Narrative approaches to initial psychiatric consultations: Amanda’s story (con.)

So in Amanda’s case, I asked her about the problem early in the interview.
S: What brings you in to see me?
Amanda: I’ve been depressed, and I think I need medication.
S: What has the depression been like?
Amanda: I feel like I just want to get out of my skin. I’ve been isolating myself in my room and dwelling on my problems. I’m unsure of myself and that makes me feel even more down on myself. Nothing I’m doing to try to feel better is working. I’m doing a bad job on my schoolwork, and I don’t even know what I want to be studying for. I feel scared about what’s coming up next in my life, like I should be doing a better job of knowing what I want….I feel like I’m arbitrarily redefining things….Overall, I feel like I am making bad decisions about my life and not living my life right.

You can hear the story that Amanda tells about the meaning of what she is experiencing. She understands her challenges in not yet knowing what she wants to study in college and not doing as well as she would like academically according to the plot-line, “I am making bad decisions and not living my life right.” My thought is that this theme may be contributing to her suffering, and I anticipate finding openings for developing new narratives after I have heard a full account of her concerns.
In our conversation above, you can also hear that the first time the problem is mentioned, I offer an externalized description of it. By externalized I mean a description of the problem as separate from the person’s identity . When I paraphrase her statement ‘I’ve been depressed’ with my phrase ‘the depression’, Amanda responds by offering a rich and meaningful description of her experience. Most people welcome an externalized description of what was a negative identity conclusion. They experience relief in changing the description of the problem from an adjective describing them to a noun affecting them.

In my conversation with Amanda, I proceed to develop the history of the problem’s influence on her, in an externalized way. From the many different people who have told me about the ways that depression has been disruptive in their lives and from my studies in psychiatry, I know that at times depression can cause a whole group of negative effects. My next questions are designed to understand if Amanda’s depression is causing some of these problems.

S: Is the depression interfering with your concentration?
Amanda: Yes! I can’t concentrate at all and it’s hard to get my work done.
S: Has the depression influenced your sleep?
Amanda: I’m sleeping all the time, and it’s still hard getting up in the morning.
S: Does the depression bring thoughts that life is not worth living?
Amanda: Once in a while I do get thoughts of taking my life, but I know I would never do that.
S: When did the depression first appear?
Amanda: Since February, about two months ago.

You can hear multiple examples of externalization in these questions. The low-key, redundant description of her problem in an externalized way conveys to Amanda she is not the depression, that the depression is unwanted, and that she is not to blame for the effects of the depression. This offers an alternative to the self-blaming narrative Amanda came in with. Externalization works against negative identity conclusions and tangibly changes the person’s experience of the problem. Gathering information this way feels better to patients. It’s therapeutic. Explaining or pointing to the process of externalization is not necessary for people to benefit from it. They simply experience the difference. However, at times making the process of externalization more overt can be helpful in creating new stories that support a person’s priorities and preferences. (I’ll say more about externalizing and unpacking problems in the next chapter.)
Next in my conversation with Amanda, I developed the history of her resistance to the problem, as fully, or more fully, than the history of the problem’s influence on her. Everyone who consults with a psychiatrist or psychotherapist has been attempting to resist their problems. My goal is to open space to illuminate all the ways in which someone has been and might be successful in limiting the influence of the problem in their life.

S: When do you feel the best nowadays?
Amanda: When I’m doing art.

I am a little surprised by her answer. From what I know about depression, it tends to make it difficult if not impossible to engage in any self-motivated creativity, let alone to feel best doing so. Prior to working narratively, my questions may have ended here, and I may have simply encouraged Amanda to ‘do more art’. But in narrative work, the goal is first to notice and then to develop the story of this “unique outcome” . It’s an opening for developing an entirely new narrative. A unique outcome is an experience or idea, no matter how small, that stands apart from the problem or the problem’s usual effects. It is a bit of evidence of the success of the person in living as they prefer despite the problem.
On it’s own, one unique experience isn’t a story, and it doesn’t have much power to offer new meaning to a person’s experience. But when it is connected with other similar events according to a theme, a new narrative emerges. As narrative psychiatrists, we seek out the kernel of a story that explains a unique outcome, and then we generate compelling tellings of this story. That is, we seek out the same things that make for good literature: ravishing detail, memorable language, singular characters, dramatic plot-lines.
The story of how someone is succeeding in resisting her problems is one we cannot know ahead of time. Only the person resisting knows exactly how she is doing it. This is one of many reasons why our work in narrative psychiatry must be collaborative.

S: It’s unexpected to me that you are able to enjoy making art despite the depression. How are you able to do this?
Amanda: I wasn’t always able to enjoy making art, but I learned to say to myself: I’m learning a skill. It may not be perfect. This is a process. I’m doing this because I enjoy it. I don’t have to have so many expectations of what it has to be like.
S: Wait, let me be sure I can get all this down! (writing furiously) I’m learning a skill. It may not be perfect. This is a process. I’m doing this because I enjoy it. I don’t have to have so many expectations….
Amanda: So many expectations of what the art has to be like. I learned to take a break when I got frustrated. I used to destroy art I made that I didn’t like, but I disciplined myself to tolerate my less successful work. I learned to say to myself, I have to make bad art on the way to making good art. This is necessary to become an artist.
S: (Still writing) You learned to say, I have to make bad art on the way to making good art. This is necessary to become an artist.

As Amanda offers the story of how she has learned to be able to enjoy making art even in the face of depression, I write down and repeat out loud all the things she has said to further strengthen her knowledge through my saying them and her hearing them.
When I have a detailed, lively and full account of the development of her skill in resisting negative appraisal of her art and in promoting her artistic self-development, then I seek to develop this alternative story into other areas of her life and across time. In doing so, we are continuing to co-create a narrative of Amanda’s life that offers her a way of understanding and telling the story of her current dilemma that fits with identity conclusions that she finds invigorating. In seeking to generate a rich alternative tapestry, there are always many different threads of the story that may be taken up and more vividly developed. In this conversation for example, I could have chosen to thicken the story of Amanda’s connection to art or elicited the particularities of how she learned to tolerate ‘bad art’. Here is what I did do:

S: I’m wondering if this same philosophy of looking at making art as a process could also be applied to your life in general. I’m wondering whether or not figuring out what you want to do with your life is something of an art, and if you can say some of the same things, such as: “I’m learning a skill” and “This is a process.”
Amanda: (Her face lights up) Yes! I never thought of it that way!

We go on to discuss ways in which figuring out her life may involve making decisions, such as about her major, her friendships and her priorities, and about how she is trying to find a balance between allowing for openness without losing control or becoming apathetic. We discuss her sources of inspiration in the process of living her life.
At the conclusion of our fifty-minute conversation, Amanda reports feeling more relaxed and optimistic, feeling that she knows how to direct her life in the directions in which she wishes it to go while being open to new possibilities. She says she is feeling much better, and is no longer interested in anti-depressant medications.
I offer to send her a synopsis of our conversation, which she welcomed, as a way to further flesh out and support her new story about herself. It was a help to me that I had the resources to dictate this letter and have it typed for me, and that it served as part of the medical record documentation of our meeting.

Dear Amanda,
I am writing to summarize some of the points of our conversation to provide documentation to you of some of the things that you have been doing that have been useful in helping yourself to successfully live your life.
You noted that the days you feel best are the days you go into the art studio and spend time making art. You have been able to continue to make art despite depression because of being able to say the following things to yourself:
• I’m learning a skill.
• It may not be perfect.
• This is a process.
• I’m doing this because I enjoy it.
• I don’t have to have so many expectations of what it has to be like.
In addition, you are able to take a break when you become frustrated with yourself, and also you are able to resist doing things that are destructive to your work or to yourself. Furthermore, you are able to say to yourself: “I have to do this work to move toward a goal.”
You are considering whether the same philosophy of looking at art as a process might also be applied to living your life in general. You are considering whether or not thinking that figuring out what you want to do with your life is something of an art, and that saying yourself some of the same things such as: “I’m learning a skill” and “This is a process” may be useful in allowing you to relax and let other things surface.
You have described several sources of inspiration to you currently, including: art, plays, women you admire, and professors. In particular, you note that people who are able to work with what they have and make the most of it are especially inspiring and you are considering speaking to some people and interviewing them about how they are able to do this. Other sources of inspiration include: hard physical labor, being outdoors, making friends, and spending time with people.
You mentioned that you thought being able to read a document such as this might be useful to you in creating more space in your life for relaxation and optimism, and might help you to direct your life in directions you wish while being open to new possibilities.
This letter itself can be considered a work in progress. Please feel free to bring this to our next meeting and also to make any corrections that seem appropriate to you so that this document can be most accurate and helpful.
I look forward to speaking with you at our next conversation.
SuEllen Hamkins, MD
College Psychiatrist

Amanda continued in brief psychotherapy with the therapist who had referred her to me, and her depression resolved without medications. One year later, Amanda consulted with me again. She reported that our conversation the previous year had been very helpful, and that her depression had faded as she became more active and made new friends. She presented now with some specific relationship concerns she wished to speak about in individual therapy, and met with a psychotherapist for several sessions. One year after that, she engaged in a psychotherapy group with the intention of enhancing her abilities to express her feelings in intimate relationships.
This interview illustrates how empathically connecting with the patient, externalizing the problem and gathering a full, richly detailed, emotionally meaningful history of resistance to the problem in an initial psychiatric consultation is therapeutic. In narrative psychiatry, the initial psychiatric consultation is a collaborative conversation in which a new story of meaning and identity can emerge.

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Identifying and Cultivating Strengths & Values in Initial Psychiatric Consultations

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