Michael White Narrative Therapy

Narrative Therapy
Background and Theoretical Base
Meaning making is an important part of the human experience. We have to be able to explain to ourselves the value of an experience or event and how it fits into our life schema so those experiences that are positive or negative, each require a meaningful explanation to accept as part of ourself. When those explanations which we can call narratives provide for us a foundation and or a path for future growth and development we hold on to it and find ways of using it repetitively in the service of growth. When the narrative does not provide that path or foundation for development, or it takes away the opportunity for growth and development, holding on to it renders the person functionally trapped.

That narrative that is a roadblock becomes a problem that the person lives and uses as their functional guide. If the latter is used as a guide and foundation the impact may possibly keep the person from doing the things he or she prefers, and the goals he or she want and view the self only in terms of what they don’t achieve. The underlying belief is that an individual’s experiences are ambiguous and there are many interpretations possible about any event that occurs in the person’s life. Even though the client may create an initial interpretation of an event it may be an interpretation that the client later finds unacceptable. In such cases the person then needs to find a way to create their preferred narrative so that he or she can feel good about themselves and the meaning of the event or experience that provides strength and support.
Michael White, the founder of the Narrative Movement, believed that people created narratives about events and experiences in their life and use this narrative to reach some conclusion about themselves and their identity.

Problems are created when a person internalizes a conversation or story that provides a narrow or unflattering description of self, one that is not positive to them. This can limit the person's self-concept, and they neglect to see other valued aspects of themselves. Problems are maintained when a person internalize the problematic story, or dominant narrative, and accept that it reflects the truth about themselves or the event. They then internalize the problems to be about them or the selves of others, or that the relationships are the problem. This leads the person to sink deeper into the problem rather than finding a solution to the problem (White,

2007).
For a Narrative Therapist, problems get resolved when a preferred narrative, is created. This can be done by helping a person to create a new story, or rather re-author their own story. For the client, in creating their own preferred narrative, they are no longer passive in their own life and he/she is active in the process of understanding of their experiences (White, 2007). In therapy, the client is helped to construct a new, more positive story about themselves or the problematic event. In this way, a reframe becomes unnecessary because the client's understanding of experiences going forward will be influenced by the positive story, and the story the client prefers. The therapist is to listen to how the client has told their story, how they believe things to be and why. Together the client and therapist explore other parts of the client's life when they have been successful, identify goals and how they would prefer their life to be. Through this process the client develops a new understanding of their problems, their conceptualization of these problems and what this means for their own self-understanding. Narrative therapist believe that these reframes won't be sustained unless they fit into the stories that people have constructed about themselves and their lives, in this way the story is created by therapist and client. The new story is a part of the person’s ‘whole’ life, the experience does not stand alone.
Narrative therapy interventions also consider the importance of the narrative that the client has created regarding their whole life, from birth to the present situation. Often conceptualizations or understandings of causes or meanings of events are created with similar explanations or narratives over various problems or events in life. The client also benefits from the creation of a consistent narrative that places events or problems within the context of a whole life. This also shifts the client’s understanding of the meaning this problem or event has within the story of their entire life, as a single event.(Neuner, Schauer, Klaschik, Karunakara, & Elbert, 2004) Creating this reconstruction of life, focusing on a preferred narrative created with their identified goals in mind provide a positive touchstone that the client can return to when new problems arise.
Tree of Life
The ‘Tree of Life’ is a psychosocial support tool that was developed working with children severely affected by HIV and AIDS that is based on Narrative Practices. Developed by Ncazelo Ncube-Mlilo (REPSSI) and David Denborough (Dulwich Centre Institute of Community Practice) while working with children in South Africa. The Tree of Life uses the metaphor of a tree to represent various aspects of the life and invites the participants to tell stories of strength and hope about their lives rather than about sadness or grief. According to the training manual, Mainstreaming Psychosocial Care and Support: A Manuel for Facilitators. (2007), narrative practices place importance on ensuring safety when working with people and re-telling problem-saturated stories about the negative or traumatic events that people have experienced can compromise their safety. This is because this keeps the focus on the problems and pain in their lives. These stories referred to as ‘first stories' we hold about themselves, are often without hope. The ‘Tree of Life’ is designed to help and support participants while they create the ‘second story' of their life. The ‘second story' is focused on the dreams, hopes that the individual has for their life and the skills and support available to achieve them. This process invites people into the counseling process by focusing on the best things about their life, both in the past, present and future. This includes considering their family history, skills and competencies and important relationships in their lives now and in the past. By starting the counseling process focusing on the positives in a person's life challenges their feelings of depression, desperation, hopelessness, and defeat. According to the manual, the Tree of Life was created to allow these children to have a safe space to be able to talk about some of their past traumas without further traumatizing them (Denborough & Ncube-Mlilo, 2007).
The developers of Tree of Life suggest that metaphors in most cultures have important meanings and associations for people and that they are often used in cultures that have a history of oral storytelling to teach important values, knowledge, and skills to members of the community (Denborough & Ncube-Mlilo, 2007). In this way, the structure of the Tree of Life and the use of metaphor to provide knowledge or teach a lesson is culturally appropriate. The Tree of Life tool was developed in Africa, and they have found that it is easy to implement and that participants easily engage in the activities and offers a way to be introduced to therapeutic process in a more culturally sensitive way. For Africans, trees are usually seen to represent life or as providing nourishment or shelter, as a sign of strength, security or healing, as messages that help merge the counseling process into the local culture (Denborough & Ncube-Mlilo, 2007).

The use of this tool is most effective in a group and the ideal number of participants to have in a Tree of Life group is around 12. There should be a main facilitator to lead the group and others to provide a more supportive role in assisting participants with the task. Group leaders and facilitators should have completed their own Tree of Life before facilitating or leading a group (Denborough & Ncube-Mlilo, 2007). The process was originally developed to take place over an 8-hour day, with frequent breaks, but it has been implemented over six weeks or so, a few hours at a time. There are four parts to the Tree of Life process.
In part one, the participants are encouraged to draw and share their trees. Facilitators introduce the notion to the participants by talking about trees in general and more specifically ask them to imagine that they are a tree and to think of their life as the various parts (Denborough & Ncube-Mlilo, 2007). They are told that they will be drawing a tree on a big piece of paper and include the roots, the ground the branches, the leaves and the fruit. Participants are encouraged to begin drawing the roots of the tree and participants are prompted to talk about and write on their tree or draw about where they have come from, the history of their family and who had taught them. Next is the metaphor of the ground that their tree in anchored and this is intended to represent what goes on in their daily life. They are encouraged to explore, talk about write or draw information such as who they live with, what they do every day and favorite things. Discussion about the trunk of the tree is next, and this represents the participant's skills and talents, and the facilitator focuses not only the skills the participants identify themselves but what other might have said about them. The branches of the tree represent hopes, dreams, and wishes for the future and conversations about how to hang on to these hopes and dreams are encouraged. Important people in the child's life is represented by the leaves of the tree, and attention is paid to being sure that even important people who are no longer present in the person's life are represented. The fruits of the Tree of Life are a metaphor for the gifts that the individual has been given. The manual stresses that these are not intended to represent material gifts but suggest considerations of acts of kindness or care from others as gifts. At the completion of part one, the participants should have completed drawings of trees with representations of each part either with words or drawings or pictures. Throughout this process, the participants have shared their stories with other members and counselors while discussing each metaphor and are meaning in the lives of each participant, who have been taking notes or have some recollection of the story of each participant's tree.
The second part, the Forest of Life begins when each participant has completed their Tree of Life and take turns sharing their story (Denborough & Ncube-Mlilo, 2007). Participants are encouraged to post their tree on the wall next to each other to form a forest of trees. Once all the trees have been placed together on the wall, the participants are asked to come forward and share something with each group member by writing it on their tree. The goal is to have them offer encouragement and support to each other. The retelling of the stories of the participants is done at this point by the counselors or facilitators and using the participants words when possible talk about their hopes and dreams for the future, the gifts they have received, their skills and talents. They also focus on talking about the gifts they have been given and reflecting on the relationships that have been important in their lives.
The third part of the Tree of Life is a discussion about the Storms of Life ( Denborough & Ncube-Mlilo, 2007), this metaphor is used to talk about some of the dangers or hazards that the trees may face. This can provide the facilitators with a safe place from which to talk about the troubles or dangers the participants may face. The discussion may also turn to talk about the animals that are also in the forest with the trees and what might they do to protect themselves from the storms. This allows for brainstorming about ways that participants may protect themselves from problems in their life, as well as reflect on the changeable nature of storms, being present sometimes and not others, and finally the participants are encouraged to talk about what they can do when the storm has passed. This allows facilitators to ask the participants how do they plan to hold onto the lessons they have learned, even in the face of the storms of life?
The final portion is a celebration and the presentation of certificates (Denborough & Ncube-Mlilo, 2007). Family members and community leaders are often invited, and the counselors who have worked with the children are encouraged to comment on their certificates about the child's strengths or gifts. Often there is some song or dance performed as a part of the celebration.

Narrative Exposure Therapy
Narrative Exposure Therapy (NET) another tool in Narrative Therapy was developed in 2002 as a short-term standardized treatment for trauma spectrum disorders specifically for those who have experienced complex or multiple traumas.

In Narrative exposure therapy a client creates a narrative that tells their whole life story, from their birth to the present day, and in this context focuses on providing a detailed report of their traumatic experiences (Neuner et al., 2004). Further, the goals of NET are both to reduce the symptoms of PTSD by habituating the client to the emotional response to the traumatic memories, and to construct a detailed narrative regarding the trauma experiences within the context of their whole life. Theories regarding PTSD symptoms and the role of emotional processing have suggested that memories of traumatic events become distorted and lead to a fragmented understanding of the traumatic memories, which is thought to maintain the symptoms of PTSD. In Narrative Exposure Therapy, the client works with a therapist to construct a detailed account of their life. This account or autobiography is recorded by the therapist at the end of the session. It is read back to the client at the beginning of the next session, when the client can correct the information that the therapist recorded. During the retelling of the recorded story and when discussing any traumatic event, the therapist asks for the client's current emotional, cognitive, physiological and

behavioral reactions and probes for additional observations. The client is encouraged to relive these reactions while reporting what happened during the event. The discussion about the event is not terminated until there is habituation of the emotional reaction as evidenced by client report and observation. In the last session, the client receives their written autobiography (Neuner et al., 2004)

Research of interventions with African Populations
Tree of Life has been used in several different countries with a variety of populations including both children and adults. Recently a study was published (Schweitzer, Vromans, Ranke, & Griffin, 2014) regarding a single case study of the use of the Tree of Life tool with teenaged girl, a refugee from Liberia who had settled in Australia. The study attempted to identify the underlying therapeutic process within the tool that helped the participant adopt their preferred narrative. Investigators found that the Tree of Life encouraged the participant to become more comfortable with and feel free to explore her unique possibilities and consider her preferred outcome. Further she was able to link her new preferred narrative to both her past and her future. The investigators also found that her participation in the Tree of Life group process encouraged her to develop self- insight, reflection, and empathy for others regarding past events. The group in this study developed a strong sense of cohesion and facilitated members feeling a sense of belonging and relational support. The authors of this study reported that Tree of Life and the group process provided a corrective emotional experience for the participants. Further in witnessing others express hope about their own life and future allowed participants to have the space to consider different ways of thinking about their own life and future.
Narrative Exposure Therapy (NET) has also been used in working with refugees who are fleeing from conflict in their home country, often in environments that continue to be unsafe or unstable in Africa. In one such study, (Neuner et al., 2004) NET was compared with supportive counseling or psychoeducation in the treatment of PTSD symptoms within a population of Sudanese refugees living in a refugee settlement in Uganda, who had been diagnosed with PTSD. The study found that NET was superior to counseling and psychoeducation concerning PTSD symptoms while comorbid symptoms of depression and anxiety did not improve with any of the three treatments offered. The authors suggest that this may have been impacted by the fact that there was a worsening of the living conditions within the camp over this period as well as continued instability in their homeland. Further, at one year follow up the NET group continued to present with better outcomes on the PTSD measures than either of the other groups. However, the author's note that while the narrative exposure therapy participants achieved a reduction in their symptoms, their symptom scores remained high, though the change was clinically significant with 71% of the NET participants no longer meeting criteria for PTSD according to DSM-IV criteria. The authors of the study noted that a unique motivator of the Narrative Exposure Therapy treatment was the expectation of a written biography at the end of the treatment. Participants reported that they wanted their life story written down so that they could pass it on to their children as well as wanting to educate others about their experiences (Neuner et al.2004).

Similarly, a review study (Robjant & Fazel, 2010) reported similar findings regarding the outcomes for participants, diagnosed with PTSD and treated with NET, or KIDNET (a version of NET adapted for use with children). The authors reviewed all the studies available at the time regarding the effectiveness of NET in treatment trials with this population. They reviewed a total of nine studies, including both adult and children in various settings. A total of 176 adults and 40 children and adolescents in published studies treated with narrative exposure therapy. In all of these studies, participants show a significant reduction of PTSD symptoms, the majority of the improvement in their symptoms continued through the follow-up periods. They also found that the results for the treatment trials they reviewed suggest that NET is an effective treatment for PTSD even in participants that have been traumatized by organized violence and conflict and in settings that continue to be insecure. The authors acknowledge that overall studies involved small sample sizes and suggest that further research needs to be carried out regarding NET and its effectiveness.

The authors of this study (Robjant & Fazel, 2010) further discussed advantages they found using for using narrative exposure therapy. They reported that NET consistently had low dropout rates for participants and while Narrative Exposure Therapy involves participants tell the story of their life including their traumatic memories and the emotions involved, participants' willingness to continue treatment suggests that NET is highly tolerable. They suggest that because oral storytelling is important in many cultures, NET may be more culturally acceptable than other treatments for PTSD. Though the studies reviewed were conducted in both high and low-income countries, lay counselors from the area were able to be trained in as little as six weeks to provide effective treatment to participants. This suggests that NET could be both pragmatic and sustainable in even low-income areas experiencing conflict. The investigators do offer as a limitation of their study the fact that all but one of the studies reviewed were carried out by the team that developed this approach, suggesting the need for additional studies.