Journal of Creativity in Mental Health, 9:511–522, 2014

Copyright © Taylor & Francis Group, LLC

ISSN: 1540-1383 print/1540-1391 online
DOI: 10.1080/15401383.2014.914457

Creating Space for Connection: A Column

for Creative Practice

This column is designed to underscore relationally-based creative interven-

tions used by counselors and psychotherapists in their practices. Our intention
is to provide examples of novel, innovative ways of working with clients
in their efforts to deepen self-awareness and their connections with oth-
ers. Although the interventions within this column will be presented in a
linear “how to” manner, an essential premise of this column is that inter-
ventions submitted for publication have a contextual and relational basis.
Basic to this column is the therapeutic focus of working through latent hurts
and impediments to our clients’ health and happiness. Client goals generally
involve creating the requisite emotional space needed for genuine relational
choice for connection to manifest. If you have created a useful therapy tool,
or if you have adapted an existing creative tool that you would like to
share with readers, please follow submission guidelines in the author infor-
mation packet available at http://www.creativecounselor.org/Journal.html.

Narrative Therapy Integration Within

Substance Abuse Groups

ASHLEY A. CLARK
Walden University, Culpeper, Virginia, USA

Cognitive-behavioral therapy and motivational interviewing have

gained increasing importance within the literature body as
approaches to utilize when working with the substance abuse
population. Despite a strong focus within the research on
these approaches, however, substance abuse and substance
abuse-related behaviors continue to have a detrimental effect on
the community. As research demonstrates the potential efficacy of

Address correspondence to Ashley A. Clark, Counselor Education and Supervision,

Walden University, 1300 Sunset Lane, Ste. 3120, Culpeper, VA 22701, USA. E-mail: ashley.
clark@waldenu.edu

511
512 A. A. Clark

narrative therapy in various areas, evaluation of its application in

substance abuse services is important. Integration of two narrative
therapy techniques with potential integration into group therapy is
introduced with the rationale, assumptions, and objectives of the
approach. In addition, adaptations and limitations are discussed.

KEYWORDS narrative therapy, addiction, group processes,

storytelling, substance abuse counseling

Once referred to as “victimless,” substance use and substance abuse has

gained increasing attention given the number of victims it has left in its path.
According to the Centers for Disease Control and Prevention (2013), more
than 40,000 deaths within the United States in 2009 were attributed to drug
use. Based on this number, every 15 min in the United States, an individual
dies due to drug-induced causes. As if these numbers were not staggering
enough, the National Institute on Drug Abuse (NIDA, 2012) estimated that
more than $600 billion is spent annually due to substance abuse issues within
the United States. Although some of this money can be attributed to criminal
offenses, the remainder of the costs associated with substance use and abuse
is associated with decreases in work productivity and increases in health
care costs. In fact, “there are more deaths, illnesses, and disabilities from
substance abuse than from any other preventable health condition” (NIDA,
2012, para. 2). Statistics such as these serve as a call to individuals within the
counseling profession to provide effective services that meet the individual
needs of those who have become victimized by the effects of substance use
and abuse.
Although once established as a specialty of its own, counselors work-
ing within general populations are finding themselves treating individuals
with substance use, abuse, and dependence issues. In fact, the NIDA (2012)
estimates that only about one tenth of individuals treated for substance use-
related issues received their treatment in facilities specializing in substance
abuse and addiction. This leaves the remaining 90% of clients receiving
substance abuse-related services in more traditional or general settings.
As DeAngelis (2001) noted, the trend from an entirely inpatient focus on
the treatment of substance abuse to a more outpatient context has resulted
in this switch in thinking and an increased ability for professional counselors
to reach more individuals dealing with substance abuse-related issues.
As Butt (2011) noted, the majority of addiction treatments are based on
cognitive-behavioral principles, which compose the foundation for 12-step
programs. These approaches attempt to change negative thinking patterns
that result in self-destructive behaviors with the belief that by changing these
thought patterns, the behaviors will also change. Despite a heavy reliance
within the research literature on cognitive-behavioral intervention when
 Narrative Therapy 513

working with individuals with substance abuse issues, other researchers have
questioned the use of a one-size-fits-all approach toward working with these
issues (Butt, 2011). As a result, more recent research has focused on the
integration of other theoretical approaches within the treatment of substance-
related issues. Cooper (2012), for example, argued for the integration of
motivational interviewing (MI) in working with this population. Because
of the heightened rates of resistance in working with substance-using and
-abusing individuals, MI provides the counselor with tools in moving a
client from a potential state of denial, continuing through establishment
of substance use as an issue, and eventually leading to the implementa-
tion of plans to eliminate its use. Despite notable effectiveness of these
approaches within the research body, however, Brewer, Elwafi, and Davis
(2013) argued that deficiencies still exist with the ability of substance abuse
treatment approaches to reach an optimal level of clients. As a result, contin-
ued evaluation of interventions that integrate various theoretical approaches
is needed.
In an attempt to utilize narrative therapeutic strategies with an outpa-
tient substance abuse group, two consecutive narrative-focused interventions
were utilized. This article serves not only to provide information about the
process of implementing these activities but also to present the fundamental
rationale, assumptions, and objectives as well as to discuss potential
adaptations and limitations of the approach.

RATIONALE

Evidence obtained in a study conducted by Trevino and Richard (2013)

revealed that drug treatment providers (DTP) who integrated more evidence-
based practices (EBP) received larger portions of discretionary governmental
funding (DGF) than did programs that did not rely as heavily on these
practices. Unfortunately, however, Trevino and Richard concluded that the
relationship between EBP and DGF is not strong enough to encourage all
DTP to adopt these methods. As a result of this weak correlation, DTPs
continue to utilize methods that lack an empirical foundation. Although the
number of DTPs utilizing EBPs is less than optimal, the reasoning for such
underutilization may actually be the result of failure within the research
to evaluate theoretical approaches outside of cognitive-behavioral therapy
(CBT) and MI as well as an absence of available therapeutic processes and
interventions that can be adopted to meet the needs of the individual clients
and setting.
According to Brown and Augusta-Scott (2007), narrative therapy is a
nonconfrontational, collaborative approach that places the client in the role
of an expert of his or her own life. Through this theoretical lens, problems are
viewed as distinct from people. Much like the relationships that individuals
514 A. A. Clark

develop with other people in their lives, they, too, develop relationships with
their problems. Change is therefore dependent on changing the relationships
individuals have with the problems in their lives. By gaining control of this
change, individuals develop the ability to reauthor aspects of their lives.
Consequently, individuals gain an understanding that they do not need to be
defined by their problems but instead can create a new story of themselves
and their experiences.
Differing stories can exist simultaneously. From these stories, individuals
often draw themes that connect events and bring meaning to issues that an
individual is facing. As the Dulwich Center (2000) noted, investigation of
the journey created by these stories is the foundation of narrative therapy.
Potentially based on the audience, the story may change and aspects of the
story that are focused on may affect an individual’s overall identity.
Effectiveness of narrative therapy has been evaluated with numerous
clients and presenting issues. Cloitre (2013), for example, evaluated the
use of Skills Training in Affective and Interpersonal Regulation (STAIR) nar-
rative therapy (an integrative CBT approach) with clients diagnosed with
posttraumatic stress disorder and noted a timeline of 9 months for treat-
ment in reducing substance abuse and self-harm behaviors. Hannen and
Woods (2012), on the other hand, demonstrated the effectiveness of a nar-
rative approach in working with an adolescent also dealing with self-harm
behaviors. In addition, Chan, Ngai, and Wong (2012) identified the poten-
tial effectiveness of narrative approaches when working with individuals
with substance abuse issues. Although the totality of these three articles
does not necessarily demonstrate the potential impact of narrative therapy
as an EBP, the promising effects demonstrate the need to further evaluate
these approaches in working with various individuals. Based on this need to
gain further evidence of the viability of narrative interventions in substance
abuse therapy, two specific interventions, the Narrative Novel and Letter to
Letting Go, were developed and utilized within the context of an outpatient
substance abuse group.
Both the Narrative Novel activity and Letter of Letting Go were devel-
oped based on the principles of narrative therapy. Specifically, the Narrative
Novel, which is described in the Process section, provides the opportunity
for individuals to rewrite their story of recovery and process the external
power of the substance within their recovery. The Letter of Letting Go, also
discussed in the Process section, allows for individuals to conceptualize the
addiction as a relationship and the substance that can be removed from their
lives. In developing these interventions and utilizing them with clients, it is
important to understand the impact of individual stories on self-identification.
With the goal of supporting individuals in recovery, these activities were
developed.
 Narrative Therapy 515

ASSUMPTIONS

In integrating the Narrative Novel and Letter of Letting Go with a group

of female substance addicts in various stages of recovery, the following
assumptions were made:

1. CBT and MI provide valuable tools for utilization in substance abuse ser-
vices; however, these two techniques are not foolproof approaches to
addressing substance addiction in all populations.
2. Despite the largely subjective nature of narrative therapy measurement
(Butt, 2011), studies conducted by Cloitre (2013), Hannen and Woods
(2012), and Chan et al. (2012) evidence the applicability of narra-
tive approaches in working with individuals demonstrating destructive
behaviors, resulting in the potential effectiveness of narrative therapeutic
interventions in working with substance abuse issues.
3. Despite multicultural differences, the formation of the therapeutic rela-
tionship allows for a collaborative approach as opposed to the counselor
having to serve in the role of expert.
4. Participants within a group environment are willing to share their
thoughts, feelings, and experiences once they reach the working stage.

OBJECTIVES

The following objectives served as the basis of integration of the two

narrative therapy interventions:

1. Encourage clients to explore themes throughout their lives and recovery

by having individuals equate experiences with aspects of a story that they
have the potential to author.
2. Focus the clients on aspects of the problem as an external force that needs
to be eliminated through developing alternatives and exploring unique
outcomes.
3. Assist the clients in developing alternative narratives by allowing them to
be the experts of their stories as opposed to attempting to develop the
stories for them.

PROCESS
Narrative Novel
The implementation of the Narrative Novel activity occurred through the
implementation of a simple outline that can be utilized by any practitioner
working within addiction groups.
516 A. A. Clark

1. Prepare for implementation of the Narrative Novel activity by gathering

old magazines and/or newspapers that the client or clients may cut apart,
scissors, glue, writing instruments (i.e., colored pencils, markers, and/or
crayons), sheets of white standard 8.5-inch × 11-inch printing paper
(approximately 12 sheets per person), a stapler, and any other creative
materials that may increase client participation in the activity. (The more
tools made available to the client or clients, the more opportunities exist
for the client or clients to be creative).
2. Set up the room in a way such that all clients have easy access to all the
materials except for the sheets of paper (as these will be provided to the
clients). Participants will need a hard surface on which to work.
3. Introduce the group participants to the fact that they will have the oppor-
tunity to participate in an activity to reflect on their identities through
artistic expression. Explain that the purpose of the activity is to intro-
duce something new, and it is not intended to evaluate their artistic
skills. Inform participants that they will not be required to share their
finished products.
4. Instruct each individual to take three sheets of paper and to pass the
paper on to other participants. Once all individuals take three sheets of
paper, provide the following instructions:
a. You have been provided with three sheets of paper.
b. With the first sheet of paper, use any of the materials provided to
represent who you were during the worst part of your addiction.
c. With the second sheet of paper, use any of the materials provided to
represent your ideal self.
d. With the third and final sheet of paper, utilize the materials provided
to represent who you are today.
5. Provide group participants with the opportunity to complete the activity.
Because individual members can progress at different rates, it can be dif-
ficult to establish a time frame for completion. Counselors must therefore
decide how much time they are willing to provide for this activity and
may wish to make determinations regarding completion based on obser-
vations of group progress. Providing reading materials for individuals
who finish early may be beneficial.
6. Once participants have completed the activity, reconvene the group. Ask
for volunteers to share their representations beginning with the picture
representation of their past identity, continuing to their ideal identity,
and ending with their current identity. While the participants share their
representations, the counselor or a group cofacilitator should engage the
group members in reflection on what this means about their identity
and the impact of substance use. Facilitation should target the differ-
ences between representations when utilizing drugs as opposed to those
representations of recovery.
 Narrative Therapy 517

7. After all individuals who wish to share their representations are provided
the opportunity to share their diagrams, each individual should be pro-
vided with approximately nine sheets of paper. (It may be easiest to
separate the paper for each participant while they are working on their
original three pieces of paper.
8. Once all participants are provided the additional paper, the counselor
or cofacilitators should provide participants with the following instruc-
tions.
a. Take the picture representation of your past self and place it on top
of the blank sheets of paper face up.
b. Take the picture of your desired self and place it upside down
underneath the pile of blank papers.
9. The counselor or facilitator then explains how the front picture serves
as the coverage page, the start of the story for their recovery, while
the ideal self represents the conclusion of the process. Facilitation of
the discussion should evaluate the clients’ understanding of the story’s
author. The group leader may also question clients regarding how the
story may be different if instead of a story of recovery it was a story
of their addiction, including discussion of how the author would likely
change from the individual having control to that of the drug or drugs
having control.
10. Participants are then instructed to insert the final representation of their
current identity into the story to represent where they see themselves as
being in the process. Facilitation of discussion between group members
regarding their reflections of where they are as opposed to where they
were and want to be is beneficial for continued reflection.
11. Finally, participants are instructed to name their story and, if willing, to
reflect on the reasoning behind the title.

A Case Illustration
Jackie is a 29-year-old mother of two who was court ordered to substance
abuse treatment after testing positive for cocaine and amphetamines upon
birth of her daughter. At the time of birth, Jackie’s daughter, Jean, along with
her 3-year-old son, Braxton, were removed from her custody and placed
with her mother and stepfather. Already in a tumultuous relationship with
her mother due to her mother’s own substance abuse issues when Jackie was
growing up, the relationship became even more strained once the placement
occurred. Jackie is only allowed to see her children under supervised visits
by the court and undergoes random drug testing as a condition of these
visits. She lives with her current boyfriend whom she met in a Narcotics
Anonymous meeting. Her boyfriend, Jake, has 3 years of sobriety. Jackie,
on the other hand, has been struggling with her sobriety. Although it has
been 1 year since her children have been taken, Jackie’s longest period of
518 A. A. Clark

sobriety has been the current period of 3 months. In addition to attempts to

increase visitation and potentially regain custody of her two children, Jackie
is working on obtaining her driver’s license and was recently hired part-time
at a local convenience store.
Jackie’s representation of her past self consists of darker images. She
found words such as “failure,” “hopeless,” “quitter,” and “angry,” which she
attached to the page. In addition, she added a picture of a storm cloud, an
individual all alone in a room, a gun, police tape, a tombstone, and a large
bottle of whiskey. Upon reflection, Jackie reported that drinking and drugs
represented the largest part of her life. She noted that the drugs consumed
her and made her feel as if she had failed. She further stated that these
feelings of failure resulted in her drinking and using more. At the time, she
noted that she felt as if she had no future and was always looking behind
her back due to concerns that the cops were tailing her.
In the picture representation of her future self, Jackie utilized brighter
colors. In the picture, she drew a house, car, and children playing. She
attached words, including “success,” “confident,” “proud,” and “survivor.”
Upon reflection, Jackie noted that in this picture, she had regained custody
of her children. She noted that she is a proud mother and her children love
her. When asked about the part that drugs and alcohol play in this picture,
she replied, “They are long gone.”
Finally, in the picture to represent her current self, Jackie placed a score
board, a bottle of soap scum remover, a hospital bed, and a broken glass.
The picture contained more neutral tones and included the words “work
in progress” in large block letters. In reflection, Jackie noted that she felt
like a construction zone. She noted that as she built herself up, she would
come upon stumbling blocks. She stated that the scope scum remover was
a reminder that the addiction would return if she did not keep a careful eye
on it and take care of the things that caused it.
Reflecting on the timeline of the story, Jackie noted that the presence
of drugs was the driving factor to the past and that the driving factor to
the future would be how much time she was able to remain away from the
drugs. She noted that she did not want to be defined by her previous choices
but instead who she wanted to be. She noted that in the past, she had seen
drugs and alcohol as a friend but now recognized that they were only her
enemies. When asked to place the current picture in the book, Jackie placed
it third, noting, “I know I’ve made progress, but I have a lot more to do.”
Finally, she titled the book “A Better Me” and noted that the journey would
bring about someone who had never been present.

Letter to Letting Go
After implementation of the Narrative Novel and processing of the insights
gained from the activity, counselors and group leaders can follow up with
 Narrative Therapy 519

a supplemental activity entitled Letter to Letting Go. Implementation of the

activity can be accomplished by following a series of steps.

1. Participants should be provided with access to lined notebook paper and

a writing instrument.
2. The counselor or group facilitator should then provide the following
instructions to the clients completing the activity:

We have discussed the impact of drug use on your identity when you
were at your rock bottom and the impact of absence from drugs in
reaching your personal goals. Based on this discussion, it is appar-
ent that drugs have played an instrumental part in your experiences.
As with anyone who plays a large part in our lives, it is hard to let
go. To achieve this, it is time to write a letter to your drug of choice.
In this goodbye letter, make sure to thank your drug of choice for
the good times, while providing the reasons as to why you are saying
goodbye. Write whatever comes to your mind. When you finish, make
sure to sign it.

3. Once participants have completed the letter, offer them the opportunity
to share the letter with the group. For those individuals who do choose to
read their letter aloud, provide time for them to process their emotional
reactions to writing the letter.

A Case Illustration
Jane is a 48-year-old mother of four. All of her children were raised within
the social services system. After 6 months of clean time, she has begun to
seek out a relationship with her children now 24, 22, 21, and 19 years old
and grandchildren now aged 4 years, 2 years, and 9 months. Jane reports
that her drug of choice was methadone and notes that her earliest use of
the drug was when she was 13 years old. She notes that she quickly slipped
into the grasp of addiction and began prostituting herself for money. Upon
each birth, she promised herself she would get clean to be able to take
care of her children but was never able to follow through. Drug-addicted
and living on the streets, Jane had limited contact with her children, who
were all raised together in a loving foster home. Since then, they have all
become independent and are somewhat guarded about the potential to form
a relationship with Jane given her history of drug use.
In her letter, Jane writes, “Dear Methadone. It is with such sorrow that
I say goodbye to you. Sorrow not for what you have given to me but for what
you have taken away from me. You were my best friend. We did everything
together. You never turned your back on me. Remember those parties and all
the late nights. Well they were fun at the time. Fortunately, I have outgrown
you now. Because of you, I lost everything I loved. I lost my children, my
520 A. A. Clark

family. I lost my confidence, my integrity, me. I am off to find myself now

without you. Please do not fight me on this as it is hard for me to walk away.
With you, it was easy because you hid all my problems. I must face them
now. Gone but not forgotten, Jane.”
As Jane reads her letter out loud, she begins to cry. “I never realized that
it was not me using. The drugs made me into something else, something that
I never wanted to be.” She reflects on the fact that similar to saying goodbye
to an old friend, there is a sense of loss. She notes that she will treasure the
good times but never forget the bad and will continue to forge ahead to the
future.

ADAPTATIONS OF THE PROCESS

Given Alavi et al.’s (2012) assessment of similarities and differences between

substance addiction and behavioral addiction, adaptations of both the
Narrative Novel and Letter of Letting Go are possible. Specifically, Alavi et al.
noted that other than the source of obsession (i.e., substance vs. process),
both types of addictions involve an individual becoming captivated by the
results. For example, in substance addiction, individuals become obsessed
with the physical implications of taking the substance. In sexual addiction,
on the other hand, individuals become obsessed with the physical reactions
relative to the action of having sex. The abundance of similarities between
the two types of addictions mirrors the similarities of 12-step approaches in
addressing these issues.
According to Butt (2011), addiction often results in a feeling of guilt by
the addict. As a result of the guilt, individuals often develop a story in which
they are to blame for their problems. Continued use then serves as a method
to punish oneself for his or her choices and interactions. Narrative therapy
serves as an opportunity for individuals to rewrite their stories in a way
that removes the blame from the individual. Adaptation of the previously
discussed interventions would likely also be beneficial in dealing with other
issues including instances of self-harm behaviors.
Despite the fact that the identified interventions were utilized in a group
setting, counselors might also wish to integrate these interventions into an
individual setting. Although utilization in an individual therapeutic relation-
ship will not inform the client of the experiences and responses of other
individuals dealing with addiction, research has demonstrated the efficacy
of narrative therapy in individual settings (Brown & Augusta-Scott, 2007).
Therefore, an individual approach may be considered.

REQUIREMENTS AND LIMITATIONS

According to Butt (2011), despite numerous studies that support the effective-
ness of narrative approaches in counseling, narrative therapy is not without
 Narrative Therapy 521

its limitations, the most argued of which is the difficulty associated with
measurement of the approach’s success. Because the approach is rooted in
philosophical underpinnings, measurement of narrative therapy’s effective-
ness may be largely subjective in nature. As a result, increasing focus on the
use of EBPs could potentially make narrative approaches extinct unless they
are integrated with other approaches.
Cloitre (2013) further revealed limitations of a narrative approach given
the necessity for clients to be able to articulate their stories. As such, clients
with reduced verbal or cognitive abilities might be less likely to benefit from
narrative approaches within counseling. Because of this, it is important for
counselors to assess the cultural appropriateness of their clients in integrating
these interventions.

CONCLUSION

Despite a strong reliance on CBT and MI in work with substance-abusing and

addicted individuals, such approaches are not always effective with clients.
Because counselors in general counseling settings are likely to encounter
individuals working through addiction, especially to substances, it is impor-
tant that all counselors are aware of various interventions to utilize to
optimize treatment success. The Narrative Novel and Letter to Letting Go serve
as two potential interventions to utilize with these populations.

REFERENCES

Alavi, S., Ferdosi, M., Jannatifard, F., Eslami, M., Alaghemandan, H., & Setare,
M. (2012). Behavioral addiction versus substance addiction: Correspondence
of psychiatric and psychological views. International Journal of Preventive
Medicine, 3, 290–294.
Brewer, J. A., Elwafi, H. M., & Davis, J. H. (2013). Craving to quit: Psychological
models and neurobiological mechanisms of mindfulness training as treatment
for addictions. Psychology of Addictive Behaviors, 27, 366–379.
Brown, C., & Augusta-Scott, T. (2007). Narrative therapy: Making meaning, making
lives. Thousand Oaks, CA: Sage.
Butt, M. (2011). Using narrative therapy to respond to addiction: An experience of
practice in Pakistan. International Journal of Narrative Therapy & Community
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Centers for Disease Control and Prevention. (2013). Illegal drug use. Retrieved from
http://www.cdc.gov/nchs/fastats/drug-use-illegal.htm
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externalize the problem: A substance abuse case. Journal of Systemic Therapies,
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Cloitre, M. (2013). The case: Treating Jared through STAIR narrative therapy. Journal
of Clinical Psychology, 69, 482–484.
522 A. A. Clark

Cooper, L. (2012). Combined motivational interviewing and cognitive-behavioral

therapy with older adult drug and alcohol abusers. Health & Social Work, 37,
173–179.
DeAngelis, T. (2001). Substance abuse treatment: An untapped opportunity for
practitioners. Monitor on Psychology, 32(6), 24–26.
Dulwich Center. (2000). What is narrative therapy? Retrieved from http://www.
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Hannen, E., & Woods, K. (2012). Narrative therapy with an adolescent who self-cuts:
A case example. Educational Psychology in Practice, 28, 187–214.
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ment practices and discretionary government funding. Business and Economics
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Ashley A. Clark is a doctoral student in Counselor Education and

Supervision at Walden University, virtual campus.
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