I would like to address some of the points raised by Professor Jeremy Holmes in his letter.

He asks whether my omission of the psychodynamic approach was ‘tactical’ or ‘technical’. It is the case that psychodynamic psychotherapy has been unable to demonstrate any convincing evidence supporting the explanatory basis of the psychodynamic approach. This does not necessarily mean that evidence cannot be found. It is a problem experienced in all science to differing degrees, ^{Reference Ladyman1} the question being: how do we derive scientific knowledge, how do we know that what we know is right?

These evidential problems are bound up with another question raised by Professor Holmes, namely the general validity of all ‘meaning’ statements. The history of psychiatry reveals the evolution of the meaning-centred approach. Porter & Berrios ^{Reference Porter and Berrios2} detail its development: the confinement of reason during the Enlightenment, through the liberation of the ‘hysterical’ patient with Freud as ‘interpreter’. An extrapolation of these developments ultimately presages the next phase of evolution: a reappraisal of what an acceptable interpretation of the ‘patient voice’ should be. Inevitably, there will always be a degree of interpretation; the question is how much interpretation is plausible without supporting evidence? The narrative method adopts a stance which attempts to liberate the patient perspective by laying down the fetters of possibly invalid interpretations which up until now have been lacking in evidence and may ultimately remain so unless we can design a process which demonstrates their validity as explanatory statements. Ultimately, the level of evidence demanded is dictated by the claims of a theory. The narrative approach is an adjunct to facilitate communication; it makes no claims to diagnostic or explanatory validity, unlike psychoanalysis or psychodynamics. The explanatory statements within psychodynamics are often stretched beyond the limits of plausibility in a search for meaning without any adequate supporting evidence. Narrative aims to liberate the patient's own voice from overly speculative interpretations, it promotes patient equality and transparency, valuing what helps the patient in their suffering.

My argument was not to be divisive or champion the pre-eminence of any one modality over another, be that biological, social or psychological. The jostling for authority between these camps is well known and in my opinion fruitless. My main aim in writing the article was to highlight the current dilemma we face as clinicians in trying to understand patient meaning, and argue (I hope) for a discussion about the integration of all strands of current learning leading to a comprehensive, multidimensional, meaning-centred approach. This would better reflect the complex aetiology of mental illness and surely help to create a humane working method which would promote a deeper understanding of our patients. It would also lead to the realisation that our patients are equal participants and allow us to move into the next phase of psychiatry, the overdue liberation of the patient's own voice, freeing them from any single interpretive or explanatory authority and allowing further recognition and hopefully alleviation of their suffering. The narrative approach is well equipped to facilitate this transition.