Applying Narrative Therapy to Case Study

Applying Narrative Therapy

Clinical Practice with Individuals and Families III

Client Information

Client is a sixty-five-year-old cisgender Caucasian female utilizing she/her pronouns. Client currently lives alone in a one-bedroom apartment in the Riverdale section of the Bronx.

Brief History of Issue

Primary Issue  

Client voluntarily sought mental health support to address recent stressors directly related to dynamics with her only daughter. Client’s daughter is a thirty-eight-year old cisgender female and lives with her husband and two children in Woodstock, New York. Prior to marrying her husband and moving upstate, client’s daughter was a successful artist and happily independent individual living in Brooklyn. During this time and in years prior, client reports she and her daughter had a fun-loving relationship. This relationship, however, began to change shortly after client gave birth to her first child. Within a year of giving birth to her daughter, client’s daughter’s husband was diagnosed with cancer. Unable to manage the children and the role of caretaker for her husband, client offered to support her daughter. Unable to sacrifice her career as a music teacher in Westchester country, client reluctantly suggested her daughter’s family move into her apartment.  Despite major reservations, client felt she had a motherly obligation to her daughter in this traumatic time of her life. Ultimately, client’s family lived with her for one full year, client having been displaced from her bedroom to the living area of her tiny apartment. During this time, client reports feeling consistently stressed and anxiety-ridden as she was forced to take on the role of babysitter, maid, and roommate. Unable to communicate these feelings, client became growingly resentful of her daughter who, in the client’s opinion, failed to acknowledge the chaos and disruption nor appreciate her mother’s generosity. Though client identified a strain in their relationship, she reports having felt hopeful she and her daughter would recover from this challenging period of time. For the next two years, client reports maintaining a decent relationship with her daughter though acknowledged a shift had occurred during their stint as roommates.

This past summer, client’s daughter again requested she and her family move into her mother’s apartment as she had been offered a job as a professor in Manhattan. Still unable to communicate honestly, client agreed her daughter’s family could live in her apartment. Knowing there was a time frame to this professional engagement, from May until August, client felt these constraints would make the experience manageable. Fast-forward to July, client reports exploding on her daughter and demanding she and her family find new living arrangements. Since this altercation, client reports she and her daughter communicate only on an as needed basis. Client reports feeling the need to cut her daughter from her heart despite feeling an obligation to be a support system for her.

Beginning of Issue

 Although issues have become especially problematic recently, client reports a history of unhealthy communication between herself and her daughter. Client raised her daughter alone and describes her as being hot-headed and aggressive all of her life. 

Prior Management of Issue  

Client has engaged in therapy in her younger years to address her tumultuous relationship with her ex-husband. Client has never addressed her relationship with her daughter in a clinical setting. 

Client Data

Developmental History   

 Client was born and raised in the Bronx, New York. Client reports her father was a severe and angry alcoholic. Client describes her mother as a saintly woman as she cared for her family tirelessly. Though client talks highly of her mother, she critiques her for being overly dedicated to a man who treated his family so poorly. Client has one younger brother who she describes as mentally ill. Client reports having to care for him after the death of her parents though maintains he currently leads a self-sufficient life.

 Client was married one time to her ex-husband who she describes as angry and despicable. Client reports having had to raise her daughter alone and cut communication ties with her ex-partner.

Employment History

 Client is a self-employed musician, teaching violin to students in Westchester Country.

Description of Intervention- Narrative Therapy

Historical Background

 Clinician has decided to utilize narrative therapy as the main intervention in work with client. Developed by David Epston and Michael White between 1970 and 1980, narrative therapy is rooted in the notion of separating the person and the problem (Van Wyk, 2014). Rooted in social constructivist thinking, specifically the idea that context plays a complex and significant role in the experience of each individual, Epston and White promoted a strengths-based approach towards working with clients, viewing them as the expert on their lives (Van Wyk, 2014).  Passionate in their positions that objective reality does not exist, Epston and White theorized that guiding clients to externalize problems to create alternative narratives can empower their lives (Van Wyk, 2014).

Major Tenants

 Narrative therapy offers clients the opportunity to consider their life stories from different perspectives (Payne, 2006). Payne (2006) outlined the theoretical approach taken by a clinician using narrative therapy in treatment: Each person has a dominant story related to presenting issues at the onset of therapy, with each of these stories reflecting the ways in which they have come to make meaning of his/her/their problem. Initially, the clinician works to clearly label the presenting issue (Payne, 2006).  Once labeled, the clinician then works with the client to reframe the ways in which the problem is viewed, stressing the importance of learning to see the problem as a reflection of human experience rather than an innate part of an individual’s psychology (Payne, 2006). Additionally, the clinician guides the client to consider the impact larger societal narratives have on the ways in which individuals navigate the world (Payne, 2006). That is to say, society, particularly Western society, is constantly sending messages that influence human experience (Payne, 2006). These powerful messages allow individuals to feel a sense of success or failure that can oftentimes become viewed directly as a reflection of one’s own strengths or deficits rather than influenced by the proscriptive messages we receive (Payne, 2006). Essentially, narrative therapy is used to guide a client to consider a problem from various perspectives outside the lens of the problem being inherent to the person. This experience provides clients with the tools to create new narratives in which to view their various life stories. 

Goals for Treatment

 Freedman and Combs (1996) referenced Michael White’s writing as he discussed Gregory Bateson’s comparison of narrative therapy to maps. They wrote, “White reminds us how Bateson used the metaphor of ‘maps,’ saying that all our knowledge of the world is carried out in the form of various mental maps of ‘external’ or ‘objective’ reality, and that different maps leads to different interpretations of ‘reality”’ (Freedman and Combs, 1996, p.15). Narrative therapy invites clients to consider routes of a problem that may have never been explored. Ultimately, the goal of narrative treatment is the creation of more satisfying stories for clients; as clients gain insight into dominant, self-blaming narratives, they, with the help of the therapist, co-author new, more preferred outcomes (Murdock, 2009).

Why Narrative Therapy?

 As worker reviewed various interventions to implement with client, it seemed most appropriate to utilize either solution focused or narrative therapy. The determining factor in choosing narrative therapy was the intervention’s focus on learning to recognize the role external and cultural factors play in how individuals navigate their worlds (Morgan, 2000). Where solution focused therapy would be helpful in determining client’s goals for her relationship with her daughter, narrative therapy offers the client an opportunity to consider her role as a mother in new and informative ways (O’Connell, 2012). If used effectively, narrative therapy treatment can help client reframe her views about motherhood, which will likely alleviate negative emotions and positively impact client’s relationship with her daughter.

Assessment

 Clinician has had two sessions with client where she has primarily explored her relationship with her daughter. Though work has been brief, sessions have exposed client’s struggle with her role as a mother. Client’s dominant narrative in regard to motherhood appears to be one which tells the story of good mothers as those who sacrifice their own needs for those of their children. This narrative has been heavily influenced by client’s mother’s role as a caregiver, which represents the client’s cultural background, having been raised in a house where gender stereotypes were present and clearly defined. When client became a mother herself, she worked tirelessly to provide for her child without support from her ex-partner or other family members. Client reports having had no choice but to sacrifice her own desires for the betterment of her daughter. At this point in her life, client feels stressed and conflicted as she continues to find herself making sacrifices for her daughter. Client reports feeling a sense of shame and guilt as she no longer wants to support her daughter as directly and tirelessly as she has in the past, creating internal conflict as client has such strong associations of what it means to be a good mother.  All of this considered, the goal of narrative therapy in treatment is to provide client with the space to reshape, or expand, the narrative of her experiences with and perceptions of motherhood. Brown and Augusta-Scott (2007) referenced the effectiveness of narrative therapy in guiding clients to locate the origins of the stories individuals tell.  If utilized effectively, client will gain insight into the various complex factors that have impacted her perceptions of motherhood. While exploring these avenues, client will learn to identify her current life desires and needs without judgement or pressure.

 Considering the exploratory nature of narrative therapy, worker feels he does not need to gather an abundance of information to carry out treatment. Thus far, worker has collected sufficient detail about client’s presenting problem as well as her cultural and historical background. This information has allowed worker to determine client will benefit from dissecting her past through previously unexplored perspectives.  Reflecting on previous sessions, worker posed the following three questions which have proven effective in deciding to utilize narrative therapy in treatment: 1) Can you tell me about your relationship history with your daughter and describe how you communicate with her? 2) Can you talk about your upbringing, including information about your parents and siblings as well the culture in which you associate? 3) Can you talk about what it means to be a good mother? These questions provided necessary insight into client’s dominant narratives. From this information worker learned: Client is feeling extremely conflicted about her relationship with her daughter. While she feels pressure to continue to support her, which is rooted in client’s culture and upbringing, she has reached a point in her life where she can no longer take responsibility to care for her daughter’s needs. At this point in her life, client is willing to jeopardize her relationship with her daughter as to avoid acute stress and chaos. This resignation, however, does not provide client with a sense of peace. Quite oppositely, this determination has lead client to critique her skills and values as a mother. The decision to choose herself over her daughter for the first time in her life has precipitated client to question one of the most important roles in her life.

Intervention in Action

 It is worker’s intention to begin narrative therapy intervention in next session, session three, with client. Worker plans to briefly explain the intervention to client then specifically focus on utilizing the intervention to explore her presenting issue. As client is laboring under the belief that she is demonstrating qualities of a bad or selfish mother, worker intends to spend most of the session exploring the ways in which client has come to perceive the idea of good and bad mothers. As session has obviously not occurred, the following dialogue is a projection of the exchange that will occur between client and worker:

Worker: Over the past two session, we have identified that your major focus in therapy is related to navigating the current dynamics of your relationship with your daughter. I have been thinking about our work moving forward and think the use of narrative therapy would be beneficial. To give you a bit of background, narrative therapy is rooted in the belief that we should learn to look at individual’s problems or issues as being separate from them as a person. In other words, we look to take blame away from the client as being the cause of a particular problem. This intervention allows individuals to explore life stories, or narratives that may have not been explored in a curious and non-judgmental way. As the clinician, I am here to help guide this exploration. What do you think about this idea?

Rationale for Worker’s Words: Before starting this intervention with client, it is necessary to provide her with a basic framework and to clearly identify the issue we will be focusing on. I want to make it exceptionally clear that the intention of this intervention is to learn to look at a problem as separate from the client’s psychology. I also want to make it evident these new narratives will be co-constructed as a dyad.

Client: So you think this intervention will help address the growing stress I’m feeling with my daughter?

Worker: Great question. While I think exploring new narratives will certainly positively impact your relationship and stress level, we will not be explicitly dissecting the conflict between you and your daughter. Rather, I was thinking we would begin by using this intervention to explore your role as a mother and the ways in which you have come to perceive what it means to be a good mother.

Rationale for Worker’s Words: Although client labels her presenting problem as conflict with her daughter, there are many nuances to this problem which can be looked at independently. As client has made the decision to distance herself from her daughter, this has triggered an emotional experience where she is questioning her role as a mother. It seems appropriate to start narrative work here. 

Client: How do you think this will help address my issues?

Worker: Well, in our work thus far, I have noticed you tend to stress that you feel you feel shame and guilt around having to distance yourself from your daughter; you also have labeled yourself as selfish for wanting to lead a life independent from your daughter. I think it will be useful for us to explore different stories that exist in your history that might give us some insight into how you have come to view your role as a mother. By doing this, I think these feelings of guilt and shame may take on new meaning that will allow you to view yourself through a less critical lens.

Rationale for Worker’s Words: Worker believes narrative therapy will be effective in exposing the values client has come to hold in regard to her role as a mother. Client appears conflicted between honoring certain value systems and leading a life in contrast to these beliefs. Worker holds the opinion that client’s past has influenced her to believe a mother must embody certain characteristics yet her current instincts are telling her to abandon elements of this persona. Through the use of narrative therapy, worker hopes client can learn to see the power of dominant stories as well as come to understand her current desires to separate from her daughter as sound and reasonable.

Client:  Okay, I’m certainly willing to give this a try.

Worker: Great. In that case, I thought we could start by you telling me more about your mother and the role she played throughout your life.

Next Steps

 Madigan (2011) highlighted the importance of re-authoring when utilizing narrative therapy: As clients explore histories with their therapists that have often been neglected, these unexplored narratives set the stage for the construction of new, more preferred realities.   Thinking ahead to next steps with client, worker intends to focus on re-authoring her dominant narrative around motherhood, specifically related to the influence of her own mother’s style of parenting. As previously mentioned, although client talks about her mother in a loving manner and though client tends to parent in similar ways, she appears to harbor some feelings of resentment towards her mother’s willingness to remain in a destructive relationship. Client has mentioned that her mother consciously made this decision because she would sacrifice anything to care for her children. By exploring this sensitive, and seemingly, neglected history, worker believes insight gathered through this exploration has the power to help client create a new narrative regarding her current role as a mother, one which validates and normalizes her desire to lead a life that is not directly connected to her daughter. Carr (2006) wrote about narrative therapy treatment noting the contradiction that often exists between clients’ dominant narratives and the real life experiences they have encountered. This point is especially resonant as worker considers his client: Client’s dominant story speaks to her feelings of obligation to support her daughter because she has received messages throughout her life, most directly from her mother, that caring for and sacrificing for a child is a mother’s top priority. In her lived experiences, client has come to see that sacrificing for her daughter in recent years is stressful and unmanageable. As client comes explored neglected narratives, worker expects to co-author a new narrative with client, one which allows mothers to separate from their children and still be a supportive parent.

Critical Analysis

 Considering work thus far, worker believes his general rapport with client has created an environment where narrative therapy can thrive. Etchison and Kleist (2000) stressed the importance of the therapeutic alliance in narrative work, specifically in creating a space where the client can freely explore issues without judgement or blame. Worker is confident client has felt comfortable in exploring areas of her life where she has been previously felt shame. Additionally, worker has collected detailed information from client regarding her background that reveals major elements of her dominant narrative related to motherhood.  This information has been helpful in setting the foundation for narrative intervention as client and clinician have worked to label the presenting issue.

 Regarding approaching this treatment differently, it is difficult to assess what could have been changed as worker had completed two sessions with client before developing the proposed intervention. Though worker was mindful about choosing this client as he thinks she will respond well to narrative therapy, he is eager to start this work with other patients beginning in the first session, assuming the individual’s intake suggests the intervention would be appropriate.

 Thinking ahead to potential limitations of the proposed intervention, worker worries the client might become frustrated at the exploratory nature of the work. As she voluntarily sought treatment to address stress and anxiety related to her relationship with her daughter, it is logical to wonder if she might feel narrative work is too psychodynamic. Though worker is under the impression client will respond well to the intervention, oftentimes people are looking for strategies that alleviate negative symptoms using more concrete methods than is provided through narrative therapy. 

Conclusion

 The foundations of narrative therapy have been carefully considered in the planning of the proposed intervention. Worker is confident in his assessment of client and believes she will engage meaningfully in narrative work and results of treatment will positively impact her current functioning.

 On a more personal note, delving into the theoretical underpinnings and implementation of narrative therapy has inspired worker to carefully consider this mode of treatment in his repertoire of therapeutic modalities.

References

• Brown, C., & Augusta-Scott, T. (2007). Narrative therapy: Making meaning, making lives. Thousand Oaks, Calif: Sage Publications.
• Carr, A. (2006). Family therapy: Concepts, process and practice. Chichester, West Sussex, England: John Wiley & Sons.
• Etchison, M., & Kleist, D. M. (2000). Review of narrative therapy: Research and utility. The Family Journal, 8(1), 61–66. https://doi.org/10.1177/1066480700081009
• Freedman, J., & Combs, G. (1996). Narrative therapy: The social construction of preferred realities. New York: Norton.
• Madigan, S. (2011). Narrative therapy. Washington, D.C: American Psychological Association.
• Morgan, A. (2000). What is narrative therapy? An easy-to-read introduction. Adelaide, S. Australia: Dulwich Centre
• Murdock, N. L. (2013). Theories of counseling and psychotherapy: A case approach. Boston: Pearson Publications.
• O’Connell, B. (2012). Brief therapy series: Solution-focused therapy. London: Sage Publications.
• Payne, M. (2006). Narrative therapy: An introduction for counsellors / Martin Payne.
• Wilcox, J. (2014). The development of theory in narrative family therapy: A reflective account. Cumbria Partnership Journal of Research Practice and Learning, 4(1), 64-67.