Psychiatric Truth and Narrative Hermeneutics

15 Psychiatric Truth and Narrative Hermeneutics Bradley Lewis What is psychiatric truth? How do psychiatrists understand it? How do they use and abuse it? These questions preoccupy this chapter, and I will give my perspective from the start. I see psychiatry as a philosophical and narrative hermeneutic practice (Lewis, 2011). This means that “psychiatric truth” always involve questions of interpretation and meaning-making. In keeping with some of the central principles of philosophical hermeneutics, I see humans as meaning-making creatures, or, as Charles Taylor so memorably put it, “self-interpreting animals”—constituted by the way we interpret ourselves and our worlds (Taylor, 1985, p. 96). I appreciate Hans-George Gadamer’s foundational insight that interpretation is not “an isolated activity of human beings but a basic structure of our experience of life. We are always taking something as something. That is the givenness of our world orientation, and we cannot reduce it to anything simpler or more immediate” (Gadamer, 1970, p. 87). Or, as John Caputo puts it, philosophical hermeneutics means that interpretation is unsurpassable and that, when we encounter the world, both inner and outer, it’s interpretation “all the way down” (Caputo, 2018, p. 4). Narrative hermeneutics adds to philosophical hermeneutics by layering in narrative meaning-making as part of the larger process of human meaning-making (Brockmeier & Meretoja, 2014; Freeman, 2017; Ricoeur, 1991, 1992). This narrative addition is particularly relevant for interpreting ideas of self, identity, and difference and how we tell the stories of our lives (Lewis, 2011, 2017). From this perspective, psychiatric practice is a subset of philosophical and narrative hermeneutics. Psychiatry, in other words, is a dialogic practice of working with people to make meaningful interpretations of their selves, their worlds, their suffering, their joys, and their psychic differences (the ways that mental states vary and “normal” mental states only scratch the surface of psychic possibility). Bradley Lewis, Psychiatric Truth and Narrative Hermeneutics In: The Use and Abuse of Stories. Edited by: Hanna Meretoja & Mark Freeman, Oxford University Press. © Oxford University Press 2023. DOI: 10.1093/oso/9780197571026.003.0016 Psychiatric Truth and Narrative Hermeneutics 341 The interpretive truths that emerge in psychiatric work help answer fundamental questions of life: Where are we, where have we been, and where do we want to go? The answers, often provisional, to these questions guide therapeutic choices and treatment options. The interpretive truths that emerge are not absolute or grounded in certainty, but they are also not “relativistic” or “nihilistic.” They can be evaluated as useful, not so useful, or even harmful for coping with life and making sense of life stories and life trajectories. Moreover, depending on the relational process through which these psychiatric truths emerge, they can be evaluated as ethically fair and politically just or the opposite—ethically and politically abusive. A narrative perspective on psychiatry is not the norm. Although I work as a psychiatrist, I am also a humanities professor, which may in part explain why my preoccupation with the questions of narrative hermeneutics and psychiatric truth is unusual. If we compare my perspective with two recent general textbooks of psychiatry—The American Psychiatric Association Textbook of Psychiatry (APATP; Roberts, Hales, & Yudofsky, 2019) and Introductory Textbook of Psychiatry (ITP; Black & Andreasen, 2021)—we can see that these kinds of questions are far from psychiatry’s self-identifications. The authors of these textbooks, both published by the American Psychiatric Association (APA), dive quickly into the details of psychiatric diagnosis and treatment with little to no discussion of broad philosophical questions like “truth” and its use or abuse. Obviously, textbooks like these do not represent the entire field of psychiatry or even individual practitioners in all their density, complexity, and contradiction. Nor do “American” textbooks like these represent the diversity of approaches to psychiatry across the globe or even in “America” (wherever that is). Nonetheless, they do give us useful examples of how a major institution of psychiatry, the APA, understands and represents itself, and they provide a useful opening into how a significant part of psychiatry considers questions of truth and the abuse of truth. Before spending more time with APA psychiatry, however, I find it helpful to start from the other side of the clinical encounter with the kinds of problems people bring to psychiatry. After all, people, not people trained as psychiatrists, are the key stakeholders of psychiatry. The field is about helping these stakeholders, not about helping psychiatrist. There are many ways to bring in stakeholders perspectives, but I find one of the most useful ways is through the arts. Aesthetic experiences and creative works are often about the kinds of conflicts and complexities of the human condition that bring people to seek clinical help, and the arts provide a public way to consider 342 The Use and Abuse of Stories these complexities. Plus, the arts are not usually created by clinicians and do not, as a rule, prepackage human life through clinical frames. For this chapter, I use Edwidge Danticat’s short story, “Sunrise, Sunset” as a window into human conflicts that can become “psychiatric problems” in a clinical situation (Danticat, 2019). I then consider two imaginary clinical encounters if the lead character, Jeanne, were to come to a psychiatrist for help. The first encounter is with an APA-trained diagnostic psychiatrist and the second is with a narrative psychiatrist. My argument is that narrative hermeneutics helps make sense of both these encounters, whether or not the psychiatrist uses a narrative frame. The chapter concludes with some reflections on the implications of this argument for psychiatric practice, research, and education. Jeanne In the middle of Danticat’s story, Jeanne and her father are in a heated conversation about truth: “What’s really wrong with Manman?” [Jeanne] asks, desperate to change the subject. “We’re not done talking about you,” her Father says. “What’s wrong with her?” she insists. “She’s not herself,” he says. “It’s more than that.” “What do you want me to say?” “We need to know the truth.” “We,” he says, pointing to her mother, then to himself, “already know the truth.” (p. 147) Jeanne and her Father both use the word “truth,” but they are thinking about something very different. Jeanne is thinking about doctors, brain scans, and diagnostic truths. She is concerned because her mother’s memory problems are getting worse and she is acting strangely—leaving appliances on, having “blank spots” of confusion and disorientation, and storing her keys in “unusual places like the bathtub, the oven, or the freezer” (p. 138). Plus, Jeanne is concerned because she has a newborn son, Jude, and she is afraid her mother Psychiatric Truth and Narrative Hermeneutics 343 will not be able to help take care of him. Or worse, that her mother will mistake Jude for a doll and do something harmful to him. Jeanne’s father, on the other hand, has no interest in having medical “tests done” and getting a “definitive diagnosis” for his wife (p. 138). “You don’t poke around for something you don’t want to find,” he tells her repeatedly (p. 139). The truth he is concerned about is not the diagnostic truth but the lived truth of the family’s situation. Her father tells Jeanne that he is concerned that Jeanne is not accepting the truth of their lives or her baby’s needs. Jeanne’s mother, he explains, “won’t be able to take care of [Jude] for you. You’ll have to do it yourself ” (p. 146). In addition, he’s concerned that the final truth is that their life together as a family is coming to an end: “I’ll soon have to put her somewhere. . . . I’m not saying it will happen tomorrow, but we’ll have to put her somewhere one day” (p. 147). This is not the only truth animating Jeanne and her father’s struggle. The reason Jeanne changes the subject to her mother in this conversation is that she is trying to avoid talking about herself and the truth of her own life. Both her mother and her father believe that Jeanne is shirking her responsibility as Jude’s mother. Jeanne, from her mother’s perspective, “spends most of her days in their bedroom, hiding,” something that Jeanne’s mother “never had the luxury” of doing and certainly not of “lying in bed while relatives took care of her and her children” (pp. 134, 143). Jeanne’s mother thinks that Jeanne cannot “stay sad” forever and that “even if you don’t feel like living for yourself, you have to start living for your child, for your [eventual] children [to come]” (p. 144). What would happen, Jeanne’s mother thinks, if she “had stayed sad when she had arrived in this country?” Jeanne’s mother tries to explain all this to Jeanne. She even shouts: “You have to fight the devil. . . . Stop being selfish and living for yourself. Start living for your child” (p. 145). Jeanne’s father is in agreement with her mother in telling Jeanne the same thing in this conversation. “Did you have this child for her. . . ? . . . It doesn’t seem like you want him?” (p. 146). The implication is clear: Jeanne must pull herself up, exert her willpower over her sadness and sloth, and take responsibility for her situation. Jeanne doesn’t see it that way. She thinks her parents are oversimplifying. But, on the other hand, she is unclear herself about what is going on: “whatever it is she is feeling, she wants to tell [her father], isn’t about not wanting her son. It’s about not being up to the task; the job is too grand, too permanent, even with her husband’s help” (p. 146). Jeanne finds it “hard to explain to her father or to anyone else, but something that was supposed to kick in, 344 The Use and Abuse of Stories maybe a light that was meant to turn on in her head, never did. Despite her complete physical transformation, at times she feels as though she has not given birth at all” (p. 146). The only thing that Jeanne is clear about is what her sadness and her withdrawal is not. “It’s not that she doesn’t want her son, or wishes he hadn’t been born, it’s just that she can’t believe that he is truly hers” (pp. 146–170). A Literary Case To see how psychiatry becomes involved in these kinds of struggles over truth, it helps to imagine Jeanne’s story as a “literary case” (Lewis, 2011, pp. 78–79). This becomes possible if we simply imagine that Jeanne goes to see a psychiatrist during her time of crisis. Danticat places the struggle between Jeanne and her father in the middle of her story. From the perspective of plot, this is a time of rising tension in Jeanne’s life. “Whatever she is feeling,” as Jeanne puts it to herself, is causing increased conflict for her. The longer she stays in this feeling and the longer she stays outside the normative expectations of her family, the community, and the larger society, the higher the stakes. We see from this that Danticat’s plot structure follows a common pattern of conflict, rising tension, crisis, and resolution. Danticat begins with a main character, Jeanne, caught in a conflict that gets worse over the course of the story. The conflict worsens to a point of crisis, a point where change is forced on the character. Finally, in the resolution of the story, the character evolves, arcs from her previous position, and makes changes that resolve the previous tension and conflict. As we will see, however, Danticat adds an important twist at the end to this common plot structure. In creating literary cases, we can also imagine that the character’s crisis has gotten worse than it did in the story. This allows us to consider severe crises similar to ones that psychiatrists often see in an emergency room situation. For example, we could imagine that Jeanne becomes suicidal or perhaps accidently overdoses on alcohol and benzodiazepines before coming to see a psychiatrist. However, for this story, there does not seem to be a need to add to the crisis; the stakes are already high enough. If Jeanne came to see a psychiatrist before the story’s resolution, it would be the task of psychiatry, like the task of the story itself, to consider and help find, or not, a resolution of Jeanne’s conflicts. One of the things that is particularly Psychiatric Truth and Narrative Hermeneutics 345 interesting about literary cases is that we get to see resolutions that are often very different from the ones that psychiatry tends to imagine and work toward. For now, though, I won’t reveal the resolution that emerges in the story, but instead consider the kinds of resolutions that might evolve in two very different kinds of clinical encounters with two very different psychiatrists: a diagnostic psychiatrist and a narrative psychiatrist. In the scenario I imagine, Jeanne goes to a diagnostic psychiatrist first and then comes to a narrative psychiatrist for a second opinion. Two Clinical Encounters Diagnostic Psychiatry What might unfold if Jeanne saw a diagnostic psychiatrist in her time of emerging crisis? The two APA textbooks do not use the label “diagnostic psychiatry,” but the label fits pretty well with the definitions and conceptual approaches to psychiatry they articulate. The ITP, for example, tells us that “the primary purposes of psychiatry as a discipline within medicine are to define and recognize illnesses, to identify methods for treating them, and ultimately to develop methods for discovering their causes and implementing preventive measures” (Black & Andreasen, 2021, Preface). The textbook explains, [t]he study of psychiatry, the branch of medicine devoted to the study of mental illnesses, is therefore a discipline dedicated to the investigation of abnormalities in brain function manifested in diseases that afflict individuals in interesting and important ways. The clinical appearance of these abnormalities may be obvious and severe, as in the case of schizophrenia, or subtle and mild, as in the case of an adjustment disorder. Ultimately the drive of modern psychiatry is to develop a comprehensive understanding of normal brain function at levels that range from mind to molecule and to determine how aberrations in these normal functions lead to the development of symptoms of mental illnesses. (Introduction) The “diagnostic psychiatry” center of this psychiatric self-identification shows up with ITP’s emphasis on “mental illnesses,” understood as “aberrations” and “abnormalities in brain function manifested in diseases.” 346 The Use and Abuse of Stories For diagnostic psychiatrists, abnormalities in brain function always accompany mental illness, and the goal of diagnostic psychiatry is to identify these abnormalities from the most severe mental differences all the way to milder and seemingly situational states of affairs like “adjustment disorder.” ITP explains that a key reason for this focus on diagnosing mental disorders is that “diagnoses are often used to choose an appropriate treatment” (Chapter 1). ITP sees the goal of diagnostic psychiatry is to advance “clinically and scientifically” enough that “specific treatments for particular disorders or groups of symptoms” are possible. This does not always mean biomedical treatments, but when ITP gives treatment examples, medications are the ones that are closest to mind. “For example,” the ITP explains, “antipsychotic medications are typically used to treat disorders such as schizophrenia, in which psychosis is prominent, as well as for forms of mood disorder in which psychotic symptoms occur. A diagnosis of mania suggests the use of mood stabilizers such as lithium carbonate or valproate” (Chapter 1). Another label I could have used for this approach is “precision psychiatry.” The APATP uses this term to articulate an emerging approach to psychiatry that is even more centered on diagnostic logics and biomedical science than the one promoted by the ITP (Roberts, Hales, & Yudofsky, 2019). Precision psychiatry, for the APATP, “captures the prowess of the present and the promise of the future” and the implications are dramatic (Foreword). A revolution is under way in psychiatry. We are witnessing the emergence of precision medicine for psychiatry: “precision psychiatry.” Precision psychiatry is an integrative approach, one that pulls together the scientific foundations of the discipline and recent technological advances and directs them toward closing the gap between discovery and clinical translation. (Williams, Ball, & Kircos, 2019) The chapter goes on to explain, The goals of precision psychiatry are threefold: precise classification (i.e., a specific understanding of the pathophysiology of each individual patient— what has gone wrong?), precise treatment planning (i.e., tailoring treatment plans in a personalized manner—how can we fix what has gone wrong?), and precise prevention (i.e., targeted and tailored prevention strategies— how can we keep things from going wrong?). Psychiatric Truth and Narrative Hermeneutics 347 Repeatedly, the APATP tells us that, in precision psychiatry, the “primary focus is on the organ of dysfunction in psychiatry: the brain,” and, as such, the primary treatments of interest are biomedical. However, despite the APATP’s excitement about precision psychiatry, it also admits that “this approach is not yet a clinical reality.” The full advent of precision psychiatry will take considerable social and technological changes. For now, then, it seems that the best label for the APA approach to psychiatry is the more modest, but still dominantly biomedical, approach I am calling “diagnostic psychiatry.” If Jeanne saw a diagnostic psychiatrist, the psychiatrist would interview Jeanne and listen to her responses through the lens of a diagnostician. Jeanne would talk about many things, but the psychiatrist would tune her ear to aspects she could interpret as signs and symptoms of a psychiatric diagnosis. The process would not be hard because aspects of Jeanne’s situation easily fit the signs and symptoms criteria in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) for “Major Depressive Episode” as outlined by the ITP (APA, 2013, Chapter 6 “Mood Disorders”). The psychiatrist would interpret Jeanne as experiencing “depressed mood and loss of interest,” which gives Jeanne both of the required symptoms of Major Depression (only one of these is required to make the diagnosis.) In addition, Jeanne’s experiences could easily be interpreted to include five additional symptoms (only three of which would be required): weight gain, hypersomnia, fatigue and loss of energy, feelings of worthlessness, and diminished ability to think or concentrate. Jeanne’s experiences also fit the additional criteria of “causing significant distress or impairment in social, occupational, or other important areas of functioning.” They have lasted “more than two weeks.” And Jeanne’s diagnostic psychiatrist could easily subcategorize her symptoms as coming from “peripartum onset.” This means that the “depressive . . . episode [occurs] during pregnancy or within the first 4 weeks postpartum.” Further specification would include “late onset,” which means “if the onset is at age 21 years or older.” And she would further specify the severity, either “mild, moderate, or severe.” Probably moderate to severe. The psychiatrist would understand this diagnosis as both common and dangerous: “about 3%–6% of women will experience the onset of a major depressive episode during pregnancy or following delivery” and “at its most severe, the mood episode may become psychotic and/or life threatening to the mother or child” (Chapter 6). With a diagnosis, Major Depressive Episode, the psychiatrist would then recommend treatment, or as the ITP calls it, “clinical management.” 348 The Use and Abuse of Stories Figure 15.1 Latuda website (Latuda, 2021). Interestingly, when I looked up the ITP from my university library online resources, I got a pop-up advertisement for lurasidone (Latuda)—an antipsychotic medication approved by the FDA (in 2010) for diagnoses of schizophrenia and then later (in 2013) given approval for diagnoses of depressive episodes combined with “bipolar I disorder.” I followed this popup to the Latuda website and, perhaps not surprisingly, find treatment recommendations very similar in structure to the ITP’s chapter on “mood disorders.” The Latuda ad shows us a seemingly happy family having a picnic in an urban park with a smiling and engaged mother, father, daughter, and family dog (yes, even the dog seems to be smiling) (see Figures 15.1 and 15.2). The ad copy (Latuda, 2021), clearly directed to clinicians, tells the clinician reader that “Latuda may help your patients suffering from depressive symptoms get where they want to be.” This copy suggests that either the mother or the father (Latuda is only approved for adults) had a depressive episode in the past, took Latuda, and is now where they want to be: happy, engaged, enjoying a picnic. The image is placed in a larger notebook of what looks like cases with a vague generic family modeled on a 1950s Norman Rockwell painting, for which the family we have been discussing is only one example, all of whom, after Latuda, will become normal and “grateful for small things” (Figure 15.3). The Latuda ad works from the same perspective as an older antidepressant ad for venlafaxine (Effexor) (see Figure 15.4). In the Effexor ad (Effexor XR, 2021), we see directly the history that was only implied in the Latuda ad. The Effexor ad shows a woman looking straight at the reader, who is presumably a psychiatrist since it is published in a psychiatric journal. The woman is likely Figure 15.2 Latuda website (Latuda, 2021). Figure 15.3 Latuda website (Latuda, 2021). 350 The Use and Abuse of Stories Figure 15.4 Effexor XR advertisement (Effexor XR, 2001). being interviewed, just as Jeanne was being interviewed, and the diagnostic psychiatrist interprets signs and symptoms for either depressive episode or generalized anxiety symptoms (visualized in the black-and-white image at the top left). The psychiatrists gives Effexor and the woman becomes happy and engaged with her young child: “I got my playfulness back.” The child is just old enough, as in the Latuda ad, that the initial conflicts may have been peripartum, like Jeanne’s. ITP’s clinical management follows the same approach as the two ads. Once a diagnosis has been made, ITP tells us that “several medications are available to treat depression” and that they “work by altering levels of various neurotransmitters at crucial nerve terminals in the central nervous system” (Chapter 6). The ITP recommends “treatment should begin with an SSRI [selective serotonin reuptake inhibitor] because agents in this medication class are well tolerated and safe in overdose.” The ITP goes on to outline treatment course, the use of additional or “augmenting” medication if the first medication is not effective, and recommendations for various other medication complications. The expectation is that “most patients will improve relatively quickly, even within the first 1–2 weeks after starting medication, although Psychiatric Truth and Narrative Hermeneutics 351 full response will take longer.” The ITP tells us that the medications have similar effectiveness and that, when treated, “65%–70% of persons . . . will improve markedly” (Chapter 6). This means that persons will lose their sadness and lack of interest and become happy (or at least not sad) and engaged in their lives, like the parents in the ads. After detailing medication treatments, The ITP includes a section on “other treatments”—making clear, if there were any doubt, that anything besides biological treatments are “other” (Chapter 6). Psychotherapy shows up in this section, not so much as a treatment, but as a way to help people cope with having a psychiatric disorder. Experiencing an episode of mood disorder is often a major blow to the patient’s confidence and self-esteem. Consequently, most patients could benefit from supportive psychotherapy in addition to whatever medications are prescribed. During the acute episode, the clinician will typically let the depressive wound begin to heal. As the patient recovers, the clinician may begin to review with him or her the various social and psychological factors that could be causing distress or that might have worsened because of depression. Work, school performance, and interpersonal relationships all can be impaired because of a mood disorder. It is important to help patients assess these problems and recognize that the illness is responsible—rather than feeling that they themselves are responsible—and to instill confidence that they can now begin to restore and repair whatever injuries have occurred as a consequence of their episode of mood disorder. (Chapter 6, emphasis added) If additional psychotherapy is needed beyond supportive psychotherapy, The ITP recommends cognitive-behavioral therapy and interpersonal therapy. From this description, we can get a good sense of what Jeanne’s experience would be like with a diagnostic psychiatrist. The psychiatrists would complete her interview and tell Jeanne she has a Major Depressive Disorder. The psychiatrist would explain that this illness is caused by abnormalities of “neurotransmitters at crucial nerve terminals in the central nervous system.” The psychiatrist would recommend an SSRI, let Jeanne know that she should start to feel better in a couple of weeks, and would work with Jeanne in supportive psychotherapy to monitor the medications and make changes or add additional medications. The psychiatrist would educate Jeanne about her illness and explain that the “various social and psychological factors” causing 352 The Use and Abuse of Stories her distress are likely because of her illness. Jeanne should not feel responsible: “the illness is responsible.” Narrative Psychiatry If Jeanne came to a narrative psychiatrist for a second opinion, the narrative psychiatrist would also start with an interview. Texts that outline narrative psychiatry approaches include my Narrative Psychiatry: How Stories Can Shape Clinical Practice (2011) and SueEllen Hamkins, The Art of Narrative Psychiatry (2013). The narrative psychiatrist would be interested in Jeanne, her story, and the way that Jeanne tells her story. The psychiatrist would be open to the story’s variables beyond what could be interpreted as signs and symptoms, and she would be curious about the many possible narratives it might contain. Although the narrative psychiatrist would not force a prepackaged clinical meaning on to the story, she would be open to possible meaning formations that might emerge from clinical paradigms. The narrative psychiatrist would thus understand Jeanne’s experiences with the diagnostic psychiatrist’s approach because the story Jeanne tells contains seeds of a biological interpretation. From a narrative hermeneutics perspective, biological interpretations of Jeanne’s story are just that: “interpretations.” After all, from a narrative hermeneutic perspective, it is interpretation all the way down. But, the narrative psychiatrist would also be interested in additional clinical perspectives as well. She would be interested in childhood influences and experiences of loss and trauma that might be open to psychoanalytic interpretations. She would hear kernels that make sense from a cognitive behavioral perspective, and she would see how Jeanne’s story makes particular sense from a family therapy perspective. Moreover, the narrative psychiatrist would listen for how Jeanne’s story would be open to a humanistic and existential meaning, as well as more alternative and nonclinical meanings such as political, feminist, anti-racist, postcolonial, spiritual, and creative reading just to name a few (Lewis, 2011). Each of these interpretive frames opens up and foregrounds aspects of Jeanne’s story which are left out and backgrounded by the previous approach. Each might allow ways for Jeanne to make sense of her situation, and each provides metaphors for selecting key elements of attention. Each could be used by Jeanne to help re-story her troubles, and each provides possibilities Psychiatric Truth and Narrative Hermeneutics 353 for a new narrative identity for Jeanne. Each of these possible stories—from the most mainstream models of diagnostic psychiatrists to the most alternative and radical models of postcolonial theory or creative celebration—have in common that they all organize human existence at the deep level of ontology, epistemology, and ethics (Meretoja, 2014a). They all provide an ontological truth, a way of knowing that truth, and a choice of whether to embrace that understanding of being and knowing. But, at the same time, they also all have in common that they are limited in themselves or in combination. Even as a group or in some hybrid combination, they all leave out additional and novel possibilities for Jeanne beyond these particular frames. The narrative psychiatrist’s first step then is to hear Jeanne’s situation with this kind of openness and, as John Keats puts it, negative capability—the capacity of “being in uncertainties, Mysteries, [and] doubts, without any irritable [and premature] reaching after fact and reason” (Keats, 1988, p. 539). The next step would be to help Jeanne make choices about how to proceed in light of these many options. Following the basic ethical principle of informed consent, the narrative psychiatrist would give Jeanne background on the array of treatment possibilities so she could make informed choices. The narrative psychiatrist would explain that she herself practices a narrative approach that integrates resources from a variety of treatment models and beyond. This approach recognizes that any number of therapeutic schools can be helpful for people and that a variety of insights and strategies can be woven together to form a narrative of a person’s past, present, and future that can be helpful. If a narrative approach were to sound good to Jeanne, she and the narrative psychiatrist would continue working together. If not, the psychiatrist would work with Jeanne to find a suitable referral. If they do continue working together, the goals for the clinician and Jeanne will be to develop an empathic understanding of her lived experience, form a quality therapeutic alliance, and find acceptable resolutions—or not—for her troubles. At the time of Jeanne’s crisis, when we imagine her coming to therapy, she seems to have run out of possibilities. Her story seems to have led to a dead end, and her feelings of hopelessness and helplessness seem like her only options. What possible hope for a satisfactory resolution can there be in the face of such despair and difficulty? This is where the last one hundred years of clinical literature, along with the thousands of years of broader cultural wisdom, can be extremely helpful. Both Jeanne and her narrative clinician will bring a great deal of preparation 354 The Use and Abuse of Stories to the task. They both have heard thousands of stories over the course of their lifetimes about how people resolve crisis and how people evolve beyond being stuck in bad situations. The narrative psychiatrist will have paid particular attention to the many narratives that arise from psychiatric and psychotherapeutic models and approaches (Jones-Smith, 2014). She will also have been deeply attentive to the lived experience perspectives of memoirs, mad studies, and mad pride activists who are critical of and unhappy with psychiatric models and approaches (Beresford & Russo, 2020; Bruce, 2021; Green & Ubozoh, 2019; Hall, 2016; LeFrancois, Menzies, & Reaume, 2013; Mad in America, 2021). These many critical, mad studies perspectives have in common the key disability studies mantra “nothing about us without us.” Mad studies perspectives also have in common an emphasis on recognizing and abolishing the debilitating effects of structural prejudice (ableism and sanism) on the lives of those with mental difference (Russel, Ali, & Lewis, forthcoming). From a mad studies perspective, “stigma” doesn’t do justice to this kind of structural exclusion and subordination of mental difference, which works much more like racism, sexism, and classism than it does stigma. Finally, the narrative psychiatrist will have attended a lifetime of plays and films, plus she will have read widely in the world of fiction, memoir, and biography, all with an eye to their relevance for clinical work. Jeanne’s story also highlights how narrative psychiatry can easily blend empirical research data and outcome studies with this larger narrative frame. Narrative psychiatry recognizes that research data can be helpful in decisionmaking, but, unlike more typical evidence-based medicine (EBM) favored by diagnostic and precision psychiatry, narrative psychiatry pays equal attention to the question of personal values. In this way, narrative psychiatry works well with what philosophical psychiatrist Bill Fulford calls “valuesbased medicine” (VBM). The first principle of VBM gets to the heart of the issue: “All [clinical] decisions stand on two feet, on values as well as on facts, including decisions about diagnosis (the “two feet” principle)” (Fulford, 2004, p. 208). This means that data alone cannot determine clinical decisions and choices of diagnostic models. Even in cases where there is good data to support a clinical diagnosis and intervention, that alone does not determine the decision. From a narrative hermeneutics perspective, the final decision still depends on how the interpretation of the data lines up with the person’s life choices and life goals. Fulford gives the example of an artist who ultimately decides against taking lithium even though there were good data to support its use (and even Psychiatric Truth and Narrative Hermeneutics 355 though it helped her calm her racing thoughts) because the experience of lithium reduced her capacity to visualize color. For the artist in Fulford’s example, the effect of lithium on her experience of color was more important than its effects on her moods. The lithium experience was part of an array of reasons why the artist resisted and refused the clinical rediagnosis, or “metagnosis,” of her situation. Narrative medicine scholar Danielle Spencer coined the term “metagnosis” for the situation where one becomes newly aware of a long-standing “condition.” As Spencer puts it, “in contrast to diagnosis, metagnosis effects a change in terms of knowledge, such as a shift in our understanding of disease or of identity itself. Hence meta, for change, and gnosis, for knowledge” (Spencer, 2021, p. 3) This change of has “immediate pluridimensional consequences. A diagnosis may offer support and/ or stigma; destabilization and/or empowerment. . . . The way we organize the world has repercussions” (pp. 249–250). Using the prefix “meta”(gnosis) rather than “dia”(gnosis), Spencer highlights the change of perspective/perception more than the absolute truth of the offered perspective/perception. The clinician’s diagnosis in Fulford’s example, in short, was a reinterpretation, a metagnosis, of the artist’s experiences as a clinical mood disorder. The ontology of herself as an “artist” was preferable to the ontology of herself as a “patient.” The epistemology of aesthetics was more important than the epistemology of clinical science. And, from a VBM perspective, the ethical choice of embracing the ups and downs of an artistic life (without medical framing) was preferable to the ethical choice of embracing the ups and downs of a medicalized life. The artist’s story of her racing thoughts is not necessarily over, however, with the decision to refuse psychiatric treatment. Since we are working with metagnosis rather than diagnosis, the artist has not rejected an absolute truth, only an interpretive metagnostic possibility. She still has the flexibility to come back to the clinician’s interpretation, or some kind of hybrid both/and story at a later point, depending on how her situation and her storied interpretation of that situation evolves. Similarly, in the context of informed choice, whether or not Jeanne opted for medication, the narrative psychiatrist would be perfectly comfortable with her decision (including her decision to change her mind later). Narrative psychiatry, in other words, does not denigrate biological explanations, disease models, or psychopharmacologic treatments for mental states. However, and this is critical, narrative psychiatry does not idealize disease models of explanation and treatment either. For the narrative psychiatrist, medication questions involve not only biological effects and side effects, but 356 The Use and Abuse of Stories also the effects and side effects of organizing one’s psychic life through a biomedical frame. Some people will choose, or not choose, this frame for values and reasons that include, but that also go beyond, the details and data surrounding particular medications. For narrative psychiatry this makes perfect sense because biological explanations are not an exception to the narrative psychiatry’s general understanding of the ways that metaphor and plot work to shape narrative identity. Medical models function as metaphors, and, like other metaphors, they create a kind of “seeing as.” It is true that when people inhabit scientific frames they often come to experience “seeing as” in a deeply naturalized way, to the point where “seeing as” becomes “being as” (“I have a chemical imbalance”). But this process is not different from other uses of metaphor to structure experience: it is just another example of the role of metaphor and linguistic structures in the formation of storytelling plots and narrative identifications. Once one enters a narrative perspective, the option of a biomedical story becomes a choice, just as a humanistic story or a cognitive-behavioral story or a creative muse story would be. This similarity between psychological and medical treatments opens up to the issue of common therapeutic factors, sometimes called “placebo effects,” in psychotherapy. It is well known that much of the effectiveness of therapeutic interventions, including medications, comes from the positive effect of a quality therapeutic alliance (Duncan, Miller, Wampold, & Hubble, 2010). Narrative psychiatrists put empathic connection, relation, and dialogue in the foreground of their work, which means that their clients have an excellent chance of developing a quality therapeutic alliance. This narrative hermeneutic alliance will account for a major portion of the therapeutic effect regardless of the specific stories used—including, interestingly enough, the story of medication. All this could play out with Jeanne in many ways. She might come to the narrative psychiatrist with very clear ideas about how she would like to go forward. She might say, “I don’t want to spend a lot of time whining about this stuff. I want go back to the diagnostic psychiatrist for medication to make it go away.” Or she might say, “I am not a medication person, and I won’t take medication. I didn’t like how dogmatic the other psychiatrist was and I want to find additional options for dealing with this situation.” Or she might say, “I saw a TV show about how helpful cognitive therapy can be for depression, I would really like to give that a try.” Or she might say, “I’ve been going to a feminist anti-racist support group for women of the Haitian diaspora at the Psychiatric Truth and Narrative Hermeneutics 357 local college. I never realized how personal these larger political issues could be and how often mainstream clinicians medicalize them without understanding them! It has me rethinking everything in my life, my marriage, my son, my career choices. I feel like I need time and an open space to reflect on and make sense of what I am learning there.” Or it could be that Jeanne does not have any particular preferences. She might say something like, “I have no idea how to proceed. You’re the doctor; what would you suggest?” In any of these situations, the early work would be to help Jeanne gain a fuller sense of her narrative options. If she comes with a preference, the narrative psychiatrist would offer to help situate her preferences within the context of other options. If she did not have a preference, the narrative psychiatrist would outline the most common alternatives. Included in both of these presentations would be the option of a narrative approach which remains open to the many options and their possible integration. It would be clear in this presentation that the choice of approach rests with Jeanne. Part of this process would be deciding if Jeanne and the narrative psychiatrist should work together. If the approach Jeanne wishes to pursue is one that the narrative psychiatrist is competent to provide, then that would certainly be an option. The expected outcome, or resolution in narrative terms, would be that if Jeanne engaged with a particular option, or if she worked with a narrative psychiatrist who helped her develop a hybrid option or a novel option tailored to her sensibility, then she would create a correlating story that would connect with her sadness. This new story would become an important strand in the tapestry of stories that makes up her sense of self. It would help organize her understanding of how her past contributed to her present sadness, and it would project toward her future relationship with that sadness. Jeanne’s new narrative identity would provide a new way of being with her sadness, with new goals, new interpersonal relations, new subcommunities, and new norms, expectations, and rituals. By developing a new way of being, Jeanne’s sense of sadness would be transformed and reconfigured. If this did not happen, then Jeanne and the narrative psychiatrist would have the option of increasing the intensity of their work, or being patient and staying longer with the narrative process, or changing approaches all together. If we compare this process with the ending of “Sunrise, Sunset,” we see the way Danticat’s resolution for Jeanne is also a narrative resolution. Jeanne comes to re-story her situation and that re-storying allows for a new, at least temporary, resolution. But, interestingly, the new story Jeanne adopts does 358 The Use and Abuse of Stories not fit easily with common mental health models. Compared with mental health models, Jeanne develops a novel option. Throughout “Sunrise, Sunset,” as we saw, Jeanne’s parents believe that Jeanne must exert her willpower over the sadness and take responsibility for her situation. This model, known as “acedia” in its Christian roots, goes back to the experience of desert monks who experienced acedia less as possession and more as a temptation or a vice. Acedia in monks was characterized as “exhaustion, listlessness, sadness or dejection, restlessness, aversion to the cell and ascetic life, and yearning for family and former life” (Jackson, 1986, p. 66). This temptation was thought to be most severe at midday, and so it also went by the name “noonday demon.” Acedia eventually came to be linked with the sin of sloth and the moral life of everyday Christians. Like sloth, acedia was a state to resist through exertion of willpower. This is just the opposite of most clinical models of depression. For these models, depression is something that happens to people, not something that they can control. But, with acedia, there was a clear moral injunction against giving in to the states we might call depression (Jackson, 1986, p. 69). We do not know where Jeanne’s parents got their acedia model. Although the model has lost its name in everyday parlance, it is certainly a popular if not the dominant model of “depression” in US common sense. It is possible that Jeanne’s parents picked it up in the United States. It is also possible that it comes from their Haitian background and/or their religious connections—we know that Jeanne’s brother is a priest, and her mother finds comfort in religious rituals. However Jeanne’s parents came by an acedia model for Jeanne, it right away puts the family at odds with most psychiatrists and mental health workers. As we learned, in no uncertain terms, from the diagnostic psychiatrist: “the illness is responsible.” This means that most psychiatrists and certainly a diagnostic psychiatrist would feel compelled to resist the resolution that Jeanne comes to at the end of the story. Danticat ends the story in a dramatic concluding resolution. Just as Jeanne had feared, her mother mistakes Jeanne’s baby, Jude, for a toy doll and, in this confusion, threatens to drop him off the balcony to his death. The impact of the peril and vulnerability is so high that Jeanne, in this very same moment, has an equally dramatic transformation of mind. She goes through a kind of conversion that shifts her whole experience of herself and her identity. The danger of the situation is palpable, and it is clear that her mother will not be able to hold the baby much longer: Psychiatric Truth and Narrative Hermeneutics 359 “Manman, please,” Jeanne says, straightening herself up. “Souple Manman. Tanpri. . . .” Jeanne walks toward her husband, approaching carefully, brushing past her father, who appears to be in shock. “Manman, please give me my baby,” Jeanne says. She tries to speak in a firm and steady voice, one that will not frighten her son. Her mother regards her with a dazed look that is now too familiar. “Let me have him, Carole,” Jeanne says. Maybe not being her daughter will give her more authority in her mother’s eyes. Her mother may think that Jeanne is someone she has to listen to, someone she must obey. “Baby,” her mother says, and it sounds more like a term of endearment for Jeanne than the realization that she’s holding a small child. “Your baby?” Carol asks, her arms wavering now, as if she were finally feeling Jude’s full weight. Jeanne lowers her voice, “He’s my child, Manman. Please give him to me.” (Danticat, 2019, p. 151) The story suggests that this transformation is a turning point for Jeanne toward the acedia model and her parent’s interpretation of her situation. Through this shift, Jeanne comes out of her sadness, her withdrawal, her lassitude, and she embraces her role as a mother with power and dignity. Jeanne’s epiphanic embrace of an acedia story may or may not hold. If it does, although the model would be counter to most mental health models, it would not be a surprise or a difficulty for her narrative psychiatrist. The work with narrative psychiatrists would be a dialogic process that would not privilege the outcomes toward clinical models and would be open to novel possibilities. Not only that, the narrative psychiatrist would not denigrate “willpower” models and would likely be aware of examples where willpower became an extremely helpful frame for working through sadness (Lewis, 2012, pp. 56–57). In this way, narrative psychiatry can resemble humanistic and existential models that see people as able to resolve their own difficulties and come up with their own resolutions if given time and care. But, importantly, Jeanne’s transformation both is and is not the end of the story. Although it is a turning point for Jeanne, the story has one more section where Danticat tells what happens to Carol, Jeanne’s mother. The incident with Jude is a turning point for how the family sees Carol as well. They call the ambulance and the medics quickly turn Carol into a patient, shine a light in her pupils, take her blood pressure, strap her to the gurney, and plan for 360 The Use and Abuse of Stories a “psychiatric evaluation” with “brain scans and spinal taps” (pp. 152, 154). Jeanne’s mother has been transformed into an “Alzheimer’s or dementia” patient (p. 154). The family, particularly Jeanne’s father, had been holding out against this diagnostic or, better yet, metagnostic interpretation of Carol. It was not a truth he felt was important. But, at this point in the story, the family shifts perspective and joins with the medical model. This is just the opposite of what happened in Jeanne’s case—where the family resists clinical models through a narrative of acedia. This eventual joining with the medical model in Carol’s case and not joining with it in Jeanne’s case means that the family is neither for nor against clinical models. The family uses them and does not use them depending on the situation. Importantly, this is still not the end of the story. After both the resolutions of Jeanne’s conversion experience and her mother being turned into a patient, Danticat’s narrator drops in a crucial qualifier: “Jeanne knows, too, that this moment, unlike a birth, is no new beginning.” Danticat’s narrator is overturning conventional narrative plot here to make clear that these resolutions are no final or happy ending. The narrator’s qualifier is critical to avoid oversimplifying what has happened, and it fits well with Hanna Meretoja’s work historicizing narrative fiction’s relationship between narrative and experience (Meretoja, 2014b, 2018). Whereas realistic fiction and early narrative theory tends to see experience as shaped by narrative, later “crisis in narrative” work in theory and fiction goes in the other direction to see narrative as imposing on experience and creating illusions and distortions. This either/or binary of narrative/anti-narrative has shifted in recent theory and fiction toward models of narrative that are beyond this binary. In theory, this shows up in postpostmodern theories like metamodernism and renewalism (Rudrum & Stavris, 2015). In fiction, it shows up in writers like Michel Tournier or Julian Barnes, who draw out the relationship between narrative and experience in a complex toggle that brings ontology, epistemology, and ethics together outside of simple either/or relations (Brockmeier & Meretoja, 2014; Meretoja, 2014a). Danticat’s qualifier “this is no beginning” fits well with this both/and relationship to narrative mediation of experience, narrative truth, and narrative choice. For both Jeanne and her mother, the new narrative resolutions they are inhabiting shape the way they understand the world, how the world makes sense, and what they will do going forward. But, and this is key, it is only true as long as it is true. There are no rigid beginnings and endings, there are narrated beginnings and endings Psychiatric Truth and Narrative Hermeneutics 361 that helps us navigate the world but are always revisable into new narrative beginnings and endings. This both/and understanding of narrative would fit well with Jeanne’s work with a narrative psychiatrist. Her new narrative truth based on an acedia model, something like, “I embrace my responsibility as a mother and will fight any parts of myself that go the other way,” is not set in stone and remains open to revision. It can shift or it can combine with other narratives to create hybrid options depending on what happens next in Jeanne’s experience and in her reflections on her experience. It can be relatively stable or it can be transient. It can be total in the sense that Jeanne’s sees herself like this all the time. Alternatively, it can be partial. Jeanne sees herself like this in some ways, but not in others, in some situations, but not in others. Narrative Psychiatry, Mental Health Humanities, and Mad Studies Pulling back from these individual clinical encounters gives us a chance to reflect further on psychiatric truth and consider the implications of narrative psychiatry for future practice and research, and in psychiatry. Although the two APA textbooks of psychiatry do not speak of “truth” or “psychiatric truth,” they do speak a great deal of science, evidence, precision, and diagnostic accuracy. This creates a tension and clash with narrative psychiatry’s more flexible approach to truth and psychiatric truth. To work through this tension, I find it helpful to rethink the hidden pedagogy of most psychiatric training. This means rethinking how a clinical science background trains psychiatrist to think in terms of one, and only one, true world. Much of the challenge of rethinking this pedagogy has less to do with the word “true” and more to do with the word “world” in that prior sentence. Philosopher Clive Cazeaux provides a helpful analysis of the term and shows the metaphorical role it played in the much-discussed “science wars” of the 1990s (Cazeaux, 2007, p. 139). The science wars involved a heated dispute around the question of whether science discovers the world or whether science constructs the world. Both sides of the science wars appealed to the “world,” but each used a different metaphor to understand the term “world.” Defenders of science as discovery understood “world” in terms of an ultimate truth independent of human cognition. Defenders of science as construction understood “world” in terms of phenomenology of experience—something much more akin to 362 The Use and Abuse of Stories the idea of a worldview or zeitgeist. The same term, “world,” brought up very different associations for the competing sides, and the metaphorical oscillation between world as ultimate truth and world as zeitgeist created the either/or conditions of a bitter battle without compromise. Many clinicians, steeped in a clinical science background, adopt the ultimate truth metaphor for “world,” and this puts them on the discovery side of the science wars. But clinicians do not have to stay true to their training, nor do they have an obligation to enlist in the science wars. They can put their background in perspective by recognizing the metaphorical nature of what they have been taught. Plus, they can avoid the science wars altogether by adopting a new metaphor for “world” beyond the oscillating options of world as “ultimate truth” or world as “zeitgeist.” If clinicians adopt an understanding of “world” that combines these two meanings as a narrative perspective on ultimate reality then they can avoid fighting altogether. This combined narrative perspective on the notion of “world” allows clinicians to understand that the conflicting interpretations of Jeanne’s story are alternative takes on reality, alternative points of view. None of these competing perspectives “discovers” the final reality of Jeanne’s situation, nor do they completely “construct” her situation. Each provides a narrative perspective that evokes, highlights, and foregrounds some aspect of her real situation while simultaneously backgrounding other aspects. By rising above their clinical training to adopt a new metaphor for “world” outside of the dueling possibilities of the science wars, clinicians can embrace the possibility of multiple perspectival realities of Jeanne’s situation without it seeming absurd or insane. Narrative psychiatry provides the tools for practicing clinicians to reach this possibility, and the evidence of Danticat’s story suggests that narrative affords multiple advantages for clinical practice. By adopting the narrative approach of multiple worldviews, practicing clinicians avoid not only the science wars but also the tired debates in the clinical world between antipsychiatry and pro-psychiatry. Narrative approaches allow clinicians to interpret Jeanne’s story without denigrating any single worldview (by calling it a “myth”) and simultaneously without idealizing any one view (by calling it the “objective truth” or ultimate reality). Narrative approaches do this without disregarding “evidence-based” medicine. If one adopts a science-based model, or any other model, it matters greatly how evidence is marshalled and interpreted within the model, who gets to participate, and whose interests are being served. For example, we have known for many years—see former Psychiatric Truth and Narrative Hermeneutics 363 editor of the New England Journal of Medicine Marcia Angell’s The Truth About Drug Companies: How They Deceive Us and What to Do About It—the problematic uses and abuses of “truth” in the pharmaceutical industry’s promotion and hype of psychiatric medications (Angell, 2005; Gøtzsche, 2013; Healy, 2012; Sismondo & Greene, 2015). And, finally, narrative approaches do this without falling into “anything goes” style relativism. The approaches people choose matter greatly. Indeed, the approaches people take shape their identity and their future. Which narrative people choose not only organizes the past and present, but it provides a compass for going forward. Even though the stakes are high, the options are still many. There is no one path that people must pursue. Adopting this kind of flexibility and sophisticated narrative nuance creates practicing clinicians who avoid dogmatism— the bellicose insistence on any necessary “one way”—and who are open to helping clients find the path that best suits their needs and desires. This is why narrative psychiatry works well as a theoretical scaffold for building mental health humanities and mad studies coalitions and programs across campus and beyond. Learning from narrative psychiatry allows us to acknowledge that there will be ongoing differences around how to research, teach, and practice mental health and mental health care. Rather than fight this diversity or try to find a single necessary approach, narrative psychiatry opens the opportunity of embracing the complexity and multiplicity of approaches. From this perspective, cognitive science, behavioral science, neuroscience, and medical science all have their place, and they all do what they can to help explain and predict aspects of mental difference. At the same time, the possibility of finding valuable understanding from the arts and humanities also has its place. This hardly means that any work in the sciences or the arts and humanities should be embraced uncritically, but it does mean that we can learn about mental difference, mental health, and mental health care from both the sciences and from the arts and humanities. This provides an opportunity to move forward in this direction through affinity organizing similar to what has happened in health humanities, narrative medicine, and disability studies. Although their focus is physical health and physical difference, these domains have begun to pay attention to mental health and mental difference. The significance of mental health for health humanities can be seen in projects like Creative Practice for Mutual Recovery, the Madness and Literature Network” and the Dementia Arts and Wellbeing Network showcased by the International Health Humanities Network (International Health Humanities Network, http://www.healthhumanities. 364 The Use and Abuse of Stories org/). Similarly, scholars are using the signifier “mad humanities” to bring together disability studies to articulate the role that humanities and “mad literary studies” can play in developing these connections (Stefan, 2018). Important steps are also being made in psychology through the development of “psychological humanities” (Freeman, 2020; Healy, 2017; Sugarman & Martin, 2020; Teo, 2017). In addition, disability studies’ arguments for democracy, “nothing about us without us,” particularly stand out in the context of mental health. Mental health research, education, and practice is a source of deep conflict and contention in contemporary culture (Mad in America, https://www.madinamer ica.com/). What is important to see is that much of the critical concern with mental health care practices arises from issues of democracy and sanist prejudice (Russell et al., forthcoming). Recent mad studies work has moved beyond critiques of psychiatry organized around ontological claims, such as the “myth of mental illness,” to broader claims for democracy and epistemic justice: Who is included in the creation of mental health knowledge(s) and practices? Who is excluded? Why are these inclusions and exclusions created? How can we open up our knowledges and practices surrounding mental difference to a greater diversity of perspectives? How can we include more disciplines, more methods of knowing, more points of view, and more approach alternatives? And, most importantly, how can we include the perspectives of the key stakeholders, those of us who are impacted by these knowledges and those of us who are most unhappy and aggrieved with how the knowledges and practices have emerged? By setting up mental health humanities and mad studies communities around the world that include a broad base in the arts and humanities as well as mad pride activists and scholars, we can make meaningful steps to expand the practice, research, and education of mental health. All of this makes sense when we use a narrative hermeneutics model to understand psychiatric truths. Obviously, this approach would not be attractive to all, but, just as with health humanities, narrative medicine, and disability studies, the impact of these programs can go beyond the programs themselves. Even Jeanne’s diagnostic psychiatrist, were she to live in a future world that included mental health humanities and mad studies, would have exposure to more than scientific approaches. With this additional exposure, she would have a greater possibility of avoiding the kind of scientist dogmatism which can come from a too limited understanding of psychiatric science. She would have a greater possibility of hearing Jeanne’s story beyond signs and symptoms. Psychiatric Truth and Narrative Hermeneutics 365 Sascha DuBrul, long-time mad pride activist, puts it this way: “I believe in the power of people’s stories and in the power of language, metaphor, and collective narratives. One of the keys to our larger political struggles lies in our ability to own and rewrite our personal stories” (quoted in Roth, 2019, p. 240). 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