Narrative Psychiatry: How Stories Can Shape Clinical Practice

4. Narrative Psychiatry

57 chapter four Narrative Psychiatry Having reviewed the emergence of narrative medicine and narrative approaches to psychotherapy integration, we are now in a position to draw out the implications for narrative psychiatry. The history of psychiatry has led to its own conceptual knots and practical predicaments . As for narrative medicine and narrative psychotherapy integration , the turn to narrative provides a way out of these difficulties. This chapter starts with a story of psychiatry’s beginnings leading to its current conundrums. It follows with a discussion of the similarities and differences between narrative medicine, narrative psychotherapy integration, and narrative psychiatry. A Brief Story of Psychiatry My story of modern psychiatry does not begin with Flexner or Freud. Instead, it begins in late nineteenth-century Germany with Emil Kraepelin and what many call the first era of “biological psychiatry” (Shorter 1997, 69). Researchers in this era argued that “mental illnesses are brain diseases ,” and they advocated a clinical-pathological research method that extrapolated back and forth between clinical findings and autopsy findings (Fulford,Thornton, and Graham 2006, 152; Porter 2002, 144; Shorter 1997, 73–76). Emil Kraepelin brought this method to international attention when he used it to set up a psychiatric department in Munich that contemporary psychiatrists Nancy Andreasen and Donald Black call“one of the greatest departments of psychiatry of all time” (Andreasen and Black 1995, 9). The department included such neurological and psychiatric luminaries as Alois Alzheimer, Franz Nissl, and Korbinian Brodmann, and in the early decades of the twentieth century, their work was the nodal point for a period of tremendous optimism in psychiatric research. 58 Narrative Psychiatry These researchers firmly believed that systematic use of the clinicalpathological method would discover brain abnormalities that lay behind major psychiatric conditions. Kraepelin fueled this optimism by his success articulating a clinical distinction between dementia praecox (later called schizophrenia) and manic depressive illness which is still used to this day. And, even more, the optimism was fueled by the neuropathological discovery of two organic mental disorders: Alzheimer disease and general paralysis (syphilis of the brain). These last two discoveries were “world changing” events—“for the first time a specific psychiatric disease had been shown to have a specific neuropathological cause”—and the race was on to replicate similar findings throughout psychiatry (Fulford,Thornton, and Graham 2006, 152). Despite this optimism, further research yielded little in the way of useful findings. Biological psychiatrists pressed on, undaunted by their limited findings, and continued to push their neurobiologic models. They pushed so hard and the models eventually became so fantastic that their colleagues started condescendingly referring to them as “Brain Mythologies ” (Fulford, Thornton, and Graham 2006, 153). By the late 1920s, alternative approaches gained increasing attention, and the first era of biological psychiatry lost its pride of place. The two most important alternatives were Sigmund Freud’s psychoanalysis and Karl Jaspers’s phenomenological psychiatry. Of the two, Freud’s psychoanalysis was the most popular and also most radical break from biological psychiatry. Even though Freud started out as a neurologist and early on had also hoped that brain science would explain psychiatric problems, he eventually had to abandon this goal. A major factor in Freud’s abandonment of brain research was fiscal necessity. Because Freud was forced into clinical practice to make a living (rather than academic research) and because patients with psychoneurotic complaints were the most available, Freud developed a clinical practice specializing in psychoneurosis .This meant that he had to quickly develop methods of treatment for these patients. As Freud put it, “Anyone who wants to make a living from the treatment of nervous patients must clearly be able to do something to help them”(Freud 1959, 16).The only treatments available at the time were electrotherapy and hypnotism. Freud found electrotherapy to be completely unhelpful, so he turned to hypnotherapy and eventually to “psycho-analysis” (1959, 30). Narrative Psychiatry 59 Freud’s turn to hypnotherapy and psychoanalysis was a historic choice because it meant that he had to “abandon the treatment of organic nervous diseases” (1959, 17). Leaving behind his earlier work in neurology, Freud turned instead to understanding his patients’ experiences. He put the same painstaking attention into understanding the interpretive links of his patient’s psychic life as the biological psychiatrists had put into cataloging symptoms and examining brains. He did not, however, take the next step and consider the philosophical issues at stake in such a...