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Background: Some psychiatric patients are presented as hopeless, burned out, and devoid of social graces. Staff of mental health centers and hospitals are not encouraged to view these people differently. A narrative perspective allows anyone to emerge as a richly complex human being.
Method: A course presented students with the opportunity to create narrative descriptions of patients presented by medical staff as hopeless.
Results: One student's narrative of “Murphy the Motor Mouth” is presented; it shows the validity and usefulness of the narrative approach in reconstructing a person to be avoided as an interesting, valuable, and richly complex human being.
Conclusion: Murphy in story emerges as more interesting and worthy of knowing than the clinical Murphy constructed by medical staff. Narrative approaches offer a richness and intimacy that fosters a more therapeutic and effective relationship between patients and staff.
In our contemporary psychiatric settings, patients are sometimes presented as hopeless, recalcitrant, and “burned out.” In this article we present the result of the interaction of a faculty and a student to change a “burned-out” patient into an interesting person through elicitation of his narrative. Narrative medicine has emerged as a new approach to humanize medicine,1 along with promoting empathy,2 and inculcating cultural competence.3 These approaches have not necessarily failed, but medicine still contains powerful dehumanizing influences.4
As part of a course in narrative medicine, students were encouraged to find patients who had been dehumanized and to interview these patients to produce a narrative of interest about people who had been previously presented as uninteresting and burned out. The patient described herein was presented as a hopelessly recalcitrant “bipolar” with no redeeming social graces. We present an alternative narrative to show how narrative approaches can redeem the hopelessly lost, at least in the eyes of their caregivers, and foster more effective treatment.
The story: Murphy, the “Motor-Mouth” was a special patient, but the staff at the hospital didn't agree. His big presence, loud voice, and insatiable thirst for interaction were dramatic. He often laughed and made the sterile halls of the hospital come to life. But no one was laughing with him. I (MPV) was informed that Murphy was a Bipolar I substance abuser whose energy needed constant pharmaceutical correction. The staff hesitantly concurred that he was an interesting person, but tenaciously resisted the urge to know him. Yet, to me Murphy continued to stand out. The superficial level with which he had been conveyed became clear as I got to know him.
Murphy presented as a tall, well-built male in his early fifties. His raspy voice projected from a large mouth with few teeth. He frequently asked, “How are you doing?” and cheerfully waved from across the room. Murphy loved to tell old stories, new stories, or retold stories. Once he got going, one could sit back and enjoy a fairly linear, often fast and disorganized, cascading monologue. Murphy was a Caucasian and Pacific Islander mixed male born in Provo, UT. He was raised in a large Mormon family with three brothers and five sisters. Murphy enjoyed a stable childhood with a family rooted in faith. He never experienced abuse or neglect. Murphy recalled fishing as a child and legendary moments in high school football. He boastfully shared many nicknames including “Kuntukinte,” “Dizzy D,” and “Baby Brain,” but could not recall their origin or meaning. After high school Murphy joined the military. He favorably recalled his time in Korea. Murphy loved the food and the people. He said “I felt love with the people” and “I ate kim chee.” His time in Korea also increased his appreciation for the US. He said, “People here are spoiled brats; they don't know. They're just used to having food every day.” He did not experience trauma in the service and was discharged after two years.
A few years after his military service, Murphy experienced two traumatic events: witnessing the murders of his girlfriend and cousin. These events took place in his early thirties. Murphy appeared impenetrable to sadness until these memories emerged. They could silence a Murphy monologue above all else. Despite his high energy, Murphy's ideology was easygoing. He was a person of the people, someone who did not strive for riches and power. Murphy often felt misunderstood and found refuge from judgment with his friends. Murphy claimed to “hang out with handicap people because they accept [him] for who [he is]” and said “[His] friends work at McDonalds.”
Murphy experimented with drugs and alcohol at an early age. He was smoking cigarettes in the third grade and by the eighth grade using alcohol, marijuana, LSD, and cocaine. He used LSD every day in the summertime as a late adolescent. Despite his avid use, Murphy felt he was cautious. He “[found] out what [was] safe.” He did not blindly use any drug that came his way; Murphy did his homework. He read books and sought information before feeling comfortable with a substance. Murphy claimed drugs didn't affect his mind and that they were “just an experience.” He was impenetrable to the effects of drugs. Murphy felt drugs played little part in his life path or current predicament. Despite his research and cautiousness, Murphy did experiment with some extremely dangerous substances. He used ice and sniffed paint, yet remained unscathed. Murphy was a proud marijuana smoker. He animatedly illustrated the joy of using marijuana in all its varieties. He felt it brought friends together and enhanced life.
Murphy's legal and psychiatric history were unclear. Murphy served five years in prison for robbing a bank. He said he was wrongly convicted, but wanted to serve the time and move on with his life. Murphy was diagnosed with Bipolar I disorder in his early thirties after “staying up for six days and six nights.” His first manic episode appeared to have followed the deaths of his cousin and girlfriend. However, because of Murphy's often tangential, disorganized, and fast speech, he could not construct a coherent timeline. Murphy did not feel he had a mental illness; rather, a “motor mouth because doctors only give him a limited time to talk.” Doctors had not listened to him in the past and “[he knew] what it is like not to be heard.”
Murphy loved to “talk story.” He was mostly interested in talking about life. When asked to talk about his experiences with pharmacologic agents, he often sidetracked. At the time of the class, he was taking lithium (600 mg twice daily), aripiprazole (30 mg daily), and benzotropine mesylate. He was first placed on lithium subsequent to his Bipolar I diagnosis. He felt very similar on or off drugs. When asked why he took medication, Murphy said, “Because I claim disability and my doctors think I am safe.” However, the medications gave him substantial digestive side effects. He recalled diarrhea so severe that “[he] kept wiping [himself], ….” Murphy told many stories of being unable to get to the bathroom fast enough and enduring this very tangible consequence. However, all the side effects disappeared when he took benzotropine mesylate. Murphy spoke highly of benztropine mesylate and treated it as a saving grace. He insisted on taking benzotropine mesylate while on any psychoactive medication. Without it, the side effects were unbearable.
Benzotropine mesylate was Murphy's favorite drug. He said it reduced his digestive symptoms. Benzotropine mesylate is known to cause euphoria and excitement. Murphy could have been enjoying the side effects rather than the drug's primary mechanism. Passion can be expressed in many ways. Some endure years of practice and devote countless hours to perfect a craft. This brand of passion is most familiar to our modern day society. Yet, how many forms can passion take? Must it be hardworking? Murphy was a man of passion. He devoted himself to a lifestyle. From a young age he passionately sought an easy “feel-good sensation.” He walked a path of least resistance to a place of highest pleasure. Undoubtedly, this passion led to drug use. Drugs meet all Murphy's criteria. To Murphy, his behavior was not a bad habit or pathology, it was him. In accordance with his philosophy, he didn't resist physician's orders. Rather, he took the prescribed drugs, added one for entertainment, and continued to live out his passion. Sparring with an opponent who rolls with every punch inevitably leads to the aggressor being unwilling to enter into the dance of the defendant. Murphy took the lead and all medicine could do was to avoid stepping on his toes.
“In a larger sense, the biological study of mind is more than a scientific inquiry of great promise; it is also an important humanistic endeavor. The biology of mind bridges the sciences—concerned with the natural world—and the humanities—concerned with the meaning of human experience. Insights that come from this new synthesis will not only improve our understanding of psychiatric and neurological disorders, but will also lead to a deeper understanding of ourselves.”
—Eric Kandel, MD5
Narratives give physicians the skills, methods, and texts to learn how to imbue the facts and objects of health and illness with their consequences and meanings for individual patients and physicians.1,6,7 The narrative about Murphy was more humanizing than the clinical story circulating among the medical staff. In the above story, Murphy emerged as a competent, optimizing, goal-directed human being in stark distinction to the role cast by the medical staff as burned out, hopeless, uninteresting, and annoying. The shift of focus from clinical to narrative allows us to consider the impact of this change of focus. The patient comes to the clinician with a story to tell and wants someone else to hear this story and to reverence it.8 But the clinician's role is not simply to be the passive hearer, but to become a participant-observer and a listener. Our narratives carry important messages, both to ourselves and to whomever we are asking to listen. Murphy's narrative carries a message of competence in contradistinction to the usual clinical narrative of incompetence in which he is usually presented. He maintains an aura of joy in a usual story of despair. A narrative perspective allows Murphy to be seen in all his complexity: his strengths, his joys, his weaknesses, and his despair. All of these operate for such a richly complex individual.
A narrative perspective enriches ordinary clinical care and humanizes medicine to appreciate people as more than their diagnosis and symptoms. It exposes students to narrative ideas while studying standard clinical presentations and it allows students to appreciate the richness of human life over the reductionism of much of clinical science. For this reason, it should be encouraged within the clinical sciences. At the University of Hawaii, we are beginning to create a Narrative Medicine program to humanize the clinical sciences and to create bridges with the indigenous medicines of the Pacific Rim, which are decidedly based upon stories and the healing impact of “talking story.” Murphy is one of the many patients who would benefit from a narrative approach to psychiatry.
Rita Charon, MD writes that “Narrative medicine has evolved as a means to honor the stories of illness, whether told by the patient, family member, doctor, or nurse. More sharply it has become a way to probe the narrativity of disease, of health, of healing, and of the relation between the sick person and the one who tries to help.”1 One's story is more than “just” information. It is us giving to another a part of our soul: our essence. A person's story is more than a case history of symptoms to be noted as part of a medical assessment; it is something to be prized and honored. Writing of time spent with her patients, Charon has this to say “Through the attention I donate and the authenticity he displays, we grow together in knowledge, in action and in grace, hoping for the best, making it out together …”1 This makes narrative into a shared experience where both clinician and patient can give to each other and learn from each other.
Narratives give physicians the skills, methods, and texts to imbue the facts and objects of health and illness with their consequences and meanings for individual patients and physicians.
Over the past five decades research has demonstrated the immense importance of therapeutic alliance, empathy, and collaboration. Successful treatment is reliably predicted by the presence of these three factors. The aforementioned variables were nonexistent between Murphy and the staff. Murphy was presented to Michael, the student from a distant and critical perspective in which the patient was receiving treatment. The staff offered little interest in Murphy's perspective as his job was to take what he was given. This is not Murphy's first stay at the hospital and it likely won't be his last. Patients like Murphy are often regarded as “treatment failures.” Yet, in the absence of the three most crucial elements of effective treatment, it appears that he's not failing treatment; treatment is failing him. Viewing patients through a narrative lens turns a clinical case into a person. When patients become people, collaboration and empathy exist more naturally and the patient enters into a bilateral relationship. The narrative approach is not simply a way to conceptualize, rather a catalyst for the implementation of more effective treatment of our mentally ill.
The author(s) have no conflicts of interest to disclose.
Public asylums for maniacs have been regarded as places of confinement for such of its members as are become dangerous to the peace of society. The managers of those institutions, who are frequently men of little knowledge and less humanity, have been permitted to exercise towards their innocent prisoners a most arbitrary system of cruelty and violence; while experience affords ample and daily proofs of the happier effects of a mild, conciliating treatment, rendered effective by steady and dispassionate firmness.
— Treatise on Insanity, Philippe Pinel, 1745–1826, French physician, described as the “father of modern psychiatry”