Writing letters directly to patients A narrative view

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Writing letters directly to patients A narrative
view

• Dave Green

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Why not?

• The DoH guidance document offers several examples
  of healthcare professionals who have written to
  their clients and copied the correspondence to
  relevant colleagues
• There may be psychological benefits gained from
  responding to the spirit of the Copying letters
  to patients initiative by taking more
  opportunities to tap the therapeutic potential of
  this direct communication

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Narrative principles

• An approach developed from systemic family
  therapy and associated with the Australian
  Michael White
• Argues that the language we use to describe
  ourselves fundamentally shapes our experience
• We are the stories that we tell and are told
  about us
• A lot of those stories are problem-saturated

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More than one tale to be told

• White follows the social constructionist tenet
  that there are always a number of legitimate
  alternative accounts of events
• So somewhere alongside the dominant narrative (of
  for example a clients incompetence) lie other
  subjugated stories (of untapped potential
  perhaps)
• The therapeutic task is to identify and elaborate
  these alternative identities

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Narrative techniques

• White can be pretty inaccessible in his writing
  about therapeutic method but
• Keep an ear open for the counter melodies in
  conversation
• Seek out exceptions to the dominant narrative (so
  called unique outcomes)
• Seek to thicken and consolidate an alternative
  view of self by further questioning (How did you
  manage that?)

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Narrative letters

• Letters can fulfil a number of principal
  functions in narrative therapy
• They allow the therapist to challenge a
  problem-saturated account by emphasizing an
  alternative view of the individual
• They provide an enduring reference point for the
  person to consult whenever they wish
• They offer the possibility of including others in
  the correspondence as witnesses

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Clinical illustration

• Ron suffered from a touch of cancer at age 6
  and was treated with surgery
• Annual follow-up indicated he had made an
  excellent recovery with minimal side-effects
  (minor scarring on his neck)
• At age 14 his Mum became very concerned about
  Rons psychological well-being. He was moody and
  involved in bullying at school

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Why now?

• Ron had his own theories about why he was finding
  life so hard at the moment
• He had been challenged about his scarring by
  older lads who refused to believe he had been
  treated for cancer as a child
• He had become increasingly aware of
  cancerrelated news items on TV
• He felt that the experience of cancer had spoiled
  his life chances and self-respect

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However

• Ron spoke with insight and eloquence. It wasnt
  hard to be impressed by him
• When his experiences were validated by me and his
  parents and we respectfully asked questions he
  replied thoughtfully
• He could begin to consider other ways of
  understanding what his having had cancer might
  mean to him and others in his life

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Writing it all down

• I wrote directly to Ron with his parents
  agreement. He chose to show them the letter
• Again with common consent I copied the letter to
  the referring Consultant Oncologist to keep her
  in the picture
• After our initial work together Ron elected to
  keep in occasional contact so he had a place to
  reflect if he needed, so I wrote letters to him
  3 times in all.

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A wider challenge

• Narrative letters are often, though not
  exclusively, written to young people
• This rights an imbalance in the expert patient
  movement (see Childrens Voices Project produced
  by CHI 2004)
• Perhaps the very act of writing to young people
  about their treatment takes their views seriously
  and challenges the assumption that children lack
  competence and need to be protected by wise
  adults.