How do we understand our own illness, and how does it affect us? When a patient is ill, how can healthcare professionals—especially nurses—help shape a positive understanding of what is happening?
In the Journal of Psychiatric and Mental Health Nursing, J. A. Aloi discusses techniques to help patients edit their own story. Although focused on mental health, the author includes how
the generalist nurse in all areas of nursing can help patients create multiple perspectives.
The article is written from
a postmodern, social constructionist point of view. I don’t consider myself a postmodernist, despite all my interest in narrative. I might disagree with the philosophical viewpoint of the article. I do agree, though, that making a patient conscious of their own narrative and questioning them about its origins is profound and useful.
In a narrative approach, the story conveys the person’s perception of reality and is considered the basic unit of experience.1 … The notion that people make meaning is central to the belief that people have the power to change their lives. The relation of words to reality can have profound therapeutic consequences.
Postmodernists would say that that changing the language, narrative, or story of the self
serves to create the preferred reality. I would say that it changes our relationship or outlook on reality. The fact remains that our story about ourselves and how we make meaning are inseperable.
A story is a particular way to select events. A story begins with a problem. Every story is about a character trying to solve a problem, despite difficulties. The story is over when the striving to solve the problem is over. If a character wants something, and works to achieve it in the end, we usually call that a happy ending.
Aloi’s notion of a “problem-saturated story” is a visceral reminder that people, especially patients, can sometimes select only problems when telling their only story. There is one, overarching problem, which is often the illness. That problem creates difficulties, which in turn is simply another problem without a resolution, and then another problem, and so on. The story never goes anywhere, because it’s simply a problem on repeat.
Every story contains problems. The notion of a personal story being “saturated” with them is a good indicator that there’s no longer any separation between person and pathology:
the person is not the problem, the problem is the problem.2 [A narrative viewpoint] holds that a problem is something that you have, not something you are.
Especially in the context of healthcare, it’s important that we help patients realize that illness is a part of their story, but the illness is not the patient.
three main narrative techniques that can help patients see that their story is problem-saturated. All of these ideas start with attentive listening. This is a kind of listening that doesn’t seek to jump in with solutions or
assume the role of expert. This type of listening seeks only to find the moments where there is a potential for the patient to change their story.
Once those moments are identified, the nurse simply asks questions.
This approach reminded me of Parker J. Palmer’s description of a Quaker “Clearness Commission”. Dating back to the 17th century, if a Quaker had an issue they were wrestling with, they could gather a small group of friends together in confidence. That person would tell the Commission about the issue and its background. Then, the members of the Commission were governed by one rule: they may only ask questions. No leading questions or advice disguised as questions were allowed. The questions were only to help the member find clarity with the issue.3
Since a nurse spends time with patients going through illness, there’s opportunity for a nurse to be a Clearness Commission of one. Aloi’s questions center around:
- externalizing, and
Deconstruction (also called “unpacking”4) is looking for
gaps, ambiguities and conflicting plots in the patient’s story. This is looking to poke holes in the patient’s story only in the sense that a patient might have received their story, not authored it. Questioning a story to deconstruct it might include
Who gave you the idea that…?
Externalizing the problem seeks, simply put, to undo internalization. If a patient sees that a problem-saturated story might not be something they themselves have authored, they can hopefully stop the cycle of self-blame for the problems at hand. This line of questioning might include
How were you affected by others’ opinions?
Re-authoring is a process that promotes a person’s redefinition of himself and his problematic situation. The plot of the problem-saturated story can be identified and understood in terms of its influence over the person. This might be prompted by questions like
What would you like to see happen? and
What do you see in yourself now that you didn’t see before?
The article reviewed: Aloi, J. A. “The Nurse and the Use of Narrative: An Approach to Caring.” Journal of Psychiatric and Mental Health Nursing 16, no. 8 (2009): 711–15. https://doi.org/10.1111/j.1365-2850.2009.01447.x.
1 Monk, Gerald, John Winslade, Kathie Crocket, and David Epston, eds. Narrative Therapy in Practice: The Archaeology of Hope. San Francisco, CA: Jossey-Bass Publishers, 1997, p. 2. ↑
2 Monk, Gerald, John Winslade, Kathie Crocket, and David Epston, eds. Narrative Therapy in Practice: The Archaeology of Hope. San Francisco, CA: Jossey-Bass Publishers, 1997, p. 26. ↑
3 Palmer, Parker J. The Courage to Teach : Exploring the Inner Landscape of a Teacher’s Life. San Francisco, CA: Jossey-Bass Publishers, 1998. ↑
4 Moules, Nancy J., and Sylvia Streitberger. “Stories of Suffering, Stories of Strength: Narrative Influences in Family Nursing.” Journal of Family Nursing 3, no. 4 (November 24, 1997): 365–77. https://doi.org/10.1177/107484079700300404. ↑