Main characteristics

We all know the essentials of digging a hole, medically speaking, because we do it all the time, so let me delineate instead what I regard as the three main characteristics of weaving a tapestry in the clinical encounter. The first is what the poet John Keats famously called ‘Negative Capability.’1 He defined this as “capable of being in uncertainties, mysteries, doubts, without any irritable reaching after fact and reason.” I know many doctors who have acquired such a capability through personal and professional experience, but feel slightly ashamed of it, as if they are committing a sin by suspending their belief in the received truths of their education. The next characteristic is one I would call ‘courteous curiosity.’ This is an ability to ask in detail about someone’s subjective experience and to try and understand it through the patient’s own words, without judging or categorising anything, or reframing it in a more official way,. The final characteristic is unrelenting positivity: holding on to belief that every narrative has its own momentum; if it is explored with respect and kindness, and allowed enough freedom, it will reveal a potential to surprise both doctor and patient alike. Taken together, these characteristics constitute a polite but creative way of distracting the patient from a repetitive lament, but without directly saying so or crassly putting them straight into the box labelled ‘psychosomatic’.

Validating people

I suspect that many clinicians will recognise the attitude I am talking about, but may never have seen it named, or read an account of it being applied. One of the best accounts I know has been offered by clinical psychologists Angela Griffin and Deborah Christie.2 It is based on their work on an in-patient ward with adolescents who have a range of severe and debilitating symptoms, all conventionally described as ‘medically unexplained’ or ‘psychosomatic.’ Their results are encouraging.

Griffin and Christie describe an essential element of their approach as ‘problem-free talk’: finding out about the person rather than the problem. Drawing on the work of the Australian therapist Michael White,3 they validate people by exploring life before the problem began, and helping them to recall moments since then, however short, when the problem was kept in its place. They use language that continually implies that the problem is external and negotiable, rather than something fixed that needs a professional to sort out. For example, they inquire how patients might visualise their problems, and get answers like ‘a small green imp’, ‘a hard red ball’ or ‘a big black cloud’. They tend not to dwell on negativity, but are strong on congratulating patients on any amelioration of their symptoms. They do not use the metaphor of weaving a tapestry, but their description of their approach fits with it nicely:

This is not ‘Pollyanna’ therapy. We know that people’s problems are real and must be taken seriously. We listen carefully to a problem if someone wants to tell us. However, our aim is to not give the problem too much oxygen. We will validate and acknowledge the difficulties, without actively probing and enquiring about them once they have been aired… Asking questions that invite young people to find their own solutions means that we don’t need to know any answers, we just need to ask questions.

Few clinicians will have the time and psychological skills that Griffin and Christie possess, but then few of us work in such challenging settings, and with so refractory a group of patients. The principles of what they do can be still applied, either as an adjunct to hole-digging, or as a more effective substitute for doing so. There are many situations in medicine where we go on digging simply because it is what we were trained to do, and always do. It is at times like these that we need to exercise negative capability, courteous curiosity, positivity, and creative distraction, and start to weave a tapestry instead.