Narrative means to normative ends: story-centred practice in statutory contexts, 2025, Foell & Launer (has mention of ME/CFS)

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The Lancet
PERSPECTIVES
The art of medicine
Volume 406, Issue 10508
P1080-1081September 13, 2025
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Narrative means to normative ends: story-centred practice in statutory contexts​

Jens Foell<a>a</a> jensfoell@nhs.net ∙ John Launer<a>b</a>
Affiliations & NotesArticle InfoLinked Articles (1)
aPlas Menai Health Centre, Llanfairfechan LL33 0PE, UK
bUniversity College London Medical School, London, UK

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Narrative medicine places the patient's story at the centre of health care. It assumes that, in almost every clinical encounter, patients need to tell their stories, feel that these have been heard attentively, and go away with new narratives that make sense to them. These may or may not include elements of explanation, advice, or treatment. However, if the development of their stories has not been effective, patients are unlikely to feel satisfied.

We are both teachers of narrative medicine. One of the commonest reservations we meet is that clinicians find a narrative approach helpful for consultations that invite a non-directive, exploratory approach—for example, in myalgic encephalomyelitis/chronic fatigue syndrome—but they usually cannot imagine using it in encounters where the doctor is obliged to give advice, make a strong recommendation, or even to act against the person's wishes. Typical cases cited in this context involve child safeguarding or assessments carried out under the Mental Health Act that may result in compulsory admission to a psychiatric unit. We disagree with this view. One advantage of a narrative approach is that it enables the doctor to act in a way that is curious and humane when a clinical assessment might otherwise be experienced as only judgemental and oppressive. This approach can potentially give patients an opportunity to find meaning and some sense of agency even when the outcome may not concur with their wishes.

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The second author, John Launer, was a close school and college friend of mine. He started off reading English but had many medical friends at university and switched to medicine.

The piece seems to be a defence of 'narrative medicine' which appears to be an attempt to generalise from psychodynamic therapy techniques to a general method for medical interviews. The first author seems to be using the piece to justify using the psychotherapy approach in the context of detaining people under the Mental Health Act.

The idea of 'exploring' people's 'stories', which I presume includes asking about past relationships and family and so on, is something that terrifies me, having seen how much harm it can do. In the absence of any valid evidence base for it being useful I don't think it should enter into any medical interview.

It is nice to see them get the name of ME/CFS right though, even if it is something that is best kept well away from 'narratives'.
 
If this gets accepted, the next logical step will be to start using psychologists as screeners for doctors. If the therapists’s divine insight doesn’t tell them that you’re just resistant to changing your behaviours and beliefs, you might be granted an audience with a medical doctor.

Maybe someone could develop an app with an AI chat bot so you can tell your story from the comfort of your own home.
 
I don't see how this has any applicability to ME/CFS. It seems mostly to be used as a tool to build fake rapport, which most people can tell anyway so the purpose is wrong, makes the clinician lose all credibility, with good reason, and sticking strictly to psychological issues. Which is what we've already had for decades, to widespread miserable failure.

I'm sorry but when I go see a physician, I'm not looking for a friend. No offence to them, I just don't care about them personally. They are professionals doing a job (at least that's the idea) and small talk and "rapport" matter about as much as with a plumber. Not that it's ideal, there is some value to it, but they just don't listen, and simply lack the tools and skills to do something meaningful with it.

It looks explicitly to be about behavioral disorders, and problematic behavior in general, so that makes the inclusion of ME/CFS not just wrong in itself, but it emphasizes how they can't even tell behavioral problems apart from the consequences of illness, making the whole thing not just useless, but harmful. To this ideology, feeling awful because of illness is an entirely independent psychological process from the illness itself, purely a reaction to it, not actually part of it.

When you look at the history of medicine, you find roughly three prongs: public health, biomedicine, and the rest. Public health is mostly a social, engineering and political issue, medicine is only one part of it, and it has been widely successful where it has been followed. Biomedicine is just as successful as public health measures, it has created enormous benefits, saved so many lives and improved even more. Together they add up to about 99% of the achievements of medicine, both in terms of quality and quantity.

And then there's the rest. Most of which is occupied by odd ideologies and myths, by psychosomatic ideology and its appalling biopsychosocial constructs. It has zero achievements. There isn't even a point summing them up, because it all adds up to negative numbers. This is the rest. It doesn't work, mostly because it's neither based on science, as biomedicine is, or engineering, as public health is. It has achieved nothing on its own, and likely never will. Nothing more than the overall impact of Aspirin anyway, an achievement that is frankly out of reach.

It's quite amazing how in all this so-called "patient-centred medicine", and here "narrative-centred", which has some implication that the narrative is ours, the patient is simply never part of the process. It's never our narratives or our experiences. Always theirs. They write down everything that "happened", after all. It can only be their perspective, needs and wants.

Let's do less of the things that work, and more of the things that do. This is what's expected of professionals, and it's how useful things happen.
 
Utsikt said:
If this gets accepted, the next logical step will be to start using psychologists as screeners for doctors. If the therapists’s divine insight doesn’t tell them that you’re just resistant to changing your behaviours and beliefs, you might be granted an audience with a medical doctor.

Maybe someone could develop an app with an AI chat bot so you can tell your story from the comfort of your own home.
Click to expand...
There's something dark and disturbing about recent reports of people suffering mental breakdowns, or even killing themselves, as a result of using LLMs as a therapist, which have made a lot of noise, including in terms of what is the legal responsibility of the companies, and yet it's even more supported, for a much longer time, that psychosomatic ideology and its massive failings is itself responsible for far more suffering, misery and early deaths, including by suicide, and it's not even a subject of interest. The gaslighting and negligence leading to ostracization are almost always the biggest factor of misery for us, it just piles on misery on top of too much suffering.

Instead we are blamed, our suffering is used to justify the false belief that we are doing it to ourselves, that they're just trying to help, which is false. Somehow most people find it easier to blame computer programs than human beings with agency, who have more than enough awareness of the harm they cause. It's hard to make sense of this. I guess something to do with the idea that those people who fell victims to chatbots didn't deserve it, still had some (economic/labor) value in them. Unlike us, where none of this matters, it's never anyone's fault and it all gets covered up.
 
rvallee said:
I guess something to do with the idea that those people who fell victims to chatbots didn't deserve it, still had some (economic/labor) value in them. Unlike us, where none of this matters, it's never anyone's fault and it all gets covered up.
Click to expand...
The ceiling effect on my questionnaire tells me you can’t get sicker than you already are so why are you complaining? /s
 
I've only read the abstract. If 'story' means taking a clear case history including the course of the illness and its impact on my life, that would be fine. If it means digging into my past or encouraging me to speculate on what I'm doing wrong that's keeping me sick, no thank you.
 
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