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| Clinical Toolbox | Part I - Intro | Part II - Intro | Part III - Intro | Part IV - Intro |
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PART IV NARRATIVE TOOLS FOR OPENING SPACE FOR NEW BELIEFS ___ By working through the problem,
finding solutions, taking action ___
INTRODUCTION The storing experience uncovers news of significant difference Re-authored stories. A new life “script” is written by remembering early constructive discussions of the problem and actions taken. The old plot line is rewritten with a new beginning, middle and end, and co-constructing new possibilities. Narration of the new script specifies the cast of characters and the additional strengths acquired. The new story highlights optimal experiences and evidence for change from which a person re-shapes his or her life. Part IV describes many tools for optimal and enriched experiences. Some of the tools are only seeds of ideas, but they may help create significant new beliefs and memories when encouraged by standing together and attempting to complete jointly agreed-upon tasks. Tools for optimal and enriched experiences may include recreational events or specialized activities, such as arts and shadowing or mentoring that come from the child’s dreams and desires and which reorganize moments of life with “flow”. Flow builds self-esteem, giving children a sense of power and enhanced control over their destiny. Other generative experiences include numinous or ecstatic encounters of the spirit brought on by moments of awe or by insights that allow quantum leaps of understanding. When these events are expressed as stories—and narrated through language, or the visual or kinetic arts—they add value, significance and meaning to life. Stories are narrative belief structures that organize experience in a way that shapes and changes lives. The effect of leveraging these re-authored stories to address needs and goals will build coping skills, knowledge and learning and is the basis for helping children and families who are stretched by stressful circumstances to bounce forward, transcending adversity and encouraging neuronal plasticity with new resilient brain pathways. Re-authored stories come from what happened and what made a difference: what gave birth to the child and family’s shaping of new experiences from fresh beliefs and expectations.
Documenting Progress and Change - “Amplifying What’s Different” Accountable to Client Successes and Improvements We as health care workers and educators make considerable effort to elicit improved outcomes and effectiveness. We want to bring successful responses to our client’s by reducing negative behaviors and replacing them with new skills. Ultimately, we are hopeful to obtain improved lifestyles and a quality of life. Some families will be able to identify measurable describable goals, while others, including possibly some ethnic minorities, will be much more interested in the process and present a sense of wellbeing and recognize extended family outcomes. Some traditional cultures value ways to sustain the larger family group or clan rather than have an individual focus. Collecting Change Data and Reporting What’s New In the short term, we can obtain various observable and measurable information as data points. There are many such formats, and we would refer you to our website at Other Resources. You can review these materials, reflecting how they might be used to create a greater personal awareness, especially if they are self-monitoring or recording new skills. On the other hand, more indirect methods might be required for more subjective inquiries related to satisfaction, acceptance, friendships, health and wellbeing. Having choices to voice one’s decisions, receiving recognition for a person’s valued roles, feeling included in family, school and community, and achieving a wealth of meanings from life experience all comprise lifestyle and quality of life measures described using the 1-10 scales under perceiving change. 1-10 scale Child and Family Combined Health/Risk Checklist may be used for how these dimensions might be averaged. Other tools are available incorporating indirect reporting using social validity measures for documenting progress. These use multiple informant interviews,anecdotal records, permanent products as GPA, attendance, having fewer white slips or more preferable, positive “notes” of acknowledgement, and the numbers of public postings or new after school activities. These documents are then available for narrative practices, using storying, and solution focused techniques which embody such experience by the retellings of the oral text. We incorporate such ideas in ABLE’s practices in Re-authoring Stories, Interventions or the Family Health Promotion Plan Concepts and Resiliency: Your Changing Stories. Perceiving Change Initially , how do we measure progress toward personal change, especially if it is just a small step? Acknowledging progress, however modest, increases self-awareness, AND improves motivation for further change and may offer direction. If we don’t notice and distinguish the ordinary from what’s novel or changed, then we miss an opportunity to understand improvements or to see that we are moving along and in a better direction. It is by distinguishing what is different, or better or the same, by which we take notice of change in consciousness and what might be the basis for novel and new behaviors. Some of our scales are subjective (1-10 Scales) and we model by using such measures for each visit as a rating of these subjective moods and feelings (Quality of Life Measures, which include progress, stress, comfort and confidence (See Comfort-Hassles Scale)). We also evaluate the value of our meeting together with the client in terms of goals, expectations and eliciting hope, which are reportable using the Team Management Rating Scale. These tools give us certain feedback of acceptance and satisfaction, and where we can make changes in the next encounter, they also mark where a client’s position is relative to these important self-definitions. The Past Weeks' Quality of Family Life as well as the Child’s Daily Strength Scale rates the ebb and flow of daily routines on a 1-10 scale of qualitative dimensions. The researched Youth Outcome Questionnaire, and the Adult Outcome Questionnaire at the following website: http://www.oqmeasures.com/products.htm, or http://www.carepaths.com define objective change in symptomatic behaviors using quantitative measures. Other change in ratings of children’s or families’ behavior such as the Child Behavior Checklist or quantifiable Family Assessment Measure can indicate movement in various directions using these standardized instruments. Stages of Change One way to help understand how change behavior occurs is by using the Prochaska model, shown below. Apply this scale to the position in which a particular change-seeking person stands at the time of evaluation. Try using the metaphor of a sales customer who may—or may not—be ready to buy. Sometimes people want to think about change for awhile, they may seem contemplative and merely want to window shop. Most people are at the early levels of change seeking and not yet ready for action. Possibly more than 75% of all of us are represented in the first two stages, it is at this time, interventions related to motivation, commitment and confidence are fitting. This is not necessarily time for giving advice with education or solutions and problem solving. This is a way to measure where the child-family is now. As helpers, how can we match our suggestions to a client’s readiness for change in order to help them progress to a healthier level if we don’t understand or know?
Building Motivation as a Part of Readiness Motivational Interviewing (MI) is more than a technique. MI is a process by way of listening and questioning indecision and ambivalence. Rather than teaching, it seeks to support people in the early stages of making change by using ways to mobilize intrinsic motivation. Using their own self-talk, called “change talk,” people talk themselves into change with positive statements about change, using their own reasons and arguments for it. It is in the absence of coercion and resistance where people hear themselves argue against the status quo in more committed ways. Resistance to change may be reinforced by the interviewer, as the theory of approach and avoidance conflict suggests. People will take a counter position to what is suggested if it isn’t their own idea. Reflective Listening a Prerequisite We can help our clients accomplish this just being with them, using more open-ended evocative questions, and affirmations including acknowledgement, validation, high regard, building confidence and optimism. Summaries of what’s said including reflective listening such as rephrasing, empathic recall, reframing and reflecting feelings help elicit the costs and benefits with disadvantages of the status quo and advantages of something different; read more on Understand Shared Conversations. Since behavior and social causes influence so strongly in illness and life course of developmental disabilities, we must all share this role together enacting this practice with our multiple messages in health behavior and lifestyle change. Check out www.motivationalinterview.org/ Finally Goals and Taking Action We now invite the child and family to pick from several levels or systems in the Family Health and Promotion Plan (FHPP). Having choices and choosing from a menu or a list promotes agency. By combining and utilizing the strengths from multiple contexts, strategies and social forces will work synergistically. This will ultimately reorganize developmental needs and goals into core beliefs and values which include safety, sense of belonging, having a voice, being heard and validated, relational awareness, (multiple influences), understanding and help form a sense of identity. These quality of life dimensions become our long term outcomes for intervention and evaluation: Optimizing Quality of Life Outcomes and Negotiating Resources for Resilience Our Child Asset Scale is the primary source for describing the several transactions or the reciprocal interactions of the child in their environmental contexts which give birth to these needs, goals and beliefs which are at the heart of the matter and incorporates them into personal narratives. The FHPP tools then become a way to infuse meaning and significance from experiences, through our stories, which forms opportunities for changing our identity. A focus is kept on more than the surface behaviors, but also on feelings and thoughts. We try to illuminate and bring together the diverse worlds of the child in relation to family, school and community. We believe this multiple domain approach of placing things in context may enhance motivation, change an idea, offer a new perception, create a new frame, or visualize something another way. It is like planting seeds in a garden. As a plant grows from the seed, it may make something happen even beyond itself, beyond the child, in the larger culture itself.
NARRATIVE OUTCOMES Which bring forth developmental needs A. Promoting a Sense of Protection, Safety and Well-being. This task is seminal to many of the positive experiences listed above because families need to know each member feels safe and comfortable in their own lives before venturing into the world beyond. Although defining yourself as strong and in-control helps deal with adversity, there are thresholds and a physical reality that must be recognized. The ideas here promote a secure base and have practical utility in coping with stress and oppressive situations. These are also opportunities to express personal experience and to describe suffering and beliefs about it. Most important will be how the family appraised their oppressive situation and how they used available resources to cope. Also, important is how the family’s belief systems responded, whether by feeling a stronger or weaker sense of self. We believe much of our work is in sections A, B, C and D and involves enhancing self-regulatory systems. Many of a child’s symptomatic expressions stem from grief, loss, separation, powerlessness in the face of chronic stress, or they constitutionally lack organizing abilities and a safe feeling, which further disconnects them. We see the “impact of violence” from low resources or from barriers to resources that result in poverty, discrimination, unemployment, unstable housing, no education, exposure to mental illness, substance use and threatening neighborhoods. We recommend Alicia Lieberman and Pat Van Horn’s little book, Don’t Hit My Mommy (Zero to Three Press, Washington, D.C.), to counter these violent insults. Although not all of our special-needs children come to us from situations of overt violence, many of their traumas come from neonatal intensive care and other traumatizing chronic medical conditions that have effects on parent-child relationships including psychological stress causing instability or loss of secure base. Case Study In the session the team member says, “How is home going?” Mother begins to cry and says, “Not good.” Dad looks surprised. Mother says, “There is so much yelling and Adam gets out of control.” Adam looks down and reaches for a banana, looking over to a team member for approval. The team member affirms, nodding his head. The team member then says, “When Adam gets out of control, what do you try?” Dad says, “Nothing works. I don’t know what to do with that kid. Spanking does not work.” The team member says, “Well, there are community services that help parents get a break, when things get to be too much, for instance, …”
Given the emotional volatility in the home and the family’s need for protection, safety and well being, the interviewer began by asking the father for his perceptions (the father was seen as the focus of power in the family). The father was asked about his family of origin: “On the Nursing History Form (L), you said that your mother was manic depressive and your father had explosive episodes. Sounds like things were really stressful when you were a child. How were things for you at school?” The team might then listen to the father’s story, retelling his story in a way that brings to light the stress he experienced as a child and its impact on his relationship to school. From here, the father could be asked, “What are your dreams for your family? In what ways do you want a better life for them?” Throughout the father’s storytelling, the team empathizes with the father’s feelings and his choice of positive hopes that other family members may share. This dialogue creates a bridge to discuss Adam’s need for more safety which had been revealed through the Mathews Family Feeling Interview and the Daily Strengths and How’s It Going? evaluations. B. Increasing Sense of Belonging and Relationship. Suffering leads to alienation and isolation. Spiritual empowerment can come from a sense of reconnection and affiliation with others. By listening to a client’s stories, we affirm the storyteller and connect with them because what is shared often resonates. As described elsewhere, we have dedicated much of our work to helping reconnect and reestablish bonds and ties within the family and to linking the family with the community outside. Case StudyAdam is greeted at school by Mr. Custodian: During a school conference an additional problem was revealed by the teacher: “Adam has missed lots of school this quarter, which concerns me.” Adam grumbles.
Parents: “Well, he just does not want to go, I can’t get him going and he just won’t get out the door.” A team member turns to Adam. “How friendly are the kids and teachers at your school?” Adam says, “A kid will beat me up.” The team member says, “Adam, have you told your teacher or principal about this kid?” Adam says, “No, he will hurt me. I told my Mom and Dad.” Mom says, “Yes, he told me and it really upsets me. I just cannot make Adam go when someone is being mean to him and the school is not doing anything.” The team member, says, “We know the school. Your teacher, principal and counselor really want to know about this. And they will not tell any one except the grown-ups. They will help take care of it. Teacher, how can we help Adam feel welcome, safe and hopeful about school?” The teacher says, “Adam, I am so glad you told me about this and I bet I can guess who that kid might be and we can talk about that tomorrow at school. But right now, let’s think of ways to help you feel welcome and comfortable in school.” Adam sighs, “Ok.” The teacher says, “Adam, how about Mr. Custodian meeting you outside by the door and walking in with you?” The team member asks, “Adam do you feel comfortable with Mr. Custodian?”
A sense of belonging within the family may be encouraged by discussing pleasurable family activities. Each family member could be asked to list a family activity they liked the best. The family would then be complimented for the positive activities they already provide. Examples of these can be watching selected TV programs, eating dinner together or going to the park. The significance of this to the children could be emphasized, and given its importance, the family could be encouraged to do this activity more often. For Adam and his family, this activity was planning a weekend camp-out. (Also, see The Intentional Family: Simple Rituals to Strengthen Family Ties, by Wm. Doherty, Quill, 2002.) C. Story-Making and Creating Ritual from Lived Experiences. Healthcare is very much rediscovering and helping people repair their personal stories. Stories of the events of our lives help us make sense of what happens to us and positions us to cope resourcefully. If we can tell a story about events that cause us suffering and the stories situate the events successfully within our life-narratives, then we can observe ourselves living through these events and facing the future. In this way, our suffering can be assuaged despite the disease. Ways of expressing our experience in stories other than verbally are to perform them by way of an art form or by play opportunities. Encouraging the client to tell their story enhances the voice of the patient and exposes other people to their preferences, wants and desires. Case Study Celebration at home and school for one week of Adam using only a calm voice when angry (no hitting or yelling). Phone call to teacher with parents and Adam: A team member says, “How can we celebrate Adam going one week using a calm voice?” Teacher says to Adam, “Adam, would you like to celebrate by having lunch together?” Adam, says, “Ok, if you want,” but his eyes light up and he is trying to contain his excitement. A team member asks, “How would you like to celebrate at home?” Adam responds, “I need a new video game.” The team member says, “I was thinking of something the whole family could join in together and celebrate with you …” (pauses). The team member says, “Do you have a favorite meal your Mother makes for you, that you really like?” Adam replies, “Yeah, macaroni and cheese.” Mother smiles and says, “I‘d be happy to do that.”
D. Validating, Acknowledging and Recognizing. Listening to important accomplishments in life affirms the whole person who is sharing them. Listening to their story with acceptance and interest, and to uncover shining events that would not otherwise be noted, can bring renewed validation, approval and esteem. Other ways are: public posting of an earned certificate or other printed acknowledgement; collecting the child’s best products and organizing them into a portfolio; or, reading aloud an affirmative letter from their teacher, through which the child can see themselves and their accomplishments in the eyes of others. Public acknowledgement is like seeing a positive reflection of yourself in a mirror. Case Study Acknowledgement and recognition using the child’s interest in computers: “Adam, would like to get an email from your Mom or Dad after you have gone a whole day remembering not to yell, hit or call names?” Adam responds, “I don’t care.” Mom retorts, “See, he just doesn’t care!” The team member says, “I think Mom and Dad can be the leaders in this by showing that they are noticing Adam’s behavior and that they care enough to send an email about it. Mom and Dad, are you willing to try this out to help your son?” Mom says, “Sure I will try it, but I don’t think it will do any good.” The team member says, “Just by sending this email you are making an important statement. You are telling your son how important it is to learn how to use anger in a grown-up way and that you really care about him. Now, that is quite a statement.” Father listens.
During the next visit the team listened to Adam’s family camping story involving each member working together in safety to create a mutually pleasurable situation. Each member's contribution was acknowledged and the re-telling was heightened by photographs. The ABLE Team gave the family a small scrapbook to organize and preserve the pictures of their camping story. E. Promote Shared Reflection and Mental Imaging. Stories enable us to begin to step back and observe and they give us a greater awareness of our experience and the ability to ponder a particular thing and how they may fit together. Securely attached parents listen to stories to gain insight about their child and to anticipate needs. The reflective function of stories enables a child and parent to include others people’s internal thoughts, beliefs, feelings, attitudes, desires, hopes and intentions and how these connect with facts and descriptions of the experience. Personal stories and listening to stories is a source of empathic shifts and is the origin for emotional self-regulation, coping and resilience. In this way, children and parents can take a step back to look at themselves from a distance, make better informed choices and plan responses. These tools are vital in integrating context, creating relational awareness and achieving new perspectives, giving shape to experience, and helping control behavior. These skills are developmentally available in latency and in school-age children.
By giving this active child, Adam, a disposable camera to take pictures of the weekend camping activities, we can enhance reflection of positive memories of the family’s successful endeavor. You may suggest that Adam photograph preparatory activities, as well. To encourage getting the film developed, that task would be written into the report as an assignment to complete for the next family appointment. At that next appointment, the photos could be admired and celebrated. For example, the customary job each family member performs to make the camping trip happen could be discussed and appreciated. Upon the family’s follow-up appointment, the story of individuals working together to create pleasure for all could be emphasized and could be a new story of family well being. Adam’s family decided they wanted to keep his pictures in a memory scrapbook, which was brought to the follow-up appointment. (The Intentional Family, Wm. Doherty, Quill, (2002). F. Understanding and Making Sense of Things. To the extent we use non-intrusive, open-ended, circular questions and seek explanatory attributions, we can enter the world of our client families, who have their own opinions, values and sense of themselves. There are two ways of understanding. One is an analytic mode of thinking; the other is a narrative mode. The narrative mode leads to new understanding, identity knowledge and relationship satisfaction. Case Study When the team could talk with Adam and his family about his aggression within the home: “I think it is hard for Adam to remember not to yell and call names because of his impulsivity.” To help him with that, “Adam, how would you like to fill out this paper about what kind of day you are having? Give yourself high marks when you remember to use calm words.” “Mom and Dad, this is going to be work for Adam, but it is very important. And you can help him. When you are feeling angry, you can say something like, ‘I am mad, so I am remembering to tell you calmly what I want.’ This will give him something to look up to.”
Case Study When looking at the scrapbook, Adams father said, “Yeah, look, there is a picture of Adam doing nothing but laying around … that is him alright.” A team member asked, “Adam, how did you get someone to take a picture of you?” Adam says, “I asked my Mom.” The team member replies, “There it is again: You were all working together to make something happen. Adam, you look so relaxed in this picture. How were you feeling?” Adam says, “I was happy.” The team member turns to the father and states with eye contact and warm voice, “See, Dad, you are giving your family something you always wanted to give them, something you did not have in your own childhood.”
G. Identity, Self-Worth and Image Building. Stories shape our lives and define who we are. What we say about the way we care for ourselves reflects our self-image. The agency by which we take responsibility for ourselves and others is self-determination; mastery, and sense of control are outcomes.
The team member instigates building on Adam’s strengths to build a positive self-identity in the school. Team member: “Adam, you are so good at being out-of-doors and you enjoy nature. I wonder if there is a way you could bring this to your school to help them know this about you. Sometimes classrooms decide to do a special project that includes taking care of the outdoors. Does your teacher know that you know about the outdoors?” Adam answers, “No, most the time I have to stay in from recess ’cause I haven’t got my worksheets done.” Team member: “Have you seen an outdoor place, like a park or playground, near your school that has trash on it? Would you like your assignment to be to find an outdoor space by your school that needs cleaning up? When we have our next appointment, we can call your teacher and tell her about the place you found that needs to be cleaned up. We could see if there is a way that you and she can talk to your class and make a plan to clean up the place.” This activity would build the child’s sense of worth by directing his high level of activity to community good.
In conclusion, this section draws forth a discussion of children’s and families’ heart-felt beliefs, which are the heart of the matter. People’s beliefs and what they hold to be true affect how illness and health are perceived, how the etiology of a problem is seen, how the condition is managed, how the disease is treated and it also affects the prognosis and outcome of these conditions. Beliefs at the heart of the matter have emotional and physiological connotations and greatly influence the experience of illness and disability. It is through these assumptions and strongly held opinions that we arrive at our purposes, values, preferences, desires, hopes and dreams. This is the grist for resilience, good spirit and irrepressible liveliness despite dour medical realities. It is the persistent search for those facilitative beliefs, and the chance to modify and achieve alternatives to constraining beliefs, that Part IV is based upon and serves to promote (See the Life Quality Change Survey and A Family Focus Handout for ways to derive personal qualities and values). We hope the tools in these four sections can be used within a team context to promote options and possibilities for growth and development. Within Part IV there are several dozen opportunities for positive little growth experiences, all part of relationships, using generative conversations where stories can be heard and re-told and enacted (ritualized). This strengthens the relationship between people and new ideas, so beliefs and interpretations can then be exchanged. Possibilities for a change in the heart of the biopsychosocial and cultural structures can be apprehended; so we rebuild with protein our very cells and with spirit, our souls—over and over. There are many more ideas than just these examples, of course. Perhaps you have other suggestions of ideas that have worked. Let us know of them so we can add to them to the toolbox and expand generative options. E-mail to web address c/o webmaster hpeine@utah.gov.
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