Hannen2012 Terapia Narrativa Individual Autolesion

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Narrative therapy with an adolescent

who self-cuts: a case example
a b
Elaine Hannen & Kevin Woods
a
Bolton Educational Psychology Service , Bolton , UK
b
School of Education , Manchester University , Manchester , UK
Published online: 04 Jul 2012.
To cite this article: Elaine Hannen & Kevin Woods (2012) Narrative therapy with an adolescent
who self-cuts: a case example, Educational Psychology in Practice: theory, research and practice in
educational psychology, 28:2, 187-214, DOI: 10.1080/02667363.2012.669362
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Educational Psychology in Practice
Vol. 28, No. 2, June 2012, 187–214
Narrative therapy with an adolescent who self-cuts: a case

example
Elaine Hannena* and Kevin Woodsb
a
Bolton Educational Psychology Service, Bolton, UK; bSchool of Education, Manchester
University, Manchester, UK
The National Institute for Clinical Excellence identifies educational psycholo-

Downloaded by [Northeastern University] at 06:39 09 October 2014
gists as appropriate specialists to deliver interventions to promote the emotional

well-being of children and families. A role for practitioner educational psycholo-
gists in providing specific therapeutic interventions has also been proposed by
commentators. The present study reports an evaluative case study of a narrative
therapy intervention with a young person who self-harms. The analysis of data
suggests that the narrative therapy intervention was effectively implemented and
resulted in attributable gains in emotional well-being, resilience and behaviour
for the young person. The authors discuss the role of the educational psycholo-
gist in delivering specific therapeutic interventions within a local authority con-
text and school-based setting. Consideration is also made of the development of
the evidence base for the effectiveness of narrative therapy intervention with
young people who self-harm.
Keywords: narrative; therapy; self-cutting; adolescent; educational psychologist
Introduction
Educational psychologists (EPs) and therapeutic intervention
There is a high prevalence of mental health problems in children and young people
(CYP) in the United Kingdom (UK), and growing evidence to support the efficacy
of psychological therapies (MacKay, 2007). The promotion of emotional well-being
in CYP was a UK Government priority under the Labour Party because of the
direct effect of early mental health difficulties upon social, physical, and cognitive
development, and well-being in later life [Department for Education and Skills
(DfES), 2004]. The Coalition Government has committed to the former govern-
ment’s “Improving Access to Psychological Therapies” (IAPT) initiative which aims
to improve the access of CYP to evidence based psychological therapies [Depart-
ment of Health (DOH), 2011].
The Professional Practice of Educational Psychologists [Division of Educational
and Child Psychology (DECP), 1998] states that therapeutic work with children and
their carers should feature prominently in the work of EPs. However, MacKay and
Greig (2007) observe that little has changed in educational psychology practice
since Indoe (1995) commented that the term “therapy”1is seldom heard in the
profession. The high involvement of educational psychologists (EPs) with special
*Corresponding author. Email: elaine.hannen@bolton.gov.uk
ISSN 0266-7363 print/ISSN 1469-5839 online

Ó 2012 Association of Educational Psychologists
http://dx.doi.org/10.1080/02667363.2012.669362
http://www.tandfonline.com
188 E. Hannen and K. Woods
educational needs (SEN) policy, process and practice has reduced the scope of their
work (DECP, 1998), so that innovative interventions in schools are often seen as
the responsibility of other professionals (Baxter & Frederickson, 2005). The
demands of statutory assessment work have prevented EPs from making more than
a limited contribution to improving children’s emotional health, although many
school staff would welcome EPs providing therapeutic interventions (Farrell et al.,
2006).
Some EPs may consider that professionals in Child and Adolescent Mental
Health Services (CAMHS) are more able to provide therapeutic interventions
(Pomerantz, 2007). However, EPs, with their knowledge of child and adolescent
psychology, and experience of the educational context, are well placed to deliver
appropriate therapies effectively (MacKay, 2007), particularly in schools, which
may be the best way of helping children given the familiarity of the school environ-
ment to both children and parents (Greig, 2007; Woods, Bond, Farrell, Humphrey,
& Tyldesley, 2009). EPs are named in recently published public health guidelines
as appropriate specialists to deliver interventions that promote the emotional well-
being of children and their families [National Institute for Clinical Excellence
(NICE), 2008]. Integrated working between EPs and the professionals in CAMHS
should ultimately promote improved outcomes for CYP through the coordination of
delivery of therapeutic interventions (Fallon, Woods, & Rooney, 2010; Farrell et al.,
2006; Scottish Executive, 2002).
A UK wide survey of EPs’ involvement in delivering therapeutic interven-
tions is currently being undertaken by Manchester University and is due to
report in 2012 (Atkinson, Bragg, Squires, Muscutt, & Waslisewski, 2011). The
purpose of this article is to contribute to the early stages of empirical evalua-
tion of the specific therapeutic practice of narrative therapy (NT). The impor-
tance of each specific therapeutic approach developing its own evidence base
is amply illustrated in the “Serious Case Review Report on Baby Peter”
[Local Safeguarding Children Board (LSCB) Haringey, 2009]. Developing an
evidence base for innovative approaches means they can then be used to
respond flexibly to meet the needs of individuals as outlined in the Coalition
Government’s plan for Improving Access to Psychological Therapies (DOH,
2011).
Self-harm and mental health

Self-harm is one indicator of impaired psychological well-being. The term
“self-harm” is used to describe a range of behaviours from self-injury (for example,
self-cutting) to self-poisoning (Cleaver, 2007). “Self-injury” is defined as “the
intentional destruction of body tissue without suicidal intent and for purposes not
socially sanctioned” (Klonsky and Muehlenkamp, 2007, p. 1045). Self-harm is
included in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edi-
tion, Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000), as a
symptom of Borderline Personality Disorder. It is also present in many other diag-
noses (Klonsky, 2007).
Prevalence studies suggest that one in 15 young people in the UK may be self-
harming (Mental Health Foundation, 2005), and rates of self-harm appear to be
increasing in both younger and older adolescents, particularly in girls (Cleaver,
Educational Psychology in Practice 189
2007; Hawton & Harriss, 2008). This suggests that EPs may regularly come into
contact with CYP who may engage in self-harming behaviours and that the needs
of this group of CYP are unlikely to be completely met by other specialist services
such as CAMHS. Individuals differ widely with regard to the number of previous
self-harming episodes, motives for self-harm, and psychological characteristics
(Slee, Arensman, Garnefski, & Spinhoven, 2007). Many self-harming adolescents
have experienced family problems (Hawton & Harriss, 2008), such as low parental
support and acceptance (Jones, 1991), or early neglect, violence or abuse (Best,
2005). Young, Sweeting, and West (2006) found an increased incidence of self-
harm within the Goth subculture.2 The findings suggest this was possibly due to
emulation of icons or peers within this subculture group, who accept self-harm
despite wider social sanctions, and also due to the selection of the Goth subculture
by young people with a propensity to self-harm, with the latter cause perhaps being
more likely.
Those who self-injure exhibit more frequent and intense negative emotions,
such as depression and anxiety, self-directed anger and dislike, than their peers.
The most prevalent function of their behaviour is to alleviate these emotions
(Klonsky, 2007; Klonsky & Muehlenkamp, 2007). For some, self-harm may help
to create a sense of identity when feeling alienated from the world (Allen, 1995;
Suyemoto, 1998). It may also be a form of self-punishment (Klonsky & Mueh-
lenkamp, 2007), or a means of communicating one’s pain to others to obtain sym-
pathy (Favazza, 1989). However, self-harm offers only temporary relief and it
does not address the underlying emotional difficulties (Mental Health Foundation,
2005), although in some cases it may prevent young people from taking their
lives (Best, 2005).
In the United States many adolescents who self-harm use the internet to
access information about self-harm, and to share personal stories. Sharing poten-
tially reinforces narratives so that self-harming behaviour is normalised and sup-
ported for those engaging in the discourse, despite wider social sanctions
(Whitlock, Lader, & Conterio, 2007). There may be a similar pattern of internet
use in the UK.
There is little research on the efficacy of therapeutic interventions with young
people who self-harm, particularly with those who self-cut (Mental Health Founda-
tion, 2005), which is the most common form of self-harm in community samples of
UK adolescents (Hawton & Harriss, 2008).
Narrative therapy (NT)

NT, as developed by White and Epston (1990), is based on Bruner’s (1990) view
that humans give meaning to their lives in a socially constructed world by organ-
ising their experiences of events in a narrative form in a sequence over time. Narra-
tives are self-constructed and also constructed and adapted during interactions with
others. Reflective of the culture’s social beliefs, these narratives not only represent
but shape reality and the individual’s sense of identity (Bruner, 1990). They deter-
mine how individuals interpret their lives, and how they will live their lives in the
future (Vetere & Dowling, 2005). Difficulties may arise when people adopt a single,
or “dominant”, narrative that highlights their perceived or actual deficits and is,
therefore, a “problem-saturated story” (Wagner & Watkins, 2005, p. 242).
NT aims to help people identify dominant problem-saturated narratives, dis-

cover exceptions to these narratives, and generate alternative preferred stories to
“re-author” their lives. In NT, as in the person-centred approach of Rogers
(1961), the client, not the therapist, is viewed as the expert on their life. Narra-
tive therapists communicate this by adopting a “not knowing” curious stance
(Besley, 2002, p. 129). The narrative therapist should be aware of local political
or cultural issues that may be influencing the client’s sense of moral worth
(White, 1995).
There are some small scale, mainly qualitative, studies of the effectiveness
of use of NT in specific contexts. For example, Young (2008) reports a clinic-
based brief NT intervention (single session) with an eight year old boy with
anxiety about school attendance, though there is no evaluation outcome relating
to the presenting problem. Cashin (2008) presents a short vignette of a nurse’s
positive NT intervention in a medical centre with a 13 year old boy with

Asperger syndrome who was “not coping with school”; albeit with limited
description of the elements and processes of therapy. There is, however, no
broader research base on the effectiveness of NT upon which EPs might base
their judgements about the potential efficacy of an NT intervention for a particu-
lar problem within a particular context, a situation compounded by some narra-
tive practitioners’ rejection of realist research methods as being inconsistent with
their social constructionist worldview (cf. Etchison & Kleist, 2000). Following
an extensive search of academic literature databases [for example, PsychInfo;
British Education Index (BEI)], the authors could find no peer review journal
publications evaluating the effectiveness of an NT intervention by a psychologist
within an educational context. Given the potential relevance of “narrative” to
development and maintenance of self-harming behaviour, and the incidence of
self-harming issues within educational psychology practice, the case study pre-
sented here explores the usefulness of NT as an EP intervention with an adoles-
cent who self-cuts.
As a necessary precursor to more extensive trialling of NT intervention with
children and young people across a range of contexts and relevant problems
(Frederickson, 2002), the objective of this paper is to present a detailed case exam-
ple from educational psychology practice that illuminates:
• Which NT practices are considered to be helpful by an adolescent who self-

cuts.
• What effect NT has upon the emotional well-being of an adolescent who self-
cuts.
• How NT affects the “self-stories” of an adolescent who self-cuts. [“Self-
stories” are defined by Payne (2006, p. 20) as “the stories we tell ourselves
and others about our lives”].
• How EPs might use NT in their work.
Method of the present study

Case studies are appropriate for studying real life events and processes (Yin, 2009).
A case study methodology allowed the first author, the narrative therapist, to exam-
ine a self-cutting adolescent’s account of herself as it emerged in response to narra-

tive practices.
Case study participant

“B” was a 12 year old (Year 8) girl identified as a “self-cutter” by the Special Edu-
cational Needs Coordinator (SENCo) at her mainstream secondary school following
a consultation with the school’s psychologist on the subject of self-harm. B cut her-
self in public with whatever was at hand (for example, scissors or branches). She
had begun to self-harm approximately two years previously when at primary school,
and in Year 7 she was prescribed beta blocker medication for panic attacks. How-
ever, at the time of the intervention, the panic attacks were infrequent and she was
no longer taking medication. B had no previous experience of counselling or CAM-
HS involvement. She lived with her mother, her younger half brother and her
mother’s boyfriend, who B referred to as her “step-dad”. B had limited contact with
her biological father who had remarried and started a new family. B had some addi-
tional slight learning needs. She had attained level 3 in English at Key Stage 2 (the
average is level 4), and she was in a small class of 18 pupils who were taught for
10 hours a week by their form teacher, M. B’s learning needs were considered
when evaluating her development of narrative, in that she was potentially vulnerable
to forming a dominant problem-saturated story and she might have greater difficulty
generating alternative preferred stories about her life than her more able peers
(Stacey, 1997). Her needs were also considered when applying NT, and the
psychologist therapist adapted narrative practices and language so they were
appropriate to her.
Procedure
Prior to the intervention, B’s mother gave her permission for B to participate in the
study. The first author liaised with professionals at CAMHS who then offered B a
risk assessment, which her mother declined.
Six sessions of NT, of approximately one hour in length, were held in
school at weekly intervals outside school holidays. All sessions were audio
recorded for later analysis. The narrative practices used (see Figure 1) are estab-
lished narrative practices learned by the first author, the EP, on a six day Level
One training course in NT. Understanding of these narrative practices was
consolidated during monthly group supervision with an Association of Family
Therapy (AFT) accredited supervisor, and by reading published texts on narrative
approaches. The EP also received fortnightly generic supervision from a more
experienced EP in her educational psychology service (EPS). The EP’s develop-
ment of narrative practice is set against a background of broader therapeutic
practice and training including Solution Focused Brief Therapy, Counselling
Skills at Certificate level and Postgraduate level study of Cognitive Behavioural
Therapy and Motivational Interviewing.
Therapeutic documents are a key practice of NT (Payne, 2006), and the format
of those used in this study accorded with the guidelines for NT documents in
Freeman, Epston, and Lobovits (1997) and Fox (2003). The narrative practices (see
Externalising
Externalising is designed to help persons to separate from problems they may regard as fixed or
intrinsic to their identity (White, 1995). The narrative therapist listens to the person’s description of, or
name for the problem. The person’s words are rephrased to situate the problem outside, rather than
within the person. For example adjectives (“worried”) or verbs (“worry”) might be changed into nouns
(“the Worry”). Personification can be useful in externalising conversations, for example the therapist
might discuss the problem’s “tricks”, “tactics” and“plans” (Morgan, 2000, p. 24).
Unique outcomes
The therapist listens for events that contradict the problem saturated story. These exceptions to the
problem story are “unique outcomes” (White, 2007, p. 219). A unique outcome may be “a plan, action,
feeling, statement, quality, desire, dream, thought, belief, ability or commitment ” (Morgan, 2000, p.
52). That the person attends the NT session can be a unique outcome. Questions can also be used to
elicit unique outcomes. For example “How have you managed to stop the problem from getting
worse?” (Morgan, 2000, p. 57).
Re-authoring
In “re-authoring” conversations (White, 2007, p. 61) the therapist helps the person to link present
unique outcomes with unique outcomes in their past. For example, “Have there been times in the past
when you have stood up for Fairness/got the better of Anxiety? ” The person is also questioned about
the meaning of the unique outcomes. For example, “What does it say about you as a person that you
would do this?” (Morgan, 2000, p. 63) According to White (2007, p. 62) conversations about these
alternative storylines helps to “thicken” them, which helps the person identify preferred directions and
future problem-solving processes.
Re-membering
“Re-membering”conversations consider significant figures, either still in the person’s life or no longer
present, who might support the alternative emerging story (White, 2007, p. 129). These figures, who
hold memories of the person demonstrating certain skills or traits, are honoured with “membership” in
the person’s “club of life” (Payne, 2006, p. 173). The person is invited to speculate about what this
significant other would think and say about the emerging story. The person can also dismiss people
from their club of life. An example of a re-membering question, is “Who else would know that you
stand for ‘being there for people?’”
Outsider witnessing
“Outsider witnesses” are people, known or unknown to the person, who witness the conversation
between the therapist and the person. Outsider witnesses do not form opinions or give advice on the
person’s story. Their role is to listen to the “telling”of the person’s story. During an interview with the
therapist, they then acknowledge the problematic element and reinforce unique outcomes in a
“retelling” of the person’s story (White, 2007, p. 164–165).
Therapeutic documents
The person is consulted about whether they wish to receive a therapeutic document. They may even
create the document with the therapist (Freedman & Combs, 1996). Fox (2003) identifies four types of
therapeutic document:
1. Letters that record emerging alternative stories.
2. Documents that record knowledge of particular skills or aspects of identify that the person needs to
have available to them at times of crisis.
3. Declaration documents that communicate the alternative stories to others in the family or
community.
4. Documents that contribute to rites of passage, facilitate transitions, and celebrate achievements.
Other
Questioning is used extensively during NT (White & Epston, 1990). Creative approaches such as
games, play, and drawing can be used to identify dominant narratives and develop problem solving
abilities (Freeman, Epston, & Lobovits, 1997).
Figure 1. Description of narrative practices used in the EP’s therapeutic intervention with
B.
Figure 1) were applied according to White’s (2007) Maps of Narrative Practice

which guide the NT process (see the Appendix).
B’s mother and step-father were interviewed at home. The techniques of “exter-
nalisation” and “unique outcomes” were used to explore their version of the domi-
nant problem story, and to identify and reinforce positive family narratives.
B’s class teacher, M, was also interviewed after the first NT session to broaden
understanding of B’s strengths and difficulties, rather than to inform the approach
used, although the first author helped B to “thicken” a particular unique outcome as
a result of the interview with M (see Findings section later). M also attended ses-
sion five of the intervention as an “outsider witness” within the NT process.
B’s readiness to change was assessed pre-intervention in interview using the
Model of Stages of Change (Prochaska & Di Clemente, 1982). Di Clemente and
Velasquez, (2002) suggest that change is more likely to occur if the individual is
close to Stage 3 (“preparation for change”) of the Model of Stages of Change. Prior
to the intervention, B’s response to the Model of Stages of Change suggests that
she was between Stage 2: the “contemplation” and Stage 3: the “preparation”, for
change stage of the model (Di Clemente & Velasquez, 2002, pp. 208–209). B com-
mented: “I’d love to change… I’ve always known it’s not good to do that [cutting]
… but it’s hard.”
Data gathering
Data gathering methods are summarised in Table 1.
Findings
Which NT practices are considered to be helpful by an adolescent who self-cuts?
B’s view
B reported that she considered all the narrative practices helpful, particularly uni-
que outcome conversations, outsider witnessing, therapeutic documents and re-
membering. B also found the therapeutic relationship helpful: “You’ve helped me
a lot … I can tell you everything about my life …. Because I can tell people
things it’s better around the house, so I think it’s a fresh start for me.” The first
author had involved Social Services when B reported an adult neighbour’s sexua-
lised behaviour towards her, and it is likely that the removal of this threat, and
B’s resulting feelings of safety, also contributed to B finding the intervention help-
ful. It is noteworthy that B’s self-cutting behavior pre-dated this problem with her
neighbour.
B’s response to narrative practices

Session transcripts and research diary entries were used to examine B’s responses
to specific narrative practices.
Externalising. At the start of the intervention B acknowledged that, as “Cutting was

around when anger tended to be around,” anger was a problem for her. Externalis-
ing conversations seemed to help B to view anger as a temporary state rather than
as a fixed character trait. For example, B initially said “I’m a stressie person”, but
she externalised anger more frequently as the intervention progressed: “Anger
flushes away when I support people.”
B was able to respond to externalising questions that guided her through Stages
1 to 3 of the Statement of Position Map 1 (see Appendix). For example, at the
naming stage (Inquiry Category 1), she identified when anger was triggered. She
also described the effects (Inquiry Category 2) of anger on her life, either in
response to naming questions, or when asked about the effects directly:
Table 1. Data gathering methods.

194
Method Description
Parental report • B’s mother and step-father were interviewed at home. They:
identified three targets they hoped B would meet as a result of NT on a Target Mon-
itoring and Evaluation (TME) form (Squires, 2006)
provided a baseline rating for each target on a scale of 1 to 10, and a brief descrip-
tion of each baseline behaviour.
rated and briefly described the expected progress for each target.
• Post-intervention, they rated and described actual progress on the TME in a telephone
E. Hannen and K. Woods
interview.
Beck Youth Inventories Second Edition (BYI-II) (Beck, • The BYI-II were used to assess B’s perception of her negative affect pre- and post-
Beck, Jolly, & Steer, 2005) intervention.
• The BYI-II were scored according to the manual.
Resiliency Scales for Children and Adolescents (RSCA)

(Prince-Embury, 2006) • The RSCA were used to assess B’s perception of her emotional reactivity/vulnerabil-
ity pre- and post-intervention.
• The RSCA were scored according to the manual.
Relative Influence Questions (RIQ) (White and Epston,
1990) • Scaling questions in the form of (RIQ) White and Epston (1990, p. 42) were put to B
pre-, mid-, and post-intervention.
• B’s response represented the extent to which her life was “taken up with” or “sepa-
rate from” cutting at the specified time.
• B also completed a RIQ exercise to show her relationship with anger.
Morgan (2000) argues that RIQ contribute to the externalising process that helps the person to
separate from the problem. Therefore, RIQ was both a narrative tool and evaluation technique.
(Continued)
Table 1. (Continued)
Method Description
Narrative Assessment Interview (NAI) (Hardtke and

Angus, 1998) • The NAI is a brief semi-structured interview protocol designed to explore the per-
son’s self-stories and self-perceptions before and after therapy. The NAI consists of
three open questions:
“How would you describe yourself?”

“How would someone who knows you really well describe you?”
“If you could change something about who you are, what would you change?”
• The NAI was completed with B and audio recorded pre-intervention. B’s responses
were recorded on a summary sheet.
• B reflected on the summary sheet in a post-intervention interview.
• The post-intervention NAIs were recorded, and summarised.
• The data on B’s pre- and post-intervention summary sheets were transferred to a table
which facilitated comparison.
Hardkte and Angus (2004) propose that the NAI potentially thickens unique outcome
stories by encouraging clients to reflect on their self-stories and change. Like the
RIQ, it is both a narrative intervention and an evaluation tool.
Therapeutic documents
• Therapeutic documents were given to B during the intervention.
• One purpose of therapeutic documents is to record preferred stories as they emerge in
conversation (Fox, 2003).
• B’s own words were used in the documents when appropriate.
• The documents were checked for accuracy with B, in accordance with narrative prac-
tice (Fox, 2003).
Educational Psychology in Practice
(Continued)
195
Table 1. (Continued)
196
Method Description
Post intervention Likhert (five-point rating) scale • B’s responses to the questionnaire were quoted.
questionnaire and semi-structured interview • B’s responses to the semi-structured interview were audio recorded and transcribed.
• The narrative practices used were identified from transcripts of the therapy sessions.
• B’s responses to narrative practices were organised in charts according to White’s
(2007) maps of narrative practice.
• Examples of B’s responses to specific narrative practices were also quoted to allow
the reader to assess the fit between the data and its interpretations.
E. Hannen and K. Woods
Reflective diary • After each NT session the first author recorded observations on B’s responses to nar-
rative practices and processes in a reflective diary. Observations were recorded in tab-
ular form, according to:
whether they provided positive or negative evidence for the helpfulness of narrative
practices,
whether there was a need for clarification through supervision.
• Other observations were recorded under “further reflections”.

Researcher (R):What effect is it [anger] having on your friendships and your family?
B: When my family fall out, say if I fell out with mum, mum would be
stressed and then mum would fall out with nana, and … nana would
fall out with granddad, and I’d feel stupid because it’s all come down
on me, making all my family fall out. I feel awful.
B appeared comfortable with externalising through personification. When presented

with several metaphors describing potential effects of anger on her life, she chose
one that was valid for her:
R: Would you say that anger is limiting your life, or messing up your life, or tying
you down?
B: I’d say it’s messing up my life because I’ve lost a lot of friends through anger.
B sometimes spontaneously referred to her position (Inquiry Category 3) on anger,

or explained her position in response to questions that first summarised the effects
of anger on her life:
R: So anger seems to enjoy getting you into trouble with your family, getting you
into trouble at school …. Can you tell me a little bit more about why it doesn’t
suit you?
B: Because it turns me against a lot of people …, but really I don’t mean it, and
I’ve just lost a friend.
Rather than identify her values (Inquiry Category 4), B tended to thicken the prob-
lem story.
R: So you’re not happy with anger, because often you see that the anger’s … mak-
ing you lose friends. I wonder what this suggests is important for you in your
life?
B: I don’t know, I just wish half of them would leave me alone and let me do my
own thing … If people did that I wouldn’t have much anger.
Externalising language sometimes appeared to enable B to distance herself from

responsibility for anger: “Anger just takes control of me, it’s like a new me, it just
comes and then I come back.” Further questioning that guided B though the State-
ment of Position Map 1 helped B to accept personal agency. At other times when B
had difficulty responding to externalising questions, she was able to respond after
paraphrasing, reminders of her responses in previous sessions, or when her values
were tentatively inferred:
R: So are friendships very important to you, is that something that you value?
B: It’s not that I value having friendships with other people, it’s just these people
that I’ve known for quite a while and we’re very close … and I can tell them
anything … and they won’t tell a thing [to others].
Providing B with a box of objects to stimulate her imagination helped her to pro-
vide a more “experience near” definition of the problem (White, 2007, p. 40). She
modelled the anger in Plasticine: first imitating a plastic dinosaur from the objects
provided, then spontaneously modelling a devil’s head that represented how she
appeared to others when angry. This practical activity at the start of the intervention
appeared to alleviate B’s anxiety at meeting somebody new, and she considered it
the most enjoyable activity of the intervention.
Unique outcomes. B named unique outcomes, and described their effects on her life.
For example, in apologising to a teacher after an incident, she had “made that teacher
proud”. It helped that B appreciated the positive effect of unique outcomes on others
whose guidance would help her to make social progress, for example, her teachers. B
had difficulty providing accounts in which unique outcomes were sustained, and she
mostly ended her accounts with references to violence: “And then I know I shouldn’t
have done it, but I grabbed her by the scruff of the neck …” Accentuating the posi-
tive in B’s account, for example that she had initially resisted violence when a girl
had spread malicious rumours about her, helped B to identify her values:
R: So you talked to her … you got her to tell the truth to the boys, why was that
important for your friendship?
B: Because friends don’t do that, friends don’t make trouble for their friends.
Eliciting from B how she felt she should have responded also helped B to describe
her position and values in response to the Statement of Position Map 2 (see the
Appendix).
B had difficulty consistently identifying strategies that helped her to control
anger. In addition to returning to a problem saturated story, she lost track of the dis-
cussion, or even changed the subject completely. B, who enjoyed role play was
interviewed for the purpose of helping another young person deal positively with
anger. Strengths cards (Deal & Veeken, 1996) and B’s responses to earlier questions
regarding what she should have done were used to plan her responses to the inter-
view questions. This activity helped B to focus on her successes, helpful strategies,
and her preferred direction in life.
B appeared to reflect upon what was important to her in between sessions. For
example B stated in session two, “These sessions have been helping [me] think
about stuff, things in the past.” In session three she volunteered that she would like
to contact her father, and that her anger was “building up … [because] … I’m not
seeing my dad more.”
Re-authoring. B identified a preferred future and suitable actions in response to re-

authoring conversations. For example B had named a unique outcome, her A⁄ grade
in Drama:
R: is there something that you learned about yourself, the fact that you did this per-
formance and got this A⁄?
B: I learned that it’s not all about my family you know, I have to think about myself
sometimes. … “It’s like I’m always there for other people, but I’m never there
for myself.”
R: You said you need to think of yourself sometimes …. Can you think of what
you’re doing at the moment that might show me you’re starting to think about
yourself now?
B provided a rich account of her preparations for a forthcoming talent competition.

R: Can you think of a name for this direction that you’re moving in?
B: I want to be independent.
B agreed that “moving towards independence” was a suitable name for her project.
She identified future unique outcomes related to this theme “I’m going to come out
more to mum, I’m going to start telling her things I should have told her a long time
ago” For B, being able to confide in her mother was an important step. She com-
mented in the final session, “Now I know that I can tell my mum things … I know
things can be solved.” An action from this conversation was that B would tell her
mother that she would like to contact her father. Self-harming adolescents may be less
able than their peers to solve problems effectively (Evans, Hawton, & Rodham, 2005),
and, as B was unclear about how best to contact her father, this was decided by using
a problem solving activity. B wrote a solution focused letter to her father, with the help
of the first author. Her mother checked this and agreed it was appropriate.
B, who wanted to be a singer, also said that she would concentrate more on her
voice. When B informed her mother of this, her mother said, “I never realised how
much you were focusing on that singing thing. If I’d known, I’d have started putt-
ing you in competitions.”
Re-membering. B had difficulty understanding questions designed to help her to

identify people who would be supportive of her new direction in life. She tended to
provide a further description of the problem, for example that she would not want
people to know her preferred direction, “I don’t want to tell them anything because
sometimes it gets out of hand.” Simplifying the activity, so that B was required
only to list supportive people, and recording this information in a therapeutic docu-
ment helped B to distinguish between those who were conditionally and uncondi-
tionally supportive of her. Recognising those who were conditionally supportive
may have helped B to invest less value in their opinions, thus supporting her in her
“move towards independence”. B agreed later that it was appropriate to include her
outsider witness (her teacher) in her supportive club.
Outsider witnessing. B’s teacher, M, attended one NT session as an outsider wit-

ness. The first author gave an account of B’s story whilst M and B listened. This
was because B tended to move on to unrelated topics in interview, and time was
restricted. The account included a brief description of the problem, unique out-
comes, and B’s commitment to “being there for people” and “moving towards inde-
pendence”. M was provided with a visual prompt, a therapeutic document
highlighting B’s unique outcomes at the start of the session. B listened to this inter-
view, and then she reflected on M’s comments.
In the post-intervention questionnaire, B chose “strongly agree” that involving
outsider witnesses was helpful. B responded, “She really helped me with realising
how much I’ve changed [from] when I wouldn’t tell anyone anything about what
happened at home or at school … now I know her so much I can open more and
tell her more.”
White (2007, p. 165) states that outsider witnesses should not “form opinions,
give advice, make declarations, or introduce moral stories.” Though the outsider
witness procedure was explained to M before her participation, M sometimes gave
affirmations, or attempted to draw B into the conversation:
R: Why are you not surprised that B is going in that direction [moving towards inde-
pendence]?
M: For years, this is what B’s always wanted, isn’t it B, and she’s never been fright-
ened of saying this is what she wanted to do. She’s always been very ambitious
where that is concerned, haven’t you sweetheart?
Sometimes M returned the focus to the problem story. M said of the unique out-
comes in the therapeutic document, “I think B sometimes struggles to do some of
those things when she’s upset about something.” M also invited B to validate the
problem story:
B: When she said when I say something I will stick to it, she made me realise how
much I do stick to it.
M: In the past that could be something bad, it could be “I’m not doing it!” It could
be just as much that way as something fantastic because that’s what you do, and
no talking will get you out of it, because if she’s got that mindset she’s got that
mindset, she’s stubborn, aren’t you darling!
However, M also assisted with the re-authoring process, as her established relation-
ship with B enabled her to draw attention to the link between B’s past and present
unique outcomes.
R: You wouldn’t be surprised to learn that one of B’s priorities is to be there for
people?
M: Definitely not, she’s always there for everybody who needs her … She even
wants to be there for the staff.
M described how B’s present behaviour compared positively with her past behav-
iour by commenting on B’s recent application in Maths lessons, although this was
an area in which M, rather than B, invested value. M also referred to B’s recently
acquired ability to communicate: “B’s … not been able to express her true feelings
completely. But I do feel that now she can.” In the post-intervention Narrative
Assessment Interview (NAI), B described herself for the first time as “open”. M’s
contribution as an outsider witness appeared to have helped B form this positive
conclusion about herself.
M’s continuing relationship with B was helpful in that M agreed to watch for
actions that confirmed and thickened B’s positive emerging story. M also provided
guidance between therapy sessions when B shared her therapeutic documents and
the letter she had written to her father. M said that sharing B’s story was helpful
because “I know now what’s bothering you [B] and that’s something we can talk
about.”
A difficulty of having a teacher as an outsider witness was that M responded
guardedly when questions required a personal response:
R: I wonder whether the path that B’s taken, whether it strikes a resonance with your
own life?
M: Not particularly (laugh).
However, M considered that B, unlike some of her pupils, was able to move easily
between relating to M on a personal level, and accepting boundaries as a pupil.
Therapeutic documents. The therapeutic documents included two letters summaris-

ing B’s emerging preferred story, and a document of “knowledge” (Fox, 2003, p.
27) reminding B of future steps, skills, and positive aspects of her identity. A decla-
ration document highlighted B’s emerging positive story, as identified by her out-
sider witness, and another document acknowledged B’s supportive team. B also
received a certificate celebrating her commitment to her positive story. B confirmed
that all documents were accurate. The documents were given to B during the inter-
vention, and were presented again in a folder post-intervention.
B’s mother read the documents, and this facilitated family discussion and B’s
aim of being more “open” with her mother. B also showed the documents to her
teacher, M, who discussed and thickened the more positive story and provided fur-
ther guidance for B. B appeared proud of her folder of therapeutic documents, and
she asked to include the Relative Influence Questions (RIQ) documents to further
illustrate her progress.
What effect does NT have upon the emotional well-being of an adolescent who
self-cuts?
All measures, apart from the Beck Youth Inventories Second Edition (BYI-II), sug-
gest that the outcome for B was a significant improvement in emotional well-being
over the intervention period.
According to the BYI-II there was a slight deterioration in emotional well-being
over the intervention period (see Table 2).
Table 2. B’s BYI-II pre- and post-intervention score summary.

Pre-/post- Raw T
BYI-II inventory score score Score Percentile Range
BSCI-Y self-concept Pre- 40 48 39.1 Average
Post- 33 40 18.3 Lower than
average
BAI-Y anxiety Pre- 22 57 82.7 Mildly elevated
Post- 24 59 87.6 Mildly elevated
BDI-Y depression Pre- 11 47 49.0 Average
Post- 18 56 78.7 Mildly elevated
BANI-Y anger Pre- 24 58 82.7 Mildly elevated
Post- 29 64 90.6 Moderately
elevated
BDBI-Y disruptive Pre- 5 45 37.1 Average
behaviour Post- 3 41 19.8 Lower than
average
Note: The mean T score is 50 and the standard deviation is 10; the cumulative percentage shows the
percentage of girls in B’s normative group (ages 11–14) who had scores at or below B’s T score; on
four of the five inventories (BAI-Y, BDI-Y, BANI-Y and BDBI-Y), the higher the T score and cumula-
tive percentage, the greater the severity; on the BSCI-Y, a higher T score and cumulative percentage
indicates a less positive self-concept, and a lower T score and cumulative percentage indicates a posi-
tive self-concept.
Table 3. B’s RSCA pre- and post-intervention score summary.

RSCA scale/index Pre-/post-score T Score Percentile Range
Mastery Pre- 42 25.9 Below average
Post- 51 57.1 Average
Relatedness Pre- 52 60.7 Average
Post- 56 69.6 Above average
Emotional reactivity Pre- 59 81.7 Above average
Resource index Pre- 45 31.4 Average
Vulnerability index Pre- 59 82.1 Above average
Post- 49 50 Average
B’s BYI-II profiles show a slight deterioration in indices of depression, self-

concept and anger, and a slight improvement in behaviour post-intervention. B’s
teacher, M, and mother also reported that B’s behaviour had improved post-inter-
vention although M did not link this specifically to the narrative intervention. In the
outsider witness session M said, when B was “upset about something … you
couldn’t have spoken to her … [She] cut up and … had these panic attacks … but
now even if she’s upset, we can … have a conversation … [She’s] not walking out
of lessons … [and] not having panic attacks.”
B’s Resiliency Scales for Children and Adolescents (RSCA) scores suggest that
post-intervention, B had a greater sense of mastery/efficacy and social relatedness,
and quicker recovery when aroused (see Table 3).
B’s greater perception of her personal resources and lowered emotional reactiv-
ity post-intervention suggest that she was less vulnerable and more resilient than
pre-intervention.
According to RIQ, B perceived that her life was completely “separate from” cut-
ting post-intervention, whereas one third of her life was “taken up” with it pre-
intervention. B also considered that more of her life was “separate from” anger
(80%) post-intervention than pre-intervention (50%).
B responded in her post-intervention NAI that her negative pre-intervention
descriptions or accounts of herself no longer applied. B said she was happier post-
intervention, and she no longer defined herself as a “stressie person”, nor did she
have panic attacks and she no longer responded with anger to “the slightest thing.”
B’s mother and teacher separately confirmed that B had more control of anger
post-intervention than pre-intervention. The NAI and transcripts suggested that B
felt safe post intervention. She was no longer “petrified”, and she believed that
“things can be solved.”
How does NT affect the “self-stories” of an adolescent who self-cuts?

The pre-intervention positive accounts B gave of her nurturing qualities in the NAI,
were still valid for her post-intervention. For example, pre-intervention she
described herself as “caring” and post-intervention as “supportive”. Though B
referred to herself as “still very thoughtful” post-intervention, she considered she
now thought about herself more, rather than automatically putting her friends and
family first. This suggests that B was living a preferred alternative story, identified
during the intervention, of being more considerate of her own needs.
When asked what her preferred direction in life, “moving towards indepen-
dence” might mean for her future, B said, “I’m going to come out more to mum.
I’m going to start telling her things that I should have told her a long time ago.” In
the post-intervention NAI B said that she was more “open” with others. Her view
of herself as a more “open” person had been assimilated into her sense of identity.
Parental and teacher report indicated that B was more “open” post-intervention and
more able to communicate her thoughts and feelings. Communication skills can be
a significant factor in promoting resilience [Department for Education and Employ-
ment (DfEE), 2001]
B’s family narrative was that mother and daughter were alike because of their
positive “supportive and caring” characteristics. When B indicated that she wanted
to write to her father, B’s mother supported B, and praised B’s letter, although con-
tacting her ex-husband was not perhaps in her own interest. Similarly, once aware
of B’s commitment to developing her singing, she arranged public performances for
B. In this case exploration of individual family member’s preferred ideas about
events and relationships was sufficient to modify patterns of family interaction
(Minuchin, 1998).
How might EPs use NT within their work?

The approach used with B initially bore some similarity to Monsen, Graham,
Frederickson, and Cameron’s (1998) Problem Analysis Framework. For example,
before proceeding with NT the referrer’s concerns were clarified, and it was
ascertained whether other agencies, in this case, CAMHS were, or should be,
involved. Mental health professionals at CAMHS at this stage offered to risk
assess B.
There were also similarities with Geldard and Geldard’s (2008) Process of Child
Therapy Model, in that B’s mother and step-father were interviewed without B
being present to ascertain their version of the family narrative. Consulting B’s par-
ents and teacher helped to validate information given by B. For example B said she
was still taking medication for panic attacks, whereas her mother reported that B
had stopped medication on her doctor’s advice. B’s teacher’s description of B’s rela-
tionship with her classmates also influenced the first author’s decision to help B
thicken her preferred story of “think[ing] about [her]self sometimes”. Pre- and post-
intervention measures were used with B, her parents and teacher to evaluate the
intervention. As in the Process of Child Therapy Model, the NT process was evalu-
ated throughout the intervention, and narrative practices were adapted to suit B’s
interests, learning needs and developmental level. Counselling skills, for example
summarising, reflecting, and clarifying were used to develop the therapeutic rela-
tionship and enable B to provide an account of her life.
The authors were unable to find published comparative data to show the range
of lengths of time that EPs usually spend on intervention at the individual case
level. Within the employment context of the EP narrative therapist in this case, the
total time allocation of approximately 20 hours, including necessary preparation and
supervision time, represents a very high level of intervention. However, the inter-
vention could have taken less EP time; if for example, a supportive adult from the
school had been able to help B with practical activities like writing the letter to her
father.
Integration of NT practice to EP work

The EP added to, departed from, or integrated other approaches to NT when this
was judged to deal more effectively with the presenting issue. The different roles of
EP and narrative therapist were balanced and prioritised accordingly. Child Protec-
tion Procedures involved working as an EP to mediate between B, her family, the
school, and Social Services. Before beginning NT, B was questioned about her rea-
sons for cutting, and about strategies or environmental factors that helped her to
avoid cutting. The aim was to identify those issues that might be immediately
addressed (Selekman, 2006). Two visualisations (Selekman, 2006) were introduced
when B identified that time spent alone upon reflection was helpful for her. B stated
that visualisations would be helpful for other young people experiencing anger. A
brief problem solving approach was integrated into the narrative approach when B
identified an action, but was uncertain about the best way to perform it. B consid-
ered that the problem solving activity was the most helpful of the intervention. A
suicide prevention protocol [Skills Based Training on Risk Management (STORM)
(Lever-Green and Hays, 2008)] was introduced when B referred to wanting to kill
herself. After assessment using the STORM protocol and discussion with an EP col-
league during supervision, a full mental health and psychosocial assessment was
considered unnecessary.
Discussion
Arriving at a balanced formulation of the findings
In this research case study, all qualitative and quantitative data, apart from the BYI-
II, suggest that B’s emotional well-being, resilience, and behaviour improved over
the intervention period. Much educational psychology assessment and research, par-
ticularly case study research, adopts a “mixed methods” approach, gathering and
interpreting both qualitative and quantitative data [British Psychological Society
(BPS), 1999; Plano Clark & Creswell, 2008; Yin, 2009]. The rationale for this
approach, founded in critical realist epistemology, is that the different types of data
access different “truths” (BPS, 1999). Quantitative, standardised data allow reference
to generally accepted and widely used concepts (such as “depression”, “intelligence”,
or “anxiety”); qualitative data allow access to an individual’s interpretations, and the
complex dynamics of causality (Miller and Frederickson, 2006). Whilst offering this
“best of both worlds”, mixed methods approaches in both research and assessment
do raise the challenge of data integration, particularly where data may appear to be
inconsistent.
In B’s case, qualitative, structured interview evidence of post-intervention
changes is consistent: post-intervention, B said she was happier, was no longer cut-
ting, and that less of her life was consumed by anger. Parent and teacher report con-
firmed that B’s behaviour had improved, and she was no longer having panic
attacks. B’s post-intervention account of herself introduced new positive identity
conclusions, suggesting that she was re-authoring her life to accord with her pre-
ferred alternative story, identified during therapy. Post-intervention, B’s more posi-
tive account of family life was confirmed in a telephone interview with her mother.
NT with B, and a brief exploration of the problem and preferred stories with B’s
mother appeared sufficient to modify the family style of relating (Minuchin, 1998).
Quantitative data from the RSCA (Prince-Embury, 2006) are consistent with this
generally improved adjustment, however, quantitative data from the BYI-II (Beck
et al., 2005) indicate some level of deterioration in measures of self-concept,
depression and anger. Three considerations are relevant:
• First, although reliability of the BYI-II as a measure is generally high, it is

possible that there may be a degree of unreliability in pre- or post-measures
in an individual case (for self-concept, depression and anxiety internal consis-
tency coefficient alphas are 0.91, 0.91, and 0.89, respectively; for test–retest
reliability coefficients are 0.81, 0.87 and 0.88). In B’s case there were no spe-
cific indications to suggest possible unreliability within either the quantitative
or qualitative data gathering, but the possible influence of response set or
social desirability cannot be ruled out entirely, whilst bearing in mind the US
standardisation of the BYI-II.

• Second, an element of measurement bias may relate to validity of the BYI-II
which, whilst generally satisfactory, does contain a margin of potential error
(cf. Beck et al., 2005). In this respect it may be that apparently contradictory
data points (for example, statements of being happier and less angry along-
side BYI-II measures suggesting increased depression and anger indicators)
are in fact reliable measures of different constructs for B.
• Third, the psychologist’s task as a scientist practitioner is to provide a bal-
anced and integrated formulation (Lane & Corrie, 2006). On balance there-
fore, assuming equal reliability and validity of data gathered, the researchers
view the overall picture of post-intervention outcomes for B as positive.
NT in education psychology practice

One of the aims of this work was to illustrate the use of NT within a school, and a
real life, rather than a clinical context. The NT practised in this example is itself a
piece of systemic work, involving the teacher, as outsider witness, the young per-
son, and the parent.
A frequently asked question within the evaluation of specific therapeutic
work is the extent to which the effects of the therapy might be attributable to
generic therapeutic relationship skills rather than to elements specific to the par-
ticular therapy under evaluation (Asay & Lambert, 1999). This question can only
be fully addressed through a non-specific “treatment as usual” control group
within an experimental evaluation (Cohen, Manion, & Morrison, 2007). The
present case study research, however, is a precursor to broader experimental
evaluation, allowing the identification of relevant parameters of sampling, inter-
vention and context for experimental design; as such, the present research does
not seek to definitively answer the question of generic and specific therapeutic
effects (Frederickson, 2002; Yin, 2009). Nonetheless, the identification, through
data gathering and analysis, of specific reported and observed elements of NT
(for example, re-authoring; outsider witnessing) relating to the positive outcomes
of this NT intervention, supports the conclusion that some degree of the
observed success of this NT intervention is instrumentally linked to specific ele-
ments of NT.
Based upon these findings which support the utility of the NT approach as used
here, the authors propose a model of NT practice for use by EPs. This model, out-
lined in Figure 2, contains elements of the following:
• Division of Educational and Child Psychology (DECP) Framework for Psy-

chological Intervention (BPS, 1999)
• Problem Analysis Framework (Monsen et al., 1998)
• Process of Child Therapy model (Geldard & Geldard, 2008).
The model has eight stages; the first five of which are sequential. Stage 6 is a guide
to the therapeutic process and the options within this are indicated by a broken line.
The objective of NT, “A Preferred Alternative Story”, is at the centre of the dia-
gram. Supporting methods are shown in concentric rings around Stage 6. In general,
supporting methods, including therapeutic documents, are positioned at their point

of use, although the majority of the methods can be used creatively throughout the
process. Some key factors that underpin the use of NT by EPs are positioned
around the borders of the page (Figure 2).
Stage 1: Request for EP involvement – The EP clarifies the referrer’s concerns and
ascertains whether other agencies are, or should be involved.
Stage 2: Risk assessment – CAMHS – Before beginning therapeutic intervention

with CYP who are self-harming, the EP liaises with CAMHS workers to ascertain
Figure 2. Model of narrative practice.

whether it is ethical to proceed and whether the client should be offered a risk
assessment.
Stage 3: Information gathering – Gathering information from the client, their family,
school and other agencies, helps the EP form initial hypotheses and determine
whether therapeutic intervention is appropriate.
Stage 4: Discuss therapeutic intervention with parents/carers – The EP explains the

therapeutic process and confidentiality to parents/carers, and gains their permission
to proceed.
Stage 5: Baseline measures – Taking baseline measures facilitates later evaluation

of the intervention.
Stage 6: The therapeutic process – In guiding the client through the NT Statement
of Position Map 1 and the Unique Outcomes Map (Statement of Position Map 2)
(see the Appendix), the EP might consider:
• A detour from NT if it appears that the client might benefit from a different
therapeutic approach.
• Moving to Stage 7 (evaluation) if the client:
does not respond to therapeutic intervention;
identifies a preferred alternative story and appropriate actions in response
to the Unique Outcomes Map.
• Continuing with the narrative process with re-authoring, re-membering and
outsider witnessing.
• Proceeding directly to re-membering or outsider witnessing with those CYP
who have difficulty responding to re-authoring conversations. Some CYP, sup-
ported by the knowledge gained in re-membering and outsider witnessing,
may then return to the re-authoring process.
• A narrative interview with parents/carers to thicken the client’s unique out-
comes identified during NT.
• Using a problem solving activity at “Action” stages of the therapeutic process.
Stage 7: Evaluation – The therapeutic intervention is evaluated by reviewing the cli-

ent’s progress and re-administering those measures applied at Stage 5. As scientist
practitioners EPs will need to evaluate their own actions, and those of their client,
through reflexivity, reading and supervision throughout the intervention (Lane &
Corrie, 2006), which can be tailored accordingly.
Stage 8: Mediation – The EP mediates with other adults to develop their under-
standing of the client and their preferred story, and to problem solve how others
might support the client in positive change.
This present case study raises further considerations for psychology practitio-
ners. Though teachers are expected to assume responsibility for their pupils’ emo-
tional well-being (DfES, 2004) they may have had little training to equip them for
such a role (Rothi & Leavey, 2006). Teachers are likely to be unfamiliar with the
psychological principles of outsider witnessing, which could affect their ability to
respond appropriately to the client. In this case study, involving a teacher as an out-
sider witness was advantageous in that the teacher reinforced B’s unique outcomes
in-between sessions and after the therapeutic intervention had ended. However, as
an outsider witness, she sometimes unwittingly flouted narrative conventions, rein-
forced the problem story, or referred to B as having negative character traits. In
contrast, in another case, when the first author involved an outsider witness team of
family therapists and clinical psychologists, they consistently applied narrative prin-
ciples and a non-judgemental attitude. This supports Fallon et al.’s (2010) conten-
tion that more integrated working between the National Health Service (NHS)
mental health professionals and EPs in the delivery of therapeutic approaches could
help to reinforce and maintain the gains made by the client, particularly when EPs
mediate closely with teachers and pastoral staff.
The present research usefully highlights considerations relating to the integra-
tion of therapeutic intervention with the EP’s role as a registered practitioner
psychologist employed within a local authority context. NT, in common with

other therapies such as person-centred counselling or solution focused brief ther-
apy (SFBT), holds a client-centred position which allows the therapy to be pri-
marily directed according to the client’s wishes and aims, notwithstanding certain
fundamental ethical sanctions upon the support of client aims which might cause
the client significant harm, such as suicide (Morgan, 2000; George, Iveson, &
Ratner,1999). It is possible to envisage situations where a CYP might adopt an
aim or strategy (for example, in resolving a peer or staff relationship difficulty
in school; in engineering a change in school placement), which, whilst not
clearly placing them at risk of significant harm, might be regarded as incompati-
ble with an EP’s Health Professions Council (HPC) requirements to act in the
best interests of the client and to maintain a duty of care towards them (HPC,
2009, SoP 1a.1 and 1a.5). In addition, as local authority employees, EPs work
under the direction to actively improve a range of outcomes for CYP (DfES,
2004). For example, it may become apparent to the EP during the course of
therapy that the EP’s adoption of a pro-active role with school staff might be
effective in improving outcomes for the CYP which have not been prioritised
by the CYP themselves, for example, improvements in the CYP’s curriculum
access might be hypothesised to improve the CYP’s relationships in school.
Within this, however, there is a fundamental ontological and ethical issue in that
the therapist and client might well be working within the same outcomes frame-
work (for example, Every Child Matters, DfES, 2004) but each defining these,
quite legitimately, from their own points of view. For example, whilst an EP
might be aiming to improve a CYP’s “achievement” and “positive contribution”,
the CYP’s aims and strategies within the therapeutic process might be congruent
with their own views on “economic well-being” and “enjoyment”.
In the present research, potential conflict between the roles of therapist and other
aspects of educational psychology work was addressed by B having access, in
effect, to two EPs: one EP who was leading the therapeutic intervention and another
EP who could lead on other aspects of intervention for B if necessary. In this way,
the option for B was not for either specific therapeutic EP intervention or other EP
intervention, but for therapeutic intervention with additional EP intervention if/
where necessary. Where this option is not possible, a lone EP providing therapeutic
input has to monitor the costs and benefits of the work being undertaken and decide
whether a change of intervention plan would be more efficacious (HPC, 2009, SoP
2c.1).
Providing the option to CYP of therapeutic intervention by one EP with addi-

tional access to other types of EP intervention by another EP has the advantage of
avoiding conflict and confusion in the mind of the client and potentially improving
the protection of integrity of the therapy. However, this option is also potentially
more demanding of educational psychology resources, requiring coordination of
input and boundary delineation, and possibly additional direct time input. This
option also raises interesting implications for the development and dovetailing of
role specialisations within an EPS (Fallon et al., 2010). Notably, the present authors
found no empirical research which delineates how EPs establish, embed and
develop particular therapeutic skills over the medium to longer term. Developing
therapeutic specialisations across an EPS might in fact improve the embedding and
development of EPs’ therapeutic skills and release them to some extent from the
perceived demands to maintain and extend skills across all areas of general educa-
tional psychology practice, that is “to be an expert in everything”.

Another advantage of developing therapeutic specialisations across an EPS is
that it could enable EPs developing therapeutic skills to access specialist peer
supervision. In the present case study, fortnightly supervision from a more expe-
rienced colleague in the EPS assisted in examining the broader context of B’s
case. Additional monthly group supervision sessions with an accredited narrative
practitioner provided valuable, if limited, opportunities to discuss B’s case from
a narrative perspective. The authors suggest that more research into the types of
supervision available to, and accessed by, EPs would be beneficial.
The present case study makes a potential contribution to evidence-based practice
for EPs and other therapeutic practitioners. Frederickson (2002) identifies the contri-
bution of case study research at the early and later stages of evaluating a particular
kind of intervention, with larger scale randomised control trials being useful for
establishing general efficacy once the main characteristics of the intervention and
likely target population have been determined. However, available time and funding
often prohibit EPs from setting up large scale experimental research designs and so
the present authors consider that a large series of experimentally designed case stud-
ies might be the most feasible way for EPs and trainee EPs (TEPs) to build the evi-
dence-base for NT (Barlow, Nock, & Hersen, 2008). An additional benefit of this
approach would be that a bank of case studies would provide details of the individ-
ual complexities of applications of the therapeutic process (Frederickson, 2002).
The challenge in developing a coherent series of case studies is in regulating data
gathering within each case so that cross-case comparisons can be made effectively,
in order to propose information about an intervention’s general effectiveness (Yin,
2009). For example, the present case study omitted data on school staff perceptions
of the feasibility of school-based therapeutic interventions, which would be valuable
for targeting future applications. The authors suggest that academic EPs within uni-
versity departments might collaborate with practitioner EPs within EPSs to set up
robust systems for case study research data gathering. This would serve to some
extent to regulate EPs’ therapeutic practice as well as assisting academic psycholo-
gists in developing and disseminating the professional evidence base.
Notes
1. The Macmillan Dictionary of Psychology (Sutherland, 1995, p. 468) defines “therapy”
as “Any treatment for an illness or disorder undertaken with the intention of
ameliorating or curing it”. The term is widely understood to transcend the medical con-
text (MacKay & Greig, 2007), and it is associated with concepts of “happiness”, “qual-
ity of life” and “making happier” (Indoe, 1995, p. 4).
2. The Goth youth subculture began in the UK during the 1980s. It has a dark aesthetic,
influenced by nineteenth century Gothic literature and later horror films. Goths are often
distinguished by their distinctive clothing, make-up and tastes in music (Young et al.,
2006).
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Appendix. White’s (2007) Maps of Narrative Practice

Externalising: Statement of Position Map 1
The “Statement of Position Map 1” is designed to assist therapists in developing
externalising conversations. It consists of four categories of inquiry (Payne, 2006,
p. 76):
(1) Naming the problem: Negotiation with the person of the precise externalised
definition of the problem, using the person’s terms.
(2) Effects: Eliciting a description of the effects of the problem on the person’s
life and relationships.
(3) Position: Ascertaining the extent to which the person wishes things to stay
as they are or to be different.
(4) Wider values: Asking the person the reasons for their answers to (3), and
what in their life history has led them to make this evaluation. According to
White (2007) this helps people to voice, understand, and develop what they
value in life.
Unique outcomes: Statement of Position Map 2

The “Statement of Position Map 2” focuses on exceptions to the problem saturated
story and consists of the same four categories of inquiry as the Statement of Posi-
tion Map 1 (Payne, 2006, p. 76):
(1) Naming the unique outcome: Negotiation with the person of the precise defi-
nition of the unique outcome.
(2) Effects: Eliciting a description of the effects of the unique outcome on the
person’s life and relationships.
(3) Position: Ascertaining the extent to which the person is positive, negative or
ambiguous about the effects of the unique outcomes.
(4) Wider values: Asking the person the reasons for their answers to (3), and
what in their life history has led them to make this evaluation.
Re-authoring: Re-authoring Conversations Map

The “Re-authoring Conversations Map” (White, 2007, p. 75) is based upon a text
analogy that represents stories as composed of a “landscape of action” and a “land-
scape of identity” (White, 2007, p. 81) The person provides an account where
events are linked together in sequences through time and according to specific plots
(landscape of action). The person also indicates what they think certain events
reflect about their own and others’ character, motives, and desires (landscape of
identity). The re-authoring conversations map consists of two parallel horizontal
timelines ranging from “remote history”, “distant history”, “recent history”, “pres-
ent” and “near future”. The person’s responses to landscape of action and landscape
of identity questions are plotted according to the time in history when they
occurred/might occur.
Outsider witnessing: Outsider Witness Retelling Map

The “Outsider Witness Retelling Map” charts the four stages of outsider witness
inquiry:
(1) The outsider witnesses identify the expressions that they were most drawn to
as they listened to the telling of the person’s story.

(2) They identify any metaphors or images that came to mind as they reflected
on the person’s values, beliefs, hopes and aspirations.
(3) They identify why the expressions they were drawn to have a personal reso-
nance for their life.
(4) They identify ways in which they have been moved or transported by the
person’s account.

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On: 09 October 2014, At: 06:39

Educational Psychology in Practice:

Narrative therapy with an adolescent

To link to this article: http://dx.doi.org/10.1080/02667363.2012.669362

PLEASE SCROLL DOWN FOR ARTICLE

Narrative therapy with an adolescent who self-cuts: a case

The National Institute for Clinical Excellence identiﬁes educational psycholo-

gists as appropriate specialists to deliver interventions to promote the emotional

*Corresponding author. Email: elaine.hannen@bolton.gov.uk

ISSN 0266-7363 print/ISSN 1469-5839 online

Self-harm and mental health

Narrative therapy (NT)

NT aims to help people identify dominant problem-saturated narratives, dis-

positive NT intervention in a medical centre with a 13 year old boy with

• Which NT practices are considered to be helpful by an adolescent who self-

Method of the present study

ine a self-cutting adolescent’s account of herself as it emerged in response to narra-

Case study participant

Figure 1) were applied according to White’s (2007) Maps of Narrative Practice

B’s response to narrative practices

Externalising. At the start of the intervention B acknowledged that, as “Cutting was

Table 1. Data gathering methods.

Resiliency Scales for Children and Adolescents (RSCA)

Narrative Assessment Interview (NAI) (Hardtke and

 “How would you describe yourself?”

• Other observations were recorded under “further reﬂections”.

B appeared comfortable with externalising through personiﬁcation. When presented

B sometimes spontaneously referred to her position (Inquiry Category 3) on anger,

Externalising language sometimes appeared to enable B to distance herself from

Re-authoring. B identiﬁed a preferred future and suitable actions in response to re-

B provided a rich account of her preparations for a forthcoming talent competition.

Re-membering. B had difﬁculty understanding questions designed to help her to

Outsider witnessing. B’s teacher, M, attended one NT session as an outsider wit-

Therapeutic documents. The therapeutic documents included two letters summaris-

Table 2. B’s BYI-II pre- and post-intervention score summary.

Table 3. B’s RSCA pre- and post-intervention score summary.

B’s BYI-II proﬁles show a slight deterioration in indices of depression, self-

How does NT affect the “self-stories” of an adolescent who self-cuts?

How might EPs use NT within their work?

Integration of NT practice to EP work

• First, although reliability of the BYI-II as a measure is generally high, it is

standardisation of the BYI-II.

NT in education psychology practice

• Division of Educational and Child Psychology (DECP) Framework for Psy-

supporting methods, including therapeutic documents, are positioned at their point

Stage 2: Risk assessment – CAMHS – Before beginning therapeutic intervention

Figure 2. Model of narrative practice.

Stage 4: Discuss therapeutic intervention with parents/carers – The EP explains the

Stage 5: Baseline measures – Taking baseline measures facilitates later evaluation

Stage 7: Evaluation – The therapeutic intervention is evaluated by reviewing the cli-

psychologist employed within a local authority context. NT, in common with

Providing the option to CYP of therapeutic intervention by one EP with addi-

tional psychology practice, that is “to be an expert in everything”.

sonal strengths. San Antonio, TX: Harcourt Assessment Inc.

Young, K. (2008). Narrative practice at a walk-in therapy clinic: Developing children’s

Appendix. White’s (2007) Maps of Narrative Practice

Unique outcomes: Statement of Position Map 2

Re-authoring: Re-authoring Conversations Map

Outsider witnessing: Outsider Witness Retelling Map

as they listened to the telling of the person’s story.

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