CBT and Narrative Therapy: Two Worlds Collide?

1. CBT and Narrative Therapy: Two Worlds Collide? Integrating CBT and Narrative Therapy Dr. Lindsey Hampson Chartered Clinical Psychologist Alder Hey Children’s Foundation Trust

2. Aims • Familiarisation with very basic theoretical concepts of Narrative Therapy: ‘the stories we live by’ • Understanding the different philosophical and cultural differences between both approaches • Appreciating similarities between the approaches • In acknowledging these similarities, understanding how we can use these approaches side by side • Gain an awareness of how each theoretical orientation can lend richness to the other. • Gain some helpful, practical techniques to take back to your clinical practice.

3. Historical, Cultural and Philosophical Landscape • Structuralism/Modernism vs Non Structuralism/Post-modernism • Structuralism: (from Harper & Spellman, 2006)the foundations of feeling and behaviour are to be found in structures underlying surface phenomena. • Actions resulting from ‘deeper’ mechanisms like cognitions, schemas. • ‘Expert’ to ‘fix’ dysfunctions of underlying structures.

4. A Caricature of CBT: Silverton “Is CBT a form of behaviour correction and thought adjustment which pathologises, personalises - and thereby neutralises - discontent and suffering which has social, cultural, political and economic roots, rather than being located in some ‘deficiency’ of the suffering individual diagnosed with ‘depression’?” Those thoughts do not fit with the state and are illogical. Please correct those thoughts immediately using the appropriate state approved procedures.

5. Post Modernist Movement The Panopticon Bentham Foucault

6. Non Structuralism/Post Modernism/Social Constructionism • From Harper & Spellman, 2006 and Fox, 2005) • Developed as a critique of and a response to mainstream approaches in Western Psychology. • Historical Context- ‘Against Therapy’ • No objective truth, but different versions of reality. • Reality is ‘socially constructed’ primarily through language and in relation to others. In this way cannot be separated from historical and cultural context. • Identity as a social achievement • ‘Taken for granted truths’ questioned. • Therapist as facilitating a space where more hopeful identities may emerge, rather than expert on disorder or dysfunction

7. A Caricature of Narrative Therapy

8. Therapist Stance from White and Morgan (2006) Narrative CBT

9. Strategic/ Brief Therapy Milan Family Therapy 1990 Social Constructionist Therapies Solution Focussed Post-Milan Collaborative Language Systems Narrative Therapy Tom Andersen’s Ideas

10. Narrative Therapy: The Stories we live by Polite

11. Narrative Therapy: The Stories we live by Determination Fragile/Can’t cope

12. Narrative Therapy : Terms • “Narrative” = “story” = “discourse” • Narrative = Events, linked in sequence, across time, according to a plot, what people use to weave their experiences together to give them meaning • Dominant narrative/story/plot=events linked with a particular meaning. Events that fit with this plot elevated in significance, and events outside of this plot seen as insignificant or fluke. • Present and future implications of dominant plot.

13. Narrative Therapy : Key Concepts • “The Stories We Live By” • Culturally Available Dominant Discourses • Thin vs Thick Descriptions • Internalising vs Externalising discourses • Problem Saturated Stories • Unique Outcomes (Sparkling moments/initiatives) • Re-authoring conversations/Restorying

15. “Scouse Office”

16. Scousers

17. Doing Narrative Therapy • Undermine “Problem Saturated Stories” (e.g. by externalising) • In conversation identify exceptions to these stories or “Unique Outcomes” • Ask questions which allow the client(s) to weave together new accounts • Develop these previously “Subjugated Stories” into new stories to live by! • Documents as part of sustainment and survival of preferred accounts of being.

18. Externalisation: the person isn’t the problem, the problem is the problem.

19. Externalisation, the problem’s tricks and tactics.

20. Within/Between Therapist Tension?

21. CBT Narrative Therapy • Meaning people take from their experiences: Beliefs, assumptions, attributions • Making people aware of thoughts: NATS, hot thoughts, feelings and behaviours (avoidance, safety behaviours) • Making person aware of how the problem keeps going (maintenance cycles) • Meaning people take from their experiences: stories • Making people aware of thoughts, behaviours and feelings: externalisation, statement of position map one. • Making person aware of how problem keeps going: it’s tricks, tactics, ways of operating. Similarities (Colgrave, 2005, Hampson, 2007)

22. CBT Narrative Therapy • Recruiting others in therapy, parents. • Activity between sessions: homework, behavioural experiments • Integrating meaning from novel experiences: synthesising • Recruiting others in therapy via documents, outsider witness groups etc. • Activity between sessions: therapeutic documents • Integrating meaning from novel experiences: sparkling moments, landscapes of action and identity Similarities (Colgrave 2005, Hampson, 2007)

23. Towards Integration? • Marche and Mulle (1998) CBT treatment manual for young people with OCD • Gilbert & Iron’s Compassion work (2005) • Padesky’s ‘Possibilities and Hope’ (2002) • Cognitive Emotive Narrative Therapy (CENT) Jim Byrne. • Narrative Behaviour Therapy? Griffin (2003) • Narrative CBT for psychosis (Rhodes & Jakes, 2009) • The development of ‘Jake & The Weather Scare’)

24. Why integrate? Lending Richness. • CBT can be helpful to a narrative approach to engineer opportunities for ‘sparkling moments’ where more hopeful identities may emerge. • CBT to help structure a treatment approach. For some families, they state a preference for ‘advice’ and a ‘tried and tested approach’ • Externalisation to help children engage and access thoughts • Narrative is a very creative, playful therapy. Having fun in therapy. • Externalisation to help free children from limiting influence of blame and shame

25. Why integrate? Lending Richness 2 • Narrative Therapy to mobilise resources and identify evidence that may counter the problem (landscape of action, landscape of identity in response to sparkling moments. • Narrative Therapy as creating ‘contexts of competence’ • Some families can feel invalidated by a ‘tried and tested’ or ‘by the book’ approach: that it doesn’t fit for them. Narrative Therapy works with the family’s preferred stories/ways of being. • NT Landscape of Action and Landscape of Identity are a bit like an ABC of a ‘solution’.

26. Using Externalisation Cognitively • Children find it hard to describe thoughts • Abstract thinking and Piagetian stages. Formal Operational: 13 years. • Can tell you what “Worry Tummy” told them or what “The FEAR” tried to talk them into • Can use externalisation to access triggers, NATs and emotional and behavioural consequences • E.g. Describe problem • Give it a name • Use ABC but ask “what happened before The Fear came along?” “What did the fear tell you would happen” “Then how did it have you feeling”, “then what did it have you doing?” “What did it talk the adults into doing?”

27. Exercise • Get into pairs. • Interviewer use scaffold to structure a conversation using an externalising stance using both concepts from CBT and NT. • Part One only. • Interviewer, do not attempt to reform or rehabilitate the problem, your role is one of an investigative journalist, doing an ‘expose’ on the identity and tricks of the problem. • Spend last two minutes on reflecting on process and experience of being interviewer/interviewee.

28. The Landscapes of Narrative Therapy • “…Landscape of action and landscape of identity assist the therapist in building a context in which it becomes possible for people to give meaning to, and draw together into a storyline, many of the overlooked but significant events of their lives…supporting people to derive new conclusions about their lives, many of which will contradict existing deficit-focus conclusions that are associated with the dominant storylines that have been limiting of their lives” Michael White (2007) p. 83.

29. Landscape of Action Landscape of Identity: An overlap with Synthesis? • Landscape of Action: events, steps, actions, what people did, how they did it • Landscape of Identity: their intentions, values, commitments, hopes and dreams, and principles. Their reflections on the events in the landscape of action. The meaning of the unique outcome. • Cf. Synthesising Questions in CBT often asked after a behavioural experiment to integrate new information into view of world/self/others.

30. Landscape of Action- Egs. • Where were you when this happened? • When did it happen? • What happened just before and after? • How did you get yourself ready to take this step? What preparations led up to it? • Just prior to taking this step, did you nearly turn back? If so, how did you stop yourself from doing so? • Have you done this before or was this a first time? • Looking back from this vantage point, what did you notice yourself doing that could have contributed to this achievement? • Did anyone else make a contribution? If so, what did they contribute that helped this development? • What developments have occurred in other areas of your life that might relate to this? How do you think these developments prepared the way for you to take these steps? • Have you been able to do this before? Can you tell me a story about that? What happened? (distant history) • Are you aware of any past achievements that might, in some way, provide the backdrop for this initiative? (distant history) • How do you think your life would look like in 2 years time if you continued to do the same as you did on that occasion? (future)

31. Landscape of Identity Egs. • When you agreed to go out and play with your friend, despite what Panic said, what do you think that says about what you want for your life? • Let’s reflect on this development, what conclusions might you reach about your tastes or what suits you best? • What did it take in order to do this? • Can you help me understand what that says you believe in or value? • What does this say about you as a person that you would do this? • What do these discoveries tell you about what you want for your life? • In more fully appreciating what went into this achievement, what conclusions might you reach about what Harry wants for his life? • What does this reveal to you about what motives and purposes Jenny might have? • What does the history of this struggle suggest about what Jane believes to be important? • What does this suggest about what you stand for in the world? • What does this tell you about what style of parenting suits you best? • What rules for living might you adopt to more fully embrace ‘Carefree-ness’ into your life?

32. Bob Mortimer asks about a ‘sparkling moment’

33. Sparkling moments • Using NT, externalising ‘The Fear’ and finding out it’s effects on different domains on E’s life, I found out from E that she had felt anxious at school previously when she had to talk at assembly. • Then could synthesise: what she had found out and how she could use that to be in charge of The Fear at home. • She concluded that you had to face it and it wasn’t so scary.

34. Group Exercise Number 2 • Stay in your interviewer/interviewee roles. • Use the Part two scaffold to have a re-authoring/synthesising conversation. • Last two minutes allow yourself some space to reflect on how it felt to ask those questions/be asked those questions.

35. A Real Narrative Behavioural Experiment • Jelly tots (social anxiety) • Identify hot thoughts. • Design experiment to test out hot thoughts. • Making testable predictions using externalisation. • Rating belief in what Jelly tots says • Carrying out experiment • Revisit the testable prediction • Landscape of Action • Landscape of Identity/Synthesis

36. A narrative-behavioural experiment • Jellytots says: • You’re going to be homesick 95% • You’ll have no one to talk to 80% • I won’t know what to say to people 100% • DON’T DO THIS! DON’T TRY THAT! • Predictions • I’ll feel homesick and I won’t be able to cope with it. • Not at all!x • No one will talk to me. • Not at all! x • I won’t know what to say to people • I did! We had such a giggle!

37. A narrative-behavioural experiment • What happened? Was jellytots right? • I had an amazing time! I want to learn more about meditation. I want to keep in touch with some of the girls. Jellytots stayed at home! He wasn’t right about anything. • What did you learn about yourself? • I CAN make friends! People like me. I can feel like everyone else! I can relax! I can relax and be myself away from school. I can survive (and have fun!) away from home! • What did you learn about Jellytots? • Jellytots isn’t always with me!!  For the first time since I went to XXXX school, I was able to empty my mind of all worries. Jellytots is not winning! (still there in school, but in less places outside of school)

38. Jake and The Weather Scares. A conversation following an Exposure. • L: Jake before you got on the bus, what did the Weather Scares try and tell you would happen? (revisiting the testable prediction for the behavioural experiment) • J: That I’d be scared, it’d rain and it’d be awful! • L:Did what the Weather Scares tell you come true? (revisiting the testable prediction) • J: No, I was fine. • L: How did you prepare yourself to do this ?(landscape of action) • J: Well, I felt a bit worried, but I read some comics in the car. • L: what do you think this says about your skills? (landscape of identity) • J:I’m strong • (there followed a discussion about other instances of demonstrations of ‘strength in Jake’s life-a re-authoring conversation) • L: What did you learn about what The Weather Scares say? (synthesising question) • J: They lie. They say bad things happen and they won’t. They’re a liar. • L: Would you advise a friend to listen to a liar? (synthesising question) • J: No. That’s stupid.

39. Handbooks, ‘Documents of Knowledge’ and ‘Therapy Blueprints’ • 1. CBT: a summary of everything person has learnt through therapy about causes, maintenance, and ways of overcoming the problem.(Wells, 1997) • 2. NT:‘Consulting your consultants’, whereby a person shares their special skills and documents their alternative knowledge. (Freeman, Epston &Lobovits, 1997)

40. Jake and ‘The Weather Scare’ A true story by Jake and Lindsey Hampson

41. ‘The Weather Scare’ didn’t want Jake to go out in the rain. It was afraid that Jake would find out that when he went out in the rain, that nothing bad would happen and all the things it told him were not true or not as bad. ‘The Weather Scare’ knew that if Jake found out about it’s lies then this would make it weak. It tried to boss Jake around to stop him finding out. It shouted loudly at him and told him not to go out. This made Jake feel scared.

42. Jake made a list… of all the places and things ‘The Weather Scare’ didn’t want him to go to or do. He sorted them out by using a picture of a ladder. He put the least scary things at the bottom of the ladder, and the most scary things near the top. Going to the village on the bus was least scary, so it went at the bottom of the ladder. The thing that caused Jake a little bit more worry than going to the village on the bus, was walking to the woods, so that went on the next highest rung and so on. Here’s what Jake’s ladder looked like. Going to Town on the train Most scary Going to the cinema on the train What would your ladder look like? Going to a bowling alley Walk to the village when it’s raining with mum Go for a walk when it’s cloudy Walk to the village Walking to the woods Going to the village on the bus Least scary

43. Helpful questions to talk about after each step on the ladder • What did the scare tell you would happen? • Was it right? • What did you find out? • What did you find out about the scare? • What did you find out about yourself?

44. Being a Scare-Detective • Sometimes scares take a break. Sometimes we are stronger than our scare but we don’t realise it. Sometimes there are days when we are at our best! ‘Becoming a Scare Detective’ means thinking about and looking out for times (no matter how small) when your scare isn’t as strong, long-lasting or when you were stronger. You might find it helpful to think about these questions and write your thoughts: • When are the times you’ve side-stepped your scares? • When are the times you’ve outwitted them?

45. Scare-Detectives • Or gone against their rules? • Or proved them wrong? • Or taught them (they hardly ever get things right)? • Or listened to them less? • When are the times they weren’t as strong? • When are the times you were stronger?

46. What suits you/the family best? • Using an overarching CBT approach using narrative therapy to help you access thoughts/feelings/behaviour and to help restructure beliefs through identification and unpacking of‘sparkling moments’? • Using an overarching narrative approach using CBT to help you engineer opportunities for sparkling moments • Something else?

47. Summary: towards thoughtful integration. • Despite seemingly polarised philosophical stances, both therapies hold a number of similarities. • These can be used side by side to engage the families we work with. • Colgrave (2005) suggests that what matters most is not the method or technique but the respectful application of knowledge to the families that we work with. • Using CBT and NT together in a flexible, responsive way can open up opportunities and possibilities that may have previously remained invisible.

48. References • Colgrave, C. (2005) • Fox, H. (2005) • Griffin, M. (2003)Narrative Behaviour Theray? Integration in Action, ANZFFT,March, pp 33-37. http://www.anzjft.com/pages/articles/445.pdf • Hampson, L. (2007)CBT and Narrative Therapy: Two Worlds Collide? Context, 92, pp 16-18. • Harper & Spellman • March & Mulle • Rhodes & Jakes (2009)Narrative CBT for Psychosis, Routledge. • Sween, E. (1998)One minute question:What is Narrative Therapy? Gecko, vol. 2, pp3-6. • White, M. & Morgan, A. (2006)