Why storytelling improves patient adherence

Because there have been so many views and comments on my recent post “Getting non-adherent patients to listen to and dialogue with adherent patients can improve adherence”, it got me thinking – why?

Dr Jay M. Pomerantz (assistant clinical professor of psychiatry at Harvard Medical School) “Storytelling as a Psychotherapeutic Technique” explains:

Many psychotherapists adhere to psychotherapy protocols such as cognitive-behavioral therapy, interpersonal therapy, dialectic behavioral therapy, or psychoanalytically oriented psychotherapy. Nonetheless, what actually goes on between therapist and patient is often variable and sometimes unique. One method I use involves storytelling, usually with the hope of producing insight, correcting a cognitive distortion, or providing context for an unusual feeling or happening.

All of my stories are offered as a reaction to what patients are telling me. As I listen to patients, I wonder why they are telling me these vignettes of all the many subjects that they could talk about—past, present, future, imagined or real, sad or joyful. While listening, I always have inward musings, images, and stories. It seems that I engage in constant “free association,” which Freud recommended for patients in psychoanalysis but which I seem to have adapted as a therapeutic tool. More often than not, I will share some of these thoughts with my patients, usually in the form of a story.

Over the years, I have developed almost blind trust in these associations, and they may account for what clinical success I have had in both individual and group psychotherapy.

Fundamentally, Dr. Pomerantz is telling a story that his patients can relate to (he is also listening carefully, but that’s the subject matter for another post). In the Annals of Internal Medicine study “Culturally Appropriate Storytelling to Improve Blood Pressure”, Dr Thomas Houston and his colleagues used storytellers “drawn from the patient population”. They used inner-city African-Americans because the patient population was inner-city African-Americans with hypertension. In other words, peers.

Peer pressure is often associated with negatives — for example, drugs, smoking, and alcohol. However, peer support or group therapy can be beneficial — and therein I believe lies a key factor in why storytelling improves adherence.

In a meta analysis of 48 research reports on the efficacy of group therapy for depression “The Efficacy of Group Psychotherapy for Depression: A Meta-analysis and Review of the Empirical Research”, Dr Wilson McDermut and his fellow researchers found that “the average treated participant was better off than about 85% of the untreated participants”. Of course, group therapy has been shown to be effective for many other sufferers — sexual abuse survivors and traumatic stress in war veterans, to name just two.

Of course, the “rub” is that to work well you can’t just tell any story. It has to be relevant. More importantly (and this is key), it has to be “drawn from the [same] patient population”. Of course, that can be the hardest part — finding someone with the disease, who is on treatment (and, in the case of a pharmaceutical trying to improve its product’s adherence, on its drug), who is adherent … and who is willing to tell their story! Although it may be like finding the proverbial needle in a hay stack, to do so produces great results — healthier patients, successful medical practitioners, more drug sales … but, it can be done (if you’re interested, please email me at mwong@hccatalyst.com for case studies).

Having said that there must be other reasons why storytelling improves adherence. I’m sure the hundreds who viewed the earlier post (and I) would love to hear your thoughts!

Boxcutters Jewel #524  (corollary to #523) – To improve adherence, find stories from patients who are diagnosed, on treatment, adherent, and willing to tell their story!

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