly hovering
around 150, we drew up a Certificate of Unbelievable
Progress,which we all laughed about but that he
proudly showed his son. All these approaches take ad-
vantage of the power of ritual
17
in solidifying and me-
morializing significant life changes.
Generating Support
1,8-10
One of the most effective ways of strengthening the
new, developing story is by creating a receptive audi-
ence who serve as “witnesses. The doctor is an impor-
tant member of this potential audience, but it is useful
to have patients identify other audience members as
well. A key aspect of a successful audience is that it be
comprised of people who are supportive of and opti-
mistic about the patient. Members of Mr As audience
included his girlfriend, his mother, and (symbolically)
a deceased aunt and Joe Namath. Mr A was a big foot-
ball fan.
Summary
The patient’s new story is built by linking together
hopeful thoughts and actions over time (past and fu-
ture) and space into a coherent narrative. Building these
links is not easy but can be facilitated by paying care-
ful attention to the details of change, the effects of even
small increments of change on the patient and his/her
significant others, and specific steps leading up to these
hopeful moments. In the construction of the patient’s
new story, the physician is less coauthor than light-
handed editor.
10
The physician’s goal is not so much
“selling” interpretations to the patient
18
as assisting to
deconstruct problematic behavior, note contradictory
occurrences, and wonder about their significance. The
patient puts together the pieces.
Special Article
100
February 2002
Family Medicine
In a narrative approach, the emphasis between doc-
tor and patient is on creating space for multiple per-
spectives to emerge and coexist, developing horizontal
collaborative relationships, openness, and optimism.
19
The narrative physician can develop a relationship not
just with the patient’s disease but with the patient’s life
in ways that surprise and please. As Dr B stated, “Be-
fore I began working with Mr A in a narrative way, I
really didn’t like him. When we became a team against
not caring, I stopped disliking Mr A and started to dis-
like his problem. Then, as Mr A started to care more
about himself, I started to care about him too.Mr A
created new possibilities for treatment of his diabetes,
but Dr B also created a new story about both her pa-
tient and the meaning of noncompliance. In this case,
incorporating narrative ideas led to a healing and em-
powering dynamic among doctor, patient, and the prob-
lem of not caring.
Corresponding Author: Address correspondence to Dr Shapiro, University
of California-Irvine, Department of Family Medicine, 101 City Drive
South, Bldg 200, Rte 81, Orange, CA 92868-3298. 949-824-3748. Fax:
714-456-7984. jfshapir@uci.edu.
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Howard Brody is Professor of Family Practice and Philosophy and Director of the Center for Ethics and Humanities in the Life Sciences, Michigan State University, East Lansing. As indicated by his recent books, Stories of Sickness (1987) and The Healer's Power (1992), his research interests have included the importance of narrative and power as underexplored themes within medical ethics. * Two anonymous reviewers for this journal made several helpful recommendations for clarification and expansion. 1. The most comprehensive overview of placebo research and theory is Leonard White, Bernard Tursky, and Gary E. Schwartz, eds., Placebo: Theory, Research, and Mechanisms (New York: Guilford, 1985). See also Howard Brody, Placebos and the Philosophy of Medicine: Clinical, Conceptual, and Ethical Issues (Chicago: University of Chicago Press, 1980). This research documents at great length that the bodily changes produced by placebo responses and related mechanisms are real and measurable. Thus, the term symbolic healing, as used in this paper, refers to those aspects of the physician-patient encounter that bring about measurable bodily responses; the term is not intended to suggest that the responses themselves are imaginary or fleeting. 2. For further discussion of what I have termed the meaning model, see Howard Brody and David B. Waters, "Diagnosis Is Treatment," Journal of Family Practice 10 (March 1980): 445-49; Howard Brody, "The Placebo Response, Part 1: Exploring the Myths" and "The Placebo Response, Part 2: Use in Clinical Practice," Drug Therapy 16 (July 1986): 106-18, 119-31, respectively; and Howard Brody, "The Symbolic Power of the Modern Personal Physician: The Placebo Response under Challenge," Journal of Drug Issues 18 (Winter 1988): 149-61. Other very influential treatments are Arthur Kleinman, The Illness Narratives: Suffering, Healing, and The Human Condition (New York: Basic Books, 1988), and Barbara F. Sharf, "Patient-Physician Communication as Interpersonal Rhetoric: A Narrative Approach," Health Communication 2 (1990): 217-31. 3. See Dennis H. Novack, "Therapeutic Aspects of the Clinical Encounter," Journal of General Internal Medicine 2 (September-October 1987): 346-55. 4. George L. Engel, "How Much Longer Must Medicine's Science Be Bound by a Seventeenth Century World View?" in The Task of Medicine: Dialogue at Wickenburg, ed. Kerr L. White (Menlo Park, Calif.: Henry J. Kaiser Family Foundation, 1988), 113-36. 5. Martin J. Bass et al., "The Physician's Actions and the Outcome of Illness in Family Practice," Journal of Family Practice 23 (July 1986): 43-47, and Martin J. Bass et al., "Predictors of Outcome in Headache Patients Presenting to Family Physicians-A One Year Prospective Study," Headache 26 (June 1986): 285-94. 6. See, for example, Barbara Starfield et al., "The Influence of Patient-Practitioner Agreement on Outcome of Care," American Journal of Public Health 71 (February 1981): 127-31. 7. John Ladd, "Medical Ethics: Who Knows Best?" Lancet ii (22 November 1980): 1127-29. 8. Howard Brody, The Healer's Power (New Haven, Conn.: Yale University Press, 1992). 9. Eric J. Cassell, "The Nature of Suffering and the Goals of Medicine," New England Journal of Medicine 306 (18 March 1982): 639-45. 10. This discussion makes it appear as if a few simple moves on the physician's part will assure that the patient accepts the meaning that the physician feels is the best explanation of the symptom. Of course, the real world is not so simple: sometimes a protracted process of negotiation is required for physician and patient to arrive together at a satisfactory meaning (assuming that the patient doesn't simply go out shopping for a more agreeable physician). One case of my own comes to mind in which the negotiation as to whether a recurring problem with eye pain and double vision meant "undiagnosed brain tumor, like my mother had" or "emotional stress triggered by unresolved grief over your mother's death" lasted for several years and had not finally been resolved when the patient moved to another state. 11. Warren Thomas Reich, "Speaking of Suffering: A Moral Account of Compassion," Soundings 72 (Spring 1989): 83-108.