Six-Part Storymaking – a tool for CAT practitioners

Dent-Brown, K., 2011. Six-Part Storymaking – a tool for CAT practitioners. Reformulation, Summer, pp.34-36.


Six-Piece Story Making (6PSM) is a projective technique using structured instructions to help a client create a new, fictional story which can be used in psychotherapy assessment or treatment. Despite its ready acceptance by CAT practitioners, CAT theory and practice have not been formally applied to understand the material produced by 6PSM. This article will make a first attempt at doing that, to make suggestions about how 6PSM might be more fully integrated into CAT practice and to identify avenues for further research or development. The initial developer of 6PSM (Lahad, 1992) proposes that the newly created story demonstrates the way the client habitually perceives or reacts to the world, and that this kind of communication by metaphor is useful in psychotherapy. Could 6PSM be a useful tool for CAT? How might it be integrated into CAT practice, and is it consistent with CAT theoretical positions?

Introduction

In 6PSM the client is initially given progressive instructions to draw each part of a new, fictional story. At this stage they do not respond verbally but just with sketched pictures. Once the sequence is complete, they are asked to tell the story right through without interruption. Finally the therapist uses open-ended questions to encourage the client to elaborate details further. Only then, once the story is fully elaborated, are any possible links with the teller’s own situation explored.

The client is asked to (1) create a main character (not necessarily human) in a fictional, fantasy or historical setting – ie as far away from 21st century real life as possible. The instructions lead the client/author on through (2) the creation of a task for the main character, (3) obstacles they encounter, (4) helpful factors, (5) the climax of the story and (6) its aftermath. The assumption is that the themes, conflicts, world view, problem solving etc which are displayed in the story will communicate something meaningful about the client’s own experience.

The technique is commonly taught as part of pre-registration training in Dramatherapy in the UK and has also been taught on training courses for Clinical Psychologists and Cognitive Analytic Therapy (CAT) practitioners.

Development of 6PSM

The method can be traced to studies of Russian folktales undertaken in the early 20th century by Vladimir Propp (1968). Later semiological studies by Lucien Tesnière (1959) and Algirdas Greimas (1966) drew on Propp’s work, with the focus on the story as a ‘signifier’ and how its elements communicate some deeper meaning (the ‘signified’) from one person to another.

In the 1980s Alida Gersie, an Anglo-Dutch dramatherapist, had the idea of taking the fundamental story structure proposed by Greimas and using it in reverse, as a skeleton on which new stories could be created (Gersie, 2002). She taught this story evocation technique to Mooli Lahad, an Israeli psychologist who developed it into 6PSM as part of his project to identify coping styles in the general population. Lahad has published descriptions of the method (Lahad, 1992) and taught it internationally. The method is easily learned within a few hours, popular with practitioners and free from allegiance to any particular school of therapy.

The only published research into the 6PSM has been my own PhD project (Dent-Brown & Wang, 2004a, 2004b, 2006). The research found that stories can be assessed by independent raters with satisfactory inter-rater and test-retest reliability. A degree of validity for the method was demonstrated by the association of identifiable features of stories with particular diagnoses. Specifically, stories from participants with a diagnosis of BPD had significantly more pessimistic, bleak and negative features. A qualitative sub-study into the mechanism of the method suggested that it may derive some of its usefulness from the metaphorical nature of the material, permitting more free expression of what Stiles’ assimilation model (Stiles et al., 1990) might call warded off material. In addition, the dynamic nature of the story arc (imposed by the instructions) seemed to be helpful in drawing the client/teller into closer identification of the story.

Examples of CAT Perspectives on Six-Piece Stories

One story collected during my research was (in abbreviated form) as follows:

Once upon a time there was a liontamer whose deepest darkest fear was that he was very scared of lions. They were having a new lion being delivered to the circus and this one had never been trained before and it filled the main character full of dread and he didn't know how to approach it. The character had a friend who was a real famous trainer from the past and he passed on some jewels of information on the best way to train a lion, and the character becomes confident through that. And the next frame shows the character training the lion and making it do a handstand in front of the largest crowd that the circus had ever had and so he overcame his fears and trained the lion in front of them. And the last frame shows how confident and happy the liontamer was, receiving a rosette from the Association of Liontamers proclaiming him to be one of the best in his field, so he overcame his fears and became one of the best liontamers in the business.

One application of 6PSM in CAT would be to use it as a way of eliciting reciprocal roles. As a small experiment, some fellow members of my CAT training course and I independently identified the reciprocal roles we saw being played out in this story. Interestingly, although we chose different characters as the most important ones to review, there was a strong overlap in the reciprocal roles we identified in this story. These included: Threaten-Withdraw; Protect-Trust; and Control-Submit. Other stories we rated together had similar overlaps in the RRs we identified. It might be a fruitful exercise to work with a patient, once they have told their story, to get them to identify the most important RRs within it. Experience suggests that patients can sometimes get a better ‘observing I/eye’ by looking at their created stories than by looking at actual autobiographical material. It is as if the metaphorical nature of the story lifts the discussion from the particular to the general, permitting patterns of relating to be seen more simply and clearly.

Another approach would be to use the story as a medium for discerning procedures which might be meaningful for the patient. A second story may serve as an example. This told of a crocodile who lies in wait for a boat, then overturns it and kills and eats the occupants, but nevertheless remains hungry. This story seemed much more pessimistic, negative and maladaptive, in contrast to the Liontamer story quoted earlier. Again, two of us independently developed a procedure by mapping out elements such as Belief, Action and Consequences. The overlap between our two procedures was considerable and seemed to share the following features:

  • Wanting to get a desired thing
  • Self description as bad, ruthless
  • Hiding in wait
  • Victim is unsuspecting
  • Attacks furiously
  • Helpless victim is overcome
  • Despite success, main character is dissatisfied

This is a much less positive story than the first, which although it ends apparently successfully for the protagonist (although not the occupants of the boat!) nevertheless leaves him feeling dissatisfied. This procedure was arrived at by two raters who had never met the patient in question but had simply read the transcript of his storymaking session. Again, we might guess that it would be more effective if the procedure were arrived at collaboratively, in-session with the client. As an aside, the person who created this story met six of the nine criteria for Borderline Personality Disorder, and additionally met a total of 33 other SCID-II criteria including all of those for Antisocial Personality Disorder. This picture is not inconsistent with the procedure tentatively mapped out above and may be some modest further evidence for the validity of 6PSM.

A CAT Perspective on 6PSM

The six-piece story is a co-created enterprise between therapist and client which generates some specific products: the pictures drawn by the client to illustrate the story and the words of the story itself, which ideally are audio recorded and transcribed. These features are reminiscent of the prose reformulation letter and the systematic diagrammatic reformulation (SDR) in CAT which are similar joint enterprises resulting in a permanent record. The 6PSM has characters or elements which are in relationship to one another (for example the relationship between the main character and the obstacles s/he encounters.) These relationships in the story are paralleled in a reformulation letter or SDR by the reciprocal roles. Furthermore, the dynamic nature of the story arc means that the character’s task leads them to action to which the environment responds. This sequence is paralleled in the reformulation letter and SDR by elements such as the Target Problem Procedure (TPP).

I have taught the 6PSM to CAT practitioners for several years and it has been received with enthusiasm. Practitioners grasp the practical, pragmatic uses to which it can be put and seem to accord the method a high level of face validity. What theoretical reasons might there be for this apparently good fit?

The 6PSM may offer a systematic, predictable way of encouraging the production of ‘signs and voices’ of the kind that Mikael Leiman (1997) and Bill Stiles (1997) have described. Leiman describes a dialogical sequence as having two essential parts: a sequence of events and a description of the positions that persons adopt within the sequence. The 6PSM provides a skeleton (main character, task, obstacles etc…) which drives a narrative forward and provides a linked sequence. This is the case even for the client whose ability to construct a personal narrative is grossly diminished or fragmented. The symbolic or archetypal nature of the characters and objects in a 6PSM lends may mean that reciprocal roles derived from 6 piece stories might represent a higher level, more easily abstracted role pair. My original PhD research suggested that for participants somehow the fictional nature of the story made it easier, not harder, to see personal relevance in it (Dent-Brown & Wang, 2006). The metaphor I use in training is that the story is like a film projector: the further the image is thrown onto the screen, the larger it is and the easier it is to see. This reminds me of the ‘observing I’ which we are attempting to help our clients to cultivate; the ability to describe their own experience and then reflect on it without being caught up in it.

This feature may make it useful for clients who are swamped by affect and who find it difficult to consider their situation without being caught up in an emotional response to it. However there is also a useful application of 6PSM with clients who over-intellectualise and find emotion hard to access. For these clients it may be necessary to use a metaphorical, ambiguous method such as this to generate material which is not purely concrete but has some emotional content. It is not exclusively useful for those clients who might be described as creative or imaginative; it can provide a route for clients whose ability to imagine is highly impaired. For them it still offers an observing eye/I as the stories they produce are often typical of their lives. The one group for whom it may generally not be helpful would be those with extremely fixed, concrete thinking such as some on the autistic spectrum; for them it would perhaps be asking too much that should collaborate in creating and exploring metaphorical material.

Stiles (1997) defines ‘sign’ very generally: “… a sign can be a word, a sound, a gesture, a token, a picture or a story.” (p.171) Its function is to embody both continuity and transformation, to communicate something shared but also to permit a level of ambiguity or novelty which expands the jointly constructed meaning. The 6-piece story itself (including the pictures which are drawn to begin the process) is clearly a sign, and I would argue a very effective and flexible one at that. By ‘voice’ Stiles means “…what has been called for example, role in CAT’s reciprocal role relationships, object in object relationships, and archetype in Jungian analytic psychology” (pp171-2). Stiles proposes that the information in a story is not passive (fixed, stable and uncontested – monologic) but that in living people it is active (ambiguous, mutable and situational - dialogic). In the 6PSM clients are encouraged to begin their telling of their story with the words “Once upon a time…” – a form of words which is itself a sign pointing towards fairy tales, magical transformations, strongly drawn characters and sometimes disturbing, dream-like or archetypal material.

CAT typically searches for signs and voices in the narrative of daily events and past history. Paradoxically it might be the case that fictionalised, projected stories produced by the 6PSM might be just as good or better when it comes to the task of eliciting signs and voices, as well as being more predictable – in that a storymaking session can be deliberately planned into the early part of a therapy. The collaborative nature of the 6PSM fits well with the practice of CAT and this could be extended from the production of stories to their analysis. There is every reason to think that client and therapist together might produce the most valid, reliable and useful understanding of a 6-part story and the next phase of research into the 6PSM might be to see just how this potential could be harnessed.

The paradoxical nature of the storymaking process may be part of the reason for its apparent effectiveness and the enthusiasm with which some CAT practitioners have adopted it. Storymaking is introduced to the client as a way of them communicating something about themselves more effectively, but is then told to set the story as far away from their own life as possible, and to make the main character as unlike themselves as they can. There is an inherent contradiction here: is this story in some way about the teller, or is it not? And yet it appears that it is the paradoxical nature of the story that may be helpful. It is perhaps sometimes easier to recognise disavowed, warded off characteristics in a created character than to own them for oneself. It is always possible to take cover in the fact that “This is just a story – you told me to make it unlike me.” And yet while this is true within the frame of the storytelling activity, this activity occurs within the wider frame of a therapy that is about communication.

Mikhail Bakhtin elaborated a concept called ‘transgredience’ which may at least partly resolve the paradox. Transgredience is a more or less ideal and rarely attained state and only occurs when one person can see another from the outside and as a whole, unencumbered by social or historical filters (Holquist, 1990, pp33-34.) In practice the only time transgredience is truly achieved is between great novelists and their characters; Holquist suggests that no two living people can ever be fully transgredient to one another. If I cannot achieve transgredience in respect of you, how much more difficult must it be to achieve it towards myself. And yet perhaps this is precisely what 6PSM facilitates; a character is constructed who is way outside our normal place and time, about whom we know everything and cannot be mistaken, and who knows nothing about us. Used well, Holquist interprets Bakhtin as saying, transgredience results in art.

Six-piece stories may not be great art, but perhaps they go some way to meet this criterion, and can thereby provide the benefits of identification and catharsis first identified by Aristotle (350BC). They provide a tool for achieving the ‘polyphony’ which Bakhtin detected in the works of Dostoevsky; a state where the characters of the story are not mere passive objects but have their own voices and sometimes make their own claims even against those of their author. Once the story has been generated, this polyphony can be explored by, for example, looking at reciprocal roles between elements of the story or by techniques such as empty chair work. The latter might involve improvising dialogue or statements from one character to another, or writing brief letters to elaborate the viewpoints of different elements. This is a valuable goal and one in tune with the theory and practice of CAT; to allow the patient the opportunity to identify a range of voices, some contradictory and disavowed, and to do so in a collaborative, exploratory and respectful way.

Author Details

Kim Dent-Brown trained first as an OT and then as a Dramatherapist before more recently undertaking the Manchester CAT practitioner training. He has used storymaking approaches with mental health clients for the past 20 years, with a particular interest in using 6PSM as an assessment and rapport-building tool in work with clients described as having personality disorders. In 2001 he won an NHS research training Fellowship to complete a PhD on this topic and enjoys teaching storymaking to diverse groups around the country. Kim can be contacted on K.Dent-Brown@sheffield.ac.uk and is very happy to discuss the technique and its application. He moderates an email discussion list for clinicians with experience of using 6PSM - please email him to join, briefly outlining your familiarity with the method and he will subscribe you to the list.

References

Aristotle. (350BC). Poetics - Part VI. Trans S.H. Butcher. Available from the World Wide Web at: http://classics.mit.edu/Aristotle/poetics.html

Benjamin, L. S. (1996). Interpersonal diagnosis and treatment of personality disorders (2nd ed.). New York: The Guilford Press

Dent-Brown, K. and Wang, M. (2004a). Pessimism and failure in 6-part stories: indicators of borderline personality disorder? Arts in Psychotherapy 31(5): 321-333.

Dent-Brown, K. and Wang, M. (2004b). Developing a rating scale for projected stories. Psychology and Psychotherapy-Theory Research and Practice 77: 325-333.

Dent-Brown, K. and Wang, M. (2006). The mechanism of storymaking: A Grounded Theory study of the 6-Part Story Method. Arts in Psychotherapy 33(4): 316-330.

First, M. B., Gibbon, M., Spitzer, R. L., Williams, J. B. W., & Benjamin, L. S. (1997). User's guide for the Structured Clinical Interview for DSM-IV axis II personality disorders. Washington, DC: American Psychiatric Press

Gersie, A. (2002). Some thoughts about the development of Therapeutic Storymaking. The Prompt (The magazine of the British Association of Dramatherapists), Winter 2002/03: 6-7.

Greimas, A. J. (1966). Sémantique structurale : Recherche de méthode. Paris: Larousse

Holquist, M (1990). Dialogism:Bakhtin and his world. London:Routledge.

Lahad, M. (1992). Storymaking in assessment method for coping with stress. In S. Jennings (Ed.). Dramatherapy theory and practice II (pp. 150-163). London: Routledge

Leiman, M (1997). Dialogical Sequences and Bakhtinian Voices. Brief paper given to student meeting, London, January 11-16. Downloaded from ACAT library http://www.acat.me.uk/article_download.php/144

Luborsky, L., Popp, C., Luborsky, E. & Mark, D. (1994). The Core Conflictual Relationship Theme. Psychotherapy Research, 4: 172-183.

Propp, V. I. (1968). Morphology of the folktale (L. A. Wagner, Trans. 2nd revised ed.). Austin: University of Texas Press.

Stiles, W., Elliott, R., Llewellyn, S., Firth-Cozens, J., Margison, F., Shapiro, D. & Hardy, G. (1990). Assimilation of problem experiences by clients in psychotherapy. Psychotherapy, 27: 411-420.

Stiles, W. (1997). Signs and Voices: Joining a Conversation in Progress. British Journal of Medical Psychology, 70: 169-176.

Tesnière, L. (1959). Eléments de syntaxe structurale. Paris: C. Klinksieck.

Full Reference

Dent-Brown, K., 2011. Six-Part Storymaking – a tool for CAT practitioners. Reformulation, Summer, pp.34-36.

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