Psychotherapy's Third Wave? The promise of narrative

The fundamental new direction in therapy is more than just a set of new techniques explains Bill O'Hanlon in an article first published in 1995.

MARISA, an Italian immigrant to New Zealand, worked as a house cleaner. Although she was an intelligent woman who spoke impeccable English, her block against writing had prevented her from getting a job more suited to her skills. After more than two decades in an unhappy marriage, she had recently visited a psychic who told her she had lived her life as a 'doormat'. So, she enrolled in an assertiveness training course at a nearby community college but, during a role-playing exercise, she had panicked and run from the room. She thought she was going crazy. Soon afterward, she went to see narrative therapist David Epston and within minutes of their first session announced to him, "I'm bad! I'm bad! I'm bad!"

Marisa then told Epston her life story. Born in Italy just after World War II, she was her mother's 21st child. It was only many years later that she learned that her true father was a 72 year old family friend who had been close to death at the time of her birth. While for the few remaining years of his life he had been loving toward her, her mother and her siblings viewed her as a lower form of life, telling her she was only fit to be a servant. At 13, she had been sent to work as a housekeeper for an older sister in England, where she was treated poorly and was sexually abused by her sister's husband. When she was 18, she decided to escape her family and emigrated to New Zealand where she married and found menial work. Recently, she had begun to chafe against her long subservience within her marriage, and her anger sometimes frightened her.

After the session, Epston, who was then developing his narrative approach to therapy, wrote Marisa a letter:

"I take it that telling me, a virtual stranger, your life story, which turned out to be a history of exploitation, frees you to some extent from it. To tell a story about your life turns it into a history, one that can be left behind, and makes it easier for you to create a future of your own design. Also, your story needs to be documented so it isn't lost to you and is in a form available to others whom you might choose to inspire. They will come to understand, as I have, how you were, over time, strengthened by your adverse circumstances. Everyone's attempts to weaken you, by turning you into a slave, paradoxically strengthened your resolve to be your own person. This, of course, is not to imply that you haven't paid dearly for this and haven't suffered. You almost accepted your family's attitude towards you and this accounted for the doormat lifestyle that you lived for some time.

"You probably wondered why your father loved you quite so much when your mother didn't want you. She taught you a servant mentality: that is, to do for others and expect very little in return. For a mother to betray a child into servitude, she must have had to convince herself you were bad; otherwise she couldn't have been your Judas and betrayed you. You were turned into a Cinderella with other people in charge of you. Your family did the worst for you and tried to have you believe that that was the best you could or should expect because you were 'bad'. They tried to convince you (and were undoubtedly successful for periods of time) that you deserved their punishments and cruelties.

"Seeing that medium who called you a doormat was a turning point in your life and you started your revolution with your husband because he was closest at hand. When you were a slave, you no doubt chose a partner who would be your master and you could serve, grateful for crumbs from his table. Your husband must have been shocked by your demands for justice and equality in your relationship. You had not spent all your strength in your suffering and slavery. Instead, this marked the onset of your taking action in this family. You started accepting and trusting your own experience. Your own power was being drawn upon to shape events in your life for the first time. You broke out of some of the things that were depressing you and keeping you down. You gave yourself evidence that your anger was righteous anger. I gather your appreciation of yourself gained you more respect in your husband's eyes.

In your 30s, your own power surfaced and was accepted by you. And no one could submerge it any longer. You had so much courage, in fact, that you decided to seek justice and put things right. By doing so, you drew a distinction between your history and your future, In your history, your life was defined by other peoples' attitudes and ideas about you; in your future, your life will be defined by your respect and appreciation of yourself. Your mother's death finally freed you — you no longer had to search for a mother who could never be. You were released to go forward in your life, believing in yourself. No wonder you feel dizzy with possibility. Remember, being a prisoner can make you accommodate to your prison. To be released from it is disconcerting, and many return to it for refuge. I believe you always, always, had some sense that evil was being done to you and, for that reason, you were never made into a real slave. Rather, you were a prisoner of war, degraded, yes, but never broken. To my way of thinking, you are a heroine who doesn't know her heroism."

Marisa moves on

Several weeks later, Marisa returned to therapy, along with her husband. She had reread the letter many times. It was, she said, "reality," there in black and white, and she could not deny it. As a result, she now saw herself as a person who had had a terrible life but had always been strong and had never submitted completely to a devalued view of herself. She saw the events that had recently alarmed her as evidence that she was finally leaving old 'victim' patterns behind and creating a new life. She told Epston she didn't feel a need to see him any further at that time.

Five years later, she contacted Epston again. By then, she had launched a career as a dress designer and told him, "My life has a future now. It will never be the same again." The first session and the letter, she said, had been the beginning of a life of greater self respect and achievement. For some time afterward, she had reread the letter, especially when she suffered from flashbacks of her brother-in-law's sexual abuse. After a while, she had not needed to reread the letter at all, and had finally destroyed it.

I first saw Epston's letter to Marisa a few years ago, on a plane coming back from New Zealand, in a sheaf of materials he had given me on narrative therapy. I have read scores of exciting case histories showcasing new techniques over the years, but this was different — it made me cry. I was moved by how Marisa had reclaimed her life and I marvelled at how this transformation had been accomplished.

Then, as now, I was working mainly as a brief, solution oriented therapist. Although I had occasionally witnessed dramatic transformations, most of my work was far more modest than Epston's work with Marisa. I helped people get out of stuck patterns and move on with their lives. If Marisa had come to me, I probably would have helped her with her writing block. I might have asked her what other things she had mastered after thinking they would be impossible. Could she transfer that sense of competence to writing English? I might have asked how she had learned to speak and understand English and tried to use the same methods to help her learn to write. I think I would have helped Marisa. She might have gotten a better job, incrementally improved her life, and triggered further positive changes. I think she would have been satisfied. But Epston's ambitions for Marisa had been bigger than mine would have been.

"If you come to my office," his letter seemed to say, "I'm going to help you re-invent your life. You are more than the story you have told yourself about who you are." Marisa was not only going to write, she was going to get a new life, a new chance. For Epston, it was always the stroke of midnight on New Year's Eve and each session offered the possibility of a new beginning. His work, I thought, contained the ambitions of long-term therapy within a short-term time frame. Yet there was more to it than this. And I couldn't quite grasp how it was done.

The fork in the road

In the years since that day on the plane, I have read about or watched many other therapeutic encounters involving David Epston and his friend and sometime collaborator Michael White, the main developers of the narrative method. At first, it was like watching magic. A person like Marisa would come in, walking a road they'd been on for years, a road that seemed destined to lead to more misery. During the conversation, a fork would appear, a path that had always been there, but somehow had gone unnoticed.

It wasn't that I'd never seen that happen in therapy before. I had often helped people find roads they had missed, in the form of solutions and resources that they'd previously used successfully and could apply again. At other times, I helped them find a new destination on the map, and we bushwhacked and experimented until we hacked out a bumpy new footpath.

But Epston and White seemed to go beyond that: they conjured up doorways to new identities out of nowhere. It seemed inexplicable, radical and elegant. When people found themselves in a corner, Epston and White could paint a door on the wall where it was needed, and then, like Bugs Bunny in the cartoons, open it and help them walk through it. I wanted to know how to paint those doors. But the first few times I tried to imitate what I had seen them do, I was more like Elmer Fudd, who tries to walk through the doors that Bugs has painted and crashes into the wall.

So, a couple of years ago, I invited David to Omaha, Nebraska, where I live, to give a workshop. He showed a videotape of his third interview with Rhiannon, a 15 year old girl who was close to dying from anorexia.

Accompanied by her cousin and her cousin's boyfriend, she was a skeleton lost in a large sweater, trying to make herself invisible, curling her arms around herself and slumping down in her chair. Smiling faintly in response to David's persistent questions, she insisted she felt fine and had lots of energy. David, carried away by his intense interest in her answers, could barely contain himself. He squirmed in his chair, leaned toward the girl and asked her question after question: "Can I just ask you why you think it is that Anorexia tricks people into going to their deaths thinking they're feeling fine? What purpose would it have, getting you to go to your death smiling?"

Rhiannon still would not engage. Slumped in her chair, she kept saying she felt fine. Rhiannon had recently been discharged from a hospital after losing 25 pounds in three weeks, and a physician was monitoring her condition three times a day. She was literally on the brink of death. At home, she had been lying in a fetal position and screaming until her exhausted parents took her over to her older cousin's house. As I watched the tape, I thought that even I, psychotic optimist that I am, would have given up on engaging Rhiannon and would have focused my interventions on the cousin and her boyfriend instead.

But David seemed to be even more psychotically optimistic than I am. He persisted: "Okay, okay, okay. If that's how you're feeling, how's it fooling you? Most people, when they're near death, know they're being murdered, right? How's Anorexia doing this to you? Because if it's making you feel good, or telling you you're feeling good, then I'd like for you to ask this question of yourself: 'Why does it say to you you're feeling good? Why would it do this? Why does it want to murder you? Why doesn't it want you to protest? Why doesn't it want you to resist?'"

Then, suddenly and inexplicably, Rhiannon responded. Anorexia, she said, fooled her by telling her she was fat when she was thin. "Is it telling you that right now?" David asked. "No," Rhiannon said. "I am too thin." She sat up in her chair.

David asked her how she knew that, and she replied that people who love her told her that she is too thin. "Do you think Anorexia loves you?" he asked her. "No," she said. "It's killing me."

Her voice grew stronger. Her body language changed. In response to David's continual stream of questions, she began to make plans for standing up to Anorexia and not letting it fool her into starving herself any more. David enlarged the new doorway, asking her how, in the past, she had shown herself to be the kind of person who could stand up to something like Anorexia. By the end of the session, nobody in the room was talking about her hospitalisation any more. David, Rhiannon, the cousin and her boyfriend all looked hopeful and certain. Within 10 or 15 minutes, Rhiannon had become an ally in treatment, rather than a reluctant bystander. The rapidity of this change wasn't new to me, but such turnarounds usually happen only when a client actively cooperates. Rhiannon, like many anorexics, did not look much like a customer for change — that is, until David got hold of her.

In the past five years, therapists around the world have become intrigued by narrative and related approaches to therapy that flatten out the familiar client/ therapist hierarchy and treat personal identity as a fluid social construct. To be sure, the interest in narrative is not client driven. People don't come into my office asking for help “standing up to Anorexia" or to have a liberating conversation" or asking to "deconstruct their social identities." Rather, the popularity of narrative and related approaches has something to do with their appeal to therapists — they heighten our sense of the possible; they make us feel hopeful and excited again

The First and the Second Wave

The appeal of narrative therapy involves much more than a new set of techniques. To my way of thinking, it represents a fundamentally new direction in the therapeutic world, a movement that might be called psychotherapy's Third Wave. The First Wave, which began with Freud and laid the foundation for the field of psychotherapy, was pathology-focused and dominated by psychodynamic theories and biological psychiatry. The First Wave represented a major advance because it no longer viewed troubled people as morally deficient, and it gave us a common vocabulary — codified in the Diagnostic and Statistical Manual — for describing human problems. But it focused so heavily on pathology that it skewed our view of human nature. Many people ended up identifying themselves with stigmatizing labels like 'narcissist', 'borderline personality' or 'adult child of an alcoholic'.

I was never much of a fan of the First Wave. It seemed to give our pronouncements a vast and overrated authority and turn diagnoses that were little more than social prejudices or imaginative guesses into absolute and eternal truths. The absurdity and damage wrought by our delusion that we could determine what was sick or healthy, right or wrong, was amply demonstrated in the 1970s, when psychiatrists belatedly decided by democratic vote that homosexuality was no longer a disease.

Psychotherapy's Second Wave — the problem focused therapies — emerged in the 1950s but did not entirely supplant the First Wave. The Second Wave attempted to remedy the over focus on pathology and the past. Problem focused therapies, including behavioural therapy, cognitive approaches and family therapy, didn't assume clients were sick. They focused more on the here-and-now instead of searching for hidden meanings and ultimate causes. Personality was no longer seen as seated in the envelope of the skin, but as influenced by patterns of communication, stimulus and response, family and social relationships, and even 'self-talk'.

Change wasn't seen as nearly so difficult in the Second Wave: influence some of the variables and the whole system wilt shift, including personal characteristics that looked as though they were set in concrete. Second Wave therapists saw their clients as basically sound, just making a pit stop. The goat was to fix them up as quickly as possible and send them back onto the highway of life. They didn't try to tinker with things they hadn't been asked to fix.

Although the therapists of the Second Wave included a few more women and weren't as exalted as the psychiatrists of the First Wave, they remained the experts, versed in such arcana as Gregory Bateson's double-bind theory, paradoxical interventions or behavioural techniques. Problems resided in small-scale systems; solutions still rested with the therapists. Few saw their clients as decisive agents in their own change. In fact, many saw their clients' conscious sense of self as something that had to be worked around or outwitted.

And now the Third Wave

In the early 1980s, some therapists began adopting what might be called a precursor to the Third Wave — competence based therapies. We believed that the focus on problems often obscures the resources and solutions residing within clients. Like the Third Wave that would follow, we no longer saw the therapists as the source of the solution: the solutions rested in people and their social networks.That, in a nutshell, is solution oriented therapy — grow the solution/ life enhancing part of people's lives rather than focus on the pathology/ problem parts, and amazing changes can happen pretty rapidly.

But unlike the Third Wave that would follow us, we kept our ambitions limited. Like the man who searched under the street lamp for his keys because the light was better there, even though he'd dropped them half a block away, we worked on small, manageable problems. We saw deep changes happen sometimes, almost as an act of grace or accident, and welcomed them when they did. But planning or expecting it to occur regularly seemed like setting up our clients for failure.

The First Wave's preoccupation with history acknowledged the reality of people's victimisation and yet seemed obsessed and defeated by it. The Second Wave's minimalist pragmatism helped people cope with day-to-day issues at the expense of acknowledging the depth of their pain and the richness of their lives. Both viewpoints are clearly incomplete, and this may explain some of the attraction of the Third Wave, which is arising in many different places in the world simultaneously. That is why Marisa's story so moved me. Epston did not brush aside her history, nor did he get bogged down in it — he dethroned it. He saw her as an active resister, not a passive victim. He acknowledged the tremendous power of what she had been told about herself, and separated her sense of herself from her history. And he did so without one-way mirrors or therapeutic gobbledygook, using nothing more technologically sophisticated than a letter written with dignity and feeling and respect.

The more time I have spent reading and watching the work of Third Wave therapists, the more I see similar patterns — a willingness to acknowledge the tremendous power of the past history and the present culture that shape our lives, integrated with a powerful, optimistic vision of our capacity to free ourselves from them, once they are made conscious.

The person is never the problem

The hallmark of the narrative approach is the credo, "The person is never the problem; the problem is the problem." Through use of their most well known technique, externalisation, narrative therapists are able to acknowledge the power of labels while both avoiding the trap of reinforcing people's attachment to them and letting them escape responsibility for their behaviour.

Externalisation offers a way of viewing clients as having parts of them that are uncontaminated by the symptom. This automatically creates a view of the person as non-determined and as accountable for the choices he or she makes in relationship to the problem.

"Narrative ideas lend themselves to respect and empowerment, not only for clients, but for therapists as well," says psychologist Richard Ruhrold, clinical director of the Bowen Centre in Indiana. After learning about externalisation, he used it with a family whose adolescent son was identified as having a "crappy attitude". "So we decided to name the problem Crappy Attitude," says Ruhrold. Using externalisation, the family and I found ourselves talking about how Crappy Attitude had been working to rule the boy's life and had caused many problems for the boy, his family and others. Rather quickly, we were all caught up in a discussion of how the young man could help himself and how each family member might help him 'fight Crappy Attitude'. This session was very positive and productive. An atmosphere of collaboration arose from that discussion that probably wouldn't have resulted from viewing and talking about either the boy or the family as the source of the problem."

"Ironically," says Canadian family therapist Karl Tomm, "this technique is both very simple and extremely complicated. It is simple in the sense that what it basically entails is a linguistic separation of the problem from the personal identity of the patient. What is complicated and difficult is the delicate means by which it is achieved. It is through the therapist's careful use of language in the therapeutic conversation that the person's healing initiatives are achieved."

One brief therapist I know unsuccessfully tried using externalization after reading White and Epston's book, Narrative Means to Therapeutic Ends. "I would externalise and it would fall kind of flat," he told me. "My clients would look at me blankly. 'So, I'm under the influence of Depression. So what,' they would say. I knew I was missing something, but I wasn't sure where to go with it or what I was missing."

What many therapists fail to understand is that, as Karl Tomm explains, "What is new about the narrative approach is that it provides a purposeful sequence of questions that consistently produce a freeing effect for people." Following the therapeutic sequence is a bit like building an arch, brick by brick. If you try to do the last step without having patiently spent time doing the first ones, your arch isn't going to hold up. Here is my understanding of the fundamental structure of the narrative approach:

1. The collaboration with the person or the family begins with coming up with a mutually acceptable name for the problem:

One might ask a child who has been having temper tantrums, "So, Anger has been convincing you to throw yourself on the floor and kick your feet, huh?" To a person who has been having paranoid hallucinations you could ask, "When Paranoia whispers in your ear do you always listen?" At first, the person and his or her family may persist in attributing the problem to the person, but the narrative therapist will gently persist in the other direction, linguistically severing the person from the problem label, and clients themselves soon begin to take on the externalized view of the problem.

2. Personifying the problem and attributing oppressive intentions and tactics to it:

Next, the therapist starts talking to the person or family as if the problem were another person with an identity, with tactics and intentions that are designed to oppress or dominate the person or the family. Often, the therapist will use metaphors or images that help bring the process to life for them and the clients. For example, "How long has Anorexia been lying to you?" or "How does the Alcoholism bully push your family around?"

3. Investigating how the problem has been disrupting, dominating or discouraging the person and the family:

Before the therapist tries to change the situation, he or she finds out how the person has felt dominated or forced by the problem to do or experience things he or she didn't like. The therapist might ask anyone in the room about the effects of the problem on the person and on them. This both acknowledges the person's suffering and the extent to which his or her life and relationships have been limited by the problem and provides further opportunities to create the externalization by asking more questions. The language highlights people's choices and creates an assumption of accountability, rather than blame or determinism. If the person is not the problem, but has a certain relationship to the problem, then the relationship can change. If the problem invites rather than forces, one can turn down the invitation. If the problem is trying to recruit you, you can refuse to join.

This step also increases motivation. The family and the person come together with the therapist in their common goal of overthrowing the dominance of the problem in the person's and family's lives.

4. Discovering moments when clients haven't been dominated or discouraged by the problem or their lives have not been disrupted by the problem:

This is akin to the solution focused method of searching for exceptions to the problem, only instead of asking, as solution oriented therapists might, "What was the longest time you have gone without drugs?", a narrative therapist would ask, "So what's the longest time you have stood up to Cravings?"

5. Finding historical evidence to bolster a new view of the person as competent enough to have stood up to, defeated or escaped from the dominance or oppression of the problem:

This is where the method really gets interesting. Here, the person's identity and life story begin to get rewritten. This is the narrative part. To keep this from being merely a glib reframing of the person's life, the narrative therapist asks for stories and evidence from the past to show that the person was actually competent, strong, spirited, but didn't always realise it or put a lot of emphasis on that aspect of him or herself. The therapist gets the client and the family to support and flesh out this view.

Solution oriented therapists would quickly move on to the future once a past exception is discovered, content to use that exception to solve the problem. Instead, the narrative therapist wants to root this new sense of self in a past and future so bright the person will have to wear shades. Typical questions might be: "What can you tell me about your past that would help me understand how you've been able to take these steps to stand up to Anorexia so well?" and "Who knew you as a child who wouldn't be surprised that you've been able to reject Violence as the dominant force in your relationship?"

6. Evoking speculation from the person and the family about what kind of future is to be expected from the strong, competent person that has emerged from the interview so far:

Next, the narrative therapist helps the person or the family to speculate on what future developments will result now that the person is seen as competent and strong, and what changes will result if the person keeps resisting the problem. For example, "As you continue to stand up to Anorexia, what do you think will be different about your future than the future Anorexia had planned for you?" or "As Jan continues to disbelieve the lies that Delusions are telling her, how do you think that will affect her relationship to her friends?" This step is designed to further crystallise the new view of the person and his or her life.

7. Finding or creating an audience for perceiving the new identity and new story:

Since the person developed the problem in a social context, it is important to make arrangements for the social environment to be involved in supporting the new story or identity that has emerged in the conversation with the therapist. Narrative therapists use letters, asking for advice for other people suffering from the same or similar problems, and arranging for meetings with family members and friends, to accomplish this social validation. Some questions might be: "Who could you tell about your development as a member of the Anti-Diet League that could help celebrate your freedom from Unreal Body Images?" and "Are there people who have known you when you were not under the influence of Depression who could remind you of your accomplishments and that your life is worth living?"

Not just a technique

Having just given you this formula, I have to give you a warning: if externalisation is approached purely as a technique, it will probably not produce profound effects. My biggest concern about narrative therapy is that many therapists will use it merely as a clever device. "There is nothing so dangerous as an idea," wrote Emile Chartier, "when it is the only one you have."

Because the technique is relatively easy to learn, therapists might just go around externalising problems, like earlier family therapists went around creating paradoxes or reframing people and expecting miracles. But if you don't believe, to the bottom of your soul, that people are not their problems and that their difficulties are social and personal constructions, then you won't be seeing these transformations. When Epston or White are in action, you can tell they are absolutely convinced that people are not their problems. Their voices, their postures, their whole beings radiate possibility and hope.

They are definitely under the influence of Optimism.

This article first appeared in "Human Givens Journal" Volume 2 - No. 4: 1995