Thursday Review: “Forming a Story: The Health Benefits of Narrative”

Telling a story is good for your health

In the Journal of Clinical Psychology, James W. Pennebaker and Janel D. Seagal study a group of students instructed to write about a traumatic experience, and then measure both the mental and physical health outcomes of those students. The results were measured against a control group, who were instructed to write strictly descriptive passages.

The participants who wrote about a traumatic experience recorded significantly fewer visits to a doctor in the months following the exercises.

The authors also review studies across a wide range of demographic groups which reveal that similar exercises produce positive effects on blood markers of immune function, are associated with lower pain and medication use, are linked to higher grades in college, and are even associated with faster times to getting new jobs among senior-level engineers.

The focus of the article was a writing exercise, although the authors admit writing and talking have produced comparable effects. In fact, the protocol given to the test subjects made the writing as close to a speech act as possible: The only rule about the writing assignment was that once they began writing, they were to continue to do so without stopping without regard to spelling, grammar, or sentence structure.

The big idea of storytelling communication in medicine is that structuring communication like a story is beneficial both for healthcare providers, and for patients. Pennebaker and Seagal demonstrate that the act of a patient working through a traumatic experience makes the patient healthier. They also include a nuanced discussion of why that is the case.

Clinicians can play a big role in helping the patient come to a narrative understanding of their situation. No matter what the patient is going through, storytelling helps. The authors noted that approximately half of the people wrote about experiences that any clinician would agree was truly traumatic, but even subjects who were merely under stressful conditions (such as those taking the GRE) benefited from the processing of their situation through story.

I’m not advocating that physicians play psychiatrist. The investigators make clear that those suffering from mental health issues should seek professional help. For example, they cite a study suggest[ing] that writing may not benefit PTSD patients in the absence of cognitive- and/or coping-skills training.¹

Even in a routine, brief office visit, however, one of the ways that healthcare providers can steer patients towards better long-term health is helping the patient search for and construct a “self narrative”² about whatever is being detrimental to their physical or mental health.

This sounds like a tall order, but it can be quite simple. A brief word beginning with or “See if you notice a connection between…?” or “For your health’s sake, try and stay positive about…” might be sufficient to steer a patient towards mentally gaining a narrative understanding of their situation. On a more formal level, Pennebaker and Seagal instructed their students to journal for 15 minutes a day for 4 days. It’s not out of the question to ask a patient to do the same.

Why does storytelling work at all?

The authors review three reasons postulated for the increased health outcomes associated with writing exercises of this kind:

One possibility is that by writing about emotional experiences, people simply become more health conscious and change their behaviors accordingly. Very little evidence supports this.
A second possible explanation for the value of writing is that it allows people to express themselves. The investigators briefly review several non-linguistic forms of “self-expression” which attempted to improve health outcomes and they note, Health gains appear to require translating experiences into language.
A third broad explanation for the effects of writing is that the act of converting emotions and images into words changes the way the person organizes and thinks about the trauma.

This is the grounds for investigation the authors use for the rest of the paper:

Further, part of the distress caused by the trauma lies not just in the events but in the person’s emotional reactions to them. By integrating thoughts and feelings, the person then can construct more easily a coherent narrative of the experience. Once formed, the event can now be summarized, stored, and forgotten more efficiently.

…

A constructed story, then, is a type of knowledge that helps to organize the emotional effects of an experience as well as the experience itself.

Stories and narratives happen because we are hard-wired to search for the root causes of things. From a biological perspective, we increase our chances of survival once we have constructed a story about why something happens: we’re prepared for it to happen again.

The story: comprehensive, coherent, and simple

Simple, natural phenomena are one thing, but major life events are far more difficult to comprehend. Our search for meaning and root causes quickly becomes layered, networked, and complex. The authors have a wonderful discussion about how stories can help.

Stories are comprehensive, so they can speak to the intricacies of our experience:

The beauty of a narrative is that it allows us to tie all of the changes in our life into a broad comprehensive story. That is, in the same story we can talk both about the cause of the event and its many implications. Much as in any story there can be overarching themes, plots, and subplots — many of them arranged logically and/or hierarchically. Through this process, the many facets of the presumed single event are organized into a more coherent whole.

Stories are coherent, because we have to take our vague thoughts, impressions, emotions, and hunches and put them all into a format that can be understood by someone else:

Drawing on research on conversation and language, Leslie Clark³ points out that conveying a story to another person requires that the speech act be coherent. Linguistic coherence subsumes several characteristics, including structure, use of causal explanation, repetition of themes, and an appreciation of the listener’s perspective. Referring to the work of Labov and Fanshel,⁴ Clark emphasizes that conversations virtually demand the conveying of stories or narratives that require an ordered sequence of events.

Stories are simple:

Once a complex event is put into a story format, it is simplified. The mind doesn’t need to work as hard to bring structure and meaning to it.

This last point brings up one of the important and ironic things about stories: they become more simple as they’re told more often. In my own work, the first time someone tells a story out loud from a mental rough draft, it’s usually… bumpy. There are some elements the teller knows are important, but hasn’t connected them to the thread of the story yet. There are some elements the teller thinks are important, but really aren’t. When the speaker comes around to the story the second or third time, information that is recalled in the story is that which is congruent with the story. In other words, in even an amateur storyteller’s mouth, stories smooth themselves out.

One of the dangers of stories is that they keep going. Among the vast details of our everyday experience, only the necessary details are retained in a story. This is the story being its own filter. As the story continues to be told, that “filter” can take on a life of its own and exclude facts for the sake of continuity. As Pennebaker and Seagal put it, [t]he net effect of constructing a good narrative is that our recollection of emotional events is efficient — in that we have a relatively short, compact story — and undoubtedly biased.

Listening beyond symptoms

This might sound interesting to someone curious about helping patients improve their own health outcomes through narrative, but still in the realm of theory. Going back to the findings of their study, the authors parse the different elements of a “self narrative”. In effect, they give us a checklist for the appropriate balance of elements to listen for in a medical narrative.

The investigators ran their subjects’ writing (and the writings available from some other studies) through software developed by Pennebaker named LIWC, and analyzed them with regard to four different categories of words:

negative emotions, e.g. “sad”, “angry”
positive emotions, e.g. “happy”, “laugh”
causal words, e.g. “because”, “reason”
insight words, e.g. “understand”, “realize”

As one might expect, the more that people used positive-emotion words, the more their health improved. The results from the negative emotions were the most interesting, though:

Individuals who used a moderate number of negative emotions in their writing about upsetting topics evidenced the greatest drops in physician visits in the months after writing. That is, those people who used a very high rate of negative-emotion words and those who used very few were the most likely to have continuing health problems after participating in the study.

Pennebaker and Seagal discuss a kind of happy medium: people that use too few negative words might not be able to articulate those negative feelings (i.e., “repressive copers”⁵), and thus not be able to explain their negative emotions in narrative form and move past them. People who use too many negative words appear to be dwelling on those emotions, and thus can’t incorporate them into a narrative which looks past them.

The happy medium is when high rate of positive-emotion word use coupled with some negative-emotion words suggests there is an acknowledgment of problems with a concomitant sense of optimism. People who acknowledge that negative emotions exist without getting caught in them, incorporate them into a “self narrative”, and move past them to more hopeful thoughts are those whose health is most improved by storytelling exercises.

With regards to causal and insight words, people whose health improved, who got higher grades, and who found jobs after writing went from using relatively few causal and insight words to using a high rate of them by the last day of writing. Importantly, people whose use of causal and insight word began and remained high did not benefit from writing. In other words, it is the search for and the construction of a narrative which yields positive health outcomes.

Having a preexisting story ready to go may not be sufficient to assure good health. It is the mental exercise of articulating a struggle in language and its utterance which improves health outcomes.

So, then, it’s entirely possible to nudge a patient towards better health through storytelling. Here’s a simple checklist to run through when listening to a patient:

Is the patient acknowledging the negative aspects of their condition…
…without only talking about the negative aspects?
Is the patient optimistic and using hopeful, positive terms about their condition?
Is the patient looking for a cause & effect relationship among the different facts of their condition and/or drawing conclusions?
Does the patient have any sense that what is happening or has happened to them is comprehensive? That is, is there any sense that the story of what happens can be looked at in more than one way or layer?
Is the story the patient tells coherent? That is, have they spent time thinking about an order to what they’re saying?
Does the patient have a preconceived, “stock” idea about the story of this condition?
Does the patient have a version of events that is too well-rehearsed? That is, does the patient ignore some facts for the sake of others that better suit what they believe is happening?

Conclusion

While it’s not a physician’s job to be a mental health professional, the evidence that storytelling improves physical health is overwhelming. Even if a physician isn’t comfortable enough with a patient to suggest journaling, encouraging the patient to tell their story to others or a thoughtful remark might be enough to get the patient consciously searching for and articulating their health concerns and medical traumas — no matter how slight — in rational language.

If a physician is listening to a patient describe the narrative of their own illness, it’s possible to listen for some of the signs of narrative processing, and to encourage the patient along those lines.

Sources

The article reviewed: Pennebaker, James W. and Janel D. Seagal. “Forming a Story: The Health Benefits of Narrative.” Journal of Clinical Psychology 55, no. 10 (1999): 1243–54. doi:10.1002/(SICI)1097-4679(199910)55:10<1243::AID-JCLP6>3.0.CO;2-N

¹ Gidron, Y., T. Peri, J. F. Connolly, and A. Y. Shalev. “Written Disclosure in Posttraumatic Stress Disorder: Is It Beneficial for the Patient?” The Journal of Nervous and Mental Disease 184, no. 8 (August 1996): 505–7. http://www.ncbi.nlm.nih.gov/pubmed/8752081 ↑

² Gergen, Kenneth J. and Mary M. Gergen. “Narrative and the Self as Relationship.” In Advances in Experimental Social Psychology, 17–56. New York, NY: Academic Press, 1988. doi:10.1016/S0065-2601(08)60223-3 ↑

³ Clark, Leslie F. “Stress and the Cognitive-Conversational Benefits of Social Interaction.” Journal of Social and Clinical Psychology 12, no. 1 (March 31, 1993): 25–55. doi:10.1521/jscp.1993.12.1.25 ↑

⁴ Labov, William and David Fanshel. Therapeutic Discourse: Psychotherapy as Conversation. Academic Press, 1977. ↑

⁵ Weinberger, D. A., G. E. Schwartz, and R. J. Davidson. “Low-Anxious, High-Anxious, and Repressive Coping Styles: Psychometric Patterns and Behavioral and Physiological Responses to Stress.” Journal of Abnormal Psychology 88, no. 4 (August 1979): 369–80. http://www.ncbi.nlm.nih.gov/pubmed/479459 ↑