Narrative Therapy

Narrative therapy emerges from social constructivism, which assumes that events in life are inherently ambiguous, and the ways in which people construct meaning are largely influenced by family, culture, and society.

Narrative therapy assumes that people's lives, including their relationships, are shaped by language and the knowledge and meaning contained in the stories they hear and tell about their lives. Recent approaches to understanding psychological growth have emphasized using storytelling and mythology to enhance self-awareness (see Campbell, 1968; Feinstein and Krippner, 1997; Middelkoop, 1989).

Parker and Horton argue that "Studies in a variety of disciplines have suggested that all cognition is inherently metaphorical" and note "the vital role that symbolism plays in perception" (Parker and Horton, 1996, p. 83). The authors offer the "perspective that the universe is made up of stories rather than atoms" and suggest, "Myth and ritual are vehicles through which the value-impregnated beliefs and ideas that we live by, and for, are preserved and transmitted" (p. 82).

From this perspective, narratives reveal a deeper truth about the meanings of our experience than a factual account of the events themselves. As Feinstein and Krippner note, "Personal mythologies give meaning to the past, understanding to the present, and direction to the future" (Feinstein and Krippner, 1997, p. 138).

When people tell and retell their life stories (with the help of a therapist), the stories evolve into increasingly meaningful and healing constructions. As narrative therapists listen to the stories clients tell, they assist them by identifying alternative ways of understanding events in their lives.

Thus, they help clients to assume authorship of their lives in order to rewrite their stories by breaking patterns and developing new solutions. Narrative therapy helps clients resolve their problems by

Helping them become aware of how events in their lives have assumed significance

Allowing them to distance themselves from impoverishing stories by giving new meaning to their past

Helping them to see the problem of substance abuse as a separate, influential entity rather than an inseparable part of who they are (note the discrepancy between this and the AA member's statement, "My name is Jane, and I am an alcoholic")

Collaboratively identifying exceptions to self-defeating patterns

Encouraging them to challenge destructive cultural influences they have internalized

Challenging clients to rewrite their own lives according to alternative and preferred scripts

Narrative therapy can be a powerful approach for engaging clients in describing their lives and providing them with opportunities to gain insight into their life stories and to change those "scripts" they find lacking.

Storytelling is a way of articulating a subjective, experiential truth, and it is important for the therapist and client to become aware of the significance of the story being told and its potential therapeutic value.

Narrative approaches to psychological healing have been used across various cultures for thousands of years (Katz, 1993), but they have often been overlooked by mainstream mental health professionals. Contemporary approaches to narrative therapy recognize the importance of understanding how human experience becomes meaningful.

A person's life is influenced by the narratives he constructs, which are in turn influenced by the narratives of those around him. Thus, therapy is viewed as a collaborative attempt to increase clients' awareness of the ways in which events in their lives become significant. In effect, the therapist says, "Let's be curious about your story together."

The narrative approach often involves posing questions in a way that situates the problem as an external influence. "When the problem is externalized, it's as if the person can peek out from behind it" (Nichols and Schwartz, 1998, p. 412). In substance abuse treatment, for example, a client might be asked, "How has substance abuse influenced your life?" or "Have there been times when you did not allow addiction to take over?"

Such questions can help identify positive aspects and potential resources occurring in people's narratives that can be enhanced, as well as deficits that must be overcome.

In an effort to be understood, clients sometimes tell a story as a way of educating the therapist to their culture or lifestyle. Therefore, it is essential for the therapist to appreciate the unique influences (positive and negative) of the client's specific cultural experiences and identity.

Often these stories do not constitute sharing in its usual meaning. When listening to them, one may sense that these stories have been told repeatedly over the years. It is through this sense of storytelling--as oral history--that we reveal our values, expectations, hopes, and fears. For the therapist, a story provides insight into the clients' responses, their need to act on the responses, and their desire to be heard or understood. A story can become a way for a client to become both participant and observer in order to find new solutions or break down barriers.

Response to the case study

The therapist may initially ask Sandra to describe some of the important transitional moments in her life. These may include examples of loss of innocence occurring early in her life, her experience of school, circumstances and influences surrounding prostitution and drug use, the experience of being supported by her husband, and internal resources that enabled her to enter treatment and maintain sobriety.

The therapist would ask questions about expectations she felt from family, society, and herself. She may be asked questions like, "How did addiction interfere with your attempts to be a good mother" or "How has fear contributed to your recent relapse and feelings of hopelessness?"

Positive aspects of her story and exceptions to destructive aspects of her narrative could be identified by asking questions like, "Were there times that you didn't allow addiction to make choices for you?" and "How has your ability to accept love and support from your husband helped you?"

The focus of therapeutic dialog could then shift toward developing alternatives to hopeless aspects of personal and cultural expectations. It would be helpful to remind her that recent advances in medical treatments mean that AIDS may not be the death sentence it was once thought to be.

Other important questions can help her to begin to create an alternative story: "As you begin to understand the positive and negative influences in your life, what qualities must you possess in order to remain sober and develop better relationships with your husband and children?" She may need help replacing these stories with more positive narratives about herself.

As Sandra talks about the people and events in her life, such as her childhood and her children, she can discover some of her feelings, as well as the personal meaning in her story. She can experience a great deal of healing through the therapist's feedback and questions that uncover the desires and emotions beneath her story. A continued focus on identifying, practicing, or even imagining changes in her story can begin the process of developing new ways of living.

Transpersonal Therapy

Transpersonal psychology emerged as a "fourth force" in psychology in the late 1960s and has strong roots in humanistic and existential psychologies, Jungian analysis, the East-West dialog, and ancient wisdom traditions. Transpersonal therapy may be thought of as a bridge between psychological and spiritual practice.

A transpersonal approach emphasizes development of the individual beyond, but including, the ego. It acknowledges the human spiritual quest and recognizes the human striving for unity, ultimate truth, and profound freedom. It cultivates intuitive ways of knowing that complement rational and sensory modes. This approach also recognizes the potential for growth inherent in "peak" experiences and other shifts in consciousness. Although grounded in psychological theory, transpersonal practitioners also tend to incorporate perspectives from ancient wisdom traditions.

The practice of transpersonal therapy is defined more by its orientation and scope rather than by a particular set of techniques or methods (Boorstein, 1980). Wittine suggests five postulates for a transpersonal psychotherapy (Wittine, 1989):

Transpersonal psychotherapy is an approach to healing and growth that recognizes the centrality of the self in the therapeutic process.

Transpersonal psychotherapy values wholeness of being and self-realization on all levels of the spectrum of identity (i.e., egoic, existential, transpersonal).

Transpersonal psychotherapy is a process of awakening from a limited personal identity to expanded universal knowledge of self.

Transpersonal psychotherapy makes use of the healing restorative nature of subjective awareness and intuition in the process of awakening.

In transpersonal psychotherapy, the therapeutic relationship is a vehicle for the process of awakening in both client and therapist.

Integrating insights and practices in everyday life is the goal of every therapy. Bringing the transpersonal dimension to the forefront may involve the following:

Exploration of "inner voices" including those of a higher self that provides guidance for growth of the individual (Rowan, 1993)

Refinement of intuition or nonrational knowing

Practice of creativity in "formal" (art) or informal (personal relationships) encounters

Meditation
Loving service
Cultivation of mindfulness
Use of dreams and imagery

These techniques may be taught and supported explicitly in the therapy session. At times, a therapist may directly cultivate shifts in consciousness (e.g., through meditation [Weil, 1972], or imaginal work [Johnson, 1987]), providing immediate insight and inspiration that may not be available through more conventional means (Hart, 1998). This may provide clients with a skill they can practice on their own; initiating such activity represents a potential for brief intervention.

Transpersonal therapy recognizes the need for basic psychological development to be integrated with spiritual growth (Nelson, 1994). Without such integration there is danger of "spiritual bypassing," where issues of basic psychological functioning are avoided in the name of spiritual development. In other words, the basic psychological work should be undertaken first.

Substance abuse disorders may be seen broadly as an attempt to fill a spiritual void. They may also be understood as a means for the ego to defend itself against a natural drive for growth. If growth were to occur, the ego might find its dominance relinquished. Addiction, like spirituality, also raises questions of surrender (May, 1991): for example, to what and to whom do we surrender?

In a culture and a psychology that are dominated by issues of rational ego control, what is the role of constructive surrender (regularly described in spiritual traditions)? How does constructive surrender become destructive and distorted in substance dependency? In addition, substance abuse may be understood as a means for shifting out of a normal waking state of consciousness. This may be an attempt to fulfill an innate drive (Weil, 1972) for nonrational consciousness.

Response to the case study

As the existentialists remind us, there is nothing like death to rivet our attention. A glimpse of death--for example, seeing the aftermath of a serious car crash--reminds the witness of how valuable life is, bringing up other issues as well. Sandra is now confronted with death due to AIDS. This opportunity to face death and life squarely provides a chance to reconsider and reprioritize her life.

In fact, it could be argued that the best catalyst to brief therapy may be a death sentence precisely because it has the potential to wake up an individual. In many respects, helping the client wake from habitual, mechanical routines that are often based on ego protection and move toward an appreciation that the individual is not bound to or defined by a limited ego, is the goal of transpersonal therapy. This can be seen as a transformation of identity.

Many inspiring instances of people facing death, including death through AIDS, have shown that emergent spirituality can change the quality and direction of existence very quickly. For treatment, the basic sharing of these experiences with a group of others in a similar predicament often quickly moves the client beyond isolation and a sense of self-separateness to connect intimately with others who understand her situation.

This community may not only bring comfort and support but also a deep sense of communion with humanity. In this instance, breaking through the shell of isolation may enable Sandra to begin to make new connections with her family and with herself. A sense of interconnection, a central postulate and experience in the wisdom traditions, may replace her perceived isolation.

Sandra may use this opportunity of facing possible death to begin to encounter and let go of such feelings as guilt, shame, disappointment, and anger that have kept her life less satisfying than it could be. Accessing the imaginal through art or dreams, for example, can provide a clear and symbolic expression of unresolved issues. The use of rituals or rites-of-passage inspired by the wisdom traditions can provide some catalyst for shifting her consciousness through forgiveness and release.

The therapist may engage in a wide variety of methods (e.g., imagery, art, or dream work, meditation, rituals), but the heart of the work is in the simple and humane spirituality that is embodied by the therapist's loving presence along with the therapist's openness to explore the full range of human experience directly. For Sandra, this experience may be seen as an opportunity for practicing love and forgiveness, moving out from behind rigid self-separateness, facing fears, and transforming her self-definition.

Gestalt Therapy

Gestalt theory holds that the analysis of parts can never provide an understanding of the whole. In a therapeutic setting, this approach opposes the notion that human beings can be understood entirely through a rational, mechanistic, scientific process. The proponents of Gestalt therapy insist that the experiential world of a client can be understood only through that individual's direct experience and description.

Gestalt therapists seek to help their clients gain awareness of themselves and the world. Discomfort arises from leaving elements and experiences of the psyche incomplete-- primarily past relationships and intrapsychic conflicts that are unresolved, which Perls calls "unfinished business" (Perls, 1969). According to Gestalt theory

The organism should be seen as a whole (physical behavior is an important component, as is a client's mental and emotional life).

Being in the "here and now" (i.e., being aware of present experience) is of primary importance.

How is more important than why (i.e., causes are not as important as results).

The individual's inner experience is central.

For Gestalt therapists the "power is in the present" (Polster and Polster, 1973). This means that the "now" is the only place where awareness, responsibility, and change can occur. Therefore, the process of therapy is to help the client make contact with the present moment.

Rather than seeking detailed intellectual analysis, the Gestalt therapist looks to create a "safe emergency" in the therapeutic encounter. Perls' invocation to "lose your mind and come to your senses" implies that a feeling-level, "here and now" experience is the optimal condition for therapeutic work.

This may be accomplished in a fairly short amount of time by explicitly asking clients to pay attention (e.g., "What are you aware of now? How does your fear feel to you?"). The therapist may point out how the client could be avoiding the present moment through inauthentic "games" or ways of relating such as "talking about" feelings rather than experiencing them directly.

Clients may be asked to exaggerate certain expressions (e.g., pounding a fist) or role-play certain internal dialogs (e.g., through an empty chair technique). These may all serve the goal of helping clients move into the immediacy of their experience rather than remaining distant from it through intellectualization or substance abuse.

The term contact in Gestalt refers to meeting oneself and what is other than oneself. Without appropriate contact and contact boundaries there is no real meeting of the world. Instead, one remains either engulfed by the world on one hand or, on the other hand, distant from the world and people.

Substance abuse interrupts the flow of what Perls called "organismic self-regulation." The result is that individuals do not achieve satisfaction of their needs and can remain unaware of what their needs are. The substance abuser may distort or thwart the natural cycle at any of the following points:

Experiencing the need
Mobilization of energy
Contact
Satisfaction
Withdrawal
Rest

Treatment involves bringing awareness to each of these dimensions and the client's strategies of avoidance.

Substance abuse may also be understood as "introjection" in which the client attempts to "swallow whole" or "drink in" his environment without contact and discrimination. This type of client bypasses and blocks other experiences that might enable contact and the development of discrimination. Perls maintains that such a client seeks immediate confluence without preparatory contact. This pattern of interaction extends to other relationships (besides the substance) as well.

In order for this work to proceed, the therapist must maintain a fine-tuned, present-moment immediacy, even serving as a "resonance chamber" (Polster and Polster, 1973) for the client's experience. They, too, must be able to make and sustain contact with the client and with their own reactions.

Response to the case study

The Gestalt therapist begins with Sandra's current experience of the world, starting with awareness and attention. The therapist may simply help her become aware of basic sights, sounds, somatic reactions, feelings, and thoughts as well as what her attention drifts to. The immediate contact between therapist and client is a component of the "now" where these sensations are explored directly.

The therapist might notice and ask about her style of eye contact, or her fidgeting body, or stream of thoughts (e.g., "What is it like to make eye contact now? What is the sensation in your body at this moment?").

Sandra may also identify certain issues such as substance abuse, relationship difficulties, and the threat of death from AIDS that seem to dominate her life. The therapist might invite her to name and explore the sensation that the thought of death, for example, brings; perhaps this involves a sense of a void, or feeling cold and dark, or a feeling of engulfment.

She then may be asked to become these sensations--for example, the therapist may ask her to be "the void" and encourage her to speak as if she were that void. This may then open possibilities for a dialog with the void through acting out the opposite polarity: separateness and choice. This might involve using an empty chair technique in which the client would literally move into the chair of the "void," speak as if she were that, and then move into an opposite chair and respond in a dialog.

A therapist could also explore her introjection through questions such as, "How is this void different or the same as from the feeling of alcohol or in relationships with your children or husband?" She might also use this same technique to dialog with family members, or certain aspects of herself.

Sandra seems to have a great deal of "unfinished business" that involves unexpressed feelings (e.g., anger, longing, hurt). Experimentation with these sensations may begin to free her to express and meet these feelings more directly. All of this work encourages Sandra's experimentation with new ways of relating both during and outside of the session in order to move into the "here and now" and work toward the resolution of "unfinished business."

The Existential Approach To Therapy

The existential approach to therapy emphasizes the following six propositions:

All persons have the capacity for self-awareness.

As free beings, everyone must accept the responsibility that comes with freedom.

Each person has a unique identity that can only be known through relationships with others.

Each person must continually recreate himself. The meaning of life and of existence is never fixed; rather, it constantly changes.

Anxiety is part of the human condition.

Death is a basic human condition that gives significance to life.

The core question addressed in existential therapy is "How do I exist?" in the face of uncertainty, conflict, or death. An individual achieves authenticity through courage and is thus able to define and discover his own meaning in the present and the future. There are important choices to be made (e.g., to have true freedom and to take responsibility for one's life, one must face uncertainty and give up a false sense of security).

A core characteristic of the existential view is that an individual is a "being in the world" who has biological, social, and psychological needs. Being in the world involves the physical world, the world of relationships with others, and one's own relationship to self (May and Yalom, 1995, p. 265). The "authentic" individual values symbolization, imagination, and judgment and is able to use these tools to continually create personal meaning.

Existential therapy focuses on specific concerns rooted in the individual's existence. The contemporary existential psychotherapist, Irvin Yalom, identifies these concerns as death, isolation, freedom, and emptiness. Existential therapy focuses on the anxiety that occurs when a client confronts the conflict inherent in life.

The role of the therapist is to help the client focus on personal responsibility for making decisions, and the therapist may integrate some humanistic approaches and techniques. Yalom, for example, perceives the therapist as a "fellow traveler" through life, and he uses empathy and support to elicit insight and choices. He strongly believes that because people exist in the presence of others, the relational context of group therapy is an effective approach (Yalom, 1980).

Preliminary observations and research indicate individuals with low levels of perceived meaning in life may be prone to substance abuse as a coping mechanism. Frankl first observed this possibility among inpatient drug abusers in Germany during the 1930s (Frankl, 1959).

Nicholson and colleagues found inpatient drug abusers had significantly lower levels of meaning in life when compared to a group of matched, nonabusing control subjects (Nicholson et al., 1994). Shedler and Block performed a longitudinal study and found that lower levels of perceived life meaning among young children preceded substance abuse patterns in adolescence (Shedler and Block, 1990).

In the context of treating substance abuse disorders, the existential therapist often serves as a coach helping the client confront the anxiety that tempts him to abuse substances. The client is then focused on taking responsibility and making his own choices to remain substance free.

If he chooses to avoid the anxiety through substances, he cannot move forward to find truth and authenticity. The challenge for the existential therapist is to help the client make personal decisions about how to live, drawing upon creativity and love, instead of letting outside events determine behavior.

Time and Existential Therapy

Although existential therapy may not have been designed for practice in a time-limited fashion, its underlying principles relating to the client's struggle for meaning in the face of death can be applied to a time-limited setting. Brief therapy (no matter what the modality) must be concerned with the "here and now." Both existential and brief therapies are also concerned with the limitations of time. Hoyt suggests that in brief therapy time should always be an issue for discussion, and the therapist should make a point of reminding the client of his use of time and the time scheduled for terminating therapy (Hoyt, 1995).

Mann's model of time-limited psychotherapy (Mann, 1973; Mann and Goldman, 1994), although based in part on psychodynamic theory, also uses an existential approach to the primacy of time. In Mann's approach, the time limitation of brief therapy is emphasized to help the client confront issues of separateness and isolation. This facilitates the client's becoming engaged in and responsible for the process of recovery.

Response to the case study

An existential therapist may help Sandra understand that her diagnosis of AIDS forces her to confront the possibility of death and, consequently, face the responsibilities thrust upon her by life. The therapist could accomplish this by helping her understand that her life (like everyone else's) is finite.

Therefore, she is challenged to forge meaning from her life and make difficult decisions about her relationships and ways of dealing (or not dealing) with choices about substance abuse. The focus in her therapy would be on choosing the life she wants to live.

The therapist would assist her in dealing constructively with anxiety so that she can find meaning in the rest of her life. This could be accomplished by engaging her in the struggle to assume authorship of her choices. She may be encouraged to "play out" scenarios of choices she faces and acknowledge the accompanying fears and anxieties.

She might be asked, "What keeps you from sharing your fears with your husband, and accepting the possibility of his support?" or "Imagine yourself expressing your love for your children and regret for the mistakes you have made." Thus, the therapist would help her understand that making difficult choices in the face of death is actually a way to find integrity, wholeness, and meaning.

The teachings of the existential therapist, Yalom, can be a useful resource in dealing with issues related to death, since he has worked with terminally ill cancer patients for many years, helping them to use their crisis and their danger as an opportunity for change (Yalom, 1998).

Yalom explains that although death is a primary source of anxiety for a client, incorporating death into life can enrich life and allow one to live more purposefully.
 
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From SAMHSA/CSAT  Treatment Improvement Protocols
TIP 34: Brief Interventions and Brief Therapies for Substance Abuse