| Beyond Empowerment: Revering the storyteller |
© Phil Barker and Poppy Buchanan-Barker 2003 The Evidence of Story-makingAlmost
seventy years ago, in an attempt to describe the complex phenomena of
psychosis, Harry Stack Sullivan coined the term ‘problems of living’
(Evans, 1996). Thomas Szasz (1961) later popularised the expression, by
describing how a wide range of people experienced great problems in living with others and (often) in living with themselves.
These facts of human living become obvious when we spend time with
people who are ‘mentally suffering’ (Lynch, 2001). The nature of the
distress associated with such suffering, and its effect on their
private and public life, is gradually revealed as we are granted
privileged access to their story. Indeed, aside from the often fanciful
interpretations and observations, which professionals make about people
in their care (Kirk and Kutchins,1997), all that we have to work with is
the story, which embraces everything of any significance for the
person. This is the heart of the person’s human experience and, as
such, should be the primary focus of any attempt to help the person.
Despite
the increasing emphasis on ‘evidence’ the inescapable fact of mental
health practice is that stories are the most valuable, yet neglected,
form of evidence. Practitioners – whether nurse, psychologist or
psychiatrist - only know that a person is making progress or
getting, when they shape their own story of what has been said, heard,
noticed or otherwise presented as ‘evidence’ to their professional
senses. Ironically, such everyday evidence is often discounted in
favour of counting, rating or framing diagnostic abstractions from the
person’s lived experience of problems of human living (Kirk and
Kutchins, 1997). Professionals
also have long been encouraged to think and write in the third person,
in an attempt to make their story appear more ‘objective’; as if they
were not an integral part of the story telling. History may well judge
this practice to be deluded in its self-deception. This mimicry of the
objectivity of the natural sciences ignores the critical facts of human
behaviour: that when one person encounters another, a singularly
unpredictable and creative exchange develops. Given that any story
requires both a teller and a listener, it follows that each will bring
different thoughts, feelings and other reactions to influence the story
content. As the story-teller engages with the story-hearer, a co-created story emerges; one which belongs to neither alone, but to both as a shared experience. Re-Authoring the StoryThese
reflections are critical for any understanding of the role of story in
mental health care. According to de Shazer’s own story of
psychotherapeutic change, all therapy “boils down to stories about the
telling of stories, the shaping and reshaping of stories so that
troubled people change their story” (de Shazer, 1994:p xvii). This
reflects as much the everyday practice of nursing, social work or
medical practice, as it does the more formal listening process of
psychotherapy. We have spent a combined 65 years listening to the
stories of people, variously described as physically, mentally,
emotionally or behaviourally, challenged, challenging, disturbed,
distressed, disordered and otherwise upset, ill or abnormal. We long
since came to the conclusion that the various labels, classifications,
categories and definitions, which professionals conjure with, obscure
rather than illuminate the person’s story. However, the diagnostic
story continues to hold its power in mental health practice, despite
the increasing realisation that this is just one way of condensing a person’s story of distress (Kirk and Kutchins, 1997; Parish, 2003). The
Finnish psychiatrist Yrjo Alanen and his colleagues developed a very
pragmatic approach to the story of schizophrenia, recognising that (and
their families) needed help to : “conceive
of the situation (e.g. admission) as a consequence of the difficulties
the patients and those close to them have encountered in their lives,
rather than as a mysterious illness the patient has developed as an
individual” (Alanen et al, 1991). This
attitude emphasised the centrality of the lived-experience of the
person at the centre of the maelstrom of mental illness, and of those
‘significant others’ who are often indirectly influenced by it.
Alanen’s work displays a great sensitivity to, and respect for, the
profound nature of the person’s story (Alanen, 1997). It also
recognised that the diagnostic story might erase completely the
original understanding of the problems of living, which prompted the
person or family to seek help in the first place. This does not mean
that professionals have to abandon their various theoretical or
professional perspectives entirely. However, Alanen’s approach
illustrated the virtue of respecting the critical starting point in the
re-authoring of the story of mental distress. We
have been involved with a wide range of psychological and
psychotherapeutic ‘models’ of human service (Barker, 1999). It is clear
to us now that the differing ‘schools’ of psychiatry, mental health,
recovery, psychotherapy and counselling, are all part of the “rival
storytelling industry,” which emerged from what de Shazer called
Freud’s “Viennese tales” (de Shazer, 1994: p xiv). The psychiatric
scientism, so popular today, has bred all manner of ‘explanations’ of
human distress - from the perceived influence of the gene pool
(Wildenauer et al, 1999) to the ‘rationalism’ of Rational Emotive
Therapy (Ellis, 1980) or Cognitive Behavioural Therapy (Beck, 1976).
Each represents versions of the detective story and involves digging
beneath the story’s surface to find some ‘objective truth’. Freud was a
great admirer of the Sherlock Holmes stories and his sleuthing style of
human inquiry remains popular. The facts of the matter may, however, be
simpler, yet paradoxically more complex, than Freud or any of his 21st century neuro-psychiatric-cognitive descendants envisaged. Talking the StoryAs
Hilda Peplau once observed, in conversation: “People make themselves up
as they talk” (Peplau, 1994). The stories, which people tell about
their lives, are part of a work in progress. However, their various
meanings, significant events, and associated emotional, behavioural and
situational ‘anchors’, are as much a function of who is listening
to the story, as who is telling it. The assumption that the stories of
our lives are based on facts that exist ‘out there’, in some objective
space, is naïve in the extreme. What we are willing to tell of the
story of our lives is always contextually bound (Mishler, 1979). Story
telling is a dynamic process. As professionals, our first important
contribution to this process should be to respect the awesome nature of
this story, and to revere the storyteller. The Power of the NarrativeThese assumptions underpin the narrative approach
to helping people with problems of human living (Brunner, 1990; Caee,
1998; Crossley, 2000; Sarbin, 1986). Forty years ago Berger and Luckman
(1963) argued that: “Identity
is formed by social processes (however) the identities produced by the
interplay of organism, individual consciousness and social structure
react upon the given social structure, maintaining it, modifying it, or
even reshaping it (p. 173)”. Despite
all our talk of individual responsibility and this is largely illusory.
The ‘individual’ does not stand alone, but rather is part of a
reflexive web of influence, within which meaning making flows back and
forth. In
the contemporary psychiatric/mental health field much emphasis is given
to the importance of ‘empowering’ people (Barker et al 2000. However,
Alanen showed that there was no need to ‘empower’ people: since they
already possessed their own power – which was framed in one sense by
their story of their problems of living. By offering (and especially by
imposing) diagnoses, which people have not asked for, we disempower
them by subjugating their original story, and invalidating all the
lived experiences associated with it. Many
psychiatric professionals display divided loyalties. On the one hand
they earnestly wish to respect the person who has become the patient,
but at the same time many try to view the person through the highly
distorting lens of professional ‘objectivity’ (Parish, 2003). For
generations, psychiatric medicine (and more recently psychology and
nursing) has tried to shape itself into a scientific discipline, which
might reveal fundamental, predictable, ‘truths’ about the human
conditions of ‘illness’ and ‘wellness’. The narrative approach challenges this scientific posturing, by suggesting that people write the
story of their lives, through the ‘lived experience’ (Weingarten,
1998). The human states that we label mental ‘illness’ or ‘health’ are co-created by the person, those around the person and other, immediate and historical aspects of the person’s ‘world of experience’. Learning from the PatientMental ‘illness’ does not happen to
people, in the way that they may be struck down by a passing virus, or
a passing car. Rather, people are involved in the construction of their
mental distress, which is not to say that they ‘make it up’, any more
than any of us could say that we ‘made up’ the story of our miserable
childhood. However, people are intimately involved in the construction
of their life stories. When we swim, we become at one with the
water. We influence the water, which envelops us, to move through it,
towards our destination. However, at no time are we in control of it;
and at no time does the water control us – unless we begin to drown. In
the same way, it could be said that, to some extent, we live our lives but our lives also live us. When
people tell us their stories they often tussle with this paradox, which
lies at the heart of our lived experience. That people try to make sense of what is happening to them, what it means to them, what part they may or may not have played in generating such experiences, illustrates why we should learn from them. The
person who has become the patient is the teacher and, if supported by
family or friends, represents a small ‘university’ for the
professional. Here, metaphorically, at the person’s feet, we can learn
what ‘needs to be done’ to help the person address, approach or
resolve, their problems of living. We can
also learn what part we, or others, might play in enacting the kind of
response to these problems of living that makes sense to the person.
Here, in this shared experience, begins the re-authoring of the story
of distress. The Primacy of the PersonBy
revering the storyteller we begin to appreciate the person’s hidden
depths, acknowledging that – given the vast ocean of the person’s
experience - we can only ever hope to know a tiny amount of who and what they are, as persons. Knowing patients is fairly easy, since we have a pre-formed template in our head, informed by diagnosis or theory. People are, metaphorically, a quite different kettle of fish. The Tidal Model
(Barker, 2002; Stevenson and Fletcher, 2002) holds that the narrative
is the metaphorical rudder for the practitioner. We seek an
understanding of how the person became emotionally, physically or spiritually 'shipwrecked', and
seek to identify what might help them repair the evident damage to
their life stories, so that they may begin again to chart the course of
their life journey. But first, professionals must dip their toes in the water to begin the engagement process. To do so we need to believe: that recovery is possible that change is inevitable - nothing lasts that ultimately, people know what is best for them that the person possess all the resources needed to begin the recovery journey that the person is the teacher and we, the helpers, are the pupils that we need to be creatively curious, to learn what needs to be done to help the person, now!
The
first step towards becoming an effective helper is to recognise that
our beliefs about the person, and the possibility of their recovery,
will make a crucial difference to our practice. The ‘self-fulfilling
prophecy’ is of critical importance to the therapeutic outlook (Merton,
1968). If we believe people can move forward, they probably will and if we believe that they can’t, they probably won’t. The
Tidal Model practitioner believes that change is ongoing - people are
constantly changing, albeit in subtle ways. Consequently, the
therapeutic attention is focused on helping the person develop her or
his awareness of what is happening in the 'me-now'. What does the person feel, or think, or believe is happening right now? How does the person explain or otherwise make sense of this ‘happening’? Finally, and most importantly, what does the person believe needs to happen next?
This
focus on the person's 'lived-experience' lies at the heart of the Tidal
Model and, critically, the person’s story is always framed in the first
person – whether in the various assessments or in the development of
the care plan (Barker, 2002). This acknowledges that, despite the
legislative and bureaucratic emphasis on medical and nursing records,
the story of the experience of distress and the story of the experience
of care and treatment, belong entirely to the person in care. Stories from Practice Sally
Clay’s experience of the mental health system began in the Bronx, New
York almost forty years ago, and she believes that she continues to
sail in and out of the many states of madness (Clay, 1999). However,
she also believes that: “…health,
or sanity, can be achieved even within an affliction or a disability
(but) it is important to expand our definition of sanity to include
clarity and compassion that can exist within so-called ‘symptoms’ ”
(Clay, 1999: p32). Such views led her to comment that: “The Tidal Modal
makes authentic communication and the telling of our stories the whole
focus of therapy. Thus the treatment of mental illness becomes a
personal and human endeavour, in contrast to the impersonality and
objectivity of treatment within the conventional mental health system.
One feels that one is working with friends and colleagues rather than
some kind of “higher-up” providers. One becomes connected with oneself
and others rather than isolated in a dysfunctional world of one’s
own”(Clay, 2003). On the other side of the world, Rangipapa is
a secure psychiatric facility for people with serious mental health
problems in North Island, New Zealand. Many of the residents originate
from the indigenous Maori or Pacific Island communities, which often
reject the Western ‘story’ of ‘mental illness’. Ngaire Cook’s (2002)
ongoing evaluation of the Tidal Model at Rangipapa illustrates
the residents’ positive view of the narrative focus, and also the
‘optimistic’ expectation that ‘change is a constant’. · “The Tidal Model requires the nurse to work in collaboration with the client”. The Journey towards Self-Healing Hubble and his colleagues (1999) showed that the actual methods or techniques of psychotherapy accounted for less than 15% of the change effect. Placebo effects, hope and expectancy of change, account for 15% of the change effect; the person’s relationship with the therapist accounted for 30% and more than 40% of the change effect depended on the clients themselves. This led them to describe this as the ‘engine’ that makes therapy work: “The
client’s own generative, self-healing capacities allow them to take
what therapies have to offer and use them to self-heal”(p 14). Therapists
of all kinds certainly set the stage and serve as assistants. “They do
not provide the magic, although they may provide the means for
mobilizing, challenging, and focusing clients’ magic” (Hubble et al,
1999: p 95). The
experience of distress and the experience of care and treatment
represent critical chapters in the autobiography of the person who
becomes the patient. The evaluative stories from the Tidal Model that
are emerging from the different parts of the world offer an everyday
confirmation of the power of the story-teller, alluded to by Hubble et
al. They also suggest how nurses can play a critical role in optimising
the power of the story, in the person’s journey towards self-healing.
Perhaps reverence for the story-teller is the oldest form of
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