“We had a TBI (traumatic brain injury) today in the morning and an F20 (ICD code for paranoid schizophrenia) in the noon.”
“Could you check that ASD (Autism Spectrum Disorder) kid in the behavioural unit? Also, one dementia came in today.”
Such talk is commonly heard in corridors of psychiatric and neuropsychological clinics and hospitals as conversations between colleagues. A popular reasoning behind such statements is that it is easier and time-saving to communicate when details are filtered out and dialogues are localised to the diagnostic labels. However, what is lost in translations are not mundane details like name and place, but identities. Who remains hidden behind these labels? What are they like and why do we not see them? The search for a lost person in the patient remains a challenge in the mental healthcare system.
It may be easy to discard such concerns on the basis of how minuscule they seem in the face of scientific revolutions in treatments for severe chronic mental illnesses. Is it really that important to sit and ponder upon how one addresses the other? Or is it even crucial to know the person’s lived and unlived life in order to ‘fix’ them? What seems like a mere matter of language is instead an enigma that lies at the centre of health and healing: there is a label but there is no story behind it.
It is true that advances in medical models have empowered health professionals, but it is also true that they permit them to reduce the affected individual to a bundle of observable signs: a graph of decline and progress, a conglomeration of ‘positive’ and ‘negative’ symptoms. This particular aspect endorsed by the omnipotence of biomedical view of psychiatry and its refusal to give up the higher pedestal has drawn criticism from all areas of social sciences.
Working solely under the dominance of this model makes it difficult for a clinician to look beyond the deficit-highlighting summaries and delve into the lived experiences of the person – how do they make sense of the world? It clogs the pathway of narratives that search for hidden strengths against noticeable weaknesses. The person with all their desires and wishes, stories and dreams, likes and dislikes, interests and ambitions, is now nowhere to be seen; they are just an “F20 in Room 7”.
The Need for Narrative
“The language of psychiatry,” Foucault writes in his text, Madness and Civilization, “is a monologue of reason about madness that is established only on the basis of silence.” The silence here is maintained by the refusal to tell and hear stories that give new meanings to the signs and symptoms people carry. It negates the otherwise accepted fact that every intervention relies on a universal hope that there must be something that is intact in the person and not over what their illness has taken away from them.
Such hope is only possible through honest and open communication that is respectful of diverse voices. The space in which the professional could get to know this person, who they are and how they make meaning of their suffering and the life revolving around that suffering, is achieved only through conversations. It is often cited that brain injuries, neurological impairments, mental illness and disabilities can withhold the basic functioning of the person in many psychosocial contexts; what is often not cited is that they can never take away the person’s will to describe, narrate and generate meaning from these deficits.
The work of Oliver Sacks is a living example of this approach. In his infamous text The Man Who Mistook His Wife For a Hat, Sacks dedicates a chapter titled, A Matter of Identity, to Mr Thompson who has Korsakoff syndrome, an amnesic disorder of the brain marked by a loss of existing memories as well as an inability to form new ones. To compensate, Mr Thompson invents new and imaginary trails of events, making up novel in-depth stories about who he is and what is happening around him. Each person around him, at any given moment, has a character with vivid details and a humorous history with Mr Thompson.
Using confabulation, Mr Thompson tailored small but rich narratives to comprehend the world around him. “Such a frenzy,” Sacks notes, “call forth quite brilliant powers of invention […] for such a patient must literally make himself (and his world) up every moment.” This unconditional way of viewing many patients has formed the foundations of Sacks’ work. In the preface of the book, he writes,
The patient’s essential being is very relevant in the higher reaches and in psychology; for here the patient’s personhood is essentially involved, and the study of disease and of identity cannot be disjoined.
We use narratives not just to make sense of ourselves but also our place in the ever-changing sociopolitical sphere. A person with psychiatric and/or neurological conditions is always regarded as having lost their ‘self’ due to deficits in core cognitions which are useful in appraising life around them, but little do we know of their tendency to hold on to stories to preserve this self.
This doesn’t mean there is no suffering. Mr Thompson’s ability doesn’t ‘cure’ him of his illness but it invites him to be a part of the world that he doesn’t know is lost and that is only because his symptom is rather envisioned as an ‘ability’ — in Sacks’ eyes. There is a dire need in the Indian system to adopt such a vision when seeing, assessing, diagnosing and treating people with illnesses and disabilities that are often seen with diminished hopes. But where does one begin? It’s easier to change methods but how does one change the very perspective of a method that is so deeply steeped into a professional persona?
Case histories or case stories?
Advocating for narrative approaches in core psychiatric and neurological practice is not new. It has existed since the antecedent years when Hippocrates encouraged the idea of asking about the chronological events that led to the person’s disease. Freud’s persistent interest in working through repressed memories was akin to reauthoring ‘biographies’, which was useful in furthering the technique of psychoanalysis. Earlier times also accounted for proponents’ own methods to hunt for stories, from eminent psychiatrist Adolf Meyer’s visual concept of ‘life charts’ that he described as a “life history in the making”, to constructing the ‘whole’ of an individual through similar gestalt approaches.
Case histories are crucial mediums to understand the bio-psychosocial events and processes that have resulted in the problems that the person has come to seek help for. In the same case histories, a tiny space is dedicated to what helps the person cope with these problems. But this is rarely paid attention to in the current era. The shift from reading them as case histories to life-stories might bring changes to the ways in which people are understood and helped. Although rare in India, such approaches can still be noticed amongst medical professionals.
“Ask any medical student and they will tell you how important it is to learn to take case histories,” says Dr Anjendra Targe, a Pune-based psychiatrist who strongly advocates for narrative approaches in practice. “The art of case history-taking lies in knowing the patient as a person, a person defined by not only their presenting complaints but everything from their relationships, their occupation, their religion, employment, family background, to their social-economic status; if we get a comprehensive knowledge of their condition, we have a better chance at helping them.”
But this momentum suffered a halt when ideas of ‘quick fix’ methods came into motion. The reductionist era of cognitive-behaviourism, which relied on observable human tendencies and the ways in which mental health problems can be sorted on the surface was complicit in this halt. Today, the art and science of taking case histories is lost in the rush to find suitable labels and distortions in human behaviour.
“We are speaking the language of pure efficiency in medicine: quicker recovery, shorter sessions, rigid categorisation of illnesses, with the glaring end result: human beings as commodities,” Dr Targe says, attributing this trend to the capitalistic and technological advancement in health. “Psychiatry, the one discipline which cannot afford that, is, unfortunately, falling for the illusion of ultra-specialisation, reducing everything down to biology.”
The birth of narrative psychotherapy through the seminal work of Michael White and David Epston brought in a revolution for therapeutic approaches. Their eminent phrase highlighting the separateness of the illness from the person — “the problem is the problem, the person is not the problem” — signifies the journey to help an individual by holistically viewing them as someone detached from their problems. Through the method of story-telling and re-authoring these problem-saturated stories, narrative therapy has penetrated clinical areas such as neuropsychology and many are now trying to integrate it into practice.
Sacks’ approach to taking case histories is rooted in the art of reading stories about humans rather than lensing for pathological markers. Dr Targe notes:
Pioneers like Oliver Sacks combined medical cases with narratives of his life intertwined with that of his patients. It has taught us this important lesson: humans like stories, because humans are stories, albeit short-stories in the cosmic landscape of eternal evolution brought upon by a flux as a result of their interaction with the environment.
It is not a tedious journey to find the lost person in the patient. Although systemic and organisational issues related to healthcare, accessibility and professionalism may account for hurdles, the simple act of shifting perspectives is not too much to ask when such a huge population lying on a spectrum of mental health problems is at stake. Perhaps the first step to achieve this is to constantly remind ourselves of a quote by one of the founding fathers of Johns Hopkins Hospital, William Osler — “Ask not what disease the person has but rather what person the disease has.”
Prateek is a mental health activist and writer pursuing a masters degree in clinical psychology. His work covers an intersection of mental health and psychiatry with sociopolitical issues and human rights.