Narrative Therapy Approaches for Physical Health Problems

Facilitating Preferred Change

Lincoln Simmonds, Louise Mozo-Dutton, Lincoln Simmonds, Louise Mozo-Dutton

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429837555
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Narrative therapy is an exciting and evolving psychotherapeutic approach. Narrative Therapy Approaches for Physical Health Problems takes the reader on a journey across the territory of narrative therapy theories, principles, and practices, and its application to the field of physical health. It explicitly considers a person's context and explores ways of intervening that go beyond the individual. This includes working with medical teams, engaging in conversations about broader narratives of health and wellness, alongside ideas for adapting practice to take account of particular settings and client groups. Although a lot of theoretical ground is covered, the overarching remit of this book is as a practical guide. The book is peppered with examples, which help explain concepts and illustrate how ideas look in practice.

Narrative Therapy Approaches for Physical Health Problems is a book for all professionals who are therapeutically supporting people with physical health problems, across the lifespan. It is intended for those that have an interest in understanding more about how to address the emotional needs of the people with whom they work.

CHAPTER ONE


Problem exploration

Lincoln Simmonds

Problem exploration in narrative therapy is not simply narrative therapy’s equivalent to assessment. There is overlap with other therapeutic approaches in terms of the therapist exploring the quality of difficulties, the history of the concerns, and how the person is affected. However, the narrative therapist is not working to see how the person’s difficulties fit with models or theories of mental health. Rather, problem exploration is a re-orientating of the person (and the therapist) in terms of how they view the problem. In narrative therapy, the purpose of problem exploration is to work towards an appreciation of the person’s understanding of the problem. As with other therapies, the principles and assumptions of narrative therapy inform the assessment methods. Therefore, this chapter will begin by looking at these assumptions and principles, and how they inform practice.

I view problem exploration in narrative therapy as a foundation to re-authoring conversations. As the reader is aware, re-authoring conversations involve developing preferred stories. A preferred story is one that speaks of how the person wishes to live their life, in a way that is consistent with what they give value to. In order for a person to move towards preferred (or alternative) story development, the therapist helps the person examine and deconstruct the problem story that they bring to therapy, and this process will be discussed in this chapter.

Dominant discourses of how people experience difficulties can be very influential and often determine how people are viewed, and how people themselves relate to their own experiences. Such discourses exist in a framework of knowledge that states how these difficulties can or should be managed. People coming to therapy often have dominant (problem) stories about the difficulties they experience, which fit with dominant psychiatric, societal, or psychological models of mental health and wellbeing. These discourses of mental health are prominent, widely distributed, and strongly postulated within our society. However, such dominant problem stories may or may not be useful and helpful to the person. Problem exploration is about evaluating such discourses and their personal effects upon the person; as a potential entry point to an alternative story that fits better for the person. It is important to stress that this “storying” of the person’s life is “authored” and “edited” by the person we are working with, not by the therapist. And that this storying may differ to a societal view of “how they should be”.

Narrative, story

People come to therapy with some sense, some explanation, some story of how they are experiencing living with an illness. This story can come from many sources, such as the media, friends, family, and personal experiences. These stories or narratives are the central working material of narrative therapy. A narrative therapist seeks to explore and understand how the person sees the problem. This position requires the narrative therapist to explicitly acknowledge the expertise of the person as applied to his or her own experience.

Narrative therapy is also particularly careful to privilege the per-son’s expertise before that of the therapist. Of course, the narrative therapist can share the knowledge and experience that they have, but this is offered to the person as one possibility among others, with the expectation that the person may or may not see these offerings as either useful or helpful ways of describing their personal experience. Hence the assumption is that the person is helped by the therapist to develop the story that fits best for them.

In a relationship with the problem

Narrative therapy seeks to help the person look at the problem as being separate to themselves. This is counter to ideas or stories that infer, or directly state, that problems relating to human experience are primarily intrinsic to the person. For example, a story that suggests some intrinsic deficit, failure, or weakness in a person might be one of:

She has just not accepted that she has diabetes, after a while people have just got to “get on with it”, but she keeps acting as if she doesn’t want it.

The narrative therapist would instead invite the person to view themselves as being in a relationship with the problem:

So how does The Diabetes affect you?

Are there times when you just have enough of The Diabetes, and don’t want anything to do with it at all?

The narrative therapist deliberately talks about the problem in relational terms: promoting (or rather offering) the idea that the problem and the person are in a relationship. This helps the person view the problem as being separate to their identity. The person may then begin to see the problem as acting on them, with the potential to then see how they can act upon the problem. The person and the problem are therefore seen as being in a mutual relationship, and having mutual influence upon each other.

Stories told, stories lived

Michael White (2005) emphasised that stories are not simply redundant descriptions of people’s lived experiences. Stories actually have very real effects in that people can live by them. Stories circulated (about a person) can influence perceptions of other people, and thus how those people respond to the person. Difficulties can arise when stories we wish to hold about ourselves are in conflict with experiences. People who value stories of their independence, perhaps in terms of physical ability, may feel that a health condition instead means that they are reliant on others for care. Distress and difficulties can then ensue as a result of such views. Often, though, stories of a person giving value to independence may be less visible to healthcare staff than ones of a difficult and demanding “patient” or a person who seems to have “given up” and is not making progress.

A story circulated about a person having “given up” might lead professionals down a path of referring someone for psychological or psychiatric treatment, perhaps for depression. Whereas a less visible story about a person who feels that they have lost control over their lives could perhaps lead the team to respond to that person differently. Possibly in ways that could be more consistent with how the person wishes the team to work with them. These ideas remind the narrative therapist about the importance of developing stories that the person feels is most helpful to them. This would be in contrast to assuming that the most dominant story shared about a person is the starting point of intervention for us as therapists.

Deconstruction and contextualising

Narrative therapy seeks to deconstruct and contextualise a problem; or rather, the story about the problem (problem story). It endeavours to render the historical, social, relational, and cultural context within which a problem has developed to become known to the person.

She has just not accepted that she has diabetes.

The problem story illustrated implies that the “solution” to the problem is one of the person working to accept the diagnosis, and implications, of diabetes. This may be a helpful and useful storying for some people, in that they may be able to use this to make changes that they would regard as positive. However, it is often difficult to ascertain what such generalised statements mean. Is it a useful, accurate, and helpful story for that person? Does it really explain the particulars of this person’s experience of living with diabetes?

The narrative therapist needs to understand specifically that person’s experience, in order to learn (with the person) how best to help them. Such generalised problem stories often leave the worker with little sense of what the actual person thinks and feels, nor how the person acts in relation to the problem. Narrative therapy refers to such stories as “thin” descriptions of the problem. Thin because a more general view is far more likely to be a less detailed, assumptive description of a person’s experience. Thin descriptions, however, are dominant in society:

Well people tend to come to hospital feeling very unwell. We get them straight again with insulin, and they feel a lot better—relieved, in fact. Then as the days and weeks pass, and they realise that they have to keep testing their bloods. They learn that they have to look carefully at what they eat, and inject insulin. Well, that’s when the problems start. It’s at that point that they really just need to start accepting diabetes, and getting on with things.

The narrative therapist seeks to develop stories specific or more particular to the person’s experience of their illness. In narrative therapy, these are called “experience near” descriptions. In the above example, the worker would explore how the problem of The Diabetes affects the person across situations, relationships, and time. The worker would be developing a thick (richer) description of the problem story. The example below highlights the differences between thin and thick descriptions:

A thin description

James and his family don’t listen to the advice, I don’t think they understand that he has a lifelong condition, and they can’t just rely on exercise. He’s just not accepting that he has diabetes. They’ve been lucky during the “honeymoon period”, because the insulin has helped his pancreas whilst it is still working, but that won’t last …

A richer (thick) description of being in a relationship with diabetes

James’ father and mother were both very fit people. His father did marathons and his mother was a wild swimmer. He had been training to compete for the district trials in the 400 m and 200 m, when Diabetes came into his life. It was hard for him to believe that he had diabetes: his family had always eaten healthily, no one else in his family had this diagnosis, and his parents had been very careful with his training regime. And yet The Diabetes seemed to have the control now. He wasn’t sure he could rely on his body, or trust it any more. Mistrust and Feeling All at Sea seemed to be in league with The Diabetes. All he knew was to try and power through it, to make his body stronger, gain more control over it. He questioned how much insulin he should take: “Would his body become more and more reliant on it?”; “Might his diabetes get worse?”; perhaps there were other ways, other more natural approaches? Couldn’t he control his blood sugar through just being very fit and eating well?

Multi-storied lives

Dominant stories are often put forward as right, correct, or true explanations of human experience. This practice is supported by the idea that knowledge can be derived generally from people’s experiences, and then accurately applied to an individual’s unique experience. Thus, it can be argued from this position that each person’s experience of living can be reduced to general explanatory categories and stat...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• About the Editors and Contributors
• Foreword
• Note about Case Studies
• Introduction
• Chapter One Problem exploration
• Chapter Two Re-authoring conversations
• Chapter Three Discourse and narratives of illness
• Chapter Four Facilitating preferred change for children and young people
• Chapter Five Facilitating preferred change within in-patient settings
• Chapter Six Narrative practice and indirect ways of working
• Chapter Seven Narrative practice and the written word
• Glossary
• Index