EXECUTIVE SUMMARY

Some patients suffering from a serious illness or injury may suffer more than others. They express fear that they will never recover and can no longer enjoy their lives. Case managers can learn skills to help them change these concerns through developing a functional life story that teaches optimism.

  • Using narrative theory, case managers can teach patients how to talk to themselves in ways that will improve their outlook.
  • The main idea is to provide validation to the patient’s story and help the patient see things a little more positively.
  • Case managers can help patients shift from victims to survivors, or even thrivers.

Each time a case manager visits with a patient, the patient’s story about his or her illness is developed. This is true when patients are in despair or are feeling anxious and fearful — or the patient’s story might include optimism and hope.

What case managers often do not realize is that they can help patients shape these stories into more hopeful and positive narratives.

“The idea of narrative theory is addressing the way we talk to ourselves and others about ourselves and our experiences,” says Janice Gasker, DSW, LCSW, ACSW, professor, bachelor of social work program director, and director of the department of social work at Kutztown University in Kutztown, PA.

Gasker provides this example: “You get hit by a car and go into the hospital. You can talk about how awful your life is with the example of being hit by a car. Or you can talk about how great your life used to be, and then you got hit by a car,” she explains. “Or you can talk about how you were very busy in your life, and this accident has forced you to be still and think and be mindful about your life and relationships with others.”

In other words, the car accident and injury were a forced rest — not a tragedy or example of the universe thwarting one’s life plans.

Case managers should know that as these stories are told and developed, their shape and how people react to their illnesses, injuries, or circumstances are developed through their interactions with others, Gasker notes.

“It’s like you walk into a room and you say, ‘Is it cold in here? Or is it just me?’” she says. “We’re constantly doing that, checking with other people to see if they’re experiencing things the same way we are.”

In the car accident example, if the injured person called a friend to report the accident, and the friend’s reaction was “That’s terrible! Your life is over,” then the injured person will feel worse.

But if someone, such as a case manager, instead says, “Tell me more about how you feel about that” and helps the person get to a place where he or she can look at the injury in a more positive way, it will help the patient get to a better mindset, Gasker says.

“The idea is to create a story about either your whole life or small bits of your life that leaves you with the conclusion that you’re a healthy, happy person,” she says. “One thing that’s attractive about this is it’s something you can use in your own life, sharing elements of the theory with people you work with.”

Gasker sees these life stories as helping people move from identifying as victims to identifying as survivors — or as thrivers.

Survivors see themselves as overcoming adversity through resilience. Thrivers are people who move to new and better levels in their lives, partly because of how they dealt with adversity, she says.

Case managers and others can have profound impact on helping patients survive and thrive.

“There is one abuse story where a child was constantly being punished in inappropriate ways; one thing he had to do was stand on the stairs for extended periods of time,” Gasker says. “What was most troubling to him was there was no acknowledgement that the abuse was happening. No one said, ‘That’s horrible’ or ‘You can deal with it.’”

It was as though the boy’s abuse wasn’t happening. He was not able to begin creating a positive story because he received no validation.

But then something happened: “The family had a housecleaner who would walk by him and make eye contact with him,” Gasker says. “She would acknowledge that he was suffering, and that one small piece of light was able to help him talk about it, years later, that his life was not horrible.”

This is what case managers can do for patients: They can acknowledge that they heard the patient’s sad story. They do not have to say they believe the patient’s version of events, only show that they care enough to listen, she says. (See story in this issue on how to hear patients’ stories.)

“The most important piece of this is letting a person know that you heard their story and acknowledge the way they might be feeling,” Gasker says. “You can do more than that. But you can also stop there, and you would have made a great intervention because they need that validation before they can go on to change their story and have a survivor mindset.”