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Therapeutic Assumptions and Research Behind the Narrative Practice of Externalizing Conversations September 2005
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Therapeutic Assumptions and Research Behind the Narrative Practice of Externalizing Conversations by Carl F. Hilker III
Mary Herget, Ph.D. Chairperson
Jim Sparks, Ph.D. 1st Reader Member
A clinical research project submitted to the faculty of Argosy University/San Francisco Bay Area Campus in partial fulfillment of the requirements for the degree of Doctor of Psychology in Clinical Psychology.
Point Richmond, CA
September 2005
THERAPEUTIC ASSUMPTIONS AND RESEARCH BEHIND THE NARRATIVE PRACTICE OF EXTERNALIZING CONVERSATIONS
This clinical dissertation by Carl F. Hilker III has been approved by the committee members signed below who recommend that it be accepted by the faculty of Argosy University/San Francisco Bay Area Campus in partial fulfillment of the requirements for the degree of
DOCTOR OF PSYCHOLOGY
Clinical Dissertation Committee:
Mary Herget, Ph.D. Chairperson
Jim Sparks, Ph.D. Member
Table of Contents Abstract Chapter One: Study Formulation and Definition Introduction Problem Statement Purpose Statement Significance and Clinical Rationale Chapter Two: Methodology Summary of the Study Interpretive Process Literature Sources Definition of Key Terms Chapter Three: Literature Review Therapeutic Assumptions of Externalizing Externalizing Problems Objectifying and Personifying a Problem Reducing Blame for a Problem's Existence Tracking the History of a Problem Deconstructing Sociocultural and Political Effects/Assumptions Creating Space to Consider Possible Alternatives Allowing for the Creation of Alternative Stories Building Personal Agency over Preferred Qualities Not Assigning Causation to Problems Making Deadly Issues More Discussable Acting as an Oppositional or Anti-Language Researching the Narrative Therapy Approach Establishing a Narrative Perspective on Research Impact of the "Interpretive Turn." Reconciling research with narrative values. The effects of political and social views about therapy. Influence of Narrative-Inspired Co-Research Reciprocal connection between therapy practice & research methodology. The use of externalizing practices in co-research. Types of Research into Narrative Therapy Evaluating narrative therapy in general versus specific practices. Research on externalizing practices. Chapter Four: Findings and Discussion Evaluation of Externalizing Practices Clinical Implications of this Review Conclusions about Externalizing Practices Where Would Narrative Therapy be Without Externalizing? Analysis of Current Research Summary Implications for the Future Future Research Methods Proposals for Research References
Abstract The narrative approach to therapy outlined by David Epston and Michael White is broadly premised on the assumption that people's lives are socially constructed through the multiple stories they tell, and that these stories are colored by the cultural and historical contexts within which they occur. The process of externalizing is a narrative therapy practice that establishes a context where people experience themselves as separate from the problems in their lives. Such practices focus on the relationship between the person and the problem instead of upon a problem-person. The person is not the problem; rather the problem is the problem. More than a therapeutic technique, externalizing practices assist in exemplifying the social constructionist worldview of narrative therapy. Accounts of the usefulness and therapeutic value of externalizing practices come from practitioner descriptions and anecdotal client accounts of the therapy process. Efforts to utilize methodological research for studying the therapeutic qualities of externalizing practices have been limited. Contributing factors to this dearth of data include the unique and sometimes complex social constructionist principles of narrative therapy, the political and social sensibilities of those among the narrative therapy vanguard, and researchers' comparative lack of training in qualitative research methodology. There are recent signs within the narrative therapy community and the qualitative research field which suggest that novel forms of method-based research involving collaboration between researcher and participant can yield promising results. This study proposes that research methods that employ the narrative practice of co-research offer excellent opportunities to evaluate the therapeutic qualities of externalizing conversations.
Chapter One: Study Formulation and Definition Introduction Narrative therapy is a relative newcomer to the field of talk therapy - having first taken form in the late 1980s. In fact, many different themes have been emphasized in what is understood as the narrative metaphor, including ways of understanding people's identities and vantages from which to understand problems and their effects on people's lives (Morgan, 2000). Narrative therapy can also refer to particular ways of talking to people about their lives, problems, constraints, and their reflections on social, cultural, and political contexts. The purview of this study is restricted to that version of narrative therapy chronicled by Michael White and David Epston. Their groundbreaking book, Narrative Means to Therapeutic Ends (1990), represents an initial comprehensive effort to illustrate their conceptualization of narrative therapy as well as the therapeutic effects of its operation. Since that time, a torrent of literature - by these and other practitioners &endash; has continued to evolve our understanding of the meaning and uses for the narrative therapy which White and Epston are widely considered founders. Grounded in postmodern and social constructionist modes of thinking about the world, the narrative approach or "stance" can be recognized by many of its characteristic qualities. One of its most pervasive and distinct qualities is the practice of externalizing . In stressing the point of its importance, consider Michael White's response to a question posed to him regarding narrative therapy (Epston, 1993, p.161); "Michael, if you hadn't invented that 'talk' we refer to as an externalizing discourse, where do you think your work would be today?" White's reply was a conclusive, "Nowhere!" Externalizing practices create a context in which problems are treated as separate from people. People are invited to discuss problems and constraints in a manner that separates them from these issues. This process is quite unique within a Western culture that values a scientific medical model that situates problems within individuals' biology and character. Problems are conceptualized from the narrative vantage point "as existing outside people as a linguistic device to reorganize our thinking in ways that counter shame and blame, minimize defensiveness, and promote client agency or the capacity to act on behalf of themselves in relation to problems" (Madsen, 1999, p. 169). However, the process of externalizing is more than simply a stylish therapeutic technique for talking with clients about problems. Externalizing conversations are a hallmark of the theoretical and therapeutic foundation of the narrative approach. It is conceived as a philosophical way of thinking about people, their problems, and informs the attitude by which therapists continually engage clients in conversation. Consider the following observation offered by O'Hanlon (1994): I have to give you a warning &endash; if externalization is approached purely as a technique, it will probably not produce profound effects. If you don't believe, to the bottom of your soul, that people are not their problems and that their difficulties are social and personal constructions, then you won't be seeing these transformations. When Epston or White are in action, you can tell they are absolutely convinced that people are not their problems. Their voices, their postures, their whole beings radiate possibility and hope (p.28). Informed by philosophical ideas from writers such as Jacques Derrida and Michel Foucault, narrative therapy assumes a non-traditional stance where notions of reality are not rooted in positivist notions about the existence of "deep structures" to self-identity or "essential truths" about people. Such thinking is often referred to as structuralism. Narrative therapy is, alternatively, informed by poststructuralist ideas. Poststructuralism refers to a movement away from the idea that there are deep or real structures in people &endash; e.g. a real self, a true self, which can be discovered by experts. This outlook resists the search for essential truths about people and questions notions of therapist "objectivity" and "expertise" in therapeutic work. Moreover, narrative therapy operates under the social constructionist assumption that "problems are anchored and supported by cultural discourses or taken-for-granted cultural prescriptions about how we should act" and make sense of our lives (Madsen, 1999 pg. 171). The way people understand themselves and their relationship to the world is developed and shaped by their interactions in the world. Externalizing practices presuppose such ideas about culture and its influence on reality and self-identity, and actively seek to engage people in conversations that allow identified characteristics (particularly problems) to be seen as external to oneself. Externalizing discourse represents a manner of speaking that summons a social constructionist perspective and allows for the creation of alternative life narratives that open doors to an expanded array of choices in our lives. As narrative therapy becomes a more established therapeutic approach, an increasing body of literature seeks to address the therapeutic qualities of narrative practices. This study specifically seeks to draw attention to the purported therapeutic qualities of externalizing practices and to critique the nature and depth of research that has been conducted to date using such practices.
Problem Statement Narrative therapy is reaching into its second decade on the scene of psychotherapy and its community of adherents is expanding. Moreover, narrative practitioners and writers regularly profess the therapeutic qualities of narrative practices such as externalizing. Yet, how can these therapeutic qualities best be understood? How persuasive are the arguments concerning its effectiveness? What type of work is conducted with clients that conveys that such practices are indeed beneficial to people? And lastly, how solid is the narrative-inspired research (often called co-research) that makes use of externalizing practices? As the body and breadth of narrative-based literature accumulates, there appears to be a growing emphasis on validating the therapeutic effectiveness of narrative practices (such as externalizing), particularly as they relate to certain types of problems people encounter in their lives (such as eating disorders, domestic violence, depression, etc.). A distinctive quality of the therapeutic stance of narrative therapy lies in the manner in which it borrows from the postmodern philosophical tradition. Similarly, narrative-based research appears to be unique from other types of research in the mental health professions. Conventional forms of research often search for empirical conclusions (as with quantitative designs) and typically rely on the researcher's expert role to collect, codify, and interpret data (as is the case with many forms of qualitative methodology). Narrative-inspired research, conversely, focuses on the subjective nature of experience and seeks to de-emphasize the therapist's role as an expert. In particular, the narrative enterprise of co-research is often employed as a research method that is not only used to expound on the therapeutic qualities of the externalizing process, but is conducted with clients in an externalizing manner of speaking ( Epston, 1999). But, does the unique style of narrative-inspired research support the therapeutic claims made by its adherents? Is the research compelling enough to draw the interest and respect of those in the mental health community not accustomed to the narrative tradition? Is there more conventional research literature that supports the therapeutic claims by narrative therapy? Should it even be a goal of narrative-based researchers to ground their research in widely accepted design methodology?
Purpose Statement The purpose of this study is to take an in-depth critical look into the narrative practice of externalizing &endash; focusing intimately on its various uses and purported therapeutic qualities. A considerable amount of literature exists on the various ways in which externalizing practices function. Much of the literature is sprinkled with various tantalizing therapeutic qualities attributed to externalizing practices, often within the context of how externalizing serves other narrative practices &endash; such as deconstructive listening, relative influence questions, discovering unique outcomes, etc. An externalizing stance is additionally inherent to the narrative practice of co-research. However, the uniqueness of this study is in the singular manner in which it focuses on the various ways in which externalizing practices are employed within narrative therapy and the extent to which they are evaluated through research. With this aim, the study answers the following research questions: 1. What does the narrative therapy literature maintain as the salient therapeutic qualities and values attributed to the practice of externalizing? 2. In what manner and depth has methodological research attempted to validate the therapeutic qualities of externalizing practices?
Significance and Clinical Rationale Narrative therapy is an increasingly popular orientation within the field of psychotherapy; and while some practitioners in psychology seek to restrict the title of "theoretical orientation" to only a few approaches typically founded in the early 20th century, the narrative-inspired orientation arguably has a rich, albeit recent tradition grounded in social constructionist ideas about the human condition. Narrative therapy proposes many innovative ideas and therapeutic practices. Key among them is the practice of engaging people in externalizing conversations. Sometimes viewed as simply a therapy technique, externalizing practices address wider implications about how clinicians view the world, understand clients' problems, and by association, how clients view themselves and their ability to make changes in their lives. While narrative-inspired texts discuss externalizing practices to varying degrees, this study is distinguished by the manner in which it focuses singularly on the use of and therapeutic value associated with externalizing practices. By doing so, this study provides a richer understanding of the theory and practice of externalizing approaches to clinicians experienced in narrative work, as well as to those new to the narrative approach. It also offers an opportunity to explore in-depth the types of research behind narrative therapy and externalizing practices. An evolving body of narrative-inspired literature and research is being conducted that may assist in placing narrative therapy alongside other documented and researched therapeutic approaches. An objective of this study is to further that literary process, specifically as it relates to the practice of externalizing. This study's uniqueness lies in the manner in which it focuses solely on the issues and therapeutic implications surrounding externalizing practices. By doing this, it represents novel work in the field of narrative therapy literature, and will assist in explaining a key narrative practice to the larger clinical psychology community.
Chapter Two: Methodology Summary of the Study This study assembles and illustrates the therapeutic qualities attributed to the narrative therapy practice of externalizing, reviews current research literature on narrative therapy and externalizing practices, and critically appraises the manner in which narrative-inspired research makes use of externalizing discourse . The overall effectiveness of this study derives from a comprehensive survey and critical analysis of the current literature.
Interpretive Process This study comprises a comprehensive survey of the existing literature on the narrative therapy practice of externalizing and provides a critical evaluation of the research literature conducted on narrative-inspired methods. A final chapter will combine viewpoints from existing literature, as well as my own clinical interpretation, concerning the effectiveness of the narrative community in sharing its research practices with the larger mental health community in a compelling manner.
Literature Sources In following the approach outlined above, this study has drawn from a wide range of scholarly-based literature. Specific sources include the following:
Key descriptor words for this study include, externalizing conversations/practices, narrative therapy, narrative therapy and research, and externalizing practices and research.
Definition of Key Terms The following are definitions to key terms used throughout this study. These definitions are also cited as footnotes in the text to assist the reader. Constructivism &endash; A term based on the idea that knowledge is constructed by a person's prior knowledge as well as new personal experiences. Initially embraced by some in the therapy community, constructivism eventually was critiqued as being too relativistic and insufficiently attentive to the ways reality is also constructed through culture, class, race, etc.
Discourse - For the purposes of this study, the term will reflect that described by Hare-Mustin (1994, p.19-20), whereby discourse is "a system of statements, practices, and institutional structures that share common values…. The ways most people hold, talk about, and act on a common, shared viewpoint are part of and sustain the prevailing discourses." Discourses have a powerful influence on how they allow for and shape people's life stories, and they typically reflect established structures of social and power relationships. Examples of discourse include those about normative standards (body image, success, self worth, manhood, etc.), professionals' role as experts, and discourses about pathology (Freedman & Combs, 1996).
Ethnographic research &endash; Research relying on the notion that one can describe what people think by analyzing what they say (Fetterman, 1989). Ethnographic interviews are typically audiotaped, transcribed verbatim, and then analyzed to identify emergent themes and categories among the many words people use to describe a given experience. Within the narrative therapy application of ethnographic research, clients are actively engaged in the interpretive process of the meanings of their words and experiences of therapy.
Externalizing conversations &endash; this term can refer to the practice of externalizing the problem. Yet, this study also uses the term to encompass the pervading narrative therapy stance held with clients that regards people's sense of self, reality, and problems as socially constructed. This stance is a distinctive element of the narrative therapeutic alliance between therapist and client.
Externalizing practices &endash; Those efforts by the therapist to engage a client in conversations that seek to separate a problem, constraint, or internalized quality from the client's own identity. Such practices allow for the notion that "the person is not the problem, rather the problem is the problem."
Grounded theory - A methodology that attempts to develop theories that are grounded in the research participants' own experiences. The role of the researcher is to reflect on the participants' experiences in a manner that allows these experiences to be organized and categorized. The goal is to develop a coherent body of knowledge or theory that is derived from participant descriptions (Gaddis, 2004).
Qualitative research - Qualitative research does not rely on statistics to show confidence in the results. Confident conclusions are based more on the findings and interpretations that are produced by rigorous and systematized observation and documentation of the particular phenomenon in question (Maione & Chenail, 1999). Qualitative research is a general term used to describe a group of methodologies dedicated to the description and interpretation of social phenomena (Maione & Chenail, 1999). Such methodologies include, but are not limited to, ethnography, discourse analysis, narrative analysis, grounded theory, phenomenology, frame analysis, hermeneutics, and conversation analysis.
Quantitative research - Research that focuses on measuring and counting facts and the relationships among variables, and that seeks to describe observations through statistical analysis of data. It includes experimental and non-experimental research and descriptive research ( i.e. research that attempts to describe the characteristics of a sample or population).
Social constructionism &endash; Refers to the notion that a person's sense of reality is malleable, and shaped largely by social and cultural forces mediated by language. The focus is on the processes (i.e. discourses) by which people come to describe, explain, and account for the world and their position in it (Gergen, 2001).
Therapeutic - The American Heritage Dictionary defines therapeutic as, "having healing or curative powers." This study uses the word therapeutic in that context, and explores both the claims and research that speak to the "healing and curative powers" of externalizing conversations.
Unique outcome - Anything that does not fit with the dominant problem-saturated story. For example, if a client's problem is social anxiety, a unique outcome could be an instance when the anxiety was overcome or simply didn't present itself as a problem at that time. From a narrative perspective, it is important that the client perceive an incident as a unique outcome. If imposed by the therapist, the client may have misgivings about the incident truly being a unique outcome.
Chapter Three: Literature Review Please note that the literature review presented below is a curtailed version from the original presented to my dissertation committee. The goal of this portion of the chapter is to expand upon some of the operating assumptions regarding the therapeutic value of externalizing practices, and to critically review the manner in which narrative practices have been researched, with specific focus on externalizing conversations.
Therapeutic Assumptions of Externalizing Certain assumptions or presuppositions are made within many intellectual enterprises in general and more specifically surrounding the artfulness and creativity of therapy and what may be considered therapeutic. A narrative therapist's questions to a client often rest upon assumptions as to how both the question and answer will be useful to the client. Therapists' work with clients is driven by what is assumed to be therapeutic for a client at a given point in time. These therapeutic assumptions spring forth from a multitude of wellsprings &endash; one's past work with similar clients, information imparted by "experts" in the field, data borne from research, etc. The notion of what is therapeutic not only sustains the therapist during each session, but provides the lifeblood of the entire therapy enterprise in its continued refinement of "standard of care" and the evolution of the field. Within the realm of narrative therapy, the implementation of externalizing conversations has taken a defining role. In fact, many of the major applications of narrative therapy &endash; whether it be working with certain problems (such as eating disorders, depression, domestic violence, children acting out, etc.) or how to achieve specific results (such as discovering unique outcomes , deconstructing problem stories, or building alternative stories) involve the use of externalizing conversations. In many respects, the process of externalizing is the workhorse of narrative therapy. But, why and how does externalizing work? What aspects of externalizing conversations do clients of narrative therapy find useful and therapeutic? And how well has it been thought through by those who assert its therapeutic usefulness? In relatively informal ways, many narrative-inspired practitioners have utilized feedback from clients. For example, White notes that when soliciting feedback from those who consult him about their experience in therapy, "very often it is the engagement with externalizing conversations that is identified as a turning point for them in their efforts to satisfactorily address their problems and concerns" (White, 2000, pp.3-4). Specifically, he mentions that externalizing conversations made it possible for people to "separate their sense of identity" from the previous problem-saturated accounts of themselves (White, 2000). The remainder of this section explores in-depth several of key therapeutic assumptions and elements of the narrative practice of externalizing. They are presented as follows: 1) Externalizing problems 2) Objectifying and personifying a problem 3) Reducing blame for a problem's existence 4) Tracking the history of a problem 5) Deconstructing sociocultural and political effects/assumptions 6) Creating space to consider possible alternatives 7) Allowing for the creation of alternative stories 8) Building personal agency over preferred qualities 9) Not assigning causation to problems 10) Making deadly issues more discussable 11) Acting as an oppositional language or anti-language While not an exhaustive list, these elements are among the most frequently cited by narrative-inspired authors as the therapeutic qualities that render externalizing conversations useful. These qualities are not characterized as occurring in isolation from one another, but are seen as intertwined and interdependent. This section illustrates these assumptions in detail. A subsequent section critiques the thoroughness to which these elements have been found to be useful in therapy.
Externalizing Problems When people turn to therapy for assistance, they have often reached a point where they believe there is something wrong with them &endash; that they or something about them is problematic (Carey & Russell, 2002). By this point, the problem has become internalized. People assume the problem is a facet of their nature or inner-self. The problem has become fused with the person's identity. The narrative stance assumes that people can most easily examine the effects of problem-saturated stories of their lives when a discussion is conducted via externalized conversations. Externalizing establishes a context where people experience themselves as separate from the problem. Such a conversation shifts the client's relationship to problems, and shifts the conversation to a focus on the relationship between the person and the problem instead of a singular focus on a problem-person. Much of the literature suggests that the first step in the externalization process is to use the client's language to describe the problem, modifying it so that the problem is objectified, and then questioning the objectified problem about its intentions and goals for the client. This process allows the problem to become a separate entity and thus external to the person or relationship - decoupling the connectedness between the person(s) and the problem (White & Epston, 1990). This process often begins simply. For example, during an initial session a client may comment that he feels he has a problem with making major decisions in his life. The consulting therapist may ask externalizing questions such as: So, "indecision" has made it difficult for you to arrive at certain decisions in your life? Has long has "indecision" been influencing your life? What strategy does "indecision" employ to get you off-kilter and unable to make up your mind? The therapist in this example has used the term indecision in an externalized manner, and will determine if this or another term fits best for the client. Clients often do not need a lengthy explanation of the externalizing process. Rather, the therapist simply engages the client in externalizing conversations in a comfortable and conversational manner. If the therapist maintains this linguistic stance during the consultation and asks externalizing- inspired questions, clients will begin to experience a difference between how the therapist is talking about the problem and how they have likely been thinking about the problem for a considerable time. As the therapist's use of externalizing language takes hold with the client (which may take any number of sessions), the client may begin to think about his problem or constraint in a different fashion &endash; one where he slowly becomes separate and distinct from the problem. Therapeutic opportunities now begin to emerge. Michael White found the process of working with people to externalize their problems compelling in the way it helped in the struggle against these problems. In the landmark book co-authored with David Epston, he notes (White & Epston, 1990, p. 39): I have concluded that, among other things, this practice [externalizing the problem]: 1) Decreases unproductive conflict between persons, including those disputes over who is responsible for the problem; 2) Undermines the sense of failure that has developed for many persons in response to the continuing existence of the problem despite their attempts to resolve it; 3) Paves the way for persons to cooperate with each other, to unite in a struggle against the problem, and to escape its influence in their lives and relationships; 4) Opens up new possibilities for persons to take action to retrieve their lives and relationships from the problem and its influence; 5) Frees persons to take a lighter, more effective, and less stressed approach to "deadly serious" problems; and 6) Presents options for dialogue, rather than monologue, about the problem.
Objectifying and Personifying a Problem The idea of personifying the problem is closely linked to the quality of creating space. Yet, it does deserve its own discussion. Narrative therapy is quite distinct from other modalities of treatment, such as psychodynamic therapy, in the manner in which it strives to create a therapeutic setting for clients where problems are indeed experienced as something external to them. Creating a conversation where the problem has its own persona can be vital to experiencing it as external. Clothed with a discrete set of intentions, beliefs, agendas, and expectations that may be distinct from those of the client, the problem suddenly begins to take on a life of its own. Freedman and Combs (1996) also note that as the problem becomes externalized, it begins to be the focus of objectification rather than the person. This process may indeed assist in creating space for experiencing new choices, but the narrative literature suggests that the therapeutic value of personification lies in how it assists a client in experiencing the problem as separate from her &endash; the realization that the problem may have beliefs and intentions that are not in the best interests of the client. Faced with this realization, she must decide how to respond. Will the problem continue to make decisions for her or will she? Whose agenda is more important, hers or the problems? Has the problem lived up to its promises to her (if any where made)? What does the problem want for her in the future? What does she desire? How does the problem try to trick her into buying into its way of life rather than hers? Such questions as these are considered useful in helping to separate the person from the problem(s). What questions like these have in common is their personifying and objectifying attitude about the problem. The problem is brought to life by the implicit notion that it has its own consciousness and purpose.
Reducing Blame for a Problem's Existence People who consult therapists often feel a sense of blame or shame for the problems they suffer. Indeed, many cultures hold value in people taking responsibility for their problems, and if a little blame and shame is felt along the way, that may be supported by many cultural conventions as well. Narrative therapy takes a different tack. While certainly important for people to take responsibility for addressing problems in their lives, the narrative approach attempts to decouple the effects of blame and shame from the act of taking responsibility for one's problems . Madsen (1999, p.179) comments that blaming clients for their problems "never seemed particularly helpful." He further elaborates that, The process of externalization allows for the separation of blame and responsibility. By thinking of problems as external entities that invite, coach, or trick us into particular responses, we can remove blame from individuals. People are not to blame for their difficulties; problems are to blame for their difficulties. Problems can be seen as inviting particular ways of being. However, externalizing conversations also allow space for clients to consider whether they might want to decline such invitations. Questions can be asked that represent irresistible invitations to responsibility. We can promote responsibility by irresistibly inviting it rather than by demanding it. (p.179). With blame and shame for a problem's existence decoupled from the desire to take responsibility for one's actions, the narrative literature maintains that therapeutic space is opened up whereby a person can feel more empowered to create and choose preferred ways of responding to the influence of a problem or constraint.
Tracking the History of a Problem Tracking the history of a problem is also referred to as mapping the problems influence. Typically taking place within the initial session with a client, the process may also proceed throughout the course of the therapy as new experiences come to light. Tracking the problem's history is often seen as a two-step process that lays the foundation for the discovery of unique outcomes and the co-construction of alternative life stories for the client. Once a problem is named and separated (i.e. externalized) from the person, a narrative therapist may ask questions that inquire into the history of the identified problem. This history can include stories from the distant past, the last few months, or just a few hours prior. The goal is to establish a baseline for understanding the historical influence of the problem over the person's life (Morgan, 2000). It is important to maintain an externalizing stance when tracking the history of the problem. The nature of questions is such that the problem(s) remain separate from the person consulting the therapist. In addition, the conversation may use the identifying term for the problem (such as Self-Doubt or Imposed Silence). This way, the interaction between the person and the problem is more clearly visible. Such questions might include: When did you first notice the problem entering your life? At what point in the last year was the problem the strongest in your life? When the problem is influencing you, what are its requirements for how you should act or think? When tracking the history of the problem in someone's life, people often assume the problem maintains a static effect over time. Michael White developed the use of relative influence questions for assisting persons in externalizing the problem and tracking the history of the problem (White, 1986a). He often uses such questions during an initial interview to immediately engage the person in the activity of separating their lives and relationships from the problem(s). An example of how relative influence questions operate is when a therapist asks a client to think about their life over the past year in terms of a percentage. The therapist may then ask: "Over the past year, what percentage of the time was negative thinking in charge of your life, and what percentage were you in charge?" Such questioning may inquire about last month, last week, or maybe just before the client entered the therapist's office &endash; basically anytime during the past. The intent is to get the client thinking about the times and the degree to which the problem was in control of the person, as well as those times when the problem's influence on the person's life was relatively weaker. When tracking the history of problems, White (1986a) posits that it is important to break relative influence questions into two modes of inquiry. The first type encourages people to map the influence of the problem in their lives and relationships. These questions aid people in identifying the problem's sphere of influence across various interfaces&endash; their behaviors, emotions, beliefs, attitudes, etc. When the problem's influence is understood across multiple interfaces in one's life, greater opportunities become available for discovering unique outcomes where the problem's influence may be weak. These newly discovered areas can represent the framework for affirmative action and an increased sense of personal agency (White & Epston, 1990). Once the influence of the problem has been identified, the stage is then set for the next mode of questioning - inviting invites clients to map their own influence in the life of the problem. These questions often bring forth information that challenges the prevailing problem-saturated story and assists people in discovering competences and skills that heretofore had been neglected under the duress of the problem. An example of this might be a discussion in which a person recalls an incident(s) where she overcame her "public speaking fear" and was able to stand up in class and present. Questions might be asked such as; What quality was it that forced the "speaking fear" to take a back seat and put you in charge of what you wanted to do? Why was it important for you to not let the "speaking fear" take charge during this particular incident(s)? Tracking the problem in a two-staged process affords the benefit of gathering a solid history about the problem as well as searching for clues to a person's non-static relationship with and influence over the problem. The effect of these two modes of questioning is to encourage a person to move… out of a fixed and static world, a world of problems that are intrinsic to persons and relationships, and into a world of experience, a world of flux. In this world, persons find new possibilities for affirmative action, new opportunities to act flexibly (White & Epston, 1990, p. 42). The new information that may come from the above-described discussion often results in the discovery of "unique outcomes" &endash; neglected moments where a person was in control of the problem or contexts where the problem was not present. These unique outcomes can then be used to piece together alternative stories that are less problem-saturated and represent new opportunities in people's lives.
Deconstructing Sociocultural and Political Effects/Assumptions Earlier in this chapter, it was discussed how the narrative stance implicates cultural and historical influences in contributing to problems and constraints affecting people's lives. By giving consideration to those cultural and political forces involved in shaping our identity, awareness can be gained about how life stories are shaped by broader cultural stories/traditions. As a consequence, new understandings of life that are influenced less by self-blame and internalized weaknesses can be constructed. A significant component of externalizing conversations is that considerations beyond the individual can be taken into account. People's relationships with problems tend to be shaped by history and culture. Externalizing conversations can explore the broader implications of how gender, race, culture, sexuality, class, and other relations of power have influenced the construction of a problem(s) (Carey & Russell, 2002). In this context, externalizing allows for a deconstructive process that challenges those beliefs and ideas that maintain problems and are often viewed as taken-for-granted "truths" or cultural "common sense" knowledge. White (1995) states, "I believe that, although internalizing conversations obscure the politics of experience, externalizing conversations emphasize the politics of experience" (p. 24). From a narrative stance, clients are invited to engage the therapist in conversations that unpack these stories and see them from different perspectives, so that the manner in which they have been constructed may be apparent (Freedman & Combs, 1996). Attention is always paid to the context in which stories exist (particularly problem-dominated stories) and the ideas and beliefs that help maintain their influence. Exposing the politics of how identity is formed, externalizing conversations are viewed as providing clients a language in which to protest the influence of broader cultural discourses. Carey and Russell (2004) and Madsen (1999) further this idea through their discussion of how externalized language is utilized in the narrative practice of re-authoring conversations. These conversations involve the co-construction (i.e. between therapist and client) of preferred narratives that assist in addressing those constraints that brought the client to seek counseling. An externalizing stance is maintained as the preferred story is re-authored. What do such questions look like? The conversations and particularly the deconstructive-inspired questions asked by narrative therapists have a distinct flavor. They are geared to assist the client in exposing the underlying cultural and political assumptions supporting dominant ways of thinking. The therapist listens for, and seeks to inquire about the assumptions that are suspected of serving the interests of the problem. Morgan (2000) offers some questions a narrative therapist might ponder and ask a client, including:
Thinking about and asking these questions set the stage for a deconstructing conversation about the effects and assumptions of culture and politics in the life of the problem. In addition, the externalizing stance is claimed to afford the client increased flexibility for experiencing new possibilities for acting in relation to the problem.
Creating Space to Consider Possible Alternatives Creating space via externalizing practices is one of the most universal therapeutic effects written about in the narrative-based literature (White & Epston, 1990; White, 1995; Freedman & Combs, 1996; Madsen, 1999; Maisel, Epston, & Borden, 2004). Moreover, the sense that an opening is created between a person and his problems is often one of the initial effects first noticed when engaged in externalizing conversations. The idea behind the concept of creating space is that clients can gain room for the consideration of alternative stories and/or action (Morgan, 2000). Negative identities tend to have a fixed, unremitting quality to them &endash; often leaving people little breathing space to view alternative stories and new courses of action. In such circumstances, externalizing conversations are used to help create space for the client to "experience an identity that is distinct or separate from the problem" (White, 1995, p. 23), as well as consider alternatives to the problem story. Interestingly, when confronted by externalized questions, it often becomes evident that negative identity conclusions are only "thinly" developed (White, 1995, 2004). The social and cultural stories that perpetuate their troublesome existence often escape direct challenge. Externalizing conversations allow for the unpacking of these thin identity conclusions (White, 2004). In fact, White (2004) comments, I believe that one of the primary achievements of externalizing conversations is this unpacking of the thin conclusions that people have about their own and about each other's identity. In this activity, these conclusions are deprived of the truth status that has been assigned them &endash; these conclusions cease to carry the authority that they did (p. 124). A working assumption in much of the narrative-inspired literature is that people typically embrace this process and find it therapeutic by allowing them the space to think and act in more preferred ways. According to White, "In follow-up sessions, when we have discussed with persons their experience of the externalizing of the problem, many have remarked that it had the effect of 'freeing' them to act independently of the problem" (White & Epston, 1990. p. 66). The literature also suggests that a common response to externalizing conversations has been a sense of relief &endash; relief that a person is not the problem and that there are ways of getting more in touch with other, less problem-dominated narratives that speak about who he/she is (Carey & Russell, 2002). The creation of therapeutic room to think and act contributes to shedding light on other aspects of a person's life that the problem(s) had been historically obscuring.
Allowing for the Creation of Alternative Stories Conventionally, experience is thought of as simply what happens, and people store experiences as they happen and retrieve them through memory. The narrative process, on the other hand, is informed by the notion that experience is colored and shaped by the meaning people assign to each experience and that it is attended to (or not) as it seems relevant to the stories people are living. As such, when narrative questions are asked, the assumption is not that people can retrieve particular experiences with particular predetermined meanings. Rather, narrative questions allow the therapist to co-author experience with the client. Narrative questions do place a "spin" on a client's experiences - beginnings and endings of experiences are suggested or highlighted, and portions of experiences are expanded upon in great detail while other segments are given shorter shrift (Freedman & Combs, 1996). The intended goal is that listening with an externalizing attitude has a powerful deconstructive effect. From the therapist's perspective, such a stance biases the therapist to interact differently with people than she would if she saw them as in possession of intrinsic characterological problems. An externalizing stance creates a different "receiving context" for the client's stories, one in which the therapist can work with problems without viewing the client as pathological (Freedman & Combs, 1996). When one is working with alternative stories of people's lives, if a client mentions a particular character trait as if it is inherent to them (e.g. It's my determination that helped me get the job.), this then becomes an opportunity to invite the person into an externalizing conversation that can lead to a thicker, more developed description of this trait. Unpacking the trait of determination can aid in learning about its history and how it is linked to helpful personal skills and knowledges (Carey & Russell, 2002). This unpacking can lead to further development of other preferred qualities, as well as enriching preferred stories in a person's life.
Building Personal Agency over Preferred Qualities The narrative literature asserts that externalizing conversations don't simply focus on de-labeling people and their problem(s). Such conversations also take place with regards to preferred qualities as well (such as competence or determination). However, just as competence is a cultural creation (from a poststructuralist perspective), it is possible for the narrative therapist to ask questions about how this quality came to exist, its effects, what it says about the person, what other personal qualities it is linked to, and where it is most and least prominent in the person's life. This process can make qualities such as competence more meaningful and relevant in a person's life (Carey &Russell, 2002). In addition, once a problem and its specific components have been externalized, clients can be invited to notice opportunities to take action against the externalized problem (Tomm, 1989). In an early paper by Michael White, he addressed the problem of schizophrenia with a client, asking the following narrative-inspired questions designed to internalize personal agency (White, 1987): If it was possible to do so, would you like to limit the influence that schizophrenia has been on your life?... Can you see how schizophrenia has been coaching you into withdrawing and avoiding people?... How did you manage to defy schizophrenia's instructions to avoid people and come to this meeting today?... What do you imagine this might tell you about your ability that you might not otherwise have noticed?... In what other ways have you stood up for yourself and not let schizophrenia push you around?... How ready are you to take a further step against the withdrawal habit that has such a grip on you?... Would you prefer to be a weak person with a strong habit or a strong person with a weak habit?... When you submit to schizophrenia's efforts to push you into an unreasonable position, how does this invite your parents to do all the reasoning for you? (p. 19) Such a line of questioning is a dramatic departure from what might be considered more traditional ways of working with a schizophrenic client. The client is being challenged to think about his own relationship with schizophrenia &endash; as if the disorder was something distinct or external to him. The aforementioned questions are designed to be reflexive &endash; meaning they allow the listener to ponder her/his role in the meaning of the question. From a narrative stance, a therapeutic assumption is that the very nature of these questions infuses the notion that the client indeed has choices, and that the client is an active agent in the course of her own life &endash; even when facing challenges such as those involving schizophrenia (Tomm, 1989). When questions strike a meaningful chord with a client, the questions' implied notion of individual choice is internalized as part of the patient's evolving identity. This can also constitute a new and powerful experience which can be used as part of a burgeoning alternative story. Such therapeutic conversations are designed to foster personal empowerment and lead to a heightened sense of personal agency. In their article on exploring externalizing practices with families that have difficulty internalizing their own competencies, Kahle and Robbins (1998) illustrate how externalizing the success a family experiences can be useful in inviting the family to internalize their own competencies. They view the externalization of family successes as an additional use for externalized conversations &endash; one less discussed in narrative literature. Whereas the process of externalizing the problem involves making the problem a separate entity from the client in order to depersonalize the problem, Kahle and Robbins (1998) suggest that, Externalizing the success is an associated concept that is employed in order to counter another type of depersonalizing. Some families are not willing or able to take responsibility for victories over the problem. When asked questions designed to elicit the meaning that they have made about these victories, some families respond by providing explanations that negate their own involvement in these unique outcomes. In other words, the reasons the family provides for these unique outcomes are often externalized and, thus, depersonalized (p. 63). Externalizing successes is seen as a supplement that can be useful to assist clients in the process of internalizing personal agency. It is not meant as a replacement for externalizing problems (Kahle and Robbins, 1998). Externalizing successes is illustrated in the following example: A family consulting a narrative therapist about their problematic relationships with one another engages in externalizing conversations about the effects of anger and disapproval in their lives. As the effects of these problems are mapped out, the family discovers that there have been times when the problems have not been present or their influence has been minimized. In discussing why the problems are absent or reduced at certain times, the family may be reluctant or unable to articulate qualities within themselves that have assisted in overcoming the problems' influence &endash; instead attributing these unique events to chance or external events such as "It was a sunny day and we all felt happy". At this point the therapist may believe the family members have depersonalized their victories over the problems. In response, the therapist might invite family members to entertain ideas of personal agency via a new externalizing conversation &endash; one focusing on the qualities that led to the victory. Questions might be asked that get the family to ponder their behavior when the problems were absent &endash; e.g. "Johnny, what did you notice about how you were feeling when the anger had less of a grip on you?" Johnny may respond, "I think I was being patient with my sister instead of reminding her of all the mistakes she usually makes." If other family members agree on the role of patience in stemming the anger and disapproval, the therapist may chose to externalize the successful concept of patience in further discussions with the family. The therapist may ask, "What is happening when you are being patient? Where did this idea of patience come from?" and so on. The intention is to invite the family into externalizing conversations about the role and effects of the desired quality of patience so as to assist family members in the process of internalizing personal agency over the problems of anger and disapproval.
Not Assigning Causation to Problems Externalizing conversations are typically thought of as benefiting the client. For instance, externalizing practices create a forum where people can become less identified with their problems or constraints, and alternative stories are allowed to take shape (Freedman & Combs, 1996; Madsen, 1999). Yet, externalizing practices also provide a unique perspective on problems and opportunity for the therapist as well. Amundson, Webber, and Stewart (2000) point out that, Externalization "passes over" having to ask a problem from where it comes, avoiding the investiture of a problem with too much theory or falling into the danger of "believing leading to seeing." To speak of the problem as a thing in itself permits us the most powerful ethical position we [therapists] can assume: to not inadvertently cooperate with any definition of the Other, no matter what the psychological, sociological, or political correctness offered by a particular symptom or theoretical system happens to be (p.27). The practice of psychology often lends itself to theorizing about the origins of clients' problems &endash; with or without their consent or agreement. For instance, systems theory may find causation within the family system &endash; whereby the problem or symptom needs to exist in order to maintain the family homeostasis. In psychoanalysis, problem formulation is an essential part of the work. The problem may be interpreted as a symptom of an underlying characterological pathology that has its origins in repressed childhood experiences. However, externalizing conversations afford the narrative therapist a unique opportunity, "of not having to choose, not having to impose any single rendition, whether parent conflict, attention seeking, structural analysis, or psychological diagnosis" (Amundson, Webber, & Stewart, 2000, p.27). Externalizing practices allow for a non-deciding stance on the part of the therapist. They can also disarm internalizing discourses that seek blame for the problem's existence (Morgan, 2000). Meanwhile the vigor of the therapy is maintained by turning over to the client (typically through the use of narrative-inspired questions) the important task of making sense of the problem, bringing it to life, detailing its history, and eventually tailoring appropriate measures for responding to the problem or constraint. Externalizing allows for "theoretical pluralism" in regards to a problem's possible origins and permits the therapist to be a "theoretical conscientious objector" (Amundson, Webber, & Stewart, 2000). In this way, the practice situates the therapist in a position that honors the poststructuralist perspective espoused by narrative therapy - whereby the myriad forces that shape the meanings we bestow our lives can be accounted for.
Making Deadly Issues More Discussable Problems often have a grim and oppressive quality to them. By the time a person or family has reached the point of seeking consultation, they may be immobilized in the face of the problem. The problem(s) may feel like the dominant force in their lives. From a narrative perspective, the therapist wishes to respect the seriousness of the problem, yet the oppression and the immobilization it tries to foster are forces that are sometimes best to counter. A narrative perspective often seeks to counter the oppressive nature of problems by employing externalizing practices in a way that reduces the deadly effect of the problem, thus reducing the grip it has on an individual or family and allowing for space to be created whereby changes can be made. This may mean using play, humor, irony, lightheartedness, etc. in the discussion of the problem or constraint. Particularly in the narrative-based literature on working with families (e.g. Freedman, Epston, & Lobovits , 1997; Selekman, 1997; Nylund, 2000) practitioners discuss the importance of playfulness and creativity in facing serious problems. Making deadly issues more discussable often surfaces with families due the presence of children in the family and their unique developmental stages and family roles. In fact, White (2000) notes that it was with children that he first began exploring the possibilities of externalizing conversations. Based on his sense of success with children, he expanded the practice to his work with adolescents and adults. Reflecting on children's ability to engage in externalizing processes, White (2000) was struck by…their sheer delight in entering these more imaginative ways of speaking about what were so often considered to be deadly serious problems; and their joy in stepping into these conversations in ways that defied many a prediction about their continuing inability or powerlessness to address this predicament or that (p. 5). Provided an opportunity, many children prefer to interact in a playful manner (Freeman, Epston, & Lobovits, 1997). Engaging children in a dialogue-saturated methodical and problem-solving manner often results in a child's disengagement from the therapeutic process. Freeman, Epston, & Lobovits (1997) address the need for playfulness and creativity when tackling deadly issues with families in the following way: The price of choosing seriousness for us as therapists may be the dampening of our own resources, such as the ability to think laterally, remain curious, be lighthearted enough to engage playfully with a child, and have faith that the situation is resolvable. Lacking these, we may have our wits dulled, lose our appeal to kids, or become overwhelmed. Do we dare to be playfully creative in the face of worrisome problems? What happens when we engage our imagination, humor, and resourcefulness in opposition to the deadly seriousness of problems? We believe this leads to the rise of inspired problem-solving and the downfall of serious problems (p. 3). Too serious an approach on the part of the therapist may work to the advantage of the problem, particularly if the risk is of excluding or alienating the children of families who are seeking assistance. Freedman, Epston, & Lobovits (1997, p. 4) further suggest that, "When children and adults meet, play provides a common language to express the breadth and depth of thoughts, emotions, and experience &endash; in this way, we share a lingua franca." While there are many approaches to making deadly issues more discussable, the use of externalizing conversations is widely discussed in the literature as a vehicle for making problems less serious, lighthearted, more discussable, and ultimately defeatable. As White (1989/1997, p. 6) has observed, externalizing conversations, "frees persons to take a lighter, more effective and less stressed approach to deadly serious problems." The literature also discusses creative non-verbal methods of externalizing that involve tasks such as art and family activities. For example, Selekman (1997) points out that, Having the child go to combat with his or her family against the problem in the form of a family ritual or externalize the presenting problem in the form of a drawing on paper taps into the child's spirit of fun, which helps lead his or her family in the direction of change (p. 119). Again, it is at the intersection of playfulness and creativity that the entire family can join together and constructively address the constraints they face. Moreover, such externalizing practices act to lift the weight of shame and blame off of both children and adults in a family.
Acting as an Oppositional or Anti-Language The narrative stance is one that is situated in a social constructionist framework &endash; i.e. that our sense of what is "real" in the world and who we are (as individuals and as a society), is constructed by the language we use and the stories made possible through the use of this language. An impetus of narrative therapy is to call into question (i.e. deconstruct) not only dominant stories we might subscribe to, but also the dominant forms of discourse used to construct these stories as well (White & Epston, 1990; White, 1995; Freedman & Combs, 1996; Maisel, Epston, Borden, 2004). If externalizing conversations are a workhorse of narrative therapy, one of their most powerful utilities is the manner in which they operate as an oppositional language to dominant discourses (White & Epston, 1990; White, 1995; Freedman & Combs, 1996). White (1995) remarks that a key point about externalizing conversations is how they introduce novel ways of thinking and speaking about a given problem, as well as alternative ways of acting in relation to the problem or constraint. He goes on to suggest that, "In promoting these externalizing conversations, we are engaged in an activity that is not entirely a pro-cultural activity (White, 1995, p. 42). This activity challenges the taken-for-granted cultural-bound ways of speaking about people's lives and relationships. Epston (2005) eloquently adds to this theme by succinctly proposing; As an anti-language its purpose is to make trouble for particular meanings, which have been disguised as universal, masqueraded as timeless, or taken on the guise of "nature" or naturalness. Another purpose is to challenge the guarantee of any structure of meaning &endash; language, code, dialect &endash; as being decisive and definitive (Epston private notes, 2005). Externalizing conversations are a method for exposing that which is often hidden and presupposed in the taken-for-granted dominant language/discourse intertwined with our culture (White, 1995). The anti-language collides with the dominant language, exposing the hidden meanings, presenting a client with unmistakable juxtapositions by which to view the dominant language that has heretofore immersed their worldview. Externalizing conversations have been envisioned as a way to "exoticize the domestic" by inviting people to identify and unpack the cultural knowledges they live by (White, 1993, p.39). The practices associated with externalizing problems are considered therapeutic counter-practices to the dominant culture. They engage people in a process with the intention of de-objectifying themselves and each other, and make room for the possibility for alternative life choices. As Pare and Lysack (2004) point out, "Externalizing talk is one example of the deliberate use of language as a "tool" or scaffold by which we [i.e. therapists] are acting into the conversation with the intention of inviting a person to entertain new possibilities." The anti and the dominant discourses generate "colliding worldviews", each fraught with its own implications, both contesting for the speaker's adherence (Epston, 2005). From the clients' perspective, what is presumed to arise from such a collision is a unique therapeutic opportunity to understand problems, realize that options exist, mount counterstrategies against said problems, and create new linguistic tools for constructing alternative meanings and stories. Through engaging in an anti-dominant language discourse, people are more prepared to separate from and objectify the problem(s) and devise an anti-problem stance. This anti-problem stance is often overt and combative in the way it speaks against and opposes the dominate language, particularly when dealing with deadly problems such as anorexia/bulimia, alcoholism, domestic violence, etc. When discussing the oppositional language, Maisel, Epston, & Borden (2004) stress that, The main purpose of anti-a/b [anorexia/bulimia] language is the rolling back of the power of a/b, the re-voicing of the person, and the recreating of her world. Through this anti-a/b language, the person returns to the position of a critic of a/b and an advocate for herself and others who have been subjected to the abuses of a/b's power (p.84). But in confronting the condemning and marginalizing discourse of the problem's dominant language, externalizing conversations can have a surprising tone as they inquire in ways that seek to counter the effects of the problem discourse. As a practical example of externalizing conversations as an anti-language tool, consider Maisel's comments on the ways in which challenging the rhetoric of anorexia/bulimia requires an anti-language: If a/b [anorexia/bulimia] speaks with arrogant authority, then Anti-anorexia speaks with humility, raising questions rather than issuing pronouncements. If a/b evaluates and degrades the person then an Anti-a/b language allows for the appreciation of the person and the critical scrutinizing of a/b. If a/b inscribes itself into the identity of the person, then Anti-a/b will expel anorexia from that identity and locate it in social and political contexts (Maisel, personal communication, May 24, 2005). Lastly, while the anti-language must continually be constructed, it provides a "structure of resistance" that stands in opposition to the dominant structure (Epston, 2005). Condemnations and dead ends offered by the dominant discourse can be provided new, richer life-enhancing forms of expressions.
Researching the Narrative Therapy Approach Art and science are not enemies. The painter operates within the bounds of physical laws &endash; blue and yellow make green; when two objects occur in close juxtaposition, they appear related, and so on. The effective artist works within these laws to apply novel contexts and interpretations. In the same way, the effective [evidence based] therapist is more than a technician who applies sterile technologies to solve problems (Beutler, Bongar, & Shurkin, 1998, p. 75). The above quote is an artful and in some ways hopeful interpretation of the relationship between practitioner and researching communities in psychology. But in practice, sometimes the rules of painting don't adequately apply. This section seeks to explore the various ways and degree to which narrative therapy has been researched, with particular emphasis on externalizing practices when applicable. The results have implications on the manner in which the use of externalizing is understood, as well as wider inferences about the future relations between narrative and research practices. Overall, compared to other therapy approaches, narrative therapy has been receiving only modest attention in the research. Research focusing extensively on externalizing practices is even slimmer, with many of the relevant studies either giving externalizing only a basic discussion or evaluating its usefulness in conjunction with other forms of treatment such as group therapy, psychoeducation, etc. Evidence of the usefulness of externalizing is mixed. Some studies suggest clients find it much less important than other identified aspects of therapy, while other research implies that it has notably useful and distinct effects that warrant further investigation.
Establishing a Narrative Perspective on Research The narrative tradition emphasizes a distinct set of values for both research and practice. A review of the literature reveals that a pivotal source of concern among narrative-inspired therapists has to do with how "traditional" research practices privilege professionals' interpretations and understanding over those of clients (White, 1995; Epston, 2001; Gaddis, 2004). Therapeutic ideas and practices have historically been influenced and constructed primarily by professionals in the field; whereas those subject to this expanding therapy knowledge historically have had little voice over what has been helpful or hurtful (Gaddis, 2004). The narrative worldview actively takes a stand against this precedent. Gaddis (2004, p.38) stresses that his perception of a narrative worldview assumes that "clients do not make sense of therapy in the same way that I do." Consequently, he situates his narrative stance in a way that never assumes he as a therapist knows what is most helpful for clients. Clients must be intimately involved in their own therapeutic construction (Gaddis, 2004). The intimate involvement of both client and therapist has widely been referred to as co-research within the narrative community (for example, White, 1995; Epston, 2001; Maisel, Epston, & Borden, 2004). This mode of working has an emerging tradition within the narrative community as both a research methodology and a therapeutically minded way of conducting therapy consultations.
Impact of the "Interpretive Turn." The narrative therapy tradition ushered in by practitioners such as White and Epston was heavily influenced by developments in the field of cultural anthropology. For instance, in the 1970s and 80s a dramatic development known as the "Interpretive Turn" took shape in the field of cultural anthropology, which had subsequent repercussions in the development of social work and therapy (Denborough, 2004). According to Denborough (2004), this movement was associated with cultural anthropologists Clifford Geertz (1983), Renato Rosaldo (1992), Edward Bruner (1986), Victor Turner (1986), and Barbara Meyerhoff (1982), among others. Questioning what had widely been accepted practice in anthropology, these authors proposed that it was impossible for anyone to have an objective view in their research. They showed how anthropologists subjectively shape their research and in turn influence the communities they seek to study (Denborough, 2004). They called into question the presumed objectivity of the anthropologist, and stressed that their field must acknowledge how their own cultural beliefs, practices, ethnicity, etc. influence their research. In response to the embedded interpretative nature of their work, these authors proposed an alternative form of research, a form of ethno-methodology that privileged the meanings and interpretations of the people being studied (Denborough, 2004). This ethnographic methodology called for inviting people of various cultures and groups to interpret and document their own lives and culture. Thus, the "subjects" were to become active research partners, and lend accountability to the research (Denborough, 2004). The narrative therapy concept of co-research has its origins in the Interpretive Turn movement. Co-research is discussed further in a subsequent section.
Reconciling research with narrative values. Earlier in this study, it was discussed how narrative therapy's poststructuralist and social constructionist ideas seek to uncover taken-for-granted assumptions and respect how knowledge is subjectively constructed. This is in direct contrast to the positivist, scientific method that seeks to discover knowledge that is independent of socio-cultural and historical context. It is from this positivist tradition that psychological research has its roots. As mentioned earlier, the narrative worldview is one grounded in the idea that reality and truth are subjectively created constructs, not universal truths to be "discovered." Observing the relative lack of research and empirical studies supporting narrative therapy, Etchison and Kleist (2000) note that this circumstance may be due to what they see as the constructivist orientation of narrative therapy, which is inconsistent with quantitative research methods . Research objectivity, which is adamantly denied by the constructivist perspective, remains a cornerstone of quantitative empiricism. Etchison and Kleist (2000, p.65) suggest that, Constructivist approaches to researching therapy emphasize a qualitative understanding of one's meaning given to experience (Nelson & Poulin, 1997) in context, without imposing the requirement of researcher objectivity. Participants and researchers in qualitative inquiry are regarded as coresearchers (Gale, 1993) who together explore the meaning of experience. Constructivist-based research places importance on the interaction between participants and researcher as a necessary component for quality data gathering and analysis (Merchant, 1997). Gaddis (2004) discusses both his passion for narrative therapy and his interest in formulating a method of research that is both faithful to the narrative worldview and useful for advancing professional therapy knowledges. He presents two qualitative research methods that he believes are in some ways concordant with narrative principles: interpersonal process recall interviews (Elliot, 1986) and grounded theory analysis (Strauss & Corbin, 1990). He employed these methodologies in an earlier study of clients' experiences of narrative therapy (Gaddis, 2002). Interpersonal process recall is a unique type of interview method that uses audio or videotapes to stimulate recollections of past experiences (Gaddis, 2004). Participants watch tapes of past events (i.e. therapy sessions) and describe the experience they recalled during those events. Gaddis (2004) stresses the importance of "de-centering" the researcher's role in collecting this information. An important feature is to allow the client to reflect freely on their experience, without the researcher guiding or overly-interpreting their responses. Grounded theory is a methodology that attempts to develop theories that are grounded in the research participants' own experiences. The role of the researcher is to reflect on the participants' experiences in a manner that allows these experiences to be organized and categorized. The goal is to develop a coherent body of knowledge or theory that is derived from participant descriptions (Gaddis, 2004). Gaddis found this methodology useful for smaller studies, but ultimately argues that grounded theory risks emphasizing the researcher's construction of meaning over that of the client. Muntigl (2004) is also interested in examining narrative therapy, specifically how it facilitates client change. He demonstrates how a linguistic-semiotic analysis of narrative therapy is useful in exposing how the therapist uses narrative practices to assist a client in scaffolding alternative meanings for acting in the world. However, unlike the collaborative approach between researcher and participant that Gaddis (2004) seeks, the approach outlined by Muntigl (2004) focuses on third party observation and analysis of the discourse between therapist and client. Couture and Sutherland (2004) propose that the methodology of discourse analysis is compatible with postmodern therapies. They see it as interactive between therapist and client, with a focus on the construction of meaning in conversations. Discourse analysis "investigates the specifics of interaction between therapists and clients with the goal of identifying moments or events of change in these interactions" (p.12). Whereas Gaddis (2004) appears to be more of a practitioner seeking a research method that fits his view of narrative sensibilities, Couture and Sutherland (2004) appear to take the reverse approach &endash; a research-oriented effort to address the unique sensibilities of postmodern therapy. These two sides may illustrate how some circles of practitioners and researchers are attempting to bridge the gap between the two camps in a way that benefits the lager mental health community. Overall, while some researchers and practitioners appear to be seeking methodologies for researching narrative therapy, the volume of constructionist-focused qualitative research is modest compared with the much larger thrust of empirically-based research. Etchison and Kleist (2000) also note that only a minority of those seeking training in research methodologies and employed by major psychological journals are experienced in qualitative research methodologies. Consequently, there exists a gap of experience and occasional controversy over what types of research are deemed acceptable within given psychological communities. Michael White (1995) illustrated the perceived divergence between his role as a narrative-inspired practitioner and more formal research methodology in the following manner: Those people who are practicing therapy, along with persons who seek therapy, are primary or basic researchers, and those people who collect data in a more formal way are the secondary or supportive researchers. I've always been interested in primary research, and find the continual demand from secondary researchers that primary researchers justify their existence to be quite tedious. If the secondary researchers in our field could go further in relinquishing the moral high ground… which would include the rendering transparent of the socially-constructed nature of their enterprise &endash; then what secondary researchers do might become more relevant to what primary researchers do. I am sure they could have a very enriching collaboration (cited from Gaddis, 2004, p.47). As discussed in more detail later in this study, there is a growing body of qualitative research designed to evaluate the effects of narrative therapy practices with various populations. These studies appear to be conducted by people who have a basic understanding and respect for the narrative therapy approach. However, they may not operate as passionately within what may be termed the narrative worldview as other narrative-inspired practitioners in the field. Their aspirations may be more research-focused and less political and social. Those conducting the research do appear distinct from those writer/practitioners that are largely responsible for the accumulating body of theoretical and ideological literature that continues to outline the principles of narrative therapy. The impact of narrative's political and social sensibilities upon its accommodation with research is also explored in further detail in a later section. It remains unclear the degree of acceptance the limited body of qualitative research has among those practitioners that have deep-rooted loyalty to key narrative principles such as the constructionist nature of research, locus of power away from the therapist/researcher, etc. In the quote above, White alludes to a promising collaboration between "primary" and "secondary" researchers. The degree to which each side has reached out to each other has historically been limited. Yet, the evidence cited earlier and in later sections suggests that the effort is gaining momentum. It is important to note that the defined purview for this study is not intended to fully explore the context of the relationship between narrative therapy and research methodology. But, some mention of it is helpful as it applies to understanding the practice of externalizing and the opportunities for researching its effects. A concluding section in this study will evaluate the degree to which the written-about claims of usefulness for externalizing practices are supported by some manner of organized research.
The effects of political and social views about therapy. At this point it is useful to add a point of qualification onto the conclusions drawn by Etchison and Kleist (2000). These authors focus primarily on the manner in which the constructivist values of narrative therapy create trouble for its integration with various research practices. There is another factor at play that may also be an obstruction &endash; namely, narrative therapy's valuing of the social and political effects of its own practice. The effect of this concern can be illustrated by contrasting narrative therapy with solution-focused therapy. While narrative therapy has had a volatile relationship with research interest and practices, solution-focused therapy has a history of actively embracing various types of qualitative outcome research and actively uses this research to promote the use of solution-focused and brief therapy practices (Miller, Hubble, Duncan, 1996). Similarly, Maione and Chenail (1999) discuss that, "although there have been few qualitative studies that investigate specific therapy models, the solution focused model has been the subject of several studies" (p. 68). Solution-focused and narrative therapies share similar postmodern and poststructuralist assumptions about our sense of reality, the social constructionist nature of truth, and the primacy of the client's involvement in identifying problems and their possible solutions (see de Shazer, 1988, 1993; Miller, Hubble, Duncan, 1996). However, solution-focused therapy appears to put less emphasis on the political and social effects of its practices, whereas loyal adherents to narrative therapy often pay close attention to the injustices and marginalizing qualities of social and political contexts (see Gaddis, 2004; Redstone, 2004). Narrative therapy rejects those culturally accepted research practices that are seen as supporting taken-for-granted cultural norms and that disregard marginalized accounts of ways of living. As such, narrative therapy reaches a philosophical impasse with research that solution-focused therapy may largely avoid.
Influence of Narrative-Inspired Co-Research I have always thought of myself as doing research, but on problems and the relationships that people have with problems, rather than on the people themselves. The structuring of narrative questions and interviews allow me and others to co-research problems and the alternative knowledges that are developed to address them (p.178). The above quote is how Epston (2001) described his interest in co-research. In fact, narrative-inspired co-research has been part of narrative practice since its popular inception (see White& Epston, 1990). Moreover, Freedman and Combs (1996) convey that, "In a very real sense, all narrative therapy is co-research. When we listen carefully to people's stories we are doing research. When we ask meaning questions and preference questions we are asking people to join us in research" (p.287). Epston (2004) has noted that he arrived at the term co-research around 1988-89 when he was working with family members afflicted with a rare skin disorder. He has been prolific in the area ever since &endash; for instance, creating the Internet-based Archive of Resistance: Anti-anorexia/Anti-bulimia website (www.narrativeapproaches.com), and coauthoring a book exploring the use of co-research in assisting people in overcoming anorexia/bulimia (see Maisel, Epston, & Borden, 2004). Indeed, co-research has become a therapeutic methodology to address anti-anorexic/bulimic practices (Epston, 2004). The formal manner in which therapists consult with people about the effects of particular practices on particular problems (Freedman & Combs, 1996) may help to differentiate the look and feel of a co-research project. Another project involving co-research that is more in its beginning phase is the league of deconstructing addiction getting underway at the Dulwich Centre in Adeline, Australia (the website is http://www.dulwichcentre.com.au). Co-research is a highly collaborative effort between client and therapist to come to unique terms with a problem(s) faced by the client. What results is a "co-production of knowledge" between the therapist and client (Epston, 2004). This effort typically serves three major purposes. First, co-research assists people in discovering ways of identifying and managing problems, and constructing alternative stories in a fashion unique to each person. Secondly, the project involves documenting (with the person's permission) the unique journey undergone in naming, addressing, managing, and overcoming the problem. This often takes the form of letters, documents, and posts on the Internet similar to Blogs that constitute what are called "insider knowledges." Consultations can also take place between people who have experienced a success over a particular problem and those that are still struggling with a similar problem. Third, a co-research project often asks the client to intimately describe what was helpful and unhelpful in the therapeutic process. This information not only benefits the therapist and the wider narrative community, but also serves to level the power hierarchy between therapist and client; which possesses a therapeutic component in itself for the person being consulted. In describing part of the process, Epston (2004) reveals the following: When I first started meeting with these families we engaged in fairly thoroughgoing externalising conversations, in which the problem was a problem for everyone &endash; and here I include myself. These conversations led to the co-production of certain knowledges about the problem, and ways of responding to it, that were of pragmatic value to the families (p.31). Indeed, the work by Maisel, Epston, & Borden (2004) is an exemplar of the type of co-research currently being conducted within the narrative community. The process outlined by the authors intimately involves clients in constructing their own experience with the issue of anorexia/bulimia and assists them in furnishing personal accounts of protest against the influence of anorexia/bulimia. This documented work (combining client and therapist accounts) also provides other narrative-inspired therapists with professional knowledges that were derived by client's own accounts of what was helpful and unhelpful in the course of therapy. Thus, useful and practical knowledge is added to the body of narrative therapy literature in regards to therapeutic work with anorexia/bulimia. The authors' approach also embodies the kind of research that adheres to narrative principles about the locus of power and professional versus insider knowledges. Thus, narrative-inspired practitioners have written about the usefulness of co-research in evaluating what was helpful and unhelpful in the therapeutic conversations themselves. In some ways, this has been a part of narrative practice for some time. During narrative therapy sessions, questions are often asked to ensure that the conversation is being experienced by a client as relevant and helpful. At the completion of therapy, questions are also asked that have clients evaluate particular practices and lines of enquiry implemented by the therapist (Epston & White, 1992; Morgan, 2000). Interestingly, some within the narrative community may be feeling an inclination to incorporate or construct more clear elements of client-focused research methodology into the narrative approach. Recent literature has been published that seems to join the basic ideas of co-research more intimately with how it might better inform, validate, and expand the professional knowledges and practices of narrative therapists (see Denborough, 2004; Gaddis, 2004; Maisel, Epston, & Borden, 2004; Redstone, 2004; Clark et al., 2000). The intention is to further augment the claims made by narrative practitioners with clients' documented reactions about the helpful and unhelpful aspects of their therapy experiences.
Reciprocal connection between therapy practice & research methodology. As mentioned earlier, co-research has been a practice employed for some time, typically as a collaborative therapeutic effort for the benefit of clients struggling with particular issues. More recently, some narrative practitioners have been actively promoting its usefulness as a style of research that is commensurate with narrative principles of therapeutic change, useful in the construction of professional therapy knowledges, and also amenable to qualitative methods of analysis (see Gaddis, 2004; Clark et al., 2000; Madsen, 1999). The narrative practice of co-research has in some ways become a political and philosophical statement amidst the pervasive traditional understanding of psychological research. For instance, Gaddis (2004) concedes that research is important in formulating therapists' ideas, yet he expresses that, one of my greatest concerns has to do with how traditional research practices privilege professions' interpretations and understandings over those of clients. I have attempted to re-consider therapy research so that its main purpose is to honor clients' accounts of therapy. My hope is that this will enable us as therapists to be taught as much by clients as by other professionals (p. 37). Co-research embraces the narrative sensibility of placing therapeutic power in the hands of clients and allowing them to have ownership of how they make sense of and manage their lives. But, the approach outlined by Gaddis cannot help but be political as it actively seeks to hammer out an approach to psychological research that is in many ways distinct from traditional research methodologies, which locate interpretive and prescriptive power in the hands of professionals. If traditionally generated research knowledge seeks an elevated status when it comes to making claims about what is "true" (Gaddis, 2004), than the narrative enterprise of co-research makes an effort to deny that notion or at least to reduce the implicit hierarchies of power and knowledge (Clark, Jankowski, Margee, & Springer, 2000). Clark et al. (2000) note that, "Despite the increase in alternative forms of participatory research, there is still no clear methodology for including participants as co-researchers in the interview analysis and interpretation process" (p.57). In response, the authors propose structuring a form of co-research into a model of qualitative research methodology that utilizes social constructionist ideas as a foundation. Similar in makeup to later efforts by Gaddis (2004), Redstone, (2004), and Maisel, Epston, & Borden (2004), this method of analysis would go beyond more traditional forms of qualitative analysis by involving participants/clients more intimately in the coding and interpretation process of helpful and unhelpful qualities in the therapy experience. Informed by social constructionist theory, this research method brings together the subjective interpretation processes of both researcher and participant and transforms the research process into more of a relationship than a method. Note the following graphs that illustrate the difference between traditional forms of information analysis and validation, and that allowed under the method of co-research (Clark et. al. 2000). In the traditional model, the principle investigator consults with participants about key themes. But, it is only the investigator that uses the text generated by the participants to determine the final makeup of the research codes and themes. Within the co-research method, the roles of "expert" and "subject" become more blurred (Clark et. al. 2000). The subjective inter |