Review the attached Article regarding a Case Study using Narrative Therapy. Provide a summary, and discuss 3 learning points that will be important in using the Narrative Approach in Substa

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Treating alcoholism

through a narrative approach Case study and rationale

DAVID KAMINSKY, MID STANLEY RABINOWNNITZ, PHD RIVA KASAN, BA

LCOHOLISMI IS INCREASINNG AT

an alarming rate in most Western countries. Epide- miologic studies have

SUMMARY A case study illustrates the narrative or story-telling approach to treating alcoholism. We discuss the rationale for this method and describe how it could be useful in family practice for treating people with alcohol problems.

RESUME Une etude de cas illustre l'approche narrative ou sous forme de conte utilisee pour traiter I'alcoolisme. Nous discutons des raisons a l'appui de cette methode et nous decrivons son utilite potentielle en medecine familiale pour traiter les personnes aux prises avec

un probleme d'alcool.

Can Fam Physician 1996;42:673-676.

shown that about 10% of American working people have problems related to alcohol abuse.' In the United Kingdom, 50% of working men and 10% of working women exhibit some form of alcohol-related problem, such as work accidents and low productivi- ty. In Israel too, alcohol abuse has been on the increase.2"'

Individual psychotherapy for treat- ing alcoholism usually involves help- ing alcoholics to understand the need for help and teaching them to accept themselves as having an illness. Psychotherapy aims to identify circumstances in alcoholics' lives or lifestyles that lead to alcohol

Dr Kaminsky is on staffin the Department ofAlcohol and Drug Abuse at the Israel Ministry ofHealth in Jerusalem. Dr Rabinowitz is on staffin the Department ofFamily Medicine at the Sackler School ofMedicine at Tel Aviv University and at the Occupational Health and Rehabilitation Institute at Loewenstein Hospital in Raanana, Israel. Ms Kasan is on staffat the Occupational Health and Rehabilitation Institute at Loewenstein Hospital.

consumption in the first place, to call attention to the personal mean- ings of alcohol to the alcoholics, and to bring about permanent change. However, because alcoholics are phys- ically and emotionally dependent on alcohol, psychotherapy has limited success.4 The most common forms of psy-

chotherapy involve behavioural modi- fication and self-help groups, such as Alcoholics Anonymous (AA). The self-help approach of AA support groups has been enormously success- ful worldwide, while behavioural modification (a more manipulative procedure than traditional insight psychotherapy) has had some success. Another approach for treating alco- holism in family practice is the narra- tive or storytelling approach.

To understand and make sense of the world, people tend to structure the stream of time and events into a story with a beginning, middle, and end. History represents not only the desire for a true and reliable report of events but also a way to understand the present as an outcome of the past. Every individual has a personal and family life story. The story is already an interpretation, based on what indi-

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Treating alcoholim through a narrative approach

viduals perceive to be true, even when they have knowingly told different life stories at different stages of their lives. The storytelling approach differs from con-

ventional psychotherapy in that it involves the construction of subjective narratives rather than of logical arguments. Among the forerunners in this approach are Kleinman,' Bruner,6'7 and White and Epston,8 who stated that by talking about our lives we become the biographic narra- tors through whom we "tell of our lives." Our stories selectively include or omit information: omissions are no less important than inclusions. Hunter9 likened patients to texts to be exam- ined, studied, and understood by physicians. In analyzing narratives, we must understand the levels of explanations found in the tales (person- al, family, social, and cultural) and their emo- tional aspects. 10

Patients know, a priori, the conventions of pre- senting their problems to psychotherapists. They usually come prepared for deep disclosure of innermost conflicts and problems. However, they are sometimes less amenable to revealing compli- cated emotional processes because of the medical context or because deep disclosure of emotions is not part of the doctor-patient contract."l

Case study Ron was a 28-year-old university-educated patient married to a nurse with a 12-year-old son from a previous marriage. Ron had given up his studies and was working as head of a group of labourers. He began drinking 6 to 7 years ago after military service, probably because of army-related prob- lems and the death of his father at about the same time. He displayed all the classic signs of addic- tion: duration of alcohol consumption, abstinence symptoms, and development of tolerance.

Ron's wife worked shifts; her son came home from school at about 1400 h and Ron returned at about 1800 h. On the way home he usually stopped to buy brandy and secretly consumed some on the way home. After showering and warming up his meal, he ate and drank in front of the television. The meal was followed by more drinking. Relations with his wife's son were

strained. The boy wanted attention and needed someone with whom to consult and discuss things, but Ron was usually too intoxicated. The boy frequently begged Ron to stop drinking. Ron tended to see things in black and white at

home and at work. He expected his wife and son to conform to his standards of behaviour and punished any slight deviation. Not being the boy's natural father bothered him, and he imagined his wife and her son plotting against him. He needed to control them to boost his self-esteem as head of the family.

At work, Ron demanded much of his workers. He wanted them to be as serious about their work as he was. However, lately his work productivity had declined. His superiors reported that he was no longer working properly and often claimed not to feel well.

Family rows and work problems led Ron to seek medical help. He wanted his wife to bear his child. However, she had made this conditional on his stopping drinking and insisted that he get medical treatment. Previously, he had tried unsuccessfully to stop on his own and had once even sought psychological help. Ron's wife was initially sceptical; she doubted his ability to quit drinking. Her son was also sceptical. He said that Ron lost his temper frequently and would strike his mother and shout at him; he doubted things would improve when the drinking stopped.

At the family physician's request, the first ther- apeutic consultation using the narrative approach took place after 72 hours of abstinence. Ron ini- tially wanted an easy solution, a pill to make the ingestion of alcohol fatal. He hoped the fear of death would cure him. He was apathetic, guard- ed, and reluctant to confide in the physician, especially because he felt psychologically manipu- lated into coming. The physician recognized that the doctor-patient bond was crucial and that he first had to gain Ron's trust and total cooperation and then had to find a way of motivating Ron to abstain and adhere to treatment. The new approach was explained to Ron. He

was asked to define his goals, which he did as fol- lows: to quit drinking, to improve family relations, to persuade his wife to have another child, and to

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improve his work performance. It was suggested that he write a novel with himself as the hero.

Ron chose to write a romantic novel. He care- fully projected all his own life experiences onto the hero, defined the sort ofperson he wished the hero to be, and set out to create ways of achieving this. Ron continued writing the rest of the story, con- sulting with the physician occasionally. The physi- cian was the architect of the story, but the patient himself the independent builder of the plot. This is important because it downplays the part of the physician. For example, Ron listed a variety of immediate aims; the physician suggested it would be more appropriate to script the hero as progress- ing slowly and achieving one goal at a time. Gradually, the patient merged his own life into the story. He made the hero stop drinking, improve his work functioning, and try to regain his wife's trust by improving their family life together. Finally, he wanted the hero's wife to bear a child.

There were about 15 therapeutic sessions and, together with follow up, the encounter lasted 1 year. The meetings consisted of presentation of a new chapter setting out specific goals and their attainment or discussion of the previous chapter. Homework was encouraged and, under the physician's guidance, goals were continually being redefined and different solutions proposed and discussed. Thus, Ron was first the author and then the hero. He could dictate the scenario and act it out, yet stand aside and view it objectively.

Soon after implementing the program, the fol- lowing changes occurred. First, Ron's wife (hav- ing been counseled by the physician and seeing the germ of success) began to support him overt- ly. At the physician's suggestion, Ron began telling her whenever he felt like a drink. He car- ried around a photograph of her on which she had written that she trusted him to abstain. When he had abstained from drinking for 2 months, she was impressed. This was unprece- dented, as he had abstained for no longer than 2 consecutive days only twice before. He was allowed to handle money again (it was previously withheld because it had all been spent on liquor). Relations with the son improved. As advised, he stopped punishing the boy for disobedience. The

boy now actively sought his stepfather's company and stopped behaving provocatively.

Second, Ron's work performance improved dramatically. His employers were now consider- ing giving him a promotion and a company car. His attitude to his workers also improved. He was now more flexible and encouraged greater team- work. Finally, he became more forthcoming about himself and his problems with the physi- cian. He spoke more freely about his relations with his parents, friends, former girlfriends, and childhood memories; he aggrandized himself a lot less than previously. He also continued to play an active part in planning his future and future treatment. At follow up 8 months later, Ron was still abstinent, as ascertained by both the physi- cian's clinical impression (no sign of alcohol intoxication) and the family's reports.

Discussion Why was the narrative approach appropriate in this case? Alcoholics often find conventional ther- apy repetitive and irksome. They are usually reluctant to cooperate and comply half-heartedly with therapists' instructions. They seem to respond better to a more short-term, time-limited approach,'2"13 one that is active and creative, such as the storytelling approach, and that requires unorthodox behaviour on both sides and comes closer to art than science. Therapy takes into account the subjective element: the patient's life story. Patients' problems become not merely per- sonal, but can be separated from the person.8 Patients can become detached from the problem and later slowly make themselves part of the story they are building. Attention is paid to other sub- jective elements, such as choosing, discussing, and planning the course of therapy. This approach is effective because patients are continually correct- ing their lives under the physician's guidance rather than being led blindly by the therapist. The physician's role is passive-active rather

than conventionally active. Physicians must con- stantly resist the urge to intervene actively. They must conceal the extent of their influence and covertly steer patients in the right direction. For example, in another case, a recently arrived

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Russian immigrant was also treated for alcoholism. This man enjoyed drinking white wine with a particu- lar type of bread unavailable locally. He eventually managed to find a good substitute for the bread. The physician then asked the patient to try to think of a suitable substitute for the wine. Two visits later the patient announced that mango juice satisfied his craving. The narrative approach is not

always appropriate. In our experi- ence, it is most effective for educat- ed people who can think abstractly and creatively. Despite this limita- tion, the approach succeeds when people feel the need to take greater control of treatment and want to share their lives and fantasies col- laboratively with their physicians. Active involvement gives them a greater stake in their lives. Physicians who listen to patients' stories carefully and begin to under- stand what is being said can plot paths for the future. Only then can they choose the right moment to intervene actively and objectively, leaving it to patients to use their own imagination and initiative to help them take control of their lives and behave independently.

Further research is needed to evaluate systematically similar cases treated with the narrative approach. Treatment of alcoholics and those with other dependencies, such as drug addiction, should be studied. .

Acknowledgment We thank Dr Mordechai Mark, Director of Mental Health Services, and Dr George Glazei; Department ofAlcohol and Drug Abuse, both at the Israel Ministry of Health in _erusalem, for their support in writing this paper.

Correspondence to: Dr S. Rabinowitz, Occupational Health and Rehabilitation Institute, Loewenstein Hospital, PO Box 3, Raanana 43100, ISRAEL

References 1. Quick C, Quick JD. Organizational stress andpreventive management. New York: McGraw-Hill, 1984.

2. Barr C. T7pes ofuse ofalcohol in the Israeli population. Jerusalem: The Israel Institute of Applied Social Research, 1984 (Hebrcw).

3. Barr C. Patterns ofalcohol consumption in the Israeli population. Jerusalem: The Israel Institute of Applied Social Research, 1987 (Hcbrew).

4. Solari XI. Psychotherapeutic methods in alcoholism. In: Popham RE, editor. Alcohol and alcoholism. Toronto: University of Toronto, 1970:165-9.

5. Kleinman A. The illness narratives, suffering, healing and the human condition. New York: Basic Books, 1988.

6. BrunerJS. Actual minds, possible worlds. Cambridge, Mlass: Harvard University Press, 1986.

7. BrunerJS. Life as narrative. Soc Res 1987;54:1 1-32.

8. White M, Epston P. Narrative means to

therapeutic ends. New York: Norton, 1990. 9. Hunter KH. Doctor's stories: the narr-ative

structure ofmedical knowledge. NewJersey: Princeton University Press, 1991.

10. Stachell M, Dallos R. Change and changes: the narrative in therapy. Changes 1994; 12:60-8.

11. Rabinowitz S, NMaoz B, Weingarten N11, Kassan R. Listening to patients' stores: storytelling approach in family medicine. Can Fam Plysician 1994;40:2098-102.

12. Davanloo H. Basic principles and techniques ofshort term psychotherapv. New York: Spectrum, 1978.

13. MannJ. Time limited psychotherapy. Cambridge, Mass: Harvard University Press, 1973.

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