Why Therapists Must Be Familiar With Narrative Interviewing

In my training as an M.D. I learned that doctors ask questions about signs and symptoms, make a diagnosis and a prognostic assessment. I first started to question this traditional medical approach to patients when faced with suicidal patients. I got interested in the history of the wish to die. Without this information it was impossible to understand what had led up to an existential crisis. Obviously, the patients had to tell me their stories of how things had developed up to a breaking point. This meant that we had to switch roles: Here, the patients were the experts of their stories, while I was in the not-knowing position – a new experience for me!

Once I had learned the basics of the narrative approach, I soon discovered the enormous value of narrative interviewing – in consultation with patients that came to see me with health issues other than suicidality. Every first patient contact became a fascinating experience. I learned that patients have an amazing narrative competence in telling a coherent story of their health problem to an open-minded listener. The narrative approach has made my professional life much more rewarding – after all, human biographies are so incredibly fascinating, diverse and unique.

Narratives are the means for the therapist and the patient to find a joint understanding and allow change.

In the narrative interview the listener enters the world the narrator constructs, helps in the telling, and thus, narratives are jointly accomplished. A health professional who is a nonjudgmental and attentive listener creates trust and becomes an ally of the patient, supporting the patient in coping with adverse experiences and suffering.

I had to learn to stop myself from asking questions, and to trust the patients’ capacity to give me a coherent story of how the problem developed. To my surprise most patients spontaneously put their suicidal crisis into a biographical context. “You know, I think it goes back to my childhood, when my parents separated, and I thought it was because of me”. That is, they were not merely talking about the actual emotional crisis, but they took me back to the early years of their childhood, telling me of painful experiences, rejection, problems with self-esteem, self-blame, guilt, and many other unmet needs.

Narrative and therapeutic alliance

Starting a consultation with the patients’ history of illness engages them in the doctor-patient interaction as active participants. Of special interest here are early studies on the relationship of physician interviewing style with patient satisfaction. For instance, Bertakis et al. [1] found that “patients are most satisfied by interviews that encourage them to talk about psychosocial issues in an atmosphere that is characterized by the absence of physician domination.” In psychotherapy research the patient – therapist relationship has been a major focus in the 80’s and 90’s, including authors like Luborsky (1992), Crits-Christoph (1993), Horvath (1994), and others. The key conclusions are still valid today: (1) The quality of the therapeutic relationship is a significant factor for therapy outcome across various types of treatment, and (2) the initial phase of psychotherapy predicts therapy outcome. This is why it is important to start a new patient contact with a narrative interview.

In our department, we decided to test our hypothesis that the narrative approach was associated with higher patient satisfaction with the therapeutic relationship. Right after the interviews with patients who had made a suicide attempt, patients completed the Helping Alliance Questionnaire (HAq) [2] an instrument to measure patient satisfaction with the therapist. The results showed that the interviews were rated significantly higher when in the opening sentence the interviewer used the words “story” or “tell me”. The second finding was that interviews were rated significantly higher when the interviewer acknowledged the patients’ important life goals and needs like, for example: “You know, separation has always been a big problem in my life” [3].

A therapeutic alliance built on trust, empathy, and understanding is a necessary precondition for an effective therapy, allowing patients to mobilize their capacities to change. In working with suicidal patients it has been shown that a strong alliance formed early on in the therapeutic process was associated with a decrease in suicidal ideation and attempts [4].

Guidelines for narrative interviewing

• Take a relaxed seating position, conveying the attitude of an interested and attentive listener who has all the time in the world (even if it is only 20 to 30 minutes!).
• Invite the patient to tell the history related to the health problem that got them to seek medical consultation, with a standard sentence such as: “I would like you to tell me the story behind the problem that got you to come to see me, …. to contact the crisis center, …to consider suicide as a solution, etc.”
• Do not interrupt with unnecessary questions, trust the patient’s narrative competence.
• Never ask “why”. The reason is that this would presume that there is a simple cause, excluding the personal story related to it.
• If necessary, help the patient to continue the narrative by using open ended questions, that is, questions that can’t be answered with yes or no. For instance: "Can you tell me more?“, "I am trying to understand“ - can you help me understand?“
• When patients make a pause but the brain seems to be working: "I wonder, what is going through your head right now?”
• Go along with the patient’s subjective account of what happened. This is crucial to establish a working alliance. The medical interview, where the health professional is the expert, asking specific questions for diagnostic assessment, should follow the narrative interview, and lead to a comprehensive understanding of the health issue, and to further steps to be taken.

Summing up

“Therapy happens not in the patient nor in the doctor but between the two of them” [5]. The active collaboration between patient and therapist makes the doctor-patient interaction interesting and rewarding. Therapy is not about treating diagnoses or patients, but about working with “the person in the patient”.