Beruflich Dokumente
Kultur Dokumente
ASHLEY A. CLARK
Walden University, Culpeper, Virginia, USA
511
512 A. A. Clark
working with individuals with substance abuse issues, other researchers have
questioned the use of a one-size-fits-all approach toward working with these
issues (Butt, 2011). As a result, more recent research has focused on the
integration of other theoretical approaches within the treatment of substance-
related issues. Cooper (2012), for example, argued for the integration of
motivational interviewing (MI) in working with this population. Because
of the heightened rates of resistance in working with substance-using and
-abusing individuals, MI provides the counselor with tools in moving a
client from a potential state of denial, continuing through establishment
of substance use as an issue, and eventually leading to the implementa-
tion of plans to eliminate its use. Despite notable effectiveness of these
approaches within the research body, however, Brewer, Elwafi, and Davis
(2013) argued that deficiencies still exist with the ability of substance abuse
treatment approaches to reach an optimal level of clients. As a result, contin-
ued evaluation of interventions that integrate various theoretical approaches
is needed.
In an attempt to utilize narrative therapeutic strategies with an outpa-
tient substance abuse group, two consecutive narrative-focused interventions
were utilized. This article serves not only to provide information about the
process of implementing these activities but also to present the fundamental
rationale, assumptions, and objectives as well as to discuss potential
adaptations and limitations of the approach.
RATIONALE
develop with other people in their lives, they, too, develop relationships with
their problems. Change is therefore dependent on changing the relationships
individuals have with the problems in their lives. By gaining control of this
change, individuals develop the ability to reauthor aspects of their lives.
Consequently, individuals gain an understanding that they do not need to be
defined by their problems but instead can create a new story of themselves
and their experiences.
Differing stories can exist simultaneously. From these stories, individuals
often draw themes that connect events and bring meaning to issues that an
individual is facing. As the Dulwich Center (2000) noted, investigation of
the journey created by these stories is the foundation of narrative therapy.
Potentially based on the audience, the story may change and aspects of the
story that are focused on may affect an individual’s overall identity.
Effectiveness of narrative therapy has been evaluated with numerous
clients and presenting issues. Cloitre (2013), for example, evaluated the
use of Skills Training in Affective and Interpersonal Regulation (STAIR) nar-
rative therapy (an integrative CBT approach) with clients diagnosed with
posttraumatic stress disorder and noted a timeline of 9 months for treat-
ment in reducing substance abuse and self-harm behaviors. Hannen and
Woods (2012), on the other hand, demonstrated the effectiveness of a nar-
rative approach in working with an adolescent also dealing with self-harm
behaviors. In addition, Chan, Ngai, and Wong (2012) identified the poten-
tial effectiveness of narrative approaches when working with individuals
with substance abuse issues. Although the totality of these three articles
does not necessarily demonstrate the potential impact of narrative therapy
as an EBP, the promising effects demonstrate the need to further evaluate
these approaches in working with various individuals. Based on this need to
gain further evidence of the viability of narrative interventions in substance
abuse therapy, two specific interventions, the Narrative Novel and Letter to
Letting Go, were developed and utilized within the context of an outpatient
substance abuse group.
Both the Narrative Novel activity and Letter of Letting Go were devel-
oped based on the principles of narrative therapy. Specifically, the Narrative
Novel, which is described in the Process section, provides the opportunity
for individuals to rewrite their story of recovery and process the external
power of the substance within their recovery. The Letter of Letting Go, also
discussed in the Process section, allows for individuals to conceptualize the
addiction as a relationship and the substance that can be removed from their
lives. In developing these interventions and utilizing them with clients, it is
important to understand the impact of individual stories on self-identification.
With the goal of supporting individuals in recovery, these activities were
developed.
Narrative Therapy 515
ASSUMPTIONS
1. CBT and MI provide valuable tools for utilization in substance abuse ser-
vices; however, these two techniques are not foolproof approaches to
addressing substance addiction in all populations.
2. Despite the largely subjective nature of narrative therapy measurement
(Butt, 2011), studies conducted by Cloitre (2013), Hannen and Woods
(2012), and Chan et al. (2012) evidence the applicability of narra-
tive approaches in working with individuals demonstrating destructive
behaviors, resulting in the potential effectiveness of narrative therapeutic
interventions in working with substance abuse issues.
3. Despite multicultural differences, the formation of the therapeutic rela-
tionship allows for a collaborative approach as opposed to the counselor
having to serve in the role of expert.
4. Participants within a group environment are willing to share their
thoughts, feelings, and experiences once they reach the working stage.
OBJECTIVES
PROCESS
Narrative Novel
The implementation of the Narrative Novel activity occurred through the
implementation of a simple outline that can be utilized by any practitioner
working within addiction groups.
516 A. A. Clark
7. After all individuals who wish to share their representations are provided
the opportunity to share their diagrams, each individual should be pro-
vided with approximately nine sheets of paper. (It may be easiest to
separate the paper for each participant while they are working on their
original three pieces of paper.
8. Once all participants are provided the additional paper, the counselor
or cofacilitators should provide participants with the following instruc-
tions.
a. Take the picture representation of your past self and place it on top
of the blank sheets of paper face up.
b. Take the picture of your desired self and place it upside down
underneath the pile of blank papers.
9. The counselor or facilitator then explains how the front picture serves
as the coverage page, the start of the story for their recovery, while
the ideal self represents the conclusion of the process. Facilitation of
the discussion should evaluate the clients’ understanding of the story’s
author. The group leader may also question clients regarding how the
story may be different if instead of a story of recovery it was a story
of their addiction, including discussion of how the author would likely
change from the individual having control to that of the drug or drugs
having control.
10. Participants are then instructed to insert the final representation of their
current identity into the story to represent where they see themselves as
being in the process. Facilitation of discussion between group members
regarding their reflections of where they are as opposed to where they
were and want to be is beneficial for continued reflection.
11. Finally, participants are instructed to name their story and, if willing, to
reflect on the reasoning behind the title.
A Case Illustration
Jackie is a 29-year-old mother of two who was court ordered to substance
abuse treatment after testing positive for cocaine and amphetamines upon
birth of her daughter. At the time of birth, Jackie’s daughter, Jean, along with
her 3-year-old son, Braxton, were removed from her custody and placed
with her mother and stepfather. Already in a tumultuous relationship with
her mother due to her mother’s own substance abuse issues when Jackie was
growing up, the relationship became even more strained once the placement
occurred. Jackie is only allowed to see her children under supervised visits
by the court and undergoes random drug testing as a condition of these
visits. She lives with her current boyfriend whom she met in a Narcotics
Anonymous meeting. Her boyfriend, Jake, has 3 years of sobriety. Jackie,
on the other hand, has been struggling with her sobriety. Although it has
been 1 year since her children have been taken, Jackie’s longest period of
518 A. A. Clark
Letter to Letting Go
After implementation of the Narrative Novel and processing of the insights
gained from the activity, counselors and group leaders can follow up with
Narrative Therapy 519
We have discussed the impact of drug use on your identity when you
were at your rock bottom and the impact of absence from drugs in
reaching your personal goals. Based on this discussion, it is appar-
ent that drugs have played an instrumental part in your experiences.
As with anyone who plays a large part in our lives, it is hard to let
go. To achieve this, it is time to write a letter to your drug of choice.
In this goodbye letter, make sure to thank your drug of choice for
the good times, while providing the reasons as to why you are saying
goodbye. Write whatever comes to your mind. When you finish, make
sure to sign it.
3. Once participants have completed the letter, offer them the opportunity
to share the letter with the group. For those individuals who do choose to
read their letter aloud, provide time for them to process their emotional
reactions to writing the letter.
A Case Illustration
Jane is a 48-year-old mother of four. All of her children were raised within
the social services system. After 6 months of clean time, she has begun to
seek out a relationship with her children now 24, 22, 21, and 19 years old
and grandchildren now aged 4 years, 2 years, and 9 months. Jane reports
that her drug of choice was methadone and notes that her earliest use of
the drug was when she was 13 years old. She notes that she quickly slipped
into the grasp of addiction and began prostituting herself for money. Upon
each birth, she promised herself she would get clean to be able to take
care of her children but was never able to follow through. Drug-addicted
and living on the streets, Jane had limited contact with her children, who
were all raised together in a loving foster home. Since then, they have all
become independent and are somewhat guarded about the potential to form
a relationship with Jane given her history of drug use.
In her letter, Jane writes, “Dear Methadone. It is with such sorrow that
I say goodbye to you. Sorrow not for what you have given to me but for what
you have taken away from me. You were my best friend. We did everything
together. You never turned your back on me. Remember those parties and all
the late nights. Well they were fun at the time. Fortunately, I have outgrown
you now. Because of you, I lost everything I loved. I lost my children, my
520 A. A. Clark
According to Butt (2011), despite numerous studies that support the effective-
ness of narrative approaches in counseling, narrative therapy is not without
Narrative Therapy 521
its limitations, the most argued of which is the difficulty associated with
measurement of the approach’s success. Because the approach is rooted in
philosophical underpinnings, measurement of narrative therapy’s effective-
ness may be largely subjective in nature. As a result, increasing focus on the
use of EBPs could potentially make narrative approaches extinct unless they
are integrated with other approaches.
Cloitre (2013) further revealed limitations of a narrative approach given
the necessity for clients to be able to articulate their stories. As such, clients
with reduced verbal or cognitive abilities might be less likely to benefit from
narrative approaches within counseling. Because of this, it is important for
counselors to assess the cultural appropriateness of their clients in integrating
these interventions.
CONCLUSION
REFERENCES
Alavi, S., Ferdosi, M., Jannatifard, F., Eslami, M., Alaghemandan, H., & Setare,
M. (2012). Behavioral addiction versus substance addiction: Correspondence
of psychiatric and psychological views. International Journal of Preventive
Medicine, 3, 290–294.
Brewer, J. A., Elwafi, H. M., & Davis, J. H. (2013). Craving to quit: Psychological
models and neurobiological mechanisms of mindfulness training as treatment
for addictions. Psychology of Addictive Behaviors, 27, 366–379.
Brown, C., & Augusta-Scott, T. (2007). Narrative therapy: Making meaning, making
lives. Thousand Oaks, CA: Sage.
Butt, M. (2011). Using narrative therapy to respond to addiction: An experience of
practice in Pakistan. International Journal of Narrative Therapy & Community
Work, 2, 51–61.
Centers for Disease Control and Prevention. (2013). Illegal drug use. Retrieved from
http://www.cdc.gov/nchs/fastats/drug-use-illegal.htm
Chan, C., Ngai, K., & Wong, C. (2012). Using photographs in narrative therapy to
externalize the problem: A substance abuse case. Journal of Systemic Therapies,
31(2), 1–20.
Cloitre, M. (2013). The case: Treating Jared through STAIR narrative therapy. Journal
of Clinical Psychology, 69, 482–484.
522 A. A. Clark