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Life History and Narrative Research: Generating a Humanistic Knowledge Base

for Occupational Therapy

Article in The American journal of occupational therapy.: official publication of the American Occupational Therapy Association · May 1996
DOI: 10.5014/ajot.50.4.247 · Source: PubMed

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 NATIONALLY SPEAI<JNG
Life History and Narrative Research:
Generating a Humanistic Knowledge Base for
Occupational Therapy
roviding cosc-effeccive services
P while providing aucheneic diene-
ceneered occupacional cherapy
(Yerxa, 1967) is producing opposing
censions for occupacional cherapiscs
praccicing in che currene healch care
markec (Fleming, 1993). Alchough che
demands of che payers cannoc be
ignored, occupacional cherapiscs hiscori-
cally have been concerned noc only wich
che OLlCcomes of creacmene, buc also
with che humanisric approach char
builds rherapeuric relarionships, enrich-
es and guides che process of occupacion-
al rherapy ineerventions, and identifies
collaboracively defined rherapeu ric our-
comes (Meyer, 1922/1977). As a profes-
sion, we need co generace research rhac
examines rhe intricacies of providing
effecrive, individualized, and sarisfying
services co dienes and char addresses
cosc-effecriveness.
Narrarive and life hiscory research
are cwo approaches chac can assisr occu-
pacional rherapisrs in bener undersrand-
ing the complexity and contexrs of rhe
client and his or her experience in rhe
rherapeuric process. Narrarive refers co
rhe relaring of a scory derailing an event
or series of events in a person's life or
experiences (Polkinghorne, 1988). Life
hiscory is a chronological, person-cen-
rered case srudy using narrarive thaI'
indudes socioculrural dynamics and
offers a long and comprehensive view of
rhe person (Frank, 1984). These
research approaches provide che chera-
pisc wirh a view of che diem's daily
occuparions, rourines, family member
relacionships, socioculrural influences,
and che effeccs of rhese facrars on rhe
delivery of occupacional rherapy services
(Yerxa, 1%7). We will illuscrare rhac
The American JournaL ofOccupational Therapy
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Elizabeth A. Larson,
Shan-Pin C. Fanchiang
ELizabeth A. Larson, lv/So OTR, is DoctoraL
Candidate, OccupationaL Science,
Department ofOccupationaL Therapy,
University ofSouthern CaLifomia, 1540
ALcazar Street, CHP-133, Los AngeLes,
CaLifOmia 90033, and Private Practice
Pediatric Therapist, South Pasadena,
CaLifornia.
Shan-Pin C Fanchiang, MS, MA, OTR. is
DoctoralStudent, OccupationaL Science,
Department ofOccupationaL Therapy,
University ofSouthern California, and
OccupationaL Therapist, Uni1!ersity of
Southern California, OccupationaL Therapy
FacuLty Practice, Los Angeles, CaLifornia.
This arrick was accepred for pu blicarion
January 13, 1996.
producing and using research char
focuses on our humaniscic philosophies
ceneering on che diene's needs, personal
coneexcs, and life circumscances may sac-
isfy boch rhe demands for efficacious
rreaCmenr and consumer sacisfacrion.
Humanistic Practices in
Current Narrative and Life
History Research
Humanisric praccices, as used here, are
driven by compassion, emparhy, and
respecr and are cenrered on che digniry
and worth of che diene (Brock, 1995;
Tanner, Benner, Chesla, & Gordon,
1993). Ceneral co humanisric care is che
relacionship becvveen rhe client and che
professional. In rhe medical cradirion,
professional disrance has been espoused
as a necessary srance for healch care
praccicioners, enabling chern co acr wich
objecrive decachment and racionality
(Brody, 1992). To Zola (1982), a soci-
ologisc who experienced lifelong disabil-
iry and medicalizarion,
rhis separarion may once have been quire
funcrional ...wirh dearh a common our-
come of serious illness and hospiralizarion,
few would have been able ro conrinue
rheir work wirhout such "steeling."
Though rhe realiries rhar produced rhis
disrancing have long since passed .... We
now hear abour cold, unfeeling docrors
and rherapisrs who are so removed from
rhe partenrs rhey wish ro help rhar (hey
cannor understand and rhus help rhem
deal wirh rheir pa.in, rheir suffering, rheir
cbronic loss.... (p. 193)
lnscead of keeping a discance from
che dienc, caring and keeping one's own
emparhetic yer refleccive vantage point
(Brody, 1992) are key facecs of rhera-
peuric relacionships. To balance rhe
extremes of being eirher emmional\y
derached or drawn complecely into che
247
 cliem's narrative, Brody (1992) suggest-
ed that the narrative approach allows the
practitioner to hold an "aesthetic dis-
tance" (p. 265) [0 the cliem's s[Ory,
identifying with the client's experiences
and yet keeping some degree of critical
detachment. The goal is "maintaining in
one's imagination that separate vantage
point from which the experience of the
sufferer can be reinterpreted and recon-
nected [0 the broader context of culture
and sociery" (Brody, 1992, p. 266).
In a therapeutic sening, persons
may play the patient role by giving the
information that they believe is expected
(Howard, 1991; Mishler, 1986), not
complaining abour their currem circum-
stances or purting on a social face, and
following the directions and activities
given even if they find themselves and
their autonomy diminished in the
process (Peloquin, 1993). Heller (1961),
the famous author of Catch-22, writes
about his therapy experience after
Gudlain-Barre syndrome:
But in correctional therapy, as soon as 1
could sand a block of wood, a change was
made to a coarser grade of sandpaper. .. and
it was JUSt as punishing and demoralizing
for me to execu te then as it had been at the
beginning. (Heller & Vogel, 1986, p. 190)
With the use of a narrative research
approach, the client's story can be viewed
as containing both distress and potential
transformative experiences that empha-
size the dynamic self and choice making
rather than the adherence or lack of ad-
herence to treatment regimes prescribed
by outside authoriry (Susko, 1994).
Susko suggested that this approach
redresses power disparities and provides
more humane and healing contexts.
In health care professions, there has
been a turn toward finding and develop-
ing a relationaL ethic in addition to the
appjication of professional principles in
the service of clients (Brock, 1995;
Parker, 1990). In this context, the prac-
titioner-c1iem imeractions are as mean-
ingful as the application of professional
knowledge and skills to the client's life
circumstances and disabiliry experience.
For example, Diane Barrels, as quoted
by Brock (1995), decried a "Joe
248
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Fridayism-just the facts, Ma'am" (p.
154) approach [0 counseling, which can
leave a client devastated by providing
sufficient information but not consider-
ing the strong feelings that it may evoke.
This objective counseling approach
misses the mark by not considering the
effects of facts on the person, how the
person will respond [0 the information,
and how the information changes his or
her daily life and furure.
What may be called narrative in
practice, or the presentation of profes-
sional knowledge, the transmission of
information and the eliciting of infor-
mation from the client playa role in the
forming of the professional-cliem rela-
tionship. For example, through inter-
views of parents of hospitalized children,
it has been found that one stressful
aspect of hospitalization was "hazardous
secrets" (Burke, Kauffmann, Costello, &
Dillon, 1991, p. 42), with one being
that not all information was presented [0
the parents:
Whenever you [sic} child has sutgery, you
expect the worst-something's going to
happen. The doCtors are going to operate
and have to do more than they said. When
she had to have an operation on her
brain-she had the shunt done. AJI they
told me was that it was going to be a
drainage system. (p. 42)
West (1990) pointed our how qual-
itative research can illuminate the differ-
ences berween the viewpoint of the
health care provider and client and
hence the information both elicited by
the practitioner and shared by the client.
In his study, he distinguished between
the public and private accounts that par-
ents give about their experiences in man-
aging the care of a child wi,h disabilities,
depending on the aurhoriry and stance
of those questioning the parents. West
suggested that if clients are given more
credibiliry and attention, they will be
more willing to articulate their private
accounts and experiences, which can
affect both the relationship of the client
and provider and the service delivery.
Miller (1994), with the use of a life
history research approach, described the
reluctance of persons with borderline
personaliry disorders [0 disclose informa-
rion to rherapists, even when encouraged
to do so, Because (he diems' views of
the reasons for hospiralization differed
from those of the therapists, they were
unwilling to provide personal feelings
and information that could reveal lack of
progress in therapy and could lead to
involuntary hospitalization (Miller,
1994). The therapists and clients also dif-
fered in their views of the problems of
borderline personaliry disorders, making
consensus on the goals of treatment diffi-
cult. Miller has concluded that "the ther-
apist is a consultant and the patient
remains an expert in his or her experi-
ence" (p. 1219).
Through the use of interview and
the generation of narratives, clients'
experiences while receiving health ser-
vices can enlighten and alter the stance
of the practitioners providing services:
In ordet to gain a greater understanding of
the patient's illness experience, the resi-
den tS asked her to discuss those physical
problems which she found mOSt frustrat-
ing ... the patient noted that her main prob-
lem at the time was her lack of control
over urination. Previously she had a sched-
ule of regular urination at 9 a.m., noon,
and 3:00 p.m., each time with prearranged
help from a paid assistant. At all other
times she avoided urinating... because of
the difficulty and embarrassment involved
in asking for help transferring from her
wheelchair to a toilet ... prior to this ...she
was seen ... by [a] physician who suggested
she stop her medication for the candidal
nephrolithiasis. She reluctantly complied,
worried that she would become inconti-
nent off the medicine... this proved
true...She was frustrated that her medical
caretakers had not recognized rhe extent to
which she had systemized her daily activi-
ties. (Venrres, 1994, p. 142)
Ventres (1994) supported the regu-
lar use of narrative methodologies in
research and in the clinicians' daily prac-
tice to avoid misperceptions and misun-
derstandings in the provider-client
relationship, to recognize how the client's
illness experience affects the delivery of
services, to tailor the presentation of ther-
apeutic options, and to focus beyond the
clinic (Q the client's daily venue. The
practitioner needs to act nor only on the
client's immediately defined problems,
bur also, with the client, to identify and
April 1996, Volume 50, Number 4
 anticipate the community and future
contexts he or she faces, considering the
areas that have the most powerful effeers
on his or her daily routines (Conrad,
1990; see also Parham, 1987).
Throughout the daily interactions
between therapist and client, there are
also nartative windows of opportuniry.
Analysis of narrative conversations
between nurses and their patients with
cancer (Bottorff & Varcoe, 1995)
demonstrated that what appeared to be
small talk often served as "imporrant
lead-ins to patient disclosures or discus-
sions of sensitive information" (p. 327).
Nurses who engaged in further discus-
sion after the patient initiated small talk
were able to get to know patients
beyond their condition and acquire
more personal conrexrual knowledge of
the person. These small narrative win-
dows that occur daily in occupational
therapy services can be imporrant in sit-
uating a therapy episode into an on-
going life story (Helfrich & Kielhofner,
1994; Marringly, 1991) and in achieving
inrersubjectivity (Crepeau, 1991) and an
empathetic working relationship with
the client (Peloquin, 1995).
These uses of narrative are all in ser-
vice of what Parker (1990) has suggested
is a relational ethic that is parr of an
ongoing process beQ,veen the client and
the health care provider:
The construction of meaning is a dynamic
process that necessirares engaged listening,
alll'hentic responsiveness, muru~d disclo-
sure, and negoriarion ....As a result rhere is
a greater sensitiviry to unexpecred or subtle
changes in the narure of the siruation,
changes rhat may necessirare a reevaJuJrion
of moral oprions. (p. 38)
By engaging the client in such a
process, changes, transformations, and
shifts that occur during and as a result of
therapy or the disabiliry can be identi-
fied as they become exigenr and
addressed within the stream of ongoing
therapy. Without knowing the client,
these subtle shifts and the client's rypical
patterns could go unnoticed. In nursing,
Tanner and colleagues (1993) suggested
that knowing is central to skilled clinical
judgment, client advocacy, and develop-
menr of practice knowledge with specific
The American journaL ofOccupationaL TheraPJ'
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client populations.
Life hisrory and narrative research
can contribute to the development of
humanistic practice knowledge and a
relational ethic for occupational therapy.
Specifically, we have illustrated the
necessi ry for altering our stance roward
the concept of professional distance and
argue for a relational ethic buil t on
knowing the client; minimizing power
dispatities beQ,veen the client and profes-
sional; sharing professional knowledge
in a sensitive, graded manner; lowering
barriers to the client's sharing of person-
al information; cenrering intervention
on the most powerFul point of impact-
daily life; and engaging in an ongoing
dialogue and negotiation responsive to
the client's changing needs.
The use of narrative methods ro
bener personalize services may also affect
treatment efficacy through the place-
ment of desired, sustainable interven-
tions in the dienr's liFe contexts and
through consumer satisfaction that bol-
sters occupational therapy services in the
health care arena.
Summary
As a profession, occupational therapists
are guided in practice by the accumulat-
ed knowledge of occupational therapy.
This article demonstrates the contribu-
tions of life-history and narrative
research ro this knowledge base. We are
suggesting that in response to our
humanistic roOtS, we must pursue addi-
tional knowledge, principles of praerice,
and ethical philosophies that support
practice. We have argued that our ideo-
logic concern for the clienr must guide
our choice of epistemologies to investi-
gate the lived experience of those whom
we serve. "\X!hat is at stake here is the
erhic that is embedded in the epistemol-
ogy that gives rise to kinds of research"
(Brock, 1995, p. 157) that meet the
societal demands for professionalism and
supporr a humanistic practice. A
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Editor's Note
Due to space limitations, other articles related to the theme of Life History and Narrative in Clinical Practice will appear
in the May issue.
250
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April 1996, Volume 50, Number 4