Narrative Therapy: Potential uses for People with Intellectual Disability
Brian Matthews and Barbara Matthews
Narrative Therapy is a counselling technique that is growing in use in the mental health area. The approach uses a process to identify the problems that people may be having and the stories that dominate the person's life, and then encourages the development of more useful stories about the person. Therefore, problem stories are deconstructed and then the aim is to support the person and those in his/her support network to reconstruct stories that lead to better outcomes. While the approach is in its infancy with regard to people with disabilities and the research to validate the approach has not yet been done, we have found the approach to complement well the positive behavioural and cognitive behavioural approaches that we have used in our work with families over the last six years. This paper briefly outlines the Narrative Therapy approach and provide examples of young people with an intellectual disability for whom this approach has been useful. Hopefully, this will (a) give practitioners ideas about how some of these practices may be useful, and (b) stimulate interest and research into this approach.
It has become clearer in recent times that behavioural interventions can be supplemented by alternative treatment methods in assisting families to deal with a range of behaviours exhibited by their family member that may be of concern (Rhodes, 2003). This paper introduces the "Narrative Therapy" concept and describes how this may be used by Practitioners from a range of disciplines who are working with people who have an intellectual disability. The paper will provide a brief overview of Narrative Therapy, and then outline ways in which the practices suggested by the approach have been used to help two individuals with an intellectual disability.
In recent years there have been huge changes in the way that the community view people with disabilities. The development of the Normalisation, then Social Valorisation models (Wolfensberger, 1983) has permeated the field of intellectual disability. This has led to a deinstitutionalisation movement that commenced vigorously from the 1980s on in Australia. People with a range of disabilities now live more valued lives and engage in more valued roles than at any time in Australia's previous history.
The challenges remain, though. The promotion of community living and encouragement of young people living with their own families has meant that families and communities need to provide support to people who were previously largely cloistered away. The focus for support for people who engage in inappropriate actions has usually involved behavioural technology. Growing through a period where practitioners were often accused of being mechanistic and punishment focussed (e.g., Favell et al., 1982), the Positive Behavioural Support movement (e.g., Horner, Vaughn, Day & Ard, 1996) has gathered momentum backed by legislation and supported by equity and human rights lobbyists. However, a major issue remains. And that is how to recruit families/systems and individuals into a process of behaviour change.
It is clear that the environment has a strong influence on behaviour and that, if we can rearrange environmental cues and consequences, outcomes for individuals and families can be improved (Kennedy & Itkonen, 1993). The ways we may do this are through using more explicit cues for people with cognitive difficulties (Cafiero, 1998; Lancioni, Van den Hof, Furniss, O'Reilly, & Cunha, 1999), providing means by which a person can communicate his/her needs more clearly (Durand, 1990), and providing reinforcing activities and outcomes for people (O'Reilly & Carey, 1996). These approaches, however, are often not embraced enthusiastically by families who have been engaged in many "programs" over the years. What seems to be needed is an exploration of metaphors that can help people change. Narrative Therapy, used extensively in community and mental health work (White, 2000), provides a structure that may be helpful to augment our efforts in assisting people to achieve positive change.
The current paper outlines the ideas behind Narrative Therapy and then gives examples of the ways in which Narrative Practices were useful in helping people with an intellectual disability to achieve important life skills and to become "the boss" of actions that were of concern to themselves and their families. There is a strong connection here between the social construction of disability and the problems that people with a disability experience (Gillman, Swain, & Heyman, 1997). Narrative Practice encourages people to escape from the dominant social discourse about the problems that they experience (White, 1995, 2000).
There has been little attention in the literature to the use of Narrative Practice with people with a disability, although this approach has been used recently with some of the labelling difficulties people with a disability may experience (Nixon, 2002). Lynggaard and Scion (2002) in reporting their own work in this area have also pointed interested readers to a number of other researchers who have been exploring this approach with people with intellectual disabilities (Clare & Grant, 1994: Fidell, 1996; Perry, 1998). In the first section of this paper a brief overview of Narrative Therapy will be given based on the work of Geldard and Geldard (2001) but the interested reader is also referred to Morgan (2000) for a clear and detailed introduction to "Narrative Therapy" (the current authors prefer the term Narrative Practice). Further writings and references on Narrative Practice can be obtained through the Dulwich Centre Publications (www.dulwichcentre.com.au) and the extensive writings of Michael White and his colleagues (Epston & White, 1992; Freeman, Epston, & Lobovits, 1997; White, 1995, 2000).
The Narrative approach believes that everyone has "dominant" stories about their lives but sometimes these are not helpful (particularly if they are "problem saturated" stories) because living out the stories leads to difficulties for the person. The Narrative Practitioner's role is to help replace dominant problem stories that the person has, with other more useful stories. Therefore, problem stories need to be deconstructed and then the aim is to reconstruct stories that lead to better outcomes; these are called preferred stories. "As the person interprets each life experience, their stories, which grew out of similar past experiences, will be reinforced and thus strengthened... new experiences thicken the person's stories" (Geldard & Geldard, 2001, p. 224). So, essentially, the idea is to deconstruct the dominant stories in a person's life and reconstruct these into preferred stories.
It is argued that people tend to select memories of experiences that are consistent with the dominant story in favour of the ones that don't favour the dominant story. As more experiences are selected and gathered into the dominant story the story gains richness and thickens. This process can apply to both positive and negative stories about the person (Geldard & Geldard, 2001). However, Narrative Therapists focus on neither exploring a person's feelings or fixing the problem. Instead, they explore how people construct meanings both about themselves and their relationships with others. The process involves: (1) Listening to and understanding the person's story, (2) deconstructing the problem stories, (3) Re-storying, and (4) sustaining the change.
Listening and Understanding
The important issues in listening to and understanding the person's story are seen as relating to (a) what they select to tell you, and (b) ensuring that you have an idea about how their story fits within the family/friendship culture. Having developed an idea of what the person sees as their preferred ways of being, the practitioner can then help build a preferred alternative story
Positive alternative stories may not be easily available to the person and so it is important that we help the person identify times when they have been in control of the problem. These sparkling moments (White, 2001) help the person to identify the values that aid him/her to behave in the preferred way. By identifying as many sparkling moments> as possible, this thickens preferred alternative stories.
Deconstructing Problem Stories
The person and/or the family is then assisted to deconstruct his/her problem stories. That is, he/she is invited to look at their problem from a different perspective and to notice how these stories were constructed. It is seen as particularly important that they note the limits that the stories place on them and that they discover other possible stories-- this is often referred to as mapping the problem (White, 2000).
Externalising conversations (see Morgan, 2000) is a powerful tool for deconstructing the problem and is also advocated in other counselling approaches such as solution focussed counselling (Geldard & Geldard, 2001). The essential idea is to separate the problem from the person. Geldard and Geldard (2001) give the example of a person describing themselves as "anxious," but the practitioner asking "how does anxiety stop you from doing things." The idea is that you have difficulty fighting a problem if it is part of you, but if you are fighting something else, this can be really effective. The person is being helped to stand apart from the actions that are causing them and others concern.
Use of the person's own language is seen as critical. That is, the practitioner is asked to listen to what the person is saying and use the person's words where possible. In the work the current authors have been involved with over the last few years some of the labels we have used to describe the problem have included, The Trouble, The Tantrums, The Worry, The Self-Talk, The Geek, The Mental Thing, Sneaky Poo (this term originally came from Heins & Ritchie, 1988), and The Angries. Regardless of the label that is applied to "the problem," it must come from the person or be taken up eagerly by the person once it has been suggested.
The shift in language is seen as a critical issue by Narrative Therapists. They advise using our language in a way that is critical of the problem not the person. "So how did the tantrums trick you?" or "What did the tantrums have you doing?" instead of something like, "I hear you had a tantrum today-- tell me about it." It has been our experience that some families take to this language quicker than others but the sooner they do the more positive are the outcomes.
This stage involves encouraging the person to talk about the way they would prefer to be and what they would like to be happening in their lives. This is done through careful and respectful questioning of the person. Questions often suggested include, "did that surprise you?", or "is that something that you want more of in your life?" Another good and simple question is "is that a good thing or a bad thing?" This is seen as encouraging the person to take a position about the problem.
In re-storying the sparkling moments are explored more thoroughly as is the meaning of the preferred story. Kelly, a young woman with Down Syndrome, talks about her "Strong thinking", "Strong Memory" and her "Mind Training" abilities. Another young man with Down Syndrome, Richard, was helped to manage his grief using a "Happiness Chart" (see Brown & Brown, 2003, Chapter 9).
Therapeutic letters are often an important part of this stage (Freeman, Epston, & Lobovits, 1997). Poetry may also be used to help reinforce the preferred story (Brown & Brown, 2003, Chapter 9) and these days email is also a useful option.
Change is sustained by thickening the preferred story and identifying who in the person's family/friendship culture will support them in the process. This process is termed re-membering, a meaning that is similar but different to the normal meaning of this term. "If your Mum was here now what would she say about all of the happiness coming into your life?" (Brown & Brown, 2003, Chapter 9).
In many situations (particularly those where someone has been devastated by a major event such as sexual abuse in childhood), witnesses are invited to act as listeners to the story and to link their lives with the story. Witnesses, real or imaginary (toys are sometimes used as witnesses) validate the changes the person has experienced, confirm that they have noticed changes, draw attention to changes the person themselves may not have noticed, and relate the problems to similar difficulties the witnesses may have had in the past. The focus is on the preferred alternative story and asking questions of witnesses allows a richer description of this.
The following section includes examples of the ways in which the authors have used Narrative Practices to support two individuals to achieve positive changes in their lives.
Kelly is a young woman with Down Syndrome and a mild intellectual disability. She is now almost 18, but when she was 15 1/2 the authors were asked to provide her family with support in coming to terms with high levels of "self-talk" that were interfering with her social integration. At that time she was attending a mainstream high school and was often marginalised by her tendency to have conversations with herself in public. This problem is reported by many young people with Down Syndrome (Opolski, 2004).
The first meeting with Kelly and her family included Kelly, Kelly's mother, her father, Kelly's younger sister and older brother. The first and second authors were also present at the initial meeting. During this meeting two main issues were identified. Firstly it seemed that from a young age Kelly's life had been plagued by the "Self-Talk." The self-talk had everybody in the family doing different things. Generally it seemed that the self-talk created a fair amount of havoc in everyone's lives, especially Kelly's.
Secondly, Kelly's family were very concerned that she seemed to lose concentration on various tasks and were particularly worried about Kelly losing concentration while working in the kitchen, because this posed a real safety threat for Kelly herself and the rest of the family. All of the family agreed however, that the self talk was the thing that they wanted to start working on first; this was their priority and Kelly agreed.
From what the authors had heard during this meeting it sounded as though the self talk was so consuming of this family that it seemed to be present almost all of the time. It was noticed, however, that in spite of having had a very long first meeting (the meeting lasted for almost 2 hours) the self talk had not been present even once. Given the story about the self talk that the authors had just heard, we were pretty amazed by the absence of the self-talk during the entire meeting and pointed this out to Kelly. Barbara asked Kelly, "does this mean when you're concentrating and listening very carefully that the self talk doesn't hang around?" Kelly agreed with this. Barbara then asked Kelly if she could think of any other times that Kelly could stop the self talk from sneaking up on her. Kelly wasn't sure so Barbara asked Kelly to see if she could watch out during the week, for any other times that Kelly couldn't be tricked into the self talk. Kelly agreed to keep a careful eye out during the week. Kelly also agreed to keep a chart, which showed how many times she had won against the self talk during the week.
From the language used during our initial meeting Kelly (and her family) came to understand and welcome the idea that the "problem" that they were all talking about was the "self-talk" as distinct from Kelly herself. It was checked that Kelly understood that the problem was indeed the "self-talk" and not Kelly. Kelly responded by saying "I know, the 'self-talk' is a different issue." Kelly was asked whether she thought it was a good thing to discover that she herself was not the problem. She felt "relieved and happy" to have made this discovery. Kelly was also delighted to hear that her family and the authors all wanted to be on Kelly's side in her struggle with the "self-talk."
On our second visit Kelly was very excited. Kelly had won 50% of the time over the self talk in the first week! This was also the week that Kelly discovered the first two of her "awesome skills." The awesome skills identified and written down by Kelly are given below:
"Mind training: this is how it works. Mind training is when I train my mind to help with the self talk and to build up my friendship skills."
"Strong thinking: this is how it works. Strong thinking is when it helps me to think with my mind and store the self-talk in the filing system of my mind."
"Strong memory: this is how it works. Strong memory is another amazing skill I knew and is very useful to help me to use.
Over the following year, regular meetings were held with Kelly in order to help her identify a preferred story and gradually move toward this.
Questions that have been used to help Kelly to focus her thinking have included:
- Is the self-talk a good thing or a bad thing to have in your life?
- Is self-talk useful to you?
- What does self-talk have you thinking about yourself?
- What do other people notice the most about you do you think? Do they notice you, or do they take more notice of the self-talk?
- What kinds of things does the self-talk steal away from your life?
- Is the self-talk something that you want more of in your life or less of in your life?
- So you have discovered that the times that you are feeling bored or lonely are times that the self-talk is likely to sneak up on you?
- It seemed that you were able to take so much of your life back from the self talk after you discovered that you had some pretty awesome skills. How come you didn't know you had those skills before?
- Was it a surprise to you to discover that you already had the awesome skills that have helped you to manage to be the boss of the self-talk? Was that a big surprise to discover that you had those skills?
- I'm wondering what kinds of things the awesome skills have helped you to achieve since you've discovered that you've had them?
- It was amazing that story that you told me about the time that you set the toaster on fire when you were cooking pancakes. Has that happened since you've been using the awesome skills in the kitchen?
- We had a conversation about the times when the self-talk is really quite useful for you. I think from memory you told me that the self-talk had been useful "when I can't find something that I put somewhere?" And also sometimes when you're feeling lonely the self-talk is useful. You told me that too didn't you?
The questions above aimed to map the problem and the effects of the problem on Kelly and her family. They also identify skills that Kelly has and put self-talk in an appropriate context. Almost all "inappropriate" actions are considered useful in some situations and Kelly has identified when self-talk is useful for her. Importantly, she has identified a different story for herself now. This is exemplified by her response to the question "When we first met your main story was all about Kelly and the self-talk. What is your main story about now? Her answer was "Kelly and the Awesome Skills."
Recently, Barbara spoke to Kelly's mother and asked her how she thinks Kelly has done overall since discovering the awesome skills. She said "I still hear the self-talk sometimes, mostly when Kelly is bored or lonely. But sometimes I can go for more than a week and I don't hear any self-talk at all. And with her cookingÉ Well when Kelly is cooking her well-practiced recipes like chili con carne potatoes, I just leave her to it and it's all done. I don't really have to worry about even going into the kitchen. She needs help sometimes though with new recipes."
Richard is a young man with Down Syndrome and a mild intellectual disability. We first met Richard, almost 24 years old at the time, and his parents, in January 2001. Richard's mother's health was up and down, and as she had little time left due to her illness, there were major concerns about how Richard might deal with losing her. There were some additional concerns which involved Richard's limited range of social communication and Richard frequently focused on, and talked about the things that he perceived to be the most negative aspects of his life. While we have had an opportunity to touch on all of these issues with Richard, the focus of our work has been on understanding grief and beginning to welcome happiness back into Richard's life. The work of Hedtke (2001) was an invaluable resource in this process.
Initially, Richard and Barbara started to spend about 3 or 4 hours a week together. The first couple of meetings were used as "getting to know you" meetings. During these meetings we talked about changes.
In order to keep the family informed about our work together, everything that Richard and Barbara did together was recorded or documented in some way. Consequently Richard developed a working folder that contained lists, charts, stories, letters and copies of his poetry.
We talked a great deal about Richard's experiences of changes, and Richard soon told Barbara that he thought that small changes are pretty easy and quick to get used to. He also thought that medium changes are a bit harder and can sometimes take a bit longer to get used to, and that the biggest changes can be really hard and can take quite a long time to get used to. Richard knew by this time that he had a very big change coming up, probably the biggest of his life so far.
Barbara wondered out loud how Richard had managed all of the big changes in his life so far. Richard said he thought he managed the big changes so far because he is "competent." An important part of being "competent" is to be strong, like having "inside muscles" and "outside muscles." She then went on to ask Richard whether he had managed all of the biggest changes in his life by himself so far or were there some people who had helped him a bit. Richard said that there were some people who had helped. Barbara asked Richard who those people were and began to generate a list of people who had been on Richard's side in the past against big changes, and also talked about the people that would be on Richard's side when he needed them for the biggest change of his life. In all Richard talked about 25 people.
Leading up to, and of course after his mother's death, Richard was becoming well acquainted with grief. It was unclear though how much Richard knew about grief. There were many conversations with Richard about this, so that we could uncover and come to understand what the grief in Richard's life was like for him. We also made a chart of the things that Richard talked about, so that Richard would be able to see what having grief in his life was like for him.
Richard wanted the following to be written at the top of his chart: "Mum died at 7:30 on Friday 23 February at home. Dad held Mum's hand and so did I hold Mum's hand. Mum died of cancer and this made a big change in my life. Here is a picture of my life. The picture shows me the big change." The "picture" is a circle, with a line drawn across the circle about one quarter the way down. Inside the smaller part of the circle it says "this is the part of my life with Mum" inside the larger part of the circle it says "The next part of my life will be without Mum. This is the biggest change in all my life so far." Outside of the circle there is an arrow pointing to the line. Here it says "This line shows me that I was 24 when Mum died. When people lose somebody that they love they usually feel grief. For me, my grief makes me feel lots of different things at different times."
Richard spoke of many things that grief had him feeling. In Richard's words "sometimes I feel lonely because of ...", "sometimes I feel sad when I think about ...", "sometimes I feel scared when I think about ...", "sometimes I feel very tired ...", "sometimes I feel confused ...", "sometimes I feel angry ...", "sometimes I feel proud when I think about ...", and "sometimes I feel happy and sad at the same time ..." (Richard has since come to refer to this as "bitter/sweet"). Over a period of time, there were many interesting conversations about grief. As the chart grew and evolved, so did our understandings about the effects of grief in Richard's life. We had so many rich conversations at this time, and it became difficult to adequately explain these conversations to Richard's father. Also many questions and thoughts about our conversations around grief occurred to Barbara on reflection, thoughts and questions that she had not had the opportunity of wondering about with Richard, during their time together. So began the additional weekly ritual of letters from Barbara to Richard.
During our conversations around grief, we also talked about the possibility of keeping some happy times and memories of Mum close to Richard by making a memory book. Our conversations about Richard's experiences with his mother included talking about things his mother thought about Richard, and what she might think about him now in terms of new developments in Richard's life, things she taught him and what kinds of things that she might want for Richard's life now.
In this way Richard spoke his own story about the circumstances of his mother's death, along with some very inspiring and heartfelt poetry, poetry which uncovered the existence of new hearts (a home heart, a work heart and a holiday heart) which are new places in Richard's life for his mother. Examples of some of this poetry and more of Richard's story can be found in Brown and Brown (2003, Chapter 9).
It is hoped that the outline of Narrative Therapy and the brief descriptions of our work with Kelly and Richard has given some insight into how a person can overcome various challenges when she/he discovers that they already have the "expert" knowledge and skills to address all manner of difficulties. Indeed because of the discovery of Kelly's "awesome skills" there was never any need for the development of "programs." Similarly, Richard's discovery of himself as a "competent" person allowed him to explore his feelings of grief in a way that fitted for him. Richard also engaged in an active process of "re-membering" his mother aided by stories and materials that his mother had left for him.
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Contact for correspondence
Brian Matthews, Department of Disability Studies, School of Medicine, Flinders University, Bedford Park, South Australia, 5042
Telephone (+61 8) 82013448
Narrative Therapy, Intellectual Disability, Down Syndrome, Grief, Self-Talk
The authors wish to thank Richard Gates and Kelly North for their contributions to this paper. We also thank Professor Roy Brown and Dr Verity Bottroff for their comments and suggestions on an earlier version of this paper. Some of the ideas from the content of this paper were initially presented at the Inaugural DisAbility and Rehabilitation Professionals' Association Conference, Journeys through Life, Adelaide, December 2002
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