How to open up the story aspects of a consultation in a medical setting

Young Woman Discussing Problems With CounselorThe most important ingredients are confidence, warmth, relational competence, and education.

Confidence arises from the clinician’s conviction that mind and body are not separate compartments, that disease and stories co-exist, that the stories are hidden because we have excluded them from view, and they will remain hidden if the patients are not reassured somehow that it is truly OK to look at them.

Warmth is necessary because none of us are going to be vulnerable and reveal our stories unless we can trust the warmth of the ‘other’ (in this case the clinician). Warmth is sensed. It is transmitted in many different ways depending on the clinician’s personality.

Relational competence is about being able to listen, to be empathic, not rushing or pushing the patient, and not exercising power – such as wanting to be right, or assuming too much too early. It is about suspending the ‘expert’ position (for the moment) and being two humans together.

Education is a crucial element. People need to know that it is legitimate to be talking about their stories in a medical setting. There are many ways to do this (see Educating the patient)

Things you can do

  1. Ask the smorgasbord question? What is the most interesting, memorable, troublesome, worrying, stressful, frustrating thing that happened around the time you got unwell the first time, the second time, the last time, or the most recent time? Look for emotional patterns.
  2. If the patient mentions ‘stress’ you can say that ‘stress’ is a suitcase word—it has to be opened up to be useful. Try and identify the circumstances and feelings generating the stress.
  3. Once the person starts to talk let them talk, encourage them to tell you what it was really like. Listen to EXACTLY what they say. The use of certain words may be very helpful. Gently reflect that back.
  4. Some people find it hard to identify specific feelings. Even just acknowledging the hard thing that happened when the symptoms started may be enough to get them thinking.
  5. Don’t go all logical and cognitive in response to the story. Maybe say something like—‘it could be that that is very important in you becoming unwell’. Try not to take a ‘fix-it’ response. Many patients have never been heard in this way before and experiencing being heard is critical.
  6. Some will like to read more information (you could refer them to my books such as Meaning-Full Disease which is available cheaply downloadable from Amazon).
  7. But in the end it depends on your use of your own style of relational competence, confidence, warmth, and education. Something will open up. Every time it is an ‘encounter’ and something has to ‘co-emerge’. Rules, algorithms, techniques cannot replace the sense of exploration and adventure.