Last week I did an incredible thing.
The Missing Foundation
In the spring of this year, when the winter air was mellowing and the smells from the Hudson River west of my apartment were becoming more pungent (my mask, useful as it is against COVID-19 particles, does nothing to shield against New Jersey air), I decided to speak with my therapist about something that I had been bugging me. I wanted to talk about my hopes and dreams, specifically the ones regarding my gently budding path as a psychotherapist. I told her that I sought, more than anything, to defy the trend of psychiatric-mental health nurse practitioner’s (PMHNP’s) deviating from their therapy-inspired foundations.
In 2004, famed nurse theorist Hildegard Peplau founded the first graduate program for advanced practice nurses in psychiatric-mental health.
The program was started at Rutgers University and had its roots firmly within the work of psychotherapy (Drew, 2014). Over the past decade, there has been a low rumbling-turned-roar of a movement which emphasizes medication management as the first (and often, only) line of treatment options for…well, everything. PMHNP’s are not immune to this movement.
The following is important to grasp before we go any further: NP’s at large have been fighting a war against their characterization as “physician extenders” for as long as the role has existed. The term is a derogatory one used by some physicians to delineate what, in their minds, is the healthcare provider hierarchy. For PMHNP’s, the impact of this war has manifested as a slow transformation of what was once a nursing-model based advanced practice profession into a role that mirrors the Psychiatrist in everything but name and training.
In some Full Practice Authority states, regardless of your hours of training or graduate degree level, your day-to-day patient care activities as a PMHNP will scarcely differ from that of the MD/DO who you may work alongside with (though your salary will likely differ thanks to biased insurance reimbursement protocols). The stark truth of mental healthcare in the United States is that most psychiatrists no longer deliver psychotherapeutic services, and PMHNP’s are quickly following suit.
But, as is my way (for better or worse), my spirit yearned to break the mold. I wanted to do what therapists before did with me every week for many years. I wanted to walk alongside people, hold space for them, and, if I was lucky, watch them bloom. I had the passion and even the courage to do this; what I was lacking was the fundamental training. Since many NP’s go to graduate school for 2-3 years (not including an optional residency), it doesn’t leave much room for thorough, specialized training in psychotherapy. This is something that is a source of much contention amongst NP’s (and often the main talking point of any would-be physician opponents).
Although I had already been placed in rooms with individuals to conduct therapy, I felt like I was floundering. What qualified me to sit across from this individual and presume to counsel them on immense topics such as trauma, depression, phobia, codependency, aggression, anxiety or even psychosis? Doubt settled its thick, powdery wings around me, its familiar presence not unlike the artist’s phantom. My therapist could see the Specter overtaking me as I tried to communicate my distress to her. She swiftly but politely intervened, slicing in past my diatribe, so flawlessly, like she often does (I really must learn how to do that one day).
Okay, so, what is your foundation?
Yes, the modality upon which you build all your interventions. What speaks to you?
Many therapists use a variety of techniques in session; it is rare to meet one who is a purist of any path. If techniques are tools, then your foundation is the toolbox. My therapist’s foundation is Existentialism—this I knew from our many discussions about death, dying, purpose and the afterlife. But what could mine be? She waited patiently and I wondered if she could hear my brain chattering like a Rolodex. I was anxiously flipping through mental archives of my psychotherapy theories and techniques class.
Psychoanalysis? No, not enough evidence these days, and way too entrenched in gross gender and sex stereotypes. Positive psychology? No, some of it just rubs me as too trendy. Gestalt? Only if I didn’t mind learning the ways of one of the most zany and provocative therapists of our time. I didn’t bother to say any of the behavioral therapies, as to me they have always felt like they belonged more in the tool column than the box column. In a rush to sound competent, I said the first word that came to my mind: Humanism.
My therapist intuitively understood that I was referring to a mix of Rogerian Person-centered therapy and Maslow’s hierarchy of needs. Peplau and Watson were amongst many nurse theorists who endorsed humanistic themes as the basis of nursing care, so it wasn’t a stretch. But even as my therapist began to explain more about how I might weave Humanistic themes into my work, something in my chest felt hollow.
I was only half-listening because I knew in my soul that it wasn’t the right answer. Perhaps elements of it sprinkled through my practice, like unconditional positive regard and a fundamental belief in human ambition, but it wasn’t the foundation I so desperately sought.
It spoke to me sure, but it didn’t sing.
Back in the first summer of my Masters program, I learned about the fields of narrative medicine and narrative writing. Prior to this, I had thought my talent for writing and my passion for psychiatric-mental health were worlds apart. Distant stars connected by singular traits such as empathy and creativity, but certainly not meant to orbit closely. As it turns out, they orbit like the Moon and the Earth, often resonating with and influencing each other. I can’t remember exactly how narrative medicine led me to the realm of narrative therapy but I knew upon discovery, somewhere in the back of my mind, that it was tailor-made for people like me. People who think in stories.
Still, it’s not as if lightening struck right then and I had some amazing a-ha moment. Something was holding me back at the time, but more on that later.
At the end of this year’s balmy spring, I successfully terminated my first ever therapy sessions with my clients but somehow still felt no closer to having built my foundation. My therapist’s words languidly lingered beside me as I floated into summer, like a sun-drunk dog catching its breath on the cool wooden floor. I knew my time in my doctoral program was going to be ending eventually (yes, graduate school does end) and I wanted to give myself the opportunity to be formally trained in something.
Just as I was beginning to feel hopeless, that little something in the back of my mind jingled, and the dog bolted upright, alert, it’s bell-like tags tingling against my nerve endings. It wasn’t just jingling. It was singing.
Just take a look. Maybe now is the time.
I grabbed my cellphone. When I started to research training resources, a number of sites that I must have bookmarked at a prior moment in history came up immediately. I was pleasantly surprised to find that there were quite a few websites saved in my smartphone browser, despite me having no real recollection of doing so. It was if some past version of me had gotten a missive from the me now and knew. That one day I would come back to this wonderful world view, back to my home. To narrative therapy.
A Short Background of Narrative Therapy
So what is narrative therapy, anyhow?
Narrative Therapy was first borne in the 70’s out of the practice of social workers Michael White from Australia and David Epston of New Zealand. Just like most poststructuralist therapies, Narrative Therapy seeks to identify and deconstruct the social discourses that play a role in our lives such as individualism, pathology, and universalization. One thing that drew me to Narrative therapy when I first heard of it in the Spring was its commitment to decolonizing mental health. Narrative Therapy is not afraid to unveil and upturn the roles of racism, sexism, ableism, homophobia, xenophobia and other oppressive tropes that infect our views of ourselves as members of society.
An example of this is their commitment to finding diverse philosopher’s that challenge societal discourses, rather than just relying on the work of White and Eurocentric theorists such as Michael Foucault. By challenging traditional and modern power structures, Narrative Therapy aims to empower individuals to become change agents in their own lives—to exercise their inherent right to reflect upon and rewrite their own journeys. The powerful medium through which they do this is Stories.
With my background in Writing for Screen and Television, having written my first short fantasy tale by the precocious age of 9, I didn’t need to be sold on the life-changing capabilities of storytelling. I have spent most of my young life being moved by and seeking to move others with the elements of Story. With every iteration of the Hero’s Journey I encounter, I find myself digging deeper into the guts of my own life, finding wisdom from all the mentors I’ve been fortunate to have as a guide, absorbing strength from the dragons I’ve determinedly (and at times, unexpectedly) slain. Narrative Therapists use the language of stories and storytelling, to help individuals realize their lived experience is vast and full of promise—so long as they can read between the lines, or see what lies just beyond the edge of the page.
There are a handful of metaphors and aphorisms that are commonplace in Narrative Therapy which help elucidate this work. The first is that everyone’s life can be likened to a blank page with hundreds of small dots on it. These dots float near one another and they symbolize a memory, an event, or lived experience for the individual. Most folx that seek therapy have already been connecting the dots to tell a specific kind of story—usually the problematic one.
The problem story is also what a therapist or clinician might call the Chief Complaint—whatever situation or symptoms bring a client in to request aid. Most clients don’t ask for help until the problem story has grown so large it has overtaken their entire life narrative (another reason I am a huge advocate of destigmatizing mental health and preventative treatment). It is the Narrative Therapist’s job to take that thin, problem story and, well, fatten it up.
Fleshing out the Skeleton
They attempt to highlight the neglected dots on the page—unique outcomes when an individual behaved “out of character” or hidden perspectives from cherished and admired ones which challenge the individual’s depiction of themselves. This is one way that the Narrative Therapist and the individual begin the integral process of showing how societal narratives surrounding health, sanity, success or merit have become internalized into our world view, and how these narratives may not be serving us. Then, they begin the process of Externalization.
There is another important maxim that is often used in Narrative Therapy which explains the technique of Externalization quite succinctly: The person is not the problem, the problem is the problem. By having conversations with clients, Narrative Therapists unpack the problem and show it for what it is: a construct, like so many postmodern theories believe. They do this by assigning the problem a name, highlighting scenes where the problem appears in one’s life (physically, emotionally, interpersonally), and identifying how the problem blinds an individual from seeing the entire panorama that is their life journey. The emphasis is not on tools and techniques, or even on storytelling, so much as it is on storylistening.
Storylistening includes deep listening and double listening. Deep listening from the therapist not only validates the client’s struggles and symptoms, it also models to the client how they might begin to turn inward and listen to themselves. Double listening is the Narrative Therapist’s attempt to gain a sincere appreciation of the problem while also seeking plot points that are outside of the problem story. All this is to ultimately assist individuals in uncovering their preferred stories.
It is important to communicate that humanity’s narrative is a multistoried one. The formation of a preferred story doesn’t have the power to erase the problem story—after all, those dots still exist on your life’s page, and very well so. They’ve just been connected in a new, different way to emphasize and construct a previously hidden but now shining narrative. One that is significantly more fulfilling, meaningful, and affirming for the individual—and that, ideally, does not center the problem.
There are specific ways that Narrative Therapists can begin to construct the yellow-brick road that leads to a client’s preferred story. One of them is a precise and thoughtful line of questioning. This is less so the interrogative questions one might envision a detective asking their suspect, and more like the investigative inquiries of anthropologists when they first meet peoples from distant cultures. The following types of questions can serve as the soft brush we use to gently dust away at the structure of a client’s narrative and uncover what lies beneath.
What was the environment like when you experienced that life event? What was the season/time of year? Were you inside or outside? We encourage the individual to paint the memory in vivid hues, such that the therapist can step inside of it. We help them develop the storyline’s history: What happened before this? Was life easier for you or more difficult?
Questions about meaning
These types of questions focus on the patient’s perception of symbols in the event/issue in question. They attempt to elicit identity, value, and foster introspection. What does it mean to you that this event has occurred? How does it make a difference in your life, or speak to your character?
Questions about people
Here the Narrative Therapist aims to invite multiple points of view into the story. You may start by asking: Who else was there and how did they react to what happened? Did anyone support you? If you looked at it from their eyes, what would you see? Or if you assumed the POV of yourself five years from now, what might you be thinking?
One thing our cohort this weekend seemed curious about was the idea that Narrative Therapists are not experts or guides, so much as they are companions on a journey. Sheila Carroll describes her role as a Narrative Therapist not as a “sage on the stage” but as a “guide on the side.” Narrative Therapists summarize what they hear as they go along and help their clients develop a story that is as multifaceted as a diamond. They strive to help their clients notice hopeful courses their stories might take, but they certainly do not drag them anywhere they don’t want to go. This is because Narrative Therapists recognize people as the primary authors of their stories.
On being your life’s author
My favorite part of narrative therapy is their unique practice of documentation. Every clinician keeps some kind of documentation on the people they treat, however the style that Narrative Therapists employ is simply breathtaking. I’m talking about letter writing.
Letters to patients can be shared after every session or after breakthrough moments in a client’s journey. They illuminate unique outcomes and show a patient what the therapist has taken away from the session. Often, they gift the individual with some memorable plot points for them to hold on to. A particularly inspirational letter might invite the client to consider a few more questions about their story, welcoming further reflection between sessions.
At their very core, letters are tangible proof to our clients of all the hard work they are doing each time the come to converse with us. To write a good narrative letter, the therapist should keep the following in mind (or even ask the client directly): What do you think is important for me to remember about the conversation we just had? What should we both hold on to?
As I learned from Gene and Jill this weekend, I also learned from the therapists attending the workshop alongside me. A big part of Narrative Therapy is the power of community to corroborate our preferred stories, and to help us broaden our point of view. Working with the more experienced therapists this weekend allowed me to begin the process of entertaining a new kind of Therapist story for myself.
There were so many gems and pearls in this workshop, I could scarcely aim to describe them all. I also understand with a sharp certainty that this is really just the beginning of a lifelong education on a rather unique way of caring for individuals. Whilst Narrative Therapy may be overlooked by some in favor of Structuralist modalities, it holds a special place in my heart. This is because I know that, just like all the art I make, the work I could do with Narrative Therapy would not just be for my client’s benefit and personal growth, but also for myself.
Which brings me back to why I hesitated to dive into this field the very first time I learned about it.
In truth, I was afraid. In order to help others uncover their story, there is an essence of understanding and acceptance you must first have regarding your own. As a Seeker, my story is constantly shifting and changing. Most of this is natural, good even, but many times I find myself struggling to grasp onto the wispy strands of my values, my own life journey. In the process of helping others uncover their stories, I was afraid to be uncovered myself, uncloaked and exposed as a fraud.
It was the Specter holding me in place, wrapping its frigid arms around my chest, spindly fingers encircling my throat. Will it ever, completely, go away?
But today I am pleased to say, with all my Will, is a brand new day and with it comes a blank, inviting page. My workshop at the Evanston Family Therapy Center cemented my desire to gain a thorough education in Narrative Therapy. No longer do I shudder at the vision of myself and a client in the same room, silently hoping they can’t see past my veneer of professionalism to the quivering young girl underneath. Instead I imagine myself curiously and patiently anticipating, as I ask them for the first time:
Drew, B. L. (2014). The Evolution of the Role of the Psychiatric Mental Health Advanced Practice Registered Nurse in the United States. Archives of Psychiatric Nursing, 28(5), 298–300. https://doi.org/10.1016/j.apnu.2014.07.002
Evanston Family Therapy Center https://www.narrativetherapychicago.com/
Hagerty, T. A., Samuels, W., Norcini-Pala, A., & Gigliotti, E. (2017). Peplau’s Theory of Interpersonal Relations: An Alternate Factor Structure for Patient Experience Data? Nursing Science Quarterly, 30(2), 160–167. https://doi.org/10.1177/0894318417693286
Psychology Takeaway Podcast: Introduction to Narrative Therapy with Jim and Sheila https://psychologytakeaway.com/podcasts/