A Systematic Review of Narrative Therapy

Headnote

ABSTRACT

The aim of this study is to review the experimental studies conducted to evaluate the effectiveness of the narrative therapy approach. In order to investigate the effectiveness of Narrative Therapy, Turkish and English studies published between 2006-2022 (December) in the databases of DergiPark, YÖK Thesis Center, Web Of Science, Sobiad, Science Direct, and Wiley Online Library were searched. The keywords "narrative therapy" "collective narrative practice" "narrative therapy groups" were used in the search. As a result of the scanning, a total of 19 articles suitable for the purpose of the research were reviewed. These articles are presented in terms of research methods, study findings and therapy characteristics. The study findings show that narrative therapy is effective on dependent variables. The results show that narrative therapy has a preventive and remedial effect in group therapies with children, adolescents and adults.

Keywords: Narrative therapy, narrative group therapy, systematic review

ÖZ

Bu çalışmanın amacı öyküsel terapi yaklaşımının etkililiğini değerlendirmek için yapılmış çalışmaların gözden geçirilmesidir. Öyküsel Terapinin etkililiğini araştırmak amacıyla DergiPark, YÖK Tez Merkezi, Web Of Science, Sobiad, Science Direct, Wiley Online Library veri tabanlarında 2006-2022 (Aralık) yılları arasında yayımlanan Türkçe ve İngilizce araştırmalar taranmıştır. Taramada "öyküsel terapi" " anlatı terapisi" "narrative therapy" "collective narrative practice" "narrative therapy groups" anahtar kelimeleri kullanılmıştır. Tarama sonucunda araştırmanın amacına uygun toplam 19 makale gözden geçirilmiştir. Bu makaleler ise araştırma yöntemleri, çalışma bulguları ve terapi özellikleri bakımından sunulmuştur. İncelenen çalışmaların sonucunda öyküsel terapinin madde bağımlılığı, nörogelişimsel bozukluluklar, depresyon, travma, yas ve yeme bozukluklarında etkililiği kanıtlanmıştır. Ayrıca elde edilen sonuçlar öyküsel terapinin çocuk, ergen ve yetişkinler ile yapılacak grup terapilerinde önleyici ve çare bulucu etkisinin olduğunu göstermektedir.

Anahtar sözcükler: Öyküsel terapi, öyküsel grup terapisi, sistematik gözden geçirme

Introduction

The science of philosophy, dominated by modernist thought in the early twentieth century, significantly affected other branches of science related to human beings. Especially with modernist thought dominating the field of psychology, the objective reality was focused on, and human beings were considered an object. Toward the end of the twentieth century, the postmodernist view started to move away from absolute reality. With this view, which is dominated by a dynamic and variable way of thinking, the human being has become the subject of the life they live. Social constructivism, which provides a therapeutic approach to the postmodernist view, underlines the importance of unique realities emerging from the interactions of the individual with the environment (Işık et al. 2022). This concept, also known as social constructionism, emphasizes that reality is a phenomenon formed through social processes, and knowledge is constructed as a result of individuals' interactions with their social and cultural worlds (Akkuş et al. 2020).

Consequently, there is no single objective reality. In this approach, there is a continuum regarding the impact of the individual's social processes and relations with others on the individual (Bedir 2019). The individual in the meaning-making process shares the meanings they create with others and is affected by the meanings of other individuals in social processes (Baştemur and Baş 2021). Based on these approaches, Narrative therapy was developed by Australian therapist Michael White and New Zealand family therapist David Epston in the 1980s and has established an influential position in today's psychotherapy theories. Narrative therapy, which differs from all traditional theories, finds its place within the third-wave approaches in psychotherapy while simultaneously attaching importance to the power that emerges with the liberation of the individual from cultural pressure to know oneself. Like existentialist approaches, narrative therapy recognizes people as the experts in their lives and believes that individuals can use their resources to solve their problems (Morgan 2000).

One of the significant concepts of narrative therapy is language, and language attains meaning in two dimensions. In the first dimension, language shapes meaning and becomes postmodern thought. Individuals create meanings using language in this dimension, and language uncovers meaning within narrative use. It is critical to focus on the words and language used by the client in the therapy process because the words used facilitate the formation of a new story. The other dimension is the negative impact of the language used on the clients (Baştemur and Baş 2021). White (2011), who laid the foundations of narrative therapy, does not use some words in the therapy process, considering that they negatively affect the clients. For example, he was careful not to use words like case and case histories. She also stated that she uses the word person instead of client.

Narrative therapy suggests that people have various experiences and create various stories to discover the meaning of these experiences and make sense of their lives. However, these stories are composed not only by the subjective experiences of the individual but also by being influenced by social and cultural contexts (Çelik 2017). While the individual does not have a single story, there is no single version of stories. In a sense, stories are in a constant state of development and transformation. In this process, some stories become dominant and assume a structure that constrains the individual. The individual comes to evaluate their life through the window of these dominant stories, and this situation plays an active role in the individual's behaviors and preferences (White and Epston 1990).

Narrative therapists, on the other hand, support the clients to eliminate these painful dominant stories without changing the individual's value system. A path is followed toward creating new meanings and possibilities based on the stories that clients can share (Corey 2015). This process, called deconstruction, an important stage of narrative therapy, aims to understand how the client creates their story by breaking down the cultural transmissions causing oppression and creating useless identities and situations that create inconsistencies between their actions and preferences. In the process of deconstruction, cultural and social interactions are explored based on the client's dominant stories. Narrative therapy aims to pave the way for the client to see new perspectives by enabling clients to describe their experiences in a different and compelling language. This way, the client can discover different meanings from their thoughts, feelings, and experiences through new language (Freedman and Combs 1996).

Narrative therapists are guides who establish a collaborative relationship in a facilitative role throughout the therapy process. Basic concepts such as empathy, respectful curiosity, interest, and compassion are involved in this relationship. By maintaining a position of not knowing, the therapist follows the client's story and helps the client to construct a preferred story. The client and the counselor work together to explore the impact of the problem on the client and focus on what can be done to reduce this impact. The priority in this process is to ask questions that differentiate between the client and the problem and deconstruct the original story. The problem thus becomes an objective situation separate from the client. Narrative therapists focus on the client's views about their life instead of prioritizing diagnosis and assessment (Corey 2015). For this reason, informal measurement methods are applied to facilitate the client in expressing the subjective reality of their life (Allen 2011).

Asking questions has an important place in Narrative Therapy, as in all psychological counseling approaches. The questioning technique is used to identify the client's problems and detect coping resources. Narrative therapy includes two types of questions: exception and significance questions. With exception questions, unique moments when the problem does not arise are identified. The other type of question, significance questions, emphasizes the relevance of the exceptional times discovered for the individual and the family (Akkuş et al. 2020). The client is supposed to acquire a different experience and attain different perspectives with these questions (Freedman and Combs 1996). The aim of externalizing the problem, one of the essential therapeutic tools of the narrative therapy process, is to enable the client to distinguish between their own life and the dominant story. In particular, the client is helped not to accept the disturbing story as a way of life (Karairmak and Bugay 2010). The externalization process is structured as deconstructing the dominant story, separating oneself from the problem, and giving a name to the problem.

Narrative therapy emphasizes that the problem itself is the problem, with a strong discourse that the problem is not the person. The narrative therapy defines the problem as an "uninvited guest" and differs from many schools of therapy by using such a language. In other words, in narrative therapy, the client is treated not as a problematic individual, but as an individual who has a connection with the problem (Ilgar and Ilgar 2018). The most fundamental feature of achieving specific results, externalizing the problem and revealing dominant stories in the narrative therapy process is to include rewriting conversations to create novel and alternative stories. According to the researchers, through these conversations, the client is expected to disclose the events that they have neglected and ignored. During these conversations, achievements, skills, and positive personal characteristics that remain buried under the client's dominant story or are relegated to the background are particularly brought to the forefront. These uncovered characteristics serve as a starting point in the process of writing an alternative story. The therapist works in collaboration with the client and helps the client throughout the process of creating an alternative story. In the re-membering process, the client's memories of people who make sense of their lives but whom they have not seen for a long time are integrated into the counseling process. In this way, the client is encouraged to create an alternative story and feel safe. This process can progress not only by including positive memories but also by excluding negative memories (Payne 2006).

Narrative therapists believe that the alternative stories created by clients will be permanent only when they find a group that approves and supports them. That is, the presence of a supportive group in this process affects the client positively. The presence of a group that will witness the change is significantly efficient for the survival of the alternative stories created (Andrews and Clark 1996). Therapeutic letter writing, another significant technique, has found an important place in narrative therapy alongside family therapy. The client feels understood through therapeutic documents and develops practical skills related to their lives (Çelik 2017). By narrative letters, both the sessions are recorded and the strong points of the client are recorded. The letters also contribute to clarifying the improvement that occurs in the client by clearly revealing the difference between the dominant story and the preferred story. Appropriate reflection, empathic responses and collaboration are of great importance throughout the process, along with the many techniques used in narrative therapy. During the process, the narrative therapist listens with a sense of mystery, amazement and respectful curiosity as the client tells their story. If the client feels that they have sufficient sources of support for their own life and future, the termination process is initiated. Inviting witnesses and the use of therapeutic documents can be utilized during this process.

This study aims to review the studies on Narrative Therapy published between 2006 and 2022 with the systematic review method and to determine the effectiveness of narrative therapy on various study groups.

Method

Research Model

This study conducted a qualitative study using systematic review and document analysis methods. A systematic review is the synthesis of studies that include the research question to answer a research question by bringing them together within the framework of specified criteria (Yilmaz 2021). The document analysis method is a process that involves collecting, examining, and analyzing existing documents related to the targeted situation (Sak et al. 2021). PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were used for all details regarding the selection of the articles in this study.

Literature Review

In the study, Turkish and English studies published between 2006-2022 (December) in DergiPark, YOK Thesis Center, Web Of Science, Sobiad, Science Direct, and Wiley Online Library databases were screened to investigate the effectiveness of Narrative Therapy on therapy groups with different problems. The keywords "narrative therapy," "collective narrative practice," and "narrative therapy groups" were used. The research process was planned in 2 phases. The first phase took place in December 2022, and attention focused on the appropriateness of the titles and abstracts for the study. The second phase took place in January 2023, and the studies obtained were systematically analyzed. During the screening process, 34 studies were reached. Fifteen studies that were not in the specified year range, whose full text could not be accessed, which included approaches other than narrative therapy, and which did not provide information about the effectiveness of narrative therapy, were excluded from the review. Of the excluded studies, 10 were review studies, 2 were correlational studies, and 3 included non-story therapy approaches. Nineteen studies within the specified year range that provided information about the effectiveness of narrative therapy, whose full text was accessed, and included only the narrative therapy approach were included in the review. The "Article Review Form" prepared by the researchers was used to examine the studies. The studies were evaluated in terms of study group, research model, techniques, measurements, and results and included in the study.

Results

Information about the studies is presented in Table 1 and Table 2. Table 1 includes information on the study method, study group and outcomes, while Table 2 includes information on the narrative therapy approach applied and the characteristics of the groups formed.

Methodological Characteristics of the Studies

Sample

The age range of the participants of the studies reviewed varied between 7-75 years. Six studies were conducted on children, three on adolescents and five on adults. Only one study (Muhammadi et al. 2013) was performed on couples and four studies (Poole et al. 2009, Dastbaaz et al. 2014, Erbes et al. 2014, Nozari et al. 2019) were conducted on older adults. When the participants in the studies were examined, the research groups in 8 studies were composed of individuals with psychiatric diagnosis (major depression, alcohol dependence, eating disorder, dyslexia, autism, substance abuse, attention deficit and hyperactivity disorder, post-traumatic stress disorder). Apart from these studies, narrative therapy has also been studied with research groups consisting of individuals with different trauma and grief experiences. Furthermore, research groups consisting of women diagnosed with Alzheimer's disease and obesity were also included in the study, while the other groups did not have any diagnoses. The research groups consisted of 6 to 32 people.

Treatment and Control/Comparison Groups

While the majority of the studies (11 studies) included a control group, four studies examined the effectiveness of narrative therapy according to pretest/posttest results. In the studies with a control group, the effectiveness of the therapy was evaluated by comparing the group in which the narrative therapy approach was applied with that without the narrative therapy approach. Five of the studies with a control group were designed using a randomized design, while the remaining six studies were structured using a quasi-experimental design. The treatment groups received only the narrative therapy approach and no other approach was used.

Assignment to Treatment Groups

Random assignment method was used in five of the studies with a control group. The remaining six studies adopted a quasi-experimental design and did not use random assignment. In five studies with a single research group, random assignment was used.

Measurement Methods Used

Pre and post-test measurements were administered in 16 of the studies, and in five of these studies, follow-up evaluations were additionally included. While the follow-up periods varied between 1 month and 4 months, Ozaydin's (2021) study did not include a follow-up period. In Mukba's (2020) study, follow-up evaluations were carried out in the form of interviews. In Yazici's (2018) study, the gains were maintained after a four-month follow-up period. This is an significant feedback about the effectiveness of narrative therapy over a long period of time.

Different measures were utilized in the reviewed studies to investigate the effects of narrative therapy on different groups regarding the subject matter covered in the studies. The most commonly used measure is the Beck Depression Scale. Posttraumatic Stress Disorder Checklist and Posttraumatic Stress Disorder Assessment Scale for Children were used on traumatized groups. In the groups composed of obesity and eating disorders, the Eating Disorders Inventory and measurement tools revealing depression and stress levels were also used. For the study groups with neurological disorders such as dyslexia, autism, ADHD, and Alzheimer's, scales on different variables such as Dyslexia Checklist, Wechsler Intelligence Scale for Children, Kessler 10 Psychological Distress Scale, Beck Hopelessness Scale, Emotional Disorders Test for Child Anxiety, Geriatric Depression Scale, Loneliness Scale, Oxford Happiness Scale were administered. Different scales, such as Self-Regulation Scale, Burnout Scale, and Career and Skills Development Self-Efficacy Scale, were applied to the study groups without any diagnosis. Since the objectives and research groups of the studies obtained differ, the instruments used also vary. The reviewed studies' common purpose is to judge narrative therapy's effectiveness on the research groups, and the measurement tools used were selected to serve this purpose.

Narrative Therapy Content and Implementation in the Studies

Techniques Applied

When the narrative therapy approach applied was examined through the studies, the most frequently used techniques were externalization of the problem, creating alternative stories, obtaining unique results, rewriting conversations, and inviting witnesses. In addition to these techniques, the use of metaphors (4 studies) and therapeutic documents (3 studies) were also employed.

Session Characteristics and Number

The number of sessions in the reviewed studies ranged from a minimum of 3 sessions (Yiğit 2019) to a maximum of 16 sessions (Vromans and Schweitzer 2009). Twelve studies reported the number of sessions in the range of 8-12, two reported six sessions, and one reported 14 sessions. The narrative therapy sessions varied between 45 minutes and 150 minutes. The most common therapy duration in the studies examined was 90 minutes, and three studies did not provide information about the duration of therapy (Muhammedi et al. 2013, Turtulla 2014, Karibvende et al. 2022). Two studies did not clearly state the duration of the session and reported that it was between 45-65 minutes.

Number of Members and Therapists

Regarding the number of therapists in the analyzed studies, there was one group leader in thirteen, and no information was given about the group leader in four studies. The number of members in the studies varied between 6-32, and one study did not provide information about the number of members (Turtulla 2014).

Study Results

The post-test scores of the study groups who received narrative therapy differed significantly from those of the control groups not receiving narrative therapy in the pre-test/post-test control group studies implementing narrative therapy. In Yazici's (2018) study on adolescents, the psychological resilience scale scores of the study group receiving narrative therapy were significantly different from the control group. Moreover, the study group maintained its gains during the follow-up. These findings suggest the effectiveness of narrative therapy. Nozari et al. (2019) reported that the perceptions on aging of the experimental group comprising of older adults residing in a nursing home increased positively after narrative therapy, while their death anxiety significantly reduced compared to the control group. In another study, Park and Kim (2023) worked with men with alcohol addiction and reported a significant increase in self-esteem and a decrease in stress response scores after narrative therapy. Dastbaaz et al. (2014) found a significant decrease in depression and loneliness levels of elderly women diagnosed with Alzheimer's disease after narrative therapy. Ozaydin (2021) utilized narrative therapy in the career structuring process with 4th grade primary school students. The findings of the study revealed a significant difference between the scores of the students in the experimental group on the Career and Talent Development Self-Efficacy Scale and the scores of the control group.

In their study with children, Karibvende et al. (2022) reported a decrease in ADHD and other symptoms associated with anxiety in the experimental group receiving therapy. McKian et al. (2019) concluded that the body image perception of obese women receiving narrative therapy differed significantly. Looyeh et al. (2014) applied play therapy activities developed for narrative therapy to boys diagnosed with social phobia, and their scores on the Social Phobia Scale decreased significantly compared to the control group. The opinions of parents and teachers after the study also support the findings. In the study conducted by Mohammedi et al. (2013), which is the only study conducted with couples among the studies included, the experimental group's emotional and communicative intimacy scores increased significantly compared to the control group. An increase was also observed in the problem-solving ability of the couples in the experimental group. Rahmani (2011) determined a significant decrease in the reading errors of students diagnosed with dyslexia attending 1st, 2nd, and 3rd grades compared to the control group. Koca's (2018) study, conducted with female students, was the only study reporting no significant difference in the experimental group following narrative therapy. After the narrative therapy was applied to the experimental group, no significant difference was found in the self-regulation scores of female students compared to the control group. However, in contrast, trait anxiety scores showed a significant difference in favor of the experimental group.

In single-group pre-test/post-test design studies in which narrative therapy was applied, the effectiveness of narrative therapy was investigated in randomly selected groups. Erbes et al. (2014) observed significant decreases in PTSD criteria in the post-test applied to veterans with post-traumatic stress disorder. There was also a decrease in depression scores in favor of the group. Vromas and Schweitzer (2009) reported a significant improvement in the depressive symptoms and interpersonal relationship achievements of clients diagnosed with major depressive disorder in the post-test. A 3-month follow-up in the study showed gains to be maintained in the follow-up. In the study of Weber et al. (2006), among women with eating disorders, depression, anxiety, and stress scale scores significantly declined in the post-test after narrative therapy. Besides, individuals have been observed to have adapted the strategies related to eating disorders to their daily lives. In Cashin et al.'s (2013) study on individuals with autism, the scores of individuals on the Kessler-10 Psychological Distress Scale and Beck Hopelessness Scale significantly decreased after narrative therapy.

Poole et al. (2009) focused on older people coping with substance abuse problems. According to their findings, the participants were able to find friends more easily after narrative therapy and improved their feelings of guilt, power, and tolerance. Mukba (2020), working on bereaved children whose mother or father had passed away, noted that after the narrative therapy approach, individuals acquired new perspectives on their experiences of grief and mourning. Furthermore, individuals were able to restructure their lives after the follow-up interviews. Yiğit's (2019) mixed-design study examined high school and university students who had experienced trauma. After applying "Tree of Life," a part of narrative therapy, high school-level participants were more confused about the future than university-level participants. Males were also more confused about their identities than females. Turtulla (2014) performed predictive correlational design research with Kosovo's primary and secondary school teachers. Results revealed a significant difference in the burnout level of female teachers compared to male teachers. Besides, a positive correlation was observed between age and burnout level.

Discussion

This study reviewed 16 experimental research articles, one multiple case study, one mixed design study, and one multifactorial predictive correlational research article published between 2006 and 2022 (December). Results of the studies revealed that the narrative therapy approach had been applied to many diverse research groups in a planned manner. The narrative therapy approach has been applied to war veterans, alcohol dependents, students at different levels, and individuals with autism, attention deficit, and hyperactivity disorder. Despite the different characteristics of the research groups, the primary purpose of the studies was to demonstrate the effectiveness of narrative therapy. Children were studied in six of the studies, and the effectiveness of narrative therapy was generally explored on a variety of topics such as grief, career, anxiety, phobia, and hopelessness. The scores of the research groups in which narrative therapy was applied differed significantly based on these studies' pre-test/post-test scores. The gains were preserved in the follow-up studies (Mukba 2020, Ozaydin 2021).

The three studies on adolescents focused on psychological resilience, trait anxiety, self-regulation, and trauma. Narrative therapy did not significantly affect self-regulation (Коса 2018). However, the scores of the control and experimental groups on other variables were significantly different. This difference reveals the effectiveness of narrative therapy in studies with adolescents. In five adult studies, topics such as major depression, alcohol dependence, stress, self-esteem, burnout, obesity, and eating disorders were addressed. These studies indicated significant differences with the narrative therapy approach. Significant changes were recorded in favor of the experimental group, especially in groups with major depression, alcohol addiction, and eating disorders, through sessions based on the narrative therapy approach. Four studies with the elderly focused on trauma, death anxiety, perception of aging, loneliness, and depression. The fact that there were older adults with Alzheimer's disease in the studies with older individuals and that significant decreases in the depression and loneliness scale scores of this group reveal that narrative therapy is effective in groups with neurological disorders. Only one study on couples was found (Mohammedi et al. 2013). In this study, couples worked on emotional and communicative intimacy issues with a narrative therapy approach and achieved significant outcomes. This outcome proves that narrative therapy can be effective in couple and family therapies.

Considering the study's session characteristics, while the number of sessions generally varies between 8-12 sessions, there was a study group with three sessions (Yiğit 2019). This finding suggests that narrative therapy is also effective in shorter sessions. Regarding the number of members, the narrative therapy approach was applied to the study group consisting of 32 cases (Park and Kim 2021). This member number demonstrates the effectiveness of narrative therapy in larger groups.

While narrative therapy is among the new emerging approaches, it has a significant place among psychotherapy approaches in terms of its effectiveness. It effectively detaches the individual from their problematic past and makes them the subject of their own life. The most apparent evidence of its effectiveness is the significant difference in the outcomes of the groups to which narrative therapy was applied. The narrative therapy school, which aims to discover individuals on the axis of emotions, thoughts, and behaviors, follows a path toward raising awareness in the same axis. Individuals' problems related to identity have intensified, especially nowadays. At this point, one of the most potent aspects of narrative therapy is considering the client's story away from all other judgments by considering the individual's life, culture, and beliefs. One of the most practical steps of the therapy process is to reveal the individual's dominating story and struggle with it. Rather than labeling clients and making diagnoses, attempting to understand them through collaborative therapeutic questions is an outstanding contribution of narrative therapy to the field of psychological counseling. Eventually, the counselor not assuming the role of an expert and the client being positioned as the expert in their own life contributes positively to the collaboration. This study confirmed that this method and individual therapy could be used effectively in a group or couple therapy. Its multicultural perspective can appeal to different individuals and various social segments. During the therapy process, it brings to light the problematic experiences that develop due to the pressure of society on the individual by including social and political issues. In this respect, a critical aspect of narrative therapy is to work effectively throughout the therapy to relieve the problematic identity stories that the clients have created through imposition. Discovering these predominant stories is a big step in the liberation of the client. Some criticisms of the narrative therapy approach highlight some points. In particular, individuals who expect guidance may have difficulty adapting to the nature of therapy and self-disclosure. The client's ability to express themselves is also an essential factor. At an adequate level, this feature may positively affect the cooperation and the established therapeutic relationship.

As in every research, there are limitations in this study. The major limitation of the research is the inclusion of studies that can be accessed through the identified databases in the review process.

Conclusion

Today, the effectiveness of many different psychotherapy methods is being investigated. Psychotherapy methods whose functionality has been proven byresearchers are utilized to the extent appropriate to the client's problems. Narrative therapy differs from other contemporary theories with its unique and functional techniques. Narrative therapy has brought a new perspective to the field of psychotherapy with a strong emphasis on detaching the individual from the problem. It supports the individual in building their self by eliminating all stereotypes. The individual thus begins to question the discourses imposed on them and gains awareness of the impact of these discourses on their lives. Narrative therapy, which has a solid foundation, offers functional techniques to experts working in the field and opens the doors of different perspectives to clients. This study examined which groups and in what kind of problems narrative therapy is effective, and its long-term course was revealed. Consequently, the findings of the studies show that narrative therapy has established a solid place for itself in psychotherapy. Therefore, it would be essential to include the narrative counseling school in psychological counseling and guidance programs.

Sidebar

Address for Correspondence: Nezir Ekinci, Karamanoğlu Mehmetbey University Faculty of Education Department of Educational Sciences Department of Guidance and Psychological Counseling, Karaman, Türkiye E-mail: [email protected]

Received: 26.02.2023 | Accepted: 24.05.2023

Authors Contributions: The author(s) have declared that they have made a significant scientific contribution to the study and have assisted in the preparation or revision of the manuscript

Peer-review: Externally peer-reviewed.

Conflict of Interest: No conflict of interest was declared.

Financial Disclosure: No financial support was declared for this study.

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