Kaplan + Sadock's Synopsis of Psychiatry, 11e

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28.11 Narrative Psychotherapy

to make clinical encounters much more client focused and col- laborative. Narrative psychotherapy, at its core, recognizes that there are many ways to tell the story of one’s life. The choice among these different options is a key way in which people cre- ate their identity. These choices should not be reduced to expert choices or scientific choices because they are always also per- sonal and ethical choices. In the end, they are choices about what kind of life one wants to live. Furthermore, clinicians must come to understand the value of biography, autobiography, and literature for developing a repertoire of narrative frames and options. In the end, narra- tive competency in psychiatry means a tremendous familiarity with the many possible stories of psychic pain and psychic dif- ference. The more stories clinicians know, the more likely they are to help their clients to find a narrative frame that works for them. For patients and potential service users, a narrative under- standing means that there is a range of possible therapists and healing solutions that might be helpful. An approach that is right for one person may not be right for another. There must be a fit between the person and the approach, and people should feel empowered to take seriously their intuitions and feelings. If the person getting help does not feel this fit, he or she is likely right. There may well be another approach that would work bet- ter with the person’s proclivities. Like everything else, however, judgment is critical. Therapeutic experiences of all kinds can be frustrating, slow, and uncertain. How, for example, does one know when an approach misses his or her needs and when it is something that will take time, patience, and perseverance to be helpful? From a narrative perspective, there can be no gold standard or simple answers. Only judgment, wisdom, and trial and error can decide. R eferences Adler JM, Harmeling LH, Walder-Biesanz I. Narrative meaning making is associ- ated with sudden gains in psychotherapy clients’ mental health under routine clinical conditions. J Consult Clin Psychol. 2013;81(5):839. Alves D, Fernández-Navarro P, Baptista J, Ribeiro E, Sousa I, Gonçalves MM. Innovative moments in grief therapy: the meaning reconstruction approach and the processes of self-narrative transformation. Psychother Res . 2014;24(1): 25–41. Boudreau JD, Liben S, Fuks A. A faculty development workshop in narrative- based reflective writing. Perspect Med Educ. 2013;1(3):143–154. Cassel E. The nature of suffering and the goals of medicine. N Engl J Med. 1982;306(11):639. Charon R. Narrative and medicine. N Engl J Med. 2004;350(9):862. Charon R. Narrative medicine: Attention, representation, affiliation. Narrative. 2005;13(3):261. Charon R. Narrative Medicine: Honoring the Stories of Illness. Oxford: Oxford University Press; 2006. Frank AW. Narrative psychiatry: How stories can shape clinical practice (review). Lit Med. 2012;30(1):193–197. Gaines A, Schillace B. Meaning and medicine in a new key: Trauma, disability, and embodied discourse through cross-cultural narrative modes. Cult Med Psy- chiatry. 2013;37(4):580–586. Hansen J. From hinge narrative to habit: Self-oriented narrative psychotherapy meets feminist phenomenological theories of embodiment. Philos Psychiatry Psychol. 2013;20(1):69–73. Hazelton L. Improving clinical care through the stories we tell. CMAJ. 2012; 184(10):1178. Launer J. Narrative diagnosis. Postgrad Med J. 2012;88(1036):115–116. Lewis B. Moving beyond Prozac, DSM, and the New Psychiatry: The Birth of Postpsychiatry. Ann Arbor: University of Michigan Press; 2006. Lewis BL. Narrative psychiatry. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9 th ed. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2009:2932. Teichman Y. Echoes of the trauma: Relational themes and emotions in children of Holocaust survivors. Psychother Res. 2013;23(1):117–119.

logic to argue that people understand themselves in the same way they understand characters. Narrative approaches to identity allow people to navigate the tension between essentialist and nonessentialist identities because narrative identity allows for a kind of continuity over time, a relative stability of self, without implying a substantial or essentialist core to this stability. People’s interpretations of themselves use the cultural stories with which they are sur- rounded to tell a story of self that escapes the two poles of random change and absolute identity. In this way, a narrative identity is also a cultural identification. A person’s identifica- tion may seem original, but he or she narrates them with the resources of history, language, and culture. Narrative Psychotherapy With this brief introduction into narrative medicine, narrative psychotherapy, and narrative theory, it is possible to draw out further the meaning of narrative for psychiatry. Fortunately, one of the most helpful aspects of narrative theory for psychiatry is that it provides an overarching, or metatheoretical, rationale for understanding how these many psychotherapies work. From a narrative perspective, all thera- pies involve a process of story telling and story retelling. No matter which style of psychotherapy one uses, the process of therapy involves an initial presentation of problems that the client is unable resolve. The client and therapist work together to bring additional perspectives to these problems, allowing the client to understand them in a new way. These additional perspectives vary greatly depending on which style of psycho- therapy is used. It matters, in other words, whether the therapy is psychodynamic, cognitive, humanistic, feminist, spiritual, or expressive. From the vantage point of narrative theory, however, what these different approaches all have in common is that they rework, or “re-author,” the patient’s initial story into a new story. This new story allows new degrees of flexibility for understand- ing the past and provides new strategies for moving into the future. Future Directions Recent work in narrative medicine, narrative psychotherapy, and narrative theory has opened the door for the development of narrative psychiatry. This development provides a critical cor- rective to contemporary psychiatric practice that helps to bring psychiatry back from its current obsessions with science and scientific method. This corrective is not a return to psychoanaly- sis nor does it demolish the progress of scientific psychiatry. When psychiatrists take a narrative turn, they do not throw out their other skills and knowledge. The shift to narrative is, as much as anything else, an attitude shift and an opening out to additional sources of information. It starts by bringing to the foreground that the clinical encounter is a human encounter, and it follows by opening out to colleagues in the humanities, inter- pretive social sciences, and the arts to help to better understand this human encounter. Most of all, narrative psychotherapy joins with other contem- porary efforts in psychiatry—such as the recovery movement—