Some reflections on stories in general practice

Andrew Morrice, GP and Human Givens psychotherapist

Published in JHH17.1 – Stories in medicine

I am a GP, educator and Human Givens psychotherapist, and have been involved in the BHMA and holistic approaches since 1988. In 2018, after 20 years as three-quarters time GP, I left my partnership to start JoinedUpHealth, which provides education for clinicians and the public as well as psychological therapy.

A story can be enabling and stimulating if it matches well enough to the pattern of a person’s life situation. Click To Tweet

The Tesco ad campaign sums up our primary human preoccupations: food, love, stories. For, like all animals we are intensely concerned with food and love, and with the stories our brainmind creates to make sense of the world through symbol, metaphor and narrative. Simple everyday phrases and modes of thought imply we are constantly asking ourselves, ‘what is the story here?’ Yet modern medicine has largely set its face against the subjectivity of stories as a way of learning about our work or ourselves, or for drawing conclusions, or for communicating about standards or as ways to evidence particular therapeutic approaches in practice. In doing so, medicine has marginalised a core function of our minds. As doctors or as patients we are right to be wary of what is being lost here, for the stories we tell about ourselves are significant and we tend to believe them. Even when we suspect they are not totally truthful we intuit that there is a valuable baby in our narrative bathwater.

One obvious paradox is that for centuries ‘history-taking’ was a core activity in medicine. ‘Historia’ in Greek means enquiry. This enquiry into a patient’s symptoms and life experiences is asking, ‘what is the story here, of how this came about, and how can I make sense of this?’. The questions we ask are at best aimed at helping both patient and practitioner make sense of the situation at hand. In the oldfashioned doctor–patient model, when a clinician failed to make sense of a patient’s story, the phrase ‘the patient was a poor historian’ might appear in the notes. This of course is a terribly misleading (and victim-blaming) form
of words and, if anyone is the poor historian, it is the doctor whose enquiry has failed to spin the threads into a meaningful yarn (pun fully intended).

Masterful invisibility

Of course most patients have already made their own enquiry: in our time, probably online. In the past it would have been by talking to friends, or to anyone with experience of illness, or to the wise woman down the street. Today, people often come to doctors having fitted their symptoms whether consciously or not, into a narrative perhaps improvised, sometimes pre-formed. Often their version is unspoken for fear of annoying the doctor. Nor is it at all unusual for people to know that these narratives are restrictive or even disabling. Yet at other times, when these ideas actually point to solutions, all the skilful doctor need do is play a walk-on part in their internal drama as constructively and unobtrusively as possible In such ways general practice at its best can have a quality of masterful
invisibility, of ensuring that certain things do not happen, that harm is not done. For it has always seemed to me that we therapists appear at brief – though they may be key – moments in a person’s unfolding narrative. We should be on stage no more than necessary. Even if we become major characters in some of our patients’ lives, their long narrative arc will always have started somewhere way beyond our point of view, and it will continue far into a future where in our mobile and unstable communities we doctors are unlikely to play much of a part.

Since the meaning we find in the world is active not just in our psychology but our physiology it follows that stories could be used to help and heal. Having had the great pleasure of being taught about the psycho-therapeutic power of stories by Pat Williams who directed the College of Storytellers in the 1980s, I looked for ways to incorporate these into my work as a GP. Yet it seemed a less than ideal context in which to use the full-on technique of storytelling, with its brand of gentle trance induction – the standard repetitive language, the use of cue phrases such as ‘once upon a time’, the evocation of all senses. All of this, according to Pat and others interested in the therapeutic power of stories, allows the mind of the hearer to engage with a rich web of metaphor. The advantage of this way
of engendering helpful change is that there is no need for the hearer’s conscious mind to engage in a rationalising argument with any of the content; indeed the whole point is not to reveal what the teller believes the point to be. A story can be enabling and stimulating if it matches well enough to the pattern of a person’s life situation. Then the map it offers feels to the hearer to be unfolding and constructing itself inside their own imagination. The teller of the story chooses the stimulus, and the hearer is free to respond in their own way.

My friend John

So most of the time in my work as a GP, and for obvious reasons, I found myself relating mini-stories; simple stories about what had happened to other people in similar situations, and as time went on one of the most useful techniques is one known to many as ‘My Friend John’. The idea behind this technique is you tell a story about someone in a similar situation to the person you are speaking to, and in the story you can suggest solutions and changes.

My favourite ‘My Friend John’ experience stems from a time before I knew this was what it was. A patient, who has now passed on, presented back in the early 2000s, shaky, red faced and bloated, with deranged liver function tests and everything pointing to heavy drinking. I had a great deal of sympathy for this man. He had lived through the years when his sexuality was illegal, and I imagined he had faced a good deal of difficulty in the past. In his generation drink was almost universally the self-medication turned to. Gentle but clear enquiry about alcohol produced a stout and consistent denial, so I dialled everything back and started to describe the various possibilities including that standby of general practice, the ultimately unexplained but transitory abnormality. But along with
this, a very clear account of what I would tell patient with these tests results who was a drinker: how vital it would be to stop for instance, and how these tests would be a clear warning. We checked him from time to time over the next few months and although he seldom looked any better his bloods did improve. Then the silly fashion for discontinuity of care and rising patient demand meant that I didn’t see him for several years, maybe as many as five or six, and when I did I seemed to be looking at a different man. Having dealt with whatever it was he’d come about, I said, ‘You look an awful lot better than when we last met’. ‘Well doctor, I did as you said and stopped drinking!’. ‘Ah but I never did tell you to stop, did I?’ He grinned broadly. ‘True, but I heard you anyway’.

Stories about stories

Now this story has become my standard way of describing the technique when time allows, and every now and then I’ve told it to a patient, effectively as a
‘My Friend John’s Friend John Story’. Another story about stories concerned a patient of mine who was dying of a tumour in a nursing home. I’d known this lady a while and we both knew (but never mentioned the fact) that had she consented to have a colonoscopy two years previously she would have almost certainly been curable. And now she was having a torrid time of her terminal phase, with hard to control symptoms of liver enlargement ascites and jaundice along with a terror of dying. It is sometimes easiest to simply reassure people ‘it’s going to be alright’ when they are closest to death, but on this
particularly evening when I was called out to help with her palliation, she was very restless and anxious, and something more seemed to be required. After doing all I could with her medication I decided to tell her a story. The story was of Eben Alexander’s near-death experience, which he recounts in the misleadingly titled Proof of Heaven. I have no idea how ‘truthful’ this account is, but this in a way suited my purpose.

Today many of our patients are faced with a profound difficulty making sense of their suffering.

She had her eyes closed and I started to tell the story of this neurologist who contracted severe fulminant meningitis during which, while he was in a deep coma and on intensive life support, he had a vivid journey through many extraordinary ‘other worlds’. I told her how he had concluded that death was nothing at all to be fearful of, that death is not the end and that our next stage of life is beautiful, and that indeed he had been sorry to come back to his wretched body once started on his long process of recovery. And I said if the story didn’t mean anything to her that was fine. Then I quietly left. Next morning I was told that she had immediately become very peaceful and died without needing any of the further analgesia or of the other medicines I’d arranged. The doctor who’d been called to certify in the early hours morning seemed most put out that she’d not been on a huge dose of diamorphine.

Toxic stories

The stories we tell ourselves about life have so many ramifications, and the power to transform our experience for good or ill. Whilst we can appreciate the earnest and good intentions of militant atheists and materialists, on another level it can seem that the implied or even stated narrative – that our life is ultimately accidental, insignificant, brief and ends with oblivion – leaves many people in a narrative vacuum. An idea that your life has no ultimate purpose may appear scientifically sound, but this may be of little use when the going gets tough. Some Eastern religions and philosophies have been based on similar materialist ideas, but always embedded in a far richer and more supportive matrix of practice and belief. To be sure our Western mediaeval ideas of misfortune and sickness as punishments or judgements, or even curses had little to recommend them from our perspective. But today many of our patients are faced with a profound difficulty making sense of their suffering. And into this space we step with our narrative dose of diagnosis fix: a double-edged fix if ever there was one, for we speak of diagnosis as if it turns diseases into ‘things’, which ultimately are just due to bad luck, or to our modern form of fate – our genes. Consider the grammatical structure of the phrase ‘I was diagnosed with polymyalgia’: it’s the same sequence as for example ‘I was poked with a stick’ or ‘I was issued with a uniform’, as though diagnosis is something done to us. And thus the complex web of causes, responses, and maintaining factors behind the ‘doing’ is bundled up into this neat term and rendered invisible may lie unexamined perhaps forever. So whilst diagnosis is necessary in many ways and can unlock so many resources, it can also create a new kind of prison of meaning for both practitioners and patients, by simplifying and channelling the narrative; particularly if the diagnostic label gives the difficulties implied a false impression of weight or permanence. It supposes that the monolithic pre-formed one size fits all diagnostic category is a close enough fit for the patient at hand.

Which reminds me of one last story, traditionally told of the sage-fool Mullah Nasrudin;

Nazrudin found a weary falcon sitting one day on his window-sill. He had never seen a bird like this before. ‘You poor thing’, he said, ‘how ever were you to allowed to get into this state?’ He clipped the falcon’s talons and cut its beak straight, and trimmed its feathers. ‘Now you look more like a bird’, said Nasrudin.

Further reading

  • Parkinson R. Transforming tales: how stories can change people. London, Philadelphia: Jessica Kingsley Publishers, 2009.