Tuesday, April 2, 2013
Robyn Fivush and Chikako Ozawa-de Silva
In the third CMBC lunch in three weeks, Robyn Fivush (Psychology, Emory University) and Chikako Ozawa-de Silva (Anthropology, Emory University) offered differing, albeit complementary, perspectives on the role that telling one’s story can play in healing psychological wounds.
Naikan and Narrative
Ozawa-de Silva spoke about the transformation that patients undergo in Naikan, a Japanese therapeutic practice, which employs a method of eliciting narrative reconstruction of past events. Naikan stands out from other forms of narrative-based therapy in that it does not involve any active social interaction. It proceeds entirely between patient and practitioner. “Naikan” means inner looking or introspection. A therapeutic session takes place over the course of a week, during which time the patient undertakes an examination of past acts and deeds from the third-person perspective.
The shift in perspective from the first- to the third-person is the crucial component of Naikan therapy. The shift is initiated by a series of structured questions designed to help patients gain a better understanding of themselves, their relationships, and the fundamental nature of human existence. The client is asked to choose a significant person in their life to focus on (typically starting with the mother) and then to record answers to the following three questions: (1) what did you receive from this person? (2) what did you give in return? and (3) what trouble did you cause this person? Note that there is not a fourth question about how this person caused trouble for the client. That is because focusing on how we have been troubled comes easily to most of us, and runs counter to the shift away from the first-person perspective that Naikan intends to facilitate.
In order to foster deep introspection, during the treatment period the client is not allowed to talk to anyone, read, or watch television. One signal of transformation over the course of the week is the client’s increasing use of the passive voice. Instead of saying “I love…,” for example, the client will begin to say “I am loved.” This shift indicates that the client has become more reflective and begun to think from the other person’s perspective. Although the shift in perspective does nothing to alter external circumstances, it does alter how the client views those circumstances, and can make them less painful. Ozawa-de Silva noted that for this reason Naikan is described as a “cure without curing.”
Ozawa-de Silva identified three positive changes typically undergone by the time Naikan therapy terminates. (1) Increased sense of connectedness with others. Through their reflections on the roles that other people have played in their lives, clients come to see that they are not as “self-made” as previously thought. (2) Increased sense of self-acceptance. Many clients start Naikan therapy suffering from low self-esteem. Naikan helps them to gain a more balanced perspective on themselves. People start to accept their imperfections more, because they feel relief that they have friends and relatives who accept them for who they are. (3) Greater sense of gratitude. This point is connected to the first two. Naikan reflections highlight the ways in which other people have played important parts in the client’s life, leading to a sense of appreciation of others’ roles. According to Ozawa-de Silva, these upshots of Naikan bear a close relation to the three main categories of positive mental health: emotional well-being; psychological well-being; and social well-being. The positive effects of Naikan are measurable even months after the end of the therapeutic session.
Is Storytelling Always Therapeutic?
Narrative clearly plays a central role in the therapeutic successes of Naikan. In American culture, too, it is widely held that talking through negative experiences can have therapeutic import. Fivush’s presentation sought to interrogate this widely held view and to highlight some potential limitations of storytelling for therapy. She agreed that narratives are instrumental in the formation of identity, but insisted that it should not be taken for granted that storytelling is always therapeutic, especially when the subject’s experiences were especially traumatic or stressful.
Fivush began by looking at some of the evidence in favor of the therapeutic benefits of storytelling. In the 1970s, David Spiegel (UCSF medical school) designed a study to investigate the potential benefits of support groups for terminally ill women. At the time it was believed that talking about their symptoms and pain would merely create stress for patients and their families. On the other hand, there was a growing interest in how best to care for the “whole patient,” including emotional and psycho-social well-being. In order to test his hypothesis that it would be helpful for terminally ill patients to talk to and provide support to one another, Spiegel assigned 50 or so women to support groups of 10-12 women each, with 30 or so left out to serve as a control. Initially, no differences in diagnosis or symptoms were detected. After a year, however, the women in support groups reported doing better in quality of life measures (such as stress and anxiety levels), even though there was no difference in their physical health compared with the control group. More strikingly, after 10 years, it was possible to conclude that on average women in support groups survived a year and a half longer than those in the control. This suggested that the support groups worked to increase longevity.
Unfortunately, these results were a fluke. Hundreds of similar studies have since been carried out, and none has generated Spiegel’s results. This is a case, Fivush explained, where a sensational finding that has failed to replicate has become entrenched in the public mind anyway. Even though there is no good evidence for the claim, it is widely believed that support groups enhance survival rates. Even if they have no effect on survival, however, it is true that support groups improve quality of life.
What is it about being in a support group that improves quality of life? According to Spiegel, there is something critical about sharing your story. Social psychologist, James Pennebaker, knew about Spiegel’s study and undertook to investigate further the therapeutic power of storytelling. In particular, Pennebaker was interested in the effects that “expressive writing” might have on well-being. He randomly assigned a group of college freshmen to an expressive writing assignment where they were asked to write their deepest thoughts and feelings for twenty minutes a day for three days in a row. Another randomly assigned group of students was given a non-emotional writing assignment, and another group wrote nothing. At the end of the semester, Pennebaker took base-line measures of psychological and physical health. Freshmen involved in expressive writing were found not only to report higher levels of psychological well-being (less stress, anxiety, etc.), but also had higher GPAs. Since Pennebaker’s study, the effects of expressive writing have been widely studied, and the general findings are robust. Even improvements in physical health, such as t-cell functioning, have been correlated with expressive writing. Such studies provide strong evidence that talking about our experiences is good for us.
Fivush cautioned, however, that while storytelling is therapeutic on average, there are some individuals who actually get worse when they share their story. For many people, storytelling contributes to cognitive processing of negative experiences. It is not that such individuals learn to see their negative experience as a good thing, but rather, as in Naikan, it enables them to take a different perspective on their life, and provides for a sense of growth. But Fivush stressed that narrative does not facilitate cognitive processing in everyone. She gave the example of 9/11 first responders, who were required to talk about their experiences as a way of dealing with the trauma they experienced in order to keep their jobs. For many of these individuals, sharing their stories did not help them at all; on the contrary, it served merely to re-open their wounds. Certain individuals do not show signs of cognitive processing when reconstructing the story of a traumatic event. Rather they exhibit what is called “rumination.” Instead of processing what happened to them in a productive way, narration leads some people to dwell on the negative experience in a counter-productive way. They wonder, for instance, why it had to happen, or even come to the conviction that life is awful and can never be the same again.
Although there is solid evidence that storytelling helps most people in most scenarios deal with negative experiences, Fivush’s main point was that this should not be taken for granted in all cases. For some people, sharing their stories may even have a detrimental effect on their well-being. It is not clear why some tend to engage in rumination rather than cognitive processing. It may be that those with worse childhoods tend to be more ruminative. Whatever the reason, such counter-examples to the benefits of narration need to be taken into consideration. They indicate that there is more to learn about exactly who benefits from narrative therapy and why.
On this question of who benefits and why, an interesting discussion ensued in the Q&A on gender differences and the benefits of narrative. Fivush pointed out that expressive writing has been shown to be more effective in improving the well-being of males. The reason for this is interesting: females tend to be much more naturally emotionally expressive than males, so the exercise in expressive writing does not have as sharp an effect for them as it does for males, who tend to lack outlets for emotional expression. In our culture, more value is placed on talking about past experiences if you are female. By adolescence, girls begin to co-ruminate with girlfriends. This can actually lead to negative consequences for health, however, since rumination, as indicated above, is a risk factor for depression.
Ozawa-de Silva and Fivush addressed the question of the role of narrative in therapy from very different perspectives, and emphasized contrasting points. On one hand, Ozawa-de Silva talked about the successes of a very specific form of narrative therapy – Naikan. On the other, Fivush raised questions about the benefits of narrative in therapy from a general standpoint. Nevertheless, there was no disagreement about the fact that by and large storytelling is a powerful therapeutic technique. It is just that, for some people, reconstructing the story of a traumatic event can lead to unhealthy rumination rather than to healthy cognitive processing. Ozawa-de Silva suggested that the specific focus in Naikan on fostering cognitive processing may therefore be an important factor in its success. The need to be sensitive to this distinction between situations where narrative leads to unhealthy rumination, and situations where narrative leads to healthy cognitive processing was perhaps, then, the chief take away from the lunch.