David Nylund on Narrative Therapy, Curiosity and Queertopia

David Nylund: Well, that’s a challenge, but I’m going to give it a go. I imagine if you asked me at a different time, I might have a different take on it. Narrative Therapy is based on a narrative metaphor and the idea that people are multi-storied. And people get locked into a singular story which tends to be deficit-based and internalized. The job of the narrative therapist is to create a conversational context, usually through questions, to trace these thin, deficit-based stories that contradict the dominant stories that are always apparent. The job of the narrative therapist is not to coach them or help them build skills, but to trace those alternative stories that are always present but, as Michael White would say, “thinly known.” And through different narrative practices like questions and letters, to help thicken that story so it begins to gain some momentum and density. And when people can step into that story, they come to maybe a different version of who they are.

DN: I like the idea of a co-editor, where it’s a collaborative inquiry. The therapist is decentered, but is definitely influential, attending to certain things and not others. It’s based on a critique of individualism. It’s a very anti-individualist approach, and it’s very much informed by post-structuralism and thinking relationally. People are always in relationship to others, to a larger cultural narrative. I think narrative pays a lot of attention to how people’s stories are shaped by larger cultural narratives, or what Foucault would call discourses. I think one of the aspects of narrative that really drew me to it was its focus on how peoples’ problems and struggles are not their own, they’re shaped by the larger culture. So, it leads narrative into a certain kind of arena of social justice, which is what I was drawn to as a social worker.

DN: The intention of the narrative therapist is to not be impositional or directive. I would refer to it as invitational.

DN: And yet, the narrative therapist is informed by a couple of basic premises: that people are multi-storied and many of these stories contradict each other; that people always have skills and abilities and values that run in contradiction to their dominant story that is often very deficit-based or problem-focused; and that problems are separate from people. For Michael White, the problem is the problem, the person is not the problem. Peoples’ lives and problems are always relational and informed and shaped by the larger culture, especially around issues like normative ways of being related to race, class, gender and sexuality. And some of those dominant norms help shape peoples’ lived experiences and can contribute to their problems. So, the narrative therapist enters through an invitational conversation from a stance of curiosity about these alternative stories and what they might mean. I think the job of the narrative therapist is not to determine whether these alternative stories are good or bad, but to invite their client to become curious about them. And that might be an entry point into some new stories, and that entry point is often referred to as a unique outcome.

DN: The first step would be to be curious about depression. Perhaps you would externalize the depression, and then you’d be curious about what the depression means to the person, to the client. I don’t want to assume some clinical DSM version of what depression is. I want to understand it from the client’s perspective and their meaning around it. Now that it’s externalized, we might explore the effects of the depression on their life. I might ask questions like, “How is the depression affecting your thoughts about yourself?” “How it is affecting your relationships?” “Who’s in league with the depression?” “What supports depression?” “If you look back on your life, were there some people or experiences that contributed to depression’s hold over your life?” Through these questions, which are referred to as deconstructive questions or relative influence questions, we always find some contradiction or gap, because no story is seamless. There’s always some event or disruption; one day, one moment where the depression wasn’t as strong. It might be the client reached out to a friend. It could even be the act of coming to therapy is a unique outcome.

I might start out by asking, “Did depression want you to come to the session today?” “I’ve worked with many clients with depression, it tries to convince them that therapy won’t be helpful. So, do you think it tried to do some of that?” “How did you defy depression’s dictates to come to the session, and what does that reflect about your hopes, your values, your ethics?”

One of the things that is important in Narrative Therapy, but also one of its challenges, is that it requires clinicians to rethink some taken-for-granted ideas in our field, especially around identity. From a modernist perspective, therapists like Jill Friedman and Gene Combs refer to internal states of identity. It’s based on this idea that identity is fixed, it’s static, it’s inside the person. It’s often linked to biology, and it’s outside of language and history and context. From a narrative perspective, it’s more of what I like to call intentional states of identity. 

DN: I like to think of identity as fluid, performed and in context. It’s relational, and about people coming to know themselves in relationship to others and in relationship to what’s important to them, their values, their ethics, their hopes. And so, a narrative therapist is really curious about their clients: their hopes, their intentions and their values that run in contradiction to, in this case, depression. And that leads to a very creative use of language and questions to help that alternative story, maybe anti-depression, to become thicker through reauthoring questions. And these re-authoring questions might be circulated to other folks in their life such as, “I imagine some of your folks in your life have an outdated version of you. What do you think is the best way to bring them up to date in terms of your journey away from depression?”

The two challenges to the narrative therapist are to rethink and to challenge some core assumptions that we’re trained in our field and in the larger culture to believe. But your main tool is the use of creative questions that come from a stance of curiosity. This is very different from, for example, CBT or some of the more traditional models where the therapist is more of the expert helping coach people to develop skills. They might make more direct statements. They might interpret the client’s experience for them. In narrative, you’re influential but you’re decentered; maybe you lead from behind and you keep up that stance of curiosity. I think therapists are curious, but narrative therapists practice a kind of curiosity about how things might be other than what they have been - a curiosity about hope and possibility. 

DN: Yeah! At the same time, I think narrative gets associated with positive psychology or solution-focused; or in my field of social work, a strength-based perspective. To me, it’s much more than that. It’s like these alternative stories that speak to a whole possibility. Values are always present. There’s evidence of it, and it’s inviting people to speculate about their significance. So, it isn’t like you’re having to find them or search for them, and it’s not about applause and cheerleading. It’s like coming from that place of honoring peoples’ experience, and there’s always things that stand outside the problem.

DN: That’s a great metaphor. Definitely.

DN: I think one quality would be a real ethical stance of curiosity and respect for the client. I think there must be the ability to entertain multiple perspectives and not get captured by one singular truth. It might mean having to give up some of our training of being an expert. It also might be a commitment to social justice. And I think what often what attracts folks to Narrative Therapy is its demand to be intentional. If you look at most models, like CBT, for example, you won’t see much attention placed on how, let’s say, thought distortions are shaped by racism or the larger culture or dominant norms. It’s just very highly focused on the individual. I think there’s this commitment to seeing things within the larger social context, which then opens up this ethic of justice. Narrative uses language that can be social justice-oriented. The person is not oppressed, the problem is oppressive. The narrative therapist might ask, “Is it fair that the problem of oppression is cutting you off from your hopes?

As a social worker, I have a commitment to social justice. A lot of narrative therapists also have this experience of standing outside the norm in their own lived experience, in a good way, like a rebel or an outlaw. You know, like a commitment to a broad notion of queer. It’s not necessarily tied to gender and sexuality, just this broader definition of queer as a critique of norms and of normativity. I know that a lot of narrative therapists are committed to critiquing taken-for- granted assumptions or norms. I think that a narrative therapist is also drawn to new ideas and staying curious. It requires not just learning, but kind of more of an unlearning. It can be really challenging for people, especially if you’ve invested time in a model like CBT. It can be hard to give that up a bit.

DN: It’s a great question. My preference is to start with unlearning. I don’t think I’m the majority there. I think my classes are as much about unlearning as learning, and I tell my students that. For example, last night in my class, I was presenting an overview of different family therapy models, and most of the students are also in a class to learn the DSM.

But then I said, “Here’s another way of doing assessment.” And I introduced them to Karl Tomm’s ideas of assessing relational patterns, not people. So, a lot of my teaching is offering alternatives to the ways one can do the work. It’s a kind of tension between learning and unlearning. I think everywhere in the States, you have to learn some of these dominant ways of working in terms of charting and having to do diagnoses for billing purposes. You might have to use the more traditional language as shorthand to connect with other colleagues. So, I think narrative therapists have to find a way to entertain multiple perspectives simultaneously, even if they contradict each other.

DN: It was a conference in Osaka, Japan, and on the panel was the top voice of CBT therapy in Japan, and he challenged me about, like, “Hey, this is all great, but what do you think of evidence-based treatment?” And that was in 2001. Evidence-based therapy is much stronger than it was even then. I don’t have an easy answer for that one. I think that you’re right, unless the way you work has evidence from that more traditional notion, quantitative meta-analysis, randomized clinical trials, it doesn’t get the same respect. And that’s been an ongoing journey and struggle for me and my work. I’m in a privileged position now because I’m a professor and I’m the clinical director of the Gender Health Center, which is an agency working with trans and queer communities, but when I was earlier in my career, I had to work in hospitals and other settings. County mental health, community mental health, hospitals at Kaiser, and I just had to learn to be subversive, kind of covert, and let the work speak for itself.

And you know, I think one thing that we’ve done at the Gender Health Center is use some of Scott Miller’s ideas around feedback-informed treatment, which is considered evidence-based now and has been sanctioned by SAMHSA, Substance Abuse Mental Health Services Administration. They’ve done a lot of random clinical trials and meta-analyses proving or having evidence that it’s not the model, it’s more about the alliance.

And alliance starts with how the client is doing. You create a culture of feedback. So, it’s interesting that some of the core ideas of feedback-informed treatment line up with narrative, right? Creating a culture of feedback, checking in, privileging the client’s voice. So, that’s one of the ways, strategically, we’ve been able to give narrative a voice. We use those measurements and the online program that gives all this data.

To me, unfortunately, it’s a reality that you need to have numbers. So, that’s one way we do it, and then there is a growing body of research on the effectiveness of narrative. It tends to be mostly qualitative. So, there is some evidence, but again, qualitative doesn’t earn the same merit as quantitative.

DN: It’s an ongoing journey. I think a lot of narrative therapists are just subversive, and they might also be able to work more independently in their private practices. It always helps if somebody in the agency who is a leader or director is supportive of narrative. That can help.

DN: Right.

DN: Right.

DN: Okay. And when you say gender queer, are you referring to folks who identify as non-binary or are you talking more just—

DN: Often, what you just referred to is a term that’s used and that comes out of queer theory and queer scholarship, is heteronormativity. The norm that heterosexuality is the only sexual orientation and that the gender binary male/female is the only healthy way of being. So, I think what you’re referring to is everybody who stands outside that heteronormative way of being in their identities or practices. I think narrative therapy lends itself well to that because narrative therapy comes from this deconstructive lens, so it really is curious about these taken-for-granted assumptions, in this case, about gender and sexuality. Narrative Therapy is informed by post-structuralism, and one of post-structuralism’s theoretical allies is queer theory, so there’s this connection between queer theory and narrative, because both are informed by social constructionism and post-structuralism, which pay close attention to dominant norms and language that can oppress folks.

So, it opens up that kind of dialogue about who gets to decide what’s normal. A lot of the conversations will be around these deeply entrenched gender norms, like masculinity, femininity, and around sexual identity. And I think it gives you some vocabulary; narrative offers a vocabulary to have those conversations.

DN: At the Gender Health Center, we often do what has traditionally been called reflecting teams or outsider witnessing. Some folks refer to them as response teams. So, I’ll be interviewing a client in the presence of my colleagues, and my colleagues will then have a conversation amongst themselves while the client and I observe or listen in on that, and they’ll reflect on what stood out in the conversation, where did it take them? The comments are situated in trying to attend to the alternative story. So, I was doing that just yesterday with a 32-year-old person who was assigned male at birth who identifies as a trans female. However, she is in a family that comes from a very conservative faith tradition, and that’s held her back because she’s afraid of losing support from her parents.

So, she’s really holding back on moving forward with her transition, meaning like hormones or surgery, because of her fears of how her family and her support network will handle it. So, instead of focusing on those issues, I was really curious about how, in spite of the religion that she was raised with, she was able to challenge that. What gender norms did she have to defy in order to even come to see me? And what did that say about her hopes for her life? I asked, “When you think about a person who comes from that background like yourself, and they’re beginning to consider that they’re trans, would you have respect for that person? Do you think it would take some bravery or courage?” And then, I started to ask questions like, “Who in your life might support this idea that you’re brave?”

And from there, she discussed a friend who supports her gender identity. And that led into some of the restraints and limitations of masculinity and toxic masculinity. I just kind of hovered around that, and then I said, “If you were to get a further appreciation of your bravery in living the counter story, what difference will that make towards your next step?” And that led to a conversation of coming to one of our programs at the Gender Health Center. It’s a respite program. It’s often more of a social context for trans folks who are feeling really isolated and disconnected to meet. You know, three days a week, they have this respite program. It’s for six hours and just kind of a place to hang out, relax, be yourself. They do some narrative work there, but it’s more just a meeting place.

So, by the end, she was open to going to that place. And then we talked about her ability to be more overt in her gender expression, and I noticed that she was wearing painted fingernails and earrings. We then talked about what those acts meant about her and ability to navigate her world, given that her parents wouldn’t be supportive because of their faith. I asked her to consider, “If I move forward, does that mean I’m no longer sinning?” And these kinds of discourses. That was the conversation, and then we had a reflecting team. And of course, in the team, there was various therapists who were queer or trans, so now this client is seeing community and support. One even shared that they also came from a deeply conservative religious tradition, and they talked about their journey and how they were able to move forward in their own life. So, that kind of gave the client some hope and inspiration. 

DN: Most therapists, most social workers I know, including my students, come from a place of ethics and wanting to help and might see themselves as open minded and progressive. When it comes to issues around LGBTQ, however, that acronym doesn’t account for the different hierarchies of worthiness, like gay white men have more power and privilege than, let’s say, lesbians, and then bisexuals are kind of held in somewhat of a suspicious or more marginalized status, and then T is at the end. Often, the T is rendered invisible or not really discussed. So, people will say, “I’m an ally for the LGBT community,” but not really know what T means, never having worked with folks who identify as trans. And so, they might go into a session with somebody who identifies as trans with these predetermined, taken-for-granted ideas of gender.

The client might identify as a trans woman but be expressing their gender in a way that’s read as masculine in our culture. And so, what the well-meaning clinician might do is mis-gender the person by not using the pronouns that the client identifies with. The therapist might not share their own pronouns, it’s sort of taken for granted that there’s a normal gender. They might focus more on voyeuristic curiosity about genitalia and might have normative ideas of what it means to be trans. And for trans folks, there’s no one monolithic trans experience.

And then, I think the therapist who’s cisgender--this being a term for somebody whose gender identity is congruent with the sex they’re assigned at birth--may have a lot of unearned privilege in many areas. I am cisgender and don’t get misgendered. If I go to a doctor, the forms are very clear for me. My gender is right there, I click the box male. I don’t have to worry about spaces like restrooms and public bathrooms. I don’t have to worry about questions about my genitalia or dating or all that sort of stuff. Cisgender people don’t necessarily have to worry about being harassed in public because of their gender presentation. So, I think therapists who have cisgender privilege often don’t really take that into account in their work with transgender people.

Another thing that I’ve been really thinking about a lot more lately is the Black Lives Matter movement and some articles I’ve read around transgender allies. I see myself as an ally, but I’ve been reading some material asserting that simply being an ally is not enough. It becomes an identity, a noun, not a practice, and you know the ally almost gets centered, and people build their whole career on being an ally and profit from it, but not necessarily helping the community. That was really hard for me to look at because I do good work. I try to use my voice to support marginalized communities like trans folks. I’m writing a book on it, I do speaking engagements, and so it got me to rethink about what is my role? Am I putting myself out there? Is there any sacrifice? And so, there’s these new ways of rethinking allyship and referring to being an ally as more of a co-conspirator or an accomplice. And that’s happening in Black Lives Matter movements. We don’t want white allies, we want white co-conspirators, where you hold your white colleagues and friends accountable. So, it would be like me, as a cisgender person, really holding other cisgender people accountable for when they make transphobic comments. So, I think those are some of the things that might contribute to well-meaning therapists who are cisgender inadvertently imposing certain ideas that are cisnormative or transphobic. 

DN: That’s a great question. I don’t think so. I’m going to take that position of a queertopian, through a queertopian lens. A colleague of mine, Julie Tilson and I, wrote some about queertopia, and I’ve given some speeches on it. One was at an event called the Transgender Day of Remembrance, which is an international event - it’s a very somber, moving event about honoring and recognizing all the folks who were trans or gender nonconforming who were murdered over the past year. So, one of the years, I was asked to do a talk about what it’s like to be cisgender and then about what a queertopian world would look like. In a queertopia, we would dismantle the gender binary. There would just be multiple genders. There wouldn’t be a need to police sexuality, you know, these hierarchies of gay and straight. There would be a loosening up of these strict identity categories, because I think identity categories can be useful, but they also impose restraints and limitations.

If somebody comes out as gay, there’s all these normative ideas of what it means to be gay. So, it can become another opportunity for policing and surveillance. There would be more of a loosening up of these identity categories. There wouldn’t be a DSM. There would be more work in the communities and community work rather than just individual clinical work. I think it would also be intersectional, so there would probably be a lot of focus on anti-racism and looking at some of the ideas about what it means to be male. There would be a loosening up of those ideas. And there would be a lot of just understanding of people’s identities and lived experiences, not necessarily related to their biology, their genitalia. Those are some of my thoughts about what a queertopia would look like. 

DN: It would be more like a deprivatization of the culture.

DN: We have this queertopian vision where mental health would get out of the way of people’s journey or transition, but that’s not the reality. Things are better. The standards of care when working with trans folks have moved a bit more towards depathologizing trans identities. In the DSM-IV, there was Gender Identity Disorder, now it’s Gender Dysphoria. The WHO (World Health Organization), in their next ICD - version XI, will no longer include gender dysphoria in the mental health section. It will be in the sexual health section. So, there is this movement forward. There are more trans voices, including trans folks who are providers, therapists. So, that’s the ideal, where it’s moving. But there still is this requirement by insurance companies and by physicians to diagnose a person with gender dysphoria. It needs to be medicalized in some way or psychiatricized, and since that’s the reality, I’m going to try to use my privilege, my credentials, to help make that gatekeeping as painless as possible, to not go through too many hoops.

What that might mean for me is that instead of a trans person having to see a mental health professional for a three to six session evaluation--which is a big cost and presents a barrier for so many folks, because this population is underemployed or unemployed--I don’t charge them if they need a letter. And I do it as fast as possible. I don’t really question them around whether they have a legitimate trans identity. I’m just using the letter to be an advocate, using letters as another form of co-conspiracy. It’s me saying, “You need this, I’m going to do it as fast as possible. One day, I hope we don’t have to do this, but in the meantime, you know, this is a way I’m trying to help support you.”

DN: And then what I do for trans youth is to write a second letter. So, there’s the traditional clearance letter/assessment in which I diagnose them and say why they need hormones or surgery out of medical necessity, but then I’ll also write a counter letter, a narrative letter that is more about their own standards of care, their own appreciation of their gender journey, so they get two letters.

DN: I think over time, I’ve figured that out. So, in my assessments, I’ve focused less on “Do you meet the standard, the criteria?” I’ll even say, “You know, I’m supposed to ask these questions. Why do you think I’m not going to ask them?” And they’ll say, “Because I already know that stuff. I know what hormones do. I know what the side effects are.” So, I focus more on their journey, on their narrative. I was working with this trans youth, where I asked him, “In your journey, have you thought about the kind of masculinities that you want to take up?” A lot of the conversations are more along those lines: their hopes, their visions of their own life, their gender identity.

DN: So, in working with trans children and teens, one thing that is really important is that young people are pretty clear about their gender identity. There are these discourses that they’re not capable of making decisions, I’m talking more teenagers where they might want to start taking hormones or hormone blockers. There’s this idea that they’re not capable and mature enough to make those decisions. As a narrative therapist, I look at how there’s a lot of discrimination like youth oppression, not honoring their voices. One thing is just to really honor their version of their gender identity and not to begin from the notion that they’re confused about their identity. That would be one thing, in terms of working with trans youth.

I think another thing is to have conversations about how is it that they’re able to navigate this in spaces like schools that can be pretty tough and where there can be a lot of bullying. It is about helping them develop strategies to advocate for themselves and protect themselves. I use them a lot as consultants to other trans youth.

I’m working with one young trans man who then consulted another one of my clients and their parents because they’re earlier in their journey and had some questions. The dad is really concerned about hormones and their effects. So, I’ll use my other families’ experiences to help each other. I find that in my work with queer and trans youth, I’m always amazed and honored about how they’ve had to live their life and that they have these amazing ideas we can learn from as adults.

DN: Around how to look at gender and sexuality differently.

DN: Exactly.

DN: Thank you. I appreciate that.