Experience has revealed many ways of accessing the story/illness connections. The Smorgasbord Question often throws up something, and if this is followed carefully and intelligently will frequently lead to the nub of the story.
Sometimes the very words of a patient tell it all, like in one of my very early cases, of a woman with a severe rash on her face for five years. As I listened she twice said she was keeping a ‘brave face’ on her husband’s depression. Her words and her rash matched. This is an example of symbolic disease about which I have written elsewhere (Publications). Detecting symbolic disease requires the clinician to listen very intently to exactly what a patient is saying. Sometimes it is not about words but about inescapable congruence. For example, a person was vaginally and anally raped as a child and developed undiagnosable inflammation and bleeding of the genitals and rectum as an adult, on entering a relationship.
Once some patients know there might be a connection between their life experiences and their symptoms they may be quickly aware of the meaning of their symptoms.
Sometimes it is about echoes. I always look for repeat stories surrounding multiple occurrences of the presenting symptoms. A girl, aged 13, who developed headaches when her father died of a brain tumour. The headaches lasted 6 months. They started again at age 17 when her first boyfriend dumped her for her best friend, Again the headaches lasted months. They started again at 21 years when she got pregnant to a young man who disappeared to Australia. And then the headaches continued for 15 years. The pattern here is of feelings about men who leave or abandon her. For clinicians like family doctors, who are short of time and get to know their patients well, it may be easier for them to watch for such patterns over several visits. Certainly psychotherapists will function this way.
Once some patients know there might be a connection between their life experiences and their symptoms they may be quickly aware of the meaning of their symptoms. This why educating patients about mind and body connections is so important. It is generally better for a patient to discover or notice the truth themselves. We need to avoid the need to be clever clinicians. Sometimes it is absolutely right to draw the patient’s attention to something that is obvious to us. But we must remain there for the patient and timing is important.
Finally, every clinician will find that if they are truly interested and there for the person as a person, and if they invite the story, then it will start to emerge. As the two of them wonder together about the connections, the various feelings and meanings will emerge. How that happens will depend a lot on the unique ‘space’ opened up between these two unique people. See Co-construction.