9 February 2018

Making sense of narrative therapy

Clinical Mental Health

When you meet up with a friend and ask them how they have been, you expect to hear stories about their life.

Perhaps they have been having a difficult time because they have been fighting with their partner, and the boss at work is overloading them with tasks. You confide that a project you are working on isn’t going as well as you had anticipated, but that you are also excited about a new person you have started dating.

What most of us don’t do is give each other hard metrics. I don’t tell my friend that my anxiety is back up at an eight out of 10, even though I had been enjoying a relaxing four out of 10 on my recent holiday.

The key premise of narrative therapy is that stories are the way we make sense of ourselves and the world around us.

Thus, understanding and rewriting these stories can be a powerful therapeutic tool in addressing mental-health concerns, narrative practitioners say.

This style of psychotherapy grew out of the work of two family therapists from Australia and New Zealand, who developed it in the 1980s and saw the approach fleshed out and grow in popularity over the years. The University of Melbourne now offers a masters degree in narrative therapy, and its practices are taught among other psychology courses in the country and around the world.

While narrative therapy is not a mainstream psychological discipline, many mental-health workers incorporate its techniques into their practice. Professor Glen Bates has been a clinical psychologist for decades, and while he specialises in cognitive behaviour Therapy (CBT), he says narrative techniques have been useful, particularly in treating his patients with trauma and social anxiety problems.

Proponents of narrative therapy hold that we all have different stories involving ourselves and other people related to various facets of life, from relationships to work, success, family or health. These stories are key to our identity and how we view the world, but they are incomplete and can be distorted.

We experience an incomprehensible number of events over a lifetime, and to make sense of it all we weave a narrative out of different pieces of information, keeping some that seem important and discarding others that seem irrelevant.

For example, if you have an idea of yourself as a good student, you will accumulate and hold onto memories of a time when you were praised by a teacher or when you performed well on a task. A bad mark in a test might be written off as the result of a bad day, or a poor night’s sleep.

But sometimes these narratives might be off. You might recognise that disconnect in a friend who sees every setback in her life as proof she is a failure, whereas your perception is of a conscientious woman who simply takes more risks than the people around her.

Does this matter? Well yes it does, because it affects the way a person interacts with others and deals with opportunities in the future. If an opportunity arises to continue studying or to undertake a more challenging job, someone who sees themselves as a good student or an achiever is more likely to take that opportunity, reinforcing that positive mindset.

Stories change over time, though. For example, falling into an abusive relationship where your partner continually focusses on times when you have “failed”. This may begin to rescript your narrative, and undermine your confidence to undertake new challenges.

A narrative therapist will look at this script with a patient, and if they both determine that the story is unrealistic or unhelpful, will begin the process of “rewriting” or “reauthoring” the script to give it more depth and nuance.

While the field of psychoanalysis may still carry the connotation of digging up deeply hidden, unconscious memories, Professor Bates says the purpose of narrative therapy is the opposite.

The idea is to talk about the biggest and most obvious stories because these will likely have the most power in their lives, the Swinburne University of Technology lecturer explains. “What we do, is get your perspective on what happened.”

Nonetheless, childhood and adolescent events can be pivotal in shaping a patient’s narrative, because they are incorporated into the emerging idea of self. Over time, these scripts weave different events into them and discard those that don’t align with the plot.

Patients who experience significant social anxiety can often point to an incredibly vivid negative experience or set of experiences in their younger years in a situation that is similar to the current one causing them problems, Professor Bates says. He says the research supports the idea that these memories often coincide with the beginning of the person’s social anxiety.

“We don’t remember everything that happens to us, but we do remember important events,” he says. The most important ones will usually be accompanied by stories of other similar experiences, which can help the clinician identify the scripts.

To illustrate the point, Professor Bates recounts the experience of one of his patients, whose recent distress over what she felt to be bullying at work was reminiscent of a similar experience in grade two. When she thinks about the memory from her childhood, the image is clear and the memory vivid. “She knows what the uniforms are, she can hear the voices and what people are saying to her. She can hear the whole thing,” Professor Bates explains.

The reason this is important is because it provides an opportunity for her to reflect on the significance of the memory then, and how it is still affecting her life now.

Professor Bates could then use techniques such as guided imagery to take her back to that point in her childhood and find other possible interpretations for what occurred. As an adult, she has a greater understanding of the world and can bring compassion to her younger self.

“You then break down the idea that ‘I’m inadequate’ or ‘I’m unlovable’ or ‘people hate me’,” Professor Bates says. “That is what a lot of therapy is about anyway – just another way of looking at things.”

 

 

 

GUIDING PRINCIPLES

Since its conception by the social workers and family therapists, Australian Michael White, and New Zealander David Epston, the Dulwich Centre in Adelaide has become one of the leading institutes providing information and education on narrative therapy.

One of the key principles underpinning this therapy is that the person seeking help shouldn’t be blamed, and this is epitomised in the mantra: “The person is not the problem, the problem is the problem.”

Separating the person from their problem, known in narrative therapy as “externalising”, is a post-structuralist approach that recognises the social, economic, political and other factors that lead to psychological and emotional distress in a person’s life.

Practitioners also eschew a traditional therapy-patient hierarchy, which is done by positioning the patient as the expert in their own lives.

One way of doing this is by allowing patients to describe their concerns in their own language.

Individuals may find themselves receiving therapy for a problem, but not agree with the label they are given by the medical or psychological establishment.

“These are names given to them, and they have no power over that,” explains Ms Tileah Drahm-Butler, a social worker at Cairns Hospital, who works closely with Aboriginal and Torres Strait Islander people. Narrative therapy has been seen as particularly useful for Aboriginal and Torres Strait Islander people, for whom storytelling is an important part of the culture.

The problem is that time and energy spent trying to convince a patient to accept a diagnosis are resources that could be used for treatment, so allowing patients to use “experience near” definitions for their concerns becomes a practical way of overcoming stigmatising or incomprehensible labels, she says.

For example, Ms Drahm-Butler says she might ask an anxious patient where they carry their fear, or what their fear looks like for them, and use that language in therapy with them, while also providing a patient history or letter to other clinicians that explains the situation in commonly accepted medical terminology.

Ms Drahm-Butler says that while she understands the need for diagnostic psychological labels to ensure the client can access treatment and resources in our current system, “for some people that won’t fit”.

One example is a client of Ms Drahm-Butler’s who presented to the hospital with chest pains, and said it felt like she was going to die. After being tested and then receiving the all-clear from the cardiovascular team, the clinicians determined the patient was having panic attacks.

This is a common occurrence, Ms Drahm-Butler says, with patients left trying to gel the experience of feeling like they were about to die with the diagnosis of anxiety or a panic attack.

For this one woman, who was experiencing domestic violence, the word “panic” was something that she associated with a hysterical response to a scary event.

Instead, the patient described her feelings more like being overcome with anger.  “We started to talk about being so pissed off, and being so angry, that your body has a physical response,” Ms Drahm-Butler explains. “Then she was able to talk about other times she could feel that coming on, and it was always around the violence and the injustice of that.”

A narrative approach recognises the role of those external factors in the patient’s mental wellbeing, and reassuring them that it is not the individual themselves who is disordered, weak or wrong.

In this case, Ms Drahm-Butler says there was “injustice going on and her body was responding to that”.

Externalising the problem in this way is also thought to make it easier to enact change. After all, it is easier to change a behaviour than it is to change a fundamental personality trait.

Nevertheless, Ms Drahm-Butler cautioned against externalising acts of violence. “That’s one area where there can be a little bit of confusion or misinterpretation. We never talk about a problem as though the person doesn’t have responsibility over it – people have to be accountable for violence.”

HOW DOES IT WORK?

While it may seem that reinterpreting memories may be easier to do if they are recent and fresh in the person’s mind, narrative therapy can be just as useful in situations that occurred long ago.

“If you think of an autobiographical memory, it’s not something that is located deep in the past, it’s actually something that’s created now by you,” Professor Bates says.

“So, if you give me one of these important memories you have, it is your current view of that experience, and it’s created by what happened to you, but also how you’ve interpreted it and your view of yourself.”

“These memories represent the issues for you now,” Professor Bates says. “If we look at you telling the story, the sorts of things you’re emphasising in your story are broad unresolved issues that are connected to the problem that you have now.”

And because the story is being created in the retelling here and now, it can be adapted or rethought as you review it, he says.

Re-authoring the memory may change its emotional power by fleshing it out with more neutral or positive details. But the core elements of the memory won’t necessarily change. For example, a woman experiencing domestic violence might talk about how weak she is for staying, but a narrative practitioner could draw her attention to the strength she is overlooking in herself, Ms Drahm-Butler says. As a clinician, she might draw attention to the reasons the woman stays, which may be to protect her children, and the ways in which she displays resilience by trying to prevent the worst harms.

This helps to create a more complex and optimistic self-image.

Similarly, Professor Bates says narrative therapy strives to create “integrated memories” that recognise the good and bad in past events rather than simply ones that cause distress. A particularly difficult time during childhood could be recognised as an opportunity in which the client developed self-knowledge and useful skills, and could be viewed as a period in which his mother was going through a tough time.

Professor Bates is clear that the approach is not designed to create a Pollyanna fantasy of past experiences where nothing was ever hurtful, rather, it is about integrating the memory into a constructive story of your life.

“An integrated memory is showing you know how something fits into your life,” he says.

On the other hand, non-integrated memories are painful memories that the client hasn’t resolved, that keep coming back. A period of humiliation or regret that continues to cause angst would be one of these “contaminated” memories.

Of course, narrative therapy is not for everyone. Professor Bates says some people may be less suited for therapy that relies on memories.

He gives one example of a patient whose anxieties or troubles mostly manifest in physical symptoms, and so as someone who doesn’t spend much time reflecting, a narrative approach may not be especially useful.

EVIDENCE

Narrative therapy has, at times, been viewed with some scepticism by mainstream psychology and psychiatry, in part due to the challenges in evaluating a more amorphous approach than something such as CBT, and in part due to its deviation from accepted psychological labels.

There is some evidence for its use in anorexia, anxiety, youth mental health and depression and PTSD, and proponents say the approach can be useful for many more. As yet, the evidence base is limited.

However, Professor Bates says the approach is often well-received by patients, many of whom find it an “A Ha!” moment in understanding themselves.

“For people who find this approach useful, it is helping them making sense of their life, as well as their past, present and future.”

The idea of the life story being a form of understanding one’s identity and personality has developed rapidly, alongside traditional personality theory in psychology, he says.

Trait theory, which is the idea that we have fixed characteristics underlying our behaviour, is the traditional conception of personality. These “Big Five” personality traits are summed up in the acronym OCEAN: openness to experience, conscientiousness, extraversion, agreeableness and neuroticism.

“We know that people who have anxiety and depression tend to be higher on the broad personality dimension of neuroticism, that they’re ‘hardwired’ more towards anxiety, anger, depression and emotional distress,” Professor Bates says.

But while that explains some of people’s behaviour by capturing the “climate” of a personality, it doesn’t actually describe how we engage with life, he says.

“Your day-to-day existence has more to do with your stories and your experiences of them.”