A narrative therapy approach to counseling

Wolter, J.A., DiLollo, A., & Apel, K. (2006). A narrative therapy approach to counseling: A model for working with adolescents and adults with language-literacy deficits. Language, Speech, and Hearing Services in the Schools, 37,168-177. Impact Factor Information: The 2009 impact factor is 1.273, and the 5-year impact factor is 1.720. LSHSS ranks 24th of 92 journals in the Linguistics category and 21st of 52 journals in the Rehabilitation category. LSHSS is now an online-only journal. This change went into effect on January 1, 2010, for all four ASHA journals. LSHSS’s final print issue had a circulation of 51,234. Accept/Reject Rate for decisions made 2006-2008 Decision No. Rate Accept 75 35% Reject 139 65% Total 214 100%

LSHSS

A Narrative Therapy Approach to Counseling: A Model for Working With Adolescents and Adults With Language-Literacy Deficits Julie A. Wolter Utah State University, Logan

Anthony DiLollo Kenn Apel Wichita State University, Wichita, KS

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gap currently exists between language-literacy remediation practices and the therapeutic requirements that some adolescents and adults may need to make literacy gains. Although recent research has resulted in increased knowledge of the linguistic components to be targeted in the areas of reading, writing, and spelling when working with individuals with language-literacy deficits (LLD) (e.g., Abbott & Berninger, 1999; Apel & Masterson, 2001; Singer & Bashir, 1999), treatment without a counseling component may not be complete (Luterman, 2001; Stacey, 1997). That is, despite these recent advances, language-literacy remediation may not be enough to overcome factors such as decreased self-esteem, feelings of disillusionment, and fear of failure—problems that are pervasively ABSTRACT: Purpose: Remediation efforts with adolescents and adults with language-literacy deficits (LLD) may be hindered by concomitant factors such as decreased self-esteem and self-efficacy. Despite sound linguistically based remediation practices, treatment lacking integrated counseling components may fail to achieve optimal outcomes. In this tutorial, we recount a counseling approach, specifically a narrative therapy counseling approach based on constructivist theory, to be used with adolescents and adults with LLD. Method: A review of the literature includes research on the use of counseling in communication disorders settings and on the application of a narrative therapy counseling approach with individuals with decreased self-esteem. The key components and steps of narrative therapy are described, and applications for use with adolescents and adults with LLD are suggested. Sample

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found in adolescents with LLD (Kavale & Forness, 1996; Thomson & McKenzie, 2005; Wagner, Blackorby, & Hebbeler, 1993). Moreover, an individual who has long lived with a disability for many years may be reluctant to view life differently as a person with increased abilities (Fransella, 1972; Landfield & Leitner, 1980). For example, a person who has lived with LLD may be reluctant to view life as a literate person, resulting in decreased motivation to improve literacy and lost opportunities for literacy experiences that have the potential to strengthen literacy skills (Stacey, 1997). Therefore, a language-literacy intervention approach that includes a counseling component that addresses issues such as self-concept and decreased self-esteem may maximize treatment gains (Crowe, 1997). vignettes of a counseling component for a 22-year-old student with LLD who is enrolled in literacy intervention are used to illustrate some of the key points of a narrative therapy counseling approach. Implications: A narrative therapy counseling approach that is integrated into language-literacy remediation may be an effective way of addressing concomitant factors such as decreased self-esteem in adolescents and adults with LLD. Readers of this article are challenged to seek additional counseling training and to begin to conduct research to determine the feasibility, effectiveness, and efficacy of integrating a counseling component into speech and language therapy. KEY WORDS: counseling, constructivist, narrative therapy, literacy, language

SCHOOLS • Vol. 37 • 168–177 • July 2006 * American Speech-Language-Hearing Association 0161-1461/06/3703-0168

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Counseling has been considered an important component of treatment for communicative disorders (Crowe, 1997; Luterman, 2001) and is included in the American Speech-Language-Hearing Association’s (ASHA’s) Scope of Practice for speech-language pathologists (SLPs) and audiologists (ASHA, 2001). The number of university communicative disorders programs providing training courses on counseling, however, is limited, and hence the integration of a counseling component in the remediation programs of individuals with communicative disorders is often an element that SLPs and audiologists do not include or understand (Luterman, 2001). The term counseling has multiple and varied definitions both within and outside the field of communication sciences and disorders. In this article, counseling is defined as an endeavor in which people communicate together and a clinician facilitates an individual’s adjustment to the communicative and noncommunicative consequences of a disorder (Webster, 1977). Furthermore, we follow Luterman’s (2001) perspective of “counseling by listening and valuing” ( p. 5) and subscribe to the belief that, as clinician-counselors, we cannot do any harm to clients by such actions (Luterman, 2001; Webster, 1977; Webster & Ward, 1993). A small number of studies have been conducted to determine the effectiveness of counseling in the remediation of individuals with communicative disorders. Researchers have shown that counseling is an effective component of remediation in working with clients with laryngectomy (e.g., Blood et al., 1994), aphasia (e.g., Cunningham, 1998; Hartman & Landau, 1987), fluency disorders (Evesham & Fransella, 1985; Fransella, 1972; Stewart & Birdsall, 2001), and language disorders (Stacey, 1992). In the area of language-literacy remediation, however, research has yet to be conducted that documents the effects of a counseling component integrated into the SLP’s remediation practices. Moreover, specific counseling approaches to be used with adolescents and adults with LLD, and the theories supporting the use of such approaches with these individuals, have yet to be identified. Although research that examines the effects of integrating a counseling component in the language-literacy treatment of individuals with LLD has yet to be conducted, research has been conducted that documents the low self-esteem that is often found in individuals with LLD (e.g., Thomson & McKenzie, 2005; Wagner et al., 1993). Students with learning disabilities, a label that individuals with LLD are generally given, have been found to have significantly lower self-esteem than their typical peers (Kavale & Forness, 1996; Thomson & McKenzie, 2005). Moreover, individuals with LLD have been found to have pervasive feelings of low self-esteem and embarrassment well into adulthood (e.g., Johnston, 1985; McNulty, 2003). For example, McNulty conducted a qualitative phenomenological study on 12 adults who had been diagnosed with LLD as children. Results revealed that all participants experienced feelings of inadequacy and decreased self-esteem as a result of encountering academic failure and ultimately being labeled with an LLD. In the counseling domain, several psychotherapeutic approaches have been found to successfully address issues such as decreased self-concept and self-esteem in adolescent offenders (Viney & Henry, 2002), individuals who have been labeled with attention deficit/hyperactive disorder (Mancuso, 2003; Mancuso, Yelich, & Sarbin, 2002), adolescents with anorexia (Madigan & Goldner, 1998), and adults dealing with alcoholism (Shoham, Rohrbaugh, Stickle, & Jacob, 1998; Winslade & Smith, 1997). These approaches

focused on replacing the decreased self-concept that was often entrenched with an individual’s problem (e.g., clients viewed themselves as “alcoholic” or “anorexic”) with a self-concept that encompassed the individual’s strengths (e.g., clients began to view themselves as people who are effectively managing the problem). In essence, these counseling approaches facilitated individuals to begin to view themselves beyond the limited vista maintained by the problem. Narrative therapy1 is a specific counseling approach that adheres to the aforementioned psychotherapeutic principals of replacing a dysfunctional self-concept with a more functional, personally satisfying image of the self. Moreover, narrative therapy is a user-friendly approach that the authors believe is amenable to the knowledge and skills of clinicians in the field of communicative disorders. Thus, we present one model that may be used for counseling adolescents and adults with LLD and that can be integrated into traditional treatments by SLPs. This model is based on a narrative therapy approach to counseling that was developed by White and Epston (1990). Furthermore, our model is influenced by narrative therapy approaches such as those that have been documented as being successful with individuals with addiction problems (e.g., Winslade & Smith, 1997) and eating disorders (e.g., Madigan & Goldner, 1998), and those that have been adapted for use by SLPs as part of a remediation approach for working with individuals who stutter (DiLollo, Manning, & Neimeyer, 2000; DiLollo, Neimeyer, & Manning, 2002) and children with LLD (Stacey, 1997). As the key components and steps of narrative therapy (see Table 1) are described in this tutorial, examples from a literacy intervention with a 22-year-old college student with LLD will be provided to illustrate concepts.

NARRATIVE THERAPY AS A FRAMEWORK FOR COUNSELING ADULTS AND ADOLESCENTS WITH LLD The basic concept of narrative therapy is that people are “story-tellers” and that the stories they tell about themselves, and that others tell about them, significantly shape their behavior and sense of self (Madigan & Goldner, 1998; Neimeyer, 1995; Winslade & Monk, 1999). Personal narratives serve to create meaning from experience and, as such, are used for anticipating events, planning actions, and orienting the self in the world (Dimaggio, Salvatore, Azzara, & Catania, 2003). Our personal narratives, however, are co-authored by significant others and many other sources in our lives, often imposing subplots to our stories that are unwanted and personally limiting (Drewery & Winslade, 1997; McKenzie & Monk, 1997; Neimeyer, 1995; Winslade & Monk, 1999). These unwanted subplots are often formed from cultural or political stereotypes that “place people in particular positions or relationships with others and themselves and prompt them to describe the world from particular vantage points” (McKenzie & Monk, 1997, p. 93). Often, these personally limiting subplots can come to dominate the narratives of individuals and can lead them to interpret their world 1 Within this tutorial, the term narrative refers to an individual’s personal story that influences how events and experiences are interpreted and consolidates self-understanding and guides behavior.

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Table 1. Basic steps of a narrative therapy approach to counseling.

Step

Therapist

1 Externalize the problem.

Model externalizing language.

2 Map the influence of the problem on the life of the person. 3 Map the influence of the person on the life of the problem. a. Unique outcome questions

Encourage a “thick” description; Listen for “clues” to alternative storylines.

Ask for details about times when the problem was absent, ignored, or overcome. Further develop the alternative story.

b. Unique account questions c. Unique redescription questions d. Unique possibility questions e. Unique circulation questions f. Questions that historicize unique outcomes

Help clients reflect on, and develop meaning from, the unique accounts that they have identified. Invite clients to speculate about a future that is implied by their unique accounts and redescriptions. Acknowledge the social context of personal narratives. Help clients create links between the alternative story and aspects of past stories.

only in ways that support that dominant story. Neimeyer (1995) stated that, “indeed, clients often seek or are referred to therapy when they are identified with their problems and subjected to a ‘dominant narrative’ that disqualifies, delimits, or denies their personhood” ( p. 22). Stacey (1997) suggested that the dominant narratives of young people living with LLD may have been imposed by others as a result of the outcomes of educational and developmental assessments. She stated that “these descriptions usually involve deficit-based terms that implicate their whole persons and encourage young people to develop a hopeless, defeatist lifestyle” ( p. 222). Moreover, studies of young children with LLD revealed that following experiences of failure, children expect to be unsuccessful on literacy tasks (Lipson & Wixson, 1997). These negative beliefs regarding reading achievement and school performance increase with age (Marsh & Yeung, 1996). Therefore, adolescents and adults with LLD are very likely to possess a “defeatist” attitude that, at times, may result in feelings of hopelessness for overcoming literacy problems. To illustrate this point, we turn to the example of Anna,2 a 22-year-old college student with LLD who attended a universitybased speech-language-hearing clinic in the summer of 2002. Having been enrolled previously in literacy treatment for one semester, Anna was “frustrated” with what she felt to be “slow progress” in her reading, writing, and spelling abilities. She appeared disillusioned by what she perceived to be minor results that were not contributing toward “fixing my (her) dyslexia.” When asked to describe herself, Anna depicted herself as “happy, frustrated, dyslexic, and dumb,” but then added that she was a “hard worker.” Anna stated that she just felt overwhelmed and frustrated with what she perceived as slow progress. She believed A pseudonym was used for the purposes of this tutorial.

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Give the problem a name; Talk about the problem in the 3rd person. Provide a detailed description of the impact of the problem on all aspects of their life.

Begin to notice times when they have dealt with the problem successfully. Start to make sense of the exceptions to their old story. Begin to see a broader identity beyond the problem. Construct possibilities for a different future than the one the problem had planned for them. Identify significant persons with whom to share their emerging alternative story. Establish a memorable history of the alternative narrative.

that if her problems could not be “fixed” before the start of the next academic semester, she would be “doomed to fail.” When the clinician verbalized her hunch3 that it sounded like Anna just felt like giving up and did not think therapy was worth the work, Anna agreed with this view and stated that therapy could feel “frustrating” and she felt “worn out with working so hard for nothing.”

Problem-Saturated Descriptions and Dominant Narratives White and Epston (1990) described individuals as having a problem-saturated description that may become the dominant narrative in their life. That is, when a person seeks counseling, he or she usually believes that there is a problem in his or her life. This way of thinking dominates one’s life, thus becoming the dominant narrative that affects how one anticipates and acts through life. Payne (2000) and White and Epston suggested that the problem-saturated narrative is often a thin description of the person’s life. They call it this because certain events, details, and elements not related to the disorder are omitted or unnoticed by the individual. For example, an individual with LLD may have a thin description of academic failure in that he or she only sees the academic failure as a result of having LLD. Other events or details such as family discord, holding several jobs, or missing tutoring sessions may not be viewed by the individual as relevant details contributing to academic failure. This thin description of a dominant narrative is evident in the account by Stacey (1997), who described children with LLD as developing an essentially defeatist or hopeless dominant narrative. 3

The term hunch refers to a specific active listening counseling strategy used by Webster (1977), in which the counselor attempts to put into words what he or she thinks the client is saying.

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Moreover, we illustrated this point through the example of Anna, who appeared to have carried just such a narrative forward into adulthood. It is possible that adolescents or adults with LLD may, like the children described by Stacey, become “stuck” in a problem-saturated narrative. Putting it in White and Epston’s (1990) terms, the thin description of an individual’s life, which is centered around living with a literacy deficit, dictates how events are perceived and life is lived, with little attention or meaning attributed to times when the dominant narrative did not apply or was overcome. DiLollo, Manning, and Neimeyer (2003, 2005) found that one factor in the maintenance of stuttering for persons who stutter was that they attributed little or no meaning to periods of fluency, even following successful therapy. DiLollo et al. suggested that in order for treatment to be beneficial in the long term, exceptions to the stutterer-dominant narrative need to be made more meaningful to the persons who stutter. Similarly, it might be argued that for individuals with LLD to progress in literacy remediation, they must be helped to pay attention to the growing exceptions to their defeatist narrative and move beyond the problem-saturated accounts of themselves toward a richer description or narrative that encompasses strengths and abilities. The richer description would include events, details, and elements that are not related to the disorder. For example, in the individual with LLD who experiences academic failure at the time of a parental divorce, the event of the divorce would need to become a part of the richer narrative of unrelated factors that may be influencing the individual’s school performance. Strengths such as times of perseverance during this stressful period may be pointed out and included in the richer description to help the individual with LLD perceive him- or herself as more than a disability. An excerpt from the intervention with Anna helps illustrates this point. Through self-reports, Anna appeared to be stuck in a problem-saturated narrative. She viewed and perceived her life through a limited lens as a person with an LLD. This was evident in her descriptions of herself as “dyslexic” and “dumb,” and in her beliefs that her LLD was the cause of all her failures in school and her personal life. Just before her summer intervention, Anna had been placed on academic probation. Anna believed that the cause of all of her school struggles was her LLD; she did not consider other possible contributing factors such as working several jobs in addition to attending school full time. Moreover, Anna seemed frustrated with her personal life and wanted to be more like her sister, who was “smart and is now getting married.” She also believed that her reluctance to read aloud in contexts such as her bible study or to participate in spelling games at a college social function was holding her back socially. Anna seemed to view her life through the thin description or problem-saturated narrative of a person with LLD. She appeared in need of help to see times or events in her life when her disability did not dominate or affect her life and to develop a better understanding of her strengths and abilities. Thus, a narrative therapy counseling approach was integrated into her language-literacy treatment.

Externalize the Problem The first step in the process of narrative counseling is to externalize the problem (Payne, 2000; White & Epston, 1990). This is done by first having the client come up with a meaningful name for the problem. In most cases, the name will be reflective

of the nature of the problem (e.g., fear or shame), but what is most important is that the name is meaningful to the client and that it represents to him or her the specific problem being experienced. White and Epston suggest that naming the problem can give the client a sense of control over the problem and may also help the client to focus better on the precise nature of the problem. Following naming of the problem, one can “externalize” or focus on separating the problem from the person. As the problem is objectified or even personified, problems that were once considered fixed or attributed to the individual become less restricting, and increased possibilities develop to retrieve one’s life from the influence of the problem (White & Epston, 1990). The therapist uses externalizing language that implies that the problem is affecting a person rather than existing within the individual (Payne, 2000). Metaphorical language is a helpful way to externalize a problem and can facilitate a new problem perspective (DiLollo et al., 2002; Payne, 2000). Using metaphorical language, the problem can be directly personified and becomes an entity in itself, with its own actions, feelings, and resulting influences on the individual (e.g., “Depression stopped youI” “Stuttering made youI”). The counselor and client then can begin to work toward gaining control over or dealing with this separate entity. Once the problem is named and externalized, then this language should continue throughout all sessions and be incorporated into what are considered externalizing conversations (Drewery & Winslade, 1997). In working with adolescents and adults with LLD, naming the problem and engaging in externalizing conversations may be one way to help clients begin to change the way they view their problem. The effects of a lifetime of failure and labeling may result in individuals “internalizing” their problem, essentially taking on the role of “I am dyslexic” or “I am learning disabled” and leading them to look to the SLP to “fix” them. This step in the narrative therapy process can be illustrated by Anna, who was encouraged to name and externalize her problem. The clinician and Anna discussed many of the existing names for her perceived deficits, including learning disability, dyslexia, language-learning deficit, and learning difficulties. Given all these terms, Anna felt that the appropriate name for her problem was “LD” for “learning disability.” From that point on, LD was referred to as a third person in all discussions. This enabled Anna to begin, perhaps for the first time, to perceive the problem (LD) as the problem rather than herself as the problem.

Map the Influence of the Problem on the Life of the Person As described previously, clients often come to therapy with a thin, problem-saturated account of their lives. This step in the narrative counseling process reflects an attempt to facilitate clients’ expansion of their stories to include a more detailed or thick description of their lives. A thick description is a richer narrative in which events are perceived to reflect the complexities of life and are not necessarily influenced by only the problem or deficit. Epston and White (1995) recommend first exploring or “mapping the influence of the problem” on the individual’s life and relationships. Following the initial thin description, the therapist may facilitate and encourage a richer description of the person’s account of the influence of the problem on his or her life by asking clarifying and extension questions, which Epston and White term, “relative influence questions.” As a result of placing the



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problem description within a wider scope, the possibility of finding experiences that are inconsistent with this problem-saturated narrative is increased (Payne, 2000; White & Epston, 1990; Winslade & Monk, 1999). It is the job of the counselor to listen for “clues” (Payne, 2000) that might point toward potential alternatives to the dominant narrative. When working with an individual with LLD, exploration of a richer narrative may help the client and therapist fully understand the effects of the influence of LLD and provide opportunities to identify clues to potential alternative narratives that are not focused on failure, inadequacy, or disability. Epston and White (1999) suggested examples of relative influence questions that can be framed in the context of working with individuals with LLD. These questions might include: (a) When did LD4 first show itself in your life? (b) How does LD affect your life? How does it lead you to relate to friends/parents/spouse/children? (c) What has LD prompted other people to think or say about you? (d) How has LD influenced your career choice? (e) If LD continues on its current track, what is your view of what this would mean for you in a week/month/year/5 years from now? It should be noted that relative influence questions such as these use externalizing language and personify the problem, which helps clients strengthen their externalizing perspective of LD. In addition, questions such as these may help clients with LLD begin to focus on how their lives have been dictated by the literacy deficit, which in turn may strengthen their resolve to take a position on, and undermine the influence of, the problem. As an example, once Anna had named her problem, she was given a take-home written exercise that required her to explore her dominant narrative from an externalized viewpoint. Anna was instructed to write a narrative about LD’s influence on her life. She was asked to write, as best she could, about LD as if “he” was a separate person in the narrative. She and the clinician discussed the content of this written narrative during the following session. In Anna’s written narrative, she described LD as “controlling my (her) thoughts, feelings, and actions.” She explained that LD had “stopped plans” in her life and “puts up many road blocks.” She further elaborated that LD caused her to “hide something” as she “must be careful LD does not embarrass me (her),” which resulted in her avoiding talking and writing in class and prevented her from joining in on extracurricular activities (i.e., reading at her bible study). She further stated that “LD, and everyone else, does not understand how my life is hard—it is hard just to pick up a pen or turn a page.”

the problem-saturated, dominant narrative. These contradictory experiences are referred to as unique outcomes (White & Epston, 1990) or sparkling moments (Monk, 1997). By exploring these times and experiences that are inconsistent with the problemsaturated narrative, the therapist and client can begin to explore and construct a narrative outside of the influences of the problem. An important concept at this time is that the alternative narrative is not considered something “new” but is reflective of traits and strengths that the client already possesses and, to a certain extent, has demonstrated despite the existence of the problem. Continuing with the same illustration, Anna completed a subsequent take-home written exercise that required her to write about what it would be like if LD did not dominate her life. This second question allowed Anna to explore her life without her deficit and find times when the problem might not control her. Anna wrote that without LD, she “would have so much freedom.” She explained that “I would not have to be embarrassed when I could not read or write and could be as smart as everyone else.” She further stated that “without LD I would not have learned many thingsIto be compassionate and observant.” She felt that “LD made me (her) a stronger person, a person who knew the real meaning of work.” As before, Epston and White (1995) suggested a series of questions that might be used to facilitate the goal of mapping the influence of the person on the life of the problem. These questions are divided into categories that reflect the process of deconstructing the old story and reconstructing an alternative story based on the exceptions to the dominant narrative noted earlier in the process. Unique outcome questions. These questions are designed to invite clients to acknowledge actions and intentions that contradict the dominant story. Some persons with LLD may initially have difficulty with these questions. As we stated earlier, persons with LLD may pay little attention to times when their problem was not present or was overcome. Consequently, when working with persons with LLD, examples of literacy successes or effective coping strategies may need to be pointed out to them initially by the clinician (i.e., from the “clues” that the clinician listened for during the relative influencing questioning). Between treatment sessions, clients also might be assigned the task of identifying and noting further examples of their unique outcomes. Examples of unique outcome questions that might be useful with individuals with LLD include the following: & Have there been times when you have been able to overcome LD’s influence over you?

Map the Influence of the Person on the Life of the Problem

& You mentioned that you work at a job. How do you prevent LD from taking over then?

The next step in narrative therapy involves breaking down the old, problem-saturated narrative and replacing it with an alternative narrative that has a different focus. White and Epston (1990) suggested that, as the name of this step implies, not only does the problem have an impact on the life of the person, but the person has an impact on the life of the problem. Therefore, this part of the narrative therapy process focuses on identifying and attending to times and experiences that are inconsistent with

& It appears that you overcame LD when you read and filled out the forms at the doctor’s office. How did you accomplish that and how did it make you feel?

4 In all example narrative therapy questions, LD, the label that Anna chose as the name to externalize the problem, will be used.

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By exploring unique outcomes, potentially empowering new narratives may emerge. As presented in the previous question examples, the therapist may help to develop the client’s unique outcomes by noting and facilitating the exploration of experiences when the individual with LLD overcame literacy obstacles. These unique outcomes then will become the foundation of an alternative narrative as both the therapist and client begin to reconstruct and co-author this new empowering self-story.

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Unique account questions. With the foundation laid for a new narrative, the counselor can facilitate reconstruction of a preferred alternative story through further questioning. The client and counselor can begin to focus on exploring unique outcomes in depth through the use of what Epston and White (1995) called “unique account questions.” Through these questions, clients are encouraged to explore the previously discovered unique outcomes, inviting them to make sense of these exceptions to the dominant narrative that may not have even registered previously as significant. These questions also may focus on strengths that have been identified as contributing to the unique outcomes, leading clients to become increasingly aware of their inner power, which previously may have been thought of as a “fluke.” As clients begin to view strengths as a meaningful part of themselves, they can speculate on how these assets can be incorporated into an alternative narrative (DiLollo et al., 2002; Epston & White, 1995). Further elaboration of unique outcomes with individuals with LLD may include focusing on strengths such as resilience or perseverance in the face of living with LLD. How this person persevered in the past may be discussed, and ways the individual can use this skill in working toward increased literacy abilities can be explored. In addition, times when an individual was successful in a reading or writing task need to be focused on and shaped for the future. Perhaps the person was able to instantly read words that he or she previously laboriously sounded out. These unique outcomes can be projected into the future as the therapist and client discuss how specific literacy remediation strategies eventually result in literacy tasks becoming easier. As a result of increased literacy skills, multiple possibilities for future endeavors (e.g., jobs, helping on the school newspaper, joining a book club) may be pursued. Possible unique account questions that a clinician-counselor might ask a client with LLD include the following: & Given how familiar LD is to you, how were you able to protest its pushing you around? & How might you stand up to LD in the future and refuse its requirements of you? & What can you tell me about your history that would help me understand the development of your ability to defeat LD? Unique redescription questions. As one’s dominant, problemsaturated narrative is deconstructed through the exploration of unique outcomes, personal meaning changes and, as a result, one’s personal narrative also changes. Through the linguistic process of telling and re-telling one’s story, novel meanings are described with new language; thus, a person’s story is re-authored (Payne, 2000). The therapist is a co-author in the story as his or her biases influence the development of meanings through the questions asked, unique outcomes explored, and nonverbal gestures that validate the individual’s placement of meaning. Thus, the therapist and client work together to co-author a new empowering dominant narrative that is viable in the individual’s life. Unique redescription questions that might be useful with clients with LLD include the following: & By freeing yourself from LD’s hold over you, do you think in any way that you are becoming less “language disabled/dyslexic?” & What does this achievement reflect about the sort of person you are that is important for you to know? Are you

the first to know this about yourself, or have others known this about you in the past? If others have known this, what told them? These types of questions invite clients to begin to glimpse an outline of a broader identity beyond the problem that encompasses strengths that were often ignored or overlooked because of the influence of LD. They also help clients view the emerging alternative narrative in a historical perspective rather than as something “new” and foreign. Unique possibility questions. Ironically, successful therapy can generate fear and anxiety because it disrupts the continuity of clients’ self-narratives, even if the changes are in desirable directions (Neimeyer, 2000). Unique possibility questions can help reduce such anxiety by helping clients “envision a preferred future that is coherent with the best moments of the past, rather than at odds with its essential meaning” (Dilollo et al., 2002, p. 36). Epston and White (1995) described these types of questions as “future-oriented, backward-looking” questions. In essence, they are designed to encourage clients to imagine possible futures unencumbered by the influence of the problem and then examine the present for potential change. Clients are facilitated to look at the present to determine what they are currently doing that is most important to reaching that future and what else might need to be done. Such questions may be useful to clients with LLD in helping them to envision a future without the dominating influence of LD. Incorporating “unique possibility” questions into latter stages of therapy may help clients integrate personal narratives that do not include the dominating influence of LD, thereby avoiding the fear that they are simply “covering up” their literacy deficits. Unique possibility questions for clients with LLD might include the following: & What will the future be like without LD’s influence dominating your life? How is this future different from the one that LD would have planned for you? & Knowing what you now know about yourself and your preference for living life without LD’s influence, how will this knowledge affect your next step? Unique circulation questions. Because personal narratives are lived out in a social context, the developing alternative narrative needs to be established in the client’s specific social context (Drewery & Winslade, 1997; White & Epston, 1990). White and Epston stated that the inclusion of others in the newly developing story is essential to anchoring and continuing development of that narrative. Similarly, Payne (2000) suggested that telling and re-telling of the emerging alternative narrative can be a powerful means by which the story becomes “confirmed and influential in the person’s life and identity” ( p. 157). This step may involve identifying individuals who may have initially predicted success for the client, individuals who may be supportive of the emerging story, individuals who may have great influence with the client, or individuals who may be likely to resist the changes that the client is attempting to make. The client then can plan meetings to relate the alternative narrative to these varying audiences. As the individual tells and retells the story to these audiences, the repetition and responses from people with significant influences in that person’s life help to solidify the story. In addition, the audience is given the opportunity to re-tell



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the emerging story back to the client, further reinforcing the meaningfulness of the narrative. In working with individuals with LLD, there may be a need to help these persons accept their newly developed personal narrative within their social context. This may include identifying and finding supportive individuals who will accept and foster their alternative stories, as well as identifying those who may be resistant to the changes. For many adolescents or adults with LLD, living with an LLD may always be part of their personal narrative. Although specific language-literacy skills can be improved continuously through remediation efforts, these skills may never develop to be at the level of those of their typical peers. Despite this, the current abilities and language-literacy efforts of these individuals, as well as other strengths and skills they demonstrate, can and should be focused on to foster development of a personal narrative that is based on strengths and abilities rather than experiences of deficit. Examples of unique circulation questions for persons with LLD might include the following: & Now that you are overcoming LD’s influence in your life, who else should know about it? What difference do you think it would make to their attitude toward you if they knew this news? & Of the significant people in your life, who do you anticipate would have difficulty accepting the new life you have chosen, free from LD’s influence? Questions that historicize unique outcomes. As previously discussed, it is important that clients see their alternative narratives not as something “new” but as reflective of traits and strengths that they already possess. This allows them to take “ownership” of their story rather than see it as something alien that might overwhelm their “old” narrative. Questions that historicize unique outcomes serve to ground the emerging, alternative narrative in aspects of the clients’ own past, establishing it as having a “memorable history” and increasing the likelihood that it will be carried forward into the future (DiLollo et al., 2002; Epston & White, 1995; White & Epston, 1990). For persons with LLD, the final focus in narrative therapy is to help them accept their newly developed personal narrative within their social context. This may include identifying and finding supportive individuals who will accept and foster their new stories. For the adolescent or adult with LLD, living with an LLD may always be part of the personal narrative. By sharing the alternative story of oneself as a person with LLD who is working to improve specific reading and writing skills, the burden of hiding a disability may be lifted. Furthermore, sharing this alternative story may provide opportunities for support and help in the language-literacy remediation process. Examples of historicized questions that might be used with persons with LLD could include, for example, the following: & Of the people who knew you growing up, who would have been most likely to predict that you would break free from LD’s influence? & What qualities would this person have seen in you that would have led him or her to believe that you would have been able to achieve what you have? An illustration of mapping the influence of the person on the life of the problem. As a way to help Anna begin to view her

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personal narrative in a novel way to deconstruct her old story and reconstruct an alternative, empowered narrative, the use of a metaphor was employed. Metaphors can be a particularly powerful way to move beyond the constraints of language to capture the deeper emotional and personal issues at the core of the person (DiLollo et al., 2000; Stacey, 1997). Anna was given the exercise of describing an image of how LD related to her. Anna described that living with LD was “like someone with no hands.” She believed that a person without hands could not open the door and “just needs someone to take that one stepIwhich is to open the doorIthey can do the rest.” Following this session, she was given a written take-home exercise to determine how she might change her image as a person with no hands. During the next session, Anna stated that she had worked hard on thinking about how she could change this image and believed the answer was God. The clinician had a hunch that this response was what Anna had thought she was expected to say, and thus decided to explore a different area for that moment. Anna was asked to recall that she had talked about opening doors, and the clinician wondered aloud if she felt that there were obstacles other than her hands that were keeping her from opening the door. Specifically, she was asked if there was “anything in front of the door.” Anna promptly answered “Roadblocks!” She then elaborated that she felt that the fact that she constantly hid her literacy deficits from others and her decreased self-esteem were significant roadblocks in her life. The clinician asked Anna what she meant when she said that she hid her deficits. Anna responded that she was keeping the secret of her deficit from everyone in her life, including her close friends, because she was afraid that they would think she was dumb. As a result, she was constantly avoiding topics and situations that would require her to reveal herself. When Anna was asked if there were any ways to change the hiding in her life, she concluded that she could tell the people she was close to in her life about her LLD. By the end of the session, Anna and the clinician had drafted a plan of when and how to tell her close friends, roommates, and boss about her deficit. When the clinician stated that she thought they were making nice progress, Anna lifted her fists in the air and exclaimed “Yes, but I just need to find my hands!” The clinician questioned her about where her fingers were, and then slowly touched Anna’s index finger in her clenched fist and asked, “What have we just been talking about?” Anna appeared to understand and together she and the clinician unclenched her fingers as the clinician said “Who are your fingers?I They are your best friend (they uncurled her first finger), your roommates (uncurled her second, third, fourth finger), and your family (uncurled all her fingers).” Anna exclaimed, “I found my hands!” The “discovery” of Anna’s hands was significant to her as it allowed her to explore and imagine a new personal narrative in which she was an empowered main character. The clinician had facilitated Anna to begin to think about her deficit in a novel way and to develop a richer narrative. As a result, Anna was no longer seeing herself as being helplessly influenced by her problem, but as a person who could proactively influence her problems and change. Instead of viewing herself as a person who needed to hide her deficits, she saw others as a support network that could help her in achieving her goals to improve her reading, writing, and spelling. In addition, by drafting a plan to tell others about her deficits, she was historicizing her unique outcome

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by creating a social context for her new role as a functionally literate person who was actively dealing with a deficit. Anna returned the next session and appeared animated and eager to tell the clinician about her previous afternoon. She exclaimed that she had told her boss about LD the day before. She said she went to work and her boss commented on how happy she appeared and she replied “I found my hands!” When her boss questioned her about what this meant, she proceeded to tell her how she struggled so much with reading and writing. “And they were just floored ‘cause I did so well hiding it. And they knew something was wrong with me, and a couple of months ago she told her husband she thought I was sexually abused or something because I was so cautious and fearful with a bubbly attitude.” When the clinician asked Anna if she was surprised by this, she said “Yes, because my worst fear would be others laughing at me and then I’d be embarrassedIand here she thought something more was there and it wasn’t as severe as being abused.” By telling others such as her boss about her new empowered narrative as a person who is actively managing an LLD, Anna could begin to historicize and solidify her new narrative in her social environment. Moreover, the fact that her boss perceived her as having been abused also helped Anna to realize that her past actions of hiding her deficit were not reflective of her new empowered narrative of being a strong young woman effectively dealing with LLD. Over the next several sessions, Anna went on to tell her best friend as well as her roommates about her LLD. Before this, the clinician and she had drafted a plan as to how she might react if these individuals reacted positively or negatively to her news. Anna’s experiences were positive because Anna felt that her close friend did not feel sorry for her as she had feared, but instead felt impressed by all that she had achieved despite her troubles. This again helped Anna to create a context and historicize her new self-empowered narrative of an individual who is capable of overcoming difficulties. In discussing her deficits with her roommates, Anna expressed an increased feeling of control. She stated that “we talked about it for five minutes and that was it. We didn’t make it a big issue, and I think I am the one that’s going to be able to be in control of that. I can make it a big issue or I don’t have to make it a big issue.” This new use of language and attitude over being in control reflected Anna’s adoption of her new empowered role. In addition, Anna decided to read aloud in her bible study group. She and the clinician discussed possibilities as to how she could make it less frightening and developed the solution of pre-preparing by obtaining the weekly reading before the meeting. These novel solutions helped Anna test her new self-narrative as a person who was open with her deficits and who could function as an adequate reader. Through guided exploration, Anna was able to come up with viable solutions. She could test her new hypothesis in structured contexts (e.g., telling close friends, pre-prepared weekly readings) that would most likely result in success. As a result, Anna was experiencing herself in a new role as the lead player in an alternative self-narrative and was beginning to develop a social context in which she could create a support network for her emerging empowered story. Once Anna appeared to have constructed an alternative narrative, the subsequent sessions focused increasingly more on language-literacy goals and less on narrative therapy. Anna had begun to reconstruct her narrative as a person who lived with a

literacy deficit and was working to improve her literacy skills. It seemed that Anna was no longer stuck in a problem-saturated narrative that dictated her thoughts and actions. She appeared more open to realistic goals and could imagine herself in different contexts as she tested her hypothesis of a story with a new and more open Anna. On the final session of the summer intervention, Anna and the clinician discussed progress and future goals. Anna told the clinician that she needed to be “open and honest and not hide.” She went on to say that, “In the beginning of our time together, I went in (to treatment) to try to fix myself and you convinced me that wasn’t going to happen, and now I’m a different person around everybody, from my friends to my grandma. I had this burden on myself and I didn’t realize that I am hyper or I withdraw from people, but now I am making steps forward. I went to language therapy and I discovered that I hid and I don’t want to relapse.” When the clinician asked what her next step was, Anna replied “When the opportunity arises don’t shy from itIpeople around me, others, andImyself.” On the basis of her statements, it appeared that Anna had re-authored her story to be a person with a deficit that she was actively working on improving. Language-literacy remediation changed from a situation in which Anna felt threatened and frustrated to an opportunity to be embraced. Anna began to seek multiple opportunities to map her influence over her LLD outside of the treatment room and times to share her challenges with others. With a narrative counseling component to her language-literacy intervention, Anna viewed treatment as a valuable opportunity and a means for continually improving her language-literacy skills. Anna changed her story from a person who was dominated by her deficit to a person who managed and lived with a deficit. Following the summer semester of 2002, Anna moved away and transferred to a different university to pursue a degree in a health-related profession. Had her intervention continued, most likely the balance of treatment would have shifted more on improving her specific LLD using “traditional” methods (e.g., Abbott & Berninger, 1999; Apel & Masterson, 2001; Singer & Bashir, 1999). Narrative therapy, however, would still have played a role in the remediation as Anna evolved and began to generalize her literacy skills. Together, Anna and the clinician would need to continue to co-author Anna’s emerging alternative narrative as a literate person with newfound abilities, strategies, and strengths.

CHALLENGES AND FUTURE DIRECTIONS SLPs need to recognize their own boundaries and limitations of knowledge and skills in the area of counseling. Counseling, however, should not be considered an optional part of speech and language intervention. It is an essential component of remediation practices within the field of communication sciences and disorders (Crowe, 1997; Luterman, 2001; Webster, 1977). Unfortunately, less than half of the communication disorders training programs throughout the country offer a course in counseling within their own department, and almost a quarter of the programs do not offer a course at all (Luterman, 2001). Moreover, instruction in counseling may be limited to information counseling only and not in the broader view of “listening and valuing” counseling, as



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described by Luterman. Therefore, clinicians without adequate education in counseling must seek the appropriate training and education needed to implement counseling approaches. Readers are encouraged to further their knowledge in counseling by attending workshops and reading the sources cited in the current article. Clinicians never can predict how much of and when the counseling component will be required as part of a remediation program; however, they should be prepared and knowledgeable about how to implement a counseling approach. Furthermore, the specific instances of when a client needs to be referred to a psychologist or a counselor for personal issues beyond the scope of the SLP’s abilities cannot be specifically pinpointed; professional boundaries for specific issues vary because of clinicians’ background and experiences. As detailed in ASHA’s Scope of Practice (2001), SLPs must consider and adhere to the limitations in their knowledge and skills. Finally, at this time, no research that documents the feasibility or effectiveness of counseling as part of an intervention with individuals with LLD is available. The purpose of this tutorial was to introduce one theory-based counseling approach and to provide examples of how it can be used in language-literacy remediation. The next step is to gather evidence for its use through quantitative and qualitative research means.

In summary, counseling appears to be an integral component of treatment for working with adolescents and adults with LLD. By integrating a counseling component into language-literacy remediation, concomitant factors such as decreased self-esteem or self-concept may be addressed to help clients maximize treatment gains. Currently, the training of integrated counseling approaches and research documenting the efficacy and effectiveness of counseling approaches in the area of speech-language pathology and audiology is underdeveloped. Readers of this article are challenged to seek additional counseling training and to conduct research to determine the feasibility, effectiveness, and efficacy of integrating a counseling component into speech and language therapy. This tutorial has described one theory and counseling approach to working with adults and adolescents with LLD. Narrative therapy is a user-friendly and applicable counseling component that can be integrated into language-literacy intervention with adolescents and adults with LLD. Individuals with LLD may be “stuck” in a problem- saturated narrative that may prevent progress in language-literacy remediation. The process of deconstructing the problem narrative and co-constructing an alternative empowering narrative is multifaceted. The clinician and client need to work together to produce rich narratives and explore unique outcomes. By expanding on the discovered unique outcomes, the client and clinician begin to co-author a new story for the client. Once this viable personal narrative is developed, the client may begin to use it to gain new meaning in life by telling and retelling the new narrative to supportive significant others. In this process, the individual may become more receptive to embracing life as a person who lives with and effectively manages an LLD.

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Received November 3, 2004 Accepted September 18, 2005 DOI: 10.1044/0161-1461(2006/019) Contact author: Julie A. Wolter, PhD, Utah State University, Department of Communicative Disorders and Deaf Education, 1000 Old Main Hill, Logan, UT 84322. E-mail: [email protected]



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A Narrative Therapy Approach to Counseling: A Model for Working With Adolescents and Adults With Language-Literacy Deficits Julie A. Wolter, Anthony DiLollo, and Kenn Apel Lang Speech Hear Serv Sch 2006;37;168-177 DOI: 10.1044/0161-1461(2006/019) The references for this article include 6 HighWire-hosted articles which you can access for free at: http://lshss.asha.org/cgi/content/full/37/3/168#BIBL

This article has been cited by 1 HighWire-hosted article(s) which you can access for free at: http://lshss.asha.org/cgi/content/full/37/3/168#otherarticles This information is current as of August 16, 2010 This article, along with updated information and services, is located on the World Wide Web at: http://lshss.asha.org/cgi/content/full/37/3/168
