In traditional therapy, the therapist analyzes or explores the patient’s nonverbal and verbal production for signs of illness. Treatment is based on these impressions. In narrative story psychotherapy, the therapist carries a much greater burden: to discern story meaning and collaborate with the patient to reconstruct a stable and coherent self and story.
The patient's stories of her daily life and social interactions inform the therapist of issues of self-esteem, social interaction, expression, communication, and sense of self. This rapport is necessary for the therapist to enter into a collaborative relationship. The therapist can help the patient externalize a problem a see it as a separate thing to be solved. This allows collaborative brainstorming sessions focusing on resolution or problem solving issues. If the problem involves another person, externalization reduces interpersonal conflict because neither person is objectively is seen as being at fault. Emotions attached to the story can be addressed to produce a healthier outlook. Survivors of ABI tend to be depressed and focus on negative aspects of their lives. Narrative therapy helps them look for the positive, unique outcomes, or sparkling events. Often, the ABI person comes to the therapist depressed and expresses a bleak future. The narrative story therapist helps the person problem solve and reconstruct her stories to have a healthier outlook on the event and life.
In story form narrative therapy, the survivor provides her dominant stories and then, working with the therapist, collaboratively analyzes them for deconstruction and revision. Deconstruction of the conversations loosen the dominance of the stories and the survivor and therapist can then work to reconstruct them, integrating the contents of the old stories with the newly available memories, contents and stories. A criticism of narrative therapy is that it holds the social constructionist view that there are no absolute truths, only points of view. Critics question whether narrative therapy has given the same amount of respect to those who respect different forms of therapy, as well as whether narrative therapy has begun to make gurus of its leaders. There might be a few instances of this, but none I have heard of.
I find it interesting that while the critics may be right for the therapeutic needs of some non-ABI patients, the critics actually provide support for narrative story therapy benefits of it for survivors of ABI. ABI is an injury that causes a global intellectual and emotional impairment; the patient looks at her world through a fog. The life stories which she narrates are first viewed through this fog and it is possible that some of her problems and deficits cannot be solved with non-collaborative psychotherapy. Narrative story therapy gives the patient a clearer view of her world and raised self-esteem is paramount.
Self narration has consequences. As ABI survivors, we need to write our stories. Inevitably, that means journals, memoirs, or autobiographies or a combination. Prior to their injuries and after, some people have demonstrated strong convictions about their rights to speak and write without fear of censorship. When we tell our stories, we are judged by those that listen to them or read them. I am referring here to the personal judgment of veracity and credibility made as a natural part of the reader’s process of understanding and deconstruction. Peer judgment occurs whether or not there is accompanying verbal performance. Writing itself is performance and the results can be judged. The daily performance of identity is intuitive and unconscious.
Deficits in self narration are most noticeable when there is flattened affect of mood and impairment of the ability to describe one’s own thoughts, values, emotions, likes, and self perception. Impairment of self narrative shows a temporal structure, sustained by long-term memory, that supply the experiences we interpret as an impaired self, unable to establish a satisfying identity. The loss of affect in a survivor of ABI can be unnerving to the untrained observer. The survivor is often unaware of the blunting of affect due to previous therapeutic intervention, but otherwise expresses herself normally.
Effective deconstruction of a person’s stories is necessary for effective treatment. Persons with brain injury are not likely to benefit from a superficial examination and collaboration. Aphasia is not only a speech problem. As mentioned above, it can also be a writing problem. Agrammatic aphasia is of primary concern to a therapist using the narrative story therapy technique. While a person may demonstrate a speech deficit, her writing or reading and interpreting may also be inhibited. Persons with agrammatic aphasia cannot comprehend and cannot create or write sentences that are not in anything but the simplest elemental grammatical structure. Treatment by training the survivors in sentence structure, verb use and placement, and how to write an object-related clause can improve the language ability of the survivor. Adult survivors may find this disturbing or depressing because most have completed high school and know that they learned these things and should know them. Acceptance of the deficit and the need for new or re learning is difficult emotionally.
A closer look at story narratives allows a researcher or therapist to study how the ABI survivor is organizing and expressing complex ideas. Very complex ideas may be expressed in very simple ways with few words. Knowing the premorbid education of the patient is crucial. For example, in treatment with my therapist, if I spoke about a complex brain injury subject as if I understood it thoroughly and the therapist did not know that I was a lawyer and studied brain injury for years, the therapist could easily conclude I had recently read about the subject, was leaping to conclusions, and did not have a true (e.g., full comprehension) grasp of what I said. This would likely cause the therapist to ignore or question the validity of my comments. The therapist must inform herself of all relevant premorbid education, abilities, competencies, and specialization of the patient before beginning the task of narrative deconstruction.
Competent story analysis takes into consideration the answers to the following questions:
- Are there economic and/or social influences affecting the status of the brain injured?
- How does the performance distinguish the brain injured person from the non-brain injured?
- Does the elicitation and expression of the stories influence the performance?
- Is there correlation of the story performances? Story analysis necessarily involves discerning whether all of the elements of a story are present.
While not fictional, our stories have characters, plot, dialogue, drama, scene, setting and monologue. Detecting the elements and separating each for further study and for completeness by a therapist is appropriate. When writing to reconstruct our identity and stories, we should be aware that our identity is not something we are born with. It is something we were taught and learned; something we can be caused to unlearn by brain injury, and something we can reconstruct. When writing our stories about our historical and present self, we need to be ready to see ourselves differently than we may recall (true of uninjured persons and survivors). We may be tired of therapy, frustrated with ourselves, and feel that we have a gloomy future. By writing about our self, as best we can recall self within the context of memories, we can re-identify what we were interested in and when it changes, understand why and find new interests. We examine how we think, feel, and act, what matters to us and what doesn't.
Identity is both the product and the process of self-narrative story construction. ABI and psychological problems are embedded in the process of deconstructing, revising and constructing stories of identity. Narrative story psychotherapy can be equated to a collaborative dialogue designed to transform our stories and narrative of identity. The more traditional narrative psychologists use a metaphor of self as a personal narrative; a memoir. There are several basic features of psychological processes by which self-stories are constructed, structure, function, change and assumptions concerning authoring of the stories. As we write memoir, for ourselves and for healing, we reconstruct self and create a new identity with healthy and worthwhile interests and pursuits.