Healing Stories: Narrative in Psychiatry and Psychotherapy

This seductively titled book is a rather densely written text that plunges at times into contemporary philosophy and literary criticism, although it is primarily about aspects of clinical understanding and practice. It consists of ten chapters about various aspects of narrative by different authors, among them a chapter by each editor.

The focus is on the role of narratives— that is, "stories"— as they are constructed; in how people define and think of themselves and of others; in relationships; and in medicine, particularly in psychiatry and psychiatric treatment. Having been trained and having practiced with an understanding of the fundamental importance of narrative, I found little new here, but the book serves as a reminder that this perspective is neglected in much current practice, which is so dominated by biologic as well as behavioral science and by economic factors. These factors push us toward "problem-oriented records" rather than "histories," toward purely descriptive diagnoses without "formulations," and toward quick treatments aimed at symptom relief. The ill person is lost to the illness.

Some of the chapters contain many wise observations and interesting discussions. They include illustrations of psychotherapy, where listening to and understanding the patient's initial story gradually leads to transformations that give the resulting story greater coherence and plausibility; in other instances these transformations can result in less rigidly held stories, leading to the patient's greater openness to new experience. The reminder that memory always involves some revision to fit one's story is timely, as is the recognition that some situations— for instance litigation— invite somewhat distorted story making.

Chapters on different theoretical, cultural, and political orientations make it clear that therapists also have their favorite narratives through which they see their patients, and that using such narratives as a fixed lens is limiting to patients and to the treatment endeavor. Different authors urge somewhat different checks on the therapist's explanatory formulation, including confirmation by the patient, coherence and consistency, plausibility, and therapeutic efficacy. It is not implied that the treatment goal is to arrive at "the truth."

Despite its many interesting discussions, the book has problems. It is hard to identify the group of readers to whom the book might best be suited. Seasoned therapists won't learn enough that is new, and it does not seem a particularly good introduction for the inexperienced.

In several chapters the treatment focus on a patient's personal narrative, with its relativism and ambiguity, so helpful in compassionate comprehension and psychotherapy, is absurdly misapplied. An example is in the sometimes tedious chapter entitled "Sacred Tales," where the author writes that in medicine's attention to the physical at cost to the psychological, "It would be seen as a more heinous omission to fail to identify an untreatable brain tumour by neglecting to arrange the appropriate brain scan than to fail to pick up a treatable disturbance in family relationships." Well, it seems to me that the scan would be needed to determine whether the tumor were treatable or untreatable, and that missing a treatable tumor would indeed be more heinous by most standards.

Similarly, the chapter on dementia, while commendably discussing the function of narratives and the need for caregivers to understand them, quite ignores the profound physical impairment of the severely demented person, in whom the operation of more general psychological mechanisms should at least be seriously questioned.

Other annoyances are that no identifying information about the authors— their disciplines, degrees, background, or other writing— is included. The editors are listed only as from the department of psychiatry of North Devon District Hospital in Barnstaple, United Kingdom. The book was carelessly edited and has numerous typos as well as misspelled names. Kleinman, who contributed the preface, is spelled Kleinman and Klienman; Bruner is Bruner and Brunner on the same page; and Kohut becomes Hans Kohut. Finally, the print is small, and the typeface of the case histories, stories, and quotations is best described as minute.

Dr. Mogul is associate clinical professor of psychiatry at Tufts University Medical School in Boston.