Tell me a Story
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My friend, Connie Regan-Blake, is a storyteller. We met in Chattanooga Tennessee over thirty years ago. I was a librarian at Erlanger Hospital, and Connie was "Miss Daisy," who rode around in the public library's book mobile and told stories to children. In the early 1970's, Connie and her cousin, Barbara Freeman, a children's librarian in the main Chattanooga Public Library, quit their jobs, sold most of their belongings, and took off to tell stories around the country and then the globe. As the Folktellers, Connie and Barbara performed for over twenty years; lead workshops for teachers and librarians; and taught a college seminar on stories and storytelling. Barbara and Connie are soloists now, having developed their own style and repertoire. If interested, a short bio on Connie is at http://www.uncc.edu/brocker/connieregan.htm . It is from listening to Connie tell stories and talk about the importance of storytelling that I gained an appreciation and respect for the art.

During the 2003 AOTA Annual Conference in Washington DC, Steve Zeitlin, PhD, was the featured scholar at the ninth Breakfast with a Scholar, sponsored by the American occupational Therapy Foundation (AOTF). Dr. Zeitlin is director and cofounder of City Lore, an organization dedicated to the preservation of New York City's-and America's-living cultural heritage. (www.citylore.org ) Martha Kirkland, AOTF Executive Director, heard about Dr. Zeitlin and City Lore through its response to 9/11. A short article, "9/11: Commemorative art, ritual, and Story," by Zeitlin and Ilana Harlow is in the Fall/Winter 2001 issue of Voices: the Journal of New York Folklore. http://www.nyfolklore.org/pubs/voic27-3-4/dnstate.shtml

Steve is author and coauthor of a number of award winning books on America's folk culture including A Celebration of American Family Folklore (Pantheon Books, l982); The Grand Generation: Memory Mastery and Legacy (U. of Washington Press, l987); City Play (Rutgers University Press, l990); Because God Loves Stories: An Anthology of Jewish Storytelling (Simon & Schuster, 1997); and Giving a Voice to Sorrow: Personal Responses to Death and Mourning (Penguin-Putnam, 2001). His children's books include While Standing on One Foot: Puzzle Stories and Wisdom Tales from Jewish Tradition (Henry Holt, l996); Cow of No Color: Riddle Stories and Justice Tales from World Traditions (Henry Holt, l998); and a book on world cosmologies, The Four Corners of the Sky (Henry Holt, 2000). He is the author of a new volume of poetry, I Hear America Singing in the Rain (First Street Press, 2003).

During his presentation, Dr. Zeitlin showed slides of individuals engaged in occupations across the lifespan and spoke of the role these occupations play in "...creating memory, mastery, and meaning in life." Read the one-page article in the AOTF Connection at: http://www.aotf.org/html/connection.shtml . Dr. Zeitlin was pleased and surprised to discover that occupational therapy practitioners are interested in their clients' stories as a means to create a client-professional relationship and to assist in evaluation, problem solving or clinical decision making.

Maureen Hayes Fleming, EdD, OTR, FAOTA and Cheryl Mattingly, Ph.D., an anthropologist, looked into the importance of the clients' stories during the Clinical Reasoning studies done at Tufts University over a decade ago. See Mattingly, C. & Fleming, M.H. (1993). Clinical reasoning: forms of inquiry in therapeutic practice. Philadelphia, PA: F.A. Davis. In her 1998 monograph, Healing dramas and clinical plots: the narrative structure of experience, Dr. Mattingly opens chapter one with this sentence. "Attention to human suffering means attention to stories, for the ill and their healers have many stories to tell." [p. 1]

This is an excerpt from the Bio for Dr. Mattingly on the USC web site. "As an anthropologist, a major area of my work has been the study of stories in health care. Interest in narrative has grown tremendously over the past several years in all the health professions, including among physicians. Stories can be especially relevant for occupational therapists because it is often through hearing stories that people learn what it is like for someone to live with disability. And the stories people tell also give many clues about what they care about, what matters most in their lives. This is important because when occupational therapy is most effective, it connects treatment interventions to those areas of deep concern to clients." http://www.usc.edu/assets/ot/faculty/CherylMattingly.shtml . Following are additional publications Mattingly authored or co-authored on this topic.

Helfrich, C., Kielhofner, G. & Mattingly, C. (1994). Volition as Narrative: Understanding Motivation in Chronic Illness. The American Journal of Occupational Therapy, 48, 311-317.

This paper expands the current concept of volition in the Model of Human Occupation. The present version views personal causation, values, and interests as traits that determine choices to engage in occupations. Through a detailed investigation of the life histories of two persons with psychiatric disorders, this paper illustrates how volition is embedded in a personal narrative. Two features of narratively organized volition are highlighted: (a) how narrative places decisions and actions within a plot, thus giving them meaning in the context of a whole life, and (b) how the personal narrative motivates the person by serving as a context for choosing and action. Thus, the paper illustrates how persons seek to narrate their lives and live their life narratives.

Mallinson, T., Kielhofner, G. & Mattingly, C. (1996). Metaphor and meaning in a clinical interview. The American Journal of Occupational Therapy, 50, 338-346.

This study examined the narrative features of 20 life histories gathered from psychiatric patients with the Occupational Performance History Interview. The aim was to identify how narrative features were present in the patient interview responses and to illustrate how such narrative features can be located. We found that the patients organized their interview responses with deep metaphors that served to "emplot," or give meaning to, the life story. This article illustrates how patients used the deep metaphors to both circumscribe and frame possible solutions to the problems in their lives. Deep metaphors are consistent, recurring images of a life story that give coherence to, and aid in, the interpretation of the events of that life. Moreover, we explored how metaphors can be located in patient life histories and their implications for occupational therapy.

Mattingly, CF. (1989). Thinking with stories: Story and experience in a clinical practice. Boston, MA: Massachusetts Institute of Technology. (Dissertation)

Mattingly, C. (1991). The Narrative Nature of Clinical Reasoning. The American Journal of Occupational Therapy, 45, 998-1005.

Narrative reasoning is a central mode of clinical reasoning in occupational therapy. Therapists reason narratively when they are concerned with disability as an illness experience, that is, with how a physiological condition is affecting a person's life. In this paper, narrative reasoning is contrasted with propositional reasoning, and two kinds of narrative thinking are examined. The first is the use of narrative as a mode of speech that can be contrasted with biomedical discourse, in which disability is framed as physical pathology. The second involves the creation rather than the telling of stories. Therapists try to "employ" therapeutic encounters with patients, that is, to help create a therapeutic story that becomes a meaningful short story in the larger life story of the patient.

Mattingly, C. (1998). Healing dramas and clinical plots: the narrative structure of experience. Cambridge, MA: Cambridge University Press.

Mattingly, C. & Lawlor, M. (2000). Learning from stories: narrative interviewing in cross-cultural research. Scandinavian Journal of Occupational Therapy, 7, 4-14.

This paper argues for the importance of eliciting stories when trying to understand the point of view and personal experience of one's informants. It also outlines one approach to eliciting and analyzing narrative data as part of a complex and multi-faceted ethnographic study. The paper draws upon ethnographic research among African-American families who have children with serious illnesses or disabilities. However, it is not a report of research findings per se. Rather, it is primarily a conceptual paper that addresses narrative as a research method. Features that distinguish a story from other sorts of discourse are sketched and current discussions in the occupational therapy and social science literature concerning the importance of narrative are examined. The heart of the paper focuses on a single narrative interview and examines what we learn about the client and family caregiver perspective through stories.

The following references, arranged by author, are from OT SEARCH.

Barrett, L., Beer, D. & Kielhofner, G. (1999). The importance of volitional narrative in treatment: An ethnographic case study in a work program. Work: A Journal of Prevention, Assessment & Rehabilitation, 12, 79-92.

The revised theory of the model of human occupation expands the concept of volition to include volitional narrative. This paper focuses on the application of this theory of volition to a client's experience in a work program. This ethnographic case study describes the volitional narrative and life world of one client who attended the occupational therapy work based program. For fifteen months, the client was the subject of narrative interviews, participant observation, videotapes and telephone contacts. The findings will illustrate how knowledge of a client's volitional narrative and life world can shed critical light on understanding treatment conflicts. Finally, the discussion will underscore how important it is for work based programs to be designed to encourage therapists to adapt their treatment approaches to maximize the opportunities to seek out the client's volitional narratives with the client's life world.

Blanche, E.I. (1996). Alma: coping with culture, poverty, and disability. The American Journal of Occupational Therapy, 50, 265-276.

This article raises questions about the ways culture affects the nature of health care services. By examining the life story of Alma, a Central American woman who has a daughter with disabilities; her interactions with health care providers; and my own assumptions about cultural differences, I note the impact of cultural differences on coping and adaptation in Alma and in the health care system when working with poor, non-English-speaking clients.

Borg, B. & Bruce, M.A. (1997). Occupational therapy stories: psychosocial interaction in practice. Thorofare, NJ: Charles B. Slack, Inc.

Braveman, B. & Helfrich, C.A. (2001). Occupational identity: exploring the narratives of three men living with AIDS. Journal of Occupational Science, 8, 25-31.

The relationship between occupation and identity has received increased attention in recent years. This article explores the usefulness of the construct of occupational identity as measured by the Occupational Performance History Interview (OPHI-II) in understanding the evolving narratives of three men living with AIDS who participated in a vocational rehabilitation program. The narratives of the three men are described and the impact of AIDS and an attempt to return to work on each individual's occupational identity is discussed. Narrative slopes are presented for each of the three men. Directions for future research are suggested.

Chaudhury, H. (2003). Quality of Life and Place-Therapy. Journal of Housing for the Elderly, 17(1/2), 85-103.

The multidimensional "quality of life" conceptual model is one of Powell Lawton's landmark contributions in gerontology that has influenced several studies, including the exploratory study of "place-therapy." Key dimensions of the QOL model, such as temporality, subjectivity influenced and inspired this study that explored reminiscence of personally meaningful past places among cognitively intact and impaired residents in four nursing homes. The therapeutic potential of place-based reminiscence is proposed as an avenue in understanding and enhancing the quality of life for older adults in long-term care facilities. Place is used a means to recollect the rich narrative of lived experiences of the individuals who often become anonymous care-receiving nursing home "residents." Potential avenues for further inquiry in place-therapy are indicated.

Clark, F. (1993). Occupation embedded in a real life: interweaving Occupational Science and occupational therapy: 1993 Eleanor Clark Slagle Lecture. The American Journal of Occupational Therapy, 47, 1067-1078.

This lecture presents an example of research in the genre of interpretive occupational science and demonstrates how occupational science can inform clinical practice. The innovative qualitative methodology used blended elements of the anthropological tradition of life history ethnography, ethnomethodology, the naturalistic methods used by Mattingly and Schoen to study practice, and especially narrative analysis as described by Polkinghorne. The bulk of the paper is presented in the form of a narrative analysis that provides an account of a stroke survivor's personal struggle for recovery, a story that emerged from transcription, coding, and analysis of transcripts from approximately 20 hours of interview time. First, this narrative analysis provides an example of how the occupational science framework can evoke a particular kind of storytelling in which childhood occupation can be related to adult character. Storytelling of this kind is later shown to be therapeutic for the stroke survivor...

Clark, F., Carlson, M. & Polkinghorne, D. (1997). The Issue Is: The legitimacy of life history and narrative approaches in the study of occupation. The American Journal of Occupational Therapy, 51, 313-317.

Fanchiang, S.P.C. (1996). The other side of the coin: growing up with a learning disability. The American Journal of Occupational Therapy, 50, 277-285.

This study is a narrative analysis of the life history of Dale, a 25-year-old man with a learning disability who received sensory integrative treatment in early childhood. The analysis revealed that Dale's self likely developed through occupational engagement with three interconnected themes: "my mother said" and "parental tricks"; "adrenaline surges" and "hell-raising"; and work, "deal-making," and self-construction. These themes depict Dale's self-construction, character development, occupation selection, and adaptation. In addition, these themes revealed how his parents used principles based on his sensory needs and learning problems to organize his childhood occupations and assist with his adaptation. The concept of occupational metamorphosis is also proposed to describe a person's search for and selection of occupations that satisfy biological and sensory needs. This study supports the idea that the complex nature of adaptation can be revealed through an occupational history, and that adaptation is multifaceted and not absolute.

Fazio, L.S. (1992). Tell me a story: the therapeutic metaphor in the practice of pediatric occupational therapy. The American Journal of Occupational Therapy, 46, 112-119.

In the crafting of therapeutic intervention, pediatric occupational therapists are challenged to provide therapeutic modalities that are as stimulating and imaginative as the child's world, while offering appropriate and meaningful solutions to the child's problems. Storytelling, coupled with the visual, auditory, and kinesthetic stimulation of guided affective imagery, offers a stimulating treatment approach for both the child or adolescent and the occupational therapist. This paper provides an overview of the use of storytelling, metaphorical forms and expressions, and guided affective imagery in occupational therapy with children.

Frank, G. (1996). Life histories in occupational therapy clinical practice. The American Journal of Occupational Therapy, 50, 251-264.

This article defines and compares several narrative methods used to describe and interpret patients' lives. The biographical methods presented are case histories, life-charts, life histories, life stories, assisted biography, hermeneutic case reconstruction, therapeutic employment, volitional narratives, and occupational storytelling and story making. Emphasis is placed [on] the clinician as a collaborator and interpreter of the patients' life through ongoing interactions and dialogue.

Gahnstrom-Strandqvist, K., Tham, K., Josephsson, S. & Borell, L. (2000). Actions of competence in occupational therapy practice: A phenomenological study of practice in narrative form. Scandinavian Journal of Occupational Therapy, 7, 15-25.

This study examined the phenomenon "what are occupational therapists doing when they feel competent". Data were provided by eleven occupational therapists who narrated clinical cases in which they had felt themselves to be competent. The empirical phenomenological psychological (EPP) method was used to analyze and interpret the data. The result revealed that on a general level the experience of feeling competent as an occupational therapist derived from achieving results in the rehabilitation project that were satisfying for both participants (the therapist and the client). The strategies for accomplishing this were related to the empathic competence of the therapists. This competence involved interpreting clinical situations as well as understanding the relationship between motive, meaning, decision and time. Further it involved bringing objects, in the form of adaptations, technical aids, structures, simplifications or compensations, into the clinical situation. These abilities together had a great impact on the therapeutic outcome by shaping the clients' lifeworld to make it richer and more active.

Josephsson, S., Backman, L., Nygard, L. & Borell, L. (2000). Non-professional caregivers' experience of occupational performance on the part of relatives with dementia: Implications for caregiver Program in occupational therapy. Scandinavian Journal of Occupational Therapy, 7, 61-66.

The aim of this study was to describe how non-professional caregivers understood and responded to the problems of everyday life in their interaction with a family member suffering from dementia disease. Data were obtained through interviews. The analysis was performed using a comparative qualitative approach. The findings demonstrated how the caregivers' strategies for handling everyday problems varied and reflected a personal understanding of the relative's life history. On basis of these findings and previous research, the implications for therapeutic interventions by occupational therapists were presented and discussed.

Kelly, L.M. & Mosher-Ashley, P.M. (2002). Combining reminiscence with journal writing to promote greater life satisfaction in an assisted-living community. Activities, Adaptation & Aging, 26(4), 35-46.

The Leave-A-Legacy Program at Alterra Wynwood in Leominster, Massachusetts, is an example of a successful emergent, multi-faceted, reminiscence and writing program within an assisted-living community. A group of residents meet voluntarily once a month, along with a facilitator, to read aloud from their journals, write and reminisce. The program has an enthusiastic facilitator who contributes greatly to its success by encouraging its members to translate their newly recalled memories into a journal where they can be clearly organized. Consequently, these memories and stories will be preserved on paper and available to read for many generations. The members benefit from the therapeutic reminiscence sessions, which enhance their social relations and improve memory by sharing personal stories from their youth. Additional benefits accrued through the writing program include reduced anxiety and the capability to boost one's immune system.

Kielhofner, G. & Mallinson, T. (1995). Gathering narrative data through interviews: empirical observations and suggested guidelines. Scandinavian Journal of Occupational Therapy, 2, 63-68.

With growing interest in the narrative aspects of occupational therapy practice, the question arises as to how therapists can effectively gather narrative data. This article explores the formal interview as a means of obtaining stories. Secondary analysis of existing data was used to examine when and how the Occupational Performance History Interview elicited and suppressed patients' narratives responses. Based on the findings and on literature concerning the nature, guidelines for successful narrative interviewing are offered.

Kirsh, B. (1996). A narrative approach to addressing spirituality in occupational therapy: Exploring personal meaning and purpose. The Canadian Journal of Occupational Therapy, 63, 55-61.

Spirituality has been recognized and documented as an essential component to be included by the occupational therapy profession in client-centred service delivery. However, methods of addressing and enhancing spirituality in occupational therapy practice remain relatively unexplored within the profession. This paper discusses the benefits of a narrative approach in addressing spirituality in everyday practice. It explores narrative as a mode of expression, its relationship to occupational therapy and its usefulness in addressing the spiritual component of the individual. A case study is provided to illustrate how a narrative approach enables an understanding of meaning and purpose in one's life.

Labovitz, D.R. (Ed.). (2002). Ordinary miracles: true stories about overcoming obstacles & surviving catastrophes. Thorofare, NJ: SLACK, Inc.

Larson, E.A. & Fanchiang, S.P.C. (1996). Nationally Speaking: Life history and narrative research: generating a humanistic knowledge base for occupational therapy. The American Journal of Occupational Therapy, 50, 247-250.

Larson, E.A. (1996). The story of Maricela and Miguel: a narrative analysis of dimensions of adaptation. The American Journal of Occupational Therapy, 50, 286-298.

OBJECTIVES. A mother-child life history was analyzed to examine the multiple dimensions of adaptation in a family grouping, including temporality, maternal values, and life contexts. METHOD. In-depth interviews, participant observation, and documents (e.g., therapy notes, medical records) produced the data for this study. A multiple step narrative analysis included narrative shaping, analysis of major life turnings, and macrostructural analysis of the progress toward life goals. RESULTS. This mother-child life history portrays the challenging life events of a Mexican-origin mother, Maricela, seeking care and assistance to further the development of her son with disabilities, Miguel. Major turnings in her life had both costs and benefits for her in the present and future. Analysis of her multiple roles of mother, professional, daughter, lover-wife, and spiritual devotee revealed that Maricela's life choices, driven by maternal values, diminished the achievement of her personal goals, except those related to her maternal and spiritual roles. Maricela chose actions to realign current and future happenings with her desired life trajectory for her son, which instead of enhancing life conditions for the family often involved short-term and long-term costs. CONCLUSION. This mother-child life history demonstrates that a series of moral, relational, and circumstantial factors influence a mother's projected life courses for herself and her child. Adaptation appears to be a dynamic process of realigning life paths to desired life courses, with success evaluated not in a microcosm of time, but from a larger view as these actions contribute to the achievement of desired life goals within a constellation of the person's life goals.

Lentin, P. (2002). The human spirit and occupation: surviving and creating a life. Journal of Occupational Science, 9, 143-152.

The following life history, from a qualitative study, gives an insight into the strategies humans use to survive, accommodate, adapt and transcend hostile environments and a frightening world. The value and meaning of the occupations one man engaged in spanning 46 years of his life are explored. Occupations are examined that helped him survive captivity and severe abuse from infancy to adolescence, then through the process of recovery, and finally to participate in life, as an adult. Life history and narrative analysis were used to identify a number of significant periods and themes in his life, as a boy, imprisonment; as a youth, abandonment and hiding; as a young adult, claming up, venturing out and healing; as an adult, panic and coming out; and then as a man, life began, filling bricks, and making a wall to stand on, creating a life and reclaiming England. Occupational pathways that traverse these periods and which develop over time are elaborated, along with the factors that motivated, facilitated or inhibited occupational engagement, occupational performance and life participation. The knowledge of our human vulnerability and the existence of inhumanity among humans are things we prefer not to think about. This article challenges the unthought known and provides valuable information on the place and meaning of occupation to human beings.

Lyons, K.D. & Tickle-Degnen, L. (2003). Dramaturgical challenges of Parkinson's disease. OTJR: Occupation, Participation and Health, 23, 27-34.

Being able to engage in satisfying and effective interpersonal interactions is an important component of health. Parkinson's disease (PD) is an example of a chronic illness that can make social interactions difficult and awkward. The aim of this study was to explore the nature of the challenges people with PD face during social occupations. Following a collective case study design, two men and one each participated in two qualitative interviews. Dramaturgical analysis of the interview data was conducted to offer insight into why some interactions are problematic. Elements seen in the stories of problematic encounters included a dramaturgical challenge created by PD symptoms, resulting discomfort or confusion, and the adoption of an attitude or action to surmount the challenge. Using dramaturgical analysis to explore the occupational form of social interactions can develop knowledge about the facilitation of social well-being.

Molineux, M. & Rickard, W. (2003). Storied approaches to understanding occupation. Journal of Occupational Science, 10, 52-60.

Occupation is a complex and multifaceted phenomenon, one that truly tests the range of research methodologies available to occupational scientists. In recent times there has been resurgence of the use of personal stories as a research method in a wide range of disciplines and occupational scientists have begun to recognize their particular value in furthering our understanding of occupation and humans as occupational beings. There are many types of personal stories and these include life story, life history, and oral history. The boundaries between these are becoming increasingly blurred and so researchers are beginning to take a more eclectic approach in their use. There is, however, little doubt that stories are well suited to the study of occupation as they permit an exploration of personal meaning, temporality, occupational historicity, and the wider contextual dynamics that impact on occupational engagement. When combined with narrative methods of analysis, oral history provides a powerful method for making sense of what people do. Research which employs oral history and narrative analysis produces field and research texts which both further our understanding and appreciation of the occupational nature of humans and their experience of illness.

Mostert, E., Zacharkiewicz, A. & Fossey, E. (1996). Claiming the illness experience: using narrative to enhance theoretical understanding. Australian Occupational Therapy Journal, 43, 125-132.

The narrative of a young woman's experience of cancer is used to illustrate how strategies employed by health practitioners can affect clients' perceptions of the causes of illness and also the outcome of both present and future illness experiences. Clinical reasoning strategies of occupational therapists are introduced and links are made to the possible reasoning strategies employed by the clinicians in the narrative. The discussion centres around a client's health beliefs, her feelings of decreased control, her perceptions of the illness experience, and the way narrative reasoning could have improved her experience.

Neville-Jan, A. (2003). Encounters in a world of pain: an autoethnography. The American Journal of Occupational Therapy, 57, 88-98.

Pain, a major health problem in the United States, is a highly complex and subjective experience that is poorly understood by many medical, psychological, and rehabilitation practitioners. In this paper I use a qualitative research methodology, autoethnography, to present a personal narrative about my experience of chronic pain. In this research I am both the research participant and the researcher. I begin with my personal narrative. I then problematize conceptions about chronic pain and discuss them from the point of view of my own narrative and from stories and ethnographies in the literature. Finally I reflect on how occupational therapists can more effectively work with persons with chronic pain.

Polkinghorne, D.E. (1996). Transformative narratives: from victimic to agentic life plots. The American Journal of Occupational Therapy, 50, 299-305.

Basic to occupational engagement is a person's personal power to author choices. Impairment in functioning moves some clients from an agentic identity of self to a victimic identity. The change in identity causes previously self-directed clients to adopt a passive and acquiescent stance toward their lives. The recovery of occupational functioning includes the restoration of the person's sense of agency. Recent developments in self theory emphasize the self as a process rather than a substance or thing. Narrative is the discourse mode most able to express identity as a process. Victimic identity is manifest in a self-story in which protagonists have lost power to affect change in their lives; agentic identity is manifest in self-stories of active agency. A study of clients' rehabilitation by Cochran and Laub found that clients' change from victimic to agentic identity moves through four phases: incompleteness, positioning, actualizing, and completion.

Precin, P. (2002). Client-centered reasoning: narratives of people with mental illness. Boston, MA: Butterworth-Heinemann.

Price-Lackey, P. & Cashman, J. (1996). Jenny's story: reinventing oneself through occupation and narrative configuration. The American Journal of Occupational Therapy, 50, 306-314.

Two life history interviews were conducted to discover how one woman, Jenny, experienced a traumatic head injury, rehabilitation, and recovery. Narrative analysis of the transcribed interviews revealed a rich story of how Jenny had fashioned her identity and character through childhood occupations, including studying classical literature and music, and how she drew upon resources developed in childhood to engineer her recovery. It also illustrated how Jenny used a recursive process of narrative construction and engagement in self-devised graduated occupations, including studying, playing music, writing, computer graphics, and theater production, to create a new identity and develop capacities to process complex information and exercise creativity. Jenny's story illustrates the usefulness of gaining a perspective on patients as occupational beings through the gathering of life histories focused on occupation, the importance of collaborative patient-therapist goal setting, and the necessity for considering both the doing (practice) and the meaning (narrative) aspects of occupation. Her story supports many scholars' arguments that the therapeutic relationship, and thus occupational therapy practice, may be enhanced through the use of life history interviewing in occupational therapy evaluation and treatment.

Spencer, J., Davidson, H. & White, V. (1997). Helping clients develop hopes for the future. The American Journal of Occupational Therapy, 51, 191-198.

The purposes of this article are (a) to examine cognitive, emotional, and spiritual aspects of hope as reflected in the literature; (b) to describe three clinical approaches that have been used in occupational therapy to engage clients in development of hopes for the future; and (c) to consider practical issues that have been raised by therapists seeking to incorporate development of hopes in their practice. Literature from health care and the social sciences indicates that cognitive, emotional, and spiritual aspects of hope are interwoven in a complex process that evolves over time after major loss. Three alternative clinical strategies for collaborating with clients in developing hopes are reviewed, including a goal-setting and goal-attainment approach, an occupational change approach, and a life history approach. These clinical strategies are illustrated by the stories of an elderly mental health client, an adult rehabilitation client, and an adolescent orthopedic client, which are drawn from research in which the authors have been involved. Discussion of issues involved in incorporating hope work into daily practice is based on the experiences of practicing therapists who participated in a workshop. These include pragmatic issues of documentation and reimbursement of this aspect of practice as well as clinical issues of how to develop hopes among clients who appear hopeless.

Walsh, A.L. & Crepeau, E.B. (1998). "My secret life": the emergence of one gay man's authentic identity. The American Journal of Occupational Therapy, 52, 563-569.

This qualitative study explores the life history of Bruce, a gay man, from the perspective of homophobia. Homophobia is the fear and hatred expressed toward gay men, lesbians, and bisexual women or men as well as persons suspected of being gay, lesbian, and bisexual. Homophobia may become internalized, creating a form of self-hatred derived from the negative stereotypes associated with homosexuality. Bruce's life was shaped by the homophobia of others and his own self-hatred, leading to isolation and a lack of a projected authentic identity. This article focuses on the affective meanings related to significant events in Bruce's life history and how they contributed to transformation in his life from victimic to agentic themes. It is important for occupational therapy practitioners to recognize the influence that homophobia and internalized homophobia have on therapeutic interventions.

Weinblatt, N., Ziv, N. & Avrech-Bar, M. (2000). The old lady from the supermarket -categorization of occupation according to performance areas: Is it relevant for the elderly? Journal of Occupational Science, 7, 73-79.

Within the profession of occupational therapy there has been a long-standing tendency to classify a person's occupations according to set and concrete categories. Such perception is typical of the modern era. This article addresses the validity of categorizing occupation according to performance areas, in the world of the elderly. The story of an elderly lady's visit to the supermarket provides the backdrop for a theoretical discussion regarding the multiple levels of function and meaning of occupation, particularly for the elderly. The story is examined in relation to concepts of classification according to performance areas. On this basis, the relevance and therefore the validity of such classification in the world of elders' occupations is questioned. In their conclusion, the authors suggest that readers approach the issue of occupations and the elderly in the spirit of post-modernism, a framework more suitable.

Wright-St Clair, V. (2003). Storymaking and storytelling: making sense of living with multiple sclerosis. Journal of Occupational Science, 10, 46-51.

This paper presents one interpretive element of a qualitative study aimed at understanding the lived experience of women with multiple sclerosis. Data were gathered from 16 women by way of a focus group interview (six women) and ten semi-structured individual interviews. Symbolic interactionism was used to build a theoretical foundation for interpreting the day-to-day dynamic relationship between the person, the symbolic meaning of their illness, and their occupations. Narrative quotes have been used in the text to illustrate how the raw data informed the interpretive process. People often use metaphors when it is hard to depict the subjective meaning of things in everyday words. As women in this study talked about living with multiple sclerosis, they crafted narrative images richly embroidered with metaphor. The women's engagement in the intuitive occupations of storymaking and storytelling reveals a rich use of analogies and metaphors to make meaning of and to develop occupational strategies for managing the intrusiveness of their illness in their everyday lived world.

The remaining eleven citations are recent articles from the nursing and medical literature

Archibald G. (2003). Patients' experiences of hip fracture. Journal of Advanced Nursing, 44, 385-392.

BACKGROUND: Hip fracture is a major cause of mortality and morbidity, particularly among older people, but there is little information on how individuals experience this. AIMS: This study was conducted to explore the experiences of individuals who had suffered a hip fracture. The aim was not to produce generalizable findings but, rather, to generate a rich description of the experience of incurring and recovering from a hip fracture, to inform nursing practice. METHOD: Phenomenological methodology was used. A purposeful sample of five older patients was interviewed, following a stay in a community hospital for rehabilitation after surgical repair of a hip fracture. The unstructured interviews were tape-recorded, transcribed verbatim and analysed for significant statements and meanings. FINDINGS: Four major themes emerged: the injury experience, the pain experience, the recovery experience and the disability experience. The injury experience consisted of storytelling, recalling the experience of the injury itself. The pain experience consisted of coping with the pain. The recovery experience involved the operation, beginning the struggle of recovery, and regaining independence. The disability experience consisted of the disability itself, depending on others, and being housebound. CONCLUSIONS: Pain management, meeting psychological and physical needs for nursing care, planning for discharge, and ensuring a reasonable quality of life are areas for nursing care development. Consideration of appropriate settings for rehabilitation is needed and there should be further investigation into improving quality of life after discharge.

Bailey P.H. & Tilley S. (2002). Storytelling and the interpretation of meaning in qualitative research. Journal of Advanced Nursing, 38, 574-583.

AIM: This paper reviews literature on narrative analysis and illustrates the meaning-making function of stories of chronic illness through analysis and discussion of two case studies from a study of acute episodes of chronic obstructive pulmonary disease (COPD). BACKGROUND: Individuals living with COPD experience acute exacerbations characterized by extreme dyspnea, but there has been little research to provide understanding of these events from the perspectives of individuals with COPD, family caregivers, and nurses. Narrative analysis -- considered in the context of the aims of qualitative research -- illuminates how these people make sense of acute exacerbation events by telling stories. DESIGN AND METHODS: In an ethnographic study, 10 patient-family nurse units in two Canadian general hospitals participated in interviews concerning acute episodes of COPD. Narrative analysis enabled identification of several story forms and their functions. RESULTS: Examples were found of a story told twice with different meanings, and of a patient's 'death story' used to communicate distrust of the nurse's ability to recognize the seriousness of distress and implications for its potential course. These examples are presented, and interpreted with respect to issues of meaning. CONCLUSIONS: The analysis indicates that stories told by patients in the context of nurse-client interactions inform understanding of the individual's acute exacerbation events beyond the biophysical.

Chelf J.H., Deshler A.M., Hillman S. & Durazo-Arvizu R. (2000). Storytelling. A strategy for living and coping with cancer. Cancer Nursing, 23, 1-5.

The purpose of this focused program evaluation was to explore attitudes and beliefs about storytelling as a strategy for coping with cancer among participants who attended a cancer-related storytelling workshop. The response rate was 70% (n = 94) and included persons with a diagnosis of cancer, their loved ones, and members of the public. The program coordinators used a theoretical model described by Heiney (1995) that explains how storytelling may produce therapeutic effects in four domains: cognitive, affective, interpersonal, and personal. A questionnaire was designed to determine the extent that conference participants perceived therapeutic benefits in these domains as a result of attending the workshop. Statistical analysis consisted of descriptive summaries of individual questions and domain scores. Findings showed that 97% of the respondents agreed that storytelling was a helpful way to cope with cancer. Most of the respondents reported agreement with the therapeutic benefits of storytelling in all domains, with 85% agreeing that hearing others' stories of living with cancer gave them hope. Although the results of the evaluation were very positive, further study is needed to demonstrate the efficacy of storytelling as a strategy for coping with cancer.

Clarke A., Hanson E.J. & Ross H. (2003). Seeing the person behind the patient: enhancing the care of older people using a biographical approach. Journal of Clinical Nursing, 12, 697-706.

Recent policy statements have stressed the need for fundamental changes to the NHS, especially to the hospital care of older people. Person-centred care underpins such changes. If practitioners are to deliver person-centred care, then they need to learn more about the patient as an individual. One way that this might be achieved is through biographical approaches. This paper describes the findings of a developmental study undertaken over a 6-month period to investigate the introduction of a biographical approach to care on a unit in a NHS hospital. It concentrates on the views of the practitioners who used the approach. The study aimed to explore whether a biographical approach - in the form of storytelling - might be used to encourage person-centred practice. Using a practice development approach, the study explored the views of older people, their family carers and practitioners regarding their participation in life story work. Initial data were collected by focus groups with staff from a nursing home who regularly used life stories as a basis for care planning. Further data were collected through focus groups, semistructured interviews and observation - undertaken before and after the introduction of life story work - with older people, family carers and practitioners. Findings revealed that life stories helped practitioners to see patients as people, to understand individuals more fully and to form closer relationships with their families. Support workers also said how much they enjoyed using the approach to inform their care. Further longitudinal research is required to investigate biographical approaches more fully and to work more closely with practitioners to explore how biographical approaches can be undertaken as part of standard practice and be integrated into the culture and management of care.

Crossley M.L. (2003). 'Let me explain': narrative emplotment and one patient's experience of oral cancer. Social Science & Medicine, 56, 439-48.

Recent research has investigated the way in which serious illness potentially poses a threat to peoples' sense of ontological security by throwing into doubt assumptions about time and the future. One of the main ways in which people adjust to such threats is through the use of narrative (either consciously or unconsciously) which helps to make sense of illness. Of particular relevance to people learning to live with a cancer diagnosis, is the concept of 'therapeutic emplotment' developed by Del Vecchio Good et al. (1994). This concept refers to the way in which oncologists are taught to structure temporal horizons for their patients in a particular way in order to instill and maintain hope in the context of arduous and toxic treatments. Using a case-study of one man's process of adapting to oral cancer (John Diamond's posthumously published serialised diary entries in The Times), this paper investigates the way in which such 'therapeutic emplotment' is implicitly incorporated by the patient, providing an underlying plot structure to his story. Following Diamond's diary entries over the 4 years duration of his illness, this paper analytically divides them into six main stages, documenting the underlying temporal structure and themes accompanying each stage of adaptation. The paper illustrates the way in which 'therapeutic emplotment' encourages the patient to focus on the immediate present and to place faith in the efficacy of specific treatments. However, it also explores how the attempt to live in the context of such a plot is fraught with anxiety for the patient, and how it co-exists with other largely 'unspoken narratives' of uncertainty, fear and skepticism in relation to the power of medicine. The main aim of the paper is to document, for the first time, the process of 'therapeutic emplotment' from the oral cancer patient's point of view.

Frank A.W. (2000). The standpoint of storyteller. Qualitative Health Research, 10, 354-365.

The legitimacy of an interest in illness narratives that is therapeutic, emancipatory, and pre-occupied with ethics is defended in response to Atkinson's critique of this interest as a blind alley. The value of storytelling as complementary to story analysis is argued, and the importance of recognizing one's own standpoint is emphasized. The conclusion considers how qualitative methods can inform changing relationships between illness, health, medicine, and culture.

Gale D.D., Mitchell A.M., Garand L. & Wesner S. (2003). Client narratives: a theoretical perspective. Issues in Mental Health Nursing, 24, 81-89.

Comment on:
Issues in Mental Health Nursing, 24, 91-106.

The role of subjective client narratives in health care represents a clinical and therapeutic tool, useful in complementing objective, scientific data. Of particular interest to mental health practitioners is the role narratives play as a therapeutic tool to guide clinical practice. This paper lays a foundation for understanding the importance of narrative in the psychotherapeutic process.
It provides a brief overview of narrative theory and methods of structural analysis in order to provide a theoretical approach that can be utilized by nurses to address clients' needs.

Haidet P. & Paterniti D.A. (2003). "Building" a history rather than "taking" one: a perspective on information sharing during the medical interview. Archives of Internal Medicine, 163, 1134-1140.

Comment in:
Archives of Internal Medicine, 163, 1131-1132.

Patients and physicians enter the medical encounter with unique perspectives on the illness experience. These perspectives influence the way that information is shared during the initial phase of the interview. Previous research has demonstrated that patients who are able to fully share their perspective often achieve better outcomes. However, studies of patient-physician communication have shown that the patient's perspective is often lost. Researchers and educators have responded with calls for practitioners to adopt a "narrative-based medicine" approach to the medical interview. In this article, we review the literature on narrative-based medicine with an emphasis on information sharing during the medical interview. We suggest a framework of skills and attitudes that can act as a foundation for future work in educating practitioners and researching the medical interview.

Pessin N, Lindy DC, Hicks K, Dreschler A. (2002). Sharing stories, healing shattered lives.
Caring, 21(1), 6-9.

Because of our capacity to provide crisis-oriented mental health services in the field throughout the city, we have played a role as one element of New York's emergency mental health response system. Our goal in the aftermath of September 11, 2001, is to allow the victims to tell their stories. By sharing their stories, individuals start the process of moving from helpless victims to proactive survivors.

Sakalys J.A. (2003). Restoring the patient's voice. The therapeutics of illness narratives. Journal of Holistic Nursing, 21, 228-241.

Reflective and insightful autobiographical accounts of illness not only illuminate fundamental disruptions in selfhood and continuity of life that accompany illness, but authors of such accounts also maintain that narration is an important way to make sense of an illness episode, to restore personhood and connectedness, and to reclaim the illness experience from the medical meta-narrative. That witnessing and helping to order illness narratives can be a caring/healing nursing practice modality with significant healing potential is supported both by narrative theory and by nursing's theoretical and philosophical legacy. The challenge for the nurse guided by narrative ideas is to give primacy to the patient's voice, to listen for meaning rather than for facts, and to provide a relationship enabling the evolution of the patient's story.

Yamada S., Maskarinec G.G., Greene G.A. & Bauman K.A. (2003). Family narratives, culture, and patient-centered medicine. Family Medicine, 35, 279-283.

Comment in:
Family Medicine, 35, 614; author reply 614.

BACKGROUND AND OBJECTIVES: As part of our family medicine clerkship seminar on the patient-physician relationship, third-year students write about an illness episode within their own families. METHODS: Using a grounded research approach, we examined 260 student narratives to extract the most significant meanings. RESULTS: Significant themes that emerged include the role of family members in illness episodes, specific influences resulting from the family's ethnicity or religion, experiences with socially unacceptable illnesses, experiences with death, appreciation of the moral trajectory of illness, and situations that display the fallibility and limitations of medicine. CONCLUSIONS: Writing exercises can help students recognize the centrality of narrative and of cultural values in medicine so they are better able to understand their patients and provide more patient-centered medical care.

1/30/2004

Compiled by Mary Binderman, MSLS
American Occupational Therapy Foundation
Bethesda, MD.