Storytelling & Storylistening Creating a Wisdom Environment in Long Term Care

Everyone has their own wisdom, and when you let a person talk, you allow this life wisdom to emerge” (Rinpoche, 1994)

A study carried out several years ago suggests that a nursing home can indeed be a home (Groger, 1995). The circumstances under which the sense of home can be realized for a particular person include such things as that the person has a chance to contemplate, and participate in the placement decision, and have prior knowledge and a positive experience with a particular facility. Other important factors include the quality of family and social relations and being able to establish some degree of continuity between home and nursing home in terms of activities and/or living arrangements (Groger, 1995).

Insofar as this objective can be achieved, there are very important benefits for all participants in what we will explain as the long term care biographical encounter (Randall & Kenyon, 2001). These participants include residents, staff, administration, volunteers and families. In fact, the benefits expand to an even wider constituency, namely, our culture at large in terms of the way we perceive aging, frailty and the end of life.

In order for a nursing home to be just that, it is necessary that the person who is to become part of that situation always retains their sense of self-determination, or, in narrative terms, their wisdom story, which is capable of being expressed in their life situation. This right to self-determination, from an ethical point of view, is lost when someone is treated as dependent. Further, as recent research is demonstrating, frailty and disability are not necessarily correlated with reported loss of independence (Kaufman 1994), and the ability to make choices about one’s life.

The problem for a frail person often originates in their outside story, with the way they are “seen” by others, not with their way of viewing themselves inside, or with the meaning that the person himself or herself places on their frailty. This is not to say that frail persons do not need assistance, or that we can always get exactly what we want as individuals. Rather, It is a matter of really including the voice of the resident in decisions that affect their lives significantly.

But how do we go about achieving this desirable objective? Holmes (2000) argues that a nursing home needs to focus on the whole person, that is, physical, emotional, social and spiritual needs. Further, we need to create a home-like atmosphere that “recognizes and respects the dignity and uniqueness of each resident, staff member, volunteer” (Holmes, 2000, p. 10), as well as any other persons associated with a nursing home.

In what follows, we would like to outline an approach that can contribute to the implementation of the foregoing objectives. This view is based on the principle that our life stories are one of our most intimate and precious possessions, that they contain our unique ordinary wisdom (Randall and Kenyon 2001), and that there are particular conditions that can facilitate the expression of our wisdom stories and therefore allow us to restory our lives (Kenyon and Randall, 1997) in the direction of enhanced quality of life.

A crucial insight with respect to creating a wisdom environment in long term care is that, with increasing frailty, it becomes more and more important for the caregiver to assist the frail person to continue to story his or her life, and to develop better ways to listen to that story. This is not an easy approach, as it requires a continuous refinement of the art of storylistening, as well as a willingness to know your own story better. But the payoff is worth the effort.

Narrative Gerontology: The Stories We Are

The basic principle of narrative gerontology (Kenyon, Clark & de Vries, 2001) is that we age biographically as well as biologically, socially, and so on. From this point of view, our lifestories are not simply something we have as when we say, for example, “That’s the story of my life”. As human beings, we are always seeking to create and discover meaning and the vehicle for that meaning is our lifestory. Thus, it is more correct to say that we are our lifestories. Storytelling is a basic human activity. It is the way that we make sense of life to ourselves and to others. The story we tell ourselves about life significantly influences our emotions and our actions.

Equally important, we do not story our lives in a vacuum, rather, we coauthor our lifestory with those around us. This is true throughout life. Our story begins with our family of origin, and, in fact, even earlier if we think about our genetic background, and continues through our development and experiences until the end of our life. It is important to note that, from this perspective, a person always has a story to tell, that they are attempting to create. This personal wisdom story does not end in frailty, disability, or even in death, since, among other possibilities, our stories carry on in others.

You may notice that there is a basic paradox at work here. On the one hand, we each have a unique, inviolable, inside personal lifestory, which is the source of our own wisdom. However, at the same time, we create/discover that wisdom in the larger story that we live within (Kenyon and Randall, 1997). In the long term care setting, the resident’s inside story intersects with those of the staff, volunteers, administration and families - thus, the term “biographical encounter”. It is important to emphasize that this coauthoring is not simply a matter of exchanging pleasantries; the language we use and the stories we live by contribute to making us who we are. Language can, therefore, act as either a door or a window. To take a common but effective example, if a caregiver refers to a resident as “dear”, or uses the phrase, “how are we today”, they are creating a barrier between themselves and the resident by objectifying that person. This simple intervention can alienate a resident and prevent them from feeling “at home”. In contrast, when we call a person by their name, we are communicating a story of basic acceptance and dignity. We human beings can accept many inconveniences if we feel that we belong and that we are valued as a person. How much more important is this need to us if a nursing home is our home, our place of refuge? It is not an exaggeration to suggest that this need for basic acceptance is as important as eating.

Guidelines for Creating a Wisdom Environment

There are a number of conditions that can facilitate a wisdom environment in long term care and they include the following. What follows should not be considered an exhaustive list, but rather important suggestions in a dynamic and creative enterprise.

1. When to Story and when not to Story—Even though storytelling is a basic human need, it is neither ethically appropriate, nor beneficial, to force anyone to tell their story. A person should always be given the choice to tell their story or to withhold it.
2. Stories are Always Meaning-ful-The levels of frailty have increased significantly in the long term care setting. Thus, it is a challenge to create new ways of listening to the lifestories of persons with cognitive impairment and language limitations. However, if we begin with the assumption that a resident is attempting to tell us something that is meaningful to him or her, then we are at least entertaining the possibility that we will be allowing that person’s story, basic dignity and wisdom to emerge (Holst, Edberg & Hallberg, 1999). We can be creative in devising strategies for storylistening with persons of limited cognitive ability. These types of strategies may involve photographs, for example, in the form of a life-album created by family members or friends and even staff. Or, they may involve ongoing efforts to understand how language is used differently by dementing persons. Often, storylistening may involve simply that, being there with someone and listening. This can be the most challenging form of creating a wisdom environment, since most often our tendency is to do something. Yet, in some situations, a story gets communicated in a look, a touch, a gesture, and nothing more is required.
3. Whose Story Is It—A wisdom environment will be effective to the extent that all participants in the biographical encounter are willing to storytell and storylisten. That is, each of us needs to be open to our own inside story, in order to be capable of really entering the life world of another. Very often, although meaning well, we simply project our values and stories on to another and therefore act on false assumptions. Ideally, then, residents, staff, volunteers, administrators, and families, all need to contribute to the emergence of their own wisdom and that of others. This is a challenging task and is easier for some people than for others.
4. Creating Wisdom Strategies—The implementation of conditions for a wisdom environment in long term care is a dynamic and creative activity. Strategies can range from the simplest of interventions, to more elaborate programming. Here are just two examples:
   • Single word Exercise: This exercise can be directed to residents or to staff, or even to both groups together. An overhead is presented with one word displayed. The word could be, as examples, “apple”, “barn”, “cat”, “vacation”. These seemingly innocent words are very powerful in eliciting stories and creating intimacy among group members. In our view, this approach, in many contexts, can be more effective than traditional reminiscence techniques that focus directly on life experience (For example, “Tell me about your childhood”).
   • Guided Autobiography: This approach, carried out in a non-judgmental, confidential environment, focuses on general life themes. Participants reflect and write a maximum of two pages on topics such as the “history of money” in their life, “significant others”, and “work and career”. Depending on the group, other themes can include views of “loss, death and dying”, and “sources of meaning” in life. Subsequently, participants share their stories in a small group, with each person speaking for a maximum of ten minutes. Guided Autobiography is not intended as therapy, but it is often therapeutic in the sense that it is particularly effective in facilitating the emergence of ordinary wisdom (Kenyon, 2001). Wisdom here refers to such experiences as coming to value a life (For example, I was not just a housewife). The focus in Guided Autobiography is on “getting the story out”, rather than on analyzing or interpreting that story. The wisdom emerges from the storytelling in an accepting storylistening environment. This approach can be used as an in-service programme, or with residents at an appropriate level of cognitive functioning.

Conclusion

The distinctive feature of the narrative approach is that it is open-ended, stories can, in principle, be rewritten, and people can restory their lives. Therefore, we should never assume that a person is locked in by the story that they are currently telling themselves about their situation. There are many examples of people who have radically restoried (Kenyon & Randall, 1997) their lives. By establishing a wisdom environment, we make it possible for more of us to make the transition to long term care a meaningful and life affirming experience for all those involved in this biographical encounter.