Declaration of Independence: A Narrative Intervention

People have been using documents to mark important events and decisions ever since writing was invented millenia ago. It is said that the ten commandments were documents carved into stone tablets, and carried around by the Israelites as representations of their covenant with God. Similarly, every religious tradition has some form of sacred text. Documents play a pivotal role in human relationships as well, both political and domestic. The Declaration of Independence is a political example, along with innumerable other famous documents (the Declaration of Independence, the Magna Carta, the Bill of Rights, and many others). Domestic examples include marriage licenses, contracts, restraining orders, among other things.

Narrative Therapy draws on this human tendency to create documents signifying important moments, decisions, and changes. Documents serve as a symbol - a visible manifestation to clients and to others - of what clients have achieved, decisions and changes they have made, and preferences they have for their future vis-a-vis the problem(s) that brought them to therapy. The documents used in Narrative Therapy may be modeled after various documents, social, political, religious, or otherwise. Contracts, letters, certificates and diplomas are some common examples. Often the problem, externalized and sometimes personified, is addressed in the document (for example, a letter can be addressed to or from the problem, and contracts may be drawn up between the client and the problem).

An illustration of this kind of intervention that is particularly fitting for today, Independence Day in the U.S., is a Declaration of Independence from the problem. The format I've used is as follows:

Choose an area or issue in your own life from which you would like to declare independence. Write your own Personal Declaration of Independence following the five-part structure of the U.S. Declaration of Independence, develop each as thoroughly and as creatively as you can.

I. Introduction (Preamble)
Why are you writing this document? From what are you declaring independence? What are the conditions causing the desire to separate?

II. Philosophical Foundation
What human rights and privileges support your right to declare your independence?

III. Nature of the Complaint
Describe the actual situation, including three or four specific grievances detailing how your rights have been violated.

IV. Explanation of Previous Actions
Describe what the ideal or tolerable situation would be. Specify what remedy is needed to correct the complaint, and detail what efforts have already been made to address the problem and achieve the ideal or tolerable state.

V. Resolution
State in your own words that all other efforts have failed, and describe what you intend to do now (what this Declaration of Independence means).

Don't forget to sign your document!

Over the "Cliff" - the Power of Language

The latest word out of Washington is that the Congress will not agree on any kind of legislation by tonight's deadline that would avert the spending cuts and tax increases set to take effect tomorrow. There are any number of things I could write about this situation - perhaps about the importance of compromise, the implications for social services, or the class inequality which will mean the poor shoulder a heavier burden. All of these issues are important. However, from a psychological perspective, what has stood out to me throughout conversations on this topic is how the language we use to talk about it influences its emotional impact.

Notice in my first sentence that I referenced "spending cuts and tax increases," rather than the more common phrases that are being used to describe the situation. In contrast, media and politicians speak of the "financial crisis" as "the fiscal cliff." Words like "crisis" and "cliff" imply threat and danger. These words are chosen to incite anxiety among the public, and therefore to further stir up an already tense political climate.

Post-modern schools of practice such as Narrative Therapy, and Acceptance and Commitment Therapy are based on the premise that our perceptions of "reality" are based on language rather than fact. They build on Social Constructionism's stance that all "truths" are constructed through social processes. What all this means is that we use language to construct reality, and the reality we end up with is more a function of the language we choose than "facts."

In therapy, we work with clients to alter their perceptions of reality by changing the way they think about things. We may call it reframing, or cognitive restructuring, or reauthoring, or interpretation, but the desired result is that people will find more flexible and less negative ways of making meaning out of their experiences.

The same process might apply to the so-called fiscal cliff. Because talk of "going over the cliff" calls up a vivid image of...well, falling off a cliff...the natural response is to want to dig in our heels and cling to something for safety. That reaction does not inspire balanced and flexible ways of thinking about our economy!

Unfortunately, "tax increases" and "spending cuts" have also become layered with socially-constructed meaning. These seemingly-neutral descriptions have become rallying cries for partisan politics - the words elicit a negative, defensive response from conservatives and liberals, respectively. Unfortunately, this effect of language has paralyzed our entire political system, preventing any of our politicians from taking a balanced, flexible approach - an important ingredient in any meaningful compromise.

I don't have an answer or solution here. It is more of an observation, and an encouragement to be aware of the impact of language - the language you choose, and the language you hear - and consider whether that language is the only, or most helpful, way of thinking and speaking.

Accepting Responsibility

I run a weekly group based on Narrative Therapy, which begins with "externalizing the problem" as a way to separate the problem from the person who has the problem. In Narrative Therapy parlance, "the person isn't the problem. The problem is the problem." In other words, the problem is not personality, nature, temperament, or other intrinsic qualities, but something removed from the person's identity. Viewing it this way opens up new choices and possibilities for the the person to change his or her relationship with or response to the problem.

I've written before about the objection sometimes raised that externalizing the problem absolves people of the need to take responsibility for their problems. In that post, I presented an argument that the reverse is true - that externalizing the problem is what actually makes it possible to take responsibility for change. I wanted to talk a little more about this topic today, following an interesting interaction in group yesterday.

I asked the group to do a write letters from and to their problem. They all wrote for several minutes. Little did I know that one of them was writing something totally different. When it was her turn to share, she stated that she did not believe in personifying the problem because she had used a similar strategy as an excuse for not working to change it - basically, that she had claimed the problem was its own entity, and she therefore had no control over it. Therefore, she says she wants to avoid taking a similar approach in treatment.

Ok, I can accept that some people have reservations about this approach, and may take some convincing before they are able to try it (and, by trying it, experience how it is actually empowering). However, what she chose to write instead of the group activity seemed (to me, at least) even more likely to become a way to avoid responsibility for change: she wrote about the possible neurological etiology of the problem (an etiology, mind you, that has not been clearly demonstrated by research to date).

A neurological explanation of the problem is the kind of construction of person-as-problem that Narrative Therapy is trying to undo. It seems much more likely to me that this woman will see herself as unable to change something neurological - and therefore not responsible for changing - than that she claim no responsibility for changing her responses to an outside influence (e.g., the personified problem). In fact, a goal of Narrative Therapy, and other postmodern therapies, is to counteract the way the medical model of mental "illness" disempowers clients by pathologizing them. The goal is to see clients, and help them see themselves, as having agency in their own lives - to help them see that they are actually able to accept responsibility for the shape their lives take.

It seems there is no one-size-fits-all approach to doing so, however. Perhaps any way we might frame the problem could be experienced by clients as a way to accept or avoid responsibility, depending on the particular client and his or her worldview, etc. I happen to think externalizing the problem is more likely than other approaches to empower the majority of clients, but it's still important to recognize that (1) it may not work for everyone, and (2) it's not the only way to achieve that end.

How do you think about and help clients to accept responsibility for shaping their lives?

Why I Believe in Externalizing the Problem

People without much exposure to Narrative Therapy (clients and therapists alike) can be somewhat skeptical of the core Narrative intervention of externalizing the problem. Most basically, this intervention is a manner of speaking and asking questions that frames the problem (whatever problem it may be) as an entity separate from the person. This is most often accomplished by objectifying or personifying the problem - i.e., describing it as a separate object or person/creature/being (obviously, the process draws heavily on metaphor). 

When people object to this practice, they tend to raise at least one of two points: (1) objectifying or personifying the problem belies the fact that it is an "illness" and may therefore be a form of denial, and/or keep people from receiving needed treatment; and/or (2) attributing the problem to something external may be seen as a means of absolving responsibility for the consequences of the problem, or for change. 

First, my response to these objections: 

1) Narrative therapy is based on a philosophy called social constructionism, which basically contends that all of our perceptions of "Truth" are no more or less than ideas that we've collectively agreed upon - they are socially constructed (i.e., built). The concepts of "illness" and "treatment" are just that - constructions of our particular social location. In other parts of the world, and in other eras, the same physical symptoms that we label an illness (cancer, for instance, or seizures, or whatever) have been described quite differently, with very different interventions. When it comes to selecting among available constructions, what really matters is what leads to better outcomes in people's lives (however they define that for themselves!)

2) Construing the problem as internal - as part of the person who has the problem -  tends to cause people to feel bad about themselves, and/or about the potential for change. People are actually less likely to take action to address a problem when it is seen as internal. In contrast, framing it as external creates some space for the person to maneuver - to see possibilities for change by redefining their relationship with it, and adjusting their responses to it.

Now, I'd planned to follow my response to the objections with a summary of what I see as the benefits of externalizing - but my response already captured many of them. Most notably, externalizing the problem creates room for alternatives - identifying exceptions to the problem that already exist, and taking advantages of every opportunity to subvert the problem to shape one's life in preferred directions. Part of how externalizing accomplishes this is by removing blame. If the problem is external, it's not your fault that it's there. It's only your responsibility how you choose to respond to it. In contrast, if you are the problem (whether because you "are" ill, or have a certain personality or temperament, or whatever), it's natural to feel like it's your "fault" - and all the guilt/shame/blame that accompany that assumption. While the result of "illness" or "problem-focused"   constructions is often to objectify the person (a diabetic, a schizophrenic, etc), externalizing reverses this process by intentionally objectifying the problem itself. The immediate result is an improvement in self-image, including belief in one's own capacity to resist or overcome the problem.

Externalizing also offers a language to talk about, and a way to identify, the strategies the problem uses to get a hold of the person, as well as ways that the person can begin to resist - things s/he can choose (other than whether or not to have the problem, which is often not something under her/his direct control) that affect the problem and her/his relationship with it. In this way, new directions are unearthed, and preferred life circumstances begin to become a reality.

Can shifting language really accomplish all this? Yes - to the extent that the language is internalized. It helps a little to say it without believing it, but it helps a lot to actually believe it. I've seen rapid, significant change happen just from making this shift.

What do you think about externalizing problems, and narrative theory more generally?

A Psychodynamic Slant on Motivation for Change

When we think about a client's motivation, probably the most common lenses we use are stages of change and motivational interviewing. We think about ambivalence, and how to shift the balance of pros and cons. We think about resistance, and the overall function of the behavior in the person's life. But we may not always think about identity.

However, the role of identity deserves consideration here, as psychodynamic theorists well know. Specifically, motivation to change seems to be closely tied to whether the behavior in question is ego syntonic or ego dystonic. Something that is ego syntonic is seen as an acceptable part of the ego (i.e., one's self-image, or identity), while something that is ego dystonic is seen as unacceptable to or in conflict with one's self-image.

These terms were developed by Freud, in reference to repressed material and ego defenses, but I learned them in the context of diagnosis. Specifically, I was taught that many of the personality disorders are ego-syntonic (which makes sense if they are based on personality structure), and some Axis I disorders can also be experienced as ego-syntonic, including dysthymia and anorexia nervosa. Various forms of addiction may initially be experienced as a choice, and therefore ego-syntonic, and not become ego-dystonic until well after physiological dependence has locked someone into continuing the behavior. In contrast, the majority of Axis I disorders are ego-dystonic; in other words, they are experienced as being at odds with one's identity, almost like a foreign incursion into the self. As a result, people are generally more motivated for treatment and change.

It makes sense, right? If something feels authentic to your self, you don't feel the need or desire to change it - you don't see it as a "problem," but a reality or state of being. However, if it feels like it's interfering with your true self, it's natural to want or need a solution to the problem. (Note, however, that wanting change to happen does not necessarily translate into feeling like one can or should do anything to bring about change - for example, people who are depressed universally want to feel betterm, but often feel unable to make the behavioral changes providers recommend).

Nevertheless, people enter treatment at all levels of motivation (sometimes because they want change, and other times as a result of external pressure to change) - that means that we are likely to encounter, from time to time, clients who experience the "presenting problem" as ego-syntonic. What can we do to raise these clients' awareness of the dissonance between the problem and their selves?

Two possible interventions spring to mind:
1) Externalizing conversations, a la Narrative Therapy - this therapeutic approach frames the problem as something separate from and external to the client, often by objectifying or personifying it. Then, by beginning to see it as something external, clients are helped to recognize the discrepancies between their own feelings, beliefs, goals, and values, and those the problem seems to be pursuing. For example, my clients with eating disorders can come to recognize that while they're trying to achieve perfection, their eating disorder is trying to kill them. These two goals are mutually exclusive; therefore the eating disorder begins to feel ego-dystonic.

2) Values-based action, a la ACT - while this approach does not intentionally externalize the problem, it does seek to elucidate clients' most deeply held values and goals, and encourages clients to identify and pursue goal-directed behavior that is in line with their values, irrespective of "inner experiences" (symptoms, feelings, thoughts, sensations, urges or memories). This in achieved, in part, through mindfulness and acceptance skills.

Are there other approaches you use or think might be effective with clients who experience their presenting problem as ego-syntonic?

Finding the Exception

It's so easy to fall into the trap of "always" and "never." How often do we use these words about ourselves and others in ways that amplify our problems? "I'm always going to be a failure." "I'm never going to kick this habit." "I always ruin relationships." "I never going to feel any differently." This kind of thinking portrays problems as permanent and pervasive, creating a sense of learned helplessness - after all, if things will always be this way and never get better, what point is there in trying to change them?

In this kind of "all or nothing" thinking,  we conclude that something will always or never be true in the future, because our minds are filled with examples of when it was true in the past and present, rather than examples of when it was not true. Trying to be helpful, our brains enact a kind of mental filter that keeps us from recognizing the exceptions to our "always" or "never."

It takes work to find these exceptions, not because they're not there, but because we pay less attention to things that don't fit our expectations and explanations - the stories we have about who we are and what the world is like. Even so, it is possible and important to do so - important because the seeds of change are often sown in experiences that don't fit our problem-oriented expectations. Successful change is less about reinventing the wheel, and more about slowly expanding the exceptions until they become the rule, and problems become exceptions.

Therapists can help in the process of identifying exceptions both because therapists are outside observers, without the filter of prior expectations or assumptions shaping what they hear, and because therapists are trained to ask questions that help unearth hidden exceptions. Postmodern approaches to therapy (such as Narrative Therapy, and Solution-Focused Brief Therapy) focus the most on exceptions, because they assume that meaning is constructed (i.e. built by people), and can be deconstructed and reconstructed differently. However, even behaviorism utilizes exceptions, seeking to change behavior by reinforcing a preferred behavior when it occurs - basically, calling attention to the exception with a reward, in order to increase the likelihood of it happening again.

I believe that there is always (yes, I mean always) an exception to the problem - there is a time, place, or circumstance when it is less likely to occur, or less intense when it does occur. There are parts of our experience that do not make it into the problem-focused "always" and "never" stories. Finding these exceptions creates hope that change is possible, and suggests ways to go about it.

Where do you find exceptions, for yourself or in your clients?

Externalizing the Problem

One of my favorite interventions, taken from Narrative Therapy, is externalizing the problem. It can be used with adults and children, in individual, family, and group therapy, to help people broaden their perspectives on what have often become narrow problem-centric life stories.

Psychodynamic theories have used the term "externalizing" to refer to the ego defense of blaming problems on an external person or entity rather than taking responsibility for them. Obviously, externalizing from this perspective is not an asset to treatment.

However, Narrative Therapy defines externalizing quite differently. Rather than assuming people will try to avoid taking responsibility for their problems, Narrative theory suggests that people have come to see their problems as TOO intrinsic to the self. As a result, they may have developed a "problem-saturated" self-image, and feel helpless and hopeless about the possibility of change. When this has happened, an important first step in the change process is separating out the person from the problem.

This is achieved not by identifying someone ELSE as the problem, but by recognizing the problem as an entity unto itself, and seeing the problem (rather than any person) as the problem. Using some imagination and creativity, people can be encouraged to objectify, and even personify, the problem in a way that allows them to consider new ways of responding to it.

It also can be a way of beginning to identify exceptions to the problem. The therapist can invite the client to talk about times the problem was more or less strong or active, and times when the client got the upper hand over the problem. New solutions start to crystallize out of this kind of exception.

It's also an opportunity to begin to explore the client's preferred relationship with the problem.  While it may not be possible to eliminate every problem, it may be possible to establish a different relationship with the problem so that it's less...problematic.

I've been trying to use this intervention with a 10 year old boy, who stutters, and has been told (according to his mother) that it is incurable due to the physiological mechanism causing it. When asked about his goal for treatment, he says that he wants the stuttering to stop, while his mom wants him to be less frustrated by the stuttering, and more able to accept it.

My first attempt at externalizing with this client was to ask him to draw the problem as if it were a thing, creature, or person. This intervention did not work - he drew himself, stuttering. Instead, I decided to try something more personally relevant to him, and asked him to bring in his favorite video game. He brought in a WWE wrestling game, and described his favorite characters, as well as the "bad guys." When asked which character would represent his stuttering, he readily identified one of the bad guys, with a tag-team partner who could represent frustration. Since my client could describe all of the characters' favorite strategies, he was quite willing to do some observatory research for me this week, and try to figure out what the favorite moves of stuttering and frustration are. (We'll see how successful the intervention was based on what he comes back with this week!)

Have you ever tried externalizing the problem with a client, with either a positive or negative response?

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