Narrative Therapy: An Unchartered Realm of Possibilities



Narrative Therapy: An Unchartered Realm of Possibilities Karelia Cribb-Lokhorst University of Calgary Narrative Therapy: An Unchartered Realm of PossibilitiesNarrative therapy, introduced to the therapy community by White and Epston (1990), has been around for over two-decades. Narrative therapy as a practice is used throughout the world and its concepts are spread through conferences, trainings, research articles, and books. However, there still seems to be hesitation within the scientific community around the validation of narrative therapy as a practice, mainly due to a lack of empirical research (Busch, 2007). Currently, the standards for evaluating therapy place a high value on quantitative research to validate empirically-based treatments (Busch, 2007; Stillman & Erbes, 2012). However, qualitative research has been the main form of research used to explore narrative therapy, as it aligns well with narrative’s social constructivist, post-modern epistemology. The dilemma is that if qualitative methods of conducting research continue to be undervalued, and there continues to be a lack of quantitative, “rigorous”, research around narrative therapy, individuals’ access to and exploration of narrative therapy as a practice will remain limited. The purpose of this review is three-fold: (1) To explore reasons for the lack of empirical research around narrative therapy; (2) Examine research that has been conducted around narrative therapy across the years; and (3) Explore possibilities for the future of research in the field of narrative therapy; research that which would allow it to be seen as a valuable contender in the field of psychotherapy. When searching for research articles around narrative therapy, this writer used the University of Calgary online library search function (Summon, ProQuest) as a main tool. As well, this writer used web search engines such as Google, Google Scholar, Bing, and Yahoo to conduct a general search, using terms such as “narrative therapy and research”; “case studies and narrative therapy”; and “narrative therapy and outcome”. This writer also used WorldCat to search for various articles around the topic. As well, this writer located original sources from secondary reviews and utilized previously owned articles and books on narrative therapy. Narrative Therapy: A New ParadigmNarrative therapy is grounded in social constructivist and post-modern tenets, influenced by the work of Foucault (White & Epston, 1990). Bruner (1987) describes how individuals share their experiences through a narrative; a temporal form of recording experiences in “lived” time, the essence of which cannot be captured by any other means. The practice of narrative therapy is based on the exploration of the meanings used to define peoples’ existence; and empowering others to “re-story” their lives (White & Epston, 1990). The main concepts of narrative therapy include: (1) Client and therapist as “co-researchers” of the problem; client seen as the expert; (2) Extracting the problem story (including the externalizing of problems, or locating the problem outside of one’s self); (4) Deconstructing dominant stories (exploring cultural discourses and unitary knowledges that have shaped one’s story); (4) Enriching preferred stories (including the recognition of unique outcomes, any behavior or thought that contradicts the problem story); and (5) Living and witnessing of preferred stories (people living their desired lives, with others as witnesses; White, 2007; White & Epston, 1990). The therapist often adopts a questioning approach to assist individuals in gaining new perspectives, termed unique re-descriptions (e.g. “How does the problem drive you to treat yourself and others?”; White & Epston, 1990). Currently, very little quantitative-empirical clinical research exists to support narrative therapy as a practice (McLeod & Balamoutsou, 1996; Ramey, Tarulli, Fritjers, & Fisher, 2009). When introduced, narrative therapy reflected a shift in paradigms, from a language of science grounded in “generalizing”, “categorizing”, and one of “expert knowledge” to an acknowledgement of the existence of multiple truths and realities (White & Epston, 1990). Narratives are constantly changing and evolving; the challenge is being able to capture these stories in a moment in time and translate them into the language of science (Stillman & Erbes, 2012). Henceforth, providing empirical support for narrative therapy, without compromising its constructivist, post-modern epistemological approach to human nature, remains a challenge for most researchers. The empirically-based practice (EBP) movement has been highly influential in defining the ideal ways to conduct research around the validation of therapy practices; deeming randomized control trials (RCT) as the “gold-standard” (Strong, Busch, & Couture, 2008; Tilsen & Nylund, 2008). The popularity around using EBP as a standard for therapy models dates back to the 1990’s, when the American Psychological Association (APA) Division 12 published criteria around empirically validated treatments (American Psychological Association Presidential Task Force on Evidence-Based Practice, 2006). The aim behind this publication was to showcase the utility of psychology in the treatment of “disorder”, as a contender alongside medication. Within the publication, 18 treatments were found to have empirical support on the basis that they had undergone “rigorous” testing through randomized control trials (RCTs) with a particular population and a treatment manual. The framework for empirically supported treatments (EST) has not aligned well with theory and practice in the majority of humanistic, family, and social constructivist approaches to therapy (Neimeyer, 1993; Strong, Busch, & Couture, 2008). One of the downfalls of narrative therapy not being seen as a valid practice is that it can limit the exploration and use of its practices, both within the therapy room and institutions throughout the world (Stillman & Erbes, 2012). Qualitative research aligns well with the practice of narrative therapy, as it draws upon rich descriptions of peoples’ experiences. Strong, Busch, and Couture (2008) see therapeutic dialogue as offering fruitful insight into exploring how therapists and clients influence each other’s understanding around their communication. Strong et al. (2008) suggest that the spoken word should be seen as a way of evaluating therapeutic change (referring to it further as conversation evidence) as the work in therapy often occurs through dialogue between client and therapist. One of the more recent reports from the American Psychological Association Presidential Task Force on Evidence-Based Practice (2006) advocated for the use of a wider range of methodologies to evaluate outcomes to inform the practice of psychology. This recommendation opened the possibility that therapy models that did not fit the current methods of evaluation, such as narrative therapy, could be considered as valuable through a different lens (Busch, 2007; Strong et al., 2008). The next section of this review is dedicated to exploring the current research around narrative therapy. Narrative Therapy and Qualitative ResearchIn order to preserve the tenets of narrative therapy, and to honor peoples’ stories, as opposed to reducing them to “subjects” or “objects”, most of the research around narrative therapy has adopted a qualitative approach (Gardner & Poole, 2009). Narrative therapy principles acknowledge the client, as opposed the therapist or researcher, as the expert in their lives (White & Epston, 1990). The person is seen as holding vast knowledge (termed insider knowledge by Madigan, 2011) and insight into the problem, based on their years of experience together. Narrative therapists have introduced “co-research” to reflect the involvement of both client and therapist in the investigation of the problem (Epston, 1999). An example of this can be seen in an article by Tilsen, Russell, and Michael (2005), where Tilsen co-authors an article alongside a Michael, a 9-year-old boy, and his mother, Sally Russell. The article describes how Michael tackled his “nemesis”, “Unnimbleness” (otherwise known in the scientific world as Aspberger’s, p. 29). From the first moment Tilsen speaks with Michael’s mother on the phone, Tilsen makes it clear that she is not the expert. Through their work together, Michael was able to create a new story for him and his family. Case studies are another common form of research around narrative therapy. Young(2008) conducted a case study in a walk-in clinic setting with an 8-year-old boy who was experiencing pain and had regularly missed school due to anxiety. In her study, Young (2008) explored transcripts of her conversations with the boy and his mother, making references to an appendix to illustrate the narrative principles guiding her work. When the boy returned four months following the first session, he and his mother shared that the boy’s school attendance had improved, and that he had a sense of mastery over “Worry”. Hannen and Woods (2012) conducted a case study on a 12-year-old girl who was an identified “self-cutter”. At the end of the study, the girl described being happier, not cutting, and that anger had less of a presence in her life; statements that were confirmed by others in her life. These statements suggested that the girl had begun to re-author her life and was beginning to pursue her preferred life story. Busch (2007) completed a discursive evaluation of six narrative therapy case study transcripts; examining changes in clients’ discourses throughout the process of narrative therapy. Busch (2007) found that the majority of clients in the case studies moved from a problem-saturated to a strength-based narrative. In the end, he found that five out of the six reports showed the effectiveness of narrative therapy in producing change for clients. Based on his analysis, Busch (2007) concluded that the “establishment and fostering of a productive dialogue may lie at the heart of successful psychotherapy” (p. 19). The limitations around case studies such as the ones listed above include the inability to “validate” the findings empirically. This is often due to the design of the study; small sample sizes; limited length of intervention; as well as limited details around therapy process and outcome (Hadden & Woods, 2012). However these forms of research still offer a rich form of knowledge that otherwise may not have been available. Various researchers have examined individuals’ perspectives (both therapist and client) on narrative therapy through an interview (ethnographic research) format. O’Connor, Meakes, Pickering, and Schuman (1997) used interviews to examine eight families’ experiences with narrative therapy, including what they found helpful and not helpful, and the meaning they attributed to their experiences. Reports from all of the families indicated that they found narrative therapy to be effective in reducing the effect of their problem. The main theme throughout the participants’ responses was that they sensed they were “on the right track”, further suggesting the clients had drawn upon personal agency to tackle their problems (O’Connor et al., 1997, p. 489). As well, several clients shared appreciation for being seen as experts in their lives. A few components that were identified as unhelpful included the “slow process” and that it felt “artificial” (O’Connor et al., 1997, p. 490). The researchers identified that those participants that were involved in narrative therapy for a year or longer, often communicated positive impacts on their lives. One limitation of this study was that the researchers did not describe the processes underlying the narrative therapy approach; rather, they summarized main themes elicited by clients. In a subsequent study, O’Connor, Davis, Meakes, Pickering, and Schuman (2004) explored therapists’ perspectives on the impact of narrative therapy on families. The overall theme around the feedback was that narrative therapy was seen to have a positive impact on families and was successful in “unburdening” families from their problems (p. 29). In another ethnographic study, Gardner and Poole (2009) explored practitioners’ and participants’ (older adults struggling with addiction) perspectives around the use of narrative therapy. Two therapists conducted group therapy for a period of eight weeks with 12 adults over the age of 55 (from various cultural groups) seeking help for addictions and mental health concerns. Feedback from interviews with the participants indicated that narrative therapy had a positive effect on all participants; eight participants claimed a positive impact on their substance misuse and four reported current abstinence. Based on the reports by participants and therapists around the value and effectiveness of narrative therapy, it was suggested it is a helpful therapeutic approach for older people with addictions. A few limitations of the study include a smaller sample size, lack of details around therapeutic process, and the design of the study. One of the strengths of the study was the inclusion of participants from various cultural groups, increasing the ability to generalize the results. The value of ethnographic research designs lies in the ability to gather complex, detailed, responses from participants that can shed valuable information on the area being explored (in this case, narrative therapy). Research on Narrative Therapy ProcessIn a qualitative study of narrative therapy based on linguistic theory methods, Muntigl (2004) transcribed and analyzed audiotapes from six narrative therapy sessions involving a therapist and a couple. In his analysis, Muntigl (2004) used a linguistic-semiotic approach to explore the discursive process around narratives; seeking insight into how clients navigate meaning-making in therapy. Muntigl (2004) found that therapists’ emphasis on naming the problem and its effects fostered clients’ development of resources around meaning-making and assisted in shifting language around problems and unique outcomes. The scientific limitations of this type of research include the small participant size (one couple); the lack of description around the couple’s cultural background; only one person analyzing the transcripts; and the lack of focus on therapy outcome. Several researchers have attempted to examine the processes underlying narrative therapy using a quantitative approach. Over the years, researchers have developed coding systems to gain a deeper understanding of narrative processes within therapy (Core Conflict Relationship Theme, Luborsky, Popp, Luborsky, & Mark, 1994; Narrative Process Coding Scheme, McLeod & Balamoutsou, 1996; Narrative Processes Coding System, Angus & Hardtke, 1994). Recently, Ramey, Tarulli, Fritjers, and Fisher (2009) and Ramey, Young, and Tarulli (2010) explored the processes within narrative therapy using quantitative and qualitative research through a scaffolding conversations map, based on White’s (2007) work around narrative maps. The researchers describe White’s (2007) redefinition of the term externalization as reflecting a scaffolding process (drawn from the work of Vygotsky, 1978, as cited in Ramey et al., 2009), through which the therapist invokes subtle shifts in children’s awareness and instills a sense of mastery over problems (Ramey et al., 2009). In their first study, Ramey et al. (2009), explored scaffolding and concept formation within client-therapist interactions in narrative therapy. The researchers’ aim was to see whether narrative therapy as described by White (2007) aligned with narrative therapy in practice. In an attempt to quantitatively confirm the results, the researchers used observational coding and analysis to examine small process units from videotaped therapy sessions. Child responses were found to follow therapists’ utterances at all levels of the scaffolding conversations map, confirming White’s (2007) initial belief around therapist scaffolding in the zone of proximal development. As well, child and therapist utterances demonstrated progression through the sequential stages of concept formation over time. Ramey et al. (2010) also examined the videotapes of narrative therapy sessions using a qualitative perspective. In examining patterns within the sessions, the researchers found further support for White’s (2007) descriptions of scaffolding and concept formation. Once again, the limitations for the above study include the small data size (use of only eight single therapy sessions), and a lack of information around participant background. The researchers identified this study as the first known study to compare narrative therapy’s empirical process with intended process. However, the research did not provide support for outcome around narrative therapy as a practice. Matos, Santos, Gon?alves, and Martins (2009) explored one aspect of the narrative therapy process (unique outcomes) and its connection with outcomes for female victims of partner violence. As a reminder, unique outcomes reflect any action or thought that contradicts the problem. In this case, the problem was defined around the impact of violence and abuse on the women. Based on literature around narrative therapy, and previous empirical research, the authors created a coding system of unique outcomes (which they referred to as innovative moments, or IMs), which they entitled the Innovative Moments Coding System (Goncalves, Matos, & Santos, 2008, as cited by Matos et al., 2009). Due to the influential role IMs play in the process of change in narrative therapy, Matos et al. (2009) proposed that IMs be seen as process measures; however at this preliminary stage of research, they referred to them as intermediate outcome measures. The authors’ intention behind this study was to explore whether IMs (and which ones) were connected to a certain outcome (good vs. poor), and when these IMs appeared during the course of therapy. The participants of the study were ten women who were currently experiencing partner abuse and enrolled in individual narrative therapy (guided by principles from White & Epston, 1990) with a therapist at a Portuguese university clinic. The researchers assessed the following variables pre and post intervention: Clinically relevant symptoms; severity of abuse; therapeutic alliance; clients’ beliefs toward violence; and process of change (coded according to five different types of IMs: action, reflection, protest, re-conceptualization, new experiences). In an analysis of 127 therapy sessions, the researchers defined two possible outcome groups for the 10 participants: (1) Good outcome (reduced symptoms and decrease or non-existence of victimization from partner) or (2) Poor outcome (did not meet above criteria). In an analysis of the variables after the therapy sessions, five participants fell within each outcome group. Through statistical analysis, the researchers found that the good-outcome group had a higher salience of IMs, more specifically for the re-conceptualization IM. As well, the researchers found that for the good outcome group, the re-conceptualization and new experiences IMs tended to emerge mid-way and increased their salience throughout the therapy sessions; whereas the presence of these IMs was almost absent in the poor-outcome group. The results of the above study indicate that a focus and further exploration of IMs may be an important aspect of narrative therapy (Matos et al., 2009). The researchers see the appearance of re-conceptualization IMs as reflecting individuals’ shift towards becoming the authors of their story and personal agents of change in their life. As well, the authors see the re-conceptualization IMs as playing a role in attracting other IMs (action, reflection, protest) and giving them meaning, aiding in the transforming of the client’s old story to a new one. A few of the limitations of this study include the research design (only exploring one component of narrative therapy); the small sample size; no independent factors between therapists and researchers; only one therapist collecting data; the inclusion of the participants who dropped out of the study in the poor outcome group, providing the possibility for skewed results; and the possibility of other factors having an impact on change or differences (e.g. education level, finances, support network). As well, Matos et al.’s (2009) evaluation of the narrative therapy process relied on the authors’ own coding system, rather than on White’s (White & Epston, 1990; White, 2007) descriptions of narrative therapy. Despite this, the researchers suggest a level confidence around the findings based on the coding process; interjudge reliability; and the significant results obtained within a small sample size. Further research around IMs may provide more evidence around their connection to narrative therapy and outcome. Research on Narrative Therapy and OutcomeStudies, such as the ones described above, are essential in exploring the processes which underlie narrative therapy and their possible connection with change and outcome. While valuable, these studies only touch on processes within narrative therapy. The next few studies attempt to evaluate outcome in regards to narrative therapy as a practice. Besa (1994) used a single-system research design to evaluate the effectiveness of narrative therapy in reducing parent-child conflicts through anecdotal reports, using a multiple baseline analysis of target behaviors. To measure outcome, the target behavior was defined (in measurable terms) as the behavior the family wanted to decrease around the parent-child conflict (e.g. arguing). The child’s parents were trained to track the target behavior as performed by the child during the different conditions. The participants in the study included six families with children between the ages of eight and 17, presenting with parent-child conflict. In the first condition, the therapist limited their intervention to defining and externalizing the problem and exploring its relative influence in the family’s life. During the intervention condition, the therapist began to explore unique outcomes with the family; introducing behavioral contracts as the main intervention. In order to reduce the number of variables attributed to change, Besa (2004) introduced a time lag for the introduction of the intervention condition with the second family. During the last condition, the parents were asked to track the target behavior for a period of time after the study. Besa (1994) anticipated the identification of unique outcomes as having the largest impact on reducing target behaviors. In analyzing the results, five out of six families showed improvements in regards to a reduction in the frequency of target behaviors, based on the parents’ tracking. As well, the time-lagged baseline measures indicated a link between narrative therapy interventions (around unique outcomes) and behavior changes for the five families. In the end, the researcher suggested the feasibility and practicality of single-system research designs in evaluating the effectiveness of narrative therapy. One of the limitations of this study included the reliability of parent’s tracking of the child’s behavior; no checks were done by the researcher around this tracking. This could be seen as a weakness within the scientific community and the results challenged. As well, the behavior contract introduced by the therapist may not reflect the true essence of narrative therapy; it could be seen as the therapist imposing expert knowledge as opposed to waiting for change to occur. As well, there was only one therapist who conducted the study, leaving room for the results to be linked back to the therapist as opposed to narrative therapy as a practice. Often times in cases where empirical testing was conducted on narrative therapy and outcome, the methods were not rigorous enough to stand up to other empirically supported therapy models. This is where the gap lies around research with narrative therapy that has excluded it from being heard within the mainstream scientific community (Vromans & Schweitzer, 2011). One of the challenges researchers have faced in evaluating narrative therapy is the difficulty of “manualizing” narrative practice without compromising its philosophy. However, without a manual, it is challenging to systematize its application for research purposes (Stillman & Erbes, 2012). Vromans and Schweitzer (2011) attempted to tackle this problem by designing a manual based on principles within White and Epston’s (1990) work. A general sequence was introduced with the manual to assist with clarity; alongside an explanation around the circular nature of narrative therapy which cannot be reduced to a set of steps and procedures. In their study, Vromans and Schweitzer (2011) investigated depressive symptom and interpersonal relatedness outcomes around the use of narrative therapy with adults experiencing major depressive disorder. The participants consisted of 38 individuals between the ages of 18 and 60, who had experienced a major depressive episode. The intervention spanned across eight 50-minute individual narrative therapy sessions, guided by the manual devised by the researchers. In an attempt to minimize the variables, the researchers eliminated participants who had comorbid Axis I and II disorders as well as those who were currently using antidepressants (or who had changed medication use throughout the study). There were a total of 24 therapists that participated in the study, who were deemed competent at implementing a narrative therapy approach after a two-day intensive training period. Weekly group supervision of therapists was conducted to help facilitate the integrity of the therapy. The researchers devised a scale for rating therapists’ adherence and competence to the therapy intervention according to the manual, which they entitled the Narrative Therapy Integrity Schedule (N-TIS). Through the observation of videotaped sessions, two independent raters evaluated therapists’ adherence to the intervention. In assessing the data, the results showed that the therapists were maintaining the integrity of the manualized narrative approach. Findings from the study provided support for the researchers’ hypotheses around the effectiveness of narrative therapy in the improvement of depressive symptoms and interpersonal relatedness scores. Nearly 75% of the participants reported reliable improvement in depressive symptoms, with 61% moving into the functional population and more than 50% achieving clinically significant gains. These gains were comparable to outcomes found for other therapies (e.g. cognitive behavior therapy) in benchmark research. Improvements for depressive symptoms were maintained up to a 3-month follow-up mark. A few limitations of the above study, which also pose barriers within other narrative therapy research, are the small sample size; limited length of intervention; and limited cultural background (Caucasian). These weaknesses can limit the level of confidence and generalizability around the results of the study. As well, the two day training may not have been sufficient for therapists to become skilled in the use of narrative therapy. The researchers attempted to address this using ongoing supervision; however, in the future, studies may want to utilize therapists who have extensive experience in narrative therapy. As well, this study was limited to exploring depression; future studies may want to expand and explore other contexts and disorders. In the end, the researchers found empirical support for the effectiveness of narrative therapy in treating adults with major depressive disorder, further adding to the research already completed in the field of narrative therapy. This was one of the first studies to attempt rigorous investigations of narrative therapy outcome. In reflection, one needs to question whether research is truly reflecting a narrative therapy, social constructivist paradigm, or whether some elements still reflect notions of the existence of “expert knowledge”, which act to subjugate and classify individuals according to clinical diagnoses (Madigan, 2011; White & Epston, 1990). As well, is it possible to conduct research that provides empirical support for narrative therapy while protecting its core beliefs? Stillman and Erbes (2012) are in the process of completing a pilot project for narrative therapy that would meet the requirements of evidence-based research, while maintaining the integrity of narrative therapy. Part of their process (similar to that of Vromans & Schweitzer, 2011) included the creation of a manual for narrative therapy, based on principles in order to reflect the true nature of narrative therapy and allow for the practice to be applied systematically. The bottom line is if the researchers could demonstrate that sessions were informed by a manual, they could say that narrative therapy was measurable. As well, they could finally say that the effects of narrative therapy, and not the individual therapist, were being examined. If the results were consistent, they would show the results of therapy measured the effectiveness of the narrative principles described in the manual. As well, if the researchers could train other therapists, the results of subsequent studies could demonstrate even more the effectiveness of narrative therapy. The therapists involved in the research engaged in three 2-day weekend trainings, a month apart, where they took on different roles (interviewer, interviewee, and audience) to gain different perspectives on their questions and their reflection of narrative principles. Practice sessions were videotaped in order for therapists to review and critique their skills. The design of this training addressed one of the limitations of Vromans and Schweitzer’s (2011) study, limited therapist training. Stillman and Erbes (2012) also created a method of observation to be used by raters to confirm that the therapists were following the manual. The raters involved in the study were oriented to narrative therapy through videos and involvement in therapist training. This element reflects another aspect of the research that may add confidence to the results found. Stillman and Erbes (2012) selected trauma as their area of focus, with the target population being veterans experiencing post-traumatic stress disorder (PTSD). In the process, the researchers eliminated participants with other possible diagnoses in order to ensure the target problem was being treated. Instead of specifying the focus of the therapy sessions, the researchers left this open to the participants, trusting they would know what they wanted to address. This is one aspect that differed from the research by Vromans and Schweitzer (2011) in that it reflected narrative therapy principles; mainly that the client is the expert and knows what is best for their lives (White & Epston, 1990). As well, the study measured clients’ self-reported measures of their symptoms and well-being. Evaluation forms and questionnaires to track feedback around the sessions for participants were also provided. These methods combine the value of qualitative research in eliciting clients’ feedback and knowledge with empirical, quantitative methods, which can provide validation for narrative therapy as a practice. Summary and ConclusionsThe aim of this literature review was to explore the reasons underlying the lack of empirical support for the use of narrative therapy in the scientific community. The importance of exploring and enhancing research around narrative therapy is to provide the opportunity for its voice heard alongside other effective therapy practices. Narrative therapy has valuable and diverse insights and practices to offer the therapeutic community that need to be made heard and known. In conducting a thorough review of research literature around narrative therapy, this writer uncovered a few of the weaknesses and strengths surrounding current methodologies used to examine narrative therapy. The methodological orientation of qualitative research aligns well with the philosophical tenets of narrative therapy; mainly that people hold rich and valuable knowledge about their experiences (White & Epston, 1990). In narrative therapy practice and research, clients are viewed as co-researchers and experts in their lives, as opposed to subjects or objects (O’Connor et al., 1997; O’Connor et al., 2004). Co-research conducted by both therapist and clients around a problem can elicit insider knowledge and build a bigger case and defense against the problem (Madigan, 2011). Case studies can help to provide detailed accounts of peoples’ stories of triumphs against the problem (Young, 2008). Ethnographic studies can provide rich, descriptive feedback around of the value of narrative therapy and the impact on a person’s life; as well provide insight into how people make meaning of their experiences (O’Connor et al., 1997). As well, this type of qualitative research centralizes the person’s experience as the focus for determining the effectiveness of narrative therapy. The case studies and ethnographic studies explored in this review indicated that narrative therapy had an overall positive impact on individuals’ lives (Busch, 2007; Gardner & Poole, 2009; Hannen & Woods, 2012; Young, 2008). As well, the data collected around client feedback indicated that people value being seen as the expert in their lives (O’Connor et al., 1997). The impact of narrative therapy as reported in these studies cannot be dismissed simply because of the format in which it is communicated. In order to advance research and provide further support for narrative therapy, there needs to be further exploration of problems within various contexts and amongst different cultural backgrounds.Qualitative research needs to be seen as a valuable form of collecting data, as it can often reveal rich descriptions of experience that one would not find with more systematic, empirical investigations of human behavior (O’Connor et al., 2004). There is a need for the scientific community to expand the range of research methodologies that are deemed as “valid”. One of the issues around EBP is the possibility of restricting access to certain therapy models, if these models do not meet the requirements of this form of evaluation (Busch, 2007; Strong, Busch, & Couture, 2008). Many researchers in the field (as well as the American Psychological Association Presidential Task Force on Evidence-Based Practice, 2006) are advocating for the acknowledgement of different forms of research as valuable ways of evaluating the usefulness of therapy models (Busch, 2007; Gardner & Poole, 2009; Strong, Busch, & Couture, 2008). Tools developed to explore the processes underlying narrative therapy, such as the ones mentioned within this review (e.g. Narrative Processes Coding System, Angus & Hardtke, 1994) can provide a rich understanding underlying the means in which people create and re-create their life stories through narratives. For example, research by Muntigl (2004) witnessed the various semiotic resources that clients brought to therapy and how they used these resources to create alternative possibilities for their lives. Studies by Ramey et al. (2009, 2010) used a coding scheme based on the work of White (2007) and discovered that the processes that unfolded within the therapy room aligned with White’s descriptions in his work on scaffolding and concept formation. The study by Matos et al. (2009) was the most rigorous of the outcome studies around process, highlighting the possible role unique outcomes play with positive therapeutic outcome. In the end, research that explores the processes underlying narrative therapy can help build a deeper understanding around how it operates and highlight key components around narrative therapy practice (Busch, 2007; Strong, Busch, & Couture, 2008). Alongside a lack of acknowledgement around the use of qualitative means to validate narrative therapy, the lack of quantitative research around narrative therapy presents a current barrier to recognizing it as a viable therapy practice. In an examination of the research presented in this review, a main theme running through the majority of the studies is that they often have a small participant base; a lack of diversity around participants; limited research design; and a short length of intervention; all of which can present challenges around validating and generalizing the findings. There is a need for these issues to be explored and addressed through future research in order to provide valid support for narrative therapy as a practice. Another dilemma around “validating” narrative therapy lies in the fact that narrative therapy and mainstream science speak two different languages (Gardner & Poole, 2009; Stillman & Erbes, 2012). The principles underlying narrative therapy (e.g. belief that “objectivity” and “truth” do not exist) pose a limitation to conducting research in traditional ways (Neimeyer, 1993; O’Connor et al., 1997). Researchers have found it challenging to design empirically-based research around narrative therapy while protecting its epistemology and keeping its true essence intact (Gardner & Poole, 2009; Stillman & Erbes, 2012). As well, narrative therapy is not easily operationalized, due to fluidity around its processes. Rather than attempt to translate narrative therapy into steps and procedures and risk compromising its integrity as a practice, researchers have begun to design manuals based on principles from the original work by White and Epston (1990; Stillman & Erbes, 2012; Vromans & Schweitzer, 2011). The results of the study completed by Vroman and Sweitzer (2011) have opened up possibilities for narrative therapy to be further recognized in the scientific community, alongside other “valid” approaches. However, this study was one of the first few studies to demonstrate rigorous investigations around narrative therapy outcome and was still limited by participant size. If future studies (such as the current pilot project by Stillman & Erbes, 2012) can demonstrate empirical support for narrative therapy, while protecting its core principles, narrative therapy has a greater possibility of becoming an eligible contender in the therapeutic realm. In conducting research around narrative therapy, researchers need to ask the following question: Does the research have the possibility to compromise narrative therapy as a practice? And if so, what can be done to address this within the study? In analyzing the research of Besa (1994), the study was described as centering around “parent-child conflict”; however the focus was around the children’s problematic behavior. Vromans & Schweitzer (2011) relied upon the classification of therapeutic “disorders” through diagnostic criteria. As well, the narrative interventions explored by Besa (1994) consisted of behavioral contracts, introduced by himself as the therapist. These notions can serve to undermine the principles of narrative therapy, perpetuating the beliefs around expert and unitary knowledge, and individualizing and pathologizing problems (White & Epston, 1990). This writer is not suggesting that these studies cannot provide valuable data for supporting narrative therapy as a practice; rather the recommendation is for researchers to take caution in protecting the original tenets of the practice. The recent pilot study developed by Stillman & Erbes (2012) holds promising implications for the future of narrative therapy as it explores narrative therapy using a quantitative and qualitative approach; drawing upon two valuable ways of conducting research that elicit very different responses, both of which contribute in valuable ways to the field of science. In the end, this writer recognizes the need for further quantitative research around the processes and outcome in regards to narrative therapy in order for it to gain voice within the therapeutic world. At the same time, this writer is calling for a shift in the mentality of the scientific community in acknowledging qualitative research as a valuable way of gathering evidence, through the exploration of individual realities and truths. The future for narrative therapy and its acceptance within the scientific community seems hopeful as we watch studies, such as the one being piloted by Stillman and Erbes (2012), unfold. ReferencesAmerican Psychological Association Presidential Task Force on Evidence-Based Practice (2006). Evidence-based practice in psychology. American Psychologist, 61(4), 271-285. doi:10.1037/0003-066X.61.4.271Angus, L., & Hardtke, K. (1994). Narrative processes in psychotherapy. Canadian Psychology, 35(2), 190-203. Retrieved from cpa.caBesa, D. (1994). Evaluating narrative family therapy using single-system research designs. Research on Social Work Practice, 4(3), 309-325. doi:10.1177/104973159400400303Bruner, J. (1987). Life as narrative. Social Research, 54(1). Retrieved from , R. (2007). Transforming evidence: A discursive evaluation of narrative therapy case studies. The Australian Journal of Counselling Psychology, 7(2), 8-15. Retrieved from , D. (1999). Co-research: The making of an alternative knowledge. In D. Epston. (Ed.), Narrative therapy and community work: A conference collection. Retrieved from , P. J., & Poole, J. M. (2009). One story at a time: Narrative therapy, older adults, and addictions. Journal of Applied Gerontology, 28(5), 600-620. doi:10.1177/0733464808330822Hannen, E., & Woods, K. (2012). Narrative therapy with an adolescent who self-cuts: A case example. Eduational Psychology in Practice: Theory, Research, and Practice in Educational Psychology, 28(2), 187-214. doi:10.1080/02667363.2012.669362Luborsky, L., Popp, C., Luborsky, E., & Mark, D. (1994). The core conflictual relationship theme. Psychotherapy Research, 4(3/4), 172-183. doi:10.1080/10503309412331334012Madigan, S. (2011). Narrative therapy. Washington, DC: American Psychological Association. Matos, M., Santos, A., Gon?alves, M., & Martins, C. (2009). Innovative moments and changein narrative therapy. Psychotherapy Research, 19(1), 68–80. doi:10.1080/10503300802430657McLeod, J., & Balamoutsou, S. (1996). Representing narrative process in therapy: Qualitative analysis of a single case. Counselling Psychology Quarterly, 9(1), 61-76. doi:10.1080/09515079608256353Muntigl, P. (2004). Ontogenesis in narrative therapy: A linguistic-semiotic examination of client change. Family Process, 43(1), 109–131. Retrieved from Neimeyer, R. A. (1993). An appraisal of constructivist psychotherapies. Journal of Consulting and Clinical Psychology, 61(2), 221-234. Retrieved from ’Connor, T. S., Davis, A., Meakes, E., Pickering, M. R., & Schuman, M. (2004). Narrative therapy using a reflecting team: An ethnographic study of therapists’ experiences. Contemporary Family Therapy, 26(1), 23–39. Retrieved from O’Connor, T. S., Meakes, E., Pickering, M. R., & Schuman, M. (1997). On the right track: Client experience of narrative therapy. Contemporary Family Therapy, 19(4), 479–495. Retrieved from Ramey, H. L., Tarulli, D., Fritjers, J. C., & Fisher, L. (2009). A sequential analysis of externalizing in narrative therapy with children. Contemporary Family Therapy, 31(4), 262-279. doi:10.1007/s10591-009-9095-5Ramey, H. L., Young, K., Tarulli, D. (2010). Scaffolding and concept formation in narrative therapy: A qualitative research report. Journal of Systemic Therapies, 29(4), 74-91. Retrieved from Stillman, J. R., & Erbes, C. R. (2012). The corner: An innovation in research in Minnesota. Journal of Systemic Therapies, 31(1), 74-88. doi:10.1521/jsyt.2012.31.1.74Strong, T., & Busch, R., & Couture, S. (2008). Conversational evidence in therapeutic dialogue. Journal of Marital and Family Therapy, 34(3), 388-405. doi: 10.1111/j.1752-0606.2008.00079.xTilsen, J., & Nylund, D. (2008). Psychotherapy research, the recovery movement and practice-based evidence in psychiatric rehabilitation. Journal of Social Work in Disability & Rehabilitation, 7(3/4), 340-354. doi:10.1080/15367100802487663Tilsen, J., Russell, S., & Michael (2005). Nimble and courageous acts: How Michael became the boss of himself. Journal of Systemic Therapies, 24(2), 29-42. Retrieved from Vromans, L. P., & Schweitzer, R. D. (2011). Narrative therapy for adults with major depressive disorder: Improved symptom and interpersonal outcomes. Society for Psychotherapy Research, 21(1), 4-15. doi:10.1080/10503301003591792White, M. (2007). Maps of narrative practice. New York: Norton. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton. Young, K. (2008). Narrative practice at a walk-in therapy clinic: Developing children’s worry wisdom. Journal of Systemic Therapies, 27(4), 54–74. Retrieved from ................
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