The Four Ps, Narrative Psychiatry, and the Story of George Engel

Jonathan Bolton’s (2014) “Case Formulation after Engel” gives an insightful presentation of the difficulties teaching quality clinical work in psychiatry. Plus, he provides a valuable heuristic for organizing psychiatric thought through the “4P model.” The catalyst for his article seems to come from teaching psychiatric residents a course in ‘case formulation’ at a time when other faculty are saying ‘case formulation is considered passé.’ This dismissive denigration puts Bolton in a difficult situation and suggests a need for allies.

One place to look for allies is in the world of narrative medicine and psychiatry. Bolton does not define case formulation, but he does describe some of the functions it provides for clinical work. Most of these functions are narrative functions:

1. 1. It helps the clinician to see the person as something “unique, complex and situated” rather than simply a diagnostic type (Bolton 2014, 181).

2. 2. It puts the person’s concerns in the context of time and history: it is “diachronic” (182)

3. 3. It organizes that history into a “plot” (182) with a beginning, middle, and end—or, more to the point of clinical work, with a past, present, and future.

4. 4. It organizes complex problems, that often require incommensurate disciplines of knowledge to make sense of them, into a coherent frames or “stories” that are experienced as “true,” “thick,” “well-constructed,” and “generous.”

Putting these narrative functions together it seems that a key aspect of Bolton’s goal in teaching case formulation is, as he says himself, to help clinicians “tell better stories, thicker stories” (182).

If we understand ‘case formulation’ in this way, we can align Bolton’s work with similar efforts by his medical colleagues under the banner of ‘narrative medicine’ (Lewis 2011a). One way to tell the story of narrative medicine is to go back to 1960s and 1970s when increasing numbers of medical clinicians and scholars recognized that an exclusive biomedical model was not enough. To be of help in times of morbidity and mortality, clinicians needed a broader knowledge base that includes philosophy, ethics, literature, the arts, anthropology, sociology, politics, economics, religion, and so on. These expanded knowledges organized into fields like ‘bioethics,’ ‘medical humanities,’ ‘medical anthropology,’ ‘medical sociology,’ and ‘disability studies.’ Some worked inside medical infrastructures, such as bioethics and medical humanities, some in the arts and sciences, such as medical anthropology, medical sociology, and disability studies. ‘Narrative Medicine’ can be seen as an umbrella term that brings these fields together for their usefulness at the bedside. The goal of narrative medicine, like the one Bolton is working on, is to help clinicians to develop better, truer, richer, more generous stories and case formulations in the service of healing and coping.

A challenge for Bolton is that psychiatry has not been a significant contributor to narrative medicine. The easiest way to tell the story of psychiatry’s relative absence from narrative medicine is that psychiatry did not have a felt need for this work until later in its history. Near exclusive focus on biology happened in medicine before it happened in psychiatry. Medicine became almost exclusively biological starting in 1910 with the advent of reforms inspired by the Flexner report. Psychiatry, on the other hand, was just entering into its psychoanalytic paradigm at that time. It did not become so exclusively focused on biology till 1980 and the publication of third edition of the Diagnostic and Statistical Manual of Mental Disorders. It took medicine around 50 years to respond to an overly biological focus and, now, 30 years after psychiatry’s biological turn, it too is starting to need an expanded knowledge base comparable with narrative medicine. The good news is much of the work from narrative medicine is relevant to psychiatry, and, as this journal attests, interest in philosophy and psychiatry has started to emerge. In addition, there are rich resources for psychiatry available in the domain of narrative psychotherapy (White 2007). Putting this all together, psychiatry is now building its own domain of ‘narrative psychiatry’ (Hamkins 2014; Lewis 2011b...