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Issue Editor Foreword

Issue Editor Foreword

Beyond Narrative Structure to Competence, Identity, and Client-Centered Care

Editor(s): Hinckley, Jacqueline PhD; Associate Professor Emeritus; Bourgeois, Michelle PhD; Professor

Author Information
doi: 10.1097/TLD.0000000000000065
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The elicitation and assessment of narrative discourse play an important role in helping clinicians identify the impact of linguistic impairments on the most common form of social communication—the personal narrative. Evaluating narrative abilities is an important area for clinical research and intervention so that individuals with communication disorders can participate in this most basic of social interactions. Attention to the structure, coherence, cohesiveness, length, informativeness, or linguistic complexity of narrative discourse is critical to providing our clients with the basic building blocks for producing narratives.

The importance of narrative in our practice goes beyond the evaluation and treatment of the narrative skills of our clients. Narrative is more than just the right combination of linguistic structures, words, or sentences, embedded in the correct narrative structure. Narratives reflect our culture, our perceptions and beliefs, and our conceptualizations of our listeners. As Lewis (1955) wrote, “Narrative deals with experiences, not with propositions” (p. 3). Indeed, the clinical encounter is an experience that can be captured in the narratives of either the client or the clinician. Stories are the way people make meaning out of sequences of events and experiences. As human beings, we also make meaning of our disabilities, our interactions, and our life events through narratives.

The purpose of this issue is to expand our understanding of what narrative is and what it does in clinical practice. The life story of clients is a narrative, and their experience as a client or their experience living with a communication disorder can be expressed through narrative. These narratives shape how clients live the whole of their life, not just how they respond or behave in a clinical encounter. Thus, our attention to our clients' life and illness stories can broaden our views of our clients and enable clinicians to implement a holistic, person-centered approach to our services.

To allow our clients' narratives of their disability or life events to become an integral part of how we provide service, we must first be able to listen carefully to what our clients are telling us. Listening to narratives is an active process that can change the meaning of the event being told to the speaker, as well as enlightening the listener to the priorities, cultural views, and values of the speaker. It also establishes a relationship between the speaker and the listener, and that relationship will be based on the acknowledgement of the broad meanings conveyed in a narrative. As Ochberg (1996) explained,

If I say to you, speaking of the wedding I attended last week, “And then there was the most amazing coincidence!” I expect you to reply, “Really? What happened?” I will be surprised and not especially pleased if instead you say, “Isn't it interesting how you make ordinary events so dramatic?” (p. 97)

Person-centered care demands that we listen to the life stories of our clients with a humanistic ear, rather than a linguistic ear, focused only on the semantics, syntax, or story structures that are produced. Listening to the meaning in these holistic messages is equally critical as attending to narrative structure and elements, because it is in the broad messages that our clients are expressing: What the clinical process means in their lives, their search for a new identity, or how they abstract meaning from illness or injury.

For example, the article by Ryan, O'Dwyer, and Leahy (2015) in this issue is an example of a form of counseling that uses narrative to change how one views a communication disability, such as stuttering. In the article by Hinckley (2015), the telling of the narrative of the original injury that produced the communication disability is accomplished despite language limitations. Fraas (2015) also describes how these narratives can produce opportunities for clinical growth.

NARRATIVE PRACTICE

A number of major trends in the use of narrative inquiry and narrative practices underpin the articles in this issue. In general, a narrative approach to practice has sprouted from the acknowledgement that the experience of patients, and the witnessing thereof, is a critical component to excellent health care (Charon, 2006). The clinical encounter is a narrative itself; it has a setting, characters that include the client and the clinician and perhaps others, a conflict in the form of a current problem, a climax in the story that is reached as the client and clinician work on the problem, and a resolution of some kind. Honoring the first-person narratives of our clients' experiences, combined with reflection, yields a person-centered, holistic practice. Bringing a narrative perspective with reflection to clinical practice is being referred to as “narrative medicine” (Charon, 2006) or “narrative-based practice” (Hinckley, 2007). A narrative approach to practice is being adopted in many different disciplines because it broadens clinicians' scope from the impairment to the whole person.

The International Narrative Medicine Network began at an international meeting in June 2013 in London, where papers leading to several of the articles in this issue were first presented (i.e., the articles by Fraas, 2015; Hersh, 2015; Hinckley, 2015; and Ryan et al., 2015). As such, they represent some of the early work in a narrative-based approach to inquiry and practice in the field of communication sciences and disorders. The Narrative Medicine program at Columbia University and the Center for Narrative Practice in Cambridge, MA, are examples of centers where the application of narrative methods and practices are being developed and applied across disciplines. These centers and the work they foster are sources that can be consulted by interdisciplinary researchers and clinicians.

Person-centered care has three main elements, as summarized on the basis of a review of 60 articles across disciplines: (1) patient participation and involvement, (2) the relationships between the patient and the clinician, and (3) the context in which care is provided (Kitson, Marshall, Bassett, & Zeitz, 2012). Patients' narratives are a means by which clinicians involve patients in their own care and establish and maintain clinician–client relationships. The context of care is altered when patients' stories are acknowledged and clinicians become an active part of those stories.

Narratives play a critical role in the diagnostic process, because they are the medium for communicating what has happened to the client. They allow for the construction of meaning, and the development of empathy between the client and the clinician (Greenhalgh & Hurwitz, 1998). During intervention, narratives not only encourage a holistic approach but are also in and of themselves therapeutic, as exemplified by the article by Isaki, Brown, Alemán, and Hackstaff (2015) in this issue. Fostering a narrative approach in client education increases the likelihood that recommendations will be remembered and implemented (Greenhalgh & Hurwitz, 1998). According to this view, the narrative tasks of the clinician are to pay attention and to witness the lived experience of our clients.

The conceptual basis for narrative approaches comes from phenomenology. Phenomenology is a branch of philosophy that seeks to understand what people experience and how we experience it. Narrative inquiry is a way to fully investigate the human experience (Clandinin & Connelly, 2000). The three key elements of phenomenology (Hinckley, 2013) are present in the articles in this issue. First, the first-person point of view is a critical aspect for studying human experience, and all of the articles in this issue seek out and preserve the perspective of clients as narrators of their own lives. Second, a phenomenological approach requires the detailed description of an individual's experience, and this is supported by the qualitative methods applied. This is evident in the articles by Hersh (2015), Hinckley (2015), and Guendouzi, Davis, and Maclagan (2015). Third, the act of reflection on these descriptions and experiences is key to phenomenology, which is exemplified by these same authors, who incorporate their own reflections in the analysis and results of their articles. Fraas (2015) takes a step further and reflects on how patients' narratives can contribute to the development of the clinician. Ryan et al. (2015) explain how reflection guided by the clinician can result in changing the life story of an individual who stutters about the role of his or her disability in his or her life. Finally, Isaki et al. (2015) describe how reflections of caregivers engaged in a therapeutic writing experience can contribute to learning to cope with altered lives. In somewhat different ways, each of these articles incorporates the first-person point of view, descriptions of experiences, and reflection on those experiences—either by the teller or by the listener.

We are happy to introduce this set of articles that expands our understanding of how narratives demonstrate more than just a set of linguistic skills and shows how the meaning of lives can be changed through a narrative process.

—Jacqueline Hinckley, PhD

Associate Professor Emeritus

Michelle Bourgeois, PhD

Professor

Communication Sciences & Disorders

University of South Florida

Tampa

Issue Editors

REFERENCES

Charon R. (2006). Narrative medicine: Honoring the stories of illness. New York: Oxford University Press.
Clandinin J., Connelly M. (2000). Narrative inquiry: Experience and story in qualitative research. San Francisco: Jossey-Bass.
Fraas M. R. (2015). Narrative medicine: Suggestions for clinicians to help their clients construct a new identity following acquired brain injury. Topics in Language Disorders, 35, 210–218.
Greenhalgh T., Hurwitz B. (Eds.). (1998). Narrative based medicine: Dialogue and discourse in clinical practice. London: BMJ Books.
Guendouzi J., Davis B. H., Maclagan M. (2015). Expanding expectations for narrative styles in the context of dementia. Topics in Language Disorders, 35, 237–257.
Hersh D. (2015). “Hopeless, sorry, hopeless”: Coconstructing narratives of care with people who have aphasia post stroke. Topics in Language Disorders, 35, 219–236.
Hinckley J. J. (2007). Narrative-based practice in speech–language pathology: Stories from a clinical life. San Diego, CA: Plural Publishing.
Hinckley J. J. (2014). Phenomenology. In Ball M. J., Muller N., Nelson R. L. (Eds.), Handbook of qualitative research in communication disorders (pp. 93-112). New York: Psychology Press.
Hinckley J. J. (2015). Telling the story of stroke when it's hard to talk. Topics in Language Disorders, 35, 258–266.
Isaki E., Brown B. G., Alemán S., Hackstaff K. (2015). Therapeutic writing: An exploratory speech–language pathology counseling technique. Topics in Language Disorders, 35, 275–287.
Kitson A., Marshall A., Bassett K., Zeitz K. (2012). What are the core elements of patient-centred care? A narrative review and synthesis of the literature from health policy, medicine, and nursing. Journal of Advanced Nursing, 69, 4–15.
Lewis R. W. B. (1955). The American Adam: Innocence, tragedy, and tradition in the nineteenth century. Chicago: University of Chicago Press.
Ochberg R. L. (1996). Interpreting life stories. InJosselson R.(Ed.), Narrative study of lives (Vol. 4, pp. 97-114). Thousand Oaks, CA: Sage.
Ryan F., O'Dwyer M., Leahy M. M. (2015). Separating the problem and the person: Insights from narrative therapy with people who stutter. Topics in Language Disorders, 35, 267–274.
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