1 Introduction

Developed in the field of collective narrative practices (CNPs), initially conceived by the social worker David Denborough, collective narrative methodologies understand that the meanings given to lived experiences are produced from the historically and culturally situated mode of specific social groups. In this sense, in situations of suffering, stories often have a dual narrative, one limiting and/or generally focused on the problem, called the dominant narrative, and another that speaks of the values, skills and knowledge that strengthen individuals and, concomitantly, the communities to which they belong; these are the alternative narratives (White 2012; Denborough 2018). Among the technical resources used in CNPs to recognise and strengthen alternative identity narratives are the collective narrative methodologies.

The first developed methodology and the most used to date is the Tree of Life (Ncube 2006). This collective practice was developed by Ncube (2006) in partnership with the Dulwich Centre, a worldwide pioneering and leading research and practice centre in CNPs, aiming to provide care and support to vulnerable children in South Africa. According to Ncube (2006), the use of the tree metaphor in line with the principles of CNPs proved powerful by providing a solid foundation for people to talk about stories of suffering, not only producing a cathartic moment for emotions saturated with problems but also enabling an expansion and strengthening of values, skills and knowledge (Ncube and Denborough 2011).

The Tree of Life methodology consists of four parts. First, participants are invited to individually draw a tree in which they point out the people, events and objects that compose the inheritance they carry with them: in the ground, they note what sustains them in the present; on the trunk, they retrieve their personal skills and values; on the branches, they reclaim their dreams, purposes and hopes; on the leaves, they mention important people in their life stories; on the fruits, the gifts the person considers they have received from life; and on the flowers or seeds, the contributions each person would like to leave for their community.

In the second stage, participants are invited to build a Forest of Life. At this time, all the trees created by the group are arranged side by side for everyone to observe, recognise and share the differences and similarities. The third stage is the Storm of Life, a moment in which the group reflects on the challenges faced by the trees and the whole forest, as well as on the challenges experienced, identifying resources developed to resist these challenges.

In the fourth and final stage, external and/or defining ceremonies are conducted, where their life stories are recognised, safeguarded, celebrated and shared with witnesses (which can be specific individuals, groups and communities). In these ceremonies, the progress made is acknowledged, and resources are jointly considered to honour the skills, values, bonds, dreams and gifts identified throughout the therapeutic journey, consolidating changes and alternative narratives found during the process (Ncube 2006; Denborough 2008a; Ncube and Denborough 2011).

Beyond the context initially proposed by Ncube (2006), this methodology has been applied in various countries, including Spain (Chimpén-López et al. 2022), England (Farooq et al. 2021), Australia (Nicholas 2021) and China (Hung 2011), and for all age groups, including children (Ncube 2006), adolescents (Fischera and Damazer 2021), and adults, demonstrating its usefulness for diverse audiences with various demands, such as studies published with refugees (Schweitzer et al. 2014), in the context of teaching and education (Randle-Phillips et al. 2016), and in individuals with various diagnoses such as bipolar disorder (Ibrahim and Allen 2018) and HIV/AIDS (Vitale et al. 2019).

There are studies on its use in patients with chronic diseases (Haselhurst et al. 2021), but there are no studies on its use in people with fibromyalgia. Considering the medical-diagnostic discourse as a predominantly female rheumatologic syndrome, fibromyalgia is characterised by the presence of widespread chronic musculoskeletal pain, as well as fatigue, possible mood changes, sleep disturbances, and memory symptoms without a clear aetiology to date (Clauw 2014; Bellato et al. 2012). Women with fibromyalgia have their identities hardened by labels such as ‘it is all in your head’, complainers, problematic, exaggerated and conflictual, resulting in a delegitimisation of their pain and complaints by health professionals, family and acquaintances, devaluing and invisibilising their demands, limits and needs (Briones-Vozmediano 2017; Wuytack and Miller 2011).

In this qualitative research, adaptations and specific uses of the collective narrative methodology Tree of Life in a group of women with fibromyalgia who were treated at a multidisciplinary care institution for people with rheumatic diseases are presented.

2 Context of the Group and the Research

Nine women who were diagnosed with fibromyalgia, ranging in age from 31 to 64 years, participated in the study (Table 1). Eleven weekly group meetings were conducted using the 'Tree of Life' methodology and were coordinated by two psychologists. These meetings are presented here through a discussion of (1) the strategies for group adherence, (2) the principles and resources that guided the coordinators' actions, and (3) how the ‘Tree’ was used and adapted (Table 2).

Nine women diagnosed with fibromyalgia participated in this study, with ages ranging from 31 to 64 years, and time since diagnosis from 5 to 29 years, as can be seen in the table below.

An initial individual conversation was conducted with each participant to facilitate group engagement, address expectations, reduce anxiety and present the structure of the meetings (Rasera and Japur 2007). This moment also allowed for clarifying questions, understanding motivations and signing the Informed Consent Form. The study was approved by the Research Ethics Committee FFCLRP—University of São Paulo under protocol number 22676719.7.0000.5561, in compliance with national and international ethical standards for research involving human subjects.

Eleven weekly group meetings were conducted using the Tree of Life methodology; they were facilitated by two psychologists. The organisation and analysis of the group sessions were carried out using the dialogical map (Nascimento et al. 2014; Spink 2010). Following the procedures of this tool, the researcher (1) fully transcribed the sessions, with line numbering; (2) produced a sequential transcription, with tables organised by speaker, a summary of the speech content, and the themes addressed—allowing the identification of positioning dynamics; and (3) constructed the dialogical map, in which each column represents an extracted theme and includes the corresponding excerpts of speech.

These meetings are presented here through the discussion of (1) strategies for group engagement, (2) the principles and resources that guided the coordinators' actions and (3) the way the ‘Tree’ was used and adapted.

2.1 Strategies for Group Adherence

In the field of group practices, adherence is a cultural challenge. This challenge seems to be sustained by the lack of popularisation and understanding of the benefits of these practices, the stigma associated with mental health care, often seen as individual and private, distrust of research practices involving recording and data dissemination, and structural barriers related to time availability and transportation.

To increase adherence among the group, we conducted an initial and individual conversation with each participant, as mentioned before. Another strategy we used was to send a text message to each participant prior to each meeting, confirming their attendance and reminding them of the schedule.

At the end of each meeting, a brief presentation was made of what would be developed in the next meeting, a move that allowed participants to think in advance about the theme, as well as opening up space for suggestions and/or requests for joint construction of the group (Lion and Souza 2022).

All meetings included a breakfast initially provided by the coordinators, and as the meetings progressed, participants spontaneously contributed by bringing pastries, snacks, juices and cakes to share. This space was conducive to strengthening bonds and sharing stories, such as when Gabriela brought a sweet bread to the group that she had found weeks earlier in a bakery, with the same flavour as the one her aunt used to make for her as a child, appropriating eating as a collective act that nurtured memories and feelings (de Certeau et al. 1997).

3 How the ‘Tree of Life’ Was Used and Adapted

Owing to its culturally adaptive nature, the Narrative Tree of Life methodology can be used in a wide range of contexts and populations, respecting the cultural, social and linguistic specificities of each group. Its symbolic and metaphorical structure allows people to tell their stories based on their own references, strengthening identities and promoting the re-signification of experiences in a way that aligns with their values and beliefs (Ncube 2006). Based on this, responding to the group's pace and aiming to provide more space for storytelling and exploration, one or two parts of the Tree of Life were developed in each meeting.

Understanding language as an action, not just as a social representation of ‘reality’, it is understood that the questioning, or the way dialogue invitations are made, influences the produced meanings (McName 2014). In this sense, Table 2 shows the relationship between the initial proposal for each stage presented by Ncube (2006).

Since the collective narrative methodology Tree of Life is open to adaptations to meet diverse contexts and demands, as pointed out by Jacobs (2018) and Stiles et al. (2021), there was an addition in the trunk of a moment to talk about skills developed due to the diagnosis of fibromyalgia. This moment allowed the participants to talk about their diagnosis without granting it agency over their stories, a proposal not found either in the original model of the methodology created by Ncube (2006) or in studies that proposed working with diagnoses using the Tree of Life.

This adaptation was made in response to a request from the participants, who realised that although they shared the diagnosis of fibromyalgia, they had finished the second meeting without talking about it more prominently, a result of both the presentation proposed by the coordinators and the roots, part of the tree developed in the second meeting, having evoked life stories beyond those permeated by the diagnosis.

In the third meeting, after the coordinators introduced fibromyalgia into the structure of the methodology, the participants unanimously affirmed that talking about fibromyalgia in this way helped them to learn ‘from the life experiences of each other', as Helena, one of the participants, said.

Crossed by the experience of a body in pain, the diagnosis of fibromyalgia seems to tell a single possible and true story about them, as Gergen and McNamee (2000) point out. The diagnostic discourse silenced narratives about these women's agency in relation to their pain, the diagnosis itself, family, work and the various aspects of their lives. Thus, discussing fibromyalgia through non-habitual and non-rigid modes, not confined by the diagnosis, made it possible to recognise, strengthen and explore identity constructions primarily sustained by three self-narratives: (a) these women's relationship with their histories and experiences as caregivers, (b) the experience of being cared for and (c) self-care. These narratives allowed them to recognise their ability to reinvent themselves in the face of life's challenges. As Ncube (2006) proposes, this approach did not make the methodology merely a moment of catharsis but rather an opportunity to expand narratives of coping. It also highlighted the need for healthcare professionals and institutions to consider the intersectionality between fibromyalgia, gender, social class and race in their care and treatment approaches.

4 Principles and Resources That Guided the Meetings

4.1 Initial Welcome to the Group

At the beginning of each meeting, the coordinators inquired, ‘How was it coming to the group today?’, seeking to understand how the participants had arrived, both from an emotional and physical perspective, to create the space for necessary demands and care. An example generated by this welcoming question was demonstrated in the fourth meeting, when on a cold day, the participants reported feeling more pain than usual. The space to speak about their comfort allowed for specific care to be reinforced, such as not extending the time initially planned for that meeting and offering tea or coffee more frequently to warm themselves up.

This moment of initial welcome proved to be a genuine moment of sharing and curiosity, allowing individual discomforts and needs to be transformed into collective care (Freedman and Combs 1996).

4.2 Externalising Conversations

As an effort to produce externalising conversations (White and Epston 1993) that would strengthen the agency of the participants with fibromyalgia, questions were introduced into the trunk of the tree: ‘When looking at your journey, what skills have you developed with the onset of fibromyalgia?’, ‘How was the onset of fibromyalgia in your life?’, ‘For how long has fibromyalgia prevented you from feeling well?’ and ‘Have you ever felt that your presence was stronger than its presence (fibromyalgia) in your life?’. In this mode of questioning, fibromyalgia was understood as something that was not passively received, inviting the participants to name and recognise the agency they had produced in their relationship with the problem.

4.3 Expanding Metaphors

In a movement not directed by the coordinators, the meanings initially given to the tree metaphor were expanded by the participants. Despite the participants being given a choice in the second meeting to choose a particular tree to use as a metaphor throughout the methodology, when talking about the flowers, the participants did not seem to recognise, in this initial choice, a metaphor that justified the description of themselves they wished to make by choosing flowers that represented them.

Adriana saw herself as a Mandacaru, a native flower sown in the semi-arid terrain of northeastern Brazil, because, just like this flower has survived many deserts and droughts, she also perceived herself as ‘strong, as no wind knocks her down’. Elsa saw herself as a tulip because ‘The flower is born and after its time passes, it dies, but the bulb remains there and sprouts again next year’.

Understanding that meaning is delimited by a circumscribed context of language and that words are not meaningless (Andersen and Bergallo 2022; Gergen 1997), the participants changed the name from forest to orchard. The group, like the orchard, would be characterised as a set of fruit-bearing trees, while a forest would be composed of a wide variety of trees that do not necessarily bear fruit. The meaning given to the word 'fruit' was also an expansion made by the participants since, in the methodology, it originally referred to gifts received from life, but in the forest stage, they used it to refer to what they had produced in their life stories.

4.4 Rescue of Significant Moments

The participants' introduction to the group was guided by a request to share a significant moment from their personal histories. This approach encouraged them to reclaim alternative self-narratives beyond those tied to their diagnosis, shifting from a passive position—of what it ‘means to be a woman with fibromyalgia’—to an active one, in which they presented themselves as women who develop practical and discursive resources to cope with fibromyalgia in their lives. This allowed them to speak about themselves outside a pathologising framework, providing rich examples of their personal skills and strategies, such as engaging in self-care actions, setting boundaries with people in their lives and delegating responsibilities, among others.

Moreover, this way of presenting themselves highlighted shared coping resources and collective stories of strength, fostering the construction of a collective identity within the group. The women recognised themselves not only in relation to fibromyalgia but also as individuals navigating the burden of multiple roles and the effects of ageing, identifying the intersecting influences of gender, race and social class. Beyond these insights into coping, the participants also pointed to being part of the group itself as a powerful resource that contributed to shaping a collective identity.

4.5 From the Individual to the Collective

In the theoretical foundation of collaborative narrative practices (CNPs), Denborough (2008b) mentions the influence of the Brazilian educator and philosopher Paulo Freire, who introduced the concept of ‘unity in diversity’. Freire (2020) proposes that recognising meeting points in a group through sharing individual experiences allows for the rescue of both individual and collective strengths in the face of dominant narratives and the logics of oppression.

The coordinators sought this recognition, as emphasised when one of the coordinators pointed out the following: ‘It seems that in all the roots, which is what I wanted to confirm with you, that faith appears as something that is uniting the roots of the stories you have been bringing; is that true?’. This observation subsequently allowed for conversations in which faith was shown as a space of support and shelter in the face of adversity, weakening consolidated narratives of loneliness and/or abandonment.

To conclude the meetings, the coordinators drew a watercolour of a large tree upon which each participant wrote their name on a branch, symbolising the tree built collectively throughout the meetings, a tree that was later presented to the community at the public closing ceremony (Figure 1).

4.6 Feedback from the Participants on the Group Process

The participants asked the coordinators for a moment in which they could provide feedback on the individual participation of each woman in the group. This request seemed to be related to their concern in meeting the expectations of the coordinators regarding the group.

As witnesses of the shared stories and seeking to respond to the request without reproducing positivist evaluation models, the coordinators prioritised an appreciative focus on the journey of each participant in the group, rescuing the values, skills and knowledge shared throughout the meetings in the form of poetry. A poem by the Brazilian poet Ryane Leão was selected for each participant, and was read and delivered to each participant along with a colourful rose.

Conducting a feedback meeting allowed the participants to appreciatively look at their stories as well as the collectively produced process, highlighting how important it was to build a space for learning and exchange that allowed the participants, as Helena pointed out, to ‘not stiffen in the face of problems’.

4.7 Final Considerations

The collective narrative methodology Tree of Life in a group of women with fibromyalgia proves to be flexible to adaptations that meet the needs, demands and cultural context of the participants. The principles and care that guided the meetings, beyond the production of bonds and adherence to the methodology, allowed the participants personal agency over their stories and strengthened alternative narratives to the diagnostic logic. This study highlights not only the intention of the Tree of Life methodology in not responding to consolidated narratives but also the commitment to the production of collective and externalising language, honouring the telling and retelling of life stories and their rhythms.

Despite the effectiveness of using the Tree of Life methodology with this population, in this study, it was not possible to determine the long-term consolidation of the alternative narratives found in everyday experience. An important limitation of this study is the absence of longitudinal data, which prevents the assessment of the sustainability of narrative changes over time. For future studies, follow-up meetings should be held to measure consolidated narratives and identity transformations postintervention. Additionally, inspired by the adaptations made when creating the trunk, we believed that modifying the methodology and creating externalising questions about fibromyalgia at each stage of creating the tree could further enhance the methodology.