Telling Tales, Tall Tales and CBT

“I’d like to tell you a story. The action begins at a point in my life, and my career, when I felt empty. I had nothing left to give. I was bored with my work, feeling that after so many decades I was just reliving the same experiences over and over again. I felt like I wasn’t learning anything new. I was tired of being assailed with supposedly new improvements in therapeutic technique, admonished to abandon whatever, I thought was working to try the next best thing. I was frustrated with the way the field had been evolving over the years, moving on from those aspects of therapeutic work that I cherished most in favour of supposedly new, ground breaking, evidenced based , empirically validated treatments. Sure, I was grateful for advances in diagnostic accuracy and precision in matching best practices, but it felt like therapy had lost its soul” (Kottler,2015).

I cannot over emphasis just how powerful the impact these opening words by Jeffrey Kottler’s  ‘Stories We’ve Heard, Stories We’ve Told” had on me. Here was somebody l could identify with fearlessly articulating what could best be described as a therapist mid -life crisis  with a degree of candour I’d never heard with the exception of  the mesmerising Gabriel Byrne in his role as psychotherapist, Dr Paul Weston in the brilliantly written and acted series ‘In Treatment’.

If you’ve never seen it you have my permission to binge on the box set now. It’s Autumn, you’re allowed.

https://en.wikipedia.org/wiki/In_Treatment_(U.S._TV_series)

Maybe some of you reading this have not put in the decades like myself and Kottler but are feeling this way already. To you people I would say, don’t fret, any disillusionment you may feel just means you are seeing the world clearly and that can only be an advantage.

If the other hand there are those of you completely satisfied with the direction of travel  psychological services are taking I would say, “ Hey, did you just drop this?” and hand you your soul back.

But first let’s look at the importance of stories. My own charts a 35 year career in mental health Thirty five years spent doing any job is a pretty long time but thirty- five years in mental health care generates its own, very particular stressors. Those who work in the NHS and have acquired Mental Health Officer Status will know that retirement is possible at 55, a recognition that providing direct care and treatment to the mentally ill is exacting. As I’ve stated in a previous blog those stressors for me were less to do with patients and more to do with relentless external pressures to do more, to do different , to do better. The narrative arc of my story is now at the point where I am faced with a critical choice . Embrace the drive towards grey steel mechanisation of service delivery as favoured by IAPT or find another route to the sun dappled uplands of psychotherapeutic practice.

In an attempt to clarify my thoughts I find myself these days , particularly after say a holiday, asking myself if I am still sufficiently interested and engaged in the task of helping to alleviate psychological pain. The answer, up until now has been a resounding yes, yes I am, but the relationship with my craft has evolved over the years and like Kottler I’m less interested in new innovations , technique and tighter adherence to protocols . Rather, I find myself collating in my head all the stories I have heard whilst attempting like Kottler to synthesise what I have learnt about the essential elements that appear to have made the most difference to my patients.

So , stories. The word itself seems to wind up those who view it as a threat to the revered evidence base . Not so the Health Evidence Network (HEN) who have recently published a report on ”Cultural contexts of health – the use of narrative research in the health sector”. The report states that “storytelling is an essential tool for reporting and illuminating the cultural contexts of health and the practices and behaviour that groups of people share and which are defined by customs, language and geography”.

HEN operates as an information service for public health decision-makers in the WHO European Region and have concluded that the focus on the cultural contexts of health in such a diverse geographical area could be better understood and improved by the use of new types of evidence particularly qualitative and narrative research. It reviews the literature on narrative research, offers some quality criteria for appraising such research and provides three detailed worked case examples one of which focuses on well-being, and mental health in refugees and asylum seekers.

“Storytelling (and story interpretation) belongs to the humanistic disciplines and is not a pure science, although established techniques of social science can be applied to ensure rigour in sampling and data analysis. The case studies illustrate how narrative research can convey the individual experience of illness and well-being, thereby complementing (and sometimes challenging) epidemiological and public health evidence”. For those of you interested in or working with migrant or refugee populations the case studies are a must read.

http://www.euro.who.int/__data/assets/pdf_file/0004/317623/HEN-synthesis-report-49.pdf?ua=1

 

If you do read these stories it will become abundantly clear that our current mental health system is not set up to allow for the granular detail of a patients narrative. An assessment system that over relies on simplistic rating scales reducing individual experiences to a number will produce a listicle but not a story. It also runs the risk of what has been described as ,”the moral economy of lying” where people will over exaggerate their symptoms in an attempt to access help. How many of us have encouraged patients to describe their absolute worst day when filling in forms for the DWP or coached a relative in need of psychological help in the dark arts of IAPT assessment procedures. I thought so.

Kottler asserts that everyone’s life has been guided and impacted by stories and that in psychotherapy, “almost everything we know and understand about our work (and our own reality) is based on either the stories that clients tell us about their condition or else the stories we tell ourselves based on our observations of them”.

When I was a child there weren’t too many books in my house. A row of sombre, brown and gilt Dickens with musty, thin, pages sprawled with tiny, indelible writing could have put me off books and stories for life if it weren’t for the local library. If you’re under 25 you might want to look them up.   I was particularly drawn to fairy stories. There was the Big Blue Book of Fairy Stories , the Big Green Book of Fairy Stories, the Big Pink… , OK imagine all the colours you can and that’s how many fairy story tomes I had access to . A vast, colourful kaleidoscope of stories. Tales of fortitude, cruelty, redemption, reward, punishment , love, betrayal, bravery, resilience, creativity, and kindness. I found inspiration and solace for my own story within those pages and still look to stories and not treatment manuals for inspiration in my work with patients. This is what humans do – our brain is a storied organ.

So when I listened to David Clark’s recent presentation on developing and disseminating effective psychological treatments at the EABCT conference in Stockholm recently I was dismayed to hear his vision of the future. There was talk of strengthening the power of CBT by ensuring therapists didn’t go ‘off piste’ and of cutting out the therapy ‘noise’ of patients talking about their lived experience in between sessions because it eroded therapy time. Patients talking about their week in between appointments typically absorbed 20 -30% of a session. Such a waste of time whereas with digital delivery there is no deviance, no human error, no off days.   This is what Mr McDonald must have had in mind when it was decided that burger you eat in Moscow will look and taste like the one you eat in Manchester. Homogenised but not , hand on heart , what you could call soul food .

https://www.youtube.com/embed/qRqVJq6LVNo

So, as I reflect on my archive of precious patient stories which outclass by a country mile my fairy story books in their tales of sorrow and joy, pain and loss, bravery and resilience I intend to continue making space and time for a story to be heard in all its messy and noisy intricacy. Kottler sums it up beautifully,” People need to talk about the stories that inhabit their dreams and fantasies, that haunt their past, that feel special or shameful, meaningful or fragmented. It is how we remember who we are. And it is how we define who we wish to become”.

 

@mspmurphy