Time in intensive care can lead to post traumatic stress and other problems. While telling stories can help psychological recovery, some patients need support in this
Susan Lecky Williams, PhD, MDiv, BA, is self-employed counsellor, clinical supervisor and lecturer.
Williams SL (2010) How telling stories helps patients to recover psychologically after intensive care. Nursing Times; 106: 4, early online publication.
Background Studies have shown both the risk of post traumatic stress following intensive care unit treatment, and the helpfulness of telling trauma stories for psychological recovery.
Aim This article is based on recent doctoral research exploring the impact of unexpected life threatening events after admission to hospital.
Method The original research used a qualitative design blending discourse, narrative and phenomenological approaches, guided by sensitivity to participants’ evolving work of pulling stories together. Patients chosen from ICU discharge summaries showing a critical life threatening event after admission gave unstructured interviews soon after discharge from hospital and a year later.
Results This article focuses on one particular finding, showing that critical illness can make it difficult for patients to construct personal stories of their experience. Limited evidence suggested overcoming those difficulties meant they had an improved sense of wellbeing a year after discharge.
Discussion Stories are an essential way in which humans make sense of their experience, which is crucial both for responding appropriately and for personal wellbeing following traumatic life events. Therefore, difficulties in “storying” significant experience can have a negative impact on wellbeing.
Conclusion Some patients need help piecing together stories of their critical illness experience.
Keywords: Intensive care follow up, Post traumatic stress, Storytelling
- This article has been double-blind peer reviewed
- Understanding the function of story processing could give ICU follow up clinics and nursing staff a clearer sense of their potential contribution to critically ill patients’ psychological recovery.
- Practice development initiatives could also enhance nursing communication. Since story construction is central to people’s core identity processes, these findings would also be relevant to person-centred nursing objectives.
After intensive care treatment, patients sometimes suffer from post traumatic stress (for example, Sukantarat et al, 2007; Cuthbertson et al, 2004; Jones et al, 2001). The issues arising from the psychological effects of critical illness can be both immediate and long term (Pattison and Dolan, 2009). Turning traumatic events into stories is considered crucial to recovering psychologically from overwhelming life experience (Meichenbaum, 2006; Tuval-Mashiach et al, 2004; Herman, 1994). However, until recent research explored the impact of unexpected life threatening events after admission to hospital (Williams, 2008), the role of story construction in resolving traumatic memories after ICU had not been investigated.
How are personal stories normally used?
Before reviewing findings from the original doctoral study, some background information on how people use personal stories and their benefits helps clarify the significance of those findings. We all use stories to make sense of our experience of both the external world and our internal world of thoughts and feelings. This organic process helps us respond appropriately to the environment, which can be crucial for survival. “Storying” our experience (the process of constructing and telling the story) is so automatic we usually only become aware of the process when something gets in the way. When an experience is personally significant, difficulties with storying can be extremely distressing.
Pulling together a story
Stories are not just handed to us, even though they often seem to come automatically. Our brains have to select and order significant information from an ocean of sensory information (Kelly, 1963) before the meaning of an experience can be understood. Experiential information is organised by linking internal and external events into an increasingly clear and personally meaningful story. Stories can have coherence on a number of dimensions (McAdams, 2006; Androutsopoulou et al, 2004; Habermas and Bluck, 2000), such as those listed in Box 1.
Box 1. Dimensions of coherence in stories
Temporal coherence: the story hangs together chronologically with a unified timeline (Ricoeur, 1991), creating order out of chaotic fragments of experience, which contributes to a sense of personal peace.
Causal coherence: the story makes sense either of why events turned out the way they did, or why the cause is uncertain.
Emotional and cognitive coherence: the story blends the storyteller’s feelings with information about events, helping them understand and cope with event related emotions.
Thematic coherence: the story links current experience to knowledge about similar kinds of experience, contributing to a growing understanding and personal wisdom about life.
Autobiographical coherence: the story weaves the event into a wider life story so the person’s sense of self can absorb and grow with the experience. This also reconstructs and stabilises that sense of self in the wake of experience which may have shattered identity processes.
Once stories are coherent enough, tellers can use them to achieve various social goals, such as gaining understanding, respect or sympathy, or even making a moral point (Mishler, 2004; Harvey et al, 2000; Baumeister, 1994). Eventually, a transformational turning point can be worked into the story, potentially even changing the plot completely (Meichenbaum, 2006) from, for instance, a tragic story of events beyond one’s control to an epic story of true grit. Through this transformation people can move on from the original experience of helpless passivity to become more active survivors.
Storying experience helps people cope with powerful emotions after trauma, and also has health benefits when coping with more general forms of stress (Tuval-Mashiach et al, 2004; Smyth and Pennebaker, 1999).
Processing past experience through storying can help people contemplate a future that moves away from that past. It can also make personal communication more meaningful. For instance, relatives and friends can be kept in touch with identities that change through experiences, both bridging relationships and enabling others to offer appropriate comfort. All this helps storytellers manage life more effectively.
Because this story process is cumulative, each step towards transformation and integration depends on completing the previous task (Salvatore et al, 2004). If the event related information is not gathered, it is impossible to construct an adequate story. If the emotions are not integrated into a coherent personal account, then the personal meaning of the event cannot be adequately grasped and then embraced within the wider life story (McAdams, 2006; Neimeyer et al, 2006). This also means that help with stories must respect patients’ level of event awareness at the time of any intervention, because, for instance, lack of emotional integration can mean they have yet to overcome obstacles to comprehending the event, such as feeling terror.
Any significant failure to complete stories can mean that thoughts or feelings from the experience may return unbidden in the form of intrusive visual or emotional memories, which are hallmarks of post traumatic stress (Herman, 1994; Horowitz, 1987). Patients may need to tell stories repeatedly to achieve both multidimensional coherence and shared understanding with relatives and friends (Harvey et al, 1990).
This research was carried out in a regional intensive care unit with full ethical approval. Participants selected from ICU discharge summaries gave informed consent before being interviewed in a place of their choice, with follow up interviews carried out a year later. All interviews were unstructured and explored participants’ experience of the critical incident and its aftermath.
Data was analysed by coding three uses of language (that is, language rich in discourse, discursive narrative, and phenomenological narrative) and applying appropriate forms of analysis, with sensitivity to the constructive process of storytelling.
Results and discussion
Problems with storying
ICU patients experienced difficulties with their ability to construct stories of their critical illness. Because people care about putting significant life experiences into stories, and critical illness experiences are inherently significant, patients were distressed about these difficulties with storying their illness.
The first hurdle: an information gap
To begin with, lack of consciousness, whether total or partial, not only meant the flow of sensory information to the brain was interrupted, but also more difficult to order. Patients were keen to collect the facts of what happened when they were critically ill. This had nothing to do with patient rights, but rather a need to know information which was first and foremost their own personal information, even if they might be the last to hear about it. This information gathering marked the crucial beginnings of story formation. One patient said:
“The thirst for knowledge is there, if you know what I mean, because it’s happened to you.”
Essentially, patients need to reclaim ownership of a momentous event in their life by knowing what happened. Another said:
“It’s hard to believe that it’s happened. And everybody else is talking about it and it’s as if I wasn’t there, but I suppose I wasn’t really.”
Not knowing was like being an outsider in this patient’s own life. Constructing her story helped her not only to gather the facts when she was ready for them, but also to believe it actually happened. This helped her overcome the shock that such a catastrophic event could suddenly have left a healthy 26-year-old semi conscious for three weeks after admission to hospital just to give birth. But she could never have absorbed that reality if she had not acquired the information about what happened first.
That information in part helped to fill a memory gap (Griffiths and Jones, 2000) about what occurred during her period of unconsciousness. However, patients’ lack of memory is not the only information gap. Even when friends, family or patient diaries contribute to personal information, people need medical information (Wessen, 1997) to grapple with the esoteric facts about their particular condition and treatment. This research highlighted a lack of reliable and timely help for patients with both kinds of information.
Struggles to organise the story
Patients struggled to mesh their own memories with facts provided by staff. In the process of telling stories repeatedly, delusional memories could eventually be reinterpreted and storied as delusional, but only after acknowledging them as real - however delusional - parts of their story (Williams, 2008). This was just one of the ways in which patients found it hard to unify the many strands of their experience.
Different strands of time: the sense of disorientation, typical of intensive care experience, was helped by blending private timeless memories with information about what was happening in real time during the illness. This blending helped patients to give their story temporal coherence. Patients who had had periods of unconsciousness found it hard to order stories in relation to time. This can be extremely disconcerting since this kind of coherence helps people feel oriented in relation to the rest of the world (Ricoeur, 1991). Also, we expect to feel oriented in time, since by the age of three most people can tell stories with some temporal coherence (Habermas and Bluck, 2000). Temporal coherence not only facilitates storytellers’ connection with the outside world, but also helps listeners connect personally with stories.
Different explanations of cause: after accounting for what happened, patients needed to explain why events occurred; the more clearly storytellers can account for why events occurred, the more causal coherence their story has. This matters, because the better patients could understand why an event occurred, the more prepared they were to take responsibility for their own healthcare again.
Struggles to make sense of new experience
Sudden illness meant patients were not prepared for what happened, which can mean they lack an adequate conceptual framework for making sense of those experiences (Janoff-Bulman, 1989). The number and complexity of new experiences for patients are compounded by all the objects and staff whose functions are often a mystery. The medical technology of an ICU can be, at the very least, an overwhelming experience, particularly if people’s faculties are impaired.
Nearness to death was also a new experience for most patients, which made it difficult for them to adequately story their experience. There is a significant difference between contemplating the meaning of death from afar (either in the abstract or in relation to someone else) and confronting its stark reality personally (Bush, 2002). Death anxiety is a common response to sudden life threatening events (Lifton and Olson, 1976). The total loss of physical control intrinsic to critical illness is intensified by the global existential loss of control in a near death encounter (Arndt and Solomon, 2003).
At the same time, though often disguised by a deceptively calm exterior, the power and quality of emotions were new to patients (van der Kolk, 1996). An emotion such as terror is not only more powerful but also quite distinct from fear, just as rage is more powerful but also quite different from anger. Also, a number of different feelings were experienced simultaneously, all at a time of physical weakness when patients were far less able to manage the power and complexity of emotions.
This multidimensional newness can overwhelm cognitive/emotional regulatory systems, resulting in numbness and shock. The experience of shock can itself be new, leaving people that much less able to pull a unified story together, since emotions are not cognitively accessible for integration into stories. People can therefore experience powerful emotions on one level while not being aware of them (Lane and Schwartz, 1987), leaving them feeling helpless and powerless over those feelings. This can feed spiralling emotional reactions to the global loss of control, encompassing both internal and external life worlds. Box 2 outlines risk factors for difficulties or obstacles in storying.
Box 2. Specific risk factors
- A diminished sense of self-efficacy (Bandura and Locke, 2003) made it less likely that patients would tackle the obstacles to story construction.
- Relatives and friends sometimes resisted patient attempts to gain information (Lepore et al, 1996), perhaps concerned about making the distress worse. But crucial social support (Brewin et al, 2000) was compromised along with the story process. One patient told her husband: “Whenever I start to ask you questions and you, you answer me them, but you would say don’t dwell on it; but it’s stuff I need to ask, but then I do, I just carry on” (Williams, 2008).
- Avoidant reactions inherent in post traumatic stress can create yet more barriers to constructing illness experience stories.
Some benefits of a coherent story
Clarity of understanding of experience had crucial benefits for recovery. Firstly, authoring (that is, assuming the authority to construct their own) coherent narratives of critical illness experience helped patients begin to regain control of their lives (Baumeister, 1994) and then manage personal healthcare again after discharge. This personal control also made it possible to reconstruct life after a major event if their former way of life was no longer viable. Telling coherent stories also diminished the sense of isolation left by the intensely individualised illness experience (Guay et al, 2006).
Even more importantly, constructing coherent stories helped patients regain a sense of wellbeing by providing a framework for transforming their experience into a personally meaningful and even beneficial event (Meichenbaum, 2006; Joseph and Linley, 2005; Tuval-Mashiach et al, 2004; Calhoun and Tedeschi, 2001). One patient said:
“When something bad happens to you, you draw strength from it, you know. Once you recover, you know, that gives you strength to recover so…it made you stronger. So there’s a good thing there. Right? And it makes you more careful, wiser, you know? So there’s another good thing.”
This patient’s story was the most coherent on all five dimensions listed in Box 1, as well as the most clearly transformed from a distressing life experience to a beneficial life event. This person was also most able to focus on the future, and the most capable of thinking realistically about the life changes necessitated by the critical illness.
This study extends previous research showing the benefits of transformed personal trauma stories for personal wellbeing to the critical care setting. It suggests the pivotal role of storytelling for psychological recovery after ICU treatment. However, as this exploratory research used a small sample, future studies are needed to substantiate these findings.
- This article is based on a study originally published in Nursing in Critical Care (Williams, 2009).
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