Narrative Therapy Compared vs Solution Focused Therapy

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Narrative Therapy vs Solution Focused Therapy

Solution Focused Therapy (SFT) is used to resolve immediate issues from a strengths based perspective

The Philadelphia Juvenile Justice Services Center (PJJSC) mission statement is to protect the community, provide and promote positive growth and development of detained youths, and promote and advocate for a juvenile justice system with a full range of services responsive to the needs of the community, family, and youth.  PJJSC is a detention facility that houses youth from ages 10 to their 21st birthday, male and females.  It is located in West Philadelphia and meant to house all delinquents from all areas of Philadelphia.  If the family does not live in West Philadelphia it could be difficult for family members to visit their children housed at this facility.

The PJJSC is not an ideal space to hold therapy.  There are time constraints with how long you can spend with a family.  There is little to no privacy because the youth must always have supervision by a residential counselor.  Family meetings are especially difficult because of the facility’s safety and precautionary requirements.  The first priority of the facility is to detain youth and to keep the community, residential staff, and the residents safe.  Therapy is necessary; however, not a primary concern of the facility.  The door must always be kept open.  The staff is often watching the parents with the youth to make sure they are not passing them anything, no matter how innocent it may seem.  For these reasons, conversations and sessions are not private.  Therefore, therapeutic sessions are not in an ideal holding space.  This makes creating a  safe therapeutic space challenging but not impossible.  When you have youth that are known to be physically aggressive the oversight is increased exponentially.  Though the environment is not ideal these youth are in need of a lot of therapeutic intervention.

Michael is the identified patient (IP); he is 19 years old.  He is being detained at PJJSC because he attempted to physically assault his adoptive mother.  Michael is diagnosed with paranoid schizophrenia since the age of 18; however, he has suffered with the symptoms since he was 12 years old.  Michael has been in and out of partial hospitalization and residential treatment facilities since the age of 13.  Michael had been home doing well for the last year; however, he had a relapse two days ago.  Michael until coming to PJJSC lived at home with his adoptive mother, Grace and her paramour of 12 years, Sean.  

Grace is actually Michael’s biological maternal aunt who adopted him when he was 2 years old.  Grace is 58 years old.  Sean is 68 years old.  Grace and Sean want to be supportive of Michael; however, they express difficulty in being able to handle Michael’s outbursts now that he is 5’10”

and 250lbs.  The outbursts are usually directed at Grace.  Michael’s biological mother, Lisa, has always been sporadically in his life; however, she has been more consistent in Michael’s life in the last six months, since she has been clean from drugs and alcohol.   Lisa is 48 years old and wants an opportunity to care for Michael.

The evening the therapist met with Michael and his family, Michael was under a chemical restraint because earlier in the day Michael attempted to run out of the lunch room, as if to escape the facility, although there was no where he could go because it is a locked facility.  The staff psychiatrist approved a chemical restraint in order to keep Michael sedated to prevent him from being aggressive and running away.  Michael suffered a minor scratch on the left side of his face in the scuffle when the staff tackled him to the floor to restrain him.  Michael refused medication while in the facility.  He was given a one to one residential counselor and separated from the rest of the adolescents in the facility for his own safety as well as the safety of the other residents.  Although Michael in being held in a delinquent juvenile facility the team realizes Michael does not belong in this facility due to his mental health diagnosis.  The judge requested Michael and his family have an assessment to determine what might be best for Michael.

The therapist went to get the family out of the waiting area to bring them back to the room that they are required to meet in.  The therapist greeted the family and made small talk on the way to the meeting room.  The room is not a social work office, which is a little softer in appearance.  It is a cold white cinder block room with no decor.  There is one desk with nothing on it, not even a phone.  There are three chairs.  The therapist must get another chair because she is expecting the biological mother to join them though she is not there yet. Michael is bought in shortly after they take their seats with his one to one residential counselor.  The residential counselor (RC) is approximately 6’4”, 300lbs, and very intimidating.  The RC never spoke a word.

1st

Dialogue

Grace

:  Hi baby, how are you, how have you been?

Michael

: Can I go home with you?

Grace

: What happened, how did you get that scratch on your face?  (Turning to the therapist)  How did he get that scratch on his face?

Therapist

: I’m not sure?

Michael

: I was attacked.

Grace

: Who attacked you? 

Michael

: I don’t know.  

Grace

: Why did they attack you?  

Michael

:  I don’t know.  Can I go home with you? 

Grace

: (Talking to the therapist.) Can you find out what happened to him?

Therapist

:  I will try to find out.  I will call you later to let you know what I find out.  I would like to focus on why we are here tonight.  We only have a limited amount of time and it is important to address some things so that we will be able to give the judge a proper report and recommendation for Michael.

Sean

:  I don’t think this is the proper place for Michael.  He is not a criminal.  He has some problems but he is not going to get the help he needs here.

Therapist

: Well, that is part of what I would like to discuss to find out what and where it would be best for Michael at this time.  Sean can you tell me when Michael had this last breakdown and how that affected you? 

Sean

:  It seems like the breakdown came right after he visited Lisa. 

At this moment Lisa walks in about 10 minutes late.  She is apologetic.  She says hi to Michael and Michael responded by saying, “Hi Lisa”.  Michael immediately turns to Grace asking, “Mom, can I go home with you?”

At this point the therapist is trying to build a therapeutic alliance with all members.  However, the flow of the meeting has now been interrupted by biological mom, Lisa, coming into the session late.  The biological mom wants to re-address the scratch on Michael’s face and she is visibly upset that Michael called her Lisa and called her sister mom; though she does not talk about it.  The therapist informs Lisa that she will investigate the scratch when they are done with their meeting; however, the therapist is fully aware of how Michael obtained the scratch but feels disclosing this will derail the meeting to focusing on the incident that happened earlier in the day, instead of focusing on a plan for Michael.  

Therapy is difficult in this facility due to the time constraints.  There is the time constraint of the therapy session itself.  Ideally, you would like to meet with a patient at least 45 minutes to an hour; however, this is not always possible.  The youth are heavily scheduled and due to the safety and security therapy is not a first priority.  For example, you could be meeting with a youth and all of a sudden the unit they are on is going to the gym.  The residential counselors are not allowed to leave any youth unattended even if they are with a therapist.  The social workers and therapist are not residential staff and are not allowed to be completely alone with a youth; therefore, if the unit goes to the gym the youth will have to stop in the middle of the session and go to the gym.  

Then there is the constraint of not knowing if the youth will be there the next day when you come back.  Due to the facility being a short term holding facility youth are often transitioned in and out on a regular basis so there is no continuity of care and often hard to have closure.  Ideally, one would need to create a therapeutic alliance, discuss the problem, get at maybe one underlying issue, and then discuss the solution or plan moving forward, all in one session.

Solution Focused Therapy (SFT) is used to resolve immediate issues from a strengths based perspective; however, the therapist felt that Narrative Therapy might be more beneficial to this family because it will allow the family to construct the problem as they see it and then the therapist and the family could co-construct a new narrative that will allow them to address the situation adequately.   Williams-Reade, Freitas, and Lawson (2014) believe that Narrative Therapy can be used in a fast-paced setting; however, it can be challenging to maintain the integrity and depth of the model of Narrative Therapy.  Williams-Reade et al (2014) discussed the four core processes that guide the application of Narrative Therapy in brief (10–30 minute) encounters.  The four core processes include 1) deconstructing the problem, 2) externalizing the problem, 3) mapping, and 4) re-authoring the story.

The therapist may not have the opportunity to work on any underlying early childhood issues that may have led them to juvenile detention; therefore, social workers/therapists are usually only dealing with crisis situations.  Narrative Therapy allows the therapist to deal with crisis situations by having families tell a story about past successful coping experiences, and it empowers people in a social justice system where there is a clear power difference betweeen staff and inmate, Freeman and Couchonnal (2006).  “Story as a model has a remarkable dual aspect—it is both linear and instantaneous”, (1986, p. 153), White & Epston (1990).

2nd dialogue:

Therapist

What is different about this time compared to other times when Mr. Schizophrenia rared his ugly head.

  Sean:

what was different was that

we would not have called the police, we would have restrained him and waited for him to calm down and then make him take his meds.  Now he is too big and we are too old.  We can no longer control him.

Therapist: 

Grace how do you think Michael was able to go so long without Mr. Schizophrenia raring his ugly head. 

Grace

:  Well, the dosage seemed to be just right and Michael did not have a problem taking his meds. 

Therapist

:  Lisa what do you think was different about Michael taking his meds or not taking his meds.

Lisa

:  he is over medicated.  Michael has said he doesn’t like the way the meds make him feel.  Well, look at him.  He looks like they have him full of drugs now.  He can’t even speak.  He is not normally like this but every time they put him on those meds he cannot function. 

Sean:

Well, yeah because you don't make him take his meds.

Grace: 

Well, I thought he was really doing well when he was taking his meds.  They don’t always get the dosage right but he was doing so well over the last months before this last episode.  The dosage appeared to be just right.  I don’t know why he stopped taking his meds. 

Sean: 

She probably told him not to take his meds.

  Lisa: 

I would never tell him not to take his meds but I do tell him that he is old enough to make his own decisions and if he does not want to take his meds then he should not have to.  Why is that guy standing there.  (referring to the RC standing in the threshold).  He doesn’t need to stand in the doorway like that.  He makes me uncomfortable.  Can’t we have some privacy. (turning to the therapist)

Therapist:  (

the therapist motions the RC out of the door) Unfortunately, it is his job to monitor Michael at all times.  He has to stay around but he can step slightly out of the doorway while we talk. How long has Michael gone without his aggressive behaviors prior to this last episode.

  Grace: 

It has been at least a year. 

Therapist

:  When did you notice Michael was no longer taking his meds.

  Grace: 

I didn’t notice or realize until I had to call 911 because he became so agitated and it looked like he was going to hit me because I told him to come in the house.  I was really afraid of him.

  Therapist: 

Lisa had you noticed that Michael stopped taking his meds. 

Lisa

: Not really, but he often complains about how the meds make him feel. 

Sean

: so did you tell him to stop taking them.

  Lisa: 

I’m not sure why you are trying to blame me for Michael not taking his meds, you treat him like he is 5.  Don’t you think he can decide on his own not to take his meds without me or someone else telling him to stop taking his meds.  Why don’t you ask Michael when he stop taking his meds.

Therapist: 

Michael, when did you stop taking your meds. 

Michael:

I don’t know. 

Lisa: 

Look at him, what has this place done to him.  Why is he like this.  You all have him over medicated.  This is not right.  He looks like someone beat him up and he is all drugged up, what kind of place is this? 

Therapist: 

Sounds like you all really care about Michael; however, I think the best way to help Michael at this time is to focus on how Michael may have come to this last break down and how we can prevent it in the future. 

Lisa, I here you saying that Michael expressed that he did not like how the meds made him feel. 

Lisa: 

Yes

.  Therapist: 

Grace, I here you say that you are afraid of Michael when he is not on his meds.

  Grace: 

(shakes her head yes). 

Therapist:

Sean, how do you feel about Michael being on or off his meds.

  Sean: 

Well, I agree with Grace that Michael appears to be able to function fine when he is on the right dosage of meds.  What did change is Michael had a new psychiatrist who started him on a new med.  Maybe Michael did not like how that medication made him feel.

  Grace:

Well, why wouldn't he tell one of us.

  Lisa: 

He did, he told me.

Therapist

: Lisa, do you believe Michael needs to be on meds to control Mr. Schizophrenia. 

Lisa

:  I’m not sure.

During this time the therapist was trying to keep the family focused on the needs of Michael as well as narrate some parts of their story that was relevant to the problem at hand.  The therapist also used the opportunity to externalize the problem and move it away from Lisa being the problem by naming the problem as “Mr. Schnizophrenia”.  The problem appeared to be that Michael had been recently started on a new med.  The therapist now needs to get the family to come to a solution so that she will be able to present a plan to the judge for Michael.  Michael was recently prescribed a new medication by a new psychiatrist.  The therapist also was able to surmise that Lisa, Grace, and Sean had differing views about Michael’s autonomy to take medications.  Thus far, the therapist was employing the narrative model.  Since there was not going to be time for a long intervention process the SFT model appeared to make the most sense in this particular situation; however, the Narrative Therapy Model appeared to be the most natural at this time for the therapist to use which also has some of the same aspects as SFT.  

Narrative Therapy like SFT can be used to address crisis situations.  SFT focuses on one identified issue formulated by the therapist and/or the client.   SFT can be a great model for people in crisis situations where a central issue can be easily identified and goals formulated from a combined effort of the therapist and the client, as noted by Biever, Clemons, Franklin, Moore, and Scamardo (2001).  SFT work is similar to narrative approaches because it shares the constructivist theoretical roots along with a belief that people hold the answers to the problems with which they present, Gitterman and Heller (2011).

Narrative therapy gave this family an opportunity to express their stories from their different view points about how the medication can or cannot help Michael remain at home with Grace and Sean.  Another option could be for Lisa to be used as respite or utilize Lisa more regularly to take on more of the responsibilities of Michael’s daily care.  The third alternative would be for Michael to be institutionalized.  Although, the therapist had options in mind she did not present the options immediately.  It is important with Narrative therapy for the therapist to facilitate and engage the family as experts in their own illness experience as described by Williams-Reade et al (2014); thus, experts in their own lives.  Williams-Reade et al (2014) also believes that people develop personal agency while including the perspectives of important individuals in the IP’s life to provide validation, connection, and support. It also allows the participants to buy into the therapeutic process and intervention.

In the case of Michael, Grace, Lisa, and Sean there is a support system between the four of them.  The therapist does not feel that Michael is able to adequately participate in the narrative portion of the therapy at this session; however, because it is family therapy, the family members are able to support Michael and develop a narrative or story that will help facilitate a plan for him.  The story will not be told for Michael, instead the stories will be told from the perspective of each family member allowing each member to develop agency and to see where they fit in Michael’s life and how they would like to fit from this day forward.  One of the central concepts of Narrative Therapy is the belief that all people are exposed to a broad range of societal messages and expectations that influence how a person makes meaning of their personal experiences, (White, 2007) as cited in Williams-Reade et al (2014).  Gitterman and Heller (2011) emphasize that the social work adage, ‘‘meet the client where the client is’’

is suited to Narrative Therapy.

3rd Dialogue

Therapist: 

Lisa, do you think the meds have helped to maintain stability for Michael in the past. 

Lisa

:  Yes, to some degree.  I just don’t think he needs to be on such strong meds.  Michael is smart and bright and has a lot of personality but you wouldn’t know it when he is on those meds. 

Therapist

:  Lisa, do you feel that Michael’s behaviors can be managed in a way other than using medications? 

Lisa

:  I’m not sure.  I just think it might be about finding the right medication. 

Therapist

:  Grace, how would you feel if Michael spent more time with Lisa. 

Grace

:  I don’t think she knows what Michael needs.  I think she just want to be his friend and she does not realize how serious Michael’s problems are. 

Therapist

:  Grace, maybe you could tell us how serious the problem is. 

Grace

:  Well, when he is not on his meds he is easily agitated, he hears voices that tell him to do things, he is a danger to himself and others and frankly, he is just scary to live with. 

Therapist

:  Grace how do you think the Schizophrenia can best be managed? 

Grace

:  I believe the meds are the only way. 

Therapist

:  Sean, do you agree? 

Sean

:  Absolutely. 

Therapist

:  Lisa

,

  did you hear how scary it can be for Grace and Sean when Michael is not on his meds. 

Lisa

: Yes.  I guess I may not have seen those parts of Michael because I only see him sporadically.  I really would like to spend more time with him and learn how to care for him but they act like I can’t learn. 

Therapist

:  Grace, do you think Lisa is capable of learning?  Yes, as long as she is willing to go the group therapy for parents of schizophrenics and really willing to learn what she needs to. 

Therapist

: (re-authored the narrative, Lisa is not the problem)  Ok, so it sounds likes Michael has been able to be stable for long periods of time when he is on his meds.  It sounds like when he is not on his meds, due to his strength and weight, it can be pretty scary when the meds are no longer working or not being taken.  It also sounds like Michael may not be taking his meds when he feels that the meds don’t allow him to feel like himself.  We need to decide where Michael will live while he gets stabilized on his meds.  Here are some options…

Freeman and Couchonnal (2006) state that a significant aspect of narrative approaches is the importance of clients' rights to define their own challenges and, through sharing their narratives, to name their own reality (Kelley, 2002) as cited in Freeman et al (2006).  Social workers can ensure that client descriptions of challenges and the effects on their lives remain privileged (Freeman et al, 2006).  The therapist in this situation allowed the family to narrate the problem in their own words; thus, describing their challenges and how the schizophrenia effects their lives when Michael is not on his medications. 

As Freeman et al (2006) states, the therapist’s role requires adopting a "not knowing" approach to the narrative and to counseling in general.  This is why the therapist asks questions, which she may or may not know the actually answer to.  The therapist is giving the family the opportunity to construct the problem with their own language.  Acknowledging families' stories also means using their labels for such stories. The therapist in this case uses the same label, “scary”, as was described by the family member, Freeman et al (2006).

The 3rd dialogue ends with the therapist about to offer the family some options.  Matima (unknown) indicates that it is important that the role of the therapist allows for an intervention that offers choice,  Matima (unknown).  Counselor educators, supervisors, and educational leaders are in a position to promote narrative approaches, which has shown to further youth social and mental health development, Ikonopoulous (unknown).

In conclusion, Narrative Therapy can be used for a multitude of diagnoses and family problems.  Narrative Therapy can also be used during times where time is of the essence.  Narrative Therapy, like Solution Focused Therapy, can focus on one central problem at a time.  Also, like SFT , Narrative Therapy is strengths based and begins where the client is.  The benefits of using Narrative Therapy would be for the family to construct and co-contruct with the therapist a story that will get at one or two underlying problems that may facilitate with re-authoring a new narrative that will allow the family to resolve an immediate issue.  Although it may be difficult, a skilled narrative therapist will be able to move a family along, sticking to the four core concepts, in a fast paced setting.  Narrative Therapy allows the family to define their own labels and with the assistance of the therapist re-authoring their narrative and it allows them to move forward to begin to heal, plan, or act.

Note: 

See follow up article to discuss how to position oneself in situations where intervention must happen even when there is a lack of  therapist-client privacy.

References

Biever, J., Clemons, D., Franklin, C., Moore, K., & Scamardo, M. (2001).  The effectiveness of solution-focused therapy with children in a school setting. 

Research on Social Work Practice, 11

(4), 411-434.  Retrieved from

http://search.proquest.com/docview/195401497?accountid=9772

Freeman, E. & Couchonnal, G. (2006). Narrative and culturally based approaches in practice with families.

Families in Society

, 87:2, 198-208 

Gitterman, A., & Heller, N. R. (2011). Integrating social work perspectives and models with concepts, methods and skills with other professions' specialized approaches.

Clinical Social Work Journal, 39

(2), 204-211. doi:http://

dx.doi.org/10.1007/s10615-011-0340-7

Ikonomopoulos, J. P., (unknown).  Narrative therapy with youth at a juvenile boot-camp facility: a single case research design A Dissertation by JAMES PETER Ikonomopoulos, McHenry County College, 2005 BA, Texas A&M University-Corpus Christi, 2008 MS, Texas A&M University-Corpus Christi, 2010

White, M., & Epston, D. (1990).

Narrative means to therapeutic ends

. WW Norton & Company.

Matima, M. (unknown).  Narrative therapy and abused women.

Williams-Reade, J., Freitas, C., & Lawson, L. (2014). Narrative-informed medical family therapy: Using narrative therapy practices in brief medical encounters.

Families, Systems, & Health, 32

(4), 416-425. doi:http://

dx.doi.org/10.1037/fsh0000082

If  you and your family would like to participate in Narrative Therapy, short or long term, contact the therapist at For Me Talk Therapy, LLC.  The therapist is Rosemarie Reid, 267-388-4909.