Narrative-Based Practice in Health and Social Care

Conversations Inviting Change

John Launer

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351864114
• Edition: 2
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Narrative-Based Practice in Health and Social Care outlines a vision of how witnessing narratives, paying attention to them, and developing an ability to question them creatively, can make the person's emerging story the central focus of health and social care, and of healing.

This text gives an account of the practical application of ideas and skills from contemporary narrative studies to health and social care. Promoting narrative-based practice in everyday encounters with patients and clients, and in supervision, teaching, teamwork and management, it presents "Conversations Inviting Change, " an established narrative-based model of interactional skills.

Underpinned by an account of theory from narrative studies and related fields, including communication theory and systems thinking, it is written for students and practitioners across a broad range of professions in primary and secondary health care and social care.

More information about "Conversations Inviting Change" is available at www.conversationsinvitingchange.com. This website includes podcasts, presentations and further teaching material as well as details of forthcoming courses, and is continually updated with information about the approach described in this book.

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CHAPTER ONE

Narrative practitioners at work

Key ideas in this chapter

• There is a usually a tension present in professional encounters between the storytelling that the patient or client brings, and the practitioner’s need for pattern recognition, action and closure.

• Narrative practice aims to integrate these as harmoniously as circumstances allow.

• This involves close attentiveness and responsiveness to language, and to the contexts that make sense of the words being used.

• It also involves offering others choices about how to make use of the practitioner, and about how to proceed at each juncture in the conversation.

• Professional power is a feature of every encounter, but self-aware practitioners can monitor this and manage it ethically.

Introduction

If you observe professionals interacting with their clients, you will nearly always observe some kind of struggle going on between two styles of conversation. This can be described as a tension between “narrative” and “normative” styles. (I have adapted this from Jerome Bruner’s (1990) distinction between narrative and “logico-scientific” discourses.)

Clients who use health and social care, by and large, have a story to tell. If you want to find out how powerful the storytelling drive is, you have only to interrupt them prematurely in their narratives – and to notice how they generally carry on from exactly where they left off. Sometimes the stories will be very clear. At other times, these may be hesitant, disjointed, fragmented, complicated, punctuated by silence, or full of things that are puzzling. Nevertheless, the flow of words will almost certainly resemble some kind of story, with characters, events, trouble, and a timeline.

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While clients want to express the uniqueness of their experiences, professionals generally try to do the opposite: to find the common denominators in these stories, and then to move towards an action or conclusion as rapidly as possible. Our utterances are therefore largely aimed at matching others’ words against patterns of description, standards, or norms. They may be norms of entitlement (“Does this person fit the criteria for the service they are requesting?”), norms of risk (“Do I need to take action?”), or norms related to a wide range of legal, scientific or administrative categories. Although a few clients are in a hurry and only want their professionals to get on with the task (and conversely, professionals can be overcome by curiosity and forget about time constraints), the great majority of work encounters are characterised by an attempt by one party to tell a story, and an attempt by the other party to take an essentially norm-based or normative stance in order to identify what decisions or actions seem necessary.

Health and social care workers seem to vary greatly in their awareness of this tension. Some exert their professional power unthinkingly and as a matter of routine, ensuring that the normative style dominates every consultation. Effectively, they screen each person’s words for whatever corresponds to their own conceptual framework (“falls,” “hitting,” “bad memory”), and conveniently tune out anything else, in order to move towards a decision or determination of some kind. The professional’s normative approach may be so dominant that it takes over the encounter completely. By contrast, some professionals are more tolerant of narratives. They may pay attention, perhaps out of empathy, in the opening part of the meeting. Nevertheless, they may often have difficulty sustaining this throughout the encounter, and will bring the normative style into play as soon as they think it polite enough to do so, thus foreclosing opportunities for clients to develop their own stories further.

Taking a narrative-based stance

While it is possible to manage any professional encounter by taking a purely normative approach, it is also possible to follow a client’s cues in a way that allows far fuller expression of their stories and leads to better decision-making. This is what it means to take a narrative-based stance. Box 1.1 gives a very brief illustration of the difference between a purely normative approach and a narrative-based one, using a fictional scenario: two different occupational therapists carrying out a home assessment for mobility aids, in the same patient.

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Box 1.1 Normative and narrative-based approaches during a home assessment

Therapist A (taking a normative approach)

Therapist A:	Well, as you know, I’ve come to look at your home because of your falls.
Client:	I’ve had a lot of them lately.
Therapist A:	Yes, your social worker mentioned that. So let’s go round and look at what we can do for you.

Therapist B (using a narrative-based stance)

Therapist B:	Well, as you know, I’ve come to look at your home because of your falls.
Client:	Yes, I’ve had a lot of them lately.
Therapist B:	Did anything cause this, do you think?
Client:	Oh, I thought the social worker would have told you. My son used to live here and always helped me get around.
Therapist B:	Is he not here any more?
Patient:	No, that’s the terrible thing. He got killed in a car accident . . .

Although the opening of the conversation in Box 1.1 is the same each time, the two occupational therapists go in entirely different directions. Therapist A remains incurious about anything except her own task, whereas Therapist B tries to understand the personal context that has made the task necessary. To do so, she actively tracks the language used by the client, picking up the signal that the son “used to live here” in order to deepen her inquiry. By the end of the conversation, each of the therapists may have reached the same point – in the technical sense of which mobility aids to recommend – or they may not. The more attentive one may decide to address other needs in addition. These might cover, for example, meeting her client’s psychological needs, advising her where she might get support for these, or arranging more practical help in the home.

Box 1.2 shows the same contrast between the two approaches, this time based on genuine transcripts of two different medical consultations with real patients. It is taken from a famous paper by the US sociologist Eliot Mishler and his colleagues (Mishler et al., 1989). It illustrates how professionals can either unthinkingly set limits to the narrative, or choose to pay attention to it. In the first consultation, a doctor ignores signals of uncertainty and anxiety to such a gross extent that the patient is effectively reduced to tears. In the second consultation, another far more attentive doctor manages to listen to a patient’s narrative in a more precise way, and to use it as a cue to inquire about something of medical importance – a witness account of a seizure the patient has suffered. It is worth examining these short extracts closely, to identify what is typical of a normative interview, and to contrast it with a more narrative approach.

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Box 1.2 Normative and narrative-based approaches in two medical consultations

Doctor A ignores a patient’s words

Patient:	It’s one spot right here. It’s real sore. But then there’s like pains in it. Ya-know how . . . I don’t know what it is.
Doctor:	Okay . . . Fevers or chills?
Patient:	No.
Doctor:	Okay. Have you been sick to your stomach, or anything like that?
Patient:	[Sniffles, crying] I don’t know what’s going on.

Doctor B pays attention to a patient’s words and uses them to seek important information (a witness account of a seizure)

Patient:	My boss hadn’t got all the parts for it, so I started working on another car, ya-know? That’s when I ended up having the seizure.
Doctor:	Okay . . . So did your boss or someone else see the seizure happen?

What is striking in the first example in Box 1.2 is that the doctor fails to hear the crucial words “I don’t know what it is” or chooses to ignore them. Instead, he focuses only what he believes matters to him as a physician, namely to progress through a litany of possible symptoms. As a result, the patient’s anxiety escalates further. Paradoxically, this upsets the patient so much that it makes the doctor’s task of taking a history even harder. In the second example, by contrast, the doctor appears to pay attention to the words of the story and visualise the exact scene being described. This not only results in the patient being heard, but opens up an opportunity for the doctor to seek exactly what he needs from a technical point of view: a detailed, objective account of the seizure from an observer.

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Table of contents

• Cover Page
• Narrative-Based Practice in Health and Social Care
• Praise
• Title
• Copyright
• Dedication
• Contents
• Acknowledgements
• Foreword
• Preface
• Introduction: Narrative, Health and Social Care
• 1 Narrative Practitioners at Work
• 2 Concepts: The “Seven C’s”
• 3 Narrative Inquiry
• 4 What Hinders Narratives
• 5 Helping Narratives to Develop
• 6 Families
• 7 Mental Health
• 8 Supervision
• 9 Consultancy in the Workplace
• 10 Training
• Appendix: Some Teaching Exercises
• Index