Joumat ofMentat Heatth Counseting Votume 31/Number 3/Juty 2009/Pages 225-233

Using Puppets with Children in Narrative Therapy to Externalize the Problem

Sue Butler Jeffrey T. Guterman James Rudes

A clinical application is presentedfor using puppets with children in narrative therapy to externalize the problem. A case example illustrates the clinical application. Implications for the practice of narrative therapy are considered.

In the past two decades an increasing number of counseling and psychotherapy models have emphasized narrative conceptualizations of problems and change. Narrative therapy was developed by Michael White (1995,2000,2007) and his colleagues (e.g,. White & Epston, 1990, 1992) at the Dulwich Therapy Centre in Australia. It views clients' problems as dominant stories or restraining narratives that are influenced by one's culture (White & Epston, 1990), In narrative therapy, clients are helped to replace problem-maintaining dominant stories with preferred narratives about their lives (M. White, 2000). A fundamental principle in narrative therapy is externalizing the problem (M, White, 1989; White & Epston, 1990). According to White and Epston, externalizing the problem refers to "an approach , . , that encourages a person to objectify and, at times, to personify the problems that they experience as oppressive" (p. 38), The principle of extemalization is aimed at helping clients view themselves as separate from their problems. In effect, they are encouraged to see that they are not the problem; the problem is the problem (White, 2004; White & Epston). The principle of extemalization has been applied to a variety of clinical problems and clients. For example, V,E, White (2002) developed an externalization intervention for mental health counseling to help clients discriminate between their personal strengths and the pathologizing language of the

The authors are affiliated with the Counseling Department in the Adrian Dominican School of Education at Barry University in Miami Shores, Florida. Correspondence concerning this article should be addressed to Jeffrey T. Guterman, Adrian Dominican School of Education, Powers Building, 11300 NE 2 Avenue, Barry University, Miami Shores, FL 33161-6695. Email: jguterman@mail.barry.edu.

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Diagnostic and Statistic Manual of Mental Disorders (PSM-IV-TR\ American Psychiatric Association, 2000). This article presents a clinical application for using puppets with children in narrative therapy to externalize the problem. Puppets have often been used in play therapy, a therapeutic modality that has been integrated into various clinical theories, including behavioral (Rrop & Burgess, 1993); family therapy (Gil, 1994); and gestalt (Blom, 2006). Puppets have been used in counseling and psychotherapy for different purposes, such as assessment and diagnosis (e.g., Irwin, 1993) and addressing specific clinical problems (e.g.. Brown, 1996; Bernhardt & Praeger, 1985; Carter, 1987). Some models have used puppets as "cotherapists" for their approaches, including narrative therapy (e.g.. Freeman, Epston, & Lobovits, 1997; White & Morgan, 2006). For example, these authors used puppets in narrative therapy with a nonresponsive child experiencing separation and bereavement issues. Freeman et al. described a case of a narrative therapist who imbued a puppet with personal characteristics that enabled the client to begin identifying with and addressing the problem. To date no clinical application has been found in the narrative therapy literature for using puppets with the specific intention of promoting the fundamental principle, externalizing the problem. M. White (1989) developed the principle of externalizing the problem in his work with young children with the intent of engaging their imaginations. We suggest that puppets are an effective tool for externalizing the problem for two reasons: First, using puppets objectifies the problem. Second, the application begins to create distance between the problem and the client, which is a first step in the process of externalizing the problem (White & Epston, 1990). In what follows, first, the theory and practice of narrative therapy are described. Next, a case is presented to illustrate the clinical application of using puppets with children to externalize the problem. Finally, we consider implications for the practice of narrative therapy. NARRATIVE THERAPY Narrative therapy is a strength-based clinical model informed by postmodernism, an intellectual movement developed in various disciplines that rejects modernist conceptions of objectivity (da Costa, Nelson, Rudes, & Guterman, 2007; Freedman & Combs, 1996; Lyotard, 1984; V.E. White, 2002). In particular, narrative therapy has been influenced by Foucault's (1987) sociocultural philosophy that holds that knowledge is constitutive and language-based. Foucault proposed that individuals internalize thoughts and actions that are products of normalizing ideas informed by and embedded in cultural, political, and social contexts. From his perspective, understandings of life are culturally informed; hence, in narrative therapy, problems are conceptualized as

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constraining stories that are significantly shaped by one's history (White & Epston, 1990). These constraining narratives are considered dominant stories and are experienced as oppressive in the lives, identities, and relationships of people who seek counseling. The change process in narrative therapy involves helping clients deconstruct and challenge their dominant stories and create more empowering narratives about their lives (M. White, 2000; White & Epston). Narrative therapy typically has five stages, though they are meant to serve mainly as a guide, because detours are common. Because each client is unique, the stages do not account for nuances that are distinctive to each case. The process described is meant to be used during the initial and subsequent sessions. Nevertheless, the recursive (circular, interrelated, and overlapping) nature of narrative therapy's clinical process makes it applicable to all subsequent sessions. Despite its recursive aspects, the process is explicated below in terms of discrete stages, though they are not meant to be understood as having clear boundaries. The stages consist of (a) defining the problem; (b) mapping the infiuence of the problem; (c) evaluating and justifying the effects of the problem; (d) identifying unique outcomes; and (e) restorying (cf. M. White, 2007; White & Epston, 1990). In defining the problem., the mental health counselor attempts to obtain a description of the problem irom the client. Here it is important to identify the words that most closely approximate the client's experience of the problem. Doing so allows clients to achieve a near-experience of the problem and serves to privilege their descriptions (M. White, 2006, 2007; White & Epston, 1990), Clients are often encouraged to put a name to the problem (White & Epston). For example, M. White and Epston described the case of a 6-year-old boy with a history of encopresis. During family counseling the boy and his parents defined the problem as fi-equent soiling and described a pattern of the "accidents" sneaking up and wreaking havoc on the family and taking on a life of its own. It seemed fitting, then, for the boy to name the problem sneaky poo. Naming the problem is often a first step in the process of externalizing. It creates a linguistic separation between the problem and the client. But just any name will not do. As shown in the example, it is critical for the name to be related to the words used by the client. In some cases defining the problem is difficult and for various reasons is not achieved during the first stage, or even the first session. If clients cannot define the problem, it might be preferable to proceed to the next stage, mapping the infiuences of the problem. Mapping the infiuences is a questioning process aimed at helping clients identify and increase the experience of the problem's effects and thereby help to ftirther externalize the problem (M. White, 2004; White & Epston, 1990). When mapping the influences, counselors ask how the problem has affected various domains of the client's life, including relationships, work, and daily

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functioning. An example of such questioning might be, "How is the problem affecting the picture you have of yourself?" By identifying ways a problem has affected their lives across different domains, clients are encouraged to view themselves as separate fi-om the problem. Another purpose of mapping the influences is to increase a sense of agency for the client by recognizing opportunities for identifying unique outcomes later during the clinical process. After the client has mapped various influences, the counselor can go back to these influences later and inquire about unique outeomes (described below). Evaluating andjustifying the effects of the problem invites clients to consider their own position in relation to the problemgood or bad, helpful or unhelpful, self-defeating or self-helpingin an effort to elicit for the first time a clear evaluation of the problem. This line of questioning can be novel and unexpected for clients because often other people (e.g., family members, friends, teachers) already hold positions regarding the problem. If the client evaluates the problem as negative, then the counselor seeks a justification through a series of questions. For example, the counselor might ask clients to articulate how the negative effects of the problem are at odds with their goals and intentions. If a client does not evaluate the effects of the problem as negative, it might be necessary to consider whether the "problem" is a problem for the client. In some cases, it might be helpful to return to previous stages and redeflne the problem or map its influences. The next stage in narrative therapy is identifying unique outcomes. A unique outcome is any thought, behavior, feeling, or event that contradicts or is at odds with the dominant story (M. White, 1995; White & Epston, 1990). In some cases, unique outcomes have been identifled during the previous stages in narrative therapy. Counselors use questions to help clients identify unique outcomes; for example, "How were you able to not let the problem influence you at this time?" or "What did you do to overcome the problem in this situation?" Again, the influences identified during the mapping process can be used later as a basis for identifying unique outcomes. For example, if a client were to report an influence related to worry about financial issues, the counselor might ask a series of questions to identify unique outcomes related to the worry in this domain. After identifying unique outcomes, clients are helped to ascribe meaning to these events through restorying, a therapeutic process designed to help them create a sense of empowerment, self-efficacy, and hope (Guterman & Rudes, 2005; Monk, Winslade, Crocket, & Epston, 1996; M. White, 2000). Restorying might involve the counselor asking the client, "What does this [unique outcome] say about you and your ability to influence this problem?" or "What qualities does a person require to deal with this problem?" The following is a case illustrating a clinical application of using puppets with children to externalize the problem.

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CASE EXAMPLE An 8-year-old boy, Eric, was referred by his school for mental health counseling due to disruptive behavior and fi-equent, almost daily, fights with classmates. Eric was an only child residing with his mother. His father had moved out the year before and his parents' divorce had become final three months before the referral. In a phone conversation with the counselor before the first session, his mother reported that Eric's most recent aggressive episode had resulted in one of his classmates requiring medical attention. His mother also reported that Eric had been defiant, disrespectful, and threatening toward her ever since he was a very young child, but that his behavior had escalated since she separated ^om his father. She described Eric as an uncaring child who did not consider the consequences of his behavior. Eric came to the first session accompanied by his mother. At the start of the first session, the counselor began the first stage of narrative therapy, defining the problem. The mother stated that when things do not go Eric's way at school, he gets very angry and often gets into fights with classmates. She also said that his teachers had expressed concern that when he gets angry he erupts like a volcano. She added that the pattern at home was similar. When the counselor asked Eric to describe the problem, he would not respond. After several unsuccessful attempts to elicit participation from Eric, the counselor chose to move to the next stage, mapping the influences of the problem. The counselor considered that identifying the effects of the problem at this point might help Eric define the problem and begin to understand how it was affecting various aspects of his life. This stage was also designed to create some space in language between Eric and the problem. The mother reported that Eric's anger often got him in trouble at school and led to his losing privileges. She described how his anger had contributed to frequent arguments between them, which in turn undermined their relationship. At this point, Eric began to nod his head indicating some recognition of the problem's influence. The counselor then asked Eric, "Is your nodding a sign of agreement that the anger has come between you and your mother, and steals your privileges?" Eric replied, "I think so!" Eric went on to describe several effects of the influences of the problem. The counselor summarized Eric's understanding of the problem and suggested that it had led to a host of negative feelings and experiences. Upon hearing the counselor's summation, Eric began to describe the problem as an annoyance in his life that had interfered with things he enjoys. This was a realization for Eric that established a basis for evaluating and justifying the effects of the problem. At this point, the counselor chose to introduce puppets as a clinical tool to continue working toward externalizing the problem. The counselor displayed a selection of puppets while explaining that she often uses them to

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help children with their problems. She asked Eric to choose the puppet that most closely represented his annoyance. He became more animated as he carefully examined the puppets. He eventually chose a large bug puppet. The counselor asked Eric a series of questions about how he came to choose the bug puppet and how it represented the problem. Eric began to move the puppet around the room while making a loud buzzing sound. He showed the bug sneaking up on his mother and the counselor. "Then what happens?" the counselor asked. Eric moved the bug closer and closer to his mother and the counselor. Eric only stopped when his mother playfully raised her voice, "It's bugging me!" At that moment laughter filled the room. Through the use of the puppet, the annoyance became a thing, an entityin effect, an objectification of the problemwhich, in turn, enacted the externalizing process. Toward the end of the flrst session, the counselor asked Eric and his mother if they would like to take the puppet home between sessions. The counselor suggested that it might be useful for Eric and his mother to observe the bug's annoying ways. She also suggested that Eric be assigned to consult with his mother when he was able to control the puppet, and also when it got the better of him. Both Eric and his mother agreed to the task. At the start of the second session, the counselor followed up on the task. The mother, wearing a broad smile, said it had been a much better week, although there were a few instances when annoyance came between them. With puppet in hand, Eric was attentive to his mother's descriptions of the good week. The counselor was not surprised when, upon seeking input from Eric, he only nodded in agreement with his mother's descriptions. At this point, the following transcribed conversation transpired : Counselor: Maybe I should ask the puppet how things have been this past week? Eric (still with puppet in hand): I'm not sure if it's okay. Counselor: It's okay. Mother: It's alright, Eric. Eric (speaking as the puppet): I like to bug, I like to sting. Counselor: Oh! Eric: But I hurt my stinger. My stinger got torn a little by Eric. When I tried to bug him. It hurt when he did that. (Mother smiles.) Counselor: How is it now? The stinger? Eric: It's okay. But I'm going to keep bugging! Counselor: You are? Eric: Yeah, I want to go back there again. As a result of this enactment, the puppet gave a voice to the problem. After

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Eric spoke for the puppet, the counselor moved to the stage, identifying unique outcomes. The counselor asked Eric, "Does the puppet ever speak for yoi/?" An active discussion ensued about the influences the puppet had on Eric during the past week. Eric was able to identify an instance when the puppet did not lead him to lose control. Eric then remembered that during the week a classmate called him a bad name at school and he did not erupt in his usual way. The counselor asked Eric, "How did you manage to not let that situation get you?" Eric was not able to account for how he maintained control. The counselor, however, considered this to be an opportunity to identify a unique outcome in relation to the problem. Eric had not ascribed meaning to what had occurred in school, and therefore did not yet understand the event as a unique outcome. The puppet would be used to help Eric to this by attaching meaning to the event. With Eric already characterizing the bug as the problem, the counselor asked a series of questions designed to make connections between the event of the classmate calling him a bad name and his good experience of it. For example, the counselor asked Eric, "What would the bug think about how you handled being called that name in class?" Eric responded quickly, "I don't care what the bug thinks! I like it!" Toward the end of the session, Eric came to see the event at school as a unique outcome. During the next several weeks, Eric identified additional unique outcomes related to the problem. Eric continued to take the puppet home between sessions and reported being very successftil at controlling it. He fi-equently checked in with his mother on his progress with the puppet. Eric came to one session with a bandage affixed to the bug puppet's stinger. He explained, "I tried to take its stinger out, but my mom said it's not mine to do. The bug got hurt." What came out ofthat session was Eric's caring and concern for the puppet despite his dislike for its stinging effects. As the counseling progressed, the counselor helped Eric ascribe meaning to the unique outcomes during the stage, restorying. The counselor asked Eric a series of questions, such as "What is it like to be a bug-buster?" and "What is it like to be a boy who can control his anger?" The client's focus shifted away from an emphasis on problem talk and more on his goals, purposes, and intentions. For the first time, Eric began to speak about his feelings about his father, which until this time were only expressed in negative ways. He also began to deal with his feelings of loss about his parents' divorce. Eric's mother supported these developments by offering story lines of Eric being a caring, rather than an uncaring, child. The mother's role in the counseling was understood as an outside witness. In narrative therapy, an outside witness refers to any significant person or figure who speaks with authority to the client's new, preferred narrative (M. White, 2007). The mother's responses were influential to the restorying process in several ways. They (a) acknowledged Eric's improvement, (b) identified additional unique outcomes, and (c) ascribed new meanings to her son's actions.

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After eight sessions of mental health counseling over three months, Eric's anger had dissipated. His coping skills were markedly improved, and he also improved his social skills. The counselor, Eric, and his mother reached a consensus that the counseling was no longer needed, but that counseling could be resumed if the need should arise. At the end of the final session, the counselor asked Eric if he would like to keep the puppet, Eric declined, saying, "Maybe the puppet can help some other kids," CONCLUDING REMARKS In our clinical work, we have found puppets to be an effective tool for externalizing the problem in narrative therapy. In some cases, however, it is not necessary or preferable to use puppets for this purpose. The counselor might assess that narrative therapy will be more effective and efficient without puppets, or that puppets might be contraindicated. Some children might be distracted, fearful, or otherwise not amenable to using a puppet for externalizing the problem. We have typically used puppets in narrative therapy only with young children. Older children, adolescents, and adult clients might also benefit fi-om the use of objects to help externalize the problem. Clients of all ages are routinely encouraged to objectify the problem in narrative therapy through various clinical processes, such as letter writing and naming the problem (Monk et al,, 1996; White & Epston, 1990), When counselors deem it appropriate, clients can be invited to select from an array of objects, personal or otherwise, to serve as tools to enhance the externalizing process. For example, an adult client might identify a work of art that most closely represents the problem. Finally, we wish to underscore the important role that imagination plays during mental health counseling, especially the extemalization process in narrative therapy (White & Epston, 1992). In narrative therapy, it is largely the child's abilify to imagine the puppet as the problem that crystallizes the extemalization process and thus contributes to change. That is why we consider children's imaginations to be one of the most valuable resources in narrative therapy. Of course, imagination is a ubiquitous resource that all clients possess. As counselors, it is important to recognize that our imaginations are also valuable resources as we work with clients toward therapeutic ends, REFERENCES
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