The mechanism of storymaking - A Grounded Theory study of the 6-Part Story Method (2006 The Arts in Psychotherapy), ...
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The Arts in Psychotherapy xxx (2006) xxx–xxx
The mechanism of storymaking: A Grounded
Theory study of the 6-Part Story Method
Kim Dent-Brown
a
,
∗
, Michael Wang
b
a
University of Sheffield and Humber Mental Health Teaching NHS Trust, UK
b
University of Leicester, UK
Abstract
Forty-nine participants (24 community mental health clinicians and 25 users of their services) followed a structured set of
instructions to create and tell a fictional story. They were then asked how far the fictional story communicated something about their
own life situation, and for their subjective reactions to the storymaking process. Their responses to these questions were analysed
using Grounded Theory methods to develop a theory of how such a fictional storymaking process might work in a therapeutic setting.
The majority of participants described a process of increasing and often surprising relevance with the release of strong emotions.
This was accompanied by an increasingly close identification with an initially distant main character in the story. For a minority of
participants this close identification never happened and they experienced much fewer emotions and described their stories as less
personally relevant. The Grounded Theory analysis proposes that the theme of the development of the story over time is central,
and that the responses of both groups can be understood via this model. The proposed model is discussed in relation to existing
literature on storytelling in therapy and possible applications of the method are discussed.
© 2006 Elsevier Inc. All rights reserved.
Keywords:
Storymaking; 6-Part Story; Projective tool; Qualitative research; Personality disorder; Dramatherapy
We undertook this study as part of a wider validation and reliability study of a storymaking approach called the 6-Part
Story Method (6PSM). The quantitative aspects of this study have been reported elsewhere (
Dent-Brown & Wang,
2004a, 2004b
). In addition to these quantitative elements, we wanted to use a qualitative analysis of participants’
reactions to address the question: “What is the mechanism of action for a fictional storymaking method such as the
6PSM when used as part of a psychotherapy assessment?”
Projective approaches like the 6PSM have a long history, and more than 60 years ago the instructions for the
Thematic Apperception Test (
Murray, 1943
) included suggestions that the card images used might form the basis
of a story structure. Validation of the TAT and other approaches has, however, generally been by comparing the
interpretations provided by professional raters with concurrent data such as the diagnoses of the participants. Validation
of the projective approach through the direct accounts of the participants has not been the usual practice. In this study
we sought to use these first-person accounts to answer the question above.
Storymaking approaches are a subset of narrative approaches to therapy (
McLeod, 1997
). Most other narra-
tive approaches concentrate on autobiographical, first-person accounts that resemble a historical account of actual
The work in this article was carried out in the Psychotherapy Department, Humber Mental Health NHS Trust, Skidby House, Willerby Hill,
Willerby HU10 6ED, United Kingdom.
∗
Correspondence to: ScHARR, University of Sheffield Regent Court, 30 Regent Street, Sheffield S1 4DA, UK. Fax: +44 1482 617501.
E-mail address:
(K. Dent-Brown).
0197-4556/$ – see front matter © 2006 Elsevier Inc. All rights reserved.
doi:
AIP-775; No. of Pages 15
2
K. Dent-Brown, M. Wang / The Arts in Psychotherapy xxx (2006) xxx–xxx
events—however, imperfectly remembered or recounted. Storymaking on the other hand implies fictional, third-person
accounts (
Dwivedi, 1997
) which are a metaphor for, rather than an immediate description of, actual events. Another
difference is that narrative methods concentrate on a narrative produced by the patient. Storymaking on the other hand
may involve either stories produced by the patient or, just as frequently, pre-existing stories (such as folk or fairy tales)
that are used as stimulus material to prompt further responses from the patient (
Gersie, 1991, 1992
;
Gersie & King,
1990
).
The 6-Part Story Method
The 6PSM, described by
Lahad and Ayalon (1993)
, is an example of the first type of storymaking activity: one in
which the patient creates a story which is then used in therapy. The method is widely taught to dramatherapists training
in the UK and other countries, and was devised by Israeli psychologists Ofra Ayalon and Mooli Lahad. They developed
it from a technique learned from Anglo-Dutch dramatherapist
Alida Gersie (2002)
, who had in turn been influenced
by the French semiologist
Algirdas Greimas (1961)
. Greimas had used the work of
Propp (1928/1968)
to produce a
narrative structure which he believed underlay all stories, and comprised a skeleton of six ever-present elements. Gersie
took these elements and proposed using them as the basis for newly constructed stories. The six elements as refined
by Lahad and Ayalon are:
1. A main character in some setting
2. A task for the main character
3. Obstacles in the main character’s way
4. Things that help the main character
5. The climax or main action of the story
6. The consequences or aftermath of the story
In the 6PSM the participant first follows spoken step-by-step instructions to draw a series of six pictures illustrating
the above elements. It is suggested that they pick a main character as far away as possible from themselves and their
own situation. The participant is then invited to tell the story through, without interruption, as fully as possible. Finally
the participant is asked questions about each of the six elements or the story as a whole and further discussion of the
story and its relevance ensues. An example of 6-part stories produced by two mental health team patients is included
in
Appendix A
.
The aim of the technique is “to assist the individual to reach self-awareness and improve external and internal
communication” and it has the objective of “develop[ing] contact with the client based on the therapist’s understanding
of the client’s ‘internal language’.” (
Lahad, 1992, p. 156
) The research described here was undertaken to assess whether
and how the 6PSM actually achieves these stated goals.
Method
Ethical considerations
This study was approved by the Local Research Ethics Committee. Clinician participants were mental health
professionals who responded to a general invitation to participate. Patient participants were approached by their own
clinicians on the basis of their assessed ability to cope with the potentially powerful material evoked by the method.
Participants were free to withdraw at any time and all gave their written consent to the process, including the possibility
that extracts of their contributions would be published in due course. No identifying material is reproduced here, and
pseudonyms have been used.
Characteristics of participants
We recruited clinician participants from Community Mental Health Teams (CMHTs) in a mental health Trust of
the UK’s National Health Service (NHS). Twenty-four clinicians participated, most of whom recruited in their turn
one or two patients from their caseload for a total of 25 patient participants. Patients were purposively selected to
K. Dent-Brown, M. Wang / The Arts in Psychotherapy xxx (2006) xxx–xxx
3
include some (
n
= 12) with a diagnosis of Borderline Personality Disorder (BPD) and some without this diagnosis
(
n
= 11). Two patients participated but declined to take the diagnostic interview to establish the BPD diagnosis, and
three further patients initially consented to participate but later withdrew. There were more women than men among
both the clinicians (20:4) and the patients (16:9). Patient participants were working-age adults (mean age 35.5 years,
standard deviation 9.7 years) who were not suffering from an acute psychotic disorder.
This group of participants is diverse and heterogeneous: clinicians and patients, those with a diagnosis of BPD and
those without. Part of the reason for this was the pragmatic one that the main part of this study, reported elsewhere (
Dent-
Brown & Wang, 2004a, 2004b
) was the quantitative comparison of stories from these groups. But this heterogeneity
also allowed for comparisons of the storymaking process as perceived by the different groups. A study of a more
homogeneous group (say, clinicians alone) would not be able to distinguish between features of the process common
to all storymakers, and features more commonly experienced by the subgroup of clinicians alone.
Data gathering
I (K.D.B.) taught clinicians the method for eliciting the 6PSM in groups of two or three. As part of this process each
clinician produced their own 6-part story, which was tape recorded and transcribed. This transcription included the
story itself and responses to some scripted questions about the participant’s reaction to the storymaking process. These
questions are reproduced in
Appendix B
. Clinicians in their turn recruited patients from their own caseload, selected
randomly from those with and without a probable BPD diagnosis. The clinicians elicited 6-part stories from their own
patients, also including the questions about reactions to the process. These were also tape recorded and transcribed.
In contrast to the clinicians, who recorded just one of their own stories, most patient participants recorded two stories
with a 1-month gap between recordings. Altogether 67 usable tapes were recorded and transcribed. For this analysis I
removed the sections of the transcripts which involved the telling and discussing of the stories and kept those sections
of the transcripts that dealt with participants’ reactions to and reflections on the process. These were then entered into
the NUD*IST N4 computer assisted qualitative data analysis software (
Richards & Richards, 1991
). Between them
these documents contained 10,400 words of transcribed text from the 49 participants.
In order to confirm the clinicians’ estimation of the presence of a BPD diagnosis, I interviewed all but two patient
participants using the Structured Clinical Interview for DSM-IV Axis II, known as SCID-II (
First, Gibbon, Spitzer,
Williams, & Benjamin, 1997
). No concurrent data for Axis I complaints were gathered.
Data analysis
The method of analysis I used was based on the Grounded Theory method first developed by
Glaser and Strauss
(1967)
. The detailed procedure I followed was that described by
Strauss and Corbin (1998)
. The aim of the Grounded
Theory approach is to use rich data (such as interview transcripts about a topic) to progressively develop a theory
about that topic. At each stage the emerging theory is checked against the original interviews to ensure that it does
not become mere speculation and remains grounded in the original data. The process of theory development starts
with the identification of as many points as possible of potential interest (concepts), which are then gathered together
(as categories). The theory is developed by examining the properties of categories and the relationships between
them.
This was not a classic, full Grounded Theory study as described by
Strauss and Corbin (1998)
as it lacked some of
the features this would require. In a full study for example, questions would not be scripted and asked in the same way
of every participant, but as part of a more flexible conversation between participant and researcher. However, most of
the text I analysed had been gathered by the clinicians following a fixed script, from which they were under instructions
not to deviate.
Another difference was that all the data were collected before analysis began; in a formal Grounded Theory study
early results would influence the questions to be asked of later participants so that hypotheses could be generated and
tested as the study progressed. Emerging theories might be tested by further theoretical sampling to target a group of
interest.
A third difference arose from the decision to carry out a mixed methodology (qualitative and quantitative) study.
Planning for the quantitative elements of the study meant that I carried out some preliminary literature searching and
hypothesis generation early in the process, much sooner than would usually be the case in a pure qualitative study.
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K. Dent-Brown, M. Wang / The Arts in Psychotherapy xxx (2006) xxx–xxx
Some key features of Grounded Theory were retained, however. The first was that of constant comparison; this
means that throughout the process of analysis the raw text data were retained as a primary check on any more elaborate
theorising which arose from it. For example, if I developed a tentative theory in response to a particular piece of text,
then I examined the rest of the text to see whether that theory was supported by the data or not. In the latter case the
observation was not discarded, but rather was retained as an exception needing explanation or a limit case defining the
boundaries of a phenomenon.
The second feature was that of data saturation; this relates to the problem in qualitative analysis of knowing when to
stop gathering data. Being unable to use quantitative methods of sample size selection, the idea is that data are collected
and coded (see below for a description of coding) until no new codes emerge. At this point saturation is said to have
been reached and data collection can stop. In this study I stopped data collection when all participants had been tape
recorded, but the principle of saturation was still observed. I coded text progressively and towards the end of coding
the number of new codes being added dwindled to nothing, while old codes were simply being added to repetitive,
similar data. I took this to demonstrate that saturation had been achieved and that nothing would have been gained by
recruiting and interviewing more participants.
Thirdly, I adhered to the process of open and axial coding to produce concepts and categories, each with their own
properties and dimensions, as far as possible. The coding process is described in detail in the next section.
Results
Identification of concepts
I read through entire text of the transcripts under consideration, looking for concepts that might address the central
question “How do participants experience the 6PSM process?” When I found a concept in the text I coded and named
it. The concept might be embodied in a single word, but the whole text-unit containing the word was coded. For the
purposes of this analysis, each separate line of text in the NUD*IST display was treated as one text-unit. This comprised
a maximum of 70 characters (including spaces). I gave concepts names that were as memorable and illustrative of the
concept as possible, so that later on in the process if the same concept were illustrated a second time in a subsequent
text-unit it could be marked with the previously established code.
As an example of this, the following eight text-units from the interview with Clinician 20 are shown along with
their codes (
Table 1
).
By the end of the first pass of the coding process, approximately 2100 separate codes had been applied to text-units,
comprising about 75 different concepts. In practice I made several passes, in case categories that only emerged towards
the end of the analysis might be useful to code earlier text-units.
Amalgamation of concepts into categories
The 75 initial concepts (referred to in NUD*IST as nodes) were initially unstructured and in no relationship to one
another. The next step was to gather these concepts into categories on the basis of their similarities with or differences
Table 1
Example of coding text units
Text-unit
Codes
1
...
it felt OK at the end even though I did feel a bit
A
2 exposed. I suppose how much it relates to you, that’s
B, C
3 what I think is surprising. You don’t realise it’s about you
D, E
4 when you begin, but it’s you, you can actually think it’s
C
5 about cats and what a lovely life, but even within that
F
6 context and what a lovely life it can be quite difficult.
G
7 And that’s what I think is so empowering, it’s like
H
8 that’s me in there somewhere, bits of it anyway.
C
A: calm at end; B: exposing, transparent; C: sees self in story; D: surprising elements; E: started trivially; F: seems irrelevant at first; G: process is
difficult; and H: empowering.
K. Dent-Brown, M. Wang / The Arts in Psychotherapy xxx (2006) xxx–xxx
5
to one another. For example, I gathered concepts A, B, G and H above into a category labelled “Affective reactions to
process.” This category was further divided into positive reactions such as A and H, negative reactions such as B and
G, and neutral reactions. Some concepts were allocated to more than one category, for example categories A, E and F
were also allocated to a category labelled “Start and end of process contrasted.”
The most flexible way of dealing with the 75 concepts was to copy the list of free nodes from NUD*IST, print
them out, cut them into strips and spread them out on a large table. This allowed groups of concepts to be tentatively
assembled, as well as allowing some concepts to straddle groups and giving a sense of which categories were closely
related to one another and which were more distant. At the end of this process, I had identified and named five categories
which were as follows.
First category: Parallels between story and own situation
Altogether there were 1529 text units in the transcripts analysed. There were 487 text units coded to the category
Parallels between story and own situation
. The majority (414 text units) indicated that participants thought the story
was a good metaphor for their own life and situation:
Yes, that’s what happens within my family circle. That’s too freaky. You’re getting all this just from pictures, I’m
just talking about these few pictures that I’ve drawn and now I can really see how this story relates to different
aspects of my life.
(Patient B11, borderline diagnosis)
A smaller number of text units (73) indicated that participants thought the story was not relevant in this way:
(Responding to question “Can you see bits of yourself in there anywhere?”)
No, not really because I think you
were asking to try and push it away as far as possible from me at the beginning, so I don’t think it does, I had
that in mind all the while. I suppose I might see me with the struggles I suppose, but I suppose that is everybody
we all struggle with something. But I don’t think so, no
. (Patient M3, no BPD)
But even this comment was to some extent contradicted by this participant’s general comments about the process:
Very difficult, especially not being able to use words. Yeah, a bit nervy I suppose it is like when it is something
new, don’t explore these sides very often
Given that he did not think the story showed anything relevant about himself, what sides of himself did he think
he was exploring? And what were these very strange new things he was feeling insecure about? Unfortunately the
fixed format of the interviews carried out by clinicians did not permit exploration of these paradoxes. However, these
comments may suggest that even participants who asserted that the story did not tell anything about them may in fact
have been defending against uncomfortable truths.
Second category: Progressive development of story
The next largest category (272 text units) described
Progressive development of story
, where participants drew
attention to changes that occurred as the story session progressed: some were immersed in the storymaking process,
only later becoming aware of its possible significance:
I think trying to unravel subconsciously what is happening in my head, going round and round in my head.
Although when I am writing the story it doesn’t seem that way, it is only afterwards when I’m telling the story
that it seems to
. (Patient B10, borderline diagnosis)
While others described an initial reluctance or doubt:
A bit dubious at first, a bit cynical at first. I didn’t think I could draw the story. But I did and I got to the end
.
(Clinician C16)
Within this category there were a number of responses indicating that at the start of the process the story seemed
puzzling or inconsequential, and that there was no initial plan of where the story would end.
I sort of started with a character and I hadn’t really given it much thought what I was going to do, I just started
with a main character and then the plot evolved as I went on picture by picture
. (Patient M7, no BPD)
All in all I find it quite comfortable to do, but there is little pieces
where I feel very insecure about it, they’re very strange new things, very strange
. (Patient M3, no BPD)
...
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