DAFT Conference: Narrative Approaches with people with learning disabilities Martha Laxton-Kane Consultant Clinical Psychologist & Team Lead for LD CAMHS, North Derbyshire Intro self: post: LD – work, home; FT Martha Laxton-Kane, Consultant Clinical Psychologist

Martha Laxton-Kane, Consultant Clinical Psychologist Aims Briefly outline the main principles of Narrative Therapy. Consider how Narrative Therapy can be used with people with learning disabilities and their families. Share some examples of practice. Lots of different things could focus on – term LD……. But these are two common issues / themes – just give a flavour. Talk through, with your thoughts… also share a video as a main talking point. Martha Laxton-Kane, Consultant Clinical Psychologist

Narrative Therapy: Brief Overview Many ideas originated in Southern Hemisphere with work from David Epston and Michael White Earlier work with children, more recent developments with many other groups of people with variety of ways of working eg community work with indigenous populations From Commonly Asked Questions about NT, www.dulwichcentre.com.au A school of family therapy Narrative approaches used in other therapies – family, SFT. Links to CBT – maybe more time to talk at end about how the ideas overlap. Aboriginal people – aboriginal health workers interested in using narrative ideas, stories, with reference to ‘stolen generation’ (1869-1969) (Australian federal government removed children from parents etc). Martha Laxton-Kane, Consultant Clinical Psychologist

Martha Laxton-Kane, Consultant Clinical Psychologist Stories in our lives Stories – events, linked in sequence, across time, according to a plot. Life is multi-storied As human beings, we all have stories about our lives and about other social constructs. How we have constructed a story depends upon how we have linked events together, and how we have attributed meaning to them. I have different stories in my life: as a mother, a partner, a psychologist, a daughter, but also minor ones may be that I have a story you should work for the public sector – father socialist, uncle unions, others in nhs, education, probably sought others of similar mind – all fine until undertook a piece of private work – felt was selling self out – internal conflict. Will affect your future decisions, further thickening the dominant story. Martha Laxton-Kane, Consultant Clinical Psychologist

Martha Laxton-Kane, Consultant Clinical Psychologist Everyone has ‘dominant stories’ (that may be problem saturated) that can be unhelpful to the person. The aim of NT is to help replace the dominant story with an alternative one (to a preferred story), that is currently more thinly described. Dominant stories need to be ‘deconstructed’ and then alternative or preferred ones ‘reconstructed’. Dominant stories – never produced in isolation from the broader world, affect what events are attended to It is argued that people tend to select memories of experiences that are consistent with the dominant story in favour of the ones that don't favour the dominant story. More evidence leads to more ‘richly described experiences’. Martha Laxton-Kane, Consultant Clinical Psychologist

Some more narrative concepts (adapted from Morgan, 2000) Thin descriptions – often heard early in meetings, often created by others, leave little room for movement Alternative stories – identified by the person as stories by which they would like to live their lives, rich description Unique outcomes Thin descriptions – e.g. diagnosis, ‘attention-seeker’. Descriptions that allow little chance to look at the alternative reasons or possibilities or multiple perspectives/contributory factors. Alternative stories – link with the concept of ‘re-storying’, where the therapist is looking to alter or change the dominant story in someone’s life, by thickening alternative stories, or changing the meaning attached to experiences. Martha Laxton-Kane, Consultant Clinical Psychologist

The process according to Matthews & Matthews (2005) involves: Listening to and understanding the person's story Deconstructing the problem stories Re-storying Sustaining the change. Listening to the story – and how fits with the life. How influences different aspects of their life, family etc. Supported to stand back and look at the problem and effect on their lives- noting the limitations – externalisation may happen here. Encouraging the person to talk more about the way that they want to be. – did that surprise you, is that something that you would like more of? Thereupeutic letters Thicken the preferred story – witnesses, validating changes. Martha Laxton-Kane, Consultant Clinical Psychologist

Martha Laxton-Kane, Consultant Clinical Psychologist “Briefly, Narrative Therapy uses a story (narrative) metaphor and proposes the meaning we give to our (daily) experiences is determined by the stories we have about ourselves. Stories about life and ourselves are socially, culturally and historically situated and we all have many stories about our lives and relationships: life is multi-storied. The stronger (more dominant) a story’s presence in a person’s life the more their life will be influenced by it. When people come for therapy they are usually in the grip of a (dominant) problem story about their lives. Narrative Therapy engages in externalising conversations moving from the dominant problem story (the known and familiar) to the noticing of alternative and preferred stories of a person’s life (the possible to know). These preferred stories are then systematically ‘thickened’ to enable them to have more influence on a person’s life”. (Hilton 2012) Martha Laxton-Kane, Consultant Clinical Psychologist

Martha Laxton-Kane, Consultant Clinical Psychologist Externalisation Is just one type of conversation in Narrative, but often provides the base from which other Narrative conversations are built upon. Typical questions: If you could draw x what does it look like? How has x affected your thoughts and feelings? How has x affected your relationship with your boyfriend? Is this effect a good thing or bad thing? Martha Laxton-Kane, Consultant Clinical Psychologist

Martha Laxton-Kane, Consultant Clinical Psychologist Exercise What might some of the common dominant stories be in the lives of people with learning disabilities? In LD often a focus upon incompetence and inability, so FT can help to focus upon themes of competence and abilities Themes: Intelligence, independence, living with famileis; workers involved in life; sexuality and relationships; institutionalisation and marginilisation; Winterbourne Review - what does that mean for the person? – their life, how they are viewed? Martha Laxton-Kane, Consultant Clinical Psychologist

Martha Laxton-Kane, Consultant Clinical Psychologist Balderton – meaningful for me working with adults. Average stay 30 years. Many locked for no reason. Hospitals closed in the 80’s. Martha Laxton-Kane, Consultant Clinical Psychologist

Martha Laxton-Kane, Consultant Clinical Psychologist

Martha Laxton-Kane, Consultant Clinical Psychologist The Undateables Martha Laxton-Kane, Consultant Clinical Psychologist

Martha Laxton-Kane, Consultant Clinical Psychologist Videos ……. Martha Laxton-Kane, Consultant Clinical Psychologist

General principles of working with people with ld YP with LD often described behaviourally* It will take more time – very repetitive, need smaller steps and realistic aims Need to make abstract concepts more concrete – drawing, writing, play dough, genograms with pictures, concepts into metaphors Do ask others how to respond and observe others interactions… & ask Speech and Language Therapy advice All people with LD will have different levels of ability and understanding. *challenging behaviours can mask physical causes Impairments with communication and abstract thinking e.g. why is import to turn off light ……. Go on holiday, Turkey in the sky….., can over estimate skills Martha Laxton-Kane, Consultant Clinical Psychologist Specialist LD-CAMHS

More general principles of working with people with ld …… Help retention of information with simple letter / summary. Simple agenda and cross off to help YP keep focused / concentrate. Accept going off at a tangent at times / muddled concepts. Martha Laxton-Kane, Consultant Clinical Psychologist

Adapting Narrative for people with LD The same principles apply as with the use of other therapies for people with learning disabilities Try and use more concrete concepts (which may be tricky with externalisation) Give people more time to learn and get used to different ways of talking Most of all be creative – use visual imagery to support ideas and act as reminders eg plastercene, drawings, writings, letters, embrace support workers and family etc Martha Laxton-Kane, Consultant Clinical Psychologist

Adapting Narrative for people with LD Give the person with LD more time and opportunity Use visual supports to make concepts more concrete It is suggested that for people with more severe LD may have to invite others to give them a voice / adopt their position if they cannot be included. Managing questions / conversations with different family members – clearer who asking questions to and recap frequently. May have to go into the home environment – be flexible about work Play dough Visual scales / pictures Martha Laxton-Kane, Consultant Clinical Psychologist

What I love about people with learning disabilities A challenge to social rules Small changes are very important A lack of chips and judgements Honoured to be part of families lives Honesty Laughter Learning how other people overcome marginalisation and challenges Martha Laxton-Kane, Consultant Clinical Psychologist

Martha Laxton-Kane, Consultant Clinical Psychologist Thank-you martha.laxton-kane@nhs.net Martha Laxton-Kane, Consultant Clinical Psychologist

Research into Narrative Therapy The relationship between Narrative Therapy and Evidence-based practice Co-research – archives of solution knowledges, asking people what’s helpful, co-research in training and in service evaluation Special edition of International Journal of Narrative Therapy and Community Work (2004, 2) Recent Forum article Use of externalisation with children who soil (Silver et al., 1998) Use of narrative therapy for major depressive disorder (Vromans and Schweitzer, 2010). Also studies looking at use of narrative therapy and eating disorders, and childhood stealing. MLK slide, NT examples - Silver et al. (2000) and soiling – retrospective audit of 54 children treated by externalising vs control group TAU. Results from externalizing were better and compared favourably with standards derived from previous studies of soiling. Externalising was rated as ‘much more helpful’ by parents at follow-up. Vromans & Schweitzer, 2011 – looks at outcomes from 8 studies using manualised narrative therapy. Results were comparable to benchmark research outcomes (74% clients achieved reliable improvement, 61% moved to ‘functional population’, 53% clinically significant improvement. Improvements maintained at 3 month follow-up. Interpersonal relatedness gains less substantial and not maintained. Martha Laxton-Kane, Consultant Clinical Psychologist

References and useful links Matthews, B & Matthews, B (2005) Narrative Therapy: Potential uses for People with Intellectual Disability. International Journal of Disability, Community and Rehabilitation. Hilton, A. (2012) Moving Things to Independent Life: The influence of Narrative Therapy on working with a woman affected by learning disabilities (originally appeared in Clinical Psychology & People with Learning Disabilities, Vol 10, no 2, Sept 2012). Morgan, A. (2000) What is narrative therapy ? An easy-to-read introduction. Adelaide: Dulwich Centre Publications Morgan, A. (2002) Discerning between structuralist and non-structuralist categories of identity : a training exercise. International Journal of Narrative Therapy and Community Work, 4, 52- 55. Silver, E., Williams, A., Worthington, F. & Phillips, N. (1998). Family therapy and soiling: an audit of externalizing and other approaches. Journal of Family Therapy, 20(4), 413-422. Vromans, L. & Schweitzer, R. (2011). Narrative therapy for adults with major depressive disorder: improved symptoms and interpersonal outcomes. Psychotherapy research, 21(1), 4-15. www.dulwichcentre.com.au www.narrativepractice.com Hugh Fox Solution-Focused Research : 7 mothers & 1 father, qualitative interviews about first session experience - themes: Make the best of it (no point dwelling) Wishful thinking – a constant dilemma about what could have been. All did not like the miracle question. Therapeutic relationship – time to think, amplified self-efficacy Martha Laxton-Kane, Consultant Clinical Psychologist

A Narrative Framework for interviews (adapted from Morgan 2000) PART 1 Naming the problem (externalising conversations) Tracing the history of the problem and the effects of the problem on the person’s life Situating the problem in context – deconstruction (problems survive and thrive when backed up by beliefs and values) Discovering Unique Outcomes (times when the problem has had no or less influence, stories that contradict the dominant problem story) Tracing the history and meaning of the Unique Outcome (naming an alternative story) PART 2 Thickening the alternative story ‘Re-membering’ conversations Therapeutic documentation and letters Witnesses White –fancy words, relative influence questions, statement of position map 1 Re-membering – p77 – read out first page, SW letters examples Martha Laxton-Kane, Consultant Clinical Psychologist