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Brief Report
Points of Contact:
Using First-Person Narratives to Help Foster
Empathy in Psychiatric Residents
Serina R. Deen, M.D., M.P.H.
Christina Mangurian, M.D.
Deborah L. Cabaniss, M.D.
Objective: The authors aimed to determine if writing narratives
in psychiatric training can foster empathy for severely and per-
sistently mentally ill patients.
Methods: One resident wrote first-person narrative pieces
about three different patients at a community mental health
clinic. She reviewed these pieces with a writing supervisor
weekly. The supervisor and resident examined the style of writ-
ing, choice of words, and story line to help the resident learn
about her feelings about the patient.
Results: In each narrative, different choices were made that
provided clues about that particular resident-patient relation-
ship. These writing exercises helped the resident become more
connected to her patients, develop interviewing skills, and en-
gage in more self-reflection.
Conclusion: Narrative writing effectively fostered empathy in a
PGY-1 psychiatric resident working with severely and persistently
mentally ill patients. This exercise also fostered understanding of
countertransference and improved psychiatric history-taking skills.
Psychiatry training programs may want to consider incorporating
narrative writing exercises into their curriculum.
Academic Psychiatry 2010; 34:438–441
The ability to empathize with patients is vital to
becoming a good clinician (1–3). Although many
believe that the capacity for empathy is innate, medical
educators have tried to develop exercises and tech-
niques to foster empathy in clinicians (4, 5). Coulehan
et al. (6) define empathy as “the ability to understand
the patient’s situation, perspective, and feelings, and to
communicate that understanding to the patient.” While
empathy is important for all clinicians, it may be par-
ticularly critical for psychiatrists who must rely on their
understanding of the patient’s internal experience in
order to diagnose and treat their patients. Nevertheless,
trainees may have a more difficult time learning to
empathize with patients whose internal experiences are
very distant from their own—for example, patients with
hallucinations, delusions, or cognitive impairment (7).
These differences might represent significant barriers to
developing empathy with severely and persistently
mentally ill patients, especially early in psychiatric
training.
Medical educators have found that writing narratives
can be a very powerful and effective method of fostering
empathy with patients early in training (4). As Charon (8)
writes, “Narrative competence permits caregivers to
fathom what their patients go through, to attain that illu-
minated grasp of another’s experience that provides them
with diagnostic accuracy and therapeutic direction.” Nar-
rative writing exercises have been used with preclinical
medical students, clinical medical students, and residents
to nurture all parts of the doctor-patient relationship, in-
cluding promoting self-reflection and developing empathy,
professionalism, and trust with patients (5, 9 –14). One
form of narrative writing exercise, which involves writing
autobiographical stories from the patient’s viewpoint, has
Received November 30, 2008; revised May 17, August 10, and Septem-
ber 15, 2009; accepted September 21, 2009. Dr. Deen and Dr. Cabaniss
are affiliated with the Department of Psychiatry at New York State
Psychiatric Institute and with the Department of Psychiatry at Columbia
University in New York City. At the time of submission, Dr. Mangurian
was affiliated with the Department of Psychiatry at New York State
Psychiatric Institute and with the Department of Psychiatry at Columbia
University. At this time, Dr. Mangurian is affiliated with the Department
of Psychiatry at the University of California, San Francisco. Address
correspondence to Serina Rayhan Deen, Columbia University Depart-
ment of Psychiatry, NY State Psychiatric Institute Box #99, 051 River-
side Dr., New York, NY 10032; sd2469@columbia.edu (e-mail).
Copyright © 2010 Academic Psychiatry
438 http://ap.psychiatryonline.org Academic Psychiatry, 34:6, November-December 2010
been successfully used with junior and senior medical
students (4, 13, 15).
One PGY-I psychiatric resident (SD) undertook a
project in which she used a self-reflective exercise to help
her to understand the severely and persistently mentally ill
patients with whom she was working in a community
mental health clinic.
Methods
During her rotation at a community mental health clinic,
one PGY-1 resident at Columbia University elected to
write narrative pieces about three patients of her own
choice with whom she was working. She wrote the narra-
tives during a weekly, 3-hour writing block that she built
into her 3-month elective. She wrote these pieces in the
first person, imagining that she actually was the patient
during a normal day in that person’s life. She had a clinical
supervisor for each of these patients (CM), with whom
she discussed patient care for 2 hours per week as part of
the clinical rotation. She also met weekly with a writing
supervisor (DC), another psychiatry faculty member who
did not have any interaction with these patients, to discuss
her narrative writing. Each session with the writing super-
visor lasted 1 hour during which the resident read one
piece aloud and then the two discussed different aspects of
the resident’s style of writing, choice of words, and story
line to help the resident learn about her feelings about the
patient. The goal of these sessions was left open-ended,
but it was broadly conceived as a possible mechanism to
explore countertransference.
Results
The PGY-1 wrote three narrative pieces ranging from
three to six double-spaced pages about three separate pa-
tients. Each narrative took roughly 3 hours to write.
After a few writing supervision sessions, it became clear
that the resident had chosen to write about patients with
whom she had had a difficult time developing a connec-
tion. The supervisor and the resident realized that in each
situation, these narrative choices were different and gave
clues about some aspect of that particular patient that
helped the resident to empathize with the patient’s subjec-
tive experience. They called these “points of contact.” In
each case, the resident felt that discovering these points of
contact through writing helped her to connect to her pa-
tients and to promote empathy. In addition, she felt that the
process improved her interviewing skills because she
imagined her patient’s lives more completely, thus in-
creasing her ability to ask them more meaningful ques-
tions.
Below are a few examples from the resident’s writing,
with some related supervisory process:
Patient #1: This patient was a young, morbidly obese, Latino man
with schizophrenia and a borderline low IQ who was depressed and
paranoid and said little about his feelings. The resident wrote:
My music protects me. Or maybe it just distracts me. I don’t know.
But if I can’t find my headphones, I can’t leave the house. There are
too many people out on the streets who want to jump me ...But
when I listen to my music, I can make it...Yeah, I’m nervous when
I walk out the door, but I listen to my songs, and I get caught up in
the beat, and I’m walking to the beat, and I don’t think about them
as much.
The resident had first written a third-person version
of this narrative, and had then switched to the first
person. When comparing the two versions, the supervi-
sor and resident noticed that the sentences of the first
person version were much shorter and choppier. They
thought that it might be like the rap music the resident
imagined that the patient was listening to. During this
discussion, the resident noted that in their first session,
the patient had offered her his headphones in order to
listen to music that he had composed. The resident had
liked the music and had imagined jogging to it. Thus,
the music was their point of contact. Once she found
this link, the resident was more able to empathize with
his perspective and to ask him relevant questions that
helped her to learn about him and to foster the thera-
peutic alliance.
Patient #2: This patient was a young African American woman with
schizophrenia who had marked poverty of speech and blunted
affect. Although during their interviews the resident felt that the
patient was not explicitly sharing many of her thoughts and feel-
ings, she did tell the resident that she was losing custody of her
3-year-old daughter, whom she visited once a week. The resident
wrote:
I tuck my baby doll under her pink quilt, and I turn off the light.
She clings onto my hand, and it takes all I have to peel her tiny
fingers off of mine. I take a long last look at her—I want to be
able to notice how she’s changed next week. I tell her I’ll be
back real soon. That’s what I hope. That’s all I can pray for.
That I’ll be back real soon.
In discussing the piece, the resident revealed that she
had been moved by the story of the impending loss of
custody. Through her writing, she realized that this was
her point of contact with this remote patient. Allowing
herself to imagine her patient’s feelings enabled her to
DEEN ET AL.
439Academic Psychiatry, 34:6, November-December 2010 http://ap.psychiatryonline.org
feel more empathy toward her in their subsequent in-
teractions. Interestingly, after reading the piece, the
clinical supervisor (CM) also noticed increased empa-
thy for the patient.
Discussion
Writing imaginative narratives about her patients helped
one PGY-1 psychiatric resident to connect to several emo-
tionally distant patients. Beginning in the third person, she
discovered for herself the way in which writing in the first
person enabled her to “crawl into the patient’s skin” more
easily. She “found herself” writing about things that she
had not emphasized in her meeting with her patients. She
and her supervisor discussed these “points of contact,”
helping her to better understand both her feelings about
her patients and each patient’s subjective experience.
Thus, by allowing herself to imagine things about her
patients’ lives, the resident unearthed ways in which she
had connected to the patients without even realizing it.
As Marshall and O’Keefe (13) noted, writing in the first
person changes the signifiers of “him/her” to “I/me,”
reducing the distance between the clinician and the
patient and giving the writer of the patient’s story a
stronger investment in the patient’s future and the out-
come of the medical care. While most trainees under-
stand the idea of feeling sympathy toward their patients,
it is the concept of empathy, or as Zinn (16) writes,
“understanding an individual’s subjective experiences
by vicariously sharing that experience while maintain-
ing an observant stance,” that is fostered in this exer-
cise.
In addition to fostering empathy, this resident’s experi-
ence provides some evidence that narrative writing may
offer other benefits to psychiatric residents. It promotes
self-reflection and nascent exploration of countertransfer-
ence by giving residents permission to take time to think
about their patients’ lives. While the concept of counter-
transference is usually somewhat undeveloped in new
trainees, this exercise provides a forum in which to begin
to explore how similarities and differences between their
lives and their patient’s lives may affect their interaction.
Using writing to explore countertransference was under-
taken by Bhuvaneswar et al. (17), who incorporated the
process of journal writing into a psychiatry intern’s emer-
gency psychiatry rotation. Narrative writing in particular
may also help residents to think of their patients as whole
people, rather than just collections of symptoms (14). It
may also help them to become better interviewers by
allowing them to use their imaginations to think of the
next question to ask, develop hypotheses about our pa-
tients’ motivations, and try out formulations. Thus, en-
couraging students to imagine things about their patients
can have an important role in developing them into cre-
ative thinkers who are curious about themselves and their
patients.
Despite these potential benefits, there may be limita-
tions to the use of narrative writing for psychiatric resi-
dents. This resident elected to write narratives; this might
not be as readily embraced by all trainees, especially if it
were a required course rather than an elective. In addition,
this type of exercise inherently exposes the resident’s
countertransference, and thus supervisors would have to
be extremely sensitive to this, particularly if it were done
in a group. It is essential that the participating supervisors
emphasize the ways in which these narratives are, of
course, fictions, and are thus not to be confused with their
patients’ histories. Trainees should be able to recognize
that their own imaginings of a person’s life are colored by
their own feelings and experiences and that they can learn
about themselves through their imaginings. Careful super-
vision from experienced teachers is of the utmost impor-
tance in this type of project.
This exercise could be conducted individually or in a
group setting in which group members learn from each
other’s experiences. While this writing was done about
severely and persistently mentally ill patients, it could
easily be adapted for residents working with any type of
patient population. We believe that this exercise allows
trainees to imagine their patients as complete individuals,
promotes self-reflection, and helps develop more empathic
clinicians.
At the time of submission, Dr. Deen and Dr. Cabaniss reported
no competing interests. Dr. Mangurian is a mentor for an
APIRE/Janssen Research Scholar and will receive $500 in hon-
oraria for this role.
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