Art & science | first person
Once upon a time there was an angry lion: using stories to aid therapeutic care with children Building a relationship with a child or young person is vital to gain their trust. Dean-David Holyoake investigates how storytelling can be a useful tool for the busy children’s nurse Correspondence
[email protected] [Q1 OK to print?] Dean-David Holyoake is senior lecturer/nurse consultant [Q2 OK?], University of Wolverhampton, Warsall Date of submission October 10 2012 Date of acceptance March 7 2013 Peer review This article has been subject to open peer review and has been checked using antiplagiarism software Author guidelines www.nursingchildrenand youngpeople.co.uk
Abstract Storytelling is a useful relationship-building tool to use with children, as demonstrated by the work of ‘Johnny’ and the author, his nurse. Five stages of narration (purpose, backstory, pivotal events, evaluation of effects and summary) encourage children to recognise and accept feelings such as anger, grief, shame and guilt in a safe way and make small steps towards change. It is feasible to start engaging children with simple everyday stories, and then go on to develop the tale so that the nurse and the child make additions as required. Keywords Children’s nursing, storytelling, therapeutic interaction IT IS PROBABLE that some of the first things you ever heard were stories. When you were a child your guardians might have taken great delight in telling you stories to help you nod off to sleep, entertain you or impart valuable morals to keep you safe. Some parenting traditions drift in and out of fashion, but among primary teachers, nursery staff and in early years’ centres, storytelling is still considered of crucial importance, if not the highlight of the day. So can storytelling be a skill put to practice by nurses? The answer, of course, relates to the pressures under which most children’s nurses find themselves when confronted daily with busy wards and the other priorities for their patient’s welfare that seem to demote the importance of stories. This article offers some ideas for nurses about
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storytelling through a description of the trustbuilding relationship that developed between nineyear-old patient ‘Johnny’ and myself as the nurse. I used a five-stage model known as the ‘points of a story’, developed by Duvall and Beres (2007) from the work of Vygotsky (1978) and White (2005). The five stages are purpose, backstory, pivotal events, evaluation of effects and summary. The stages encourage isolated children like Johnny to recognise and validate feelings such as anger, grief, shame and guilt in a safe way and address small steps towards change.
Purpose Johnny, whose name has been changed to protect his identity, was six years old when he was scalded. He had been watching his mother cook and reached up and tipped boiling pasta on himself. His mother rushed him to hospital, but he had extensive burns to the right side of his face, neck and arm. The shock and trauma, both physical and psychological, had affected his appearence and self-esteem. Back at school he felt odd, and even though he was bright, he found himself becoming increasingly isolated, aggressive and achieving unsatisfactory grades. It was decided that Johnny would have surgery to correct some of his facial scarring and a planned admission to the children’s ward. Johnny was beginning to reason that he was different from most children because of his scars.
Backstory During a two-week period, Johnny and I developed a relationship and a story to help him re-think his selfNURSING CHILDREN AND YOUNG PEOPLE
esteem. I was on a post-registration placement with a background in child and adolescent mental health nursing, and was a complete novice to the physical challenges faced by many of the young people in my care. Therefore, storytelling was initially my reaction to not knowing what to say. It was a spontaneous response to engage opportunistically, rather than being part of a planned strategy to develop a therapeutic relationship. The fact that Johnny was quiet, isolated and not the most popular boy meant that a persistent approach was called for. A creative approach might arouse his curiosity, and it was with this in mind that, after seeing Johnny struggling to pull the head off a plastic zebra, I took the chance and spoke to him about jungles. ‘I was really scared once,’ I said. Johnny did not look up. He was in his bed waiting to go into surgery. He was pretending not to listen. I too pretended I had not noticed that he was ignoring me. ‘It was when I had to go into the jungle on safari. I can tell you it was frightening,’ I said, but he scowled and tugged more at the zebra’s head. ‘I’ll come back later and tell you what happened, if you like.’ I left his bed area and walked off towards the nursing station. I wondered what I had started by likening my story with what he was just about to embark on. Having spent some years attempting to understand the principles of psychotherapy, I wondered about the nature of creative storytelling. According to Ong (2002) and Tambling (1991) the storyteller represents conditions for his or her own benefit and for the benefit of those hearing or reading. This emphasises that stories are not necessarily ‘truth’ and that they can be altered, adapted and changed. Considering that I had never been in a jungle, seen a zebra or been to a zoo in more than 30 years, Johnny had much room for manoeuvre. The emotions of fear, anger, sadness and frustration being exhibited by Johnny were not going to be addressed merely by the plastic surgery because, put simply, some of his scars were inside his head. This, it was explained to me by children’s nurses, is not uncommon for children in hospital, who experience a wide range of emotions. Finkelhor (1984) showed how damaged children may have difficulty trusting others and/or themselves. The child asks: ‘Why me?’, ‘What did I do wrong?’ and, as I noted in my work with Johnny, ‘How am I going to cope with the fact that no one likes me?’. These questions and key stages make up the pivotal events.
Pivotal events Nurses have to find story purposes and pivotal events quickly. The luxury of pre-preparing is NURSING CHILDREN AND YOUNG PEOPLE
rarely an option in a busy children’s ward. Yet, it is possible to develop two or three pivotal events from which to develop any story. Therefore, the initial purpose for Johnny was about increasing his self-esteem and the pivotal events were about ‘acknowledging his anger’ (the present feeling) and ‘increasing a positive self-image through notions of bravery’ (future change) by being less ‘scary to others’. It seemed that the emotional effect of Johnny’s accident had taken second place to his feelings about the visible physical trauma. His mother did not like to mention the scars in the hope that they might disappear. There was no mention of any psychological investment in his notes, yet it was obvious to all the nurses and staff that Johnny’s outbursts of anger affected his popularity and educational ability. Peers were scared of upsetting him and this reduced his social interaction. Johnny was feeling more aware that he was different as a result of his scars, but did not know about anger, sadness or making friends. Axline (1971) used a free style of play to engage with trauma-surviving children. I also noticed how his use of metaphor (the angriness of the strong and capable lion) as described by Cazeaux (2007) and Erik Erikson (1958), mirrored Milton Erickson’s techniques (Erickson et al 1976, Zeig 1980), particularly the production of curiosity. Yet, unlike other settings, I also knew I did not have much time or the luxury of a settled environment, so would have to tell stories on the hoof and in between other duties. O’Hanlon and Beadle (1997) suggest that brief therapeutic interventions sometimes work best and increase busy practitioners’ opportunities to develop points of the story that mirror the immediate feelings, expectations and outcomes for the teller and the listener.
Points of the story ‘I put a lonely zebra on the locker, but he seems to have lost his head,’ I said, ‘I wonder what happened to him? Perhaps it was a lion or something that felt angry.’ I indicated the plastic zebra torso on Johnny’s locker. He took a peek and then quickly looked away. He was in pain from the surgery and the bandages helped us both to remember this. I left him. What remained was my uncertainty about what to say next, but I was determined to find a good reason for developing these emotionally linked points of the story. I decided that they would include him being a strong yet scary lion, with a pivotal point of him being allowed to address his anger. Lawton and Edwards (1997) and Geldard and Geldard (2002, 2005) show that therapeutic joint September 2013 | Volume 25 | Number 7 25
Art & science | first xxx person storytelling supports the right of the child to be heard, presents opportunities for the child to share feelings, demonstrates acceptance and recognises the privilege it is to be able to share a story. Likewise, Gomez (1997) and Duvall and Beres (2007) suggest that the role of the therapist (nurse) includes providing a map and ‘the scaffolding around a building while it is being built or repaired’. Repairs may make it possible for the nurse to re-author a preferred way for the child of being in the world (White and Epston 1990). ‘It is a shame that the zebra can’t see things happening around him,’ I said, ‘When I was in the jungle one day I accidentally bumped into a lion.’ I paused to check Johnny was listening. To my surprise he actually looked me in the eye. I knew I had to think of something quick. ‘Do you know what lions sound like?’ I asked. He nodded to indicate yes. I knew that I had just made contact and then to my surprise he said: ‘They go roooooooarh.’ He put his hands up in a claw movement, but the bandages hid his expression. ‘Have you ever seen one?’ I asked. He shook his head to indicate no and looked at me with his wide eyes. ‘Well I have and they are very scary, that’s why people stay away from them because they are frightened of being eaten.’ ‘Well how come you never got eaten?’ said Johnny. This was actually a good question to which I did not have an answer, so I said: ‘I am going to finish doing this laundry and then I’m going to come back and tell you.’ Kaduson (2004) noted a common problem in doing work with young children is that they have an ‘inability to verbalise their feelings’. In my experience, collaboratively developing stories as a continuing engagement allowed for the creation of mystiques to motivate the young person. The use of mystery, quirky characters, magic, miracles, pretending and plot twists helps with this. Having established the main points of the story – no matter how long it takes – the aim is to then develop personal change (pivotal events) in the young person. ‘Because I learned the secret,’ I said. I waited for Johnny to ask because I knew he would. ‘What secret?’ I now had his full attention. ‘The fact that this lion wanted to play “let’s pretend”,’ I said, and Johnny screwed up his half-hidden face. ‘But why?’, he asked. ‘Well, because the angry lion liked to pretend that a miracle had happened and that people were no longer scared of him’. Stories appear to be relatively stable because they 26 September 2013 | Volume 25 | Number 7
have plot, script, characters, scenery and dynamism, and they have a beginning, middle and end. We all take something different from these elements of a story. For some children it is the excitement, for others it is trying to work out the end before it happens and for some it is locating the villain or discovering the twist. At the simplest, it may be the enjoyment of the adventure, the rhyme and rhythm, relating to the qualities of the hero and heroine, or simply the distraction from other tasks and connecting with the author or reader. Street et al (2012) explored how common narratives validate overcoming adversity by exploring the themes in these characteristic pivotal events. In my experience, an awareness of such matters may be an advantage, but they should not deter the would-be nurse storyteller from simply formulating pivotal events and points usually based on a feeling – for Johnny it was anger – and then developing characters symbolic of the desired outcome, such as a nice, brave lion. The story is the vehicle through which the nurse can build a trusting relationship (O’ Hanlon and Beadle 1997). Therefore, the use of what Brown and Augusta-Scott (2007) called ‘alternative preferred stories’ is a process of developing a joint story which can make use of what Anderson and Goolishian (1992) termed ‘not knowing’. This allows space and gives permission to validate feelings and open up metaphorical spaces, free from the technological advances of medicine, to appreciate ‘different voices or stories’ (Smith and Nylund 1997). ‘I don’t care about your stupid lion, why should I?’ Johnny scowled. It was getting late and he had just been told that his family were not visiting because of unforeseen circumstances. ‘I wish I could have said the same,’ I said, ‘But there he was roaring at me and I can tell you I was very scared indeed. I did not know what to do.’ I paused and let Johnny sit with his anger. ‘So I simply thought to myself, what would I do if I didn’t want to scare people off, because as I later learned from the lion, he was lonely and had to spend a lot of time on his own.’ I was, of course, using direct metaphor and sowing the seed for Johnny to reflect on his own situation.
Evaluation of effects The notion of opening up the therapeutic space (Barragar-Dunne 1997), guided the direction in which the story of the angry lion progressed. The use of ‘Let us pretend that the lion feels really scared too’ and ‘What should happen next?’, combined with the curiosity language of wonderment and wow, encouraged a metaphorical space for Johnny NURSING CHILDREN AND YOUNG PEOPLE
and myself to build and drive the story. Epston (1997) and Holyoake (1997, 2001) show that creating mystery and intrigue to snare the child is a wonderful, yet so often neglected skill. Epston (1997) describes how emphasising the meaning of a child’s name is a simple way of doing this. For instance, my work with Johnny linked the initial use of the plastic zebra with the idea of the lion. ‘Where did that come from?’ I said pointing at the zebra with a head. ‘It must be magic, the lion must have helped the zebra feel better about himself because now he has a head.’ Johnny beamed a smile because sometime during the previous evening he had replaced the zebra’s head and waited excitedly for me to come on duty. Like the metaphor, this symbolic act represented, I hoped this would just be the beginning of our lion and zebra story. ‘I wonder how the lion and the zebra will stay friends? I wonder what the other animals will see them doing?’
Summary From the ordinary world to the innermost cave and back again with the elixir in hand is, according to Vogler (1998), the task of the hero in most stories. And so it was with Johnny. During his two-week stay he taught me a lot about interacting with ill young people. Stories can be so universal, yet so personal, so potent, but so neglected.
Conclusion Engaging children with fictional stories can help deal with the so often neglected psychological connections to which nursing sometimes gives low priority. The story of the angry lion allowed Johnny to gain insight, skills and hope for his future in the jungle we know as life. The symbolism of the missing zebra head, like the scars he so badly wanted to disappear, would have to wait for another day, for another story. As for me I have still never spoken to a real lion and am not intending to.
Online archive For related information, visit our online archive of more than 7,000 articles and search using the keywords Acknowledgements Thanks are due to J. Shakespear, psychodynamic nurse specialist, [Q3 Is job title correct and please add place of work?] for her creativity, support and dynamics. [Q4 Please can we have her first name and email address as it is our policy to check out all acknowledgements with those mentioned] Conflict of interest None declared
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