Narrative Therapy: Case Conceptualization and Treatment

Introduction to Narrative Therapy

Narrative therapy is a postmodern therapeutic approach that focuses on the stories, or narratives, that people form and develop to explain meaning in their lives (White & Epston, 1990). Narratives are affected by social constructions and subjective interpretations of events in people's lives. The therapist attempts to help the client by working collaboratively to modify narratives that are ineffective or detrimental to the client's functioning (White & Epston, 1990). The narrative therapy approach was developed in the 1970s by Michael White and David Epston (White & Epston, 1990) and gained acceptance in counseling and psychotherapy circles following a series of influential books. Catrina Brown is a well-known therapist and author specializing in applying narrative therapy to women's issues. Narrative therapists most commonly concentrate on family and couples therapy; however, they can also be found in individual client therapy, education, and community psychology programs (Brown, 2007; Winslade & Monk, 2000).

In the initial meeting, the therapist will typically ask the client to explain their situation — their narrative — and listen attentively to everything the client relates. By using active listening techniques, the therapist can implicitly communicate to the client that they are engaged in the client's subjective experience and begin to form a therapeutic bond (White & Epston, 1990). Narrative therapists reject the traditional notion that the therapist is either an all-knowing expert or someone who knows absolutely nothing and must learn entirely from the client (Brown, 2007; White & Epston, 1990). Michael White avoids using terms like therapy, counseling, therapist, and patient, and instead views the process as a collaboration between the client and the counselor (White, 2007). Narrative therapists take the position that both the client and the therapist have specific areas of understanding and are "partial knowers," which allows them to work together in a collaborative relationship to explore the client's narratives and develop narratives that are more functional (Brown, 2007). Both parties are thus seen as equals who, by necessity, must work together to understand the client's perspective and develop alternative narratives that are more functional and free from the constraining influence of social constructions.

Change occurs through a process of seeking to understand the client's experiences via listening, reflection, and collaboration in order to alter the client's narratives. Therapists avoid traditional interpretation, pathologizing, and prediction, and instead collaborate with the client to assist them in experiencing a heightened sense of agency — that is, the ability to function effectively in society (Wells, 2011). The therapists seek to help develop satisfying narratives for their clients by deconstructing problem-saturated stories and then helping to re-author these narratives in ways that support more preferred outcomes (West & Bubenzer, 2002).

Case Example

Joanne is a 64-year-old woman who lost her long-time partner, Anne, to an unexpected heart attack one year ago. Having been together for 31 years, Joanne reported that she was having significant difficulty "moving on and taking care of basic things." She has not returned to her part-time position at the local library and generally avoids contact with friends and family — including her two adult sons from an earlier marriage — saying that she does not want to "burden" them with her problems. She has avoided dealing with much of the legal paperwork resulting from her partner's death and ruminates about her relationship with Anne, focusing on feelings of not having appreciated her enough during their time together. She feels "lost" and is unable to find purpose or meaning in her life. She experiences strong feelings of worthlessness and spends hours thinking about how she "should" have lived her life differently.

Once an avid hiker and golfer, Joanne has not participated in either activity since Anne's death. She reports that she now wakes up late, "putters around the house," and takes a nap in the afternoon. She is eating poorly, relying on takeout food and sweets for meals.

Case Conceptualization

Joanne lost her partner and has been displaying these behaviors for much longer than is typically considered a normal period of grief. It is important for the therapist to listen carefully to Joanne in order to understand how she interprets the world, how her behavior reflects her interpretation of what defines meaning in her life, and to ask clarifying questions so as to understand how the client constructs meaning (White & Epston, 1990).

Joanne appears to foster a dominant narrative in which she is somehow responsible for the events that occur within her sphere of experience — even events over which she has no control. This dominant narrative is clearly evident in her reaction to the loss of her partner. Joanne believes that if she had treated her partner better, or if she had lived a better life, her partner might still be alive. Her ruminations about how she should have lived her life, her memories of good times with Anne, and her implicit connection between her loss and her own perceived shortcomings all indicate that she feels responsible for her partner's death, even though she clearly is not. The dominant narrative is also apparent in her reluctance to open up to her own children, because doing so, she believes, would be "burdening" them. Joanne feels that any expression of her pain and grief to others — even her own family — imposes a burden on them. In order to feel useful, she believes she must be perfect. This notion of what "perfect" means to her is an important area for further exploration. Joanne feels guilt, loneliness, and even shame, as though the death of her partner is her fault. These feelings have resulted in depressive symptoms and a near-complete withdrawal from her former activities.

It is likely that Joanne has many experiences that reinforce this dominant theme. For example:

1. Joanne may have been judged negatively by her parents — or perceived that she was judged negatively — when she did not live up to their expectations.

2. Joanne may have perceived that she was judged negatively by her teachers at school when she did not meet their expectations.

3. Joanne may have perceived that she was negatively judged by her peers when she did not live up to social expectations.

4. Joanne may have judged herself negatively when she did not live up to her own standards.

These hypotheses, as well as others, would be investigated alongside additional events that may have contributed to the belief that she is responsible and accountable for everything that occurs within her sphere of perception. As Joanne's dominant narrative continues and is subjectively reinforced over the course of her life, it becomes increasingly unlikely that she would be able to recognize evidence that contradicts it (White & Epston, 1990). Life incidents that do not support her dominant narrative are probably ignored or discounted, whereas instances that do support it are remembered and selected as evidence that her dominant narrative represents reality.

References

Brown, C. (2007). Situating knowledge and power in the therapeutic alliance. In C. Brown & T. Augusta-Scott (Eds.), Narrative therapy: Making meaning, making lives (pp. 3–22). Thousand Oaks, CA: Sage.

Combs, G., & Freedman, J. (2012). Narrative, poststructuralism, and social justice: Current practices in narrative therapy. The Counseling Psychologist, 40(7), 1033–1060.

Payne, M. (2006). Narrative therapy (2nd ed.). London: Sage.

Wells, K. (2011). Narrative inquiry. New York: Oxford University Press.

West, J. D., & Bubenzer, D. L. (2002). Narrative family therapy. In J. Carlson & D. Kjos (Eds.), Theories and strategies of family therapy (pp. 45–69). Boston: Allyn and Bacon.

White, M. (2007). Maps of narrative practice. New York: W. W. Norton & Co.

White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: W. W. Norton.

Winslade, J., & Monk, G. (2000). Narrative mediation: A new approach to conflict resolution. San Francisco: Jossey-Bass.