Chapter one excerpt 1- continuation

(Continuation of chapter 1, The Art of Narrative Psychiatry by SuEllen Hamkins (Oxford Press, 2013) pp._

Narrative psychiatry is important to me personally because it is based on values that I cherish. First, it is deeply respectful of each person and his or her individual values, hopes, and dreams. Second, it values working collaboratively with patients as partners in treatment. Third, it is interested in questioning cultural narratives and operations of power in society that may be harmful to people. Fourth, narrative psychiatry does not let a problem obscure who the person is without the problem. It holds the view that problems and mental health symptoms are undeserved and that people are doing their best to resist them; that we all have problems and, at the same time, we have cherished morals, meaningful intentions, robust characters, magnificent talents, and vibrant souls; and that attending to those aspects of a person’s experience and identity inspires growth and helps people overcome their problems and move their lives in the directions that they prefer. And fifth, narrative psychiatry never gives up hope that healing is possible.

I held these values before I began working narratively, but I could only operationalize them so far. In my work in the early 1990s as a psychiatrist at a college counseling service and at a community mental health center, I was able to see the vibrant souls and strong characters of my patients as they dealt with mental health challenges, but I was less successful in helping them see these things. (For example, prior to working narratively, I would have focused my treatment of Maeli Taylor on discovering the roots of her depression and trying different psychotropic medications, as I had been taught, even though these approaches had already been tried without success. I would not have known then how to effectively help Maeli honor what she found meaningful, tell the story of her strengths and hopes, and use that story to inspire additional steps to resist the depression.) Even though I had supplemented my traditional training as a psychiatrist in psychoanalytic psychotherapy and psychopharmacology with intensive study of family therapy, I felt I just didn’t have the tools I needed to put my values into practice and be effective in the ways I wanted to be. I felt discouraged.

Then, in 1998, at a workshop offered by Michael White, I discovered narrative therapy.

[i] This was just what I was looking for! Brilliant theory and a thousand tools with which to put it into practice! From its inception, narrative therapy sought ways to be helpful those with serious mental health challenges.[ii] I immediately began adapting narrative therapy to my work in psychiatry.

So when Maeli Taylor said, “I feel suicidal every day,” my hope was to discover the smallest signs of movement toward well-being and develop them into stories of strength and meaning that could inspire and sustain her. I asked her, “What percent of you wants to die, would you say?”

“Ninety percent.”

“Okay,” I said, initially disconcerted. Ninety percent was higher than I had anticipated—but at least it wasn’t 100 percent, I thought, and that was where we might start. “Let’s first talk about the 10 percent of you that wants to live. Is that okay?” She nodded, making eye contact with me. “Would you say that that’s an improvement from when you were at your lowest?”

Maeli raised her eyebrows a quarter of an inch. She seemed surprised but intrigued by this line of questioning. “Yes.”

Already we had discovered a positive development. On its own, the fact of her small improvement would offer her little traction in resisting the dominance of the depression in her life, but linked with other positive developments in a story that honored what she found meaningful, it would make a more compelling alternative.

She and I went on to speak about what she valued and when she felt best. Slowly, Maeli told me about the good things in her life that she was enjoying, and then we spoke about what was difficult. The beginning of the “Recent History” section of my initial psychiatric consultation note captures the sense of our conversation that day:

Currently, Ms. Taylor reports that she has been able to reclaim more of her life from depression than she has ever been able to before. Currently, she reports that she is feeling OK and free of depression about 10% of the time and feels the presence of depression about 90% of the time. She notes she tends to feel more up when she is around her family, that is, her parents and her two younger sisters, because they are caring of her. She also tends to feel more OK when she goes to church, and she is helped both by the connection with the people there and her sense of spiritual connection. Furthermore, she notes sometimes at community college, she also feels OK, and sometimes feels OK in other contexts as well.

When the depression is more prevalent in her life, she experiences low energy, negative thoughts, increased sleep, difficulty getting out of bed, and increased eating. In addition, she experiences suicidal thoughts. At times, she has just thoughts; other times she develops actual plans, but [since her release from the hospital] she has been able to successfully resist acting on her suicidal impulses. One recent example is when she had an urge to take her life, she was able to think about the fact that she wanted to finish school and this prevented her from acting on it. She notes she is in her third semester studying to be a computer technician.

At the start of our session, Maeli’s affect was predominantly depressed, but as our meeting proceeded she had moments of smiling and even laughing as we traced the history of her success in overcoming a tenacious depression and in pursuing her hopes for her life. Telling the story of her success in resisting depression in my consultation note stands in sharp contrast to the usual focus and tone of the medical record created to document an initial consultation, which typically focuses on the patient’s problem and says little about successes in overcoming it.

I worked with Maeli for twelve years, applying the principles of narrative psychiatry that I will expound upon in detail in this book. Along with my treatment, she also engaged in dialectical behavioral therapy and art therapy, lived in a therapeutic residence, and had occasional hospitalizations. Maeli made gradual progress, with significant ups and downs along the way, ultimately reporting lower percentages of depression and higher percentages of feeling “okay.” She eventually stopped making suicide attempts, and instead told us when she felt the suicidal urges were becoming unmanageable, so that we could help her utilize additional supports proactively. Notably, the attitude of the crisis intervention staff changed dramatically over the years in which I worked with her, moving from a hostile stance of blaming Maeli for the severity of her symptoms, to noticing and celebrating with her every small improvement in her ability to reach out for help rather than harming herself.

Together, Maeli and I highlighted moments of living well despite a terrible depression and linked those moments into a story of recovery. Here is what she wrote as a reflection after reading this introduction:

I was very scared walking into Dr. Hamkins office for the first time. This was a new psychiatrist and I knew I would have to tell my story all over again. I was not looking forward to this. So I was very reticent and shy. I did not have to tell my story all over again though. Dr. Hamkins took a different approach. As it turned out, Dr. Hamkins concentrated more on what made me feel positive rather than what made me feel negative. Do not get me wrong, we did talk about the negative thoughts and feelings, however she concentrated on the positive ones. In our work together I recognized when I was suicidal and was able to tell the crisis team. Whether it was a phone conversation, respite, or hospitalization, I was able to get the help I needed.

We made a “postcard” that I put on my fridge saying what I wanted in a life worth living: “Tolerating boredom, loneliness, and frustration is evidence of my courage, vision, and gutsy perseverance in doing something extraordinarily difficult in the service of my vision for my life: hubby and kids, lots of animals, be happy.”

I still have this on my fridge today.

Not only did this approach seem to make an enormous difference to Maeli, it made an enormous difference to me. Rather than being suffused with despair myself at the Herculean task of achieving remission of a seemingly intractable, life-threatening depression, in focusing on stories of success, no matter how small, my own spirit was sustained as well.

[i] I engaged in a yearlong intensive narrative therapy training program at the Family Institute of Cambridge, taught by Sallyann Roth, Hugo Kamya, and Timothy Scott, in 1998–99.
[i] Michael White, “Re-authoring conversations,” (Workshop presented at The Family Institute of New Jersey, Metuchen, New Jersey, 1997).

[ii] Dulwich Centre, “Companions on a Journey: An exploration of an alternative community mental health project,” Dulwich Centre Newsletter 1 (1997): 2 – 36.