Narrative Therapy: Patient Case

Narrative Therapy

In its broadest sense, narrative therapy is a conversation in which people tell the therapist various stories of their lives. For narrative therapists, “a story” means some events tied in certain sequences at certain time intervals, and thus brought into a state of a plot endowed with meaning. This approach is based on the assumption that people are interpreting beings. Constantly experiencing an endless sequence of events, they strive to see them interconnected and explainable, giving them certain meaning. The narrative here is like a thread interweaving various events scattered in time and space into a story. The narrative approach would be the most useful for this case’s conceptualization, as it allows the person to separate the context and see these stories not as defining, but as situational. It provides the opportunity to look for other, more positive stories, hidden under the problematic ones, and establish connections between them.

Client Background

Janelle is a 32 years old single heterosexual Egyptian woman. Janelle’s family moved from Egypt to Toronto when she was 2 years old, and she has four older siblings – two brothers and two sisters. As a child, she experienced emotional distancing from her parents, as they had often neglected their parental duty in favor of their professorial and scientific work. Additionally, they often exerted significant pressure on her, demanding academical success, establishing very strict rules, and wishing for her to go to a prestigious university to study. However, Janelle decided against it and chose a smaller college, after which she quickly got employed.

During her childhood, Janelle was often bullied for being different from other children, and experienced loneliness and isolation. Still, she managed to secure several friends of her own, and her siblings also supported her. Nowadays, she is a successful professor at a local college and a well-recognized specialist in environmental science, with multiple publications and invitations to speak at various symposiums. However, her parents often complain that she needs to get married to a Egyptian man soon and settle, as all of her siblings are already married and with children.

Theoretical Framework

Human experience, essentially, consists of many stories: about who an individual is and who they are not. In other words, these stories are about an individual’s inner self: their abilities and achievements, failures and defeats, interests and intentions, work and career, relationships and connections, actions, desires, plans, and other variables. What exactly these stories will be depends on what events an individual paid attention to, how they connected them with each other and what meaning they gave them. The life of any person consists of a much larger number of events than those that they select for their stories. Which of the newly arriving events will be included in the stories is determined by the already constructed dominant stories of a given person.

However, a person is not born with these stories – they are constructed in a social and political context. In Janelle’s case, this aspect holds one of the crucial places, as she has been transferred from one culture to another at a very young age. People are not born in a vacuum, free from opinions about what a “normal” person should be, and the opinions of her family and peers during her childhood had affected Janelle a lot. Narrative therapy can help her explore these cultural stories and discourses from a different perspective. The ability to see particular stories in a broader context is the foundation of narrative practice.

Everyone uses narratives to reflect on their own experience. Thus, it often happens that people who come into counseling interpret their experience through the prism of problem stories. Janelle states that she feels alienated during the family meetings every weekend, supposedly aligning this feeling with her “inability” to fulfill her parents’ wishes regarding her. This is evident in the way she talks about these meetings, claiming that she often perceives herself as “the 15th wheel” during them, and calling them tedious and sad. Such a narrative points to a repetitive trauma from her childhood that keeps happening again and again. Negative experiences become like a magnifying glass through which people – and Janelle, specifically – look at the world. Within this framework, focusing in the perception of the present occurs only on certain things – hose that fit the traumatic story. Janelle might simply not be able see anything else in her experience that suggests otherwise.

The therapist would be able to separate negative and positive stories when they and Janelle will begin to analyze the experience brought from everything that happened to Janelle. In narrative therapy, this process is called externalization. It can start with the following questions to ask: how long have these feelings of alienation been living in her head? when did they first surfaced? what happened to Janelle then? These questions are supposed to make the difference between Janelle’s real life and how she imagined it to be clearer. While studying Janelle’s case further, the therapist might also try to find the hints of alternate – positive – stories to catch on. For example, she was always quite lonely, both during her childhood and older age; however, there were still people whom she befriended. The therapist may begin to develop this story: how did she decide to open up to other people? What prompted their friendship and how it proceeded? There is a lot of room for thought here, and the conclusions Janelle draws might help her understand herself better.

According to the narrative approach, one need to look for what is significant for a person – what they value, what they hope for, and what they want. Thus, it would be important to determine, what did Janelle strive for, making this friendship. A problem story of loneliness and rejection can be broken down, and lose power over a person when they realize that it is not true, and reimagine it as something separate from themselves. Since emotional injuries are often deeply rooted in the past – such as in Janelle’s case, as she experienced both parental and social neglect – it takes time to overcome them. Therefore, it is important to learn as much detail of the preferred stories as possible in order to make them distinguishable in human experience.

When people create new stories, new connections are formed between neurons. Concentrating on positive stories is helpful: the more people rely on their preferred stories, the faster the corresponding neural circuits in the brain become mainstream. Subsequently, there is no need to return to the injury, as the needed connections are established. Moreover, the stories do not only live on a conscious level; they affect the body, as well. Janelle experiences severe bodily symptoms when it is time to go to family gatherings due to the unpleasant emotions she had experienced during them. Any traumas, including emotional ones, cause pain that remains in the body. In the process of evolution, humans have developed the ability to very quickly respond to danger. Human biological responses to potential threats is automated. A burst of adrenaline and cortisol produces reactions in the organism – in Janelle’s case, choking, sweating, body temperature rise, and stomach crumps.

This, essentially, leads to the fact that people who have gone through trauma are able to experience these sensations over and over again under the influence of a trigger. The trigger can be anything – a place, a voice, a smell, or event such as family dinner. The same hormones are produced, and although there is no real threat or abuse, the sensations are the same. This can be a source of real stress, and in Janelle’s case, this lead to the development of social anxiety disorder. However, the narrative therapy can help her – new, positive stories can turn pain into words, help her verbalize it and understand what it means. As positive narratives would gradually manifest themselves and take shape in words, Janelle’s negative experience will moves into consciousness and resolve, so that the triggers will not activate it anymore. This would allow her to understand and make sense of it, as well as provide new perspective.

Preliminary Assessment

The assessment process for Janelle’s case would use a variety of tools to determine the preliminary diagnosis. Firstly, an informal verbal evaluation must be applied: Janelle’s symptoms and the conditions in which they manifest are assessed. She reports feeling distressed and displays bodily symptoms that include profuse sweating, stomach cramps, panic, overheating, and choking in her throat, right before she has to go to a family gathering every weekend. Thus, it can be assumed that Janelle has social anxiety disorder, as the symptoms match with the disorder’s description, and occur prior to a social event where Janelle expects to feel alienated.

Another tool that can be used for an assessment is a clinician-administered scale – for example, Liebowitz Social Anxiety scale. It one of the most widely used scales in assessing social phobias, and is conducted by a trained mental health clinician. Within the scale, 24 situations would be presented to Janelle. In 13 situations, she would evaluate her anxiety levels related to a social performance, while in other 11 situations, she would be referred to social interactions with the same task of evaluation.

Additionally, self-report questionnaires can also be used for Janelle’s case, as they are good at showing progress of the therapy through repeated self-evaluations. Social Interactions Anxiety Scale would be the most useful, as it would specifically address her fear of family gatherings. Moreover, it also assesses the patient’s avoidance tendencies, helping reveal unhealthy patterns of behavior.

Case Conceptualization

Janelle came into counselling due to the fact that recently, she began struggling with social anxiety. She reports feeling panic, choking sensations in her throat, sweating, and shaking right before she leaves her home to go to family dinners, which she attends every weekend, during the last month. Moreover, on two occasions, these symptoms were so severe she had to be taken to an emergency room by older her sister. However, physical assessment revealed that she is healthy, and the doctor advised Janelle to seek counseling for her problem. She also reports that last week, her symptoms worsened, and began to interfere not only with her family meetings, but with her other social life as well. Janelle entered the counseling seeking understanding of what is happening with her, as well as for treating her current condition.

Topical Literature Review

Cultural Adaptation Issues

Today it is impossible to find ethnic communities that would not be influenced both by the cultures of other peoples and by the broader social environment existing in the world as a whole. This was reflected in the rapid growth of cultural exchanges and direct contacts between state institutions, social groups, social movements and individuals from different countries and cultures. Foreigners face many problems and difficulties in adaptation, such as language and cultural barriers, unusual climatic conditions, difficulties in communication, and other issues. Acculturation has ceased to be viewed as an exclusively group phenomenon. It has begun to be studied at the level of individual behavior, taking into account the change in value orientations, social attitudes, and role behavior of the individual. It was found that in the process of acculturation, each person simultaneously solves two major problems – strives to preserve their cultural identity, and to be included in a foreign culture. Janelle moved to Toronto when she was 2, thus, she was already immersed in the Egyptian social environment and had to adapt to the Canadian society after migration.

Klein et al. (2020) discuss the nature of the relations between mental health of the 1st generation immigrant youth and their acculturation process – with regard to gender differences. All migrants, to one degree or another, face difficulties in interacting with local residents, whose behavior they are unable to predict. The study emphasizes that different acculturations patterns such as marginalizing, separation or integration, play a central role in the process of adjusting to a new environment, regardless of gender. Wu et al. (2018) support this claim, stating that acculturation orientation remains predictive for the mental health of future adults. Their research suggests that children who displayed higher level of resilience in the face of cultural adaptation later showed better mental health characteristics. However, this resilience heavily depends on peer support: from friends and family, which Janelle had been mostly denied during her childhood due to her parents’ business.

Berry and Hou (2017) specifically examined migrants who moved to Canada in their study, providing insight into the processes of acculturation for 2nd generation. Their study reports that integration strategy shows better results at acculturation for migrants, which, in turn, is associated with better mental health outcomes in adulthood. This hints to the suggestion that, perhaps, the acculturation strategy Janelle’s parents used was not efficient for her. Therefore, it is safe to conclude that migration and subsequent problems with acculturation in the past might have influenced Janelle’s condition today.

Childhood Bullying

At the end of the twentieth century, a special term that reflected more accurately a situation of violence in the educational environment was introduced – namely, bullying. Bullying is an issue of long-term violence, physical or psychological, performed by one person or a group, and directed against a person who is unable to defend themselves. Bullying can also be seen as a phenomenon that leads to serious psychological problems in the future. Children affected by it become anxious, they experience self-esteem and self-worth issues. Janelle reports having troubles at school in the past, as she was bullied heavily for being “different from others”. Therefore, it is important to address the issue of childhood bullying in the counseling.

Strøm et al. (2017) investigate specifically the long-term consequences of bullying in their study. Moreover, the authors also consider how the effect of bullying victimization influences psychosocial adjustment in adults, as well as if shame has a mediating role in the relationship between it and mental health outcomes. Strøm et al. (2017) conclude that, indeed, the trauma from childhood bullying victimization has a lasting and a severe negative effect on the adults’ mental health. Moreover, there is also a need to investigate the shame’s role as a mediator of it further. deLara (2019) supports the claim that childhood bullying provides psychological distress that lasts into the adulthood. The study’s analysis revealed such specific consequences of bullying as deterioration of mental well-being and relationship and trust issues. Seeing as Janelle obviously struggles with both aspects, and does not have a trustful and fulfilling relations with her parents, it is clear that childhood bullying inflicted psychosocial damage on her.

Gender Considerations

The specificity of social adaptation in the sphere of gender relations lies in the fact that its subject is a social gender community. The gender adaptation acts simultaneously as an object, as a tool, and as a result of society’s gender policy. This kind of adaptation is equally relevant for men and women, and has one of the major roles in forming the individual’s identity. As a rule, within the framework of each social system, a certain gender balance is formed, which determines the complex of social roles of male and female communities. Traditionally, the gender problem is considered as a problem of the life of women, their social status, position in society, and legal capacity. Asher et al. (2017) address the gender differences within the social anxiety disorder with their review. The authors’ findings show that women are more likely to develop severe social anxiety disorder compared to men due to increased social pressure. Thus, the study emphasizes the need for a gender-tailored approach regarding the diagnostics and treatment of social anxiety disorder, more so because men are usually more likely to seek counseling for it than women.

Ohannessian et al. (2017) support this claim, stating that the understanding of gender differences of anxiety disorder manifestations during middle to late adolescence can provide more effective intervention programs. The authors (2017) state that “for both generalized anxiety disorder and social anxiety disorder symptoms, girls were significantly more likely than boys to be in trajectory classes characterized by moderate or high initial symptoms” (p. 826). Janelle comes from Egyptian background, which is usually quite conservative about women’s role in society, seeing females primarily as wives and mothers. During her childhood and adolescence, she was constantly pressured by her parents for better performance, as well as restricted from interactions with boys, which may have served as initial basis for her current anxiety.

Nowadays, Janelle’s parents constantly pressure her into marriage and “settling down”, despite her professional success and career plans. Moreover, all of her four older siblings already have families with children, which might be another source of discomfort for Janelle. Oren-Yagoda et al’s (2021) research indicates that people with social anxiety disorder are more prone to envy their peers. The authors state that, while social anxiety causes individuals to display envy in voice and text communication, this envy, in turn, serves as a drive for sustaining the anxiety. Janelle’s behavior and reactions indicate that she is not comfortable with her family, and that she does not feel included during the gatherings. Perhaps, this is due to the fact that she does not feel like she had fulfilled the image her parents forced onto her during her childhood and adolescence, and she envies her siblings’ marital success.


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PsychologyWriting. "Narrative Therapy: Patient Case." September 18, 2023.