Imagination and Therapy (1)

Imagination-and-Therapy-1-Christian-Jonathan-Haverkampf-psychotherapy-series

Imagination and Therapy

Christian Jonathan Haverkampf, M.D.

The life story narrated by the patient is much more than just a useful tool to maintain a therapeutic interaction. It is a process which provides a wealth of insight and many starting points for individual change. While the content of the narrative can be relevant in itself, awareness for how the narrative is communicated can provide significant insight into the individual needs, values and aspirations of the patient, which is of key importance in the treatment of many health conditions, including anxiety, depression and others.

Keywords: narrative, life story, communication focused therapy, CFT, psychotherapy, psychiatry

Table of Contents

A Story. 1

A Creative Act. 2

Time and Space. 3

Unity and Purpose. 5

Narrative Technique. 6

Mind. 8

Listening. 10

The Individual Life. 12

The Social Context. 14

Navigating Life. 16

The Past. 18

Basic Parameters. 20

Identity. 21

The Self 23

Coherence. 24

Communication Patterns. 26

Awareness. 26

Selecting Communication Patterns. 28

Analysis. 29

Silence. 30

Change. 32

Reality as Fiction and Fiction as Reality. 33

Integration and Transformation. 34

Communication. 34

References. 37

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A Story

It begins with a story. The own story is usually what is the most important story to the patient at that moment. And therapy needs to do something with this story, because if it does not, the patient is not going to feel understood. ‘Story’ means that events, internal and external, are connected. Often, when patients come to therapy, they lack a sense of this connection.

Important about a story is also that it happens in relation to other people and events. Life in general happens within a context. It is thus important to see the narrative of life within the internal and external communication contexts an individual is exposed to. Changes in communication patterns, but also changes in the information one is exposed to can influence the narrative, since the connections in a narrative consist of information.

An increasing number of psychologists argue that people give meaning to their lives by constructing and internalizing self-defining stories. Beginning in adolescence and young adulthood, our narrative identities become the stories we live by. (McAdams, Josselson, & Lieblich, 2006) However, it is important to remember that it is the connections between events in the story and the meaning these events and their connections have for the individual which determines the usefulness of the story.

One can adapt a story if there is new insight or other meaningful information. Life stories usually do not change abruptly, but rather one makes small adjustments over time. Thus, a life story can imbue a significant sense of stability if one is aware of the story and works with it.

As traumatic events challenge the organization of the life story, promote the development of problem-dominated identities, and foster dissociation of experience, the integration of aspects of experience within a life narrative is made more difficult or even precluded. However, by starting the narrative process in a therapeutic setting, not only can the integration process be enlivened and facilitated, but also any dissociative tendencies reduced.

Life stories have been used in therapy for a long time. The Psychodynamic Life Narrative is a psychotherapeutic maneuver used during the first few sessions of a consultation with a patient in a crisis situation. By establishing a powerful bond between physician and patient, it offers the possibility of a rapid relief of dysphoric symptoms. (Viederman, 1983)

A Creative Act

Forming the narrative is a creative act, and it is important that it is viewed as such. This can also increase the motivation in the therapeutic session. The patient gets a sense for creating something which is relevant, while at the same time being very personal and fully owned by oneself. Thus, through the creation of a life narrative, the patient gains insight into the own self and into how the world and the interactions with it are seen.

The story is a selective reconstruction of the autobiographical past and a narrative anticipation of the imagined future that serves to explain, for the self and others, how the person came to be and where his or her life may be going. The need for the life story usually becomes greater when there are subjectively important decisions to make. Maybe this is one reason why the perceived need for a life story becomes greater in late adolescence and early adulthood. It is here where people feel and increased pressure to do the ‘right’ thing in life.

Time and Space

Time and space work differently in a narrative. It is more important how information within the narrative is connected within information space than objective time and space. After all, it is how the narrative makes sense subjectively that has an effect on how it influences future actions and interactions. Time and space in a narrative are malleable, but this is not so different from the real world shared with others. It is what we experience in an interval of time that gives rise to our concept of time, rather than an abstract notion of it. However, we need to be able to measure it to structure our experiences, and to be able to coordinate them with others in the first place. But from a therapeutic perspective, it is important to be able to experience and enjoy a moment, and whatever change happens in it, as distinct from a notion of external shared time.

We seem to have no other way of describing “lived time” save in the form of a narrative (Bruner, 2004), but this time may not be the same time as the time shared with others. Time in a narrative seems to flow differently, and by reflecting on how it accelerates and decelerates at time, we may have a sense of what is meaningful to ourselves. The meaningful moments seem to become more detailed in a narrative, when one shares with others about one’s own life, or if one reflects on the string of memories from the past.

In the therapeutic context new perspectives of time are developed. This is a result of the changing use of external and internal communication patterns. In the therapeutic setting, it is important for a therapist to observe how time and space unfold, which is reflected in the flow of information and the communication patient and therapist use. Since the imagined and associations take place within a space of possibilities and through the use of time, reflecting with the patient on imaginative and associative activities within the dialogue of the therapy can provide the parameters of the parameters of space and time both allow. Fears and anxieties may limit them, obsessive-compulsive dynamics constrain them, and psychotic dynamics distort them, as a reflection of how they affect components of reality in general.

However, as the patient gains more awareness into the own use of space and time, he or she becomes cognizant of important pillars in the construction of reality, which also helps to feel more secure in it, while having a greater appreciation for the stability of time and space, and thus reality itself. This allows a patient to feel safer and broaden the horizon in being imaginative, innovative and creative.

As it becomes safer to work with the own narrative, it becomes possible to reflect on it and make changes, which then in turn influence its future. The framework which allows and prods on towards awareness and insight in the first place is the perception of an overall narrative. A narrative thus provides a fruitful focus in therapy, while also having autoregulatory features in itself.

Unity and Purpose

The self is merely a perception of information flows, and it needs to be filled with meaning in the form of purpose, agency and efficacy. A life story can supply this sense of unity and purpose that focuses the mind on meaning in even the smaller things and seemingly cursory interactions in life. Several mental health conditions are a result if the meaning making process in life is impaired, including anxiety, various forms of depression, burnout and others. By listening to the patient’s narrative and reflecting on how and what is communicated, the patient can be motivated engage in the meaning making process. Awareness and reflection on communication patterns and dynamics helps the patient in distilling meaning when connecting more with oneself and others.

D. P. McAdams’s life story model of identity asserts that people living in modern societies provide their lives with unity and purpose by constructing internalized and evolving narratives of the self. (McAdams, 2001) Research into the relation between life stories and adaptation shows that narrators who find redemptive meanings in suffering and adversity, and who construct life stories that feature themes of personal agency and exploration, tend to enjoy higher levels of mental health, well-being, and maturity. (McAdams & McLean, 2013)

Narrative Technique

A narrative arises form content and the communication patterns used to tell it. Narrative technique is a strategy used in the making of a narrative to relay information to the audience and, particularly, to “develop” the narrative, usually in order to make it more complete, complicated, or interesting. A meaningful narrative brings about changes in those who listen to it, which also includes the narrator.

While setting and perspective can also inform about how the patient sees herself in the world and how she feels she is connected with others and himself, the plot describes what is consciously or subconsciously relevant to the narrator.

Concepts from literary studies can be helpful in reflecting on and working with the narrative.  The use of a backstory, flashbacks, flashforwards, ‘MacGuffins’, red herring and ‘Chekhov’s gun’ as plot devices, as well as defamiliarization, magical realism and (multi)perspectivity as elements of perspectivity shall just be mentioned as constituents that make up a narrative, but at the same time can be psychologically meaningful if used by a patient in the narrative. The use of irony may mask strong underlying emotions, metaphor can make the uncommunicable communicable. Allegory, amplification, distancing effect, imagery, leitwortstil, pathos, sensory detail and many other features of a narrative may be aligned more or less with specific communication patterns. The characters of the narrative themselves represent personalities or fragments of personalities, which are manifestations of constellations of communication patterns, styles and dynamics.

Mind

The mind shows its presence when the patient narrates about life. The mind creates the world and the sense of an ‘I’ in it from the information it receives, processes and communicates. The sense of self is the experience of the totality of information flows (Haverkampf, 2017b) “Life” is constructed by humans just like “a narrative” by active ratiocination. (Bruner, 2004)

The narrative of life begins from birth. Once a human being is exposed to information, there will be an urge to provide a framework for this information. In this regard, a narrative is not very different from other frameworks built for collections of information. However, there is a difference in the sense that it mirrors the development of an organism, which then also provides that organism with a sense of the future and helps in making decisions. When one can call this framework a ‘life story’ may be subject to debate because it seems to require a concept of the past and the future which develops over time. D. P. McAdams’s (1985), for example, suggested that the life story develops in adolescence. In any case, A person entirely living in the now does not need a ‘narrative’ but a well-developed instinct. It is thus our conceptualization of time which invokes the need for a narrative. The need can be reflected on and grasped in the therapeutic session.

Using the telling of a narrative to investigate the own theory of mind and how one sees oneself in the world can be an important step in gaining insight into the own needs, values and aspirations. The narrative ascribes importance to the narrator and the actors in it, which also reflects on what the patient finds relevant and meaningful in life.

Listening

Listening is one of the most important tools in psychotherapy. It is what therapists do mostly, because it leads to greater understanding and insight for not only what is being communicated, but also how it is being communicated. Listening also encourages the imagination, because we tend to invest more energy into the imagination if the information is shared. Listening also helps the patient to put the imagined into words, which can both make it more real and easier to analyze and scrutinize.

Listening and responding also facilitates a focus on the communication dynamics, which reflect the narrative structure (Haverkampf, 2018a). It needs to be kept in mind that how an individual integrates experiences, whether in the outside world or on the inside, is determined by the communication patterns used and the existing communication structures. As such, one should see communication patterns, such as listening, and the formulation of a narrative as interlinked.  Brown and colleagues, for example, have argued that both approaches, “listening to patients” and the “narrative turn”,  tend to embody similar assumptions about therapeutic transactions and roles, and that much work emphasizing narratives reveals little about how therapists and researchers work to reconstruct the clients’ accounts (Brown, Nolan, Crawford, & Lewis, 1996) Therapeutic encounters work to co-construct clients’ narratives, rather than simply reflect or explore them, (Brown et al., 1996) and communication patterns and dynamics are the elements which can be made analyzed and changed. (Haverkampf, 2010b)

The Individual Life

As already mentioned above, the own life does not happen in a vacuum, but in a highly interconnected space. Even a hermit is in contact with the natural surroundings, that send and receive information. With the exchange of information, either within oneself or in the universe as a whole, there is life, without it, life ceases. The individual life is thus not only built on information, but even more profoundly, on the exchange of that information.

Making meaning is an important part of formulating a narrative. Actions or interactions can acquire additional meaning through the view of a narrative. Seeing more meaning in the world and one’s life, has significant secondary effects, such as increased motivation and greater perceptions of efficacy and agency. An important aspect of meaning making is, however, how meaning is made. The meaning-making process should support the individual in life and further the individual primary parameters of needs, values and aspirations. McLean and colleagues, for example, interviewed thirty-one vulnerable adolescents to elicit commonly studied autobiographical memories (e.g., turning points, self-defining memories). Results showed that desistance from criminal behavior was related to agency, but not meaning-making, which was related to higher numbers of past delinquent behaviors. (McLean, Wood, & Breen, 2013)

The word ‘individual’ stems from the Latin word ‘individuus’, meaning indivisible. It refers to the properties of unity and coherence of human beings already discussed rather than the separation among them. ‘Individualism’ is in this sense frequently misused because it is often more associated with the separation among individuals rather than the properties of each of them. A narrative appeals to unity and coherence of experience because if it is split up into segments it ceases to be the original narrative. It only makes sense as a whole.

The Social Context

Listening to a patient happens within a communication context in a relationship, a work situation or the larger community as a whole. Listening to how a patient experiences situations and interactions also helps to gain insight in how they communicate with the environment and how the environment communicates with them. This can have a significant impact on the patient’s own thoughts and feelings and how the views and narrative of the inner world and the place in the outer world are constructed.

In constructing self-defining life stories, people draw heavily on prevailing cultural norms and the images, metaphors, and themes that run through the many narratives they encounter in social life. Conceptions of narrative identity began to emerge in the social sciences in the 1980s with the writings of philosopher, psychologists, and social theorists. (McAdams, 2011)

The interactions with others in a community are even more relevant than just the information that is being exchanged, because they also show how information is selected and the patterns that are being used, such as more open or more closed information acquisition patterns. A narrative influences how one sees oneself and in the world and the communication patterns that are being used. Niederdeppe and colleagues, for example, had participants view one of three messages (narrative, evidence, and a hybrid of the two) emphasizing environmental causes of obesity, or a no-exposure control condition, and reported that the narrative condition increased the belief that societal actors (government, employers) are responsible for addressing obesity, but only among liberals. (Niederdeppe, Shapiro, & Porticella, 2011)

Navigating Life

Helping a patient make better decisions in life is to help him have a sense of a narrative and to be able to navigate through the various aspects of the world.

The construction of a life-story is a major element in the development of authentic leaders. Shamir and Eilam-Shamir argued that authentic leadership rests heavily on the self-relevant meanings the leader attaches to his or her life experiences, and these meanings are captured in the leader’s life-story. They suggest that self-knowledge, self-concept clarity, and person-role merger are derived from the life-story. (Shamir & Eilam-Shamir, 2018)

Events in life can make a difference. Ligon and colleagues were able to link outstanding leaders of the twentieth century evidencing a particular leadership type (charismatic, ideological, or pragmatic) and orientation (socialized or personalized), as well as their leadership performance, to certain types of developmental events. Sim (Ligon, Hunter, & Mumford, 2008) However, it may be at least or even more important how a person integrates the event into the own narrative for the success in a leadership role in life in general. The telling of the story of one’s life in a therapeutic setting can  help the integration process, which clinically seems to reduce anxiety, fear and even symptoms of depression. (Haverkampf, 2018b)

Research into the relation between life stories and adaptation shows that narrators who find redemptive meanings in suffering and adversity, and who construct life stories that feature themes of personal agency and exploration, tend to enjoy higher levels of mental health, well-being, and maturity. (McAdams & McLean, 2013)

The Past

The past is past. The facts can no longer be changed. However, what can be changed is how one views the past, which can have an effect on present thoughts and emotions, and by extension, on the facts of the future. A life narrative is a framework which informs the perspective one has in viewing, analyzing and reflecting on the past.

In the life story, autobiographical remembering and self-understanding are combined to create a coherent account of one’s past. This coherence seems to be important as it seems to reduce anxiety and gives a person greater confidence in following one’s own compass rather than seeking for external validation from others. A coherent narrative can make it thus easier to follow one’s own perception of own needs, values and aspirations. The past can thus have a stabilizing effect if integrated into the ‘life story’ in a helpful and supportive way. This integration, however, depends on the communication patterns one uses both with oneself and others.

Adolescence is often the first point at which a developing individual has some past information and a cognitive sense and some understanding of the world to think about a ‘life story’ and a future. Habermas and Buck, for example, conducted a review of research which showed that the cognitive tools necessary for constructing global coherence in a life story and the social-motivational demands to construct a life story develop during adolescence (Habermas & Bluck, 2000). However, the life story will be revisited from then on many times later in life. This repetition hints at the benefit a person hopes to derive from figuring out and having a life story. And indeed, if this can be done in a helpful way, the benefits can be plentiful. In the therapeutic session, one often works by sheer necessity with the concept of a life story. In the society we live in, it is suggested by media and marketing virtually at every turn that one needs a life story, while propagating repeatedly a limited set of idealized template life stories. By going back to an individual’s unique past, however, it is possible, even unavoidable, that a truly unique and individually fitting narrative in progress can be conceptualized and crafted.

Basic Parameters

The basic parameters are those values which over time are unlikely to change, such as basic needs, values and aspirations, but which are important in elucidating what will bring the greatest measure of happiness, enjoyment, satisfaction and contentment over the long-term (Haverkampf, 2010a, 2018d). An economist may say these are the attributes one derives maximum utility from. Interestingly, many people have never taken the time to identify them, although it would make decisions and their life overall easier.

Life experiences and how one interacted with oneself and with others provides ample, and one may say deep information about these basic parameters. All our actions and interactions are co-determined by theses basic parameters. Knowing more about them can provide the feeling of stability people often crave for in the world. By knowing about the stable parameters inside oneself, which also leads to more stable interactions with the world, less external stabilization in the form of, for example, external validation and material goods is needed.

Simply describing one’s life in a therapeutic setting can lead to a substantial stabilization. A focus on how it is communicated can provide insight into the basic parameters.

Identity

Narrative identity is a person’s internalized and evolving life story, integrating the reconstructed past and imagined future to provide life with some degree of unity and purpose  (McAdams & McLean, 2013) and  to make sense and meaning out of his or her life. (McAdams, 2011). Identity has also been defined as ideology cognized through the individual engagement with discourse, made manifest in a personal narrative constructed and reconstructed across the life course, and scripted in and through social interaction and social practice. (Hammack, 2008)

It is important to remember that identity is a product of communication with others. For an identity to evolve it needs reference and comparison to other identities, cultural or individual narratives. Identity arises through meaningful communication with others. Mostly this is a healthy process. However, if a person, frequently an adolescent, does not experience sufficient connectedness with the own needs, values and aspirations and ‘loans’ them from others, the identity is bound to be less stable over time, leading also to greater anxiety and indecisiveness. The personal narrative in a therapeutic session can help to reestablish this connectedness emotionally and cognitively, which is may be one of its most important purposes.

It is the internalized and evolving story of the self that a person constructs to make sense and meaning out of his or her life. (McAdams, 2011) Researchers have tracked the development of narrative identity from its origins in conversations between parents and their young children to the articulation of sophisticated meaning-making strategies in the personal stories told in adolescence and the emerging adulthood years. (McAdams & McLean, 2013).

The individual identity needs to retain some flexibility over time to allow for changes due to adaptation, insight or other beneficial factors. There has to a balance of accuracy in remembering situations, actions, interactions and feedback from others, and the ability to interpret it and see meaning in it which can go beyond the face value of the memories. Singer and colleagues described how memories related to critical goals in a lifetime period lead to life‐story memories, which in turn become self‐defining memories when linked to an individual’s enduring concerns. Self‐defining memories, which share repetitive emotion‐outcome sequences, yield narrative scripts, abstracted templates that filter cognitive‐affective processing. (Singer, Blagov, Berry, & Oost, 2013)

The Self

The self is in some sense everything and nothing. It is the experience of the information flows within an individual in their entirety. Various centers in the brain receive and exchange information with virtually any other cellular systems in the body. Even the more highly specialized systems that are involved in the information cascades from the sensory organs are influenced by other information, and the internal communication highways are exposed to a host of influences from practically everywhere. While we can identify these centers and particular types of information in the central nervous system, this insight should be seen as probabilistic rather than absolutistic. It ultimately reflects the stochastics of information dynamics.

One function of psychotherapy is to assist in the reconstruction of a meaning-giving narrative of self-identity. (Polkinghorne, 1991)

Coherence

Coherence refers to relationships between parts, such as they both naturally or logically fit together, and they form a larger whole which is identifiable as such. In a coherent narrative these parts are the information bundles from experiences, whether caused by oneself or others. Basically, a narrative is like a puzzle which does not consist of colorful tiles but of information about things. Life narratives have been categorized into the temporal, biographical, causal, and thematic, but for a narrative to be ‘whole’ really means that it is beyond such categorization, that it includes all those elements and more to benefit the audience for the narrative, which is foremost the own person.

Coherence derives from how the narrative reflects on the communication patterns an individual has with oneself and with the rest of the world, internally and externally. In this regard, it can be a powerful tool in therapy, even for traumatic life events which have the power to disrupt those self-narratives with which people order their life experience.

Neimeyer and colleagues provide a clinical example in  which a client and therapist collaborate to help the former reconstruct the meaning of her mother’s suicide, ultimately moving toward greater coherence and hopefulness in the narration of her life. (Neimeyer, Herrero, & Botella, 2006)

Communication Patterns

Communication patterns are what makes a narrative possible because the latter needs to be communicated and to reflect internal and external communication events in order for it to be a narrative. If it does not contain these information exchange dynamics, it is not sustainable as a narrative.

When patients tell ‘their stories’ in the therapeutic setting, they not only communicate narratives, but through the narratives also comment on relationships, events, emotional states and any other conceivable event that left a trace in memory. For example, narratives can be about attachment in various complexities as children’s cognitive abilities develop (Oppenheim & Waters, 1995). These individual views on relationships can be helpful in the therapeutic process.

Awareness

Awareness of communication patterns is the first important step in the cascade leading to change. This often requires as a first step that a patient becomes aware of internal and external communication processes, which involves taking a step back and observing the dynamics internally and externally. By making communication a topic in the therapeutic setting the patient learns to focus on it. The personal narrative is an important early example of the process in which awareness for communication can be generated, as the therapist reflects with the patient not only on the content of the patient’s narrative but also on how it is told, as well as on the communication that may be behind or associated with the experiences the patient is describing.

Psychotherapy is only one context of many in which metaphor generation has been associated with achieving a new insight or understanding (L. E. Angus, 1992) In “talking” therapy, the personal-experience narrative provides a vehicle through which the patient and therapist can vicariously co-process experience, a common therapeutic process that is also found in music, movement, and art therapies. (Adler, 1997) Looking at talk as it unfolds in interaction can further our understanding of the relationship dynamics, the joint construction of new meanings and other interactional processes that underlie psychotherapy. (Avdi, 2008)

Language and communication abilities do not remove the ability to engage in narrative construction and telling a story. For example, children with specific language impairment and those with autistic spectrum disorders do not to show more anomalies in the global evaluation and structures of their stories, although both groups tend to make more syntactic errors, and children with autism seem to be significantly more likely to provide ambiguous references in the story. (Norbury & Bishop, 2003)

Selecting Communication Patterns

The choice of communication patterns seems to have an effect on how helpful the story is to the individual. Through the narration of personal events in a psychotherapeutic setting patient and therapist can get a sense for the things that are relevant to a patient, whether thoughts, ideas, events, feelings, and more. As long as the story can be started and developed on an empty and unbounded canvass, which the therapeutic setting widely allows, it can provide a wide range of answers about what is important to the patient. The communication patterns used by the patients become clearer as the narrative covers wide ranges of the patient’s life. This facilitates the process of helping the patient to create greater awareness for these communication patterns and more practice in working with them, as the therapist supports this process also with helpful feedback.

The object of narrative inquiry is understanding-the outcome of interpretation rather than explanation. (Kramp, 2003) This is an important process in the therapeutic setting as communication is used to make sense of events. This process of ‘making sense’ for the individual helps psychologically in myriad ways if patients can increasingly use it in their everyday life. It can increase motivation, innovation and initiative and change feeling states towards the more positive. This also helps patients to get a better sense for their internal and external communication patterns and their needs, values and aspirations in the short- and the long-term.

Taylor proposed an expanded analytic focus which considers how the versions of a biographical narrative produced in previous tellings become resources for future talk, thus setting constraints on a reflexive speaker’s work to construct a coherent identity across separate interactions and contexts. (Taylor, 2006)

Langs and colleagues explored two measures of unconscious communication, referential activity and newness of themes and extent of narrative/imagery. Findings included significant correlations between referential activity and both newness of themes and extent of narrative/imagery. Newness of themes and extent of narrative/imagery also correlated significantly with each other. Scores on the measures tended to be lowest with the therapists who spoke most often. (Langs, Bucci, Udoff, Cramer, & Thomson, 1993)

Analysis

Different communication patterns will be used during different stages in the narrative. The use and modification of different communication pattern with different communication elements has meaning in itself, while it also reflects different ways of working with information, externally and internally. Especially in the context of a more complex narrative, it is helpful for the therapist to create greater awareness with the patient for the communication dynamics, and how communication is used. It not only leads to more insight, but it also helps in working with the patient on improving internal and external communication patterns, which can have a very immediate and real effect in the patient’s personal and professional life. At the same time, an awareness for how communication patterns change when the patient recounts chapters from the individual life story can lead to insight about the patient’s basic parameters, such as basic, needs, values and aspirations (Haverkampf, 2018d).

The Narrative Processes Coding System (NPCS) uses therapy text to subdivide therapy session transcripts into topic segments according to thematic content shifts, and further subdivide and characterize these topic segments in terms of 3 narrative process codes: external description of events; subjective/experiential description; and reflexive analysis of current, past, and/or future events. (L. Angus & Hardtke, 1994)

The systematic, rigorous, meticulous and reflexive way of studying talk provided by language-based analysis constitutes a very useful, yet largely unexplored and underutilized, resource for practitioners and researchers of psychoanalysis. (Avdi, 2008)

Silence

One may forget that moments of silence are also part of a group of diverse communication elements, which can be part of communication patterns. They should not be seen as a breakdown in communication, but in themselves can convey information. For example, a patient or therapist who is reflecting on something that has been said conveys through the moment of silence that something relevant and potentially meaningful has been communicated. This communication can be further reflected upon by therapist and patient, if they are aware of the silence and can adequately decode and create meaning from it.

Silent moments entail processes that facilitate therapeutic progress, and it has been said that what remains unsaid in the psychotherapy narrative transforms narration into a therapeutic experience, in which the narrative structure the moments of silence. (Levitt, 2002) Nonverbal communication is communication, but the tools we have to describe and discuss it are often inadequate. Empathy is, for example, a very information rich form of interaction, but many content focused therapies treat it as extrinsic or do not address it at all (Haverkampf, 2019), except that it is something that would be nice to see in a therapist. Communication-Focused Therapy (CFT), on the other hand, as communication centered therapy views empathy as a form of communication that conducts the exchange of meaningful information.

Change

Telling a narrative can lead to change as the structure of narrative communication facilitates further learning. Sharing learning through narrative communication, including recounting, reflecting and consolidating can itself be further learning from the original experience. (Cortazzi, Jin, Wall, & Cavendish, 2001) Narrative communication is a basic mode of human interaction and a fundamental way of acquiring knowledge. For example, in the rapidly growing field of health communication, narrative approaches are emerging as a promising set of tools for motivating and supporting health-behavior change. (Hinyard & Kreuter, 2007)

Narratives allow for order and creativity and the same, which makes them so powerful in psychotherapeutic or any communication-related work. Josephsson and colleagues refer to this twofold function of the narrative as a mechanism for producing order and creativity and use data from qualitative empirical research relating to human occupation to demonstrate them. (Josephsson, Asaba, Jonsson, & Alsaker, 2006)

Reality as Fiction and Fiction as Reality

Fictional narratives, as in a book, a movie or advertisement, are often more powerful than a simple rundown of facts could ever be. On reason may be that fictional narratives integrate the facts into a structure, and the sense of structure is something humans desire. There are good reasons for it because it makes it possible to plan and design a future, while reducing anxiety about it. Murphy and colleagues empirically tested whether using a fictional narrative produces greater impact on health-related knowledge, attitudes, and behavioral intention than presenting the identical information in a more traditional, nonfiction, nonnarrative format. The narrative was more effective in increasing cervical cancer-related knowledge and attitudes. Transportation, identification with specific characters, and emotion contributed to shifts in knowledge, attitudes, and behavioral intentions. (Murphy, Frank, Chatterjee, & Baezconde-Garbanati, 2013)

To a certain extent, every narrative has fictional elements. A narrative is a selection of internally and externally derived information and not a faithful reproduction of factual events in shared reality, which would make it a historical account. Rather, a story can be a complete reinterpretation of the world as it is relevant and meaningful to the people formulating and adding to the story. In this sense, a life story is maybe one of the most personal creative acts, which, together with its effect on emotion and cognition, makes it such a powerful instrument for change.

Integration and Transformation

Singular events described in a therapy relationship come to be articulated, experienced, and linked together in such a way that the client’s sense of his or her life story—in essence, the sense of self—may be transformed at the conclusion of the therapeutic relationship. (L. Angus, Levitt, & Hardtke, 1999)  In the Narrative Processes model, for example, emphasis is placed on the strategies and processes by which a client and therapist transform the events of everyday life into a meaningful story that both organizes and represents the client’s sense of self and others in the world.  (L. Angus et al., 1999)

Communication

A focus on communication provides an ideal entry point into working with narratives and an effective therapeutic tool over the course of therapy, as there is much to be gained in insight from how the patient talks about the own life, and how interactions with oneself and others are described. The work with communication patterns has been described by the author in greater detail elsewhere (Haverkampf, 2010b, 2017a, 2018c).


Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy, law and economics. He works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. Jonathan is the author of over two hundred articles and several books. He can be reached by email at jonathanhaverkampf@gmail.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.

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