This is a very common dilemma for physicians when first attempting to access stories associated with physical illness. One of the main reasons we established the Post-Graduate MindBody Healthcare Diploma and Masters post-graduate programme for practising clinicians at AUT University, Auckland was that it takes time and support to become proficient in Whole Person healthcare. The problem is well-expressed in an email from an overseas physician who was attempting some story exploration:
“I have just seen a patient for a chronic and rare immune condition (diagnosis withheld for confidentiality reasons). I asked her, ‘did you notice anything that could have triggered the symptoms back in 1992?’ It took a long time, and many detours. I asked her many other times in different ways ,and she finally burst out crying saying that it all started when her husband left her, and when he came back, etc. She said herself that ‘my husband makes me sick’...
Now I am really frustrated because I don´t speak the local language very well, and I´m sure I am missing a lot of "hidden" things in the way she told me her Story. Unfortunately, I don´t know how I should go further. She is seeing a psychologist who works with our Team, and I am seeing her again in November but I don´t know how I should continue, what I should do next time...?
Thank you so much for the book you´ve written, it gave me the courage to go further than just the usual medical approach, but I realize how much I still have to learn...I felt a bit useless after I spoke with the patient, wondering "so, what now?"...If you have any advice, I would be grateful for your insight!”
The first thing to notice is that she did finally get to the story, though not without difficulty. In this case it appears that it required belief in the potential presence and relevance of story, as well as determination, persistence, and flexibility as she approached the problem in different ways, finding a way for the patient to allow the story to emerge.
In the process something must have happened in respect of trust and safety, because the patient finally not only reveals the ‘bones’ of a potential story, but spontaneously offers the words ‘my husband makes me sick’ as if this is something she already knew, at some level. (I will deal further with the practical issues of eliciting stories in another section).
But the physician’s question is essentially: ‘having got this far, what should I do next?’ There are several options.
- She might relax, be glad that she got to the story, hope that the woman has had a moment of clarity, even an epiphany, rely on the value of having made the connection between story and illness, and just wait and see what happens at the next appointment. Drawing the patient’s attention to the story may sometimes be enough. Life is a process, and what we do next depends on where the patient has got to.
- She might mention to the team psychologist that she has heard this particular story, and prompt and encourage the psychologist to explore the connections further. This will depend very much on whether the psychologist is open to the mindbody connections in a way that is helpful. Many psychologists and psychotherapists hesitate to get involved with physical illness, and may need the support of the physician to do this.
- In the meantime, before the next appointment occurs, the patient may see other professionals who will likely reinforce a biomedical-only way of treating the illness (not forgetting of course that biomedicine is useful!). Moreover, the husband in this case is unlikely to be reinforcing the story approach. Therefore our physician should not be surprised if the patient comes back and, at least initially, does not mention her story again (though she may).
- If she does not mention the story our physician could say something like ‘last session we wondered about some things in your life that might be tied up with how your illness got triggered—I have been wondering what you have been thinking about since that session.’ In this way she can start exactly where the patient has got to.
- The patient may have withdrawn completely, and adamantly rule out any further discussion, and it may be better left, perhaps with a comment ‘ok, that’s fine, but if at some stage you would like to discuss it further with me do feel free to do so.’
- The patient may have withdrawn a bit or lost focus on the story aspect, but with some fresh encouragement she may start to talk again. The story issues may become clearer. The sense of safety with the clinician gets consolidated.
- But what now? The physician is not a psychotherapist. For a significant number of patients the crucial thing is a safe, listening, empathic clinician. We do not have to fix everything. Just drawing the patient’s attention to the mindbody connections, and ‘holding the frame’ despite all the forces (other clinicians, the husband, and the patient’s own fears) against it, may be enough to turn the patient towards health. She can encourage the patient to keep focused on what she can do about her situation. Most of our mindbody clinicians in New Zealand are NOT trained psychotherapists but do very good work. What they do have is: extensive experience as human beings enabling them to recognise and identify with human stories; empathy and willingness to accompany the patient in respect of the story; a clear concept of story and disease connections; experience of the difficulties in listening for stories and the usefulness of responding to them; and the ability to call in mindbody-oriented psychotherapists to do further work as needed
- The patient may be very stuck in her story. A good therapist may be needed from the outset. In this situation the physician might see herself as a ‘midwife’, delivering her patient ready for the therapist to commence the mindbody work. This is a very important role for the physician.
- What about the therapist? Typically he/she should be a person with a good sense of a patient’s wholeness, as an undivided mindbody. The therapist will need to allow the body into the therapy. The therapist will also need to be assured that the physician is: a)managing the medical or physical treaments; b)truly supporting the therapist in including the story/disease connections as a focus.
- Finally, the physician should practise allowing both the conventional medical or other physical therapies and the stories to co-exist in the clinical consultation. It is truly OK to do good biomedicine and to listen to stories in the same session. (Indeed I could argue that it is unethical not to). One day the focus in the clinic might be more on managing the laboratory investigations and their results, and another day it may be more on the story side, or both. The patient will benefit when we treat her as a ‘whole’. In fact, quite often I think it is because I treat them as wholes that something new is allowed to happen. Nevertheless many patients are stuck in terrible story situations and a lot of work needs to be done before their diseases settle.