Shirah Vollmer MD

The Musings of Dr. Vollmer

The Open Narrative

Posted by Dr. Vollmer on April 3, 2016


The open narrative, free association, is a window into the psychological functioning of the patient. This is one of the basic tenets of deep psychotherapy, or psychoanalytic work. By observing the order, the style, and the content of the narrative, the listener can begin to develop hypotheses which lead to the guiding principles of the patient’s internal world. Frank, fifty-one, is a good example. Upon the first meeting he quickly tells me that his brother, when Frank was four, and his brother was six, passed away from congenital heart disease. Right away I am clued into this tragic death of his brother as an organizing principle in Frank’s life. Despite the fact that I later learn that Frank has been divorced twice and has three children, his primary attachment appears to be the psychological loss of his parents after his brother died. “They were never the same,” Frank tells me, despite the fact that I did not ask about them. Frank returns to the story of his brother on multiple occasions. He attributes this loss to his chronic anxiety and poor work performance. He says he could never feel confident because he could never make his parents forget about his brother. He reports that he tried to make his parents happy but he always felt that he could not. Life had dealt his family such a horrible blow, he would tell me, that the dark cloud could never recede. If I structured my interview, I would never know the centrality of this experience for Frank. The loss of his brother would be a check mark on a set of routine questions. It is only by allowing him the space to make his narrative do I learn how he has constructed his interior life. Listening to narratives is a difficult skill; one that requires intense attention and thought. It is my fear that this skill will die in my field,  as newly trained psychiatrists do not have the time with patients to hone this skill. As I continue to write this blog, this is less of a fear and more of a harsh reality. The deep listeners of the future, with few exceptions, will not be psychiatrists. The tides have changed.

2 Responses to “The Open Narrative”

  1. Shelly said

    I can see how the 15-minute medication appointments or even the physician-structured first appointments could hamper your understanding your patients. Just by the way your patient frames his narrative is key to understanding his story and by going over a structured list of questions, you would definitely miss something truly important to him. But it does sound like you are fighting a losing battle because one psychiatrist’s battle against big insurance companies can’t overhaul the system–you either live with it or learn to adapt. So have can you work with them to meet the common ground, for the good of your patients?

    • Yes, I have accepted I have lost the battle, on a large scale, but I am also heartened that on a small scale, there are still boutique practices, such as my own, where deep analytic listening is still the beginning of a treatment. There are a few of us, and that makes me sad, but in this small minority of psychiatrists/psychotherapists, there is a community.

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