health narrative assignment

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Storybridging: Four steps for constructing effective health narratives

Anniek boeijinga.

a Centre for Language Studies, Radboud University Nijmegen, Nijmegen, The Netherlands

Hans Hoeken

b Utrecht Institute of Linguistics OTS, Utrecht University, Utrecht, The Netherlands

José Sanders

To develop a practical step-by-step approach to constructing narrative health interventions in response to the mixed results and wide diversity of narratives used in health-related narrative persuasion research.

Development work was guided by essential narrative characteristics as well as principles enshrined in the Health Action Process Approach.

The ‘storybridging’ method for constructing health narratives is described as consisting of four concrete steps: (a) identifying the stage of change, (b) identifying the key elements, (c) building the story, and (d) pre-testing the story. These steps are illustrated by means of a case study in which an effective narrative health intervention was developed for Dutch truck drivers: a high-risk, underprivileged occupational group.

Conclusion:

Although time and labour intensive, the Storybridging approach suggests integrating the target audience as an important stakeholder throughout the development process. Implications and recommendations are provided for health promotion targeting truck drivers specifically and for constructing narrative health interventions in general.

Introduction

Public health communication generally attempts to motivate people to engage in (e.g. the use of sun care products) or refrain from a certain behaviour (e.g. cease smoking), typically by means of providing arguments. Processing these persuasive messages requires considerable cognitive skill ( Boeijinga et al., 2017 ; Schellens and De Jong, 2004 ) and may be too demanding for target audiences of low socioeconomic status (SES) and health literacy. As a result, this approach is likely to increase health inequities between high and low SES groups. In addition, this approach rests on the assumption that changes in motivation, or intention, will automatically lead to changes in behaviour. However, there is ample evidence for the existence of an intention-behaviour gap ( Sheeran, 2002 ; Webb and Sheeran, 2006 ): despite being successful in changing intentions, the subsequent change in behaviour often remains modest or absent. Sheeran (2002) reports that people are only half of the time successful in acting upon their health intentions. Motivation to change may thus be a prerequisite for subsequent behaviour change, but it appears to be far from sufficient.

Narratives as bridge builders

Narrative health interventions appear promising for bridging the intention-behaviour gap as well as health inequities between high and low SES groups. Narrative presents a sequence of chronological events, which comprises specific characters ( Jahn, 2005 ) and ‘a plot that intentionally relates events in the story’ ( Clough, 2011 : 704), encompassing a variety of forms (e.g. novels, plays, films, comic strips) and offering ‘meaning through evocation, image, the mystery of the unsaid’ ( Mattingly, 1998 : 8). Across time and cultures, narratives have been used to disseminate behavioural information. From infancy onwards, human beings are capable of producing and processing narratives – contrary to expository texts that are only mastered in adolescence ( Berman and Nir-Sagiv, 2007 ). In other words, humans are highly capable of comprehending information provided in a narrative format ( Graesser et al., 2002 ; Mar, 2004 ), without explicit education. This makes narratives accessible for a large audience, including target audiences with lower SES and health literacy skills ( Murphy et al., 2013 ).

Narratives may also solve the intention-behaviour gap. The Health Action Process Approach ( Schwarzer, 2008 ) posits that people may not perform the desired behaviour for different reasons: non-intenders are not (yet) motivated to perform the desired behaviour, whereas intenders may be motivated to do so but fail to put this intention into action. According to the Health Action Process Approach, planning strategies are essential in helping intenders to overcome this intention-behaviour gap. Such strategies involve specifying the when, where and how of the intended behaviour (action planning), and anticipating potential barriers and preparing successful strategies to overcome them (coping planning). Narratives are especially suited for supporting such planning strategies; they focus on specific characters, their actions and motivations, and express the unfolding events in a temporal and causal framework ( Berman and Nir-Sagiv, 2007 ). Hence, characters can function as role models showing how to put an intention into action, what obstacles to expect, and how to successfully navigate them ( Bandura, 2004 ; Green, 2006 ).

Overall, narrative health interventions have proved effective in creating positive health beliefs, increasing health attitudes and intentions, and stimulating healthy behaviours –though not for each and every narrative intervention (see for reviews, De Graaf et al., 2016 ; Shen et al., 2015 ). This variation can be explained by the diversity of narratives used in these studies ( De Graaf et al., 2016 ) and raises the question of how to develop effective health narratives. Whereas previous studies have extensively examined the mechanisms and processes involved in narrative persuasion (e.g. Murphy et al., 2013 , 2011 ), relatively little attention has been focused on the construction of health narratives.

Some researchers have provided concrete strategies and writing techniques for constructing narratives ( Gesser-Edelsburg and Singhal, 2013 ; Thompson and Kreuter, 2014 ). Several studies have described the development of their narrative health materials, including a HIV prevention video for company workers in Ecuador ( Del Carmen Cabezas et al., 2015 ), a depression fotonovela for Latinos with limited English proficiency ( Cabassa et al., 2012 ), photo stories for older adults with limited health literacy ( Koops Van ‘t Jagt et al., 2016 ), stories on obesity prevention ( Zwald et al., 2013 ), and narratives for the African American community on breast cancer screening ( Kreuter et al., 2008 ), HIV prevention ( Berkley-Patton et al., 2009 ), smoking cessation ( Houston et al., 2011 ), and hypertension management ( Fix et al., 2012 ). The majority of these studies focused on minority groups and, either implicitly or explicitly, addressed the health disparities gap. However, none of the previous studies has addressed the issue of the target group’s current stage(s) of behaviour change (non-intenders and intenders) in the narrative construction process.

This article introduces the concept of ‘storybridging’ as a method for constructing effective and well-tailored narrative health interventions, identifying meaningful steps in the construction process with regard to content and form characteristics. The method will be illustrated by examples of health narratives for Dutch truck drivers, which proved effective in increasing health intentions ( Boeijinga et al., in press ).

Storybridging: constructing effective narratives

Storybridging refers to the use of stories as a tool for bridging the gap between health inequities as well as the intention-behaviour gap. Below, the characteristics composing effective narrative health interventions are specified and converted into specific steps for narrative development.

With regard to content characteristics, a distinction is made between health narratives targeting non-intenders and intenders, as these groups require different approaches ( Schwarzer, 2008 ).

Narratives for non-intenders

According to the Health Action Process Approach, the motivation to change one’s behaviour depends on a person’s risk perception, outcome expectancies, and self-efficacy ( Schwarzer, 2008 ). Narratives can portray the negative consequences of risky behaviours, thereby increasing the audience’s risk perceptions ( De Wit et al., 2008 ; So and Nabi, 2013 ). Health narratives focusing on risk perception encompass (a) the present situation/behaviour and (b) the consequences of continuing the present behaviour. The negative consequences of the current behaviour should be presented as both severe and realistic, since ‘too severe of a threat and too low of a threat are equally as ineffective’ ( Averbeck et al., 2011 : 40).

Outcome expectancies refer to the audience’s perceptions of the expected consequences of a new behaviour. Observing a narrative character’s behaviour being rewarded can lead to positive intentions to perform this behaviour as well. Health narratives focusing on outcome expectancies thus entail (a) the desired situation/behaviour and (b) the consequences of performing the desired behaviour. The consequences should be presented as both realistic and positive for them to work as a motivator. In addition, conveying the story of a character who was able to successfully perform the behaviour may also increase the audience’s self-efficacy perception.

Narratives for intenders

According to the Health Action Process Approach, intenders will benefit from a focus on action and coping planning strategies ( Schwarzer, 2008 ). A universal narrative pattern of action and coping is ‘the hero’s journey’ ( Campbell, 2008 ): the main character – the hero – is called for an adventure into the unknown and faces the beginning of change. During the journey, the hero is tested; dragons have to be slain and barriers passed. Once the goal is achieved, the hero returns in an essentially changed, and improved, state of being. Put in more generic terms, ‘ someone is confronted with some problem which he/she/it overcomes (or succumbs to) in some way ’ ( Gordon, 1978 : 7). The way in which a recognisable character resolves recognisable problems can provide an example for the target audience on how to deal with similar problems ( Bandura, 2004 ).

Health narratives focusing on planning strategies include (a) the present situation/behaviour, (b) the desired situation/behaviour, and (c) the connecting strategy between the present and desired situation/behaviour. An important part of the present situation/behaviour consists of the barriers experienced when trying to perform the desired situation/behaviour. According to Gordon (1978) , a prerequisite for effective narratives is that the presented connecting planning strategies are well-formed , in that they lie within the target audience’s reach and control.

Again, seeing others successfully perform the desired behaviour may not only enhance the audience’s planning strategies, but also their self-efficacy perception ( if they can do it, so can I ) ( Falzon et al., 2015 ). Within the Health Action Process Approach, perceived self-efficacy is considered an important determinant at both stages of the health behaviour change process. For non-intenders, self-efficacy refers to beliefs about one’s ability to initiate healthier lifestyle behaviours ( action self-efficacy ), whereas for intenders, it refers to beliefs about one’s ability to deal with barriers that arise while performing these behaviours ( maintenance self-efficacy ).

Character similarity

A vital element for narrative characters to serve as role models is that the target audience perceives the character as similar to itself. This perceived similarity may be based on various characteristics of the character such as ‘socioeconomic status, group membership, place of residence, life experience, or attitudes, beliefs and values’ ( Kreuter et al., 2007 : 229). In depicting characters, language is essential, since the use of authentic, culturally resonant language reflects a target group’s culture, including its beliefs, norms and values ( Larkey and Hecht, 2010 ).

Perceived similarity in language and other details (social class and context, gender and profession, etc.) has been suggested as a driver for identification ( Brown, 2015 ; Cohen, 2006 ; Hoeken et al., 2016 ), which is recognised as an important mechanism for narrative persuasion. For example, identification with narrative characters has been found to influence attitudes ( De Graaf et al., 2012 ; Hoeken and Sinkeldam, 2014 ; Igartua and Barrios, 2012 ), as well as intentions and actual behaviour ( Moyer-et al., 2011 ). Not only character similarity but also setting familiarity seems a promising characteristic to make narratives more persuasive ( De Graaf et al., 2016 ). Familiarity with a character’s (living) situation was found to encourage transportation ( Green, 2004 ) and effective in increasing risk perceptions ( De Graaf, 2014 ).

Perspective

Another driver for identification is the perspective presenting the narrative ( De Graaf et al., 2012 ; Hoeken and Fikkers, 2014 ; Hoeken et al., 2016 ). First-person health narratives tend to be more effective compared to third-person health narratives ( see for a review, De Graaf et al., 2016 ). A first-person story perspective, in which the ‘I’-character is the deictic here-and-now-centre of the narrative, requires readers to take the position of the protagonist ( Graesser et al., 2002 ), thus inviting them to process the presented information from their own spatial body perspective ( Brunyé et al., 2009 ); readers appear to use ‘self’ as an anchor in organising information ( D’Ailly et al., 1995 ). In other words, the strategic use of language can guide people to identify with certain characters ( Hoeken et al., 2016 ).

Finally, the medium through which the narrative is presented may be relevant. Although Braddock and Dillard’s (2016) meta-analyses did not find clear effects for a superior effect of one medium over the other, this factor should not be underestimated regarding target audiences with lower SES and health literacy. For example, print messages may require higher cognitive demands than audio messages ( Wilson and Wolf, 2009 ).

A four-step method

These essential characteristics provide guidance for narrative development and can be translated into concrete steps. As non-intenders require a different intervention approach to intenders, the first step is identifying the target audience’s present stage of behaviour change, which determines the focus, and thus the content, of the narrative. For non-intenders, the narrative should focus on risk perception, outcome expectancies and/or self-efficacy, whereas a narrative for intenders should focus on planning strategies.

Step 2 involves identifying and selecting the content elements of the narrative, based on the audience’s stage of change. This implies foremost gaining an understanding of (a) the nature of the present situation/behaviour, including significant persons and events. In addition, the following elements need to be identified: (b) the experienced negative consequences of the present behaviour, (c) the desired situation/behaviour, (d) the positive consequences of the desired behaviour and/or (e) corresponding connecting strategies.

The third step involves constructing the story that basically is built on the selected key elements. Regardless of the target audience, stories should be isomorphic in order to be effective: that is, the story should cover the situations/behaviours as perceived by the audience, including relevant characters, events and barriers ( Gordon, 1978 ). The target audience’s characteristics and experiences gathered in Steps 1 and 2 thus function as important building blocks in constructing the health narrative, materialised in optimal character similarity, linguistic perspective and medium choice.

The final step involves pre-testing the health narrative with members of the target audience, assessing its authenticity and comprehensibility. Important aspects to test include perceived similarity (To what extent does the target audience relate to/identify with the character?), isomorphism (To what extent are the narrative’s key elements perceived as realistic and authentic?) and well-formedness (To what extent are the desired behaviour and connecting strategy in reach or control of the target audience?). On the basis of the results from the pre-test, the narrative is repeatedly edited and retested, until it is considered authentic and appealing by the target group. The final version of the health narrative thus results from iterative construction and pre-testing.

For all steps, it is important to integrate the target audience ( Miller et al., 2015 ). In Steps 1 and 2, their personal stories are used as input, and in Steps 3 and 4, they provide valuable feedback on the output (the developed story). In other words, effective narrative health interventions are co-created with the target audience.

Application

The above-presented Storybridging steps are illustrated with a successful case study of narrative health communication for Dutch truck drivers ( Boeijinga et al., in press ): a large, high-risk, low SES group with relatively unhealthy lifestyles that is hard to reach ( Sectorinstituut Transport en Logistiek [STL], 2016 ) and was underserved in attention of health intervention researchers so far ( Ng et al., 2015 ).

Step 1: identifying the stage of change

To identify the current stage of behaviour change, semi-structured, in-depth interviews were conducted with members of the target audience ( n  = 20) ( Boeijinga et al., 2016 ). Participating truck drivers were asked general inquiries about their daily life and routines (‘What is it like to be a truck driver?’) as well as more specific questions about current eating and exercise behaviours, satisfaction with one’s physical condition and previous attempts to improve one’s condition (e.g. ‘Have you ever tried to lose weight or keep from gaining weight?’, ‘Can you tell me more about these attempts?’). To avoid socially desirable answers, questions on health-related themes were posed using indirect probing questions or postponed towards the end of the interview. Each participant was debriefed afterwards about the actual nature and purpose of the research.

Step 2: identifying the key elements

The content elements were incorporated in the interview design by questions like ‘What does a typical day look like?’ ‘Who are involved?’ (present situation/behaviour); ‘What advantages and disadvantages do you experience from …?’ ‘What are your expectations on the long-term?’ (consequences of continuing present behaviour); ‘What would you like to be changed?’ ‘What changes would you like to make?’ (desired situation/behaviour); ‘What advantages do you expect or experience from …?’ ‘Why would you recommend to …’ (consequences of adopting desired behaviour); ‘What stops you from …?’ ‘How will you be able to …?’ and ‘What advice would you give other truck drivers?’ (connecting strategy).

Step 3: building the story

The story was built around the identified key elements. To enhance isomorphism and perceived similarity, key quotes and comments were extracted from the truck drivers’ personal stories and used as building blocks for the health narrative. Similarity of language was ensured to incorporate the target group’s culture. In line with previous research, the story was written from a first-person perspective. In addition, the social perspective from which the interviewed truck drivers related their personal experiences – for example, as a truck driver, husband, father and so forth – was taken into account. Health care aspects of the content were checked for accuracy with health scientists. Also, potential media formats were checked with interview data regarding media usage as well as with literature data from other studies.

Step 4: pre-testing the story

The pre-test was conducted in collaboration with a Dutch trucking company. The participating truck drivers ( n  = 7) read the story aloud, providing immediate feedback followed up by further questioning and evaluation (e.g. ‘What do you think of the story?’ ‘How does the story make you feel?’ ‘To what extent can you relate to the story?’). In addition, the story was proofread for authenticity and accuracy by important stakeholders in the transport sector, such as the Dutch National Institute for Transport and Logistics and the editors of a trucking magazine. Based on the pre-test’s results, the narrative health intervention was edited and refined.

Stage of change: non-intenders and intenders

The interviews revealed that Dutch truck drivers regard health as important and that they manage to warrant a sense of good health by comparing their own health to that of colleagues who are worse off (e.g. who suffered from heart attack or knee malfunction). This kind of downward social comparison enables truck drivers to maintain a relatively benign image of their own health status. As a result, some truck drivers feel little motivation to change their lifestyle, which qualifies them as non-intenders.

More truck drivers, however, indicated that they actually would like to live a healthier life and had repeatedly tried to do so – qualifying them as intenders. Their attempts were, in most cases, thwarted by barriers within their work environment (e.g. irregular working hours and lack of exercise facilities) and personal environment (e.g. social expectations or obligations). There are thus both non-intenders and intenders among the target audience.

Key elements: a risk narrative and planning narrative

Two health narratives were developed: a risk narrative in response to the non-intending truck drivers’ tendency to downplay their health risks, and a planning narrative to facilitate intenders to put their intention into action. Accordingly, relevant content elements for both narratives were identified.

Present situation/behaviour

The interviewed truck drivers generally described their current work situation as strenuous: ‘What is it like to be a truck driver? Working at impossible hours, unsightly hours, stressful, […] just bad for your health, just a bad job’. Their current health situation was typically related to their work; health-related issues such as overweight, obesity, worn vertebrae, stress and (chronic) fatigue were considered ‘part of the job’. The less truck drivers managed to downplay their health threats by downward social comparison, the more they regarded their present health situation as problematic.

With regard to relevant others, the partner’s role appeared to be particularly decisive. The partner (if there was one) usually prepared the trucker’s lunchbox and was in charge of the groceries and meals at home, thus playing an important role in controlling dietary patterns. At the same time, the partner’s expectations (or demands) regarding quality/family time sometimes prevented truckers from exercising during leisure time and, thus, hindered their healthy exercise habits. Crucial appeared the shift from work to home (and the balance between them). Once home, truck drivers experienced more control over their behaviours, but their lack of energy after work prevented them from exercising.

Thus, both the work and personal environment were associated with barriers; irregular working hours and a lack of exercise facilities were indicated as most decisive barriers to healthy lifestyles. The interviewed truck drivers reported unfavourable behaviours regarding both diet (irregular and unhealthy meals) and exercise (a lack of physical activity). In consultation with health scientists, a focus on exercise behaviours was chosen as most promising. Truckers’ perceived barrier of ‘lack of exercise facilities in the work environment’ resulted from their framing ‘exercise’ as ‘going to the gym’, which was generally considered too demanding or even outrageous (cf. Caddick et al., 2016 ). Reframing exercise as ‘being physically active’ may offer an alternative frame and, thereby, provide more ecological opportunities for truck drivers to act upon. Thus, truck drivers’ exercise behaviours appeared to provide a window of opportunity for improvement.

Negative consequences

Stories about other truckers being worse off provided the content for depicting negative consequences of continuing the present behaviour. For example, truck drivers described heart attacks, involving either themselves or their colleagues. Other important downsides experienced by the target audience were being unfit to engage in physical activities with their (grand)children or being afraid of not witnessing them grow up.

Desired situation/behaviour

The intending truck drivers indicated that they would like to adopt healthier lifestyle behaviours in order to feel better and fitter. Specifically, they would like to improve their physical shape so that they would have more energy during/after work. In addition, intenders indicated that they strive to lose weight, not wanting to look like ‘typical truck drivers’, who are often stigmatised and portrayed as obese, ‘meatball-eating’ men.

Connecting strategy

Stories of truck drivers who already managed to improve their health and lifestyle provided strategies for bridging the gap between the present and desired situation/behaviour. These strategies involved (a) battling the irregularity by structuring the day, (b) exercising without typical sports equipment, and (c) tackling temptations (e.g. exercising instead of watching television) by willpower. In general, the truck drivers considered themselves in control of their own health; ‘your health is in your own hands’.

Building the story: from quotes to narratives

The identified key elements served as basic elements for the stories. For both narratives, a storyline was developed around the fictitious, but representative, character with the (in Dutch) neutral name René Louwisse, a 41-year-old trucker, the father of Tim (14 years) and the husband of Anja (38 years). These features were based on the characteristics of the interviewed truck drivers; the majority was ethnically Dutch, aged between 40 and 50 years and had a partner and children. As the age of 50 was described as a turning point at which physical pains and reduced fitness could no longer be ignored or downplayed, an age of early 40s was chosen; truckers around this age generally feel no need (yet) to engage in preventive health behaviours. Given the importance and influence of the partner and children, who were frequently mentioned as drivers of motivation, both the spouse and child were elaborated upon as characters in the narrative.

Risk narrative

The risk perception narrative described René during a typical day at work (present situation/behaviour). While unloading his truck, he experiences chest pains. At first, he tries to ignore the pain since he is already behind schedule. During his general practitioner (GP) visit the next day, he is immediately referred to the hospital for examination. It turns out that an artery near his heart is clogged and requires immediate surgery (negative consequences); the subsequent operation is successful. René realises he has been lucky and that he needs to change his current lifestyle, including lack of physical activity and overweight.

The next story fragment is taken from the risk narrative with elements derived from the interviews in italics:

I was on my way to a delivery address in Germany and suddenly felt unwell . […] Once arrived, I stepped out the truck to unload. I pulled open the side of the trailer and suddenly felt real cold, very uncommon . I called Anja and said: ‘ There’s such a cramp in my chest and guts, damn ’. Usually she would comfort me and make jokes about men and their aches and pains. But not this time. ‘ I’d rather see you go to the ER ’, she said. I said: ‘Yes, will do’, but thought: no way. I’m not going to a hospital abroad, right ?

Planning narrative

The narrative focusing on planning strategies depicted René, reflecting on the road he travelled to a healthier lifestyle. Seeing his son’s embarrassment of his poor physical shape (present situation/behaviour), René decides to improve his lifestyle (desired situation/behaviour) – which proves easier said than done. His first bike ride to work is not much of a success; he arrives at his truck sweaty and red faced. The rain is not helping his resolution to cycle either, and the couch is tempting after a long day on the truck. Nevertheless, he finds his ways (connecting strategies) to navigate past these challenges and establishes a healthier life by setting fixed biking days (battling irregularity by structuring the day/week), going for walks (exercising without sport equipment) and resisting temptations (willpower) – including a specification of the when, where and how.

All three connecting strategies were incorporated in the storyline. In this way, audience members can decide for themselves which (combination of) strategy is applicable to their personal situation. In addition, an example was given on how to spend family time while getting some exercise – that is, René playing soccer with his son – in response to the experienced social expectations and obligations and the limited ‘exercise-frame’.

A story fragment illustrates how these elements were incorporated into the narrative:

On days I don’t bike, I go for a walk. That’s easy enough to organise . Anything from a walk around the block to a couple of miles, all depends on my time available . Sometimes together with Anja or the dog. […] Although it’s true, there are still days I don’t feel like doing anything. Such days, the couch is very tempting indeed. The other day, for example, it started raining just when I wanted to go out for a walk. So, I went for walk with my umbrella. […] Well, there’re always excuses for not going, but it’s a matter of focusing on the reasons for going. It’s your own choice; it’s in your own hands.

Based on the truck drivers’ preferences and on previous research findings, the health narratives were presented in a written and audio format; a survey revealed that nine out of 10 truck drivers read trucking magazines, and that they consistently listen to the radio during work ( TON Magazine, 2013 : 12–17), which was confirmed by the interview data ( Boeijinga et al., 2016 ).

Pre-testing the story: isomorphic and well-formed

The pre-test confirmed the health narratives’ isomorphism and perceived similarity. After reading the risk narrative, one truck driver remained quiet for a while and then said, ‘This story is about me, there is more to heaven and earth …’ It turned out that his name was René as well and that he had also suffered from heart failure. Generally, the desired situation/behaviour and connecting strategy as part of the planning narrative were considered well-formed. Some truckers pointed out that the home-to-work bike distance (10 km) was quite ambitious, and it was therefore altered to 6 km. The selected male voices ( n  = 3) for the audio version were all recognised as authentic. The one identified as most representative was used for the final version of the audio versions. The potential of both media formats was confirmed by the stakeholders; that is, by truck drivers themselves as well as by the Dutch National Institute for Transport and Logistics and cooperating trucking companies.

Based on the pre-test, minor changes were made. The final versions of the health narratives consisted of approximately 840 words (risk narrative: 852 words, planning narrative: 825 words). The readability was also similar for both narratives (Gunning Fog Indices: risk perception-focused narrative: 7.49, planning strategies-focused narrative: 7.13). The recorded narratives were each below 5 minutes (risk perception-focused narrative: 04: 50 minutes, planning strategies-focused narrative: 04:37 minutes). Thus, in this case study, the Storybridging approach resulted in four health narratives: (a) a written risk narrative and (b) an auditory risk narrative for non-intending truck drivers; and (c) a written planning narrative and (d) an auditory planning narrative for intending truck drivers.

Using the Storybridging method, health narratives were developed for both non-intending and intending Dutch truck drivers. A quantitative study testing the effectiveness of these narratives showed that both narratives were, via different routes and regardless of their medium, effective in increasing truck drivers’ exercise intentions ( Boeijinga et al., in press ). These findings endorse the effectiveness of the applied Storybridging method, in which the target audience served as an important stakeholder throughout the development process; their personal stories (input) formed the basis of the health narratives (output). On the basis of this case study, the article aims to offer a practical step-by-step method for constructing effective narrative health interventions.

Although time-consuming and labour intensive, the Storybridging method suggests that it pays off to first gain a thorough understanding of the problem behaviour at stake and the stage(s) of behaviour change the target audience is at (Step 1). Based on this knowledge, the health narrative’s key elements can then be determined (Step 2) and used as building blocks while constructing the story (Step 3). According to the Health Action Process Approach, non-intenders benefit from a focus on risk perception, outcome expectancies and/or self-efficacy, whereas intenders benefit from a focus and action and coping planning.

However, the theoretical concepts implicit in the Health Action Process Approach have a certain interrelatedness, which prevents a clear-cut distinction between them both in practice and while developing health narratives. The developed planning narrative, for example, depicts the story of a role model truck driver who (after a bumpy road) is currently living and enjoying a healthier life. By implying the beneficial aspects of his lifestyle change (e.g. ‘being happy with the lifestyle changes’; ‘feeling stronger and fitter’), the storyline unintentionally could lead to positive outcome expectancies as well. Planning strategies also operate in concert with perceived self-efficacy, both of which are enhanced by role model behaviour of narrative characters. With regard to persuasiveness, the story’s quality, accuracy and readability outweigh its strictness and limit in focus. The theoretical concepts should therefore serve as guide rather than fixed rules.

The final step involves pre-testing and refinement (Step 4). The developed health narratives were pre-tested in a research setting, which may differ from truck drivers’ real-life setting. The question is whether these narratives would also be read on a voluntary basis under less favourable, everyday conditions. A promising format in this regard is TON magazine , a free of charge, national trucking magazine that is widely distributed both in printed (home delivery) and digital format (available at http://www.tonmagazine.nl ), and well read by Dutch truck drivers ( Steijvers and Van der Valk, 2012 ). The importance and influence of both the work and private context give rise to another limitation. Rather than targeting the target group on its own, narrative health interventions may benefit from a multiple audience design, including significant others such as the partner. Printed home-delivered versions of professionally focused magazines such as TON may reach both the primary, professional target group members and their household members, specifically their partners. In collaboration with the National Institute for Transport and Logistics, for example, a special edition of TON magazine could be developed targeting truckers’ partners by sharing stories and tips (e.g. easy recipes and exercises) on how to facilitate healthier lifestyles. Previous research has indicated that such a holistic, multi-stakeholder health promotion approach – including individual, interpersonal and ecological levels – is an imperative need in the context of the trucking sector ( Apostolopoulos et al., 2012 , 2011 ).

To conclude, the Storybridging method offers a careful and practical step-by-step approach for co-creating narrative health interventions, in response to the mixed results and wide diversity of narratives used in health-related narrative persuasion research. The steps established are guided by the Health Action Process Approach as well as choices around narrative characteristics. An important implication of this method is that non-intenders and intenders each require a specific approach and, therefore, specific narrative content. Identifying the target group’s stage of behaviour is thus an essential first step in constructing effective health narratives. The developers of narrative health interventions are recommended to involve the target audience in each step of the development process. Narrative health interventions developed using the Storybridging method are promising in bridging health inequities as well as the intention-behaviour gap. Future narrative health interventions should be carried out following the Storybridging steps to further verify the utility and generalisability of the method.

Acknowledgments

The authors thank the truck drivers and sector partners for their time and participation.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Netherlands Organisation for Scientific Research (NWO/ZonMW), Project BGRL-11-15.

17 Narrative and Memoir

Narrative writing.

Human beings tell stories every day. We understand most of nature through stories. Though facts can be memorized, stories — the details, the description, the experience — make us believe.

Therefore, as we begin to study writing, we need to begin with the properties of the story. How do good storytellers make us believe? How can good writing draw a reader into a story? How can we harness the power of the story to make a point, even in a dry, academic context?

This lesson will reflect on those questions as well as offering concrete advice and practice outlines of typical narrative writing.

WHERE DO WE FIND NARRATIVE?

We talk about narrative writing in many ways. Books will introduce it as Narration, Narrative, and Storytelling. Narrative creeps into most of the other kinds of writing we learn about, too. Persuasive essays use short stories — often called anecdotes  — to engage a reader’s attention and sympathy. Consider the difference between these two openings to the same essay:

Which opening makes you want to read more? The second one engages its readers with a story — and we’re hard-wired, as humans, to want to hear the end of a story.

Television plays on this characteristic all the time. Think of your favorite show and the maddening, brief preview that starts before the credits roll. It’s always a quick snippet that makes you stay tuned because the writers and producers know their audience will sit through several minutes of mindless commercials just to find out how the story will continue.

In our own writing, we can use stories in just the same way. We can draw our readers into our own experiences, even if they’ve never been through anything even similar to what we have, by telling our own stories.

HOW DO WE WRITE A NARRATIVE?

A narrative essay is a piece that tells one consistent, cohesive story. In academic writing, a narrative essay will also always convey a lesson, a moral, or a point that the writer wishes the reader to take.

When we say “moral,” some people think of after-school specials and having “good behavior” tips crammed down their throat. However, the most powerful lessons conveyed through writing are often done with great subtlety. True, the punishing pace of writing expected in a college course may not leave enough time to develop a nuanced story — no one is going to churn out War and Peace  or even  The Hobbit  in ten weeks — but not every story has to have the moral stated clearly, in bold font, at the very beginning.

Think about it this way: When you were a kid, if your grandmother had sat you down and said, “Listen. We’re now going to have a thirty-minute conversation about how it’s really bad if you start smoking,” would you have listened? Probably not. If, however, your grandmother took you to visit your uncle Larry, who had terminal lung cancer, and then casually mentioned as you left that Larry had been smoking since he was your age — would you get the lesson? Would you remember it? Do you remember better the 200 lectures you had as a teenager about not being a bully, or do you remember the one time that you witnessed its effects firsthand?

In a narrative, we want to pull that same kind of trick on our readers: get our point across, but do it in a way that engages the imagination and attention. Use the power of the story.

The narrative relies on the same components that all good writing does: it needs detail, clear organization, and a central purpose (AKA our friends Development, Organization, and Unity).

NARRATIVE DEVELOPMENT: BRING THE DETAILS

Consider this passage from the very first Sherlock Holmes mystery, “A Study in Scarlet,” which describes a major character:

The author includes detail upon detail to describe this gentleman. He could have simply said, “He was dying from hunger and from thirst,” which would tell us everything we need to know. Instead, he describes how these feelings have had an effect upon the man — he is  gaunt , he’s starting to look like a skeleton, and he can barely stand without the support of his rifle.

Think of the best book you’ve ever read (or the best television show you’ve ever watched, or the movie you love), and you may be able to relate to this. Good description is the difference between hearing a game on the radio and watching it live in the stadium (or on a ginormous 3-D television). The very breath of life in a narrative will always be your ability to describe a scene.

This relies on the use of specific language. As you read through the revision section, you were encouraged to avoid phrases that your audience might find misleading. Consider this as you write a story. With every sentence, ask, “What does my audience know? What do they think?” If you say a car is “beautiful,” will your audience think of a 2018 Hybrid Honda Accord or of a 1966 Chevelle (pictured at right)? If there’s some doubt, change your words to reflect your meaning.

You may have heard the advice that asks you to “show, not tell” in writing. This is what we mean: be so descriptive in telling a story that the reader feels s/he is there beside you, seeing the swimming pool or the school’s front doors or the new car or the new child with his/her own eyes.

NARRATIVE ORGANIZATION

Narrative traditionally follows time order, or  chronological order , throughout. This seems obvious when you think about it — we tell stories in time order, starting (usually) at the beginning and working through to the end.

In an essay, pieces of the story can be organized into timespans by paragraph. For instance, if I’m describing a particularly harrowing day at work, I might have a paragraph just for the morning, and then a paragraph about my terrible lunch break, and then a paragraph about my afternoon.

Narrative essays usually can’t cover more ground than a day or two. Instead of writing about your entire vacation experience, study abroad month, two years of work at the plant, or 18 years living at home, focus on one particular experience that took place over a day or two. That’s enough for a reader to digest in a few pages, and it will also give you a chance to really lay in details without feeling rushed.

Sometimes, we start stories out of order. Many popular movies and television shows do this regularly by showing a clip of something that happens later before starting the whole show. If you’ve ever seen an episode of NCIS, you’ll be familiar with this technique: they start each section of the show with a photo of the ending scene, then start an hour or two before that scene in the live-action. Shows often jump to “One Week Earlier” between commercial breaks.

Think of the emotional impact that has upon you as a viewer. Again, it’s a trick the writers pull with their story to drive you through the boring/silly/pointless/insulting commercials so that you’ll stay with them. We want to know how the characters get to that end.

You can manipulate your audience in this way, too, but be careful; giving away too much of the ending may sometimes make a reader simply put down what they’re reading. It’s safer (though not always better) to just start at the beginning and write things down as they happened. Particularly in a first draft, sticking to the natural story order will be a good way to make sure nothing gets missed.

NARRATIVE UNITY

The final consideration in putting together a narrative essay should be unifying it around a single theme or lesson. As you draft, you may already have this lesson in mind:  everyone should wear a seatbelt.  However, remember that your reader needs to make up her own mind. Don’t insult a reader by beating them up with your lesson, and don’t leave them guessing about the meaning of your piece by leaving it out completely.

Many writers include a paragraph of reflection after telling a personal story in an essay that lets a reader know, directly, the significance that the story has on the writer’s life. This can be a good way to get a lesson across. Showing what you’ve learned or found important in an event will provide the reader with a clue about the overall meaning of the story.

You should use “I” in a personal, narrative essay . There are types of academic writing where “I” is inappropriate, but this is not one of those times. In fact, the best narratives will often be the most personal, the stories that avoid hiding behind “you” or “they” and instead boldly tell the writer’s own story.

NARRATIVE OUTLINES

The typical narrative essay follows an outline that should seem like common sense:

• Paragraph 1: Introduction
• Paragraph 2: Event #1
• Paragraph 3: Event #2
• Paragraph 4: Event #3
• Paragraph 5: Conclusion

This outline is flexible. Perhaps the first event in your story will take significant space to describe; it may need 2 paragraphs of its own. Maybe there are smaller events that happen within the larger events. Maybe for your piece, it makes sense to jump right into the story instead of spending an introduction paragraph to give some setup. What matters most is that a reader can easily follow the piece from beginning to end and that she will leave with a good understanding of what you wanted the reader to learn.

Most People Don’t Understand Memoirs  

In 2006, James Frey wrote a memoir about parts of his life when he was under the influence of drugs called  A Million Little Pieces , and after Oprah had him on her show to discuss the book – it was featured in her popular book club, of course – she was told that he “lied” about certain parts. Well, he didn’t lie. Memoirs contain what we remember. What we remember isn’t always “fact.” What I always say is that if you have all of your family members report what happened at a family gathering – like a birthday party or Christmas – whose report would be correct? No ones! That’s what a memoir is. It’s still nonfiction because it’s what the person remembers, but it’s not false on purpose. If I remember that my sister responded to me in a snotty way one day and my other sister didn’t think so, no one is correct. It’s just my memory versus hers.

Now, typically, memoirs encompass just a chunk of someone’s life, like when James Frey wrote about his drug years, but sometimes, some famous person in their 70s (or older) will write his/her memoir. No matter what, it’s simply what they remember, and I suppose if someone’s on drugs or has an awful memory, the stories could appear to be false. But they aren’t. That’s why they say, “life is stranger than fiction.”

Memoirs are part of the nonfiction category of literature; they contain a lot of description and detail, and they are typically very, very personal in content.

The Bits and Pieces of Memoir

The memoir is a specific type of narrative. It is autobiographical in nature, but it is not meant to be as comprehensive as a biography (which tells the entire life story of a person). Instead, a memoir is usually only a specific “slice” of one’s life. The time span within a memoir is thus frequently limited to a single memorable event or moment, though it can also be used to tell about a longer series of events that make up a particular period of one’s life (as in Cameron Crowe’s film memoir Almost Famous ). It is narrative in structure, usually describing people and events that ultimately focuses on the emotional significance of the story to the one telling it. Generally, this emotional significance is the result of a resolution from the conflict within the story. Though a memoir is the retelling of a true account, it is not usually regarded as being completely true. After all, no one can faithfully recall every detail or bit of dialogue from an event that took place many years ago. Consequently, some creative license is granted by the reader to the memoirist recounting, say, a significant moment or events from his childhood some thirty years, or more, earlier. (However, the memoirist who assumes too much creative license without disclosing that fact is vulnerable to censure and public ridicule if his deception is found out, as what happened with James Frey and his memoir,  A Million Little Pieces .)

Furthermore, names of people and places are often changed in a memoir to protect those who were either directly or indirectly involved in the lives and/or event(s) being described.

Why read memoirs?

To learn about other people’s lives and their thoughts about events that have occurred.  Memoirs are a personalized look at history.

How to write memoirs?

Reflect n your life. write what you remember about events that matter to you from your unique point-of-view.

Dialogue is another way to bring life to your writing. Dialogue is conversation or people speaking in your story. An engaging dialogue goes beyond what is simply being said to include descriptions of non-verbal communication (facial expressions, body movement, changes in tone, and speed of speech) and characterization. The way people speak and interact while talking reveals much about them and the situation.

Writing a natural-sounding dialogue is not easy. Effective dialogue must serve more than one purpose – it should:

• Drive the plot forward,
• Reveal information about the characters, and
• Build tension or introduce conflict.

Sample Dialogue

“So, what was it really like?” I asked.

“I’ve told you. It was amazing.”

I shifted to my side so I could look at her. “You have to give me more than that,” I insisted, “and not the mom and dad version.”

Liv mirrored my move to her side and propped up her head with her arm. Her blue eyes searched my greens, looking for the right words. “I shouldn’t–”

We broke our gaze as we heard our mom call for us. Once again, I didn’t get the truth.

Basic Dialogue Rules

• “I want to go to the beach,” she said.
• He asked, “Where’s the champagne?”
• “That is,” Wesley said, “that neither you nor me is her boy.”
• Even if the speaker says only one word, with no accompanying attribution or action, it is a separate paragraph.
• Start a new paragraph when you wish to draw the reader’s attention to a different character, even if that character doesn’t actually speak.
• For internal dialogue, italics are appropriate.

Example Memoir

Chocolate Can Kill You

Just when you think your life could not get any better, the Great One Above throws you for a loop that causes you to think upon your life, yourself, and your “little” obsession with chocolate. I am somewhat ashamed of this story, but it taught me so much. I still remember Alisa’s face when I came crying into the Valley City gym, I can hear Dad’s echoing “Are you OKAY?” consistently in my mind as if it had been a childhood scolding, and I see the image of the snow coming at me at 70mph every time I drive on a highway now.

In 1997, the morning after Valentine’s Day, I took off to see my sister in Valley City. She was there because of a wrestling meet. She is one of their prized assistants and without her, they would never get to see how goofy they look in tights. It was a crisp morning, and I cannot remember if I filled the bronco’s tank, but I did purchase a Twix bar before heading out on I-94. I vaguely remember thinking, Gee a seat belt would be good, even though the roads were as clean as they could have been in a North Dakota February. On that ten-degree morning, I met up with no one on the highway.

I was just bee-bopping along the left side of the road, listening to the radio and singing aloud as if I was Mariah Carey. It was at this time that I chomped into my first Twix bar.

In an attempt at a different radio station or something or another, I dropped the last bar between my legs onto the floor of the black beastly bronco.

This is where I become a stupid human. I tried to recapture the chocolate bar thinking, or maybe not even thinking, It will only take me a second. Whoever has said that seconds count in any accident WAS RIGHT! All of a sudden, I look up to see that I am driving 70 mph into the median’s snowdrifts. I cranked the wheel, thinking I could just drive back onto the highway. I mumble a few swear words and realize I am going 70 MPH IN A VERY DEEP SNOWDRIFT! I take my foot off the accelerator and while the front end slows, the back end has accumulated too much energy or velocity (a good physics question) and begins to lift upwards. I close my eyes, cross my arms across my chest, and crouch back into my seat and start to feel the bronco as well as myself turn and twist and hover for what seemed an eternity in slow motion. I did not open my eyes once.

And then all of a sudden, the small jolted car lands- PLOP – ON ITS WHEELS! My chair has completely reclined, and I sit up seeing smoke coming from my engine. I forget how to work my car and instinctively get out as if to show God I am alive. I stand on top of the drift becoming taller than my boxy 4×4. There are small dents in the front where you would open the hood but that is the biggest damage I can see.

“Are you OKAY?” An old couple are parked and honking at me from the other side of the highway going towards Fargo. They tell me to come with them and turn off the engine. I grab my parka and make my way through the snow to sit down in the back seat of the long car and take in that old people smell. This is when I quietly cry.

“You did a flip! It’s amazing you walked away from it,” says the old man and I think to myself sarcastically to calm down, Yeah I tried to do that. I ask them to take me to Valley City trying not to sound three and a half. Another major thought echoes What will Dad say?

They turned around at the next available bridge which was a mile away and the lady told me the exit so I could give it to the people that will tow my little bruised bronco. They talked to themselves as I tried to think of what exactly happened, how glad I was to be alive, and how I felt about it. Once inside the gymnasium, I found Alisa’s eyes and she instantly frowned and looked scared.

“Did you and Jason fight?” No, I try to say but I am crying in front of a large crowd who all seem more interested in me now than the matches. I sit down beside her and say:

“I did a flip… the bronco… flipped … it did a 360.”

“The bronco did a WHAT! ARE YOU OKAY!” She panics. I go to call Dad as she tells her friends, and they also feel sympathetic and are quite amazed. I don’t know how I managed to remember my calling card number, but I reached Mom and Dad just waking up. Once again Dad frightens me with his voice and vows to be there as soon as possible and tells me to call the highway patrol.

I was the only accident that whole day on the highway, I think, so I looked pretty silly.

Mom and Dad showed up an hour later. Mom was half-awake, and Dad looked like he’d been chugging coffee left and right. They had seen the bronco being towed incorrectly towards Fargo, so Dad feared the transmission was screwed up again much less the rest of the car. We took off for Fargo and stopped at the spot seeing the tracks lead into the snow, then 25 feet of no tracks, and suddenly a large indentation where the bronco had sat down.

Once at the Mobile on I-29, Dad jumped into the bronco to try to start it. It revved right up. I shook my head and thought of the motto, Built Ford Tough. Only the alignment and steering was off from me trying to turn it back onto the road, and the steam I had seen was the radiator fluid splashing onto the hot engine.

We had to meet with a highway patrolman, so the bronco could get a sticker and photos could be taken. I also, fortunately for the taxpayers, had to pay a Care of Vehicle bill of thirty dollars which means that the government basically can fine someone for trashing his/her own vehicle. This pissed me off incredibly after a day like I had just had. My mom had to remind me though that at least it wasn’t a medical bill.

The highway patrolman reminds me how valuable it was that I had had a seat belt on because I would have for sure gone through the windshield with that type of event and all the tossing that I had endured. That does not make replaying this event in my memory any better. As if God was saying: “No, not yet.”

It’s a common joke to not let me eat while I am driving.

That day made me incredibly grateful for my life, and for the people who came to my aid, especially my parents for spending their whole Saturday with me. Whether we were trying to contact the highway patrolman, paying the tower and the ticket, or comforting me- they never complained. Who knew chocolate could lead to such a life-threatening, yet philosophical day?

Suggested Assignment: Time to Write

Purpose:  This assignment will demonstrate the understanding of how to write a memoir

Task: This assignment frames a single event for the memoir essay.

Write a Memoir Essay.  This essay should clearly identify a significant event or series of closely tied events that convey the significance of that event or has somehow shaped your personal perspective.  Remember that you are writing for an audience that doesn’t share your knowledge of the event(s), people, setting, etc. It is up to you to make your memoir come to life.

Key Features of a Memoir:

• Invoke the 5 senses
• Use narrative suspense
• use metaphor
• include significant details
• provide descriptive language
• use effective dialogue
• include transitions

Key Grading Considerations

• The rhetorical purpose is clear, focused, and appropriate to the audience and assignment.
• The purpose is focused on the memoir.
• Shows engagement with issues of story, language, rhetoric, or thinking deeply about a personal event.
• The theme relates to a personal experience but also illustrates more universal principles.
• Transitions
• Learning Point Thesis Statement
• Topic Sentences
• Some Narrative Elements that flow with the paper
• Clear introduction, event story, and conclusion
• Dialogue is used
• Descriptions and quotes to help visualize the event
• Correct, appropriate, and varied integration of textual examples, including in-text citations
• Limited errors in spelling, grammar, word order, word usage, sentence structure, and punctuation
• Good use of academic English
• Demonstrates cohesion and flow
• Uses the rules of dialogue
• Date format

Attributions

• Memoir Content Adapted from Excelsior Online Writing Lab (OWL). (2020).  Excelsior College. Retrieved from https://owl.excelsior.edu/ licensed under a Creative Commons Attribution-4.0 International License .
• Narrative Writing Content Adapted from BETTER WRITING FROM THE BEGINNING . (2020).  Jenn Kepka. Retrieved from Better Writing from the Beginning licensed under a Creative Commons Attribution-4.0 International License .

ENG101 for Health Sciences Copyright © by Lori Walk; Christine Jones; and Aaron Fried is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License , except where otherwise noted.

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• Open access
• Published: 05 March 2019

Using narratives to impact health policy-making: a systematic review

• Racha Fadlallah 1 , 2 ,
• Fadi El-Jardali 1 , 2 ,
• Mohamed Nomier 1 ,
• Nour Hemadi 1 ,
• Khurram Arif 1 ,
• Etienne V. Langlois 3 &
• Elie A. Akl   ORCID: orcid.org/0000-0002-3444-8618 1 , 4  

Health Research Policy and Systems volume  17 , Article number:  26 ( 2019 ) Cite this article

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There is increased interest in using narratives or storytelling to influence health policies. We aimed to systematically review the evidence on the use of narratives to impact the health policy-making process.

Eligible study designs included randomised studies, non-randomised studies, process evaluation studies, economic studies, qualitative studies, stakeholder analyses, policy analyses, and case studies. The MEDLINE, PsycINFO, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), WHO Global Health Library, Communication and Mass Media Complete, and Google Scholar databases were searched. We followed standard systematic review methodology for study selection, data abstraction and risk of bias assessment. We synthesised the findings narratively and presented the results stratified according to the following stages of the policy cycle: (1) agenda-setting, (2) policy formulation, (3) policy adoption, (4) policy implementation and (5) policy evaluation. Additionally, we presented the knowledge gaps relevant to using narrative to impact health policy-making.

Eighteen studies met the eligibility criteria, and included case studies ( n  = 15), participatory action research ( n  = 1), documentary analysis ( n  = 1) and biographical method ( n  = 1). The majority were of very low methodological quality. In addition, none of the studies formally evaluated the effectiveness of the narrative-based interventions. Findings suggest that narratives may have a positive influence when used as inspiration and empowerment tools to stimulate policy inquiries, as educational and awareness tools to initiate policy discussions and gain public support, and as advocacy and lobbying tools to formulate, adopt or implement policy. There is also evidence of undesirable effects of using narratives. In one case study, narrative use led to widespread insurance reimbursement of a therapy for breast cancer that was later proven to be ineffective. Another case study described how the use of narrative inappropriately exaggerated the perceived risk of a procedure, which led to limiting its use and preventing a large number of patients from its benefits. A third case study described how optimistic ‘cure’ or ‘hope’ stories of children with cancer were selectively used to raise money for cancer research that ignored the negative realities. The majority of included studies did not provide information on the definition or content of narratives, the theoretical framework underlying the narrative intervention or the possible predictors of the success of narrative interventions.

The existing evidence base precludes any robust inferences about the impact of narrative interventions on health policy-making. We discuss the implications of the findings for research and policy.

Trial registration

The review protocol is registered in PROSPERO International prospective register of systematic reviews (ID =  CRD42018085011 ).

Peer Review reports

Narratives, also referred to as storytelling, exemplars and testimonials, can be used to convey information because they are easily understandable and memorable [ 1 , 2 ]. While there is no commonly accepted definition of a narrative, it is generally agreed that it should provide an account of an individual’s experience and include appealing detail, characters and some plot [ 3 , 4 , 5 , 6 , 7 ]. It may be communicated through a wide range of formats, including verbal (narrated), print, audio and video [ 8 , 9 ].

Narratives can facilitate information processing and provide value and emotional appeal to the information provided [ 8 , 10 ]. Additionally, people can relate to narrative information regardless of their level of literacy, expertise or culture [ 11 , 12 ]. These narratives have been demonstrated to be both memorable and persuasive [ 13 , 14 ]. Several theoretical perspectives have been considered to explain the persuasiveness of narrative information [ 8 , 15 , 16 , 17 , 18 , 19 , 20 ]; see Table  1 for a description of these models.

The communication literature offers some insights on the effects of different ways of communicating information on behaviour. First, individuals make choices based on incorporating both factual and narrative information; narrative information influences individuals’ choices directly (system 1) and indirectly via cognitions (system 2), and the persuasiveness of narrative or statistical information varies depending on the characteristics and experiences of the recipients [ 21 , 22 ]. These insights imply that it is naive to assume that it is sufficient to present people with ‘facts’, and expect that they will weigh these in a rational manner and act accordingly [ 23 ].

There is growing recognition among experts in the field of public policy-making of the need to incorporate narrative as an important component of the broad evidence base required to inform complex policy-making processes [ 23 , 24 ]. This is particularly so given that policy decisions are often value-driven and political, not just evidence-based choices [ 25 ], and that policy-makers and public health professionals operate on a different hierarchy of evidence compared to researchers [ 26 ]. For instance, policy-makers prefer information that is concise, appealing and relevant to current health policy debates [ 27 , 28 , 29 ].

As highlighted by Cairney and Kwiatkowski [ 30 ], policy-makers attach cognitive and emotional shortcuts to thoughts and action, often without fully understanding the reasons for that action; therefore, ‘bombarding’ them with evidence can be less effective than presenting them with compelling stories or using other framing techniques to harness their cognitive biases. In this sense, narrative information can be more useful than statistical data, partly because the latter can be seen as too complex, not policy-relevant, tedious or lacking context sensitivity [ 31 , 32 ].

The use of narratives in the policy environment can help identify important policy issues, point to problems with existing policies, provide evidence that a programme or law is working as intended, and assist policy-makers in thinking about the consequences of policy options [ 10 , 27 , 31 , 33 ]. For instance, personal stories of breast cancer have been key in creating significant changes in health policies and legislative allocations in the United States [ 33 ]. While there is a growing number of reports on the use of narrative-based interventions to shape policy-making, we are not aware of any systematic synthesis of that body of evidence. The objective of this study was to systematically synthesise the evidence on the use of narratives to impact health policy-making.

Study design and definitions

We conducted a systematic review of the literature, following standard methodology. We registered the review protocol in the PROSPERO International prospective register of systematic reviews (ID = CRD42018085011) and we followed the PRISMA guidelines for reporting systematic reviews.

For the purpose of this study, we conceptualised a narrative as an illustration of an experience in a story-like format, presented in either the first or the third person [ 2 ]. The terms that we considered as referring to ‘narratives’ include storytelling, anecdotes, exemplars, testimonials and policy narratives [ 7 , 21 ]. Given that the goal of this review was to inform those interested in using narrative information to affect health policy-making, we restricted our eligibility to studies where the primary purpose of using a narrative was to affect policy-making (i.e. narrative as a planned intervention). The narrative could be presented in any format (e.g. verbal, print, audio/radio, video) or perspective (first- or third-person narrative).

Public policy refers to government policy and includes programmes, plans, rules, legislation, guidelines, statements or positions taken by government or governmental departments with the aim of achieving population-level change (whether at the sub-national, national or international level) [ 34 ]. This excludes policies confined to one institution only or those related to individual-level clinical interventions [ 35 ]. We only considered public policies pertaining to health.

Eligibility criteria

We used the following eligibility criteria:

Type of studies: We included a range of types of studies to account for the diverse literature on narratives and the complex nature of evidence in the policy sector [ 36 ]. Specifically, we included randomised studies, non-randomised studies (e.g. cohort studies, before and after studies, retrospective studies, and cross-sectional studies), process evaluation studies, economic studies, qualitative studies, stakeholder analyses, policy analyses and case studies. We excluded news articles, books, letters, commentaries, opinion pieces, proposals, reviews and studies published in abstract format only. We also excluded studies where narrative was mentioned as part of the background information only.

We did not exclude studies based on date of publication or language.

Population: We included studies where the narrative intervention targeted legislators, policy-makers, representative of professional associations, governmental representatives or any other individuals involved in health policy-making. We excluded studies where the narrative intervention targeted patients or people in their individual capacity (e.g. in a clinical setting).

Interventions: Narratives used as standalone or as part of a multi-component intervention with the primary purpose of influencing health policy-making in a real-world setting. We excluded studies where the narrative was not an explicit or deliberate component of the intervention. We also excluded studies that assessed message-framing only or that used narrative for information delivery without any link to the policy cycle.

Comparison: We included studies regardless of whether or not they have a comparison group.

Outcomes: We included studies that examined the influence of narrative information on any of the stages of health policy-making in a real-world setting [ 37 ]. We stratified findings according to the stages of policy-making, as defined by the Stages Heuristic framework, as follows: (1) agenda-setting, (2) policy formulation, (3) policy adoption, (4) policy implementation and (5) policy evaluation (see Table  2 for a detailed definition of the different stages) [ 37 , 38 , 39 , 40 ]. We excluded studies that assessed proxy outcomes such as changes in knowledge, beliefs, attitude, preferences or intentions. We also excluded studies that involved individuals making hypothetical decisions. Additionally, we excluded studies that assessed the impact of narrative on public opinion only or that examined policy-making processes beyond the health or health-related sector.

Settings: We included any country, state or community

Search strategy

We searched the following electronic databases up to February 2017: MEDLINE, PsycINFO, Cochrane Library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), WHO Global Health Library, and Communication and Mass Media Complete. The search strategy combined the two different concepts of ‘narrative’ and ‘public policy’. To generate a list of search terms for each concept, we first undertook an initial targeted search of the literature, followed by an analysis of the text words contained in the title and abstract of potentially relevant studies as well as of the index terms used to describe the article. Additionally, we reviewed the search strategies of relevant systematic reviews. This helped generate an initial list of terms relevant to each of the two concepts of ‘narrative’ and ‘public policy’, respectively including, for example, narrative, narration, testimonial, anecdote, exemplar, and story, and policy, public policy, health policy, reform, lobbying, regulation, law enforcement, policy-making, government, law, legislation, decree, jurisprudence, advocacy, decision-making, etc.

The search included both free-text words and medical subject headings. We used the Boolean operator ‘OR’ to combine the terms within each concept and the Boolean operator ‘AND’ to combine the different concepts. We did not use any search filter for study type, language or date of publication. The search strategy was validated by an experienced medical librarian (Additional file 1 ).

We complemented the electronic database searches with a variety of approaches to identify additional literature, including grey literature. We manually searched Google Scholar and relevant journals like Health Affairs . We also screened the reference lists of included studies and relevant systematic reviews. In addition, we contacted the authors of relevant articles and conference proceedings for further information or additional material.

Study selection

We conducted the selection process in two phases, namely title and abstract screening, wherein teams of two reviewers screened the titles and abstracts of identified citations, in duplicate and independently, for potential eligibility and retrieved the full text of studies judged as potentially eligible by at least one of the two reviewers, and full-text screening, wherein two reviewers screened the full texts in duplicate and independently for eligibility, using a standardised and pilot-tested screening form, and resolving disagreements by discussion or with the help of a third reviewer.

Prior to the selection process, all the reviewers participated in a calibration exercise using a randomly selected sample of 100 citations. The calibration exercise allowed us to pilot the eligibility criteria to ensure they are applied in the same way across reviewers, thus enhancing the validity of the process.

Data abstraction

Two reviewers abstracted data from eligible studies in duplicate and independently using standardised and pilot-tested data abstraction forms. They conducted a calibration exercise on a randomly chosen sample to ensure adequate agreement and resolved disagreement by discussion or with the help of a third reviewer if consensus could not be reached.

Abstracted data focused on the variables of study design, timeframe and background story; health topic, organiser, target population and setting; narrative definition and theoretical framework used; format of narrative (verbal, print, audio, video) and characteristics of the narrative information (plot and characters); characteristics of the intervention used to deliver the narrative; and policy outcomes assessed.

Quality assessment

We planned to assess risk of bias and quality of reporting of the included studies, using tools appropriate for the study design. However, we did not assess the risk of bias of included studies given that existing tools to critically appraise the types of studies retrieved have not been validated, and thus have strong limitations at this stage (as well as lack of consensus). We did assess the quality of reporting of case studies according to the reporting standards developed by Rodgers et al. [ 41 ]. These standards consist of 13 items grouped into four sections, as (1) describing the design (4 standards); (2) describing the data collection (3 standards); (3) describing the data analysis (1 standard); and (4) interpreting the results (5 standards).

Data synthesis

We conducted thematic analysis and presented the results in a narrative way, stratified according to the following stages of the policy cycle: (1) agenda-setting, (2) policy formulation, (3) policy adoption, (4) policy implementation and (5) policy evaluation [ 37 ]. Two reviewers were involved in the identification of the themes. Where applicable, we provided direct quotations. Additionally, we assessed the knowledge gaps related to our topic. We assessed five domains most commonly used in published evidence gap maps, i.e. study design, interventions, setting, population and outcomes [ 42 ].

Figure  1 shows the PRISMA flow chart summarising the study selection process. Out of 12,698 citations, we identified 18 eligible studies. We excluded 438 articles at the full-text screening phase because they did not focus on planned narratives as part of the intervention ( n  = 258), did not focus on health or health-related issues ( n  = 18), did not target population-level policy changes in a real world setting ( n  = 135), were not a study design of interest (e.g. commentary, review, magazine) ( n  = 25), or contained duplicate information ( n  = 2) (Additional file 2 ).

Study flowchart

Characteristics of studies

Table  3 describes the characteristics of the 18 included studies in terms of study design, timeframe, background story, health topic, target population, organisers of narrative-based interventions, country, narrative definition and theoretical framework used, format of narrative (verbal, print, audio, video), characteristics of the narrative information (plot and characters), characteristics of the intervention used to deliver the narrative, and policy outcomes assessed.

The study designs were case studies ( n  = 15) [ 33 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 ], participatory action research ( n  = 1) [ 57 ], documentary analyses ( n  = 1) [ 58 ] and biographical methods ( n  = 1) [ 59 ]. Thirteen studies were from high-income countries (Australia ( n  = 4), Republic of Ireland ( n  = 1), United States of America ( n  = 8) and United Kingdom ( n  = 1)), four studies were from middle-income countries (Georgia ( n  = 1), China ( n  = 1), and South Africa ( n  = 2)) and one study was from low-income countries (Rwanda ( n  = 1)); one study included data from both Republic of Ireland and Australia [ 43 ].

Eight studies targeted policy-makers, legislators and/or governors only [ 44 , 46 , 48 , 50 , 52 , 53 , 55 , 59 ], one targeted national healthcare organisations only [ 47 ], and nine targeted multiple stakeholders including government and the public [ 33 , 43 , 45 , 49 , 51 , 54 , 56 , 57 , 58 ]. In one of the studies, the target audience was TV viewers; however, we only focused on the findings specific to policy-makers which was relevant to our question [ 53 ].

The included studies covered the topics of solarium tanning ( n  = 1), HIV/AIDS ( n  = 1), individuals with disabilities ( n  = 2), patient navigators for chronic diseases ( n  = 1), supervised injecting facilities for drug users ( n  = 1), abortion ( n  = 2), Medicaid Optional Coverage for Women and Infants programme ( n  = 1), needlestick injuries ( n  = 1), safety-net hospital for poor and uninsured residents ( n  = 1), birth control ( n  = 1), mental health initiatives for children ( n  = 1), cancer ( n  = 2), use of morcellators in gynaecologic surgeries ( n  = 1), approval of mifepristone for use as treatment for meningioma ( n  = 1), and quality improvement in healthcare ( n  = 1). One study focusing on personal celebrity health narratives examined a range of diseases, including multiple sclerosis, cancer, Parkinson’s disease, Alzheimer’s disease, HIV, Hugh Downs, bipolar II disorder, eating disorder, type 1 diabetes, paralysis, cystic fibrosis and amyotrophic lateral sclerosis [ 58 ].

Four of the included studies provided a definition for narrative [ 33 , 44 , 47 , 58 ] and three described the theoretical framework underpinning the narrative intervention [ 44 , 57 , 58 ]. All but four studies used a meta-narrative, which combined the stories of a large number of people to convey a thematic, systemic story as opposed to focusing on a single event or individual (i.e. episodic stories). The narrative information was presented in different formats, with some studies utilising more than one format. These formats included television appearances ( n  = 3) [ 54 , 58 , 59 ], entertainment education (prime-time network TV storyline) ( n  = 1) [ 53 ], short films, theatre and plays ( n  = 1) [ 43 ], magazines and journal prints ( n  = 2) [ 56 , 58 ], books ( n  = 2) [ 33 , 52 ], narrative action reflection workshops ( n  = 1) [ 57 ], video materials ( n  = 2) [ 44 , 56 ], posters and photos ( n  = 3) [ 44 , 49 , 51 ], booklets with testimonies ( n  = 1) [ 45 ], advocacy summaries of personal experiences ( n  = 1) [ 46 ], story cards with photos of patients on front and quotes on back ( n  = 1) [ 48 ], micro-blogs and online forums ( n  = 1) [ 49 ], and verbal (narrated) ( n  = 6) [ 33 , 47 , 50 , 55 , 58 , 59 ].

In seven studies, the narrative information was presented alone [ 33 , 47 , 51 , 52 , 55 , 58 , 59 ], whereas in 11 studies, the narrative was part of a multi-component intervention leading to the reported change in outcome [ 43 , 44 , 45 , 46 , 48 , 49 , 50 , 54 , 56 , 57 ]. Components besides narratives included organised debates, values clarification exercises, interviews and surveys in four universities, a petition for law reform and media involvement [ 45 ]; quantitative data [ 46 ]; state-wide campaign, writing to governor, lieutenant governor, or speaker of the House, talking one-on-one with the legislators, and inviting legislators to gain first-hand experience [ 48 ]; parental meetings, working with other groups in a coalition, quantitative data and media engagement [ 50 ]; research and media appearances [ 43 ]; seminars, documentation and conferences [ 57 ]; trials, reports, royal commissions and advocacy efforts [ 44 ]; media advocacy, direct political representation and lobbying and epidemiological evidence [ 54 ]; and campaign, media coverage, and review of research [ 56 ].

The included studies examined the influence of narratives on the policy outcomes of agenda-setting ( n  = 5), policy formulation ( n  = 1), policy adoption ( n  = 9), and policy implementation ( n  = 4); none looked at policy evaluation. One of the studies included data from two countries, and reported impact at different levels of the policy-making process [ 43 ]. None of the studies conducted actual evaluation of effectiveness or provided explicit evidence for the link between the intervention and the outcome.

Methodological appraisal

Additional file 3 presents the detailed assessment of the reporting of included case studies according to the standards by Rodgers et al. [ 41 ]. None of the cases studies met all 13 reporting standards. The median score was 4 (out of a maximum score of 13). Only four studies met more than half of the reporting standards [ 43 , 44 , 47 , 54 ].

Influence on policy outcomes

We present below the findings stratified according to the stages heuristic framework of the public policy process.

Agenda-setting

One participatory action research [ 57 ], one documentary analysis [ 58 ] and three case studies [ 43 , 49 , 51 ] examined the influence of narrative on agenda-setting.

Lorenzo [ 57 ] reported that a series of narrative action reflection workshops enabled storytelling and action learning by women with disability in Cape Town. These women were able to mobilise collectively for change regarding an accessible public transport system as a strategy for social inclusion. The findings have “ contributed to increasing the understanding and awareness of disability issues for people involved in policy development and implementation across the various sectors of government to improve service delivery mobilizing for an accessible public transport system so that they had equal opportunities to participation in social and economic development ” [ 57 ].

Johnson et al. [ 43 ] examined the contribution of inclusive qualitative research studies (via life stories) to policy-making related to people with disabilities’ right to relationships and to a sexual life in Ireland. As a result of research, drama and media appearances, the issue of the prohibition of penetrative sexual activity with a person with intellectual disabilities under Irish law was brought to public attention. In March 2011, two representatives from the research group were invited to consultations with the government’s legislative advisory body, the Law Reform Commission, with regard to reviewing the 1993 Act – “ The Act in the Republic has not yet been changed, but there is now a significant voice from people with intellectual disabilities informing discussion of how this might happen ” [ 43 ].

Beck et al. [ 58 ] conducted a documentary analysis of newspaper articles, letters to the editors of magazines and newspapers, televised interviews, and online databanks to identify celebrities, including athletes, actors, musicians and politicians, who have publicly shared personal narratives regarding their health situation (or that of a loved one). The authors found that the key functions that celebrity health narratives performed were education, inspiration and activism. Celebrity narratives have contributed to raising money and awareness and have also led to doubling funding for research at the National Institutes of Health for certain diseases.

Krueger [ 51 ] conducted a case study of how cancer-related organisations were integrating, beginning in the late 1940s, the voices, images and stories of young sufferers into their annual campaigns as tools for education, awareness and inspiration. The author remarked: “ Poster children were strategically used throughout the mid-to-late twentieth century to advance principles of early cancer detection and prompt treatment; to illustrate or, at times, exaggerate promising biomedical advances in the field; and to elicit emotional responses and donations from a wide audience during the escalation of the war against cancer” [ 51 ].

Shi [ 49 ] described the story of Feng Jianmei, a 23-year-old Chinese woman who was forced to have late-term abortion by local birth-control officials. Her story was exposed by family members through graphic photos, micro-blogs and online forums, provoking public outrage and widespread condemnation on social media sites. In response to tremendous pressure from the public, the National Population and Family Planning Commission announced that it would send 10 inspection teams to 19 provinces to review the policy enforcement of local family planning officials.

Policy formulation

Johnson et al. (discussed above) [ 43 ], explored the contribution of inclusive qualitative research studies to change in policy and legislation related to people with disabilities’ right to relationships and to a sexual life, also in Australia. Twenty-five people with intellectual disabilities told their life stories and talked about sexuality and relationships. Three short films of the stories were subsequently produced and used to lobby government for a change to the existing policy. The new policy draft clearly set out rights and responsibilities for people with intellectual disabilities and service providers about relationships and sexuality.

Policy adoption

Eight case studies [ 44 , 45 , 46 , 48 , 50 , 53 , 54 , 55 ] and one biographical study [ 59 ] examined the influence of narrative on policy adoption.

MacKenzie et al. [ 54 ] reviewed television and print media coverage of the campaign to regulate solaria initiated by Clare Oliver before her death from melanoma in late 2007. A frame analysis was conducted of all direct and attributed statements about the causes of, and responsibility for, Oliver’s melanoma, and about the legacy of her campaign. Oliver’s story was influential in securing regulations across all states and territories to ban access to tanning beds for those younger than 18 years.

Marcus et al. [ 53 ] assessed the educational and behavioural impact of an ER (NBC drama) storyline that addressed cancer patient navigators on primetime TV viewers. Clips of the TV episode were used by Congressional staffers to raise awareness of patient navigators in a Congressional Committee meeting. Congressional staffers reported that the episode provided a tangible example of how patient navigator programmes would work and contributed to “ critical policy discussion that led to passage of US law HR 1812, the Patient Navigator Outreach and Chronic Disease Prevention Act of 2005 ” that provides funds to model programmes that would help patients to access healthcare services.

Fitzgerald [ 44 ] retraced the policy narratives related to the introduction of supervised injecting facilities (SIFs) in Australia in documentary materials. Narrative was used as an advocacy tool to inform government of the impact of street injecting on a local community. The narrative intervention was one component of a multi-faceted intervention, including trials, reports and advocacy to promote SIF in two different parts of Australia (Sydney and Melbourne). In Sydney, SIF policy development was framed as a response to police corruption (i.e. police were viewed as villains), whereas in Melbourne, the policy narratives focused on health and welfare of drug users (with the police, here, viewed as heroes). These two framings created a different pathway for policy development. In Sydney, 22 months after the Drug Summit Legislative Response Act 1999 was passed for the trial of the SIF, the service opened in May 2001. In Melbourne, the bill failed to pass through both Houses of the Victorian Parliament.

Umuhoza et al. [ 45 ] reflected on the use of personal stories as advocacy tools to mobilise action for law reform. Narrative was part of a multicomponent intervention initiated by Rwandan Youth Action Movement to put the new abortion law into effect in 2012. The use of testimonies and stories of young people gave a ‘face’ to the issue of unsafe abortion. These activities “ played a significant role in the advocacy process for amendment of the [abortion] law which was revised when the penal code came up for review in June 2012 ” [ 45 ]. These efforts also coincided with important policy events, which opened a window of opportunity for action.

Leith and Phillips [ 46 ] presented three short case studies illustrating how qualitative techniques and consumer narratives can serve as advocacy tools to inform public policy. We focused on the case study on Optional Coverage for Women and Infants Medicaid programme as it is health related. To demonstrate to state legislators the need for continuing the programme, the state agency in a south-eastern state provided state legislators with advocacy summaries from their constituent areas. Hotline information was used to create thousands of these advocacy summaries consisting of brief narratives of three to eight sentences that gave a qualitative description of the personal experiences of callers with the system. The narratives were also supplemented by data regarding the success of the programme. Based on these narrative accounts, “ legislators were able to see first hand the impossible situations families in poverty were experiencing, and the Optional Coverage for Women and Infants program was ultimately spared from proposed legislative budget cuts ” [ 46 ].

Neuhausen [ 48 ] reported how hundreds of students and resident physicians fought for the survival of ‘Grady’, the fifth-largest public hospital and the largest provider of indigent care in Georgia. Narrative was one component of a national campaign and advocacy efforts to get state legislature to approve the non-profit conversion of Grady and to increase state funding. Stories from Grady patients describing the life-saving care provided by Grady were collected to create story cards, with photos of patients on the front and quotes on the back. These stories were described as the most powerful advocacy tool. The commissioners voted to approve the non-profit conversion which was critical to Grady’s survival. The Georgia General Assembly also approved “ increases in Medicaid reimbursement rates to trauma hospitals and authorized $58 million to support uncompensated care at state trauma centers ” [ 48 ].

Slaton et al. [ 50 ] described the stories of four family-led organisations and the impact of their advocacy efforts on systems of care for mental health. We specifically focused on one family leader’s story of involvement in legislative policy. Narratives of parents of children with mental health problems was one component of a multifaceted approach that also included networking with other families and organisations, speaking with legislators, engaging in advocacy and involving the media. According to the family leader involved in that case study, legislators now direct their staff to call the family-led organisation to better understand how certain provisions will affect children with mental health needs and their families. Additionally, parents have been invited to see legislation they have worked on being signed by the governor [ 50 ].

Trossman [ 55 ] described how the President of Massachusetts Nurses Associations used her personal story to push for needlestick legislation in Massachusetts. Following her infection with HIV and hepatitis C as a result of being pricked by a contaminated needle, Nurse Daley presented her testimony at the Massachusetts State House and let legislators who consider the merits of a proposed needlestick bill to see that there is a real person behind every injury. The day after she testified, the Massachusetts health committee put its support behind the bill, allowing it to move forward in the legislative process.

Lander [ 59 ] described how her campaign to amend the legal status of the drug mifepristone in Australia was triggered in 2005 when she was diagnosed with meningioma. Although the drug could halt the growth of tumours, it was unapproved in Australia because of its potential use as an abortifacient. The campaign involved email exchanges and ongoing contact with a Senator as well as participation in broadcasts to help raise awareness of the drug. In 2006, parliament successfully voted to repeal ministerial responsibility for approval of the drug mifepristone.

Policy implementation

Four case studies examined the role of narratives on policy implementation [ 33 , 47 , 52 , 56 ].

MacGregor and Mills [ 52 ] described how, in an attempt to enhance access to antiretroviral drugs in South Africa in 2003, a group of women involved with the Treatment Action Campaign and Medicines Sans Frontières participated in an initiative to ‘map’ their bodies as affected by HIV. Through the body maps and personal accounts published alongside the maps, women told how their lives have been transformed by antiretroviral treatment. The women’s body maps and narratives were published in a book, ‘Long Life’, which was subsequently used as a political tool to add the ‘voices’ of ordinary people to the campaign. These efforts contributed to the roll out of universal access to antiretroviral treatment drug in the public sector.

Wilcock et al. [ 47 ] reflected on the use of patient stories to inspire quality improvement within the NHS Modernisation Agency collaborative programmes. Patients’ narratives were gathered by trained interviewers in one-to-one semi-structured qualitative interviews and analysed by the NHS staff who provide their care. The stories were read out at a national meeting of the Critical Care Programme and the Coronary Heart Disease Collaborative. The authors presented two case studies illustrating how these narratives led to patient-centred changes as part of quality improvement projects within the NHS Modernisation Agency collaborative programmes in England.

Sharf [ 33 ] provided a historical view of how personal narratives of women living with breast cancer affected health policy. The author reported that personal breast cancer stories have inspired efforts by citizen advocates and legislators to provide better care and more resources for the disease (for example, changing of standard clinical procedure and creating treatment, prevention and screening programmes for lower-income women). However, the author also shed light on a case where narrative of breast cancer led to undesirable outcomes; in 1993, after being diagnosed with advanced breast cancer, Nelene Fox was advised by her doctors that her only remaining chance for survival was an autologous bone marrow transplant. Her insurance refused to pay for the procedure because the treatment was classified as experimental due to insufficient scientific evidence that it extended a patient’s life. Fox’s brother, a lawyer, sued the insurance and convinced the jury to award $89,000 in damages to her family. Media publicity about the Fox case succeeded in forcing widespread insurance reimbursement, further discouraging patients from enrolling in clinical trials. Conclusions about the efficacy of the treatment were delayed until 1999 when the National Cancer Institute announced that autologous bone marrow transplant does not benefit people with breast cancer.

Rosenbaum [ 56 ] reflected on the case of 40-year-old Amy Reed who underwent a hysterectomy with intraoperative morcellation for presumptively benign uterine fibroids (which unknowingly contained leiomyosarcoma), thus causing it to disperse. Following her death, Reed’s husband launched a campaign to ban morcellators which was picked up by The Wall Street Journal. Extensive media coverage featuring the faces of women dying of leiomyosarcoma exaggerated the risk of leiomyosarcoma, while the benefits of morcellation remained largely invisible and, thus, ‘unavailable’. Subsequently, the Food and Drug Administration undertook a review to quantify the risk of disseminating occult uterine cancers that cannot be reliably detected preoperatively, 6 months later issuing a black-box warning stating that morcellation was contraindicated in perimenopausal or postmenopausal women and in “ candidates for en bloc tissue removal ”. Many institutions banned morcellation and some insurers stopped covering the procedure or began requiring prior authorisation. The author explained that medical products are associated with two types of risk, those caused by using the products and those caused by preventing their use; the morcellation controversy is an example of the latter case given that “ there may be greater population benefits and lesser risks from continuing than from discontinuing morcellator use ” [ 56 ]. However, disproportionate focus on harms caused by use rather than non-use skewed risk perception .

Policy evaluation

We found no studies examining the role of narratives in policy evaluation.

Knowledge gaps

Our systematic review highlighted key knowledge gaps concerning the use of narrative interventions in health policy-making. We present, in Table  4 , the knowledge gaps relevant to the study design, interventions, setting, population and outcomes in the area of using a narrative to impact health policy-making [ 42 ].

Summary and interpretation of findings

This systematic review identified 18 eligible studies examining the effects of narratives on the different stages of the health policy-making process, except for the policy evaluation stage. The vast majority of included articles describe case studies.

The existing evidence base precludes any robust inferences about the impact of narrative interventions on health policy-making. Nonetheless, the findings suggest that narratives may have a positive influence when used as inspiration and empowerment tools to stimulate policy inquiries; as educational and awareness tools to initiate policy discussions (and gain public support leading to policy prioritisation); and as advocacy and lobbying tools to formulate, adopt or implement policy.

However, there is also evidence of undesirable effects of using narratives [ 33 , 51 , 56 ]. In one case study, narrative use led to widespread insurance reimbursement of a therapy for breast cancer that was later proven to be ineffective [ 33 ]. Another case study described how the use of narrative inappropriately exaggerated the perceived risk of a procedure, which led to limiting its use and preventing a large number of patients from its benefits [ 56 ]. A third case study described how optimistic ‘cure’ or ‘hope’ stories of children with cancer were selectively used to raise money for cancer research that ignored the negative realities such as limited gains made in certain paediatric cancers, the high costs of treatment, and the high prevalence of mental and physical disabilities caused by experimental chemotherapy protocols [ 51 ].

The majority of included studies did not provide information on the definition of narratives, the theoretical framework underlying the narrative intervention or the possible predictors of the success of narrative-based interventions. Only one study explicitly discussed how the framing of the attributes of narratives (i.e. sequenced events, characters, time, location, etc.) influenced policy-making differentially in two different parts of Australia (Sydney and Melbourne) [ 44 ]. Thus, uncertainties remain about how to construct and present narrative information.

Having said this, we highlight two emerging patterns that might inform the optimal use of narratives. First, all but four studies used a meta-narrative that combined the stories of a large number of people to convey a thematic, systemic story as opposed to focusing on a single event or individual (i.e. episodic stories). Second, the importance of establishing a relationship with media outlets and maximising opportunities to disseminate the narrative information was emphasised in several studies. Indeed, six of the included studies highlighted the involvement of media as an important catalyst for policy change [ 43 , 45 , 49 , 50 , 54 , 56 ]. In four studies, the narrative was picked up by media [ 43 , 45 , 49 , 56 ] whereas, in two studies, active effort was made to engage the media and maximise the reach of the narrative information [ 50 , 54 ]. Unfortunately, there is also a lack of reliable evidence on the use of media interventions to influence health policy-making [ 60 ].

Strengths and limitations

To our knowledge, this is the first systematic review examining the effects of narrative-based interventions on the health policy-making process. Strengths of our methodology include the pre-publication of a protocol, a rigorous and transparent review process, and adherence to standard methods for reporting systematic reviews [ 61 , 62 ]. In addition, we searched multiple databases and included both published and the grey literature.

A major challenge in conducting this review was how to best conceptualise and categorise narratives given the absence of clear definition and operationalisation of narrative information. This made it difficult to decide on the eligibility of some of the studies and to abstract data. This is why we relied on a consensus approach to screening and data abstraction, and iteratively revised our conceptualisation of narrative. Although we did search resources that include grey literature (e.g. Google Scholar and the WHO Global Health Library and Communication and Mass Media Complete), we could have searched additional resources such as websites of NGOs, advocacy groups and donors. Further, while some might criticise our use of stages heuristic framework, considered by some scholars to assume linearity of the policy-making process, we opted to use this framework as it is considered one of the most prominent public policy frameworks. More importantly, it did facilitate synthesis of findings and provide a simplified and useful way to view the entire policy process [ 37 , 38 ].

A major gap relates to the poor methodological rigor of the included studies. All included studies lacked actual evaluation of effectiveness or explicit evidence for the link between the intervention and the outcome. Additionally, in the majority of the included studies, the narrative component was part of a multicomponent intervention, and thus the evidence associated with the narrative may be indirect or confounded by other components of the intervention [ 34 ]. The aforementioned limitations made it difficult to make any inferences on effectiveness of narrative interventions in the health policy-making process.

Moreover, the very limited description of the narrative interventions was challenging, particularly given that they qualify as complex interventions [ 63 , 64 ]. Important aspects of these interventions include frequency and duration of exposure to a narrative, content of a narrative (for example, plot, characters, and moral of story) and perceived credibility of the speaker or message. These aspects are important to understand the specific narrative intervention that was tested, what component of the intervention was effective, and the superiority of one format over another.

Additionally, the majority of included studies failed to provide information about what framework or theory guided intervention development and outcome measurement. Several theories of narrative persuasion have been identified in the literature [ 15 , 17 , 18 ]. Thus, without such information, it would be difficult to understand the mechanism by which narrative interventions persuade health policy-makers and lead to change. Moreover, we could not determine the effect of moderators, such as the policy-makers’ characteristics on the effectiveness of the narratives.

While beyond the scope of this systematic review, we have identified studies assessing message-framing involving hypothetical scenarios on the attitudes, beliefs and intentions of health policy-makers and legislators [ 65 , 66 , 67 , 68 ]. These warrant further exploration to complement the evidence base on the use of narratives in health policy-making in real settings.

Comparison to other systematic reviews

While we did not identify any other systematic review of narratives in the field of health policy-making, we identified many in the field of clinical decision-making [ 2 , 21 , 69 ]. Perrier and Ginis found “ consistent evidence supporting the efficacy of narratives at changing screening behavior ” [ 69 ], but mixed evidence supporting an advantage of narratives over providing statistical information for screening behaviour and its determinants. Winterbottom et al. [ 2 ] found limited evidence suggesting that narratives affected an individual’s medical decisions, but it was unclear why narratives affected the decision-making process or whether they facilitated or biased decision-making. Bekker et al. [ 21 ] concluded that there is insufficient evidence that adding personal stories to patient decision aids enhances their effectiveness to support people to make informed decisions.

Implications for research

Despite the increased interest in narratives [ 6 , 23 , 24 , 70 ], the evidence base on their impact on health policy-making is of very low certainty. This systematic review highlights the challenges of assessing the impact of narrative interventions on health policy-making given the complex nature of these interventions, the difficulties in using experimental methods, and the multiple factors influencing the policy-making process [ 34 , 64 , 71 ]. Therefore, more rigorous primary research is needed to gain a better understanding of narrative interventions beyond whether or not they are effective to why and under what circumstances.

Given that narratives qualify as complex interventions, a particular focus should be on conducting realist evaluation studies. Unlike traditional impact evaluation that establishes whether change in outcomes can be directly attributed to an intervention, realist evaluation focuses on the processes and contexts of implementation that yield impact [ 72 ]. Thus, by examining ‘what works, for whom and why’, insights are gained about the interactions between interventions, implementers and health systems that make interventions more or less successful [ 73 , 74 ]. This is critical to inform the design of context-specific strategies and understand how the influence of narrative information can differ across various health systems and socioeconomic realities. Additionally, qualitative studies can help explore the knowledge, beliefs and attitudes of policy-makers towards narrative information, including their role in the policy-making process.

In addition, researchers are encouraged to promote better reporting of studies in this field, taking into account guidelines for reporting of complex interventions when describing the narrative interventions [ 75 , 76 ]. Importantly, experts in the field should establish clear definition and operationalisation of narratives to allow better research and communication on the topic.

Funding agencies have an important role in advancing knowledge and un-tapping the potential for using narrative to influence health policy-making by supporting studies that address the aforementioned knowledge gaps. This would also align with global calls for more effective and innovative approaches to bridge the gap between research and policy-making [ 77 , 78 , 79 , 80 ].

Implications for policy

Our findings suggest that, while narratives may have a positive influence on health policy change, they may sometimes lead to undesirable outcomes. Findings also allude to potential pitfalls and ethical concerns that should be taken into consideration when using narratives. First, because of the selective nature of narratives, narrators may omit details of a story or exaggerate it, so the story may not be representative of the larger reality (for example, the case of childhood cancer where optimistic ‘cure’ or ‘hope’ stories were selectively used that ignored the negative realities). Second, the reliance on narratives without scientific evidence may lead policy-makers to adopt policies that may be ineffective or even harmful or waste resources (for example, the case of reimbursing a therapy for breast cancer that was later proven to be ineffective). Third, narratives may produce biased results based on the views of one or a select number of individuals (for example, the case of discontinuing morcellator use). Because of the affective nature of narratives, policy-makers may give higher priority to diseases with more tragic stories such as cancer and HIV at the expense of other diseases with a similar or higher burden such as cardiovascular diseases [ 33 , 58 ].

These limitations and potential pitfalls do not mean that there should be no place for narratives in informing health policy-making. However, it does mean that narratives need to be held to standards of validity [ 6 , 81 , 82 ]. For instance, Hyman [ 83 ] insists that those using narratives provide persuasive evidence of typicality and completeness before assigning any weight to their stories. Sharf [ 33 ] calls for effectively combining the emotional pathos of stories with rhetorical proof.

In light of the above, we suggest using narratives that are rooted in evidence to influence health policy-making. Those designing or using narrative information need to consider all the above discussed challenges and potential pitfalls. This would be best achieved by building strong and effective partnerships between ‘evidence experts’ and those involved in advocacy. Additionally, narratives could be used to support policies that are based on widely agreed on principles, such as those of human rights and medical ethics like access to basic health services and non-discriminatory health policies.

Despite the increased interest in narratives, the existing evidence base precludes any robust inferences about the impact of narrative interventions on health policy-making. Rigorous research supporting impact on health policy-making is still needed.

Slater MD, Buller DB, Waters E, Archibeque M, LeBlanc M. A test of conversational and testimonial messages versus didactic presentations of nutrition information. J Nutr Educ Behav. 2003;35(5):255–9.

Article   PubMed   Google Scholar  

Winterbottom A, Bekker HL, Conner M, Mooney A. Does narrative information bias individual's decision making? A systematic review. Soc Sci Med. 2008;67(12):2079–88.

Toolan M. Narrative: A Critical Linguistic Introduction. London: Routledge; 2012.

Goodwyn E. Recurrent motifs as resonant attractor states in the narrative field: a testable model of archetype. J Anal Psychol. 2013;58(3):387–408.

Chatman SB. Story and discourse: Narrative structure in fiction and film. Ithaca: Cornell University Press; 1980.

Google Scholar  

Dahlstrom MF. Using narratives and storytelling to communicate science with nonexpert audiences. Proc Natl Acad Sci U S A. 2014;111(Suppl 4):13614–20.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Jones MD, McBeth MK. A narrative policy framework: clear enough to be wrong? Policy Stud J. 2010;38(2):329–53.

Article   Google Scholar  

Kreuter MW, Green MC, Cappella JN, Slater MD, Wise ME, Storey D, et al. Narrative communication in cancer prevention and control: a framework to guide research and application. Ann Behav Med. 2007;33(3):221–35.

Avraamidou L, Osborne J. The role of narrative in communicating science. Int J Sci Educ. 2009;31(12):1683–707.

Steiner JF. The use of stories in clinical research and health policy. JAMA. 2005;294(22):2901–4.

Article   CAS   PubMed   Google Scholar  

Peters EVD, Slovic P, Mertz C, Mazzocco K, Dickert S. Numeracy and decision making. Psychol Sci. 2006;17(5):407–13.

Kreuter MW, Holmes K, Alcaraz K, Kalesan B, Rath S, Richert M, et al. Comparing narrative and informational videos to increase mammography in low-income African American women. Patient Educ Couns. 2010;81(Suppl):S6–14.

Article   PubMed   PubMed Central   Google Scholar  

Reinard JC. The empirical study of the persuasive effects of evidence the status after fifty years of research. Hum Commun Res. 1988;15(1):3–59.

Shen F, Sheer VC, Li R. Impact of narratives on persuasion in health communication: A meta-analysis. J Advert. 2015;44(22):105–13.

Cacioppo JT, Petty RE. The Elaboration Likelihood Model of Persuasion. Provo, UT: ACR North American Advances; 1984.

Green MC, Brock TC. The role of transportation in the persuasiveness of public narratives. J Pers Soc Psychol. 2000;79(5):701–21.

Green MC, Brock TC. In the mind's eye: transportation-imagery model of narrative persuasion. In: Green MC, Strange JJ, Brock TC (Eds.). Narrative Impact: Social and Cognitive Foundations. Mahwah, NJ: Lawrence Erlbaum Associates Publishers; 2002. p. 315–41).

Moyer-Gusé E. Toward a theory of entertainment persuasion: explaining the persuasive effects of entertainment-education messages. Communication Theory. 2008;18(3):407–25.

Price RA. Suspenseful Narratives and Transportation; Explorations of Individual Difference Factors and Transportation as Predictors of Story-Consistent Attitudes. ETD Archive. 2017;994. https://engagedscholarship.csuohio.edu/etdarchive/994 . Accessed 25 Feb 2019.

Slater MD. Entertainment education and the persuasive impact of narratives. In: Green MC, Strange JJ, Brock TC (Eds.). Narrative Impact: Social and Cognitive Foundations. Mahwah, NJ: Lawrence Erlbaum Associates Publishers; 2002. p. 157–81. 

Bekker HL, Winterbottom AE, Butow P, Dillard AJ, Feldman-Stewart D, Fowler FJ, et al. Do personal stories make patient decision aids more effective? A critical review of theory and evidence. BMC Med Inform Decis Mak. 2013;13(Suppl 2):S9.

de Wit JB, Das E, Vet R. What works best: objective statistics or a personal testimonial? An assessment of the persuasive effects of different types of message evidence on risk perception. Health Psychol. 2008;27(1):110–5.

Davidson B. The role of narrative change in influencing policy. 2016. https://onthinktanks.org/articles/the-role-of-narrative-change-in-influencing-policy/ . Accessed 25 Feb 2019.

Epstein D, Heidt J, Farina C. The value of words: Narrative as evidence in policymaking. Evidence Policy. 2014;10(2):243–58.

Cairney P, Oliver K. Evidence-based policymaking is not like evidence-based medicine, so how far should you go to bridge the divide between evidence and policy? Health Res Policy Syst. 2017;15(1):35.

Choi BC, Pang T, Lin V, Puska P, Sherman G, Goddard M, et al. Can scientists and policy makers work together? J Epidemiol Community Health. 2005;59(8):632–7.

Brownson RC, Chriqui JF, Stamatakis KA. Understanding evidence-based public health policy. Am J Public Health. 2009;99(9):1576–83.

Greenlick MR, Goldberg B, Lopes P, Tallon J. Health policy roundtable--view from the state legislature: translating research into policy. Health Serv Res. 2005;40(2):337–46.

Bogenschneider K CT. Evidence-based policymaking: insights from policy-minded researchers and research-minded policy makers. J Marriage Family. 2011;73(3):687–9.

Cairney P, Kwiatkowski R. How to communicate effectively with policymakers: combine insights from psychology and policy studies. Palgrave Commun. 2017;3(1):37.

McDonough JE. Using and misusing anecdote in policy making. Health Aff (Millwood). 2001;20(1):207–12.

Article   CAS   Google Scholar  

Jewell CJ, Bero LA. “Developing good taste in evidence”: facilitators of and hindrances to evidence-informed health policymaking in state government. Milbank Q. 2008;86(2):177–208.

Sharf BF. Out of the closet and into the legislature: breast cancer stories. Health Aff (Millwood). 2001;20(1):213–8.

Buse K, Nicholas M, Walt G. Making Health Policy. 2nd ed. Maidenhead: Open University Press; 2012.

Verboom B, Montgomery P, Bennett S. What factors affect evidence-informed policymaking in public health? Protocol for a systematic review of qualitative evidence using thematic synthesis. Syst Rev. 2016;5:61.

Mays N, Pope C, Popay J. Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field. J Health Serv Res Policy. 2005;10(Suppl 1):6–20.

Sabatier P. Theories of the Policy Process. 1st ed. Colorado: Westview Press; 1999.

Walt G, Shiffman J, Schneider H, Murray SF, Brugha R, Gilson L. ‘Doing’ health policy analysis: methodological and conceptual reflections and challenges. Health Policy Plan. 2008;23(5):308–17.

Benoit F. Public Policy Models and their Usefulness in Public Health: The Stages Model. Québec: National Collaborating Centre for Healthy Public Policy, Institut national de santé publique; 2013.

Kulaç O, Özgür H. An overview of the stages (heuristics) model as a public policy analysis framework. Eur Sci J. 2017;13(12):144–57.

Rodgers M, Thomas S, Harden M, Parker G, Street A, Eastwood A. Developing a Methodological Framework for Organisational Case Studies: A Rapid Review and Consensus Development Process. Southampton: Health Services and Delivery Research; 2016.

Miake-Lye IM, Hempel S, Shanman R, Shekelle PG. What is an evidence map? A systematic review of published evidence maps and their definitions, methods, and products. Syst Rev. 2016;5:28.

Johnson K, Minogue G, Hopklins R. Inclusive research: making a difference to policy and legislation. J Appl Res Intellect Disabil. 2014;27(1):76–84.

Fitzgerald JL. Supervised injecting facilities: a case study of contrasting narratives in a contested health policy arena. Crit Public Health. 2013;23(1):77–94.

Umuhoza C, Oosters B, van Reeuwijk M, Vanwesenbeeck I. Advocating for safe abortion in Rwanda: how young people and the personal stories of young women in prison brought about change. Reprod Health Matters. 2013;21(41):49–56.

Leith KH, Phillips L. “In Their Own Voices” Using Qualitative Research and Consumer Narratives for Systems Change. Soc Policy J. 2006;4(3–4):19–35.

Wilcock PM, Brown GC, Bateson J, Carver J, Machin S. Using patient stories to inspire quality improvement within the NHS Modernisation Agency collaborative programmes. J Clin Nurs. 2003;12(3):422–30.

Neuhausen K. Awakening advocacy: how students helped save a safety-net hospital in Georgia. Health Aff (Millwood). 2013;32(6):1161–4.

Shi L. Micro-blogs, online forums, and the birth-control policy: social media and the politics of reproduction in China. Cult Med Psychiatry. 2014;38(1):115–32.

Slaton AE, Cecil CW, Lambert LE, King T, Pearson MM. What a difference family-driven makes: stories of success and lessons learned. Am J Community Psychol. 2012;49(3–4):538–45.

Krueger G. “For Jimmy and the boys and girls of America”: publicizing childhood cancers in twentieth-century America. Bull Hist Med. 2007;81(1):70–93.

MacGregor H, Mills E. Framing rights and responsibilities: accounts of women with a history of AIDS activism. BMC Int Health Hum Rights. 2011;11(Suppl 3):S7.

Marcus PM, Huang GC, Beck V, Miller MJ. The impact of a primetime cancer storyline: from individual knowledge and behavioral intentions to policy-level changes. J Cancer Educ. 2010;25(4):484–9.

MacKenzie R, Imison M, Chapman S, Holding S. Mixed messages and a missed opportunity: Australian news media coverage of Clare Oliver's campaign against solaria. Med J Aust. 2008;189(7):371–4.

Trossman S. MNA president uses personal story to push for needlestick legislation. Am Nurse. 1999;31(3):13.

CAS   PubMed   Google Scholar  

Rosenbaum L. N-of-1 policymaking--tragedy, trade-offs, and the demise of morcellation. N Engl J Med. 2016;374(10):986–90.

Lorenzo T. “We are also travellers”: An action story about disabled women mobilising for an accessible public transport system in Khayelitsha and Nyanga, Cape Metropole, South Africa. South Afr J Occup Ther. 2008;38(1):32–40.

Beck CS, Aubuchon SM, McKenna TP, Ruhl S, Simmons N. Blurring personal health and public priorities: an analysis of celebrity health narratives in the public sphere. Health Commun. 2014;29(3):244–56.

Lander M. The fight for a life-saving drug: a personal perspective. Med J Aust. 2007;187(11–12):706–8.

Bou-Karroum L, El-Jardali F, Hemadi N, Faraj Y, Ojha U, Shahrour M, et al. Using media to impact health policy-making: an integrative systematic review. Implement Sci. 2017;12(1):52.

Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8(5):336–41.

Higgins JP, Green S. Cochrane Handbook for Systematic Reviews of Interventions. Chichester: Wiley; 2011.

Scott SD, Hartling L, O'Leary KA, Archibald M, Klassen TP. Stories–a novel approach to transfer complex health information to parents: a qualitative study. Arts Health. 2012;4(2):162–73.

Greenhalgh T, Collard A, Begum N. Sharing stories: complex intervention for diabetes education in minority ethnic groups who do not speak English. BMJ. 2005;330(7492):628.

Brownson RC, Dodson EA, Stamatakis KA, Casey CM, Elliott MB, Luke DA, et al. Communicating evidence-based information on cancer prevention to state-level policy makers. J Natl Cancer Inst. 2011;103(4):306–16.

Brownson RC, Dodson EA, Kerner JF, Moreland-Russell S. Framing research for state policymakers who place a priority on cancer. Cancer Causes Control. 2016;27(8):1035–41.

Morshed AB, Dodson EA, Tabak RG, Brownson RC. Comparison of research framing preferences and information use of state legislators and advocates involved in cancer control, United States, 2012-2013. Prev Chronic Dis. 2017;14:E10.

Niederdeppe J, Roh S, Dreisbach C. How narrative focus and a statistical map shape health policy support among state legislators. Health Commun. 2016;31(2):242–55.

Perrier M-J, Martin Ginis KA. Narrative interventions for health screening behaviours: A systematic review. J Health Psychol. 2017;22(3):375–93.

Greenhalgh T. Cultural Contexts of Health: The Use of Narrative Research in the Health Sector. Copenhagen: WHO Health Evidence Network Synthesis Reports; 2016.

LeBron AM, Schulz AJ, Bernal C, Gamboa C, Wright C, Sand S, et al. Storytelling in community intervention research: lessons learned from the walk your heart to health intervention. Prog Community Health Partnersh. 2014;8(4):477–85.

Adams A, Sedalia S, McNab S, Sarker M. Lessons learned in using realist evaluation to assess maternal and newborn health programming in rural Bangladesh. Health Policy Plan. 2016;31(2):267–75.

Marchal B, Van Belle S, Van Olmen J, Hoerée T, Kegels G, Marchal B, Van Belle S, Van Olmen J, Hoerée T, Kegels G. Is realist evaluation keeping its promise? A review of published empirical studies in the field of health systems research. Evaluation. 2012;18(2):192–212.

Fletcher A, Jamal F, Moore G, Evans RE, Murphy S, Bonell C. Realist complex intervention science: applying realist principles across all phases of the Medical Research Council framework for developing and evaluating complex interventions. Eval. 2016;22(3):286–303.

Mohler R, Kopke S, Meyer G. Criteria for Reporting the Development and Evaluation of Complex Interventions in healthcare: revised guideline (CReDECI 2). Trials. 2015;16:204.

Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: the new Medical Research Council guidance. Int J Nurs Stud. 2013;50(5):587–92.

Uzochukwu B, Onwujekwe O, Mbachu C, Okwuosa C, Etiaba E, Nystrom ME, et al. The challenge of bridging the gap between researchers and policy makers: experiences of a Health Policy Research Group in engaging policy makers to support evidence informed policy making in Nigeria. Glob Health. 2016;12(1):67.

Langlois EV, Becerril Montekio V, Young T, Song K, Alcalde-Rabanal J, Tran N. Enhancing evidence informed policymaking in complex health systems: lessons from multi-site collaborative approaches. Health Res Policy Syst. 2016;14:20.

Shroff Z, Aulakh B, Gilson L, Agyepong IA, El-Jardali F, Ghaffar A. Incorporating research evidence into decision-making processes: researcher and decision-maker perceptions from five low- and middle-income countries. Health Res Policy Syst. 2015;13:70.

van de Goor I, Hamalainen RM, Syed A, Juel Lau C, Sandu P, Spitters H, et al. Determinants of evidence use in public health policy making: results from a study across six EU countries. Health Policy. 2017;121(3):273–81.

Moezzi M, Janda KB, Rotmann S. Using stories, narratives, and storytelling in energy and climate change research. Energy Res Soc Sci. 2017;31:1–10.

Stamatakis KA, McBride TD, Brownson RC. Communicating prevention messages to policy makers: the role of stories in promoting physical activity. J Phys Act Health. 2010;7(Suppl 1):S99–107.

Hyman DA. Do good stories make for good policy? J Health Polit Policy Law. 2000;25(6):1149–55.

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Acknowledgements

We would like to thank Ms Aida Farha for her help in validating the search strategy.

This systematic review was funded by the Alliance for Health Policy and Systems Research, WHO, Geneva. The funding body had no role in the design of the study, collection, analysis and interpretation of data, and in writing the manuscript.

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EAA, FJ and RF conceived the study. EA, FJ, RF and EL contributed to the study design. RF and EAA designed and ran the search strategy. RF, MN, NH and KA screened the articles for eligibility. RF, MN, NH and KA abstracted data from eligible studies. RF and MN assessed methodological quality of included studies. RF, EA and FE contributed to the analysis and interpretation of results. RF, EA, FE and EL contributed to writing up of the manuscript. All authors read and approved the final manuscript.

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Fadlallah, R., El-Jardali, F., Nomier, M. et al. Using narratives to impact health policy-making: a systematic review. Health Res Policy Sys 17 , 26 (2019). https://doi.org/10.1186/s12961-019-0423-4

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A research-based narrative assignment for global health education

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There is a paucity of research on novel approaches to classroom-based global health education despite the growing popularity of this topic in health professional curricula. The purpose of the following paper is to (1) describe the rationale underlying the use of a research-based narrative assignment for global health education, and (2) describe the results from an evaluation of this assignment with undergraduate public health students, including its strengths and limitations. The research-based narrative assignment was implemented during an introductory global health course for third and fourth year undergraduate public health students. The students (n = 20) completed the assignment and then wrote a two-page reflection about their experience. The author analyzed these student reflections using open coding and thematic analysis. Four salient themes were identified from the written reflections including (1) the challenge of representing persons, (2) the opportunity to develop an engaged understanding of the chosen issue, (3) seeing the bigger picture or integrating the various determinants into a coherence story, and finally (4) the struggle to create a compelling story that was based on accurate information. The analysis of the students’ reflections provides important insights into their experience conducting this assignment, particularly in highlighting key strengths and challenges of this approach. These strengths and challenges are discussed.

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Bateman, C., Baker, T., Hoornenborg, E., & Ericsson, U. (2001). Bringing global issues to medical teaching. The Lancet, 358 (9292), 1539–1542.

Article   Google Scholar  

Beaglehole, R., & Yach, D. (2003). Globalisation and the prevention and control of non-communicable disease: The neglected chronic diseases of adults. The Lancet, 362 (9387), 903–908. doi: 10.1016/S0140-6736(03)14335-8 .

Benatar, S. R., Daar, A. S., & Singer, P. A. (2003). Global health ethics: The rationale for mutual caring. International Affairs, 79 (1), 107–138.

Benatar, S., Daar, A. S., & Singer, P. A. (2005). Global health challenges: The need for an expanded discourse on bioethics. PLoS Medicine, 2 (7), e143.

Bruner, J. (1987). Life as narrative. Social Research, 54 (1), 11–32.

Google Scholar  

Bruner, J. (1991). The narrative construction of reality. Critical Inquiry, 18 (1), 1–21.

Charmaz, K. (2007). Constructing grounded theory: A practical guide through qualitative analysis (2nd ed.). Beverly Hills, CA: Sage Publications.

Cole, D. C., Davison, C., Hanson, L., Jackson, S. F., Page, A., Lencucha, R., et al. (2011). Being global in public health practice and research: Complementary competencies are needed. Canadian Journal of Public Health, 102 (5), 394–397.

Drain, P. K., Holmes, K. K., Skeff, K. M., Hall, T. L., & Gardner, P. (2009). Global health training and international clinical rotations during residency: Current status, needs, and opportunities. Academic Medicine, 84 (3), 320–325. doi: 10.1097/ACM.1090b1013e3181970a3181937 .

Drain, P. K., Primack, A., Hunt, D. D., Fawzi, W. W., Holmes, K. K., & Gardner, P. (2007). Global health in medical education: A call for more training and opportunities. Academic Medicine, 82 (3), 226–230. doi: 10.1097/ACM.1090b1013e3180305cf3180309 .

Dussault, G., & Dubois, C.-A. (2003). Human resources for health policies: A critical component in health policies. Human Resources for Health, 1 (1), 1.

Duvivier, R., Brouwer, E., & Weggemans, M. (2010). Medical education in global health: Student initiatives in the Netherlands. Medical Education, 44 (5), 528–529.

Edwards, R., Piachaud, J., Rowson, M., & Miranda, J. (2004). Understanding global health issues: Are international medical electives the answer? Medical Education, 38 (7), 688–690.

Edwards, R., Rowson, M., & Piachaud, J. (2001). Teaching international health issues to medical students. Medical Education, 35 (8), 807–808.

Geertz, C. (1973). The interpretation of cultures . USA: Basic Books.

Harden, R. M. (2006). International medical education and future directions: A global perspective. Academic Medicine, 81 (12), S22–S29. doi: 10.1097/1001.ACM.0000243411.0000219573.0000243458 .

Hawkes, C. (2006). Uneven dietary development: Linking the policies and processes of globalization with the nutrition transition, obesity and diet-related chronic diseases. Globalization and Health, 2 (1), 4.

Houpt, E. R., Pearson, R. D., & Hall, T. L. (2007). Three domains of competency in global health education: Recommendations for all medical students. Academic Medicine, 82 (3), 222–225. doi: 10.1097/ACM.1090b1013e3180305c3180310 .

Izadnegahdar, R., Correia, S., Ohata, B., Kittler, A., ter Kuile, S., Vaillancourt, S., et al. (2008). Global health in Canadian medical education: Current practices and opportunities. Academic Medicine, 83 (2), 192–198. doi: 10.1097/ACM.1090b1013e31816095cd .

Jones, A. H. (1997). Literature and medicine: Narrative ethics. The Lancet, 349 (9060), 1243–1246.

Jones, A. H. (1999). Narrative in medical ethics. British medical journal, 318 (7178), 253–256.

King, T. (2008). The truth about stories: A native narrative . Minneapolis: University of Minnesota Press.

Koehn, P. H., & Swick, H. M. (2006). Medical education for a changing world: Moving beyond cultural competence into transnational competence. Academic Medicine, 81 (6), 548–556. doi: 10.1097/1001.ACM.0000225217.0000215207.d0000225214 .

Koplan, J. P., Bond, T. C., Merson, M. H., Reddy, K. S., Rodriguez, M. H., Sewankambo, N. K., et al. (2009). Towards a common definition of global health. The Lancet, 373 (9679), 1993–1995.

Labonte, R., Mohindra, K., & Lencucha, R. (2011). Framing international trade and chronic disease. Globalization and Health, 7 (1), 21.

Magnusson, R. S. (2010). Global health governance and the challenge of chronic, non-communicable disease. The Journal of Law, Medicine and Ethics, 38 (3), 490–507.

McCarthy, J. (2003). Principlism or narrative ethics: Must we choose between them? Medical Humanities, 29 (2), 65–71.

Shah, S., & Wu, T. (2008). The medical student global health experience: Professionalism and ethical implications. Journal of Medical Ethics, 34 (5), 375–378.

Smith, R. D. (2006). Responding to global infectious disease outbreaks: Lessons from SARS on the role of risk perception, communication and management. Social Science and Medicine, 63 (12), 3113–3123.

White, H. (1980). The value of narrativity in the representation of reality. Critical Inquiry, 7 (1), 5–27.

Wibulpolprasert, S., Pachanee, C. A., Pitayarangsarit, S., & Hempisut, P. (2004). International service trade and its implications for human resources for health: A case study of Thailand. Human Resources for Health, 2 (1), 1–12.

Williams, L., Labonte, R., & O’Brien, M. (2003). Empowering social action through narratives of identity and culture. Health Promotion International, 18 (1), 33–40.

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Lencucha, R. A research-based narrative assignment for global health education. Adv in Health Sci Educ 19 , 129–142 (2014). https://doi.org/10.1007/s10459-013-9446-8

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19 Best Narrative Therapy Techniques & Worksheets [+PDF]

It is likely that the life story you tell yourself and others changes depending on who is asking, your mood, and whether you feel like you are still at the beginning, in the middle, or at the end of your most salient story.

But when was the last time you paused to consider the stories you tell?

“What is your story?”

Narrative therapy capitalizes on this question and our storytelling tendencies. The goal is to uncover opportunities for growth and development, find meaning, and understand ourselves better.

We use stories to inform others, connect over shared experiences, say when we feel wronged, and even to sort out our thoughts and feelings. Stories organize our thoughts, help us find meaning and purpose, and establish our identity in a confusing and sometimes lonely world. Thus, it is important to realize what stories we are telling ourselves, and others, when we talk about our lives.

If you’ve never heard of narrative therapy before, you’re not alone!

This therapy is a specific and less common method of guiding clients towards healing and personal development. It’s revolves around the stories we tell ourselves and others.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises will explore fundamental aspects of positive psychology including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

What is narrative therapy a definition, 5 commonly used narrative therapy techniques, 3 more narrative therapy exercises and interventions, examples of questions to ask your clients, narrative therapy treatment plan, best books on narrative therapy, youtube videos for further exploration, a handy powerpoint to use, a take-home message.

Narrative therapy is a form of therapy that aims to separate the individual from the problem, allowing the individual to externalize their issues rather than internalize them.

It relies on the individual’s own skills and sense of purpose to guide them through difficult times (Narrative Therapy, 2017).

This form of therapy was developed in the 1980s by Michael White and David Epston (About Narrative Therapy, n.d.).

They believed that separating a person from their problematic or destructive behavior was a vital part of treatment (Michael White (1948-2008), 2015).

For example, when treating someone who had run afoul of the law, they would encourage the individual to see themselves as a person who made mistakes, rather than as an inherently “bad” felon. White and Epston grounded this new therapeutic model in three main ideas.

1. Narrative therapy is respectful.

This therapy respects the agency and dignity of every client. It requires each client to be treated as an individual who is not deficient, not defective, or not “enough” in any way.

Individuals who engage in narrative therapy are brave people who recognize issues they would like to address in their lives.

2. Narrative therapy is non-blaming.

In this form of therapy, clients are never blamed for their problems, and they are encouraged not to blame others as well. Problems emerge in everyone’s lives due to a variety of factors; in narrative therapy, there is no point in assigning fault to anyone or anything.

Narrative therapy separates people from their problems, viewing them as whole and functional individuals who engage in thought patterns or behavior that they would like to change.

3. Narrative therapy views the client as the expert.

In narrative therapy, the therapist does not occupy a higher social or academic space than the client. It is understood that the client is the expert in their own life, and both parties are expected to go forth with this understanding.

Only the client knows their own life intimately and has the skills and knowledge to change their behavior and address their issues (Morgan, 2000).

These three ideas lay the foundation for the therapeutic relationship and the function of narrative therapy. The foundation of this therapeutic process has this understanding and asks clients to take a perspective that may feel foreign. It can be difficult to place a firm separation between people and the problems they are having.

Key Concepts and Approach

Making the distinction between “an individual with problems” and a “problematic individual” is vital in narrative therapy. White and Epston theorized that subscribing to a harmful or adverse self-identity could have profound negative impacts on a person’s functionality and quality of life .

“The problem is the problem, the person is not the problem.”

Michael White and David Epston

To this end, there are a few main themes or principles of narrative therapy:

• Reality is socially constructed, which means that our interactions and dialogue with others impacts the way we experience reality.
• Reality is influenced by and communicated through language, which suggests that people who speak different languages may have radically different interpretations of the same experiences.
• Having a narrative that can be understood helps us organize and maintain our reality. In other words, stories and narratives help us to make sense of our experiences.
• There is no “objective reality” or absolute truth; what is true for us may not be the same for another person, or even for ourselves at another point in time (Standish, 2013).

These principles tie into the postmodernist school of thought, which views reality as a shifting, changing, and deeply personal concept. In postmodernism, there is no objective truth—the truth is what each one of us makes it, influenced by social norms and ideas.

Unlike modern thought that held the following tenets as sacred, postmodern thought holds skepticism over grand narratives, the individual, the idea of neutral language, and universal truth.

Thus, the main premise behind narrative therapy is understanding individuals within this postmodern context. If there is no universal truth, then people need to create truths that help them construct a reality that serves themselves and others. Narrative therapy offers those story-shaping skills.

It’s amazing how much easier solving or negating a problem can be, when you stop seeing the problem as an integral part of who you are, and instead, as simply a problem.

The five techniques here are the most common tools used in narrative therapy.

1. Telling One’s Story (Putting Together a Narrative)

As a therapist or other mental health professional, your job in narrative therapy is to help your client find their voice and tell their story in their own words. According to the philosophy behind narrative therapy, storytelling is how we make meaning and find purpose in our own experience (Standish, 2013).

Helping your client develop their story gives them an opportunity to discover meaning, find healing, and establish or re-establish an identity, all integral factors for success in therapy.

This technique is also known as “re-authoring” or “re-storying,” as clients explore their experiences to find alterations to their story or make a whole new one. The same events can tell a hundred different stories since we all interpret experiences differently and find different senses of meaning (Dulwich Centre, n.d.).

2. Externalization Technique

The externalization technique leads your client toward viewing their problems or behaviors as external, instead of an unchangeable part of themselves. This is a technique that is easier to describe than to embrace, but it can have huge positive impacts on self-identity and confidence .

The general idea of this technique is that it is easier to change a behavior you do, than to change a core personality characteristic.

For example, if you are quick to anger or you consider yourself an angry person, then you must fundamentally change something about yourself to address the problem; however, if you are a person who acts aggressively and angers easily, then you need to alter the situations and behaviors surrounding the problem.

It might seem like an insignificant distinction, but there is a profound difference between the mindset of someone who labels themselves as a “problem” person and someone who engages in problematic behavior.

It may be challenging for the client to absorb this strange idea at first. One first step is to encourage your client not to place too much importance on their diagnosis or self-assigned labels. Let them know how empowering it can be to separate themselves from their problems, and allowing themselves a greater degree of control  in their identity (Bishop, 2011).

3. Deconstruction Technique

Our problems can feel overwhelming, confusing, or unsolvable, but they are never truly unsolvable (Bishop, 2011).

Deconstructing makes the issue more specific and reduces overgeneralizing; it also clarifies what the core issue or issues actually are.

As an example of the deconstruction technique, imagine two people in a long-term relationship who are having trouble. One partner is feeling frustrated with a partner who never shares her feelings, thoughts, or ideas with him. Based on this short description, there is no clear idea of what the problem is, let alone what the solution might be.

A therapist might deconstruct the problem with this client by asking them to be more specific about what is bothering them, rather than accepting a statement such as, “my spouse doesn’t get me anymore.”

This might lead to a better idea of what is troubling the client, such as general themes of feeling lonely or missing romantic intimacy. Maybe the client has construed a narrative where they are the victim of this helpless relationship, rather than someone with a problem coping with loneliness and communicating this vulnerability with their partner.

Deconstructing the problem helps people understand what the root of problems (in this case, someone is feeling lonely and vulnerable) and what this means to them (in this case, like their partner doesn’t want them anymore or is not willing to commit to the relationship like they are).

This technique is an excellent way to help the client dig into the problem and understand the foundation of the stressful event or pattern in their life.

4. Unique Outcomes Technique

This technique is complex but vital for the storytelling aspect of narrative therapy.

The unique outcomes technique involves changing one’s own storyline. In narrative therapy, the client aims to construct a storyline to their experiences that offers meaning, or gives them a positive and functional identity. This is not as misguided as “thinking positive,” but rather, a specific technique for clients to develop life-affirming stories.

We are not limited to just one storyline, though. There are many potential storylines we can subscribe to, some more helpful than others.

Like a book that switches viewpoints from one character to another, our life has multiple threads of narrative with different perspectives, areas of focus, and points of interest. The unique outcomes technique focuses on a different storyline or storylines than the one holding the source of your problems.

Using this technique might sound like avoiding the problem, but it’s actually just reimagining the problem. What seems like a problem or issue from one perspective can be nothing but an unassuming or insignificant detail in another

(Bishop, 2011).

As a therapist, you can introduce this technique by encouraging client(s) to pursue new storylines.

5. Existentialism

You might have a particular association with the term “ existentialism ” that makes its presence here seem odd, but there is likely more to existentialism than you think.

Existentialism is not a bleak and hopeless view on a world without meaning.

In general, existentialists believe in a world with no inherent meaning; if there is no given meaning, then people can create their own meaning. In this way, existentialism and narrative therapy go hand in hand. Narrative therapy encourages individuals to find their meaning and purpose rather than search for an absolute truth that does not necessarily resonate for themselves.

If your client is an avid reader, you might consider suggesting some existentialist works as well, such as those by Jean-Paul Sartre, Albert Camus, or Martin Heidegger.

The visual below helps summarize what narrative therapy is, and how it can be used.

You can download the printable version of the infographic here .

While narrative therapy is more of a dialogue between the therapist and client, there are some exercises and activities to supplement the regular therapy sessions. A few of these are described below.

1. Statement of Position Map

• Characteristics and naming or labeling of the problem
• Mapping the effects of the problem throughout each domain of life it touches (home, work, school, relationships, etc.)
• Evaluation of the effects of the problem in these domains
• Values that come up when thinking about why these effects are undesirable

This map is intended to be filled out in concert with a therapist, but it can be explored if it is difficult to find a narrative therapist.

Generally, the dialogue between a therapist and client will delve into these four areas. The therapist can ask questions and probe for deeper inquiry, while the client discusses the problem they are having and seeks insight in any of the four main areas listed above. There is power in the act of naming the problem and slowly shifting the idea that we are a passive viewer of our lives.

Finally, it is vital for the client to understand why this problem bothers them on a deeper level. What values are being infringed upon or obstructed by this problem? Why does the client feel negative about the problem? For example, what does the “stressful dinner party” bring up for them? Perhaps feelings of social anxiety and “otherness” that feel isolating? These are questions that this exercise can help to answer.

For a much more comprehensive look at this exercise, you can read these workshop notes from Michael White on using the statement position maps.

You can also access a PowerPoint in which a similar exercise is covered here .

2. My Life Story

This exercise is all about your story, and all you need is the printout and a pen or pencil.

The intention of the My Life Story exercise is to separate yourself from your past and gain a broader perspective on your life. It aims to create an outline of your life that does not revolve too intensly around memories as much as moments of intensity or growth.

First, you write the title of the book that is your life. Maybe it is simply “Monica’s Life Story,” or something more reflective of the themes you see in your life, like “Monica: A Story of Perseverance.”

In the next section, come up with at least seven chapter titles, each one representing a significant stage or event in your life. Once you have the chapter title, come up with one sentence that sums up the chapter. For example, your chapter title could be “Awkward and Uncertain” and the description may read “My teenage years were dominated by a sense of uncertainty and confusion in a family of seven.”

Next, you will consider your final chapter and add a description of your life in the future. What will you do in the future? Where will you go, and who will you be? This is where you get to flex your predictive muscles.

Finally, the last step is to add to your chapters as necessary to put together a comprehensive story of your life.

This exercise will help you to organize your thoughts and beliefs about your life and weave together a story that makes sense to you. The idea is not to get too deep into any specific memories, but instead to recognize that what is in your past is truly the past. It shaped you, but it does not have to define you. Your past made you the reflective and wiser person of today.

You can download this worksheet  here .

3. Expressive Arts

This intervention can be especially useful for children, but adults may find relief and meaning in it as well.

We all have different methods of telling our stories, and using the arts to do so has been a staple of humanity for countless generations. To take advantage of this expressive and creative way to tell your stories, explore the different methods at your disposal.

• Meditate . Guided relaxation or individual meditation can be an effective way to explore a problem.
• Journal. Journaling has many potential benefits. Consider a specific set of question s (e.g., How does the problem affect you? How did the problem take hold in your life?) or simply write a description of yourself or your story from the point of view of the problem. This can be difficult but can lead to a greater understanding of the problem and how it influences the domains of your life.
• Draw. If you’re more interested in depictions of the problem’s impact on your experience, you can use your skills to draw or paint the effects of the problem. You can create a symbolic drawing, map the effects of the problem, or create a cartoon that represents the problem in your life. If drawing sounds intimidating, you can even doodle abstract shapes with the colors of the emotions you feel, and keywords that express your reflection in that moment.
• Movement. You can use the simple medium of movement and mindfulness to create and express your story. Begin by moving in your usual way, then allow the problem to influence your movement. Practice mindful observation to see what changes when you let the problem take hold. Next, develop a transitional movement that begins to shake the problem’s hold on you. Finally, transition into a “liberation movement” to metaphorically and physically explore how to escape the problem.
• Visualization. Use visualization techniques to consider how your life might be in a week, a month, a year, or a few years, both with this problem continuing and in a timeline where you embrace a new direction. Share your experience with a partner or therapist, or reflect in your journal to explore the ways in which this exercise helped you find meaning or new possibilities for your life (Freeman, 2013).

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Narrative therapy is a dialogue in which both you and your client converse to learn about your story. As you may imagine, it requires many questions on the part of the therapist.

“Every time we ask a question, we’re generating a possible version of a life.”

David Epston

The list of questions below is intended to go with the statement of position maps, but these questions can be useful outside of this exercise too:

• It sounds as though [problem] is part of your life now.
• How long have you been noticing this [problem]?
• What effect does the [problem] have on your life?
• How does the [problem] impact on your energy for daily tasks?
• Does [problem] have an impact on your relationship with other family members?
• What effects does [problem] have on your child’s life?
• What do you think about the effects [problem] is having on your life?
• Are you accepting what [problem] is doing?
• Are these effects acceptable to you or not?
• Why is this? Why are you taking this position on what [problem] is doing?
• How would you prefer things to be?
• If you were to stay connected to what you have just said about what you prefer, what next steps could you take?

The website www.integratedfamilytherapy.com also provides excellent examples of questions to ask your client as you move through their story:

• Enabling Openings Can you describe the last time you managed to get free of the problem for a couple of minutes? What was the first thing you noticed in those few minutes? What was the next thing?
• Linking Openings with Preferred Experience Would you like more minutes like these in your life?
• Moving from Openings to Alternative Story Development. What was each of you thinking/feeling/doing/wishing/imagining during those few minutes?
• Broadening the Viewpoint. What might your friend have noticed about you if she had met up with you in those few minutes?
• Exploring Landscapes of Action. How did you achieve that? How did Tim help you with that?
• Exploring Landscapes of Consciousness.  What have you learned about what you can manage from those few minutes?
• Linking with the Exceptions in the Past. Tell me about times when you have managed to achieve a similar few minutes in the past?
• Linking Exceptions from the Past with the Present. When you think about those times in the past when you have achieved this, how might this alter your view of the problem now?
• Linking Exceptions from the Past with the Future. Thinking about this now, what do you expect to do next?

Developing a treatment plan for narrative therapy is a personal and intensive activity in any therapeutic relationship, and there are guidelines for how to incorporate an effective plan.

This PDF provides a profile of a treatment plan, including goals and guidelines for each stage and theories that can apply to the client’s treatment.

The co-founder of narrative therapy, Michael White, offers an additional resource for therapists using narrative therapy.

According to White, there are three main processes in treatment:

1) Externalization of the problem, which mirrors the steps of the position mapping exercise:

• Developing a particular, experience-near definition of the problem;
• Mapping the effects of the problem;
• Evaluating the effects of the problem;
• and justifying the evaluation.

2) Re-authoring conversations by:

• Helping the client include neglected aspects of themselves;
• and shifting the problem-centered narrative.

3) Remembering conversations that actively engage the client in the process of:

• Renewing their relationships;
• Removing the relationships that no longer serve them;
• and finding meaning in their story that is no longer problem-saturated as much as resilient-rich.

If you’re as much of a bookworm as I am, you’ll want a list of suggested reading to complement this piece. You’re in luck!

These three books are some of the highest rated books on narrative therapy and offer a solid foundation in the practice of narrative techniques.

1. Maps of Narrative Practice – Michael White

This book from one of the developers of narrative therapy takes the reader through the five main areas of narrative therapy, according to White: re-authoring conversations, remembering conversations, scaffolding conversations, definitional ceremony, and externalizing conversations.

In addition, the book maps out the therapeutic process, complete with implications for treatment and skills training exercises for the reader.

Find the book on Amazon .

2. What is narrative therapy? : An easy-to-read introduction – Alice Morgan

This best-seller provides a simple and easy to understand introduction to the main tenets of narrative therapy.

In this book, you will find information on externalization, remembering, therapeutic letter writing, journaling, and reflection in the context of narrative therapy.

Morgan’s book is especially useful for therapists and other mental health professionals who wish to add narrative techniques and exercises to their practice.

3. Narrative Therapy: The Social Construction of Preferred Realities – Gene Combs and Jill Freedman

This book is best saved for those who want to dive headfirst into the philosophical underpinnings of narrative therapy.

Casual readers interested in learning more about narrative therapy may want to try one of the first two books; students, teachers, and practitioners will find this book challenging, informative, and invaluable to their studies.

Included in this book are example transcripts and descriptions of therapy sessions in which the principles and interventions of narrative therapy are applied.

1. This quick, 5-minute video can give you an idea of how some of the techniques of narrative therapy can be applied in real counseling sessions, specifically with children and families. As Dr. Madigan quotes in this video, “we speak ourselves into meaning.”

We need to speak in ways that serve us.

3. Finally, for a fun and engaging exploration of narrative therapy for in couples counseling, click the link below. It leads to a video involving puppets and outlining some of the main techniques and principles involved in narrative couples therapy.

Around four minutes in, a breakthrough moment occurs when the therapist puppet says, “so you’re feeling anxious because you don’t know what direction this is going to take you.” This is an example of deconstructive questioning, and how it helps uncover the deeper vulnerability of any “problem.”

If you’re more a reader or if you like to go at your own pace, check out this slideshow on narrative therapy.

It’s intended for students learning about narrative therapy in an academic setting. Some of the languages may seem specific and jargon abounds, but there is some great information in here for any readers curious about the philosophy, principles, and theories behind narrative therapy.

Follow this link to view the slideshow.

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How do you tell your story? What are the chapters of your life? Do you like the story you tell, or would you prefer to change your story? These and many other questions can be answered in narrative therapy.

“There is no greater agony than bearing an untold story inside you.”

Maya Angelou

If you’re an individual curious about narrative therapy, I hope your curiosity is piqued and that you have a foundation now for further learning.

If you’re a therapist or other mental health professional interested in applying narrative therapy in your work, I hope this piece can give you a starting point for you.

As always, please leave us your thoughts in the comment section. Have you tried narrative therapy? If so, what did you think? Did you find it useful? What techniques in particular capture your interest?

Thanks for reading and happy storytelling!

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

• About Narrative Therapy. (n.d.). Narrative Therapy Centre of Toronto. Retrieved from http://www.narrativetherapycentre.com/narrative.html
• Bishop, W. H. (2011, May 16). Narrative therapy summary. Thoughts From a Therapist. Retrieved from http://www.thoughtsfromatherapist.com/2011/05/16/narrative-therapy-summary/
• Dulwich Centre. (n.d.). What is narrative therapy? Dulwich Centre. Retrieved from http://dulwichcentre.com.au/what-is-narrative-therapy/
• Freeman, J. (2013, June 5). Expressive arts workshop materials. Narrative Approaches. Retrieved from http://www.narrativeapproaches.com/expressive-arts-workshop-materials/
• Michael White (1948-2008). (2015, July 24). GoodTherapy. Retrieved from http://www.goodtherapy.org/famous-psychologists/michael-white.html
• Morgan, A. (2000). What is narrative therapy? An easy-to-read introduction. Adelaide, SA: Dulwich Centre Publications.
• Narrative Therapy. (2017). Good Therapy. Retrieved from http://www.goodtherapy.org/learn-about-therapy/types/narrative-therapy
• Standish, K. (2013, November 28). Introduction to narrative therapy [Slideshow]. Retrieved from https://www.slideshare.net/kevins299/lecture-8-narrative-therapy

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What our readers think.

Wow, this is really invalidating. It’s always so telling when mental health providers focus on “behavior change” when sometimes behaviors aren’t the issue. It’s also telling that the author assumes that mentioning children and family is not triggering to clients. What if the issue is that there is not a possibility of children or family?

Why is the assumption that telling one’s story is the issue? For many of us, we are aware of and can express our stories; that’s not the issue.

Yikes for those of us who have already had terrible and invalidating experiences with therapy.

I’m genuinely sorry to hear that the content has resonated with you this way. It’s crucial to acknowledge that everyone’s experience with mental health is unique, and what works for one person might not be suitable for another. The intention is never to invalidate anyone’s feelings or experiences. Instead, the aim is to provide diverse tools and perspectives that might be helpful to some.

Your point about the assumptions regarding family and storytelling is well-taken, and it highlights the importance of a more inclusive and sensitive approach that considers the varied backgrounds and experiences of all individuals.

If there are specific topics or resources you feel would be more beneficial or sensitive to your experiences, we’re open to suggestions.

Warm regards, Julia | Community Manager

As a mental health therapist I understand exactly what you are saying. Narrative Therapy may never be a good therapy for you and many others. It seems to me that it can be effective after the patient feels securely validated, assigns appropriate responsibility to the source of their pain, establishes safety, regains their ability to exercise choices and options, and feels a sense of value and worth. Then the patient may choose to pursue Narrative Therapy as a way to further recover from what happened to them by becoming the main character in their own life. This can be an empowering experience that allows them to validate themselves, secure their identity, strengthen their self-esteem and regard their past, present and future based on their own terms. For example, a Chapter 1 title something like: “JKL is born for themselves, not to please their parents.” A clinician needs to use sound clinical judgment about the readiness for this therapy, as is true for other therapies. Treating trauma and deep wounds is a sensitive process and takes wisdom along with skill.

Existentialism has little to do with White and Epston’s developments — please be more cautious about representing Narrative Practice. There are some more subtle inaccuracies here as well (deconstruction isn’t well represented, re-authoring and re-membering are hardly mentioned, not to mention outsider witness conversations and the abscent but implicit, to name several, but not all), but the problem I’m citing really needs to be addressed.

I always enjoy relearning the techniques of Narrative Therapy but could use a guideline that focuses on Addiction. I am a co-occurring therapist that works with Addiction and Mental Health and use externalization a lot. It would be great if you had a specific worksheet/questionnaire that addresses addiction specifically.

Thanks so much for your insight!

Kind Regards, Diane Music

Dear Diane,

Thank you for reaching out and expressing your interest in resources specifically designed for the context of addiction. It’s wonderful to hear you’re applying Narrative Therapy techniques in your work!

Although we presently lack resources specifically tailored to your case, we recommend adapting the principles of Narrative Therapy to suit the unique needs of your clients battling addiction:

– Externalizing the Problem: As you’re already doing, this can be particularly beneficial in addiction therapy. It helps the client see their addiction as a separate entity rather than an inherent part of themselves. They can then examine how ‘the addiction’ influences their life and choices. – Deconstructing Dominant Narratives: Encourage clients to explore societal and personal beliefs about addiction. Challenge these narratives and help clients construct their own, empowering narratives. – Highlighting Unique Outcomes: Help your clients identify times when they successfully resisted the ‘pull’ of addiction. These ‘unique outcomes’ can help them see their own strength and capacity for change. – Letter Writing: This can be a powerful tool for clients to communicate with their ‘addiction,’ express their feelings, or articulate their hopes for the future. – Mapping the Influence: Create a visual map of how addiction influences different areas of their life. This can be a powerful tool for externalization and for identifying areas to work on.

We hope to have more specialized resources available soon. Until then, we believe the techniques mentioned above, when applied with sensitivity and creativity, can be highly effective in a narrative approach to addiction therapy.

Thank you for the impactful work you’re doing!

Best Regards, Julia | Community Manager

“Expressive Arts. This intervention can be especially useful for children, but adults may find relief and meaning in it as well.” As an expressive arts therapist, I found this comment to be confusing and somewhat misinformed. Firstly, the “expressive arts” are not an intervention, but are a collective of psychotherapeutic techniques and disciplines. There is also an insinuation that the expressive arts (or, more accurately, “expressive arts therapy”) are mostly for children, while adults, secondarily, “may find relief and meaning in it as well.” I have worked primarily with adults as an expressive therapist. The misconception that expressive therapy is mostly for children is a bias that many of us must contend with from those who do not understand that we are trained psychotherapists who work with adults. Thank you.

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Health Narrative

The purpose of this assignment is to share and analyze a personal story about a health problem, issue, or illness you or a family member experienced. Remember, a narrative is the process of making a story, which sheds light on what we think, how we act, what decisions we make, etc. Through narratives, we make sense of our lives! Specifically, you will write a brief narrative that describes your illness narrative (experience) and then identify and discuss at least one class concept that helps you make sense of that experience (ensure that you define and cite the class concept). In other words, think about how that narrative has made a significant difference to you personally, to cultural understandings of a healthcare issue, or to the politics of how a health problem has been handled. *Be sure to Identify and discuss at least 1 class concept from the textbook to help understand the impact of your illness narrative on your life.  Textbook  below https://www.chegg.com/reader/9781478633907/20/

Do you need a similar assignment written for you from scratch? We have qualified writers to help you. You can rest assured of an A+ quality paper that is plagiarism free. Order now for a FREE first Assignment! Use Discount Code " FREE " for a 100% Discount! NB: We do not resell papers. Upon ordering, we write an original paper exclusively for you.

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The Tree of Life: A Simple Exercise for Reclaiming Your Identity and Direction in Life Through Story

In my last post I shared a book that has made a profound impact on me. It’s called  Retelling the Stories of Our Lives: Everyday Narrative Therapy to Draw Inspiration and Transform Experience by David Denborough.

As I read this book so many things about the nature of stories and their role in human life came into sharp focus. Things that I have been working out for years on my own but could only vaguely express in comparison to the clarity I found in this book.

Just having the idea of using story to work through trauma or a crisis of identity validated was a big deal for me. I knew it was possible (because I had done it in my own life) but I was completely unaware that there was a whole subset of psychologists and therapists dedicated to using stories (in a non-religious context) to heal and empower people all over the world.

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To discover this has filled me with a new wellspring of passion for learning all that I can about the power, utility, and essential nature of stories. And of course, sharing those lessons with anyone who cares to read this blog.

That’s why I’m excited to share an exercise from Denborough’s book called The Tree of Life. It’s something literally anyone can do in under an hour and yet the results can positively shape the rest of your life.

Table of Contents

The Tree of Life Concept

The tree of life concept is pretty simple and straightforward. It is a visual metaphor in which a tree represents your life and the various elements that make it up–past, present, and future.

By labeling these parts, you not only begin to discover (or perhaps rediscover) aspects of yourself shaped by the past, but you can then begin to actively cultivate your tree to reflect the kind of person you want to be moving forward.

Just as we learned in my last post that the stories of our lives are the events we choose to highlight and contextualize, in this post we will learn how to discover and highlight alternate paths through our past–which in turn create new horizons in our future.

Follow the instructions below to give it a try for yourself.

The Tree of Life Exercise

The image below is an example of what the tree of life exercise will look like once complete. I was able to complete this rough draft in about an hour. The instructions below will describe how you can create your own.

The first step of course is to draw a tree. I’ve included a video below that should help if you feel lost. However, I should note that–at least for your first draft–it might be helpful to keep it rough. You can always go back later and redraw or touch-up your existing drawing for aesthetics. This round is all about getting the information down.

Next, follow the labeling instructions below. If you can only think of one or two things per section at a time, don’t worry about it. The nature of this exercise is that as you complete each step, it unlocks more memories and ideas for other parts. You can skip around and fill things in at any time. The most helpful thing in the beginning is to just write stuff down and see where it takes you. You might be surprised!

The Compost Heap ( Optional–But Highly Recommended! )

Write down anything in your compost heap that would normally go in the other sections described below but which are now things you no longer want to be defined by.

These are often sources of trauma, abuse, cultural standards of normality/beauty/etc. or anything else that shapes negative thoughts about yourself in your mind. You can write down places, people, problems, experiences. Whatever you need to.

I blurred mine out above, but you can see it has several items. Generally they all have to do with past trauma and damaging relationships I’m trying to let go of. I’ve found that the idea of a compost heap is an extremely helpful way to think about these things. Especially since many of them are not neatly categorized as “all bad”.

There are in fact quite a few life defining lessons I learned through the things that ended up in my compost heap. And like a compost heap is supposed to do, I will eventually break those things down and re-sow the rich parts back into my life.

You can do the same with yours.

Write down where you come from on the roots. This can be your home town, state, country, etc. You could also write down the culture you grew up in, a club or organization that shaped your youth, or a parent/guardian.

Write down the things you choose to do on a weekly basis on the ground. These should not be things you are forced to do, but rather things you have chosen to do for yourself.

Write your skills and values on the trunk. I chose to write my values starting at the base of the trunk going up. I then transitioned into listing my skills. For me this felt like a natural progression from roots to values to skills.

The Branches

Write down your hopes, dreams, and wishes on the branches. These can be personal, communal, or general to all of mankind. Think both long and short term. Spread them around the various branches.

Write down the names of those who are significant to you in a positive way. Your friends, family, pets, heroes, etc.

Write down the legacies that have been passed on to you. You can begin by looking at the names you just wrote on leaves and thinking about the impact they’ve had on you and what they’ve given to you over the years. This can be material, such as an inheritance, but most often this will be attributes such as courage, generosity, kindness, etc.

(Tip: if your tree is pretty crowded by this point, perhaps try drawing some baskets of fruit at the base of your tree and label them accordingly there.)

The Flowers & Seeds

Write down the legacies you wish to leave to others on the flowers and seeds.

(Tip: again, you may wish to de-clutter your drawing by visualizing saplings, baskets of flowers, etc. on which to write these items down.)

Going Further

After completing this exercise you are no doubt swimming with ideas and possibilities. My best advice is that if an idea has occurred to you that will help you process the things you have uncovered in a positive way, do it!

Here are three things that I have chosen to do as a follow up to my initial experience.

I’ve decided to journal about the various elements on my tree. I want to explore the connections between my roots, values, skills, people, etc. in a safe way before sharing it with others in any organized manner. But I do intend to share it with others. And I already know two of the ways in which I plan to.

Writing Letters

Some of the connections are pretty easy for me to determine. I know that I wrote certain values or lessons on my tree and immediately followed them up with the name of a person or group of people. These are the people who have instilled something special in me and I intend to tell them how much that means to me by writing some letters.

Meditation Through Art

I found that the drawing part of this exercise was particularly satisfying and therapeutic in and of itself. I’ve decided to follow this initial exercise up with some more study sketches of trees followed by a series of paintings and collages that express more than mere labels can. I hope to be able to share these with my friends, family, and community in the future too.

Final Thoughts

Even though I’ve spent this whole post talking about how great of an exercise this can be, I know how scary it can feel to take the first steps in claiming the storytelling rights over your life.  It usually means confronting aspects of our past that we might feel are better left unchallenged. And that’s a valid concern.

If you are worried that an exercise like this might stir up a lot of raw emotion or trigger traumatic flashbacks, I would encourage you to complete this exercise with a therapist. Or, at the very least, with a friend or family member who will be there to talk to you and support you through the process.

Regardless of how you choose to complete this exercise, or what personal spins you put on it (which is half the fun!), I’d love to hear how it goes. Feel free to reach out to me about it via any of my social channels, my contact page, or the comments section below.

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59 comments.

I’m a trauma psychologist who is redoing her website and want to included referrals to sites I think might be helpful to people recovering from childhood trauma.

I really like your site and would like to recommend it to my readers. Would you be interested that? If so, I’ll send you the site when it’s presentable.

My license and ethics do not allow me to ask for an affiliate kickback, so I expect nothing from you in return.

All the best,

Victoria Bentley, PsyD

Sure I think that would be great. Reference away :)

Greetings Nathan. I’m about to draw my tree of life! At 58, soon to be 59, I moved from West Africa to work in Bahraini. I’m excited and anxious and on my own. I really want to write a book of my life journey and get it published. Would be good to talk to you about help with getting started….

Hey Donna, so happy for you! I’m a big believer in understanding and recording one’s personal story. Whether that takes the form of a journal, vlog, or something more formal like a book. I wish you the best of luck on that journey. If you would like my help I do do story consulting. I can help you walk through this exercise and several more that will help you structure your life story and plot the events of your life into a coherent narrative. To be clear up-front though, most of my consulting is with big brands and my rates reflect that. I charge between $500 and $1500 per session depending on session length and the amount of prep work that needs to take place beforehand. If that still sounds like something you’re interested in please feel free to get in touch via my contact page :)

If you’re more interested in a DIY approach then I would recommend the following resources:

Watch The Power of Myth on Netflix. It’s an extended interview of Joseph Campbell by Bill Moyers.

Joseph Campbell is THE pioneer of mythic story structure. I’d also recommend his most popular and influential book, The Hero with a Thousand Faces , but for many it’s a bit too academic.

Another great read is The Writer’s Journey by Christopher Vogler . This book is a much more accessible take on Joseph Campbell’s work written specifically for writers.

Finally, if you’re really serious, I’d recommend you read The Seven Basic Plots: Why We Tell Stories by Christopher Booker . I found that the hero’s journey tends to focus on the “quest” plot in most case studies. However, this book is excellent in helping you recognize and create your own variations represented by the other six basic plots.

At the end of my dream this morning an Asian woman I was staring at (bc I thought she was someone else) caught my glance, became excited, and whispered to her companions, “maybe she’s the identity tree”and proceeded to move toward me. I woke up with those words ringing in my ears, and, bc I’ve had enough dreams with final messages that proved to be meaningful, I jumped on google and typed the words “identity tree. Above article was the first (and last) thing I read, and everything about it rings true and right for doing right now. And I’m also beginning work with a new therapist in two hours. 🙏

Hi Nathan. I just came across this today after painting my tree of life. I love the idea & am going to do the exercise. I come from a past of negativity & dysfunction & the l lengthy traumatic (abusive!) marriage. When I looked at my finished tree of life (painted), it spoke to mr about my life. My first thought was, your not completely healed yet. It was as if I were looking at a tangled web. I would love to share it with you. It too was a great exercise. I believe we use colour, like words as a form of expression. My tree, though quite bright, is just not bright enough yet…

Hey Diane, I’m glad that you’ve found some level of healing with this exercise. It’s totally an ongoing process. I’ve done this exercise several times over the years and each time things change a bit, some things come into clearer focus, while others fade further into my past. Hope your self work continues with great results!

Hi Victoria,

my wife, Suzanne would be interested in your childhood trauma work. Her contact info is below – thank you!

What a lovely idea! I’m excited to use this activity in a women’s retreat I’m hosting this weekend. Many thanks for sharing this!

My pleasure! I’d love to hear how it goes for you. Feel free to message me via my contact page: https://nathanbweller.com/contact/

Thank you, I am glad I found your site. It was easy to read and understand. I will be sitting down to draw my own tree and use this technique in my practice. I am definitely adding The Tree of Life to my must read list and subscribing to your blog. I am a clinical social worker and would like to link and or reference your site.

Thanks Jacqueline!

Hey! Thank you for sharing this magical life tree experience, I really enjoyed doing this task, the drawing, the writing, focusing on the people who affect me the most in life. It was a great opportunity to do a zoom in for myself and focus on me especially in today world which is full of distractions. Great page and topic. Thank you for sharing! I really enjoyed it.

Thanks for sharing !!! I’m organizing an event for women and would love to use this for the event.

Hi Nathan, Thanks for much for this post! I’ve offered a Tree of Life workshop to colleagues at my workplace as a team building exercise. I’m getting ready to offer another and always like to google for more inspiration. I’m so glad to find you and your Tree of Life. I’m going to add the idea of a compost heap to my workshop. Thanks so much for your inspiration!!!

That’s awesome! I’m glad you found value here :)

I am looking forward to really delving into this website and it’s resources. The Tree of Life will be a useful tool for rebuilding identity after continuing to move through a lot of recent trauma. Funny, I thought I would’ve been through with trauma after having overcome so much. But it seems right when I get to the top of the mountain, I start to unravel again. I take responsibility for my mistakes. I just hope that I can keep my faith and channel my anger and pain in healthy ways and not toward others be a cause that’s most important to me not to do.

Thanks for sharing that Julie. I’m glad you’ve found this resource helpful. Good luck on your journey!

Loved your article and drawing the tree. I would like to utilize your ideas in a class I will teach. I would like permission to use your article in the class with reference and credit to you and your site.

Hi Marcia, yes please do. Permission granted. Thanks!

Hellos!! Such a lovely and powerful technique. Even I wanted to ask, with your permission may I too use your link and help people discover such a lovely way. I am into sound healing and a reiki master

Yep, share away :)

I am a graduate student. I would like to know if I could use your picture for a class assignment.

Sure, no problem. You can use my sketch above.

Sorry, I meant the picture at the top of the page. It is beautiful. I would love to use the sketch also. Thanks for sharing your exercise; it would be perfect for groups sessions with my students.

Oh ok, well I can’t give permission for you to use my featured image since it’s not mine to begin with. Notice I have a link giving the source credit at the bottom of my own post. However, Unsplash images are free to use in almost every single case. So I’m sure it’s fine. You’ll just need to read the terms for this image and give credit if they require it.

Hi, just saw your tree of life. Found it very useful and interesting. Kindly allow me to use it for a workshop of school leaders. I would start working upon my tree of life.

Sure no problem. You can use it :)

(It’s not mine, but I’ve used it here out of a book–as I’ve stated in the post–so I’d recommend crediting the creator of the exercise and his book.)

I love this book too! Recognising and reframing our stories is so powerful. And this is such a client-centred and gentle approach too. Thanks for sharing.

Thanks Lynne!

Hello, I hope this text finds you doing well. I am a keen learner and as a facilitator to young youths. I found this piece (exercise) very helpful and interesting. It would help all range of people understand themselves to navigate challenges in life, planning way forward and acknowledge for what they receive.

looking forward to learning more from you.

Thanks for stopping by Yeshi!

Thanks for sharing this. It’s an excellent exercise. I celebrated God’s work in my life through the tree.

Glad you liked it Paul!

Hello Nathan, My name is Paul. I love this tree exercise. It is lifegiving! I work for the Canadian Baptists. I would like to share your exercise with our pastors in our spiritual practices guide. Would it be okay if I did that? I can include a link to your webpage in our email as well. Please let me know. Thanks, Paul

Hi Paul! Yes, please feel free to share this exercise with your group. I myself borrowed this from the narrative therapy book Retelling the Stories of our Lives . That might also be a good resource for your group.

You may also wish to acknowledge Ncazelo Ncube-Mlilo, the African women who originated the Tree of Life in support of sufferers of HIV. I believe David Denborough was inspired by her idea. Also David is now the Director of the Dulwich Centre in Adelaide, South Australia. They do some wonderful work with narrative therapy. You might like to add their link your site: (I have no other association with Dulwich other than being a follower.)

Thank you for putting Ncazelo Ncube-Mlilo on my radar. I will have to learn more about her and her work.

Apologies in my previous post, I should have referred to Ncazelo Ncube-Mlilo as South African (not African).

Hi! I find this article and the tree of life exercise very useful. May I also request permission to use this in the book I am writing, of course with the required recognition of the source, should this request be approved. Thank you and may you be given more opportunities to bless others through your works.

I don’t mind if you reference my blog, however I cannot give permission for the tree of life concept as I don’t have that authority.

Hi Nathan, I am a mental health therapist and have added your ideal of the compost heap to the original tree of life exercise, may I copy your directions and site your website?

Yes, feel free to share and link back. However, please give credit for the idea to David Denborough and his book.

Thank you so much, I plan on using this for my patients and I have also cited your name.

Thank you! Please also be sure to credit the original source–the book linked above.

This concept of the TREE OF LIFE is wonderful. I have always been looking at a concept like this one – now I found it. Will translate it into the German language, as I am living in Germany, running an Institute for Humanistic Psychology since 1972, the first one in Germany. Will include this concept in my Orientation Analysis programme of training. It is meant for the counseling situation, not for psychotherapy. I also make use of the East London University papers, which give detailled information on what should be asked to fill into the Tree of Life. Thank you very much.

Glad you found this exercise so helpful! As a Humanist Celebrant I’m interested in learning more about your Institute for Humanistic Psychology.

hello Dr Kluma, can you share what the East London Unv papers are? I also want to use Tree of Life in counseling. thanks,

Hello, Nathan.

Thank you so much for your writing. Very inspiring and informative. I would like to lead an “the Tree of Life” activity in a mentoring session with young adult in South Korea. I am happy to introduce your blog and the book by David Denborough. I found out that the original book was translated into Korean but no longer available unfortunately. I hope this activity ignites deeper discussion between mentees and mentors. Thank you again for your great work.

That is incredible. Good luck!

Hi Nathan my name is Latasha Thomas from Marshall Texas. Been going through things. Find my self going bk in time been through truma. This tree of life do it work. Well I will try it once I get settled in. Some where there Peace.

I’m sorry to hear you’re going through tough times. Hope you find that peace.

Thank you for this exercise. Love it. I´m a MHP in Sweden just finnished my education in Art in therapy. Im so interested in storytelling aswell. Will follow your page.

Thank you! And good luck in your new career!

Hi Nathan, I’m a mental health therapist, I use therapeutic horticulture in my practice as well. Thank you for sharing the details of how this exercise worked for you. It can be use in so many ways! With your permission I’d like to use this, as well as share in my practice. Giving you, your blog and David Denborough credit and backlinks, and referral to the book. I’m glad you decided to change the format of your blog :)

Thank you for the kind words! Yes, please do use it :)

Hello Nathan, as a health instructor, I was challenged by finding an activity on values for an Open Educational Resource (OER) class on stress and health. I found the overall foundation of this activity creative, engaging, and inspiring. I would like to adapt it to meet my objectives for an OER Health Class. Is that okay? I will reference your site and the book mentioned. Please let me know what you think. Thank you for sharing!

Sounds good to me :)

Hope it works well for you and your students!

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Adjunct professor fired by DePaul after optional assignment about Gaza

By Sabrina Franza , Samah Assad , Mikayla Price

Updated on: May 24, 2024 / 8:35 PM CDT / CBS Chicago

CHICAGO (CBS) -- An adjunct professor was fired from her role at DePaul University, after offering an optional assignment to her students in which she asked them to explore the biological and health impacts Israel's war in Gaza has on Palestinians. 

Dr. Anne D'Aquino taught Health 194, Human Pathogens and Defense, across from the now torn-down pro-Palestinian protest encampment on the quad.

"Students were distracted," D'Aquino said. "A lot of them were volunteering at the encampment. A lot of them had friends that were at the encampment." It was a topic that was overall unavoidable, she said. 

Biochemist and professor Dr. D'Aquino was hired on April 1 to teach Health 194. She said this course, in particular, felt like it would allow her to discuss the intersections of humanities and biology. 

According to the syllabus, the course in part explores microbiology research and its relevance to everyday life, current events, as well as microbiology knowledge to "big picture impacts on individuals and communities."

"Taking real-world examples and applying our biology to it, and then communicating that to the general public—since many of the students will be doing that in their profession," D'Aquino said.

D'Aquino said she was terminated for asking students to do just that—offering an optional alternative to the previously-assigned topic of avian flu, and instead focusing on the effects of the war in Gaza.

"The day that I added the optional assignment, there was a large attack on Rafah, and I didn't want that to be left unacknowledged," she said. The optional assignment asked for scientific analysis and critical thinking to understand "the impacts of genocide on human biology."

Optional Assignment by Alex Ortiz on Scribd

On May 7, one day after presenting the optional assignment, she said she received a phone call from the Chair of Health Sciences, Dr. Sarah Connolly, who claimed that DePaul had received student complaints about feeling unsafe in the class and said that it was outside of the "realm of microbiology."  

D'Aquino said that Dr. Connolly noted that "for what it's worth," she had "really good content" on D2L or the online portal where students can access their class content.   

D'Aquino also said her department questioned her word choice—specifically the reference to "genocide" and "ethnic cleansing." CBS 2 asked her why she chose the words she did.

"Because those are the accurate terms," she said, "A lot of rights groups—including the  UN rights group —have demonstrated that there is reasonable evidence to accurately describe this as a genocide."

D'Aquino was referring to a report from the UN Human Rights Council in March, which found "reasonable grounds" that Israel is committing a genocide in Gaza.

"We've heard time and time again from scientists that what's happening in Gaza, and Palestine more broadly, is a public health issue," D'Aquino said. "There isn't clean water. The infrastructure for sewage and sanitation is torn down—it's destroyed. Hospitals are destroyed. Infection is running rampant."

D'Aquino has filed an appeal and believes that the termination violated her academic freedom. In the appeal, she cites eight sources to back up her claim that the assignment was related to her course, including data from the World Health Organization and a publication in the Journal of Medicine, Surgery and Public Health.

Collapsed medical and sanitation infrastructure, severe overcrowding in shelters or encampments, and malnutrition in Gaza are the "perfect storm" for infectious disease outbreaks, according to a study published in PLOS Global Public Health journal, which D'Aquino sourced in her appeal.

"There are long-term consequences of conflict due to the disruption of routine vaccination programs as well as disease surveillance and response systems. Historically, this has manifested as a resurgence in preventable outbreaks," the study said, which also looked to war in Iraq, Syria and Yemen.

In these conditions, there is "no way to mask or separate themselves from each other," D'Aquino said. 

According to the Lancet, another peer-reviewed journal cited in the appeal, the war in Gaza has led to a severe health crisis, especially for children younger than 5. The United Nations has reported more than 179,000 acute respiratory infections and a "25-fold" increase in diarrhea. 

Genocide affects not only infections and epidemiology, but also genetics, which was another part of her course, she said. 

D'Aquino highlighted the 1994 genocide in Rawada. A "first of its kind" study from the University of South Florida found that the Rwandan genocide chemically modified the DNA of victims and victim's children. The program found that the victims had gene modifications that, "genes previously implicated in risk for mental disorders such as PTSD and depression."

On May 8, two days after the optional assignment, D'Aquino received her termination letter, which cited the faculty handbook that states, " faculty are obligated to avoid significant intrusion of material unrelated to the course."

Franza : "Do you feel like there should have been a warning made?"

D'Aquino:  "Yes."

Franza:  "Was this a way of incorporating politics into your class?

D'Aquino : "No, but I also feel like I wasn't purposely trying to incorporate politics. I was really trying to make sure my classroom—I was, incorporating the diversity, equity and inclusion that I prioritize in all of my teaching; making sure that students are heard and seen. However, it's important to note that biologists, scientists, and anybody in any field—we don't exist in bubbles."

D'Aquino said only one student expressed concerns directly to her—a conversation they had openly with the rest of the class.

"I did have an outpouring of support from students who appreciated the assignment," D'Aquino said.  

She said she is disappointed and confused and said that it is still unclear to her what she did wrong.

"This is a reprimand towards me that's also sending a message to other faculty that to not speak up about this; that Palestine is not a topic of conversation in the classroom - and that you will be removed," she said. "I also think it's a message to students, too, that if your faculty; your staff can't speak about it, then you can't either."

CBS 2 reached out to DePaul about its investigation – if they asked others in the class about their experiences. The university did not answer that part of CBS 2's question, but did issue the following statement.

"DePaul University is committed to academic freedom and free speech. We are also unwavering in our commitment to ensure that no acts of hatred, discrimination, harassment, Islamophobia, or antisemitism are tolerated in our community.  " On May 8, we received multiple complaints from students regarding an assignment in Health 194, Human Pathogens and Defense . The course introduces students to the diverse microorganisms that cause significant disease within the human population. The students expressed significant concern about the introduction of political matters into the class. We investigated the matter, spoke with the faculty member, and found it had negatively affected the learning environment. The class now has a new instructor, and the faculty member has been released from their appointment as a part-time faculty member at DePaul University.   "DePaul's Faculty Handbook, consistent with the American Association of University Professors' 1940 Statement of Principles on Academic Freedom and Tenure, states that faculty are obligated to avoid significant intrusion of material unrelated to the course, to avoid any coercion of the judgment or conscience of students, to uphold the scholarly standards of one's academic discipline, and to respect the rights of other persons to hold and express different intellectual positions. "Additionally, all faculty – including adjunct faculty – have rights under our Faculty Handbook, including the right to appeal a decision on the grounds that it violated the faculty member's academic freedom. Such appeals are heard by an Appeals Board comprised of three tenured faculty members. For adjunct faculty, the process is expedited."

D'Aquino hopes to get back to teaching the same students she left mid-quarter.

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Royce Lewis is Starting Rehab Assignment at Highest Possible Level

T he Minnesota Twins lineup is starting to get healthy, and it’s on the verge of getting its biggest jolt of healthy talent yet. Royce Lewis is starting a rehab assignment on Friday.

Not down in Florida, though, or somewhere else hours away from the Twin Cities. The Twins’ rising superstar talent is joining the St. Paul Saints, right across the river… though he will have to fly to Buffalo to meet up with them.

A quick glance at Royce Lewis’ 2024 stat line will indicate two things. One, he played in just a single game. Two, his impact was felt in that single appearance.

On Opening Day, Lewis blasted a home run in the first at bat. Then, he followed that up with a base hit in his second at bat. Unfortunately, he pulled up lame between 2nd and 3rd base. He’s been out ever since.

Lewis was diagnosed with a severe quad strain, and initial timelines for his return were murky, at best. Having missed the Minnesota Twins last 48 games, he will look to quickly acclimate with the St. Paul Saints, so he can return to the big league lineup.

Related: Mitch Garver Tells Royce Lewis to Only Run 85% So He Can Stay on Field for Minnesota Twins

In his absence, it has been a combination of Jose Miranda, Willi Castro, and Kyle Farmer that have assumed duties at the hot corner. Of them, Castro has fared the best offensively with a 116 OPS+.

Miranda currently owns a 113 OPS+ and has shown that he was clearly bothered by the shoulder injury that sent him for offseason surgery last year.

How do Minnesota Twins make room for Royce Lewis?

When Lewis returns, the front office will have an interesting decision to make as far as roster construction goes. Miranda could slide across the diamond and play first, a position he is worse at.

Castro will primarily fill in as a utility outfielder. That leaves Farmer as something of the odd man out. He was kept on a $6.3 million arbitration deal this offseason, and has tallied a putrid 53 OPS+ in 39 games.

Parting with the veteran clubhouse leader would be tough from a chemistry perspective, but he has clearly been the worst performer.

Royce Lewis will return to a Twins lineup that he highlighted during an exciting 2023 postseason run. In the playoffs last year, even while dealing with another injury, Lewis smacked four home runs and posted a 1.119 OPS. It was his presence that tormented both the Houston Astros and Toronto Blue Jays into submission.

The time frame is eerily similar this time around, and with St. Paul scheduled for two weeks in upstate New York (split between Buffalo and Rochester), the Twins could presumably have their star return home to Target Field joining them against the Kansas City Royals next week.

As they look to chase down the Cleveland Guardians, having and keeping a healthy Royce Lewis will be vital to their success.

Want to see more stories like this? Follow Minnesota Sports Fan on MSN to see more of our exclusive content.

More must-reads:

• Manuel Margot Stinks but Twins May Still Win That Trade, Thanks to Rayne Doncon
• Different Minnesota Twins Top Prospect Flies Up ESPN Rankings in Latest Update
• Players Only Meeting Ended the Twins’ Losing Streak and Saved the Rally Sausage

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Out of the Centre

Savvino-storozhevsky monastery and museum.

Zvenigorod's most famous sight is the Savvino-Storozhevsky Monastery, which was founded in 1398 by the monk Savva from the Troitse-Sergieva Lavra, at the invitation and with the support of Prince Yury Dmitrievich of Zvenigorod. Savva was later canonised as St Sabbas (Savva) of Storozhev. The monastery late flourished under the reign of Tsar Alexis, who chose the monastery as his family church and often went on pilgrimage there and made lots of donations to it. Most of the monastery’s buildings date from this time. The monastery is heavily fortified with thick walls and six towers, the most impressive of which is the Krasny Tower which also serves as the eastern entrance. The monastery was closed in 1918 and only reopened in 1995. In 1998 Patriarch Alexius II took part in a service to return the relics of St Sabbas to the monastery. Today the monastery has the status of a stauropegic monastery, which is second in status to a lavra. In addition to being a working monastery, it also holds the Zvenigorod Historical, Architectural and Art Museum.

Belfry and Neighbouring Churches

Located near the main entrance is the monastery's belfry which is perhaps the calling card of the monastery due to its uniqueness. It was built in the 1650s and the St Sergius of Radonezh’s Church was opened on the middle tier in the mid-17th century, although it was originally dedicated to the Trinity. The belfry's 35-tonne Great Bladgovestny Bell fell in 1941 and was only restored and returned in 2003. Attached to the belfry is a large refectory and the Transfiguration Church, both of which were built on the orders of Tsar Alexis in the 1650s.  

To the left of the belfry is another, smaller, refectory which is attached to the Trinity Gate-Church, which was also constructed in the 1650s on the orders of Tsar Alexis who made it his own family church. The church is elaborately decorated with colourful trims and underneath the archway is a beautiful 19th century fresco.

Nativity of Virgin Mary Cathedral

The Nativity of Virgin Mary Cathedral is the oldest building in the monastery and among the oldest buildings in the Moscow Region. It was built between 1404 and 1405 during the lifetime of St Sabbas and using the funds of Prince Yury of Zvenigorod. The white-stone cathedral is a standard four-pillar design with a single golden dome. After the death of St Sabbas he was interred in the cathedral and a new altar dedicated to him was added.

Under the reign of Tsar Alexis the cathedral was decorated with frescoes by Stepan Ryazanets, some of which remain today. Tsar Alexis also presented the cathedral with a five-tier iconostasis, the top row of icons have been preserved.

Tsaritsa's Chambers

The Nativity of Virgin Mary Cathedral is located between the Tsaritsa's Chambers of the left and the Palace of Tsar Alexis on the right. The Tsaritsa's Chambers were built in the mid-17th century for the wife of Tsar Alexey - Tsaritsa Maria Ilinichna Miloskavskaya. The design of the building is influenced by the ancient Russian architectural style. Is prettier than the Tsar's chambers opposite, being red in colour with elaborately decorated window frames and entrance.

At present the Tsaritsa's Chambers houses the Zvenigorod Historical, Architectural and Art Museum. Among its displays is an accurate recreation of the interior of a noble lady's chambers including furniture, decorations and a decorated tiled oven, and an exhibition on the history of Zvenigorod and the monastery.

Palace of Tsar Alexis

The Palace of Tsar Alexis was built in the 1650s and is now one of the best surviving examples of non-religious architecture of that era. It was built especially for Tsar Alexis who often visited the monastery on religious pilgrimages. Its most striking feature is its pretty row of nine chimney spouts which resemble towers.

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635th Anti-Aircraft Missile Regiment

635-й зенитно-ракетный полк

Military Unit: 86646

Activated 1953 in Stepanshchino, Moscow Oblast - initially as the 1945th Anti-Aircraft Artillery Regiment for Special Use and from 1955 as the 635th Anti-Aircraft Missile Regiment for Special Use.

1953 to 1984 equipped with 60 S-25 (SA-1) launchers:

• Launch area: 55 15 43N, 38 32 13E (US designation: Moscow SAM site E14-1)
• Support area: 55 16 50N, 38 32 28E
• Guidance area: 55 16 31N, 38 30 38E

1984 converted to the S-300PT (SA-10) with three independent battalions:

• 1st independent Anti-Aircraft Missile Battalion (Bessonovo, Moscow Oblast) - 55 09 34N, 38 22 26E
• 2nd independent Anti-Aircraft Missile Battalion and HQ (Stepanshchino, Moscow Oblast) - 55 15 31N, 38 32 23E
• 3rd independent Anti-Aircraft Missile Battalion (Shcherbovo, Moscow Oblast) - 55 22 32N, 38 43 33E

Disbanded 1.5.98.

Subordination:

• 1st Special Air Defence Corps , 1953 - 1.6.88
• 86th Air Defence Division , 1.6.88 - 1.10.94
• 86th Air Defence Brigade , 1.10.94 - 1.10.95
• 86th Air Defence Division , 1.10.95 - 1.5.98