Promote storytelling to help patients open up
Reminiscing can empower positive thinking
Nobody knows better the anger, fear, and guilt that terminally ill patients harbor as they struggle to come to grips with their approaching death than the palliative caregivers, who are charged with helping patients and their families overcome those negative emotions and achieve a good death.
In an effort to help dying patients move past those debilitating emotions, two Minnesota psychologists believe exercises in storytelling will help the process along by allowing the patient to view his or her life more positively and help bring family members closer.
"The idea is to empower people to help them affirm their life experience," says Howard Thorsheim, PhD, professor of psychology at St. Olaf College in Northfield, MN. "We have found that story is the glue that binds us together."
Thorsheim is the co-author of I Remember When: Activity Ideas to Help People Reminisce, along with Bruce Roberts, PhD, also a professor of psychology at St. Olaf. The book is based on a 1996 federally funded study of more than 10,000 people.
Thorsheim’s and Roberts’ research on storytelling measures its value to the elderly, but Thorsheim believes there are direct applications to those who are terminally ill and their caregivers.
Mutual support is empowering
According Thorsheim and Roberts, reminiscing and telling stories helps people find common ground with others and engage in a social process that brings about mutual support that is empowering. Empowerment, under the two researchers’ definition, is a sense of well-being and the feeling that one’s life has meaning. In the palliative care setting, storytelling can help the dying patient feel empowered by focusing on positive life experiences. And encouraging patients to share their stories can cultivate strengthened familial bonds.
The value of storytelling, according to the authors, is in creating opportunity for social support from family and friends. Their research showed that as people get older they have fewer opportunities to feel supported by family and friends. The same can be said for the dying, who often feel isolated and angry.
As a result, self-esteem is affected because of the lack of support. Self-esteem is even more dramatically affected in dying elderly patients. The authors noted that men of retirement age experience drops in self-esteem because they feel their lives have lost meaning.
If a terminal illness is thrown into the mix, the patient’s ability to achieve a meaningful death can be hindered by his or her perception that life has lost its meaning, and the perception of diminished support from friends and family.
The goal of palliative caregivers is to help patients wade out of the sea of negative emotions and get them to begin addressing their social and spiritual needs. According to Thorsheim, storytelling provides five elements that promote life affirmation and help patients along the road:
1. A sense of belonging. Telling stories helps people feel closer to their families, communities, and surroundings.
2. Makes one’s name known to others and others’ names known to the caregiver. Storytelling promotes an emotional connection between people who otherwise would be strangers. It can help hospice workers break through walls and nurture a familiarity that precedes trust.
3. A sense of caring. Sharing stories promotes a closeness among individuals through sharing details of one’s life and perceiving that others are listening and are interested.
4. Sets up care. Story listening is a skill that sets the stage for giving care, while storytelling fosters trust that allows one to be cared for.
5. Provides an opportunity to ask for help. A story can often provide clues to the listener as to which emotions a person is struggling with and provide clues to get past them.
Get patients to open up
But evoking a patient to reveal intimate details of their life is not a simple task. It requires the patient to trust the caregiver — trust not only in keeping confidence, but that their efforts to share will be received favorably by the listener. If the patient believes the story is of little significance to the listener, the listener can cause the patient to retreat and make future storytelling more difficult.
Listening is a skill area where many people could use improvement. Fortunately, most people possess the skills to become good listeners. According to Thorsheim and Roberts’ book, aspects of good listening include the following directives:
• Develop good eye contact. Look at the spea-ker when he or she is sharing a life experience.
• Ask open questions. Ask for more details through simple open-ended questions. For example, ask, "Can you tell me more about that?" Asking for more details adds weight to the importance of the speaker’s story.
• Paraphrase what the speaker is saying. In your own words, offer a quick summary of what the speaker just told you. This shows the speaker you are interested in their story and promotes sharing of additional details.
• Reflect the speaker’s feelings. Saying something like, "That must have made you happy," shows the speaker you understand the emotions he or she experienced.
• Know when to keep quiet. Allow the speaker to tell his or her story without interruption. For example, don’t start in with a story of your own until the speaker has finished.
• Respect the speaker’s experience. Don’t belittle what the speaker did just because you would have done it differently.
• Concentrate on what the speaker is saying. If you are going to find common ground with the speaker, you will need to think about what is being said. If necessary, ask questions that would make the story more interesting.
Prompting people to share their life experiences can be as easy as asking them to them to tell you a story from their life, but often it takes a little more planning and prompting, says Thorsheim.
One strategy involves asking the patient about something specific that is likely to have significance in their life. For example, if the patient is a war veteran, ask him or her about where they served. If there aren’t any obvious clues as to significant life experiences, Thorsheim says caregivers can use the patient’s surroundings and mementos for topics of discussion.
Still, patients may be reluctant to open up. Gaining trust is a hurdle palliative caregivers must overcome. People withhold trust because they are not sure what will be done with the information shared or because they fear the listener may not find the story interesting, or that the listener will take a negative view.
It’s not uncommon for palliative caregivers to begin caring for a new patient who is reluctant to offer more than short answers to workers’ questions. For example, a simple "How are you?" garners the response "OK" with little elaboration on how they are actually feeling.
Thorsheim says it may be helpful if both speaker and listener establish exactly what will be discussed so that the speaker will feel comfortable and not worry that he or she will share more than the speaker is willing. For the palliative caregiver trying to prompt the patient into storytelling, Thorsheim says it’s important not to probe too deeply too soon. He recommends focusing on a picture or object on display in the patient’s home because it provides a safe boundary between what is open for discussion and what is too personal.
Practice listening skills
Palliative caregivers can engage in listening exercises to improve their listening skills and become more effective at getting patients to open up. As part of an interdisciplinary team meeting or an inservice program, Thorsheim says each attending staff member should bring an object that has a story behind it.
Attendees should break up into pairs and take turns telling their stories. The exercise begins with the listener asking the speaker about the object. The speaker then responds with a short answer that does not offer much detail, simulating reluctance to open up.
"The person has two minutes to tell his or her story, withholding information to prompt the listener to ask open questions," says Thorsheim. "It’s a powerful exercise. It promotes a level of conversation that requires trust."
The listener not only learns to ask more questions, paraphrasing when appropriate, but also learns to concentrate on what the speaker is saying to keep the conversation going. The exercise should last about 20 minutes, and then the two participants switch roles.
Thorsheim adds that health care workers who provide care in the home have an ideal opportunity to prompt those isolated by their illness into reminiscing and looking at their life as a whole, rather than by the narrow context of their illness.
"It feels good when people listen to us, express their appreciation of us, are open with us, and include us," Thorsheim and Roberts write in their book. "When this happens, we have a sense of well-being and a feeling that our life has meaning. When we are asked to tell stories of our life experiences and someone listens to us, we feel empowered."
[Editor’s note: Copies of I Remember When: Activity Ideas to Help People Reminisce, by Howard Thorsheim and Bruce Roberts, are available by mail through Elder Books, P.O. Box 490, Forest Knolls, CA 94933, or by calling (800) 909-2673, for $19.90 each.] n
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