Narrative Therapy: A Psychotherapeutic Approach

ORIGINAL
Blackwell
Malden,
Journal
JCAP
©
1073-6077
XXX
2008 of
Narrative ARTICLES
Blackwell
USA
Publishing
Child and
Therapy:Publishing
Adolescent
AInc Ltd.
PsychiatricApproach
Psychotherapeutic Nursing in the Treatment of Adolescents With Asperger’s Disorder

in the Treatment of Adolescents With Asperger’s

Disorder
Andrew Cashin, PhD, RN, MHN, NP, Dip App Sci, BHSC, Gcert PTT, MN

TOPIC: The conundrum of how to carry out psychotherapy Andrew Cashin, PhD, RN, MHN, NP, Dip App Sci,
with an adolescent whose primary currency of information BHSC, Gcert PTT, MN, is an Associate Professor, Justice
exchange is visual as opposed to linguistic, and who is Health Nursing, The University of Technology Sydney and
unable to develop a unified base of knowledge and hence NSW Justice Health, New South Wales, Australia.
generalize concepts, has confronted many mental health
nurses in their encounters with individuals with Asperger’s
disorder. At the currently estimated escalating rate of
Asperger’s disorder is one of the three diagnoses
that collectively make up what is currently considered
occurrence of 1 to every 100 individuals having an autism
to be the construct autism. Autism is a developmental
spectrum disorder, and the estimate that 80% of these people neuropsychiatric disorder characterized by marked
have average or above intelligence, it makes sense that difference in the processing and storage style of
Asperger’s disorder is frequently encountered by child and information as compared to that experienced by those
adolescent mental health nurses. Asperger’s disorder with typical development. The primary currency of
represents a different way of being in the world that is information exchange for a person with autism is
associated with a higher frequency of anxiety disorders and visual, as opposed to linguistic; and a unified base of
depression than experienced by neurotypical counterparts. knowledge about the world is not formed as part of
The inherent concretization in the externalization the developmental process. As the majority of people
techniques in narrative therapy provide a novelly successful in society do not have autism and can be considered
approach to psychotherapy with people with Asperger’s neurotypical, a serious mismatch occurs in mainstream
society between the ability of those with autism and the
disorder and in many cases resolution of the conundrum.
social demands placed upon them. As a consequence
PURPOSE: This paper considers the features of Asperger’s
of this mismatch, those with autism often experience
disorder and its consonance with the techniques of narrative
anxiety and depression to a pathological degree as
therapy, and utilizes a case example that shows the potential part of the tensions of living. This emerges at transition
efficacy of the application of this established approach in a periods and is often most intense as the person is
new context. engulfed in adolescence. A problem arises in working
SOURCES: Contemporary literature on autism and with a person with autism on these tensions of living
narrative therapy. when the tools we commonly use in psychotherapy
CONCLUSIONS: The implication of the potential are largely designed by, and for those with, typical
application of narrative therapy in psychotherapy with development. How do you use words to ease tension
individuals with autism is raised. with someone who is not a linguistic processor of
Search terms: Autism, autistic disorder, Asperger’s information? Strangely enough, the answer may be
disorder, narrative therapy found in a therapy designed to work on the stories
individuals tell themselves about the world and their
place in it. Although grounded firmly in the realm of
linguistics, narrative therapy’s focus on the here and now,
and externalization techniques, are useful in the work
with people with autism. Although instead of editing
of stories the task is largely coconstruction of the story
with the individual, the outcome can be dramatic as
Journal of Child and Adolescent Psychiatric Nursing, Volume 21, the person finds a scaffold to negotiate specific crisis-
Number 1, pp. 48–56 laden occurrences.

48 JCAPN Volume 21, Number 1, February, 2008

 Asperger’s Disorder
Autism is a behavioral diagnosis comprised of three
diagnostic entities. The diagnostic entities that together
make up autism as reported in the Diagnostic and
Statistical Manual, Fourth Edition, Text Revision
(DSM-IV-TR) are autistic disorder, Asperger’s disorder,
and pervasive developmental disorder not otherwise
specified (including atypical autism) (American Psy-
chiatric Association, 2000). There is no clear distinction
between the diagnostic constructs of autistic disorder
and Asperger’s disorder for a person that had single
words by age 2 and communicative phrases by age 3,
and has average or above intelligence. In any dis-
cussion of autistic disorder, or Asperger’s disorder, the
overall concept of autism is perhaps the most fruitful
to employ as there is no difference in treatment or
perceived cognitive processing style between each
disorder (Eisenmajer, Prior, Leekam, et al., 1996).
The behaviors that characterize autism, and hence
form the basis of a diagnosis, are clustered around
impairment in three main areas popularly referred
to as the triad of impairment (Scott, Clark, & Brody,
2000). This triad consists of impairment in communica-
tion, social skills, and cognitive and behavioral flexibility.
Each category or area of impairment is dimensional, as
opposed to categorical: It is not just about having a
behavior that can be ticked off as present, but also the
intensity and frequency of occurrence of the behavior
(Berney, 2000). In fact there lies a continuum of
impairment within each area of the triad based on the
degree and frequency of behaviors, and this is compli-
cated further by the fact that each person’s distribution
of impairment is individual and not necessarily uniform
across each area of the triad (Wing, 1996). What is
present is in the least, impairment that disrupts social
and occupational functioning (American Psychiatric
Association, 2000).
At a minimum the social use of language is
impaired and this is manifested in the inability to have
reciprocal conversations in which ideas are put out
and modified in the verbal interaction with another. It
JCAPN Volume 21, Number 1, February, 2008
is this process of reciprocal social interaction in which
thinking is often modified in a neurotypical individual
as it involves testing ideas and the personal interpreta-
tion of the world with family and peers (Binswanger,
1956/1975). This has been termed colloquially as a
“reality check.” These conversations when carefully
crafted form the basis of many forms of psychotherapy.
For those with autism, the inability to engage in
reciprocal conversation is based not only on impaired
communication but is underpinned by marked impair-
ment in the ability to guess what others are thinking
and feeling. This has been referred to as a theory of
mind deficit (Gillberg, 1998; Smyrnios & Tucker, 1997).
Marked cognitive and behavioral inflexibility is the
manifestation of the third point in the triad. In
Asperger’s disorder the inflexibility is manifested as a
dislike and avoidance of change and the presence of
obsessional ideation. Often there is also stereotypic
flapping manifested as a fully embodied excitement.
While stereotypic movement decreases with age they
are often replaced by motor tics (Cashin, 2005).
Just to muddy the waters further, people do not
remain fixed at a position on the continuum within
each area of the triad. People tend to move up and down
the continuum in relation to external or contextual
pressures. Impaired cognitive and behavioral flexibility
by definition implies a dislike for change and novel
circumstances, so it follows that when exposed to
anything out of the ordinary, the person with autism
becomes anxious and can slide down the continuum
of impairment. This slide is seen as a behavioral
regression. The variance in positioning on each of the
elements in the triad and the fluid nature of the
positioning implies that terms such as mild, moderate,
or severe autism tell little in getting a feel for what the
behavior of a person with autism is like. Asperger’s
disorder is not a mild form of autism.
What most people refer to with prefixes like mild,
moderate, or severe is the person’s associated intellectual
capacity. Common sense tells us, and it is reflected
in practice, that someone with autism and a severe
intellectual delay will look more behaviorally impaired
49
Narrative Therapy: A Psychotherapeutic Approach in the Treatment of Adolescents With
Asperger’s Disorder
than someone who has autism and an average or
above average IQ. Yet it is not the autism we are com-
menting on, but rather the overall adaptive behavior
or functioning. Our current diagnostic practices
represent a radical shift in the balance between people
diagnosed with an associated or comorbid intellectual
delay and those with average intelligence. The trend
has now reversed from 10 years ago and the majority
of people diagnosed now have only mild intellectual
delay if any (Autism Association of NSW, 2001). Such
individuals with the requisite triad of impairment and
no intellectual delay are often said to have Asperger’s
disorder.
Autism itself does not affect personality, or
what some prefer to call temperament. Just
like all people, people with autism range
form passive to active, from quiet to loud,
from “internalizes” to “externalizes” or
whatever way you wish to say it.
Autism itself does not affect personality, or what some
prefer to call temperament. Just like all people, people
with autism range from passive to active, from quiet to
loud, from “internalizes” to “externalizes” or what-
ever way you wish to say it. Like all people, tempera-
ment can affect success at social integration, especially
when mixed with a comprehension deficit. A confused
and anxious passive person in many social situations
is accommodated more than a confused and anxious
active person based on the element of disruptive-
ness. Although autism does not affect temperament,
50
it has come to be realized that the impairment of
autism contributes to high degrees of anxiety for the
person in social environments, such as that charac-
terized by school and exacerbated by the complex
social demands of adolescence. This means the person is
often reacting to stress and experiences more tension, thus
exhibiting more of the extreme end of the behavioral
repertoire than a more relaxed person.
To understand the nature of this tension, a very
brief foray into the presumed thinking and learning
style inherent in a diagnosis of autism, and how this
differs to the typical style, is fruitful. The triad of
impairment is the behavioral or outward representa-
tion of a presumed style of receiving, processing, and
storing information (Cashin, 2005). To borrow a term
that has been assimilated into the autism vernacular,
this way of handling information is different from the
typical way, it is not neurotypical (Gray & Attwood,
1999).
For most people the primary mode of dealing with
information is verbal. Thoughts are initially experienced
as images but are not processed until words are
attached. The linguistic code is not necessarily words
as we would recognize them, but more a type of
mentalese, which is “the language of thought in which
our conceptual knowledge is couched” (Pinker, 1997,
p. 90). Thoughts are stored in each individual’s own
personally constructed filing cabinet in a gestalt,
engram, or personal draw based on language. The
cabinet is arranged on the basis of like and similar ideas,
grouped into concepts. The great gifts of abstraction,
fist described by Aristotle, allows people to seek
things out and work out what is like or similar, hence
where to store and retrieve information (Gadamer,
1966/1976). Through the power of abstraction the
individual is able to store experiences in an orderly
fashion, as each experience is stored next to, and builds
upon, knowledge in similar or related areas. Through
the development of a unified base of knowledge the
person soon has a repertoire of similar or like behaviors.
When confronted with a situation the person can reach
into their filing cabinet and search for a clue of where
JCAPN Volume 21, Number 1, February, 2008
to begin. Each time a behavior is pulled out and
modified, the modified behavior is stored and in effect
not only has the person survived a novel situation, the
person has a new behavior. If this were a process that
could be seen it would appear like the scene of the
sorcerer’s apprentice in the movie Fantasia in which
every time the apprentice chops a broom in half, both
halves carry on as independent entities and the unified
base of knowledge expands. Outside information is
typically received with little distortion apart from the
person’s construction of his or her own meaning.
People with autism have a deficit in abstraction
(Scott, Clark, & Broody, 2000). They cannot construct
an individual in-head filing cabinet of organized
information about the world (Cashin, 2005). They store
information as it comes in, in chunks, and in the order
it comes in, as opposed to in an integrated base of
knowledge. A unified base of knowledge about the
world that can be generalized from one event to
another is not formed. Instead of converting things to
words or symbols it would appear that people with
autism have an unusual relative strength in visual
processing: They store images as opposed to stories
about the world (Nash, 2002). Lastly, sensory sensitivities
often mean that incoming sensory stimuli are distorted
(White & White, 1987).
One further difference is the impairment in empathy.
Typical processing of social information relies on the
ability to make a guess at what other people are thinking
and feeling. Such a process is presumed to occur
through putting oneself into the others person’s place
and imagining what they must feel like and then
projecting this back onto the person in the form of a
hypothesis. This putting yourself in someone’s place
is empathy and relies on theory of mind. Husserl
described empathy as an intentional category. Inten-
tionality means something which we are able to attend
to or take notice of. “To be subject means to have
experiences; to be experienced as subject is to be experi-
enced as having experiences. Somehow, then, the
experiences of others must form part of my intentional
life, without at the same time being my experiences”
JCAPN Volume 21, Number 1, February, 2008
(Lauer, 1967, p. 172). Empathy-based teaching forms
a large part of the teaching of social skills in any
playground. This incorporates the familiar equation of
you are bigger than student X, I am bigger than you, if
I do to you what you did to student X how would it
make you feel, so what do you think student X is
feeling? Those with autism have impaired theory of
mind and cannot solve such complex, yet taken for
granted, equations.
The different way of being that is autism results in
constantly feeling like a square peg that is attempting
to squeeze, or be squeezed, into round holes. The
round holes represent what is viewed as typical and
the expectation of behavior that is congruent with this,
even when the person is puzzled about exactly what
that is. When placed into a novel situation, as one
constantly is in the world, the person cannot reach into
their filing cabinet to find the most similar circumstance
and retrieve information, or a clue on how to proceed.
The person is truly clueless and the squeezing pressure,
real or perceived, is stress that manifests as anxiety
(Cashin, 2005). Many individuals with autism have
likened themselves to aliens trying to assimilate into
a culture that is foreign on all levels (Grandin, 2000;
O’Neil, 1999). How do therapists intervene transcul-
turally to work on the tensions of living with someone
with autism?
Narrative Therapy
Narrative therapy is a form of psychotherapy used
frequently by nurses when working with adolescents
on the tensions or problems of living. “Psychotherapy
involves the psychological treatment of problems of
living, by a trained person, within the context of a
professional relationship, involving either removing,
reducing, or modifying specific emotional, cognitive,
or behavioral problems; and/or promoting social
adaptation, personality development and/or personal
growth”(Barker, 1999, p. 8). Narrative therapy specific-
ally involves working with a person to examine and
edit the stories the person tells himself or herself about
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Narrative Therapy: A Psychotherapeutic Approach in the Treatment of Adolescents With
Asperger’s Disorder
the world to promote social adaptation while working
on specific problems of living. These complex stories
include those related to who they are as a person and
their interpretation of events that signal to them where
they fit into the world. It is very much about re-ordering
parts, or in some cases the whole of the personal in
head filing cabinet. This occurs around specific and
concrete incidents.
Although epistemologically incongruent
with what would be expected to be of use in
work with someone with autism, the tools
used in narrative therapy provide the
platform for a novelly successful and
changing approach to psychotherapy with
such less typical thinkers.
As acknowledged, this is a form of therapy that is
linguistically based and that evolved from the early
creative work of Michael White and David Epston
(1995), who made accessible what are essentially
complex concepts based on existential psychotherapy.
This is a therapy primarily created to use with neuro-
typical individuals. A foundation element is the notion
of individual construction of meaning (Epston &
White). The notion is embedded that each individual
linguistically codes information and constructs meaning
through the grouping of like ideas into concepts or
engrams (Ogden & Richards, 1952). A degree of abstrac-
tion ability is presumed. The concepts when grouped
form the unified base of meaning or knowledge likened
52
to each individual personal in-head filing cabinet
where information is stored and processed based on
the individual’s personally constructed meaning.
Although epistemologically incongruent with what
would be expected to be of use in work with someone
with autism, the tools used in narrative therapy
provide the platform for a novelly successful and
changing approach to psychotherapy with such less
typical thinkers.
It must be acknowledged that the use of social
stories in working with those with autism is common-
place. Carol Grey (2000) developed an approach where
an individual with autism is given a whole chunk of
information about a social event. This chunk includes
information about the context in which the particular
story is applicable, clear ideas or rules on what to
do, and information how the person’s behavior will
impact upon others. This is in keeping with the chunk
style learning of those with autism and compensated
for the theory of mind deficit by inclusion of informa-
tion on the perspective of others (Gray). Further,
these stories are often augmented visually to deal
up information in the currency of relative strength.
The stories are designed to provide concrete instruc-
tion on how to navigate a social encounter. However,
how to move beyond giving someone a story and
engaging adolescents as coauthors has not been
addressed. This is an important issue as it is believed
coauthorship will improve meaningfulness, ownership,
and hence utility of the story (Waites & Swinbourne,
2001). Social stories are not in themselves a form of
narrative therapy. In using social stories there is no
presumption of working on individually constructed
meanings. A deficit in the development of knowledge
related to use of social stories is that of the question of
how to engage those with autism in the cocreation of
stories.
The tools employed in narrative therapy offer the
means to engage adolescents who present with the
repetitively problem-saturated situation of not having
a clue. These tools can be applied in an epistemologically
congruent way to the information processing style of
JCAPN Volume 21, Number 1, February, 2008
those with autism that underpins the triad of impair-
ment. That is, for adolescents without a unified base of
knowledge about the world on which to draw. This is
often manifested by statements in which the adolescent
describes perceiving a need to change as nothing is
going right but having no idea of where to begin and
what change is likely to lead to success. This perception
is often accompanied by high degrees of anxiety and
depression, as the individual is constantly exposed
to novel situations, which includes variations on
situations experienced before but perhaps in visually
different circumstance, and find themselves with an
expectation of the need to perform but no knowledge
of how to proceed. The in-the-present focus of narrative
therapy allows the therapist and individual to work
on the isolation of a discrete problematic chunk of
behavior. This moves from a problem-saturated narra-
tive where everything is seen as hopeless to something
that is particular and can be worked on. The problem
through the use of externalization can be given form
and hence turned into a concrete entity freed of the
entrapment enmeshed in more abstract vision of the
problem. Concrete thinking is an element inherent in
the way of being-in-the-world represented by autism.
Externalization is a technique in which a shared view
of the problem as a concrete entity that is separated
from the individual is facilitated through a process of
questioning that forms the ground out of which may
spring the emergence of this shared vision (Freeman,
Epston, & Lobovits, 1997). As the problem is seen as
external to the individual and manageable and not
part of some ongoing, and unassailable, narrative of
personal hopelessness, energy or hope is generated.
Individual agency is increased as the person becomes
empowered as they develop clues on how to proceed
through the coauthoring of a new narrative with the
therapist related to specific circumstance.
A concrete problem that is defined leads in many
cases to a revitalization as optimism emerges that
success can occur. If the problem at first is not easy to
define, the playful techniques and creativity inherent
in the use of narrative therapy can involve ploys such
JCAPN Volume 21, Number 1, February, 2008
as setting the individual up to spy on the problem so
as to allow a better view (Freeman et al., 1997). This
injection of creativity can be far more engaging than
the relatively dry collection of data and diarizing
employed in some other cognitive therapies. The
person is positioned as curious cotherapist in place of
passive recipient of therapy right from the start. Once
the problem is defined, the adolescent is supported in
the exploration of plausible concrete means of action
and again curiosity is utilized to motivate evaluation
against preagreed concrete criteria.
In keeping with the idea of the eventual publication
of success, each part of the journey is placed in writing
and illustrated so that the journey can be traced. This
means that the information is presented visually,
which is in keeping with the relative strength of those
with autism. As the adolescent is a cotherapist, they
can take responsibility for this in the session and hence
be engaged in writing and own in effect their own
social stories. Stories that encompass discrete situations
with a concrete plan of action and motivation to
evaluate outcomes against agreed concrete measures
of success.
Narrative therapy acknowledges the “situatedness”
of individuals, or the fact that individuals are embedded
with a social context (Fishman, 1995). Work does not
take place only with the identified patient. Sharing of
the story with stakeholders allows work with significant
others on their relation to, and perception of, the
problem. This often leads into family therapy and
psychoeducation related to the information processing
style of those with autism. Problem-saturated narratives
that have evolved into viscious cycles can be identified
and virtuous cycles given space to evolve.
Case Example
Case Study One: Justin
Justin is a 13-year-old boy who was referred by
his mother on the suggestion of his school counselor.
His pediatrician had diagnosed Justin as having
53
Narrative Therapy: A Psychotherapeutic Approach in the Treatment of Adolescents With
Asperger’s Disorder

Asperger’s disorder at the age of eight. He arrived at was very sorry that he did. Justin labeled his intense
this point after previous diagnoses of first, attention anger as “the bang.” Justin was asked to describe “the
deficit disorder at age four, followed by oppositional bang” and he gave a good description of what many
defiant disorder at age six. Justin was in the second would call an intense tantrum. Once in full swing
term of year seven at the time of referral and was Justin felt unable to change his “bang” behavior. Justin
described by his mother as “not coping with school.” agreed to spy on “the bang” so we could learn how it
Justin had recently been suspended for 1 week after behaved and worked. He agreed to keep a diary (spy
an incident in which he had verbally abused and sheets) that we could look into at the next session
physically pushed a teacher in his math class. planned to be in 2 weeks. In addition to this he
Justin is now back in school. While Justin freely agreed that we should draft a letter to the school
acknowledged that the incident had occurred he had counselor to let her know of our plan so that she
been unable to explain why, or actively participate in could tell his teachers and if they spied “the bang”
any planning on how to prevent recurrence. The before Justin did, they could alert him to its presence.
school counselor had attempted to develop a graded Justin’s mother agreed to share the strategy with
strategy plan that was tied to escalating anger, but other family members.
became frustrated when Justin could not be engaged
in the process. Justin arrived in my room in the medical
center accompanied by his mother.
Upon arrival Justin’s mother described what had
led to the decision to see me, and her intense sense of
He agreed to keep a diary (spy sheets) that
hopelessness in her ability to help Justin survive
schooling. She described ongoing incidents at school,
we could look into at the next session
and before this in preschool where she constantly felt
the need to defend Justin but was at the same time
planned to be in 2 weeks. In addition to this
unable to understand why he behaved as he did. Justin
sat quietly looking out of the window but verbally
he agreed that we should draft a letter to the
participated in the session if a question was directed at
him. Both agreed to allow me to get to know Justin
school counselor to let her know of our plan
away from the problem. What emerged was a
description of a boy with a quirky sense of humor that
so that she could tell his teachers and if they
enjoyed his computer and PlayStation games. A boy
that loved animals because they were simple, but who
spied “the bang” before Justin did, they
was very confused about people. Justin said he often
felt that he did not belong, particularly at school.
could alert him to its presence.
Justin was able to describe the concrete incident
that led to his suspension but could give no account
for his behavior. It became clear that Justin’s anger
had crept up on him and that he was as surprised and Justin returned after 2 weeks with his sheets. “The
as scared by the explosion as his teacher. It became bang” had occurred three times at school and once at
clear that Justin did not label his feelings and that home. We looked for common elements and signs that
intense feelings just seemed to arrive with no warning. “the bang” was coming. Justin realized that it did not
Justin said that he had no intent to hurt anyone and creep up as quickly as he thought. He identified that it

54 JCAPN Volume 21, Number 1, February, 2008

often comes when he had been given lengthy verbal
instructions and did not know how to follow them,
when lots of people were around, and when there was
a change of plans. Justin identified some allies of “the
bang,” which were confusion and loneliness (even if
he was surrounded by people). Over two sessions we
were able to write a story specifically for the school
classroom and one for home on “bang busting.” Again
this was shared in a note to the counselor and a copy
given to his mother. Our outcome criteria were to get
to one “bang” creeping up per month. The “bang” was
defined by the earlier descriptors.
Over the coming 2 months, we achieved our goal.
Again a note was sent to the school and one given to
his mother to publicize Justin’s bang busting success.
I was also able to meet with the school counselor and
separately with Justin’s parents to discuss Justin’s
information-processing style and how environmental
adaptations could promote bang busting success as well
as how “the bang” impacted on them. At 6 months,
the time of our next agreed meeting, we met to see
if we needed to revisit bang busting with the Bang
Buster Justin.
Conclusion
Although narrative therapy is founded upon
assumptions about how people know the world that
are epistemologically incongruent with assumptions
about the information processing style of those with
autism, several of the techniques used in narrative
therapy have utility when used in therapy with
adolescents with autism. Narrative therapy tools may
well be the key to move from giving a person a social
story to active engagement of the person with autism
in the creation of the story. Although early in the proc-
ess of evolution, it would appear that using the tested
approach of narrative therapy with adolescents with
Asperger’s disorder might prove useful, research is
needed to determine the relative merit of narrative
therapy as a form of psychotherapy used with this
population.
JCAPN Volume 21, Number 1, February, 2008
Acknowledgment. This paper is based on ideas pre-
sented at the ANCMHN International Conference in
Canberra, Australia, 2004.
Author contact: andrew.cashin@uts.edu.au, with a copy to
the Editor: poster@uta.edu
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56 JCAPN Volume 21, Number 1, February, 2008