Narrative Psychiatry and Family Collaborations

NINA JØRRING, June Alexander, David Epston

• Publisher: Routledge
• Year: 2022
• ISBN:
  9781000556681
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Narrative Psychiatry and Family Collaborations is about helping families with complex psychiatric problems by seeing and meeting the families and the family members, as the best versions of themselves, before we see and address the diagnoses.

This book draws onten years of clinical research and contains stories about helping people, who are heavily burdened with psychiatric illnesses, to find ways to live a life as close as possible to their dreams. The chapters are organized according to ideas, values, and techniques. The book describes family-oriented practices, narrative collaborative practices, narrative psychiatric practices, and narrative agency practices. It also talks about wonderfulness interviewing, mattering practices, public note taking on paper charts, therapeutic letter writing, diagnoses as externalized problems, narrative medicine, and family community meetings. Each chapter includes case studies that illustrate the theory, ethics, and practice, told by Nina Jørring in collaboration with the families and colleagues.

The book will be of interest to child and adolescent psychiatrists and all other mental health professionals working with children and families.

1 A narrative family psychiatrist

DOI: 10.4324/9781003171621-2

Being met as a person worthy of respect

I was sitting in my tiny office as a young resident at the Child and Adolescent Psychiatric Hospital.

I was trying to keep track of what the mother, Sheila, was telling me. At the same time, I was desperately keeping an eye on her six-year-old son, Hans, who was climbing the furniture and getting into everything.

The mother was describing the troubles Hans faced at school, the complaints about him from people in their residential complex, the difficulties in raising him, and her fears for his future, which she already imagined being corrupted by crime and drugs.

By now, Hans had emptied the toys onto the floor and flipped the trash can so he could use it as a shed for farm animals and racing cars. He talked constantly about everything and nothing.

Despair invaded my brain, telling me that this mother was unfit, and her son was out of control. However, I tried to respond with empathy and common sense to invitations from Hans to play and, simultaneously, give my full attention to his mum.

Thoughts about the difficulties of my job were interrupted by other thoughts. How awful must it be for the mother and son here in my office? Does the mother expect me to see her and Hans as failures? What might they need most right now? Perhaps their biggest need is for respect and acknowledgement from a health professional like me?

Realizing that I needed to show Sheila and Hans my respect and faith in both of them, I said:

“Do you know the story of Emil of Lönneberga (Lindgren, 1963)? I am reminded of Emil and his mother. Do you remember all the troubles Emil made? Despite Emil's troubles, his mother loved him dearly and knew that his only goal was to make other people happy, even though his efforts often ended up all wrong. Emil's mother was the only person who understood him. Do you remember this?”.¹

To my horror and surprise, I saw tears in Sheila's eyes. She sat silently and nodded her head.

Luckily, Hans intervened. He sat on the floor in front of his mother, gave her legs a hug, looked at her with big, shining eyes, and said, “I love you too, Mum”.

I asked if they remembered what Emil became as an adult in the story. They did not. I told them: “He became chairman of the local council”.

My intention was to illustrate that I believed Sheila and Hans also had the potential for creating a good life. As a doctor, giving and holding onto hope is a calling. I view “hope as a practice, rather than simply an emotion or a cultural attitude” (Mattingly, 2010, p. 6).

Our talk about Emil of Lönneberga became instrumental to the success of our collaboration. The next time Sheila and Hans visited, Sheila handed me a huge pile of papers and said, “I have demanded and received access to all the records that the hospitals and social services have on me and Hans, here they are.² My social worker wants authorisation to remove Hans from our home. Nobody in the social services department has ever believed in me. Please read these papers. Then you will see why I need your help”.

The records contained medical notes from hospitals and procedural notes from social services and the kindergarten dating from Hans’ birth. Many interventions had been tried over the years. But the tone was the same throughout judgmental, arrogant, and condescending. The notes were written by professionals whose role was to offer help. These people, in their professional roles, had great power over this family, who were dependent on them for help. No one deserves to be seen through that kind of lens.

I marvelled at Sheila's courage in sharing the records with me. As I read, I thought, again and again, that help offered in such a condescending manner would not help.

I developed the deepest respect for Sheila and the battles she had fought. I felt terrified, imagining being in her position. I was certain that I would not have coped as well as her.

I assessed Hans with my colleagues and co-created an understanding with Sheila of his and the family's difficulties. Most importantly, we changed the narrative about Hans, from a boy being raised by a neglectful mother, to a boy whose Attention-Deficit Hyperactive Disorder (ADHD) was making parenting difficult.

We arranged a family community meeting with the social worker, school psychologist, and teacher and initiated several forms of assistance. Hans was provided with support in school and extracurricular activities. Sheila received support with her job and education. I provided her with psychoeducation on ADHD, and she was eager to learn.

Months later I received a thank you letter.

Sheila wrote that she had felt afraid before our first family community meeting. I had promised her there would be no surprises, and that I would say only what we had planned together. She had been sceptical, but I had kept my word.

Sheila also thanked me for seeing her as a mum of a child with problems, not as a mother causing the problems. She appreciated that I wanted to support her in creating a better life for her family and her son. I felt deeply humbled, receiving written appreciation for merely behaving like a decent person. All I’d done was to follow basic ethical principles of good conduct as a helper in a position that gave me great influence over another person's life.

Many years have passed since I met Sheila and Hans. I often share their story with younger colleagues and ask them to consider these questions:

Imagine, being that parent, how would you feel?

Imagine, living that parent's life; how tired would you be by now?

Imagine, what life like that might do to your parental self-esteem.

When we do this exercise, we feel overwhelmed at how difficult life must be for the parents of children with psychiatric problems and humbled by the love these parents manage to keep alive.

This insight compels us to acknowledge that parents deserve our respect and support. Giving correct scientific treatment is not enough; we must also deliver the treatment in the right spirit. A respectful, curious, trusting and hopeful spirit create the foundation for a mutual relationship necessary for treatment to be effective, and the best it can be (Sælør et al., 2014; Turns & Kimmes, 2013).

When one person suffers, everyone in the family suffers

A psychiatric illness is not solely an individual illness (Malla et al., 2015). As a narrative practitioner, I see it as mostly relational, because a person's experience of problems is shaped by stories, which are not individual constructions. We are all participants in each other's stories and thus in each other's psychological problems (Combs & Freedman, 2012, p. 1036, 2016).

This does not mean the psychiatric illness is not as real as somatic disease, and this book is not anti-psychiatric (Kendler, 2016). However, psychiatric illnesses are responses to trauma or unmet needs, too much pressure, or other reasons, and they carry a message about this, that we need to listen for (Hamkins, 2005, 2013). This makes them different. It is also important to acknowledge that one debilitating symptom, blame, is associated with psychiatric illnesses (Blum, 2007; White, 2002). This is why I use externalization (Morgan, 2000, pp. 17–31) in my language, according to the narrative mantra (White & Epston, 1990, p. 40):

The child is not the problem.

The problem is the problem.

And:

The family is not the problem.

The family has the key to solving the problem.

Families often experience that psychiatric illness drives them apart. These effects of the problems might lead us, and the families, to believe that their relationships and interactions were indeed dysfunctional before the illness, rather than a consequence of the illness (White, 2002).

Reflect on the patients you have met. How often have you thought that the parents have acted in illogical ways and wondered why they didn’t behave differently? How often have you put some or all the blame on the parents? Don’t blame yourself too much for having such a view. We are all governed by the same stories that have perpetuated our society for decades.

Mothers have been labelled “refrigerator-mums” (Bettelheim, 1967; Harris, 2018, p. 6) and explanations have centred on blaming the parents (Cohmer, 2014). Children have been institutionalized and isolated from parents who were thought to be the reason for their predicament (Eamon, 1994; Kerr & Bowen, 1988). Societal discourses (or stories) (Burr, 2003, pp. 63–80) continue to describe families as dysfunctional (Haefner, 2014, pp. 835–837).

The research and interest in biological explanations for children's predicaments have removed a lot of blame from the parents (Coleman & Gillberg, 2012). However, blame remains a “side-effect” from those theories in the 20th century (Silverman, 2012).

Changing discourses takes time, so being aware of their effects is important (Madsen, 2006, p. 47). For example, health professionals are taught to believe that we must, and can, do a better job than parents. This discourse still dominates whenever we focus on the effects of parental actions, instead of on the intentions and wisdom of the parents.

Health professionals are traditionally considered the real experts (Sutherland, 2007). For example, social workers are the experts on social aspects and psychiatrists are experts on psychiatric problems. But what about parents? They are experts on their child, their family, and their family life. Do we acknowledge this? Our position as experts puts parents and families in a non-expert-position, giving "expert” professionals the upper hand. This stance risks the obliteration of any knowledge and wisdom the family, parents, and children might have. How would we feel in their position? The experience of many families is that their knowledge is neglected and deemed unworthy of consideration.

We need to find a new way that is based both on the bio-psycho-social model (Borrell-Carrió et al., 2004) and collaboration with parents and children. Collaboration requires that we meet our patients and their families with respect and curiosity in order to incorporate their wisdom into the treatment. Treatment should not be something we do onto them, but with them (Ness, 2014).

How do we practice this? Our team uses negotiated dialogue (Strong et al., 2011). We offer ideas on what the problem might be, but only as our input to the conversation. This enables a genuine conversation and collaboration on how to move forward, away from the ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Foreword
• Acknowledgements
• Introduction
• 1 A narrative family psychiatrist
• 2 Collaborative family therapy
• 3 I am not the problem! We are the heroes!
• 4 Mattering is at the heart of the matter
• 5 Not untidy scribbles but a beautiful illustration of my life
• 6 The helping map as a guiding light
• 7 Therapeutic letter writing
• 8 Telling stories that make sense and inspire
• 9 Naming? How might a diagnosis be best for me?
• 10 Me, the medicine, and my diagnosis
• 11 Developing and co-creating shared wisdom
• 12 Empowering the entire family
• 13 Family community meetings that matter
• 14 Weaving the collaborative spirit through all our practices
• 15 A continuously curious learning team
• 16 The art of true helping; dare to care
• Afterword
• Addendum
• Index