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Narrative Therapy and Elders with Memory Loss by Elizabeth Young: Narrative
Means to Different Ends

Article  in  Clinical Social Work Journal · June 2010

DOI: 10.1007/s10615-010-0264-7

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Clin Soc Work J (2010) 38:203–206
DOI 10.1007/s10615-010-0264-7
Author's personal copy
COMMENTARY

Narrative Therapy and Elders with Memory Loss by Elizabeth

Young: Narrative Means to Different Ends
Suzanne England

Published online: 25 February 2010

! Springer Science+Business Media, LLC 2010

‘‘We don’t, we never did, go about making statements and some confidence in what we say—it is also that we
of fact to other people,or in our internal dialogue with refashion, interpret and ‘‘fictionalize’’ our accounts when
ourselves.’’ (Leguin 1980, p. 44) we tell them to ourselves. If we accept that this is the case
then we can acknowledge the high degree of uncertainty
Elizabeth Young’s article attempts to illustrate how
about what is indeed factual and inclusive in any account. I
certain techniques of classic narrative therapy can be
am not sure that reported facts matter so much as long as
applied in very brief short-term work with elderly persons
we have some opportunity to ‘‘observe’’ the therapist or the
in the early stages of memory loss due to Alzheimer’s
client in action, allowing us to interpret what is going on
Disease or a related disorder. Brief excerpts from three
according to our own interests and preferences, or to agree
interviews, each with a different client, are used to support
or disagree with the author’s own interpretation.
the writer’s argument that ‘‘narrative therapy can help
As Elizabeth Young makes clear in her piece she is
people with dementia revise their stories and reclaim their
writing about her experience in a field work placement
identities.’’ Of particular interest to Young is the potential
while completing her MSW. And although it is not
of narrative therapy to help the client resist the ‘‘cultural
explicitly stated, from her approach I would assume that
imperative’’ that one’s life be perceived in sequential order.
her paper originated as an assignment for a course, prob-
In my commentary on her article I will not critique her
ably one that required her to illustrate a practice method
account but use it as a springboard to reflect briefly on
with examples from her field work. Such assignments are
several interrelated matters: (1) the ‘‘genre’’ of therapist’s
common in social work education but I would argue that
accounts of a particular type of practice and the proble-
they may, at times, have a negative impact on learning.
matics of student accounts in particular; (2) the common-
That is, the student is reluctant to show uncertainty and
alities of and differences between narrative inquiry (my
doubt as she or he tries to fit the experience of learning a
practice) and narrative therapy as narrowly defined; and (3)
practice into the boxes of method as described in textbooks
the potential of collaboration between narrative practitio-
and canonical texts (in this case, Epston and White’s early
ners and narrative researchers.
works on narrative therapy). Such assignments may also
Accounting for oneself as a therapist or as a commen-
reinforce the dominance of ‘‘the authority’’ and make it
tator is a daunting task. As Leguin says it is not just our
more difficult for the learner to critically reflect on his own
struggle with what to say or not to say—how to give
learning. In spite of the constraints that the context of
another person or audience some sense of our experience
social work education may have placed on Young, she does
a commendable job. Not only does she demonstrate a
mastery of the early literature of narrative therapy, she
This is a comment to doi: 10.1007/s10615-008-0146-4. manages to overcome somewhat the strictures of the
expectations of ‘‘the instructor’’1 by her empathic
S. England (&)
1
Silver School of Social Work, New York University, I am using this term in the very broadest sense, not to point to any
New York, NY, USA one individual, but in reference to the hierarchical arrangements in the
e-mail: suzanne.england@nyu.edu practice of teaching.

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accounting of her exchanges with clients. Brief though they
were, these exchanges seemed to me to be trustworthy. I
did not get the sense that Young was ‘‘editing’’ to make
herself appear more adept at applying narrative therapy
techniques than she may have been at the time, and that
with more experience she will continue to reflect on her
practice and make welcome contributions to the ‘‘narrative
turn’’ in social work.
I am not a therapist nor do have any experience working
with people with memory loss but my colleagues and I
have studied and written about narratives of Alzheimer’s
and caregiving (England 1993; England and Ganzer 1992,
1994; Ganzer and England 1994, England and UIC Col-
lective for the Study of Narratives on Family Care 1993).
Based on that work what I bring to this commentary is my
continuing curiosity about the ways narrative inquiry can
be a pathway to critical examination of practice and social
policy. Young’s article refreshed my thinking about nar-
rative and dementia and led me to new questions about the
differences in my approach to narrative inquiry and the
approach of those who do narrative practice. Young’s
intent is not narrative inquiry but rather a demonstration of
a narrative practice and it would not be fair to criticize her
for not using the methods of narrative inquiry. Considering
the practical demands of her work (the agency’s agenda,
the very short term structure, and the pressures that both
bring to bear on her choices) Young is able to give us a
sense of the individuality of each client. Young has added
to a very scarce literature about narrative and dementia and
her case examples have stimulated my own thinking about
the dilemmas and challenges of writing about narrative
practice. Although Young and I approach narrative from
differing perspectives and purposes we share a common
interest in the ‘‘voice’’ of those with dementia.
By the broadest definition my own work fits into the
category of narrative inquiry, and given my lack of expe-
rience with therapy or narrative practice my commentary
on Young’s article should be taken with a large dose of
salt. However, reading Young’s article I was struck by the
rich possibilities of dialogue between narrative practitio-
ners and those of us who are narrative researchers but not
practitioners. My research on Alzheimer’s care relied
heavily on a collaborative process (England 1993) and
involved clinicians and researchers in what we called The
Narrative Study Group. Our methods were aimed at elic-
iting the different perspectives of each person in the study
group, not to arrive at a consensus but to open up con-
ceptual space and challenge the prevailing intellectual and
professional conventions in Alzheimer’s care, practice and
research.
As a practitioner and a researcher Young and I approach
knowledge building with two distinctly different orienta-
tions. Her account is in the tradition of the proof
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Clin Soc Work J (2010) 38:203–206
orientation2 and though she is not using empiricist meth-
ods, she has a definitive plan and adheres to it to make her
points about the applicability of narrative therapy with
early dementia. I, on the other hand, approach narrative
material with a discovery orientation. Rather than setting
out to prove or demonstrate my conceptual framework, my
goal is to change my own way of thinking about something.
I attempt to continuously redefine my interpretation by
looking for the novel, unexpected and contradictory in the
narrative.
Ronald Chenail’s (2002) discussion of the common
assumptions of therapists and researchers has been partic-
ularly helpful to me in sorting out the ways in which Young
and I differ in our approach to narrative work. Chenail
notes that the first common assumption is that ‘‘co-existing,
multiple realities [are] at play, including our own’’ (Com-
mon Distinctions in Contemporary Qualitative Research
Education and Systemic Family Therapy, Sec. 1).
In her account Young’s emphasis is on the outcomes of
therapy—the reclamation of identity and resistance to the
cultural imperative to perceive one’s life in chronological
order. As a narrative researcher, I might begin an inquiry
with an interest in what the narrative suggests about these
or other dynamics but with experience I have learned that
few if any of the conceptual frameworks I may begin with
stand up for long against the multiple realities and con-
tradictions of the narrative. Young no doubt understands
that irrespective of whether one has dementia, a chrono-
logical perception of one’s life is only one of the multiple
ways we remember and account for our lives. In certain
settings, e.g., when expected to provide a curriculum vitae
or information for a case history, chronology may be
expected to be the predominate structure, but in many cases
we ‘‘tell’’ our lives with other structures–by our relation-
ships, thematic threads, achievements and setbacks, and
stories within the larger story. In some ways the chrono-
logical account can be thought of as the anti-narrative
(or antenarrative, i.e., pre-story), and what Young has
identified may not be so much a cultural imperative but a
subjugation of voice.
In narrative inquiry we are as interested in what is not said
as we are in what is told. One way of describing this approach
is the ‘‘hermeneutics of suspicion’’, a method of interpreta-
tion, according to Ricoeur (1970), ‘‘which assumes that the
literal or surface-level meaning of a text is an effort to con-
ceal the political interests which are served by the text (as
cited in Pepa 2004, p. 44).3 ‘‘As Pepa explains the method,
‘‘It suspects the credibility of the superficial text…’’ (p. 1).
Narrative inquiry can illuminate the ways that gender, class,
social archetypes and other dynamics of the narrative are
2
Very likely due to the ‘‘assignment’’ aspect discussed earlier.
3
Pepa 2004, p. 44).
Clin Soc Work J (2010) 38:203–206 Author's personal copy
subjugated and hidden. By ‘‘studying up’’ in a self-critical
way it seeks to change the observer (researcher or therapist)
and to challenge and discover rather than ‘‘prove.’’ The
hermeneutics of suspicion also allows us to ‘‘suspect’’ our
own text. The act of writing for a professional journal (as I am
here) is a persuasive practice and one is expected to follow
rather strict rules to be viewed as sufficiently credible to be in
print. Were we to be excessively introspective we would
violate those rules (and not be published!). However, self-
awareness of our own text as only one of many possible
accounts, and one constrained by our sensitivities to the rules
and the profession’s political interests is a highly useful
mindset for narrative work.
The role of life history, reminiscence, and other narra-
tive oriented approaches in work with the frail elderly has
‘‘a long and honourable tradition within the practice of
dementia care …’’(Williams and Keady 2006, p. 163), and
although little has been written about how narrative therapy
per se is applicable to work with those with memory loss,
the possibilities are indeed intriguing. The methods
described in White and Epston’s (1990) pioneering Nar-
rative Means to Therapeutic Ends may be adaptable to
dementia care but Young’s article about her work seemed
to me to be overly constrained by her desire to demonstrate
the applicability of specific methods. One concern is about
whether the practice Young describes fits clearly within the
framework of therapy as usually defined and practiced in
the US. That is, a contractual arrangement between a
therapist and client to work together to relieve a specified
(and ideally agreed upon) problem, difficulty, or disorder.4
As a narrative researcher I find Young’s ideas intriguing
but my first inclination would be to test these concepts
against how the clients describe their difficulties. There are
small clues to what the clients regarded as problems or
challenges in the excerpts but none of them seem to point
to Young’s abstract conceptualization. For example Vir-
ginia describes an embarrassing episode as ‘‘scary’’ and
Young then asks a question about whether Virginia knows
what is making her brain seem like it is failing. Here it
seemed to me that Young shifted from Virginia’s emo-
tionally laden concern to her own rationally based5 thera-
peutic intention, and may have missed the opportunity to
talk further with Virginia about her fear of embarrassment
and how she coped with it (by excusing herself and going
to the bathroom—a rather adept response). From what I do
4
The narrative practices that have evolved from Epston’s and
White’s seminal work have varied and multiple ‘ends’—community
building, prevention, consciousness raising, and restorative justice, to
mention just a few. My lack of experience doing practice that fits
under the rubric of therapy may account for my possible overreaction
to the term.
5
Did the shift possibly occur because of the way the therapy was
being defined by the agency?
205
know about White and Epston’s work, I had the thought
that that fear of embarrassment was something that might
be externalized and managed. Surely such scenes would
recur and Virginia seemed to have the self-management
resources to deal with these. As a narrative researcher I am
struck by the possibility that embarrassment stories might
well be common ones for those in the early stages of
memory loss, and the different ways that people manage it
a rich vein of inquiry.
For both therapists and researchers a reflective stance is
required and if possible should be discussed in the account.
As Chenail (2002) puts it, we must ‘‘continually assess and
interpret our participation in the research/therapy process’’
(Common Distinctions in Contemporary Qualitative
Research Education and Systemic Family Therapy, Sec. 4). I
would add that since we have in common a central concern
for social justice and power relations, both practitioners and
researchers are obliged to critically examine our own loca-
tion and influence in our relationship to the client/informant/
narrative. And, as any account of practice or research is
performative and not a statement of ‘‘true facts’’, it is helpful
to both the reader and the writer that there be a statement of
the writer’s standpoint and some explanation of the multiple
contexts of the encounters being described.
It is around the question of context that Young and I seem
to differ the most. That difference is likely a function of our
divergent goals but it is also could be one of the most fruitful
areas for further collaboration by researchers and practitio-
ners. As a narrative researcher I read Young’s account with a
focus on context and what clues there might be in the state-
ments of the clients about how they were interpreting their
own experience. Were I to have access to transcripts or
videos of the interviews and reviewed them with Young I
would want to ask what her thoughts were at each point in the
interview, how she conceptualized what was going on, and
how she decided to act one way or the other. And because of
my focus on how the context of the practice socially con-
structs one’s subjective sense of chance and opportunity, I
would query Young about her perception of the chain of
vulnerabilities—both real and perceived–suggested by the
omissions in her account. This technique of reflective prac-
tice is one that narrative clinicians and researchers share and
value but may be a luxury in the context of agency practice.
However, it offers a way to look more deeply inside practice
and critically assess our practice theories.
Narrative therapy is organized around the core principal
of restorative and transformative justice, and a signature
characteristic is the de-centering of the therapist, allowing
the client to define his or her own position in relation to the
problem (White 2007, p. 39 as quoted by Rood 2009,
p. 20). Without knowing what the purpose of the brief
treatment was and by whom it was defined, we cannot
assess whether the clients in Young’s examples had the
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opportunity to do that. Absent as well is a statement of the
author’s standpoint and some accounting of the history of
how these particular interviews/therapy sessions and the
subsequent paper (originally an assignment?) came to be.
Young herself is ‘‘present’’ only in her quotes in the
excerpts from the interviews. We do not know her stand-
point or her location in the hierarchy of power (for instance
are the clients being assessed for eligibility for services?).
We know little about the context of the interviews or about
the nature of the excerpts. Were the conversations tran-
scribed verbatim, from notes or from memory? How and
why did Young decide on these excerpts? Bruner (1986)
cautions us that narrative and interpretive methods are not a
‘‘swooping down’’ (p. 10) on the text to make our point or
to confirm our theories and concepts but require us rather to
study up, allowing the voice of the client/informant to
cause us to question and challenge our perceptions of
‘‘What is going on’’ in the conversation.
Personally, my only direct experience with dementia is
with my aunt, whose short-term memory gradually disap-
peared as she became increasingly frail over the past
5 years. Much of what she experiences is mysterious to me,
but our relationship remains warm and much the same as it
has been for most of my life. She converses easily, and has
strong recall of long ago events and details about people.
Over these past years she seems to most enjoy when I ask
her questions about the family and remind her of highlights
of the past. The onset of her short-term memory loss was
subtle. At first she would tell us she was out of something
and we would discover after shopping for the item that she
already had an ample supply. In the next phase she was still
living on her own, reading avidly, doing crossword puzzles
and driving. We became concerned that she was no longer
able to keep track of her medicines and about that time, she
voluntarily decided to move to assisted living and give up
her car. We engaged an elder care management profes-
sional and thanks to her and her staff, the transition was
made much easier for my aunt and the family. As my aunt
became increasingly frail and after several hospitalizations
she is now in long term care.
My aunt is sociable, has a wicked sense of humor, and
thankfully, still recognizes family members. The past is
very much present to her—so much so that she will
describe, with obvious enjoyment, something that happened
many years ago as though it had happened that morning.
Her memory of key events of the last 10 years or what
happened in the last hour is unreliable but she is very aware
of her surroundings and the people with whom she interacts
every day. Except for the fact that she cannot care for
herself physically or organize her thoughts to keep track of
the details of her day-to-day life, her memory—mixed with
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Clin Soc Work J (2010) 38:203–206
some confabulation—is a rich mix of places, people and
scenes both near and far. It is poignant that she is well aware
of her memory limitations but in many ways her memory
has become a deep well of emotion, including pleasure.
My experience with my aunt has brought home to me an
appreciation of the particularity of any one instance of
dementia, the constant shifts that can occur, and the mul-
tiplicity of contexts that affect the situation. I am learning
too that even with dementia one can have a rich inner life
filled with vivid memories. Perhaps we don’t always
‘‘lose’’ our memory but rather find it anew.
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