Life Stories and Meaningful Connections: Reflections on a Clinical Method in Psychiatry and Medicine

UFE STORIES AND MEANINGFUL CONNECTIONS: REFLECTIONS ON A CUNICAL METHOD IN PSYCHIATRY AND MEDICINE PHILUP R. SLAVNEY and PAUL R. McHUGH* A basic method of reasoning in psychiatry and medicine seeks to understand the patient's complaints as the expressions of an individual in distress. Through knowledge of his history, personality, circumstances , relationships, and intentions we come to appreciate why the patient is thinking, feeling, and behaving as he is. This is a most natural way of reasoning about patients, and it leads almost inevitably to an explanation of distress that is presented in terms of an individual life story. A life story is a plausible, chronological, and coherent narrative that reconstructs the development ofthe present state of affairs. It starts at a certain time in the patient's life and draws together particular information about him into a linear perspective that makes his distress seem the logical and sometimes even the inevitable outcome of his past. As we assemble this narrative in the process ofhistory taking, examination, and treatment we have a growing sense of insight about the patient and his problems. At times in this process we can have a feeling of illumination, of a linkage between the patient's symptoms and life story that is immediate and convincing. The sense of conviction generated by the life-story method helps give us confidence in the face ofadifficult task, the psychotherapeutic task of helping another person to change his goals, beliefs, and behaviors. Yet despite the life story's power in the organization of clinical information and despite its support to us in the process of psychotherapy, we must ask the same questions ofit that we ask ofother methods ofreasoning in The authors are indebted to Jerome Frank and Frank Mondimore for their critical advice. * Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine. Address: Meyer 4-181, The Johns Hopkins Medical Institutions, 600 North Wolfe Street, Baltimore, Maryland 21205.© 1984 by The University of Chicago. AU rights reserved. 003 1-5982/84/2702-0382$01.00 PerspectivesinBiologyandMediane, 27, 2 ¦ Winter1984 | 279 psychiatry [I]: What are the assumptions that the method makes? What are its characteristic strengths and weaknesses? By what standards should its conclusions bejudged? Unless we can answer such questions about the life-story method we will not be able to use it within its limits, and we may not recognize that the method has a unique power to disarm criticism. Assumptions ofLife-Story Reasoning Our ability to construct a life story for die patient is based to a great extent on our capacity to make what Karl Jaspers called "meaningful connections"—empathically understood relationships between one psychic phenomenon and another. In its simplest form, the method of explanation derived from meaningful connections comprehends how feelings are provoked by events: grief by loss, homesickness by departure , happiness by fulfillment. By its extension we sense why the responses of a given individual are coherent for him, how they emerge from the nexus between his personality and the way in which he views his circumstances. Thus, we understand how a dependent person reacts with sadness when abandoned, or how a self-doubting one is rendered anxious by change. These linkages seem both natural and convincing, so that we appreciate them not only in the descriptions of people we know but also in the characters and stories of the world's imaginative literature . If this approach to understanding mental experiences and behaviors had stopped here, it might have generated relatively little interest among psychiatrists. A further step in its development was taken by Sigmund Freud, however, and in so doing he transformed and expanded it in a revolutionary way. Freud proposed that the mental life of consciousness, with its intentions , choices, and responses to actual events, was in large part the derivative of an unconscious and more basic realm. Thoughts, attitudes, and desires were seen to emerge into awareness only after modifications which served the function of disguising their original purposes and meanings. The text ofconsciousness had to be deciphered for its hidden meanings, and the explanation of conscious thoughts and behaviors had to be linked to events and processes in the unconscious realm. Since unconscious...