Here’s Narrative Therapy at India, introducing the interview series, as a way to bear witness to and archive the unfolding of Narrative Ideas and Practices in an individual’s journey. Freedman and Combs once said, “Speaking isn’t neutral or passive. Every time we speak, we bring forth a reality. Each time we share words, we give legitimacy to the distinctions that those words bring forth.” With the series, we hope that sharing these influential stories will make possible to add richness to these distinctions, and pave way to alternatives and diverse ways of honouring and being.
Our first guest to the series is Dr. Vibha Krishnamurthy, a Developmental Paediatrician and Founder & Medical Director of Ummeed Child Development Center. She is also a great proponent of Family Centered Care, a philosophy which runs through all of Ummeed’s work, which has helped in building an ecosystem for the development of children with disabilities.
Her expertise in the field of developmental disabilities has seen her as an influencer and contributor in multiple forums, examples being, (i) Committee Member of the Disability Chapter of the World Health Organization, (ii) Member of the Task Force Constituted by Ministry of Human Resource & Development and (iii) Core Member/ Independent Expert on the Technical Resource Group, of The Rashtriya Bal Swasthya Karyakram (translated as the National Child Health Program) constituted by the Ministry of Health & Family Welfare Government of India.
Vibha completed the Mental Health Training Program in Narrative ideas and practices in 2015 and uses Narrative ideas in her practice as a developmental paediatrician. She is an avid reader, walker, Yoga enthusiast and a traveller!
Yashna: If you could start by sharing what drew you to narrative ideas? How did it all start?
Vibha: My training had me believe and value mental health of the families as a very important part of caring for a child with developmental needs. And it was very clear to me right from the beginning that there needs to be a Mental Health Team. But along the way, there were also ideas around care being family centered.
I don’t think I was ever comfortable with the “physician as experts” stance. It never sat well with me. I could see some of the practitioners, when I was doing my fellowship in the US, having a different approach to it. There were all these scattered ideas in my head. And then, I used to see what Shamin and Jeh could do with the families that we were working with, the first few people I worked with. And I could see what became possible for those families because of working with them. And they would…the very fact that they would keep coming back and they would see a difference. At the same time, I was also struggling to articulate for us what our philosophy is. How do we get people to understand what Family Centered Care means?
Very often, for example, I would observe somebody within the organization and find very well-meaning people who tried to tell parents that they need to be the therapists for their child. And you need to work with the child. “You need to work with the child like this, you need to do this”, and teaching the family. And getting frustrated when there were barriers like, there are financial issues or say there was maternal depression.
So, there was this also but the key reason I ended up doing MHTP, one of the reasons: the previous block, Peggy came and she did Outsider Witness practice and interviewed me. And (chuckles) the entire MH Team was observing. And I just went, sailed into it not knowing what to expect! And at the end of the hour, of course, Jeh cried (laughs). And I was completely freaked out because I had no idea why she was crying. But in the process, I realized what Peggy had done in that 45 minutes or an hour, was that she had elicited from me, things that I believed in or I valued. Even now, when I go back and read the transcript of that conversation, I am blown away about the things that I told her about myself. And I didn’t even realize that that had happened. I said, “Wow this is really big!” (laughs). And then when I did the MHTP, that was a different story because that opened a completely new dimension for me. That’s the story about how I learnt about narrative therapy.
Pravin: And what has been some of the key ideas in narrative that have particularly struck you and guided you in your work with children and families today?
Vibha: When I first joined the Mental Health Training Program, after the first block, I was really upset with the Mental Health Team and I said, “If you guys knew all this, why didn’t you tell us before?” (laughs). I felt, here’s a way of articulating what I was struggling to articulate. So when SuEllen Hamkins had come here, it really resonated with me, what she was saying. The kind of clinician that I wanted to be, the Narrative course really helped me articulate that. It gave words to what I wanted to be. And that was the most important thing that I took away from the entire training.
What are some of the key ideas…um many things right? Beginning with double listening, going on to… what really drew me to it was the whole ‘decentered but influential’ position. There are many other things that excited me that I use even in day-to-day practice. So initially, I would say that it was hard. Because I come from a branch of practice which requires quite often for you to be giving information. It is the expectation of you as an expert. At times, you have to be directive also. But, to marry that with the limited amount of time that I have and to use an approach that is still respectful of families, engages them in decision-making and (you know they wait a long time to come see me). I want that experience to be an uplifting one. To leave the room with hope. And leave the room feeling like “I have a sense of control over this”, is really what one is hoping to do as a clinician.
And it’s been a struggle for me. Because initially when I did the course, I used to get frustrated by the fact that I see my patients so infrequently and I have these conversations, once in three months, once in six months. Sometimes, once in a year. And I used to feel, “What can I possibly do in that one hour or one-and-a-half hours, that I have infrequently?” But over time, I think I’ve learnt to pick some things that I can take with me to the clinical setting.
Pravin: You talked about marrying the approach and paediatrics in your sessions. Could you elaborate, if possible, how do you manage to do that?
Vibha: Firstly, the little things have been very helpful. Changing how I speak to the family about… “Tell me your concerns” is how a physician begins. “Tell me your problem” “What’s the problem?” “What are your concerns?”
And to begin instead by saying, “What are your hopes for today’s visit?” has been itself a game-changer, in terms of how I talk to them. Another example is, when I am asking questions… I’ve always believed in a strengths-based approach. There is a column in the paediatric intake which says ‘child’s strengths/family’s strengths’. So when I would try to elicit strengths, I was often greeted with silence. And then there was…it was really hard because…not because the family doesn’t know of the child’s strengths, I think it’s more because they hadn’t come prepared with thinking about answering the paediatrician with answering that question.
The Wonderfulness Conversation has really helped in that. “I get to know Rahul only through these sessions and if we could spend 20 minutes of you telling me about wonderfulness of Rahul, what would you say to me?” And families become very animated and excited and are able to talk about it. And give examples and that I find very useful.
I’ve used externalizing a lot and in fact, that’s what I begin with. Because families are most comfortable honestly beginning with their concerns say, “I’m worried about his attention” and “I am worried that he’s really an anxious child” or “I am worried that he’s a slow child”. And then when we explore, “What does this slowness look like right? And when are the times you don’t see the slowness?” It really leads to different things altogether.
Then she gave lots of examples from his day-to-day life. His social, his empathy, times when he had what you called “common sense”, which is not so common. He’s very pragmatic and practical, responding to something. It also emerged that he was visually way better at problem-solving than he was verbally.
And none of it was incorrect! She painted a very realistic picture of what her child was able to do and all which she saw was “hoshiyaari” (smartness) was indeed his hoshiyaari (smartness). Then they were able to talk about when do you not see it, and she said, “I don’t see that expressing itself in academic performance”, she herself spoke about limitations because academic achievement and what she could do, which would leverage his hoshiyaari in that space.
So I think it’s helped me to have very difficult conversations with people, where I could take them to places, I would’ve struggled with, seriously. In other words, initially, I tried to fit my practice into narrative therapy, which was frustrating. But when I tried to fix narrative therapy ideas and practices into my practice, that was helpful. So I said okay, this is it! I have to do all these things. I have to find out what the issue is. I have to find out, you know, what the school is saying, family is saying and so forth I have to make a diagnosis. I have to tell them the diagnosis, I have to do all that in the context of being family centered, strengths-based, and you know, all of those things. Then I was able to use the narrative ideas to inform that.
Yashna: And are there times when you hold on to some of the ideas, or some of the little things when the struggle seems to take over? Since you spoke about the time limitations, you spoke about how you need to bring in other conversations, what do you then hold on to, to keep it going in the way you would want it to look like?
Vibha: You know, I’ll give you an example. This Tuesday, a colleague was observing my session. She was observing me, while I was seeing a patient of mine who’s 18, who’s now become 18 and I’ve known her since she was little. She’s a girl with borderline intelligence and now she has obsessive-compulsive symptoms. I realised that I probably confused the heck out of my colleague (laughs), because I was switching between various maps.
And we started out with the mother, and then she spoke about the child’s sensitivity being the reason why they had come. We talked about the sensitivity, and you know, we talked about what she was calling the sensitivity, where they see it, we got into the history. We began with the externalizing map (chuckles) and then we started speaking about the times when the sensitivity was not there. So the sensitivity, what they were calling it, they managed to then convert it into “sensitive thoughts”. Because what they were, were actually obsessive thoughts, which they were calling sensitivity.
Then we spoke about the times when it was not there. Then they started getting into, you know, the unique outcomes. In between that, we spoke about some of the things the mother had done to help her and we spoke about some of that and she said…you know they were a middle income family um… suddenly she said something about getting her to cook and how she is able to make Maggi noodles by herself. Then I asked her about, you know, how did she learn that? How did she learn to make a meal? And she said, “No you know, she’s really good at that”. No, but how did you manage to get her to learn? She said, “So I would allow her to be in the kitchen and then she would watch and she would ask and I would give her an opportunity. If it spilled, I would say that’s fine”. And I said, “Oh it’s important to you to say that it’s okay, it’s fine that she makes mistakes?” She said “Ya, everybody makes mistakes and it’s important that they learn that it’s okay to make mistakes”. And she said something really nice about, “In life you should experience every colour that there is.” And she said it in Hindi but I was very intrigued by that sentence, so we picked that up and I asked her as to why that was important to her in her life.
And then we spoke about the medication. We had a whole conversation around medication and her fears about the medication, hopes from the medication, what she hopes that it would make possible for the daughter. And uh I did everything I wanted to do (laughs). I found what their hopes were for their daughter, what she had been doing so far, what she thought of medications and by the end of it, they were comfortable to give the medication an another try. Um and I spoke to the girl also and all this happened in the span of an hour where I did I wanted to do. So my colleague was probably wondering what is going on (laughs). For me, not able to follow them through to the end but I think I am able to use elements of it which serve my purpose. Quite often.
Pravin: And what has become visible ever since you’ve been using narrative ideas with families? Or what are some of the things that are different in your work with them?
Vibha: So I see very few patients now unfortunately, I see only about 4 or 5, a week. And it’s been a loss for me not to see more patients. And to have to deny that. And there was a time when I struggled so much that it was, I would actually have to say, “Oh god I have to see a client!” you know, because there was so much more to do. But now I am not feeling that so much, thanks to the training. That’s part of the reason it’s eased a little bit of the burden for me, doesn’t feel like a burden.
But one thing I can say is that it has increased my enjoyment of the sessions. It’s allowed me to be curious about people. About really finding out why they are the way they are. What makes them do the things they do. I mean, I’m just amazed by the families we see. Every story is just worth writing a book about!
There was a book I read by one of my favourite authors, Atul Gavande. And he makes a recommendation in the end to physicians, which says, “Ask at least one unscripted question every time.” And it’s allowed me to do that. So it gives me that liberty to be that way. And I think it’s allowed me to bring myself as a person into the session, other than as a physician. The thing that America Bracho went on about that you can’t leave yourself outside the door, you bring yourself in, when you go into a clinical session. And it allows me to do that and use some of these practices.
Yashna: What difference it might have made to the people you consult with, having these ideas to guide you?
Vibha: I really don’t know (laughs). I don’t know if they…I don’t know if the families feel differently. I think I know that I connect with kids and having the conversations with children… I, at least, enjoy it. Since they want to come back. I am assuming that it doesn’t seem burdensome to them either. I know that it’s some of the things that I have used that had made it possible for them to talk about things that they would otherwise have found difficult.
For example, talking about ‘strengths’ is easy for a certain kind of child, a lot of the kids that I see have not had the conversation with anyone at all. I can give you an example of a 16-year-old girl I saw with Cerebral Palsy and she spoke about her sister very warmly and said “She’s my best friend and I tell her everything and she encourages me in my art. I am so glad she’s there”. So we actually did a re-membering conversation about her sister and when we got to the point when we spoke about, “You know, well, if your sister was sitting here, what would she tell me about why she enjoys being with you? What are some of the things about you that she enjoys?” Then she was able to tell me some of the things about herself, about how she is loyal, about how she can keep secrets, so you know, it was really interesting. It made possible for conversation in a way that it would not have been possible. And umm… I’m taking a guess at what it makes possible (laughs).
Yashna: So I know you spoke about this, the position of de-centred yet influential and what are your thoughts if you could say more about why that has particularly struck you and how is it like to navigate through other positions when you may be required to do so?
Vibha: Hmm. It’s always a struggle. I think acknowledging the struggle is important. Making judgements about when you need to be which, is also important. If a family is asking you, “I feel I don’t know what to do in this situation, you need to help me make this decision”. It’s not uncommon for me to hear a family say – “Will do whatever you say doc”.
Umm…so how to frame that conversation in a way…I am influential and I do have thoughts about what might be the best at that point of time. To help the family participate in that, to participate in the decision that feels comfortable. If I feel, for example, when we’ve reached a point when it’s really important that the child has medications, then I might talk about, “What would we need to do more for them, more strongly?” About having to use medications…so if I can buy them two weeks, that’s fine. “Would it help to talk to other families? Can we do more reading about it? Can we discuss it again after you’ve spoken to your mother-in-law?” So you know, we have some of those conversations.
All it does is takes more time. May be takes another visit, but this is my personal opinion that at Ummeed we’ve probably a better compliance rate for medications. I think. Because we have some of these conversations around medications [of course, it is entirely possible that that ones who decided not to take did not come back. Have to go around looking for that data (laughs)]
To balance that is always a struggle but I like to acknowledge that struggle for myself and say, “Yes, it’s a struggle but you’ve got to do it”. But you’ve got to keep trying. So I keep trying! That’s pretty much how it is…I think, the word ‘influential’ is not in doubt and we have to accept that and yes, that’s why the family’s here. Because they value your knowledge and expertise. How to use that influence in a way that still allows the family to be in centre stage is always a struggle.
Pravin: You mentioned about ‘marrying the idea and the field’ and you also mentioned about ‘to keep on trying’, what are the things that will become possible if you continue on this journey?
Vibha: I think, that working with families in this way makes it possible for those of us at Ummeed, to make this the norm. Make it a movement. That, it is possible to be influential and yet have families make decision for themselves, made to advocate for themselves, have a sense of agency. What I hope the future will be is that this movement has a robust and is of that size that it no longer is an exception.
When I first came to this city (it was almost 20 years ago), it was a norm to have the family stay outside and the kid used to be in the room with the therapist. It was a norm for therapists never to have had that conversation with the physician. The first time I called up the speech therapist, she was quiet for a minute and then she said, “This is the first time a physician has called me up.” So those things were unusual.
Perhaps, it’s very much still the minority but it’s still becoming more common. It is an expectation now that physicians will communicate and therapists will have families participate in care. Some of those things are becoming a norm. So I hope what will become possible is that we can influence more and more people to be the same way. To engage and have people we are working with as and professionals be part of a team.
Yashna: So Vibha, do you have any know-hows or messages for fellow practitioners who hope to use narrative in their work?
Vibha: Actually, I do (laughs)! I think, the biggest thing I have to say to people like me, who end up learning about narrative therapy, is not to despair that it will not be relevant to people. Because it’s…it’s a way of thinking! If you chose to do this or train in this, you already were thinking that way. This will help you articulate in what you are already thinking. And also, it will give you tools that you can use in what you were already doing. You were already using some and it will give you more tools. And you will keep adding to this.
And the value of the community! You get a community of people who think like you. And who you will learn from, who’ll teach you more and who you’ll have something to give back to. So I would say that the message really for paediatricians, psychiatrists, physicians, particularly, who practice like I do, is that it is relevant for you. Relevant and important for you to think about.
Pravin: How has it been for you to talk and reflect on your journey with narrative ideas?
Vibha: A very special thing about being asked narrative questions is that it bears witness to something that you’ve been experiencing and haven’t talked about, right? It’s fascinating to watch MHTP (laughs) because everybody is soaking it up, they don’t want to stop those conversations. You’re hearing and knowing way more that you ever have. In that way, of course it’s lovely to share with someone some of reflections and what I think it’s been relevant in my practice. So both those things have been lovely talking to you guys about and to share some of my experiences. Thank you.
Yashna & Pravin: Thank you, Vibha.
Yashna & Pravin are Mental Health Workers at Ummeed Child Development Center, working with children and families who experience disabilities.
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