Narrative Psychiatry: How Stories Can Shape Clinical Practice

5. Mrs. Dutta and the Literary Case

75 chapter five Mrs. Dutta and the Literary Case Narrative psychiatry insights become clearer when we use them to consider case examples. Through case examples, narrative theory becomes concrete and the relevance of narrative psychiatry is brought vividly to life. Case examples also demonstrate much of the wisdom of narrative theory because they tell a story about a person and that story is necessarily shaped by the tools of narrative I have discussed: plot, metaphor , character, and point of view. In addition, case examples provide an opportunity to imagine an array of ways in which a person’s story could be framed or reframed. Choosing case examples for teaching narrative psychiatry is no simple matter, however, because any case one would choose is already framed in a particular narrative form. This means that much of the “work” of narrative framing—which is at the heart of narrative psychiatry—has been done in advance. The ideal case for narrative psychiatry would remain as open as possible and allow for as many readings as possible. Case examples originating from the clinical literature rarely fit this ideal because they are too often framed in a way that feels heavy handed and that makes it difficult to imagine alternative frames. Consider, for example, the following clinical case from the DSM-III Casebook: A 50 year-old widow was transferred to a medical center from her community mental health center, to which she had been admitted three weeks previously with severe agitation, pacing, and hand wringing, depressed mood accompanied by severe self-reproach, insomnia, and a 6–8kg (15-pound) weight loss. She believed that her neighbors were against her, had poisoned her coffee, and had bewitched her to punish her because of her wickedness. Seven years previously, after the death of her husband, she had required 76 Narrative Psychiatry hospitalization for a similar depression, with extreme guilt, agitation, insomnia, accusatory hallucinations of voices calling her a worthless person, and preoccupation with thoughts of suicide. (Spitzer, Skodol, Gibbon, and Williams 1981, 28) This case example has been tightly organized to foreground DSM-III variables consistent with a diagnosis of “Major Depression with Psychotic Features.” The story tells us that a woman has been transferred to a medical center from her community because of severe depression and that she went through something similar seven years earlier at the time of her husband’s death. We learn almost nothing about the person in the story other than the presence of a checklist of DSM-III variables. All other aspects of the person and her situation have been abstracted away. Borrowing a distinction from anthropologist Clifford Geertz, we can call these highly abstracted clinical stories “thin” stories (Geertz 1973, 7). Thin stories may be said to contrast with the “thick” stories of everyday life and the stories people first bring to a clinical encounter. In the example from the DSM-III Casebook, the story “the 50 year-old woman” first told her clinicians would no doubt be much thicker than the thin one presented in the DSM-III. The woman would have likely given a wealth of information about her troubles. Just listing the elements she might have discussed can seemingly go on forever. They might include her feelings about her neighbors, how they are out to get her, what started the tensions between them, what it is like to be a widow, her feelings about her husband and his death, what killed him at such an early age, what kind of grief she went through, what’s going on with her family, children that she did or did not have, her attempts to date again and to find companionship and intimacy, how she spends her time during the days, what she cares about, what she watches on television, a commercial she saw for antidepressants , how she supports herself, the struggles she has had to finding meaningful work, the society that she lives in and how it supports her or does not, whether she has made an attempt to get involved in politics, the state of her apartment, her diet, her aches and pains, the economy, her financial situation, sexism, racism, how people at the community mental health center have treated her, how she ended up at the medical center, just to name a few. Mrs. Dutta and the Literary Case 77 One of the most important outcomes of standard, non-narrative clinical training is to...