Commentary for CSWJ

Commentary on Narrative Therapy and Elders with Memory Loss by Elizabeth Young1:
Narrative Means to Different Ends

“We don’t, we never did, go about making statements of fact to other people,
or in our internal dialogue with ourselves.” (Leguin, 1980, p.44)2

Elizabeth Young’s article attempts to illustrate how certain techniques of classic narrative
therapy can be applied in very brief short-term work with elderly persons in the early
stages of memory loss due to Alzheimer’s Disease or a related disorder. Brief excerpts
from three interviews, each with a different client, are used to support the writer’s
argument that “narrative therapy can help people with dementia revise their stories and
reclaim their identities.” Of particular interest to Young is the potential of narrative
therapy to help the client resist the “cultural imperative” that one’s life be perceived in
sequential order. In my commentary on her article I will not critique her account but use
it as a springboard to reflect briefly on several interrelated matters: 1) the “genre” of
therapist’s accounts of a particular type of practice and the problematics of student
accounts in particular; 2) the commonalities of and differences between narrative inquiry
(my practice) and narrative therapy as narrowly defined; and 3) the potential of
collaboration between narrative practitioners and narrative researchers.

Accounting for oneself as a therapist or as a commentator is a daunting task. As Leguin

says it is not just our struggle with what to say or not to say—how to give another person
or audience some sense of our experience and some confidence in what we say—it is also
that we refashion, interpret and “fictionalize” our accounts when we tell them to
ourselves. If we accept that this is the case then we can acknowledge the high degree of
uncertainty about what is indeed factual and inclusive in any account. I am not sure that
reported facts matter so much as long as we have some opportunity to “observe” the
therapist or the client in action, allowing us to interpret what is going on according to our
own interests and preferences, or to agree or disagree with the author’s own
interpretation.

As Elizabeth Young makes clear in her piece she is writing about her experience in a
field work placement while completing her MSW. And although it is not explicitly stated,
from her approach I would assume that her paper originated as an assignment for a
course, probably one that required her to illustrate a practice method with examples from
her field work. Such assignments are common in social work education but I would argue
1
Young, E. (2008). Narrative therapy and elders with memory loss. Journal of Clinical
Social Work. doi:10.1007/s10615-008-0146-4. Retrieved 1/28/2010, from
http://www.springerlink.com/content/w84x8l745w3266u5/fulltext.pdf
2
Leguin, U.K. (1980) Dancing at the edge of the world: Thoughts on words, women,
places. New York: Harper and Row, p. 44.
that they may, at times, have a negative impact on learning. That is, the student is
reluctant to show uncertainty and doubt as she or he tries to fit the experience of learning
a practice into the boxes of method as described in textbooks and canonical texts (in this
case, Epston and White’s early works on narrative therapy). Such assignments may also
reinforce the dominance of “the authority” and make it more difficult for the learner to
critically reflect on his own learning. In spite of the constraints that the context of social
work education may have placed on Young, she does a commendable job. Not only does
she demonstrate a mastery of the early literature of narrative therapy, she manages to
overcome somewhat the strictures of the expectations of “the instructor”3by her empathic
accounting of her exchanges with clients. Brief though they were, these exchanges
seemed to me to be trustworthy. I did not get the sense that Young was “editing” to make
herself appear more adept at applying narrative therapy techniques than she may have
been at the time, and that with more experience she will continue to reflect on her
practice and make welcome contributions to the “narrative turn” in social work.

I am not a therapist nor do have any experience working with people with memory loss
but my colleagues and I have studied and written about narratives of Alzheimer’s and
caregiving (England, 1993; England & Ganzer, 1992, 1994; Ganzer & England, 1994,
England & UIC Collective for the Study of Narratives on Family Care, 1993). Based on
that work what I bring to this commentary is my continuing curiosity about the ways
narrative inquiry can be a pathway to critical examination of practice and social policy.
Young’s article refreshed my thinking about narrative and dementia and led me to new
questions about the differences in my approach to narrative inquiry and the approach of
those who do narrative practice. Young’s intent is not narrative inquiry but rather a
demonstration of a narrative practice and it would not be fair to criticize her for not using
the methods of narrative inquiry. Considering the practical demands of her work (the
agency’s agenda, the very short term structure, and the pressures that both bring to bear
on her choices) Young is able to give us a sense of the individuality of each client. Young
has added to a very scarce literature about narrative and dementia and her case examples
have stimulated my own thinking about the dilemmas and challenges of writing about
narrative practice. Although Young and I approach narrative from differing perspectives
and purposes we share a common interest in the “voice” of those with dementia.

By the broadest definition my own work fits into the category of narrative inquiry, and
given my lack of experience with therapy or narrative practice my commentary on
Young’s article should be taken with a large dose of salt. However, reading Young’s
article I was struck by the rich possibilities of dialogue between narrative practitioners
and those of us who are narrative researchers but not practitioners. My research on
Alzheimer’s care relied heavily on a collaborative process (England, 1993) and involved
clinicians and researchers in what we called The Narrative Study Group. Our methods
were aimed at eliciting the different perspectives of each person in the study group, not to
arrive at a consensus but to open up conceptual space and challenge the prevailing
intellectual and professional conventions in Alzheimer’s care practice and research.

3
I am using this term in the very broadest sense, not to point to any one individual, but in
reference to the hierarchical arrangements in the practice of teaching.

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 Narrative Means to Different Ends 3

As a practitioner and a researcher Young and I approach knowledge building with two
distinctly different orientations. Her account is in the tradition of the proof orientation4
and though she is not using empiricist methods, she has a definitive plan and adheres to it
to make her points about the applicability of narrative therapy with early dementia. I, on
the other hand, approach narrative material with a discovery orientation. Rather than
setting out to prove or demonstrate my conceptual framework, my goal is to change my
own way of thinking about something. I attempt to continuously redefine my
interpretation by looking for the novel, unexpected and contradictory in the narrative.

Ronald Chenail’s (2002) discussion of the common assumptions of therapists and

researchers has been particularly helpful to me in sorting out the ways in which
Young and I differ in our approach to narrative work. Chenail notes that the first
common assumption is that “co-existing, multiple realities [are] at play, including
our own” (Common Distinctions in Contemporary Qualitative Research
Education and Systemic Family Therapy, Sec.1).

In her account Young’s emphasis is on the outcomes of therapy—the reclamation of

identity and resistance to the cultural imperative to perceive one’s life in chronological
order. As a narrative researcher, I might begin an inquiry with an interest in what the
narrative suggests about these or other dynamics but with experience I have learned that
few if any of the conceptual frameworks I may begin with stand up for long against the
multiple realities and contradictions of the narrative. Young no doubt understands that
irrespective of whether one has dementia, a chronological perception of one’s life is only
one of the multiple ways we remember and account for our lives. In certain settings, e.g.,
when expected to provide a curriculum vitae or information for a case history,
chronology may be expected to be the predominate structure, but in many cases we “tell”
our lives with other structures--by our relationships, thematic threads, achievements and
setbacks, and stories within the larger story. In some ways the chronological account can
be thought of as the anti-narrative (or antenarrative, i.e., pre-story), and what Young has
identified may not be so much a cultural imperative but a subjugation of voice.

In narrative inquiry we are as interested what is not said as we are in what is told. One
way of describing this approach is the “hermeneutics of suspicion”, a method of
interpretation, according to Ricoeur, “which assumes that the literal or surface-level
meaning of a text is an effort to conceal the political interests which are served by the text
(as cited in Pepa, 2004, p.44).5” As Pepa (2006) explains the method, “It suspects the
credibility of the superficial text...” (p.1). Narrative inquiry can illuminate the ways that
gender, class, social archetypes and other dynamics of the narrative are subjugated and
hidden. By “studying up” in a self-critical way it seeks to change the observer (researcher
or therapist) and to challenge and discover rather than “prove.” The hermeneutics of
suspicion also allows us to “suspect” our own text. The act of writing for a professional
journal (as I am here) is a persuasive practice and one is expected to follow rather strict
4
Very likely due to the “assignment” aspect discussed earlier.
5
Nurturing the imagination of resistance: Some important Views from contemporary
philosophers. Martin Heidegger Memorial Lecture, (Ricoeur, p. 1970, as cited in Pepa,
2004, p.44). http://www.philosophos.com/philosophy_article_85.html

3
rules to be viewed as sufficiently credible to be in print. Were we to be excessively
introspective we would violate those rules (and not be published!). However, self-
awareness of our own text as only one of many possible accounts, and one constrained by
our sensitivities to the rules and the profession’s political interests is a highly useful
mindset for narrative work.

The role of life history, reminiscence, and other narrative oriented approaches in work
with the frail elderly has “a long and honourable tradition within the practice of dementia
care …”(Williams & Keady, 2006), p. 163), and although little has been written about
how narrative therapy per se is applicable to work with those with memory loss, the
possibilities are indeed intriguing. The methods described in White and Epston’s (1990)
pioneering Narrative Means to Therapeutic Ends may be adaptable to dementia care but
Young’s article about her work seemed to me to be overly constrained by her desire to
demonstrate the applicability of specific methods. One concern is about whether the
practice Young describes fits clearly within the framework of therapy as usually defined
and practiced in the U.S. That is, a contractual arrangement between a therapist and client
to work together to relieve a specified (and ideally agreed upon) problem, difficulty, or
disorder.6

As a narrative researcher I find Young’s ideas intriguing but my first inclination would be
to test these concepts against how the clients describe their difficulties. There are small
clues to what the clients regarded as problems or challenges in the excerpts but none of
them seem to point to Young’s abstract conceptualization. For example Virginia
describes an embarrassing episode as “scary” and Young then asks a question about
whether Virginia knows what is making her brain seem like it is failing. Here it seemed
to me that Young shifted from Virginia’s emotionally laden concern to her own rationally
∗
based therapeutic intention, and may have missed the opportunity to talk further with
Virginia about her fear of embarrassment and how she coped with it (by excusing herself
and going to the bathroom—a rather adept response). From the bit I do know about White
and Epston’s work, I had the thought that that fear of embarrassment was something that
might be externalized and managed. Surely such scenes would recur and Virginia seemed
to have the self-management resources to deal with these. As a narrative researcher I am
struck by the possibility that embarrassment stories might well be common ones for those
in the early stages of memory loss, and the different ways that people manage it a rich
vein of inquiry.

For both therapists and researchers a reflective stance is required and if possible should
be discussed in the account. As Chenail (2002) puts it, we must “continually assess and
interpret our participation in the research/therapy process” (Common Distinctions in
Contemporary Qualitative Research Education and Systemic Family Therapy, Sec.4). I
6
The narrative practices that have evolved from Epston’s and White’s seminal work have
varied and multiple ‘ends’—community building, prevention, consciousness raising, and
restorative justice, to mention just a few. My lack of experience doing practice that fits
under the rubric of therapy may account for my possible overreaction to the term.

Did the shift possibly occur because of the way the therapy was being defined by the
agency?

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 Narrative Means to Different Ends 5

would add that since we have in common a central concern for social justice and power
relations, both practitioners and researchers are obliged to critically examine our own
location and influence in our relationship to the client/informant/narrative. And, as any
account of practice or research is performative and not a statement of “true facts”, it is
helpful to both the reader and the writer that there be a statement of the writer’s
standpoint and some explanation of the multiple contexts of the encounters being
described.

It is around the question of context that Young and I seem to differ the most. That
difference is likely a function of our divergent goals but it is also could be one of the
most fruitful areas for further collaboration by researchers and practitioners. As a
narrative researcher I read Young’s account with a focus on context and what clues there
might be in the statements of the clients about how they were interpreting their own
experience. Were I to have access to transcripts or videos of the interviews and reviewed
them with Young I would want to ask what her thoughts were at each point in the
interview, how she conceptualized what was going on, and how she decided to act one
way or the other. And because of my focus on how the context of the practice socially
constructs one’s subjective sense of chance and opportunity, I would query Young about
her perception of the chain of vulnerabilities—both real and perceived--suggested by the
omissions in her account. This technique of reflective practice is one that narrative
clinicians and researchers share and value but may be a luxury in the context of agency
practice. However, it offers a way to look more deeply inside practice and critically
assess our practice theories.

Narrative therapy is organized around the core principal of restorative and transformative
justice, and a signature characteristic is the de-centering of the therapist, allowing the
client to define his or her own position in relation to the problem (White, 2007, p. 39 as
quoted by Rood, 2009, p. 20). Without knowing what the purpose of the brief treatment
was and by whom it was defined, we cannot assess whether the clients in Young’s
examples had the opportunity to do that. Absent as well is a statement of the author’s
standpoint and some accounting of the history of how these particular interviews/therapy
sessions and the subsequent paper (originally an assignment?) came to be. Young herself
is “present” only in her quotes in the excerpts from the interviews. We do not know her
standpoint or her location in the hierarchy of power (for instance are the clients being
assessed for eligibility for services?). We know little about the context of the interviews
or about the nature of the excerpts. Were the conversations transcribed verbatim, from
notes or from memory? How and why did Young decide on these excerpts? Bruner
(1986) cautions us that narrative and interpretive methods are not a “swooping down” (p.
10) on the text to make our point or to confirm our theories and concepts but require us
rather to study up, allowing the voice of the client/informant to cause us to question and
challenge our perceptions of “What is going on” in the conversation.

Personally, my only direct experience with dementia is with my aunt, whose short-term
memory gradually disappeared as she became increasingly frail over the past five years.
Much of what she experiences is mysterious to me, but our relationship remains warm
and much the same as it has been for most of my life. She converses easily, and has

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strong recall of long ago events and details about people. Over these past years she seems
to most enjoy when I ask her questions about the family and remind her of highlights of
the past. The onset of her short-term memory loss was subtle. At first she would tell us
she was out of something and we would discover after shopping for the item that she
already had an ample supply. In the next phase she was still living on her own, reading
avidly, doing crossword puzzles and driving. We became concerned that she was no
longer able to keep track of her medicines and about that time, she voluntarily decided to
move to assisted living and give up her car. We engaged an elder care management
professional and thanks to her and her staff, the transition was made much easier for my
aunt and the family. As my aunt became increasingly frail and after several
hospitalizations she is now in long term care.

My aunt is sociable, has a wicked sense of humor, and thankfully, still recognizes family
members. The past is very much present to her—so much so that she will describe, with
obvious enjoyment, something that happened many years ago as though it had happened
that morning. Her memory of key events of the last ten years or what happened in the last
hour is unreliable but she is very aware of her surroundings and the people with whom
she interacts every day. Except for the fact that she cannot care for herself physically or
organize her thoughts to keep track of the details of her day-to-day life, her memory—
mixed with some confabulation—is a rich mix of places, people and scenes both near and
far. It is poignant that she is well aware of her memory limitations but in many ways her
memory has become a deep well of emotion, including pleasure.

My experience with my aunt has brought home to me an appreciation of the particularity

of any one instance of dementia, the constant shifts that can occur, and the multiplicity of
contexts that affect the situation. I am learning too that even with dementia one can have
a rich inner life filled with vivid memories. Perhaps we don’t always “lose” our memory
but rather find it anew.

REFERENCES

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 Narrative Means to Different Ends 7

Bruner, J. (1986). Actual Minds, Possible Worlds. Cambridge, MA: Harvard University
Press.

Chenail, R. (2002). Common Distinctions / Common Assumptions: Qualitative Research

and Systemic Family Therapy http://www.nova.edu/~ron/quig96ex.html

England, S. E., Ganzer, C., Perez Foster, R. and Tosone, C. (2006). The speech of the
suffering soul: Four readings of William Styron's Darkness Visible.
Psychoanalytic Social Work. 13(1), 1-19.

England S. E.and Ganzer C. (1994). The micropolitics of elder care in Memento Mori,
Diary of a Good Neighbor, and A Taste for Death. International Journal
of Health Services. 24(2): 355-369.

Ganzer, C and England, S. E. (1994) Alzheimer's care and use.of services: Generating
Practice concepts from empirical findings and narratives. Health and Social
Work.19(3), 174-181.

England S. E.and the UIC Collective for the Study of Narratives on Family Care. (1993).
Moral reasoning and Alzheimer's Care: Exploring complex weavings
through literature. Journal of Aging Studies. 7(4), 409-421.

England S. E.. (1993). Modeling theory from fiction and autobiography. In Catherine
Kohler Reissman, Ed., pp. 190-213. Qualitative Studies in Social Work.
Newbury Park, CA: Sage Publications.

England S. E. and Ganzer C. (1992). The many faces of loss: Autobiography and the
Alzheimer's experience. Illness, Crises, and Loss: Multidisciplinary Linkages.
2(2), 13-21.

Leguin, U.K. (1980). Dancing at the edge of the world: Thoughts on words, women,
places. New York: Harper and Row, p. 44.

Nurturing the imagination of resistance: Some important Views from contemporary

philosophers. Martin Heidegger Memorial Lecture, (Ricoeur, p. 1970, as
cited in Pepa, 2004, p.44).
http://www.philosophos.com/philosophy_article_85.html

Ricoeur, P. (1970). Freud and Philosophy: An Essay on Interpretation. New Haven: Yale
University Press, p. 33 as quoted in Pepa, 2006.

Rood, B. (2009). A time to talk: Re-membering conversations with elders. The

International Journal of Narrative Therapy and Community Work. 1, 20.

White, M. Epston, D. (1990). Narrative Means to Therapeutic Ends. New York: Norton.

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White (2007). Maps of Narrative Practice, p. 39. (as quoted in Rood, 2009, p. 20). New
York: W. W. Norton.

Williams, S. Keady, J. (2006). Editorial: The narrative voice of people with dementia.
Dementia. 5, 163-168.

Young, E. (2008). Narrative therapy and elders with memory loss. Journal of Clinical
Social Work. Retrieved 1/28/2010, from
http://www.springerlink.com/content/w84x8l745w3266u5/fulltext.pdf