Storytelling in Medicine
Our lives are composed of stories. From the timeline of when we are born to when we age, we tell stories of our childhood traumas, our failed relationships, our struggles at work. As human beings, we are "built to absorb, interpret, and respond to stories."[1] Storytelling is thus an intrinsically human capacity, and its conscious integration into mental healthcare is imperative in developing humanistic relationships with patients.
Narrative medicine, a perspective on medicine that has gained increasing traction in the twenty-first century, focuses on this power of narrative in humanistic care. Founder of narrative medicine, Dr. Rita Charon (2001), discusses narrative as inherent in the patient-physician relationship; during a visit, the patient tells a "story of illness" in "words, gestures, physical findings, and silences," while their patient history comprises a more longitudinal form of story that gives meaningfulness and context to life and illness.[2,3] Like in the narratives we read, understanding a patient happens through not only objective observation and information but also through the fears, hopes, and implications of their life story.[4] Using words and storyline to encompass a patient's worries gives shape and control to the "chaos of illness," helping patients to judge the narrative of their condition in light of its narrative situation.[5] By doing so, storytelling in medicine reinforces autonomy and dignity: "Once the patient's biography becomes part of the care, the possibility that therapy will dehumanize the patient, stripping him of what is unique to his illness experience, becomes much less likely."[6]
The rise of narrative medicine represents a movement to supplement objective evidence-based psychiatry with a more humanistic and holistic approach. Despite the past century's gradual phase-out of psychoanalysis and anecdotal (story-based) evidence, with father of psychoanalysis Sigmund Freud noting a concern that case histories lacked "the serious stamp of science," Roberts (2000) finds several shortcomings with a solely evidence-based model of psychiatry. Evidence-based medicine prefers the general over the specific, the objective over the subjective, and the quantitative over the qualitative, lacking a metric for existential qualities like inner hurt, despair, hope, grief, and moral pain which "frequently accompany and often constitute" illness.[7] Without narrative, medicine can overlook the patient's humanity and experience of illness. Narrative medicine, on the other hand, adds individuality, distinctiveness, and context to the solid foundation offered by quantitative methods, rounding out evidence-based medicine to give a fuller picture of a patient.[8]
In this way, narrative medicine can "bridge the divides that separate physicians from patients, themselves, colleagues, and society."[9] Embracing the biopsychosocial model and patient-centered medicine, narrative medicine provides a framework to view clinical work with consequences and meanings, understanding how a situation unfolds over time.[10] As Roberts (2000) discusses, Charon (2001) also writes that scientific competence alone is not enough for a patient to grapple with loss of health or find meaning in suffering; in addition to their more objective training, physicians sometimes "lack the capacities to extend empathy toward those who suffer, and to join honestly and courageously with patients in their illnesses." If we do not emphasize narrative in relationships with patients, patients may not tell their whole story, ask the most frightening questions, or feel heard.[11] Their diagnostic might be unfocused, lacking, more expensive, shallow, or ineffective. As narrative medicine gains traction, patients have begun endorsing the benefits they reap from its practice: "more and more patients have insisted on achieving a narrative mastery over the events of illness, not only to unburden themselves of painful thoughts and feelings but, more fundamentally, to claim such events as parts, however unwelcome, of their lives."[12]
Theories of Narrative Therapy
The advent of narrative medicine provides a backdrop to the establishment of narrative therapy by White and Epston (1990), a form of therapy based on the theory that people live according to multiple stories and that identity is text which can be understood in innumerable ways.[13,14] Narrative therapy helps patients to create meaning in their own lives: its premise lies in the belief that the stories patients tell of their lives reflect how they internalize and perceive their past and present. Thus, social workers and therapists can help them to understand their reality in different, more empowering, ways.[15,16] Tadros et al. (2022) concurs, describing narrative therapy's goals as bolstering resilience and empowerment through deconstructing and reauthoring personal stories as well as giving voice to unheard individuals. Narrative therapy accordingly lends meaning, autonomy, and control to an individual's understanding of their own life story.
Narrative therapy can be further understood in the context of a few key theories and movements. Roberts (2000) discusses the idea of individual constructivism, where an individual gives meaning to events and creates a story to contain and explain their personal experiences. Tadros et al. (2022) expand this to include social constructionism, in which a group or culture socially constructs perspectives through its interactions and negotiates meaning in community to form a larger narrative. Because these cultural and social discourses can serve to alienate, objectify, or even dehumanize some people, narrative therapy works to discover alternate understandings of self that patients can be comfortable with amidst their culturally-created reality.[17,18] For instance, because cultural values and traditions often express ways in which an individual should and must live, these one-sided values can invalidate individuals who experience the world in divergent ways.[19] Narrative therapy then helps the individual to build distance from cultural discourse and hold more autonomy over their story.
Stahnke & Cooley (2022) contextualize this with the similar tenets of postmodernism, which considers reality as socially constructed and influenced by language. Postmodernism posits that there is no absolute truth, and that different versions of reality exist through the different labels or perspectives we lend to it, helping to cope with the ambiguities inherent in life.[20] Postmodernism thus does away with the concept of one objective truth waiting to be measured, and instead characterizes the truth as something provisional, ever-changing, dependent on context, and shaped by many forces.[21] To emphasize the importance of bringing subjectivity into the measurable truths of psychiatry, Roberts (2000) provides an example of a young man with schizophrenia, who participated in research interviews over the course of ten years. When asked afterwards which of the ten was the worst year of his life, he identified a year where the objective ratings collected by researchers were in fact favorable. However, it was also the year he had been traumatically rejected by his family and was abandoned, despite his schizophrenia being relatively stable at the time. Such demonstrates how the "individually meaningful" might not always be the same as the "reproducibly measurable," and how personal story should be used to flesh out the understanding of individual experience to avoid missing meaningful aspects of a person's life in therapy.[22] In this way, narrative therapy helps to supplement objective measures with personal experience and better understand the alternate understandings of reality present in different individuals.
Roberts (2000) additionally discusses psychotherapy in the context of attachment theory, a theory of emotional relationships where individuals develop secure or insecure attachments to other people depending on the stability of their relationship during its formation. During a therapeutic encounter, a patient enters with a story that is often hesitant, unsure, or disjointed; the therapist then helps to uncover a more coherent and satisfying narrative.[23] Roberts links the coherence of one's story to attachment, positing that "how we tell our stories speaks to our stance towards the world." Coherence in storytelling is, then, indicative of a secure attachment, while an insecure attachment could yield an over-elaborated, confused, or sparsely dismissive narrative.[24] In working with insecure attachment in narrative therapy, therapists help patients to find the shape and pattern of a narrative within the "chaos of experience," encouraging the patient to break down their narrative into a manageable and understandable history indicative of a now secure attachment.[25]
Narrative Therapy in Practice
In narrative therapy, the role of the therapist is to listen, get to know the client, and provide validation and acceptance as they navigate sources of strength and create meaning in the client's life.[26] Tadros et al. (2022) add that narrative therapists encourage and even challenge clients to reauthor more fitting narratives for their lives, providing space for reflection with an emphasis on compassionate connection and emotional attunement. In doing so, they must use carefully chosen language to describe and reframe the individual's experience so that they can express positive and preferred identities and values.[27] The therapist should also reinforce agency and communion at every step of narrative therapy, connecting clients' problems with their relationships and support networks, and panning to a broader picture of the client's past and present experiences of agency and communion.[28]
To understand how narrative therapy works in practice, Tadros et al. (2022) and Stahnke & Cooley (2022) break down narrative therapy into three main components:
Deconstruction
Externalization
Reauthoring
Deconstruction involves breaking down the language of a problem, event, or experience to find other possible meanings and understandings.[29] For example, a person could be understood as not just a mentally unwell person, but someone who has yet to work on learning to healthily express their emotions. Deconstruction also involves repurposing statements to frame the individual's feelings and reactions, rather than blaming others for these, using "I am feeling" as opposed to "they make me feel" statements.[30]
Externalizing focuses on viewing each client as an "individual with a problem, not a problem themselves," separating the human from the condition.[31] Reframing problems as outside of the individual rather than part of the individual, such as labeling it "the depression" instead of "my depression," can help a client regain feelings of autonomy outside of their problems.[32] In this process, therapists can explore how the problem serves a purpose in the client's life rather than constitutes their entire life: for example, the problem could be a concrete thing to project anxiety onto rather than confront unresolved issues, or it could serve as a mechanism for survival.[33]
Finally, reauthoring involves shifting the client's focus from their problems onto their own strength and resilience, reframing their trauma and lifelong battles to acknowledge their ability to overcome the uncertainty of the future.[34] Often, goals of reauthoring processes include envisioning oneself as a person who can cope instead of fixating on problems, envisioning breaking cycles of trauma imposed during childhood, developing one's own voice as a member of society rather than a burden, and identifying one's ability to make decisions for oneself and regulate emotions. In reauthoring their story, clients can take back control that had been given to their problems and survival mechanisms.
Several narrative techniques can be implemented to facilitate narrative therapy. Koganei et al. (2021) suggest developing a "landscape of consciousness and of action," in which clients make a list of beliefs that rob the power of their dreams and goals from them, in order to then reclaim that power and write stories they are satisfied with. Koganei et al. also suggest narrative tasks involving remembering and imagining one's legacy as a longitudinal contribution to a larger community story, giving additional meaning and worth to oneself through imagining impact on others. Charon (2001) speaks more broadly of elements of story that can be helpful creative resources in narrative therapy, such as paying attention to associations, allusions to other stories, and using metaphor to convey digestible meanings to a client.
Tadros et al. (2022) elaborates on the importance of metaphors to convey difficult feelings and trauma, suggesting the use of poems to reflect and unpack words, images, phrases, and metaphors. Metaphor "softens the dive into meaning," working with a client's understanding without threatening the defenses of someone who may not be ready to hear unbearable meanings of their experiences.[35] Especially with those from diverse cultures and backgrounds, using traditional stories in therapy as metaphor for their experiences can help contextualize their problems within an accessible narrative of traditional hubs of wisdom.[36] A particular example of this is the usage of the Tree of Life in therapy, a method originally developed to treat trauma in African youth.[37] In the process, participants can draw trees and reflect on the major elements of their lives such as their past, resources, and strengths, through the metaphors of roots, nutrients, growth, and branches, to facilitate their integration of their experiences in life.
Benefits and Applications of Narrative Therapy
Studies have identified efficacy and many benefits to the usage of narrative therapy. In a Japanese study of seven narrative therapy patients by Koganei et al. (2021), participants reported experiencing insight, beginning to solve problems, finding a new understanding of self, clarification of problems, and clarification of thoughts about societal problems after narrative therapy. Patients additionally felt more "forward-looking" and higher amounts of motivation, desiring to make concrete changes in their life. When scored with the Beck Depression Inventory (Second Edition), four of seven participants had declines in scores for past failure, self-criticization, and worthlessness, while three had declines in scores for self-dislike, changes in sleeping patterns, and irritability. One participant's severity of depression additionally changed from severe to minimal between initial and final meetings, while three had lower scores during the final meeting despite not reaching the threshold for minimal depression.[38] Tadros et al. (2022) additionally found narrative therapy helpful in treating certain groups: narrative therapy was statistically efficacious in treating borderline personality disorder and in reducing anxiety and panic symptoms for a woman with somatic symptom disorder. Tadros et al. also notes that group narrative therapy helped to lessen symptoms of social phobia in patients by creating a safe and non-threatening culture of story-making.
Williams-Reade et al. (2014) provide an extension of narrative therapy for refugees with post-traumatic stress disorder (PTSD), where narrative therapy was able to provide validation, connection, and support as well as help the individuals to view themselves apart from their illness. Stahnke & Cooley (2022) additionally study the efficacy of narrative therapy in end-of-life care, where telling one's story in one's final days can help make meaning out of a person's past and unknown future. By examining how painful experiences have shaped a person's life and discussing their contributions to the world, patients can feel greater integrity for their life history. When patients near death are encouraged to "rewrite" experiences that hold them back and give them regret, they are able to grieve, accept, and embrace their unchangeable reality, finding greater peace. Such leaves patients more prepared to face death, having left behind the legacy of their life narrative.[39]
More broadly, Roberts (2000) found that patients who had undergone narrative therapy were able to give more cognitive and emotional significance to their experiences, construct and negotiate a social identity, and give moral and existential weight to their actions. Therapists were also able to cultivate more empathy and deeper understanding of patients' experience with mental health through their specific personal stories: Roberts (2000) cites a case where a man described his depression as worse than watching his wife die from cancer, a story which gave weight to the desensitizing statistics and objective measurements often thrown around about depression.
Limitations of Narrative Therapy
Some limitations to narrative therapy remain, and more research should be undertaken to fully understand its benefits and effects. Stahnke & Cooley (2022) note the lack of a solid research base and assessment tools for them to understand the efficacy of its use in their practice. Although narrative therapy techniques are commonly employed by social workers and therapists, they are much less often discussed or documented as a formal therapy, giving less concrete information to work with.[40] Koganei et al. (2021) also raise caution because some participants in narrative therapy did experience anxiety and distress from their sessions, perhaps due to the stress of sharing vulnerable parts of themselves and facing heavy life problems. Increased emotional support alongside narrative therapy may be a necessary intervention to prevent adverse reactions to this intense vulnerability.
Roberts (2000) also cautions against potential misuse of narrative theories and techniques, stressing the difference between narrativization and novelization. In narrative therapy, it is incredibly important not to sensationalize a patient's story; one must be careful in word choice and metaphor to ensure they are not skewing the truth.[41] On the other hand, too much clarity or simplicity could also deny appropriate complexity, and therapists must be careful not to be insistent on one particular understanding of the truth. Attributing sufferings to particular experiences has the potential to create "shackling narratives which foreclose the future and condemn the past," which can even contribute to cultures of victimization of patients.[42] Remaining open and attentive to nuance in narrative therapy is imperative to prevent this.
Ultimately, narrative therapy allows patients and therapists to realign themselves with new, more empowering definitions and goals of recovery.[43] In adjusting to living more comfortably with the reality of one's past and present, patients can work towards goals of restoring hope, agency, and self-determination that feel both realistic and inspirational. As the narrative medicine movement continues to gain traction, incorporating narrative context and storytelling into therapy will serve as an important model on the path towards empowering and humanistic care.
Contributed by: Anna Kiesewetter
Editors: Jennifer (Ghahari) Smith, Ph.D. & Brittany Canfield, Psy.D.
References
1 Charon, R. (2001), Narrative Medicine: A Model for Empathy, Reflection, Profession, and Trust. JAMA, 286 (15): 1897-1902. https://jamanetwork.com/journals/jama/fullarticle/194300
2 Ibid.
3 Roberts, G.A. (2000), Narrative and severe mental illness: what place do stories have in an evidence-based world? Advances in Psychiatric Treatment, 6: 432-441. https://www.cambridge.org/core/services/aop-cambridge-core/content/view/AC4112C21F3E985C3174AA362D009D45/S1355514600009263a.pdf/narrative-and-severe-mental-illness-what-place-do-stories-have-in-an-evidence-based-world.pdf
4 Charon (2001)
5 Ibid.
6 Kleinman A. The Illness Narratives: Suffering, Healing and the Human Condition. New York, NY: Basic Books; 1988.
7 Roberts (2000)
8 Ibid.
9 Charon (2001)
10 Ibid.
11 Ibid.
12 Ibid.
13 White, M., & Epston, D. (1990) Narrative means to therapeutic ends. W. W. Norton & Company.
14 Koganei, K., Asaoka, Y., Nishimatsu, Y., Kito, S. (2021), Women's Psychological Experiences in a Narrative Therapy-Based Group: An Analysis of Participants' Writings and Beck Depression Inventory–Second Edition. Japanese Psychological Research, 63 (4): 466-475. https://onlinelibrary.wiley.com/doi/pdfdirect/10.1111/jpr.12326.
15 Stahnke, B., Cooley, M.E. (2022), End-of-Life Case Study: The Use of Narrative Therapy on a Holocaust Survivor with Lifelong Depression. Journal of Contemporary Psychotherapy, 52: 191-198. https://doi.org/10.1007/s10879-022-09532-z
16 Tadros, E., Cappetto, M., Aguirre, N. (2022), Treating specific phobia fear of injury through narrative therapy post-release: A clinical case study. The Journal of Forensic Psychiatry & Psychology, 33 (3): 445-460. https://www.tandfonline.com/doi/epub/10.1080/14789949.2022.2065332?needAccess=true.
17 Koganei et al. (2021)
18 Williams-Reade, J., Freitas, C., Lawson, L. (2014), Narrative-Informed Medical Family Therapy: Using Narrative Therapy Practices in Brief Medical Encounters. Families, Systems, & Health, 32 (4): 416-425. https://psycnet.apa.org/fulltext/2014-44118-001.pdf?auth_token=c50f991971df27650e05ae8e91f5b1109a193e41.
19 Koganei et al. (2021)
20 Stahnke & Cooley (2022)
21 Roberts (2000)
22 Ibid.
23 Ibid.
24 Ibid.
25 Ibid.
26 Stahnke & Cooley (2022)
27 Tadros et al. (2022)
28 Williams-Reade et al. (2014)
29 Tadros et al. (2022)
30 Stahnke & Cooley (2022)
31 Tadros et al. (2022)
32 Stahnke & Cooley (2022)
33 Tadros et al. (2022)
34 Stahnke & Cooley (2022)
35 Roberts (2000)
36 Ibid.
37 Koganei et al. (2021)
38 Ibid.
39 Stahnke & Cooley (2022)
40 Ibid.
41 Roberts (2000)
42 Ibid.
43 Ibid.