Couch is a series about psychotherapy.
A FEW weeks ago, I received an email from the Danish psychiatrist Per Bech that had an unexpected attachment: a story about a patient. I have been writing a book about antidepressants — how well they work and how we know. Dr. Bech is an innovator in clinical psychometrics, the science of measuring change in conditions like depression. Generally, he forwards material about statistics.
Now he had shared a recently published case vignette. It concerned a man hospitalized at age 30 in 1954 for what today we call severe panic attacks. The treatment, which included "narcoanalysis" (interviewing aided by a "truth serum"), afforded no relief. On discharge, the man turned to alcohol. Later, when sober again, he endured increasing phobias, depression and social isolation.
Four decades later, in 1995, suicidal thoughts brought this anxious man back into the psychiatric system, at age 70. For the first time, he was put on an antidepressant, Zoloft. Six weeks out, both the panic attacks and the depression were gone. He resumed work, entered into a social life and remained well for the next 19 years — until his death.
If the narrative was striking, so was its inclusion in a medical journal. In the past 20 years, clinical vignettes have lost their standing. For a variety of reasons, including a heightened awareness of medical error and a focus on cost cutting, we have entered an era in which a narrow, demanding version of evidence-based medicine prevails. As a writer who likes to tell stories, I've been made painfully aware of the shift. The inclusion of a single anecdote in a research overview can lead to a reprimand, for reliance on storytelling.
My own view is that we need storytelling in medicine, need it for any number of reasons.
Repeatedly, I have been surprised by the impact that even lightly sketched case histories can have on readers. In my book "Listening to Prozac," I wrote about personality and how it might change on medication. "Should You Leave?" concerned theories of intimacy. Readers, however, often used the books for a different purpose: identifying depression. Regularly, I received — and still receive — phone calls: "My husband is just like — " one or another figure from a clinical example. For a decade and more, public health campaigns had circulated symptom lists meant to get people to recognize mood disorders, and still there remained a role for narrative to complete the job.
Other readers wrote to say that they'd recognized themselves. Seeing that they were not alone gave them hope. Encouragement is another benefit of case description, familiar to us in this age of memoir.
But vignettes can do more than illustrate and reassure. They convey what doctors see and hear, and those reports can set a research agenda.
Consider my experience prescribing Prozac. When it was introduced, certain of my patients, as they recovered from their depression or obsessionality, made note of personality effects. These patients said that, in responding to treatment, they had become "myself at last" or "better than baseline" — often, less socially withdrawn. I presented these examples first in essays for psychiatrists and then in my book, where I surrounded the narrative material with accounts of research. (Findings in cell biology, animal ethology and personality theory suggested that such antidepressants, which altered the way the brain handled serotonin, might increase assertiveness.)
My loosely buttressed descriptions — and colleagues' similar observations — led in time to controlled trials that confirmed the "better than well" phenomenon. (One study of depressed patients found that Paxil drastically decreased their "neuroticism," or emotional instability. Patients who became "better than well" appeared to gain extra protection from further bouts of mood disorder.) But doctors had not waited for controlled trials. In advance, the better-than-well hypothesis had served as a tentative fact. Treating depression, colleagues looked out for personality change, even aimed for it. Because clinical observations often do pan out, they serve as low-level evidence — especially if they jibe with what basic science suggests is likely.
To be sure, this approach, giving weight to the combination of doctors' experience and biological plausibility, stands somewhat in conflict with the principles of evidence-based medicine. The movement's manifesto, published in the Journal of the American Medical Association in 1992, proclaimed a new era that would see near-exclusive reliance on systematic clinical research — the direct assessment of treatments in patients. But even the manifesto conceded that less formal expertise would remain important in areas of practice that had not been subject to high-level testing.
THAT concession covers much of the territory. Making decisions about prescribing, often I exhaust the guidance that trials can give — and then I consult experts who tell me about this case and that outcome. Practicing psychotherapy, I employ methods that will never be subject to formal assessment. Among my teachers I number colleagues I know only through their descriptions of patient encounters. One psychoanalyst, Hellmuth Kaiser, imparted his wisdom through a fictional case portrayed in a stage play. I follow his precepts daily, hourly.
I have long felt isolated in this position, embracing stories, which is why I warm to the possibility that the vignette is making a comeback. This summer, Oxford University Press began publishing a journal devoted to case reports. And this month, in an unusual move, the New England Journal of Medicine, the field's bellwether, opened an issue with a case history involving a troubled mother, daughter and grandson. The contributors write: "Data are important, of course, but numbers sometimes imply an order to what is happening that can be misleading. Stories are better at capturing a different type of 'big picture.' "
Stories capture small pictures, too. I'm thinking of the anxious older man given Zoloft. That narrative has power. As Dr. Bech and his co-author, Lone Lindberg, point out, spontaneous recovery from panic and depression late in life is rare. (Even those who put great stock in placebo pills don't imagine that they do much for conditions that are severe and chronic.) The degree of transformation in the Danish patient is impressive. So is the length of observation. No formal research can offer a 40-year lead-in or a 19-year follow-up. Few studies report on both symptoms and social progress. Research reduces information about many people; vignette retains the texture of life in one of its forms.
How far should stories inform practice? Faced with an elderly patient who was anxious, withdrawn and never medicated, a well-read doctor might weigh many potential sources of guidance, this vignette among them. Often the knowledge that informs clinical decisions emerges, like a pointillist image, from the coalescence of scattered information.
HERE is where I want to venture a radical statement about the worth of anecdote. Beyond its roles as illustration, affirmation, hypothesis-builder and low-level guidance for practice, storytelling can act as a modest counterbalance to a straitened understanding of evidence.
Take psychotherapy. Most of the research into its efficacy concerns cognitive behavioral therapy, or C.B.T., the treatment that teaches patients to moderate their habitual maladaptive thoughts. The reasons for this concentration are historical and temperamental. C.B.T. is rooted in a branch of psychology devoted to research, and the school of therapy attracts students who favor the practical and systematic over the spontaneous and poetic. There are no trials of existential psychotherapy.
But where the comparison has been made — primarily in the treatment of depression — C.B.T. does not outperform alternative approaches. (The alternatives tested are mostly distant derivatives of psychoanalysis.) And detailed research suggests that where C.B.T. works, specific techniques are not the reason. Studies of the components of therapy find that it is factors common to all schools, like the practitioner's commitment and the alliance with the patient, that do the job.
If we weigh "evidence" by the pound or the page, we risk moving toward a monoculture of C.B.T., a result I would consider unfortunate, since there are many ways to influence people for the better. Here's where case description shines. We hear the existential psychoanalyst Leston Havens describe his use of imitative statements, exclamations by the therapist that seem to come from within the patient: "What is one supposed to do?" For me, Dr. Havens's approach — sitting beside the patient metaphorically and looking outward, hand-crafting interventions on the spot — carries what I call psychological plausibility. The vignette corresponds to a convincing account of how people change.
It has been my hope that, while we wait for conclusive science, stories will preserve diversity in our theories of mind. For 17 years, starting in the 1980s, I ran a psychotherapy seminar for psychiatry residents. As readings, I assigned only case vignettes, trusting that one or another would speak to each trainee.
My recent reading of outcome trials of antidepressants has strengthened my suspicion that the line between research and storytelling can be fuzzy. In psychiatry — and the same is true throughout medicine — randomized trials are rarely large enough to provide guidance on their own. Statisticians amalgamate many studies through a technique called meta-analysis. The first step of the process, deciding which data to include, colors the findings. On occasion, the design of a meta-analysis stacks the deck for or against a treatment. The resulting charts are polemical. Effectively, the numbers are narrative.
Because so little evidence stands on its own, incorporating research results into clinical practice requires discernment. Thoughtful doctors consider data, accompanying narrative, plausibility and, yes, clinical anecdote in their decision making. To put the same matter differently, evidence-based medicine, properly enacted, is judgment-based medicine in which randomized trials, carefully assessed, are given their due.
I don't think that psychiatry — or, again, medicine in general — need be apologetic about this state of affairs. Our substantial formal findings require integration. The danger is in pretending otherwise. It would be unfortunate if psychiatry moved fully — prematurely — to squeeze the art out of its science. And it would be unfortunate if we marginalized the case vignette. We need storytelling, to set us in the clinical moment, remind us of the variety of human experience and enrich our judgment.
Peter D. Kramer, a clinical professor of psychiatry at Brown University, is the author of several books, including "Against Depression" and "Listening to Prozac."
