1. Different narratives in different doctor-patient relationships 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 1

2. Familypractice Carachterizedby: All sorts of problems Great part of workload is made up of mental disorder Long-extendedknowledge of patients Knowledge of illness story and family story 15-10-2009 2 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk

3. Aim of study 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 3 To explorewhich narratives familyphysicians told about patients withpsychological problems or mental disorder

4. Narratives 15-10-2009 4 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk Increasinginterest in narratives acrossmanydisciplinessince the 1980s The ’narrative turn’

5. The ’narrative turn’ 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 5 In psychology Bruner, J. (1986). ActualMinds, Possible Worlds. Cambridge, Mass.: Harvard UniversityPress. Bruner, J. (1990). Acts of Meaning. Cambridge, Mass.: Harvard UniversityPress. Sarbin, T. R. (1986). Narrative psychology, the storied nature of human conduct. New York: Praeger. Polkinghorne, D. E. (1988). Narrative Knowing and the Human Sciences. Albany, N.Y.: State University of New York Press.

6. The ’narrative turn’ 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 6 In psychotherapy Schafer, R. (1980). Narration in the Psychoanalytic Dialog. Critical Inquiry, 7, 29-53. Spence, D. P. (1982). Narrative Truth and Theoretical Truth. Psychoanalytic Quarterly, 51, 43-69. Angus, L. & Kagan, F. (2007). Empathic Relational Bonds and Personal Agency in Psychotherapy: Implications for Psychotherapy Supervision, Practice, and Research. Psychotherapy:Theory, Research, Practice and Training, 44, 371-377. McLeod, J. (1999). A narrative social constructionist approach to therapeutic empathy. Counselling Psychotherapy Quarterly, 12, 377-394. Schafer, R. (1992). Retelling a life: Narration and Dialogue in Psychoanalysis. New York: Basic Books.

7. The therapist is never a neutral mirror 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 7 The story is alwayscreated in an interplaybetweentherapist and patient In psychotherapy and In familypractice

8. 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 8 Consultations in familypracticecontainmanypsychotherapeutic elements

9. Method 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 9 In-depthsemi-structured interviews with 14 familyphysicians Invited to tell patient stories Narrative analysis of interviews Descriptive Interpretive

10. Results 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 10 Different participants told completelydifferentstories Differentthemes Different narrative styles Four types Storieswithdetaileddescription of patients’ situation Storiesabout emotions and relationships Storiesabout irritation Storiesaboutcategorization and biomedicalperspectives

11. 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 11 Each participant told the same type of narrative – the same narrative style – through the entire interview

12. Storieswithdetaileddescription of patients’ situation 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 12 Easy and natural to tellstories Detailedstories Deep knowledge Ownreflections Engagement

13. 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 13 I think it’s fantastic, to deal with different life stories, and to relate them to the their present lives, well, also the broadness you have as a family physician, children, wives and husbands and – well it’s a fantastic approach. And it’s a fantastic knowledge you possess.

14. Storiesabout emotions and relationships 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 14 Patient’semotionalreaction and the relationship had a creativeinfluenceon the story And I think, then she experiences a relation between two human beings. That I think is important. This is the way we work in the dialogue, to get some, what could I call it, some feelings on the table which the patient has to tackle, and I have to tackle, and then we must see how we manage. The relation between, really, what happens just between us.

15. Storiesabout irritation 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 15 Tired of patients Storiescreated by irritation Not interested in hearingincoherentstories To be honest I had actually become somewhat tired of her, so I simply could not stand it any more

16. 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 16 Family physician: Some can be enormously irritating. She made me – well, she was really irritating, unctuous, and would tell of all these horrible things she had – and how it hurt here and there. Interviewer: but was that someone you could ask to tell her life story to get another view of her? Family physician: no, she was too irritating, too peculiar. I’m damned if I think so. It must be some who – who you are somewhat interested in hearing about. I was not interested in hearing about her.

17. Storiesaboutcategorization and biomedicalperspectives 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 17 Muchshorter About Biomedical diagnoses Prescription Sickleave Medical certificates Reluctant to tell patient stories Did not knowdetails

18. Interpretation of results 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 18 Familyphysicians have differenttheoreticalframes of reference for understanding patients Differentconsultationstyles Differentdiscourses of understanding Different professional positioning Manifests itselfthrough the style of narratives theytellabouttheir patients The style is global and consistent

19. Implications 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 19 Training a narrative understandingcouldincreasefamilyphysicians’ psychologicalunderstanding of patients. The conditions in familypracticearesuitable for this approach

20. 15-10-2009 Annette Sofie Davidsen, MD, PhD adavid@sund.ku.dk 20