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Psychotherapy’s Third Wave?
The promise of narrative

Accompanied by her cousin and her cousin's boyfriend, she was a skeleton lost in a large sweater, trying to make herself invisible, curling her arms around herself and slumping down in her chair. Smiling faintly in response to David's persistent questions, she insisted she felt fine and had lots of energy. David, carried away by his intense interest in her answers, could barely contain himself. He squirmed in his chair, leaned toward the girl and asked her question after question: "Can I just ask you why you think it is that Anorexia tricks people into going to their deaths thinking they're feeling fine? What purpose would it have, getting you to go to your death smiling?"

Rhiannon still would not engage. Slumped in her chair, she kept saying she felt fine. Rhiannon had recently been discharged from a hospital after losing 25 pounds in three weeks, and a physician was monitoring her condition three times a day. She was literally on the brink of death. At home, she had been lying in a fetal position and screaming until her exhausted parents took her over to her older cousin's house. As I watched the tape, I thought that even I, psychotic optimist that I am, would have given up on engaging Rhiannon and would have focused my interventions on the cousin and her boyfriend instead.

But David seemed to be even more psychotically optimistic than I am. He persisted: "Okay, okay, okay. If that's how you're feeling, how's it fooling you? Most people, when they're near death, know they're being murdered, right? How's Anorexia doing this to you? Because if it's making you feel good, or telling you you're feeling good, then I'd like for you to ask this question of yourself: 'Why does it say to you you're feeling good? Why would it do this? Why does it want to murder you? Why doesn't it want you to protest? Why doesn't it want you to resist?'"

Then, suddenly and inexplicably, Rhiannon responded. Anorexia, she said, fooled her by telling her she was fat when she was thin. "Is it telling you that right now?" David asked. "No," Rhiannon said. "I am too thin." She sat up in her chair.

David asked her how she knew that, and she replied that people who love her told her that she is too thin. "Do you think Anorexia loves you?" he asked her. "No," she said. "It's killing me."

Her voice grew stronger. Her body language changed. In response to David's continual stream of questions, she began to make plans for standing up to Anorexia and not letting it fool her into starving herself any more. David enlarged the new doorway, asking her how, in the past, she had shown herself to be the kind of person who could stand up to something like Anorexia. By the end of the session, nobody in the room was talking about her hospitalisation any more. David, Rhiannon, the cousin and her boyfriend all looked hopeful and certain. Within 10 or 15 minutes, Rhiannon had become an ally in treatment, rather than a reluctant bystander. The rapidity of this change wasn't new to me, but such turnarounds usually happen only when a client actively cooperates. Rhiannon, like many anorexics, did not look much like a customer for change — that is, until David got hold of her.

In the past five years, therapists around the world have become intrigued by narrative and related approaches to therapy that flatten out the familiar client/ therapist hierarchy and treat personal identity as a fluid social construct. To be sure, the interest in narrative is not client driven. People don't come into my office asking for help “standing up to Anorexia" or to have a liberating conversation" or asking to "deconstruct their social identities." Rather, the popularity of narrative and related approaches has something to do with their appeal to therapists — they heighten our sense of the possible; they make us feel hopeful and excited again

The First and the Second Wave

The appeal of narrative therapy involves much more than a new set of techniques. To my way of thinking, it represents a fundamentally new direction in the therapeutic world, a movement that might be called psychotherapy's Third Wave. The First Wave, which began with Freud and laid the foundation for the field of psychotherapy, was pathology-focused and dominated by psychodynamic theories and biological psychiatry. The First Wave represented a major advance because it no longer viewed troubled people as morally deficient, and it gave us a common vocabulary — codified in the Diagnostic and Statistical Manual — for describing human problems. But it focused so heavily on pathology that it skewed our view of human nature. Many people ended up identifying themselves with stigmatizing labels like 'narcissist', 'borderline personality' or 'adult child of an alcoholic'.

I was never much of a fan of the First Wave. It seemed to give our pronouncements a vast and overrated authority and turn diagnoses that were little more than social prejudices or imaginative guesses into absolute and eternal truths. The absurdity and damage wrought by our delusion that we could determine what was sick or healthy, right or wrong, was amply demonstrated in the 1970s, when psychiatrists belatedly decided by democratic vote that homosexuality was no longer a disease.

Psychotherapy's Second Wave — the problem focused therapies — emerged in the 1950s but did not entirely supplant the First Wave. The Second Wave attempted to remedy the over focus on pathology and the past. Problem focused therapies, including behavioural therapy, cognitive approaches and family therapy, didn't assume clients were sick. They focused more on the here-and-now instead of searching for hidden meanings and ultimate causes. Personality was no longer seen as seated in the envelope of the skin, but as influenced by patterns of communication, stimulus and response, family and social relationships, and even 'self-talk'.

Change wasn't seen as nearly so difficult in the Second Wave: influence some of the variables and the whole system wilt shift, including personal characteristics that looked as though they were set in concrete. Second Wave therapists saw their clients as basically sound, just making a pit stop. The goat was to fix them up as quickly as possible and send them back onto the highway of life. They didn't try to tinker with things they hadn't been asked to fix.

Although the therapists of the Second Wave included a few more women and weren't as exalted as the psychiatrists of the First Wave, they remained the experts, versed in such arcana as Gregory Bateson's double-bind theory, paradoxical interventions or behavioural techniques. Problems resided in small-scale systems; solutions still rested with the therapists. Few saw their clients as decisive agents in their own change. In fact, many saw their clients' conscious sense of self as something that had to be worked around or outwitted.

And now the Third Wave

In the early 1980s, some therapists began adopting what might be called a precursor to the Third Wave — competence based therapies. We believed that the focus on problems often obscures the resources and solutions residing within clients. Like the Third Wave that would follow, we no longer saw the therapists as the source of the solution: the solutions rested in people and their social networks.That, in a nutshell, is solution oriented therapy — grow the solution/ life enhancing part of people's lives rather than focus on the pathology/ problem parts, and amazing changes can happen pretty rapidly.

But unlike the Third Wave that would follow us, we kept our ambitions limited. Like the man who searched under the street lamp for his keys because the light was better there, even though he'd dropped them half a block away, we worked on small, manageable problems. We saw deep changes happen sometimes, almost as an act of grace or accident, and welcomed them when they did. But planning or expecting it to occur regularly seemed like setting up our clients for failure.

The First Wave's preoccupation with history acknowledged the reality of people's victimisation and yet seemed obsessed and defeated by it. The Second Wave's minimalist pragmatism helped people cope with day-to-day issues at the expense of acknowledging the depth of their pain and the richness of their lives. Both viewpoints are clearly incomplete, and this may explain some of the attraction of the Third Wave, which is arising in many different places in the world simultaneously. That is why Marisa's story so moved me. Epston did not brush aside her history, nor did he get bogged down in it — he dethroned it. He saw her as an active resister, not a passive victim. He acknowledged the tremendous power of what she had been told about herself, and separated her sense of herself from her history. And he did so without one-way mirrors or therapeutic gobbledygook, using nothing more technologically sophisticated than a letter written with dignity and feeling and respect.

The more time I have spent reading and watching the work of Third Wave therapists, the more I see similar patterns — a willingness to acknowledge the tremendous power of the past history and the present culture that shape our lives, integrated with a powerful, optimistic vision of our capacity to free ourselves from them, once they are made conscious.

The person is never the problem

The hallmark of the narrative approach is the credo, "The person is never the problem; the problem is the problem." Through use of their most well known technique, externalisation, narrative therapists are able to acknowledge the power of labels while both avoiding the trap of reinforcing people's attachment to them and letting them escape responsibility for their behaviour.

Externalisation offers a way of viewing clients as having parts of them that are uncontaminated by the symptom. This automatically creates a view of the person as non-determined and as accountable for the choices he or she makes in relationship to the problem.

"Narrative ideas lend themselves to respect and empowerment, not only for clients, but for therapists as well," says psychologist Richard Ruhrold, clinical director of the Bowen Centre in Indiana. After learning about externalisation, he used it with a family whose adolescent son was identified as having a "crappy attitude". "So we decided to name the problem Crappy Attitude," says Ruhrold. Using externalisation, the family and I found ourselves talking about how Crappy Attitude had been working to rule the boy's life and had caused many problems for the boy, his family and others. Rather quickly, we were all caught up in a discussion of how the young man could help himself and how each family member might help him 'fight Crappy Attitude'. This session was very positive and productive. An atmosphere of collaboration arose from that discussion that probably wouldn't have resulted from viewing and talking about either the boy or the family as the source of the problem."

"Ironically," says Canadian family therapist Karl Tomm, "this technique is both very simple and extremely complicated. It is simple in the sense that what it basically entails is a linguistic separation of the problem from the personal identity of the patient. What is complicated and difficult is the

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© Human Givens Publishing Limited and Bill O'Hanlon (1995)

This article first appeared in Volume 2, No, 4 (1995) of the Human Givens journal.

BILL O'HANLON, MS., is the author of several books including: In search of solutions, Solution orientated Hypnosis: An Ericksonian Approach, A Brief Guide to Brief Therapy. He teaches workshops internationally and has a private practice.

> More information on the human givens approach can be found in the following book by Joe Griffin and Ivan Tyrrell

Human Givens: A new approach to emotional health and clear thinking

>Find out more about the issues raised in this article at the following MindFields College events

Brief Psychotherapy
strategies Seminar

How to lift depression: effective brief therapyWorkshop

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> More information on the human givens approach can be found in the following book by Joe Griffin and Ivan Tyrrell

Human Givens: A new approach to emotional health and clear thinking

>Find out more about the issues raised in this article at the following MindFields College events

Brief Psychotherapy strategies Seminar

How to lift depression: effective brief therapy Workshop

Return to top