Sarah A. Fortune and Ron R. Phillips
Young people do not always believe that mental health services are the thing that will make their life better. Treatment retention for non-hospitalized adolescents is generally below 50 per cent and can be as low as 20 per cent (Spirito, Plummer, Gispert, and Levy, 1992). The relatively low rates of treatment engagement among this population suggests that recommended treatment, or the way to which it is delivered, fails to match the resources or needs of adolescents and their families. The research literature on interventions to improve engagement in the treatment of children, adolescents and their families in mental health services is limited because high-risk young people are frequently excluded from clinical trials due to ethical and litigation concerns (Rudd, Joiner, Jobes, & King, 1999).
Therapeutic Storytelling Intervention (TSI) is an innovative group therapy technique using storytelling. TSI is based on the book Gem of the First Water (Phillips, 1989) and is being used in a community child and adolescent mental health service in Auckland, New Zealand. TSI was written and developed by family therapist and educator, Ron Phillips. The story telling and questions are manualised. The TSI process is dependant on the storytelling, the questions and the interrelationship between the facilitator and participants.
TSI follows the adventures of a peer/hero facing common adolescent struggles such as the consequences of poor impulse control, making connections between feelings and behaviors, grief, drugs and alcohol, peer relationships and parental relationships.
The TSI story is usually delivered in a group setting over a period of 16 sessions of 45-60 minutes duration. The clinician/group leader tells the story based on a chapter/s of Gem of the First Water which takes approximately 25 minutes. This is followed by a series of questions focusing on the characters challenges and behaviour in that segment of the story. After a period of several weeks, the external focus on characters of the story is gradually shifted towards focusing on the group members themselves. This is achieved by linking their behaviour with that of the character. The speed at which this transition is made is flexible and allows the clinician to employ a range of strategies that prevent the group process from stagnating or being 'hijacks' by disruptive group members.
This method of using storytelling as a psychotherapeutic tool has several points of difference when compared with traditional approaches to groups. For instance, there are only two rules in the group (1) "I wouldn't dream of talking when you are, and vice versa" and (2) "be honest with yourself and the process – if you don't want to say something just pass". Having only two rules contrasts with spending long periods of time generating and contracting rules for the group.
The second main difference is the use of externalized material for group discussion. This is based on the experience that when working with multi-problem children and adolescents, encouraging them to reveal and discuss their problems is often met with high levels of resistance and high drop out rates, particularly for boys. This may in part be due to the fact that during this developmental phased many youngsters place premium importance on being unremarkable, normal and the same as everyone else. The use of storytelling as the basis of material for the group provides safety for oppositional, anxious or depressed adolescents and prevents the disintegration of the group due to a lack of materiel for discussion within a group session.
The telling of the story creates an atmosphere where the listener will slip into an altered state of consciousness. The storyteller uses verbal and non-verbal cues to indicate that they are ready to start telling the next segment of a story. Sighs, shifting of body positions, stretches, and restful postures are experienced at the on-set of stories.
The storyteller is usually sitting when telling a story, however, even in this passive position they can convey much through the use of their body language. Shoulders, hands, feet, arms can all be used to convey messages and give the listener more eidetic information to incorporate into their mind picture. During this state of rapport the storyteller/therapist intersperses positive comments about the group and individuals. For example "Hey Leslie, I really think your hair is terrific!" or "you are really a nice group of people, I really like the way you like me". The use of predictable, positive messages is an important way to sow positive self-fulfilling prophesies in the listeners. Children and adolescents who have taken the TSI journey have approached the facilitator at a later time, and said things like "I just kept thinking about the rainbow."
TSI has been used in an outpatient child and adolescent mental health service in Auckland for a number of years. Tracking of 347 children and adolescents who attended TSI group therapy suggests that this approach goes some way to address the issue of engagement with treatment. Of the children and adolescents who were enrolled in TSI groups between 1997 and 2001, three out of every five clients attended more than 60 per cent of sessions and were described as 'graduates'. The rates of engagement are the same for males and females. Average attendance among clients who commenced TSI was 65 per cent across the period 1997-2001. Among graduates average attendance rates were between 86-89 per cent, which allows for once session missed due to illness and another to attend a school camp or similar. Based on this data a larger randomized control trial is in the process of development.
A more recent development has been the use of TSI with family groups. The use of stories with families who are facing multiple problems and have few psychological and physical resources appears to provide them with a platform for change rather than relying solely on their depleted resources. The use of TSI with families also fits well with the family systems focus of the clinic. The use of TSI with some families generally leads to a reduction in symptomatic behaviour which allows therapy to proceed without too much disruption. Used solely, or in combination with the adolescent attending group TSI, the family also tends to feel reassured that the therapists are taking their definition of the problem seriously and that 'something is being done'. This approach also facilitates treatment of parents who are resistant to attending 'counselling' because they perceive their child, rather than themselves, to have 'the problem'.
The following case study demonstrates these important elements. Two perspectives on the experience of TSI are presented. The family perspective is outlined below based on a letter written by the mother of the family.
Over the last year, my family has been on an important journey. My family consists of myself, Sam (my husband), and our four children, Grant (14), Briar (12), Joshua (11), and Lance (4). One year ago in utter desperation I phoned the clinic. The whole family was in crisis, my kids behaviour had disintegrated; we were no longer welcome at some of my friend's homes.
My former husband was a workaholic who accepted no responsibility in the rearing of these children. He would leave for work at around 3:30am every morning (even though his job was a salaried one and didn't need to put these hours in) and would not come home until around 10pm. The house was never clean enough, the kids hadn't been 'programmed' to behave and they were 'dimbos' (his word). I started to find solace in other means; I became extremely overweight and fell into some of the problems my parents had suffered from, gambling in particular.
I had started seeking professional help for Grant including a residential school. Nothing was working. On our last session, Briar threw one amazing temper tantrum where she actually attacked our counselor. The next day I received a call saying they didn't think I needed to see them again. I was very cynical about how we could be helped but I was desperate. On our first visit, me and the children met Janice Beazley and Ron Phillips. Ron told me that if I was to begin making my family heal, family counseling with TSI was recommended. The only stipulation was that we had to be prepared to do this as a family unit and that to make our children right, Sam and I had to be prepared to commit ourselves to the programmed and to start from the top.
When the sessions began, it was quite an experience. Sam and I wouldn't look at each other, we were still blaming each other for ending up here, and our children were literally trying to smash each other over. They were swearing, while verbally and physically attacking each other. Joshua was very angry about having been made to be there. He thought it unfair, as he hadn't done anything wrong. I was of the opinion we wouldn't be invited back. The story was quite enthralling; my kids looked forward to coming. They had actually started being able to sit in the room together and communicate with each other. The story was mind-provoking; we could all relate it to ourselves. It was a journey as a family, but also we were all taking our own journey alone. I so related to the journey. It broke down my defences and had my eyes opened to myself (no mean feat when I had spent nearly 40 years not daring to open those eyes). I have lost over 30 kgs, and have gone from a size 24 to a size 12. People have been flocking around me wanting to know what my secret is, what diet o pills I have been taking. My answer is loud and clear, a good dose of TSI. Sam has gone from a workaholic with no bonds with his children and no life outside of work, to a parent who has his children most weekends. Grant has started to feel good about himself and even smiles.
Sam and I have begun to forgive each other and get on with our lives. TSI has done its job and now it's up to us to carry this on. I read my copy on a regular basis and encourage the kids to do so as well. The kids and even myself, now use a lot of the terminology from the journey. This will stay with us for the rest of our lives. It has become part of our lives.
Through this programme, a family has been literally saved.
The therapists recalled a particularly important session with this family which occurred about five sessions into the therapeutic journey. Every week one child in the family would arrive at the clinic extremely oppositional and this behaviour would escalate as the sessions were due to commence. This particular week it was Joshua's 'turn'. He 'went nuts' in the waiting room yelling that he wasn't coming to the f****** sessions, and that it was all b******* adding that every person in the room was stupid and he hated them for making him miss school. Joshua's parents remained paralyzed, but with encouragement the family moved into the therapy room, leaving the door open for Joshua to join them when he wanted.
Ron began telling the story of 'The Quick Sands of Denial' where the boy is stuck in the quicksand. The Frogman tells him it is his anger and behaviour that are seeking him stuck, to which the boy responds with the typical denial "I'm not angry". The defiant denial lasts for three days and three nights. The boy is still stuck and then the Frogman says to the boy "stay stuck boy, I've got time". The paradox leads the boy to remember what a wise man said to him earlier in the journey "to be honest with yourself".
Joshua remained in the hall yelling and shouting, but soon settled down and began listening. When the questions began "what's keeping the boy stuck?", "how long do you think he can stay stuck?" Joshua started chirping in from the corridor. Joshua then entered the room, pointed his finger at Ron "I'm angry at you because you made me miss going to the airport" (on a class trip). Even though Joshua had been yelling this message at the top of his lungs, somehow no one in the family had 'heard' that he may actually have a legitimate reason to be angry nor were they able to consider they may have a role in helping their son manage this situation. Joshua and his parents agreed in the session that although they wanted therapy to be a priority, if the children had something really important on at school, they would not have to miss that in the future. This session marked a significant reduction in the opposition to participating in therapy and rebellious attempts to disrupt the sessions.
TSI incorporates the age-old tradition of storytelling with contemporary psychotherapeutic approaches. Many clients and their families do not share mental health professional views that ongoing follow-up is beneficial to them reflected in compliance rates as low as 20-30 per cent with outpatient treatment. TSI has been used in our clinic with children and adolescents with severe mental health disorders and high rates of co-morbidity. Two out of three clients are retained in TSI in an outpatient group treatment programme which is significantly higher than many similar programmes. TSI is equally successful in retaining boys and girls in treatment.
The use of storytelling as a psychotherapist technique is critical in working with multi-problem children, adolescents and their families. Frequently oppositional children and adolescents and those who have 'failed' previous treatment programmes strongly resist efforts to utilize their 'issues' as material upon which the group session is dependent. Such clients may act out in order to disrupt the group and/or terminate their inclusion (MacNair & Corazzini, 1994; Nimmanheminda, 1997). The use of stories precludes the destruction of the group by providing 'safe', externalized material for group discussion.
The high rate of retention is of particular interest to clinicians who are attempting to generate creative ways of treating children and adolescents in community mental health settings. Furthermore, TSI can be used both with groups of young people and family groups and therefore creates a significant opportunity to offer treatment to a large number of clients with relatively low levels of clinical input hours.