Narrative therapy in integrative healthcare practice

By Julie Luzarraga

Each patient we work with has their own unique story. Before they walk through the clinic doors, patients have whole lives with complicated variables that influence their health. Family histories, deeply rooted beliefs about self and other, and current stressors all impact how we feel, take care of ourselves, and function.  These components of self are often more valuable than the diagnosis our patients carry. As an integrative mental health provider, I know best practices for stress-related physical illnesses and I can make a lot of assumptions based on a new patient’s reason for scheduling, whether it is for stress, a recent hypertension diagnosis, chronic pain, anxiety, or any number of diagnosis.  But I don’t know anything about a patient until I’ve heard their story. 

Narrative therapy is a therapeutic approach that invites the patient to become a co-creator in their story versus a passive bystander, or a victim, to their circumstances. Like the principles of integrative medicine, narrative therapy assumes a role of mutual respect and collaboration between the treatment provider and the patient. The patient is seen as the expert and empowered to guide their treatment. Narrative therapy techniques can be utilized by all integrative health practitioners in developing the patient-provider relationship and co-creating successful treatment plans.

The narrative therapy lens

Seeing our patients through the lens of narrative therapy provides meaningful context.  Two patients with the same condition can present with very different stories requiring different treatment approaches. Listening to individual stories helps us to identify strengths and potential barriers to treatment and prevention early on the relationship. A simple technique is to ask a patient to tell their story about what it is they want help with. 

For example, one patient who was referred to me by her primary care provider. After reporting an increase in her chronic back pain, she had been encouraged to reduce her hours at work where she typically worked long hours and was often on her feet supervising production lines. When she did reduce her hours, she gained weight and reported further increase in pain. She was frustrated and reported starting to feel depressed. 

When I first met her, she identified that she was working too many hours and “holding stress” in her body. When I asked her to tell me the story of her pain, she told me about how important her job as a manager was to her. She had been at the company since she was a teenager and though it was hard and stressful at times, she couldn’t imagine giving it up. Having recently lost both her parents, her work community was like family to her. Her mother had been morbidly obese when she died and sedentary most of her life. Pam was convinced that the worst thing that could happen to her would be to become disabled and not be able to work. This part of her story helped me to understand the importance of keeping Pam at work. All our treatment goals would need to take that strong value into account and be realistic for her supervisory responsibilities. 

Separating the patient from the problem

In utilizing a narrative therapy perspective, it is imperative to recognize the subtlety and importance of language.  In our culture our language tends to describe illness and distress as intransient states human beings are saddled with. Phrases like “I am diabetic” or “I am victim of sexual abuse” carry burden and negativity. “I live with diabetes” or “I am a survivor” creates some distance from the problem. These types of reframes acknowledge that those conditions and experiences are just one part of a whole life, versus someone’s only identity.

Though it may seem like a small shift, there is therapeutic value in helping a patient separate themselves from their problems. It empowers patients and creates a shared language that can help the provider and patient discuss sensitive issues. I work with a patient who is 78 years old  and has recently chosen to talk about her childhood history of sexual abuse. She has carried a diagnosis of depression much of her adult life. She can easily talk about depression but has not been able to talk about her abuse. Early in her treatment she decided to call that period in her life, “when the trauma happened.”  This is the phrase we continue to use, and I encourage her other treating providers to use as well.  It creates safety for her and separates the experience from who she is today. We can then talk about the experience and the symptoms she has from it with more ease. 

Another way of externalizing the problems is to ask about the problem separately from the patient. Ask your patient how they feel and then ask about the symptoms. For example, “tell me about the heart palpitations and how long you have noticed them.” Another option is to ask what the effect has been on someone: “how have the headaches been effecting you?”

Sometimes, simply identifying something as story is very powerful and can help to remove shame.  I have a patient who routinely starts out by saying “I didn’t do a good job at taking care of myself this week.” She then lists all the health behavior changes she did not practice.  Instead of following her into the story that she did not do enough, I ask her to “tell me about that story.” Then we can talk about the barriers to the behaviors she wasn’t able to practice instead of her “not doing a good job.”

Invitation to rewrite the story

By viewing our patients for more than their diagnosis and incorporating their full story into our understanding of them, we encourage them to take the lead in rewriting their story. We want our patients to feel empowered to make the lasting changes they need in order to live fuller and healthier lives. Narrative therapy techniques ask patients, “what do you want the end of your story to be?” 

I have a patient who was diagnosed with fibromyalgia. Initially, the diagnosis was a relief.  It explained her symptoms and she felt validated. However, her own story about her condition created more symptoms. She believed the fibromyalgia would consume her and that her biggest fears of being inactive and weak would come true. She became worried about being out by herself, feared she would not be able to take care of her grandchildren, and began to isolate from family and friends. 

Our work now is to re-write this story. How does she want the end to look? From there, we will develop what steps need to happen in order to get to that ending. 

Seeing our patients through a narrative lens, separating patients from their problems, and inviting patients to rewrite their story are adaptable techniques to bring into the integrative healthcare provider and patient relationship. We all have a story to tell and those stories influence how we feel, how we interact with others, and how we take care of ourselves. Narrative therapy is a tool we can use to empower our patients to become the authors of their stories and ultimately their health.