Integration of Narrative Therapy with Expressive Art Practices

Abstract

Abstract The purpose of this research is to provide information about what is narrative therapy and how expressive art practices can integrate into narrative therapy. Since the nature of narrative therapy's structure is suitable for integration with art practices, this review study focuses on narrative therapy and narrative art practices. The adoption of this idea involves not only dominant hypothesis underlying in humanism and psychology but also approaches such as meaning, subjectivity, power and ethics (Besley 2002). [...]narrative therapy is a therapy type which is within social structuring approach with the contributions of all these adoptions of ideas (Payne 2006). According to the other hypothesis, individuals structures these metaphors socially because an individual structure these metaphors with the interaction that they make with other people. According to Morgan (2000) the stories formed by an individual covers a process and the individual links the events that are experienced in this process and finally make sense out of them in his/her way.

Headnote

Abstract

The purpose of this research is to provide information about what is narrative therapy and how expressive art practices can integrate into narrative therapy. Since the nature of narrative therapy's structure is suitable for integration with art practices, this review study focuses on narrative therapy and narrative art practices. For this purpose, in this study, what the narrative therapy is, how it came up, where therapy can be used, theoretical foundations, human nature perspective, basic concepts, the role and characteristics of the therapist, therapeutic purposes, techniques and stages of the therapy are emphasized. Then, information was given about how expressive art practices can be integrated with narrative therapy. Finally, activities, case examples and practices are included.

Keywords: Narrative therapy, expressive art, narrative art therapy

Öz

Bu araştırmanın amacı öyküsel terapinin ne olduǧu ve dışavurumcu sanat uygulamalarının öyküsel terapiyle nasıl bütünleşeceǧi ile ilgili bilgi vermektir. Öyküsel terapinin doǧasının sanat uygulamaları ile bütünleşmeye uygun bir yapısı olması nedeniyle bu derleme çalışması öyküsel terapi ile sanat uygulamalarına odaklanmaktadır. Bu amaçla bu çalışmada sırasıyla öyküsel terapinin ne olduǧu, nasıl ortaya çıktıǧı, kullanım alanları, kuramsal temelleri, insan doǧasına bakışı, temel kavramları, terapistin rolü ve özellikleri, terapötik amaçları, kullanılan teknikler ve terapi sürecinin aşamaları vurgulanmıştır. Daha sonra dışavurumcu sanat uygulamalarının öyküsel terapi ile nasıl entegre olabileceǧi ile ilgili bilgi verilmiştir. Son olarak etkinliklere, olgu örneǧine ve uygulamalara yer verilmiştir.

Anahtar sözcükler: Öyküsel terapi, dışavurumcu sanat, öyküsel sanat terapi

THE HUMAN mind has the capacity to re-create reality with stories and assess the value of their experiences in their own ways (O'Hara and Anderson 1991). People express what they experience through stories and these stories, most of the time, mirror both the problem and the perspective of the individual on life. Expressing stories is usually directly related to the community where people live as well since people come across stories in their communities. This is interpreted as if people are born in the world of stories (Işık-Terzi and Ergüner-Tekinalp 2013). That the individuals express their stories bear the meaning that the stories are internalized both individually and socially. In this case, they make an individual feel that he/she belong in their own stories as much as the social stories which are already in existence. Therefore, the individual learns what sort of comments they can make about the future events by restructuring both their own stories and the stories of others in their surroundings (Allen 2011). At this point, narrative therapy is a therapy type which grounds on restructuring the stories of individuals by valuing their stories.

Art paves the way for mental health experts to produce a concrete product such as sculpture, story, painting or dance and to make use of inner feelings and unconscious mind. Being involved in expressive arts enables clients to discover their deepest and usually secret feelings, to use symbols in order to represent their inner feelings and conflicts, and to express their inner problems physically. This process frequently leads to a more comprehensive selfdiscovery and self-expression than speech therapy allows them to do (Degges-White 2011).

By its very nature, narrative therapy is a therapy approach which is very suitable to be integrated with art therapy. The process of re-editing or re-creating stories of individuals in narrative therapy (White 2007) and the contribution of these processes in forming social stories are evaluated as rather appropriate in terms of the use of expressive arts in narrative therapy (Patrick 2011). The aim of this study is to give information about narrative therapy and expressive art therapy and to examine the integration of these two therapy types and how they can become a more innovative approach.

Narrative therapy

Narrative therapy is one of the post-modern therapies developed by Michael White, codirector of Dulwich Center in South Australia, and David Epston, co-director of Auckland Family Therapy Center in New Zealand (White 2011). White, who is a draftsman, focused on how problems affect people with the effect of Foucauldian thinking and developed his approach based on this. The adoption of this idea involves not only dominant hypothesis underlying in humanism and psychology but also approaches such as meaning, subjectivity, power and ethics (Besley 2002). Thus, narrative therapy is a therapy type which is within social structuring approach with the contributions of all these adoptions of ideas (Payne 2006). Social constructivism indicates that culture and social concept are significant in structuring knowledge (Fer, 2009). Also, the way individuals form their own meanings occurs in such ways that both individuals share their meanings with other individuals and they become affected by the meanings of other individuals in social terms (Fer and Çırık 2007). In narrative therapy, that the individuals form their own stories and become affected by the stories of the society can also be regarded as syntheses of the ideas of Foucault and other theorists of social structure approach (Özü and Akpınar 2010). White, who supports this aspect, emphasized that the stories of individuals are not only descriptive but at the same time they are structuring; also argued that the problems which co-exist with these stories are reflections of cultural practices (Gladding 2013). On the other hand, Epston argued that the process of forming stories will never end by posing a different point of view for the narrative therapy and he supported the ideas of therapist writing letters to their clients; therefore, even if therapy sessions end, forming the stories of individuals will continue lifelong thanks to these letters (Nichols 2013).

Narrative therapy which considers the stories of individuals important is based on two hypotheses (Freedman 2012). According to the first hypothesis, individuals have metaphors related to their lives. Metaphors are similes used for individuals to express the problems they encounter in their lives in a different way. Individuals consider the realities of their lives as metaphorical stories, try to express their problems in different ways or objects and make their lives meaningful using this way. According to the other hypothesis, individuals structures these metaphors socially because an individual structure these metaphors with the interaction that they make with other people. According to Morgan (2000) the stories formed by an individual covers a process and the individual links the events that are experienced in this process and finally make sense out of them in his/her way. Actually, these stories are also a sign that displays both the existence of the individual and who the individual is (IşıkTerzi and Ergüner-Tekinalp 2013) inasmuch as an individual live with stories and forms his/her own reality with stories (Corey 2009). At this point, to summarize, the stories of an individual are actually both metaphorical descriptions that reflect their social and individual realities (Karaırmak and Bugay 2010) and a tool to regulate life (Payne 2006)

According to Morgan (2000) the theoretical structure of narrative therapy is as follows. *

* Narrative therapy is an approach where individuals learn that they are the experts of their lives and the cooperation of individual and therapist matters greatly.

* Problem is separated from the self-perception and the beliefs, skills and values of an individual can be used to solve the problem.

* Asking a lot of questions and sincerity are two significant principles for a therapist.

* Conversation can proceed in different ways, there may not be a way which is thought to be exactly right.

* The decision of which way to use belongs to the individual (client).

In brief, narrative therapy evaluates individuals as the people who are in charge of their lives and thus, is based on an egalitarian approach in which individual and therapist form a cooperation with sincerity in the therapy process. The problem is out of individual's control; however, the beliefs and skills of the individual can be used for solution. For instance, instead of using the expression "you are stressful", the expression "the stress has affected your life" is preferred in narrative therapy (Payne 2006). This give the client the message that stress is not included in the life of the client and it is an extrinsic factor. In the therapy process, questions are frequently used, the clients try different ways through questions and the client decides which way to choose themselves.

When the study fields of narrative therapy are considered, eating disorders (Dallos 2004, Robbins and Pehrson 2009, Scott et al. 2013); speech disorders (Wolter et al. 2006, Spencer and Slocum 2010, Eisenberg 2014); sexual abuse in childhood (Miller et al. 2006); families with gay, lesbian and bisexual children (Salzburg 2007); bipolar disorder (Ngazimbi et al. 2008); depression in marital therapy (Rautiainen and Aaltanen 2010); conflict resolution in marital therapy (White 2009a); problems related to patriarchy in marital therapy (Dickerson 2013); post-traumatic stress disorder (Day 2009); multicultural issues (Devence-Taliaferro et al. 2013, German 2013); dissatisfaction towards body image (Duba et al. 2010); depression (Vromans and Schweitter 2009, Angus and Kagan 2013;); fear of death in elderly people (Stern 2011); memory loss in elderly people (Young 2010); obsessive compulsive disorder (Dembo 2014); substance addiction (Butt 2011, Chan et al. 2012); adolescents with self-cut behavior (Woods and Hannen 2012); trauma (Witney 2012, Landes et al. 2013); issues of spouses with different cultural backgrounds (Kim et al. 2012); social justice (Combs and Freeman 2012); autism (Cashin et al. 2013); earthquake victims and the effect of earthquake (Zang et al. 2013) and social phobia in children (Looyeh et al. 2014) are significant subjects. As can be understood from these studies, narrative therapy has a wide range use.

Theoretical basis and its perspective on human nature

The theoretical basis of narrative therapy is based on postmodernism and social constructivism (Payne 2006, Wallis et al. 2011). In terms of postmodernist point of view, narrative therapy argues that it is significant to know the family, the community and the values, traditions, habits and beliefs created as a consequence of the interaction between family and community in order to understand the problem of an individual (Biggs and Hilton-Bayre 2008). On the other hand, the language concept supported by social constructivism also reveals itself in the narrative therapy similarly. The conversation of an individual during their relationships with others is based on language and the reality can be discovered through relationships formed by language (Payne 2006).

In parallel with postmodernism and social constructivism on which narrative therapy philosophically is based, the narrative therapy has very positive opinions about humans. According to narrative therapy which is one of the postmodern therapy types that are against human diagnosis in traditional therapies, people are healthy (Besley 2002). They do not have the skills to solve their problems and they do not have sources to access for solution. Individuals have the ability to create solution by using their own sources and to strengthen their lives with alternative stories. In this case, it is believed that the subjective reality emerging from ascribing a meaning to their own experiences is created by the individuals themselves; therefore, an individual both writes the scenario of his/her life and becomes the leading role of it (Karaırmak and Bugay 2010).

Narrative therapy separates the individual and the problem. The problem is the problem itself and the individuals is not problematic. Independently of the problem, the individuals have their own potentials and have their own competences for the solution of the related problem. There are many stories in life and individuals have the strength to solve their problems by ascribing a meaning to these stories. In other words, clients are the experts of their own lives and they received help only to realize their potentials (Metcalf 2011).

Basic concepts

There are four concepts that the narrative therapy is based on. These concepts are giving new meaning to life, language, dominant stories and externalization. The first concept is giving new meaning to life. One of the fundamental assumptions of narrative therapy is "individuals shape the meaning of their lives through stories that regulate their lives" (Çelik 2017). According to narrative therapy, individuals have many stories related to their personal lives, relationships, skills, interests, successes or losses, and these stories bear a meaning (Morgan 2000). This meaning is ascribed by the individual because it is thought that people try to ascribe a meaning to their lives (Corey 2009). However, external sources (such as social norms and stories related to gender roles) have an effect on shaping this meaning as well as individuals. Narrative therapy accepts therapeutic process as a process ofgiving new meaning to life (Çelik 2017). The effort of ascribing a meaning is also an indication of individuals' being in a new structuring (Corey 2009).

The second concept used by narrative therapy is language. The emphasis of language in narrative therapy has two dimensions: first dimension is the postmodern thinking in which meaning is shaped with language (Spencer and Scolum 2010), and the other dimension is the thought that the languages that is used affect clients negatively. In the first opinion, meaning is structured by the individuals who uses the language, and the language and narrative use of language creates the meaning (Minuchin et al. 2006). At this point, the emphasis on the language created by the words used by the individual is significant since the words that are used eases the formation of a new story. In the other dimension, the language that is used affects the individuals. For instance, White does not use certain words thinking that these words effect individuals adversely. He does not use the expressions case or case histories, and instead of using the word client, he prefers the word person (White 2011). There is a language intellection which is not used in other therapies. The best examples for these are dominant stories, externalizing of the problem by metaphors, construction of desired story and ending ceremony. In brief, it can be said that the language affect individuals.

The formation of dominant story which is the third fundamental concept is as follows: the novel stories and scenarios of individuals do not belong solely to individuals in narrative therapy in which the existence of subjective reality is believed because not only individual himself contributes to the formation of the stories but also the people they interact with contributes to them as well. Even though an individual has his novel stories, there are undesired pressures which limit the individual as a consequence of the interaction with the environment; therefore, these pressures become dominant in the novel story of the individual. For instance, a client who try to write their own story listens to their parents' stories at the same time or face the stories in the community frequently. Thus, the individual perceives the world in the frame of these stories (Wolter et al. 2006). On the other hand, the formation of the dominant story of the individual is in focus in the therapy, and the client is encouraged regarding that this story can alter (Ikizer 2020).

The last concept of narrative therapy is externalization. In narrative therapy, the individual is not the problem, and the problem itself is the problem (Payne 2006). As in solutionfocused therapy, it does not focus on the solution of the problem, but rather, it focuses on restructuring of the problem. At this point, the fact that the problem is somewhere beyond the individual expresses externalization. Therefore, the individual does not perceive problems as they are in the nature of humans or as a significant part of humans. Instead, the problems are accepted as undesired attacks which destroy the nature of experience creating the feeling of failure and insufficiency (Dallos and Draper 2012). Thusly, the individual separates the problem from the self of his own with the externalization of the problem. This can cause a decrease in the feelings of guilt or shame that are felt because of the problem since this indicates that there is no correlation between the problem and the individual by externalizing the problem (Metcalf 2011).

The role and features of therapist

Therapist and client relationship in several traditional therapies cannot be seen in the narrative therapy. Therapist develops a mission in which the conditions are equal with the individual and he/she supports the idea that the individual is the expert of their lives by leaving the role of expert out. This support the formation of cooperation between individuals and therapists (White 2011). In this cooperation, therapist is "the curious student" and client is "a senior partner" who has more experience than psychological counselor (Semler and William 2000).

Although it is different from other therapies, the narrative therapists also utilize basic techniques such as listening, reflecting, explaining and summarizing; however, unlike other therapies, they ask more questions. This way, the therapist gives the client the opportunity to rearrange their dominant stories and to externalize the existent problem (Payne 2006). Rather than trying to understand what the problem is as in traditional therapies, they try to find out what the solution is (White 211). In this process, the strengths of the client are emphasized, and the clients are encouraged. They do not mind the notions such as resistance, denial and mental disorders, and they object to the diagnosing the client (IşıkTerzi and Ergüne-Tekinalp 2013). They sincerely listen to their clients with the method of radical listening. In this type of listening, the aim is not to solve the problem of the client, the aim is to better understand the story of the client (Payne 2006). At this point, they act as a facilitator. They develop compassion, curiosity, interest and respect.

In the light of these expressions, the features of narrative therapist can be stated as follows (White 2011).

* Therapist gives importance to cooperation since cooperation between therapist and the client increases the strength, and this is a significant tool in problem solution for the individual.

* Therapist does not prefer laying stress on the problems of the individual; and therapist does not focus especially on the beginning, emergence or frequency of the problem

* He/she focuses on comprehending the stories of the individual, and on how to solve the problem, how it changes, what the preferences of the individual are, the plans of the individual and what the individual wants to change.

* The individual has the strength to solve his/her problems. The therapist supports the individual in terms of revealing his/her strength that the individual needs.

* The therapist does not know everything. On the other hand, the individual is the expert of his/her life. The expertise of the therapist paves the way of structuring problems that are the aims of the individual.

* In the therapy process, the relation between the therapist and the individual can be strengthened instead of using techniques.

* In the therapy environment, the therapist gives importance to the language and uses the language used by the individual.

* The therapist is philosophically against diagnosing by using Diagnostic and Statistical Manual of Mental Disorders (DSM) since he/she does not see it as an approach which leads to the solution.

Therapeutic aims

The most significant and most fundamental aim of the narrative therapy is to help individuals or families to form more satisfying stories (Coulehan et al. 1998). It aims to restructure stories based on language used by the clients themselves (Allen, 2011), and also aims to encourage the clients to look at their problems from another perspective by improving clients' different thinking styles (Nichols 2013). The process of constructing new stories starts with cooperative approach, carries on with the ongoing stories and expression, and continues by emphasizing the strength of the one that is needed by or beneficial for the individual by re-forming the meaning and importance of the story. Finally, alternative stories which include new points of views related to the life of the individual are produces (Karaırmak and Bugay 2010). The second aim of therapy is, in some way, getting rid of the pressure formed by extrinsic problems or dominant culture with re-narrating (Correy

2009). According to White (2011), since the stories of the dominant culture are very strong, an individual internalizes these stories after a while as if they experience them. At this point, dominant discourses serve the ones who have interests in this culture, and these are not appropriate for the autonomy of the individual's life. Thus, the aim is to get rid of the pressure in the therapy.

Therapeutic techniques

There are eight techniques that are used in narrative therapy. The first technique is problemoriented defining. At the beginning of the therapy, the clients usually mention negativities, resentments and grieves in their lives. White defines this situation as being problem oriented. According to Rosen and Lang (2005), while defining the problem of the client in narrative therapy, the problem and the individual should be separated, and the problem itself should be seen as the problem. While doing this, phrases implying necessity should be excluded from the language and the discourse, and it shouldn't be forgotten that the problem has more than one dimensions. When the problem is defined by paying close attention to all these, the dominant story of the client will also be shaped (Payne 2006).

In the second technique which is asking questions, questions are asked so that the client can discover and understand their dominant stories. As in other types of therapies, the questions are not curiosity-based, rather they aim to bring experience to the clients. The question are also used in order to provide cooperation between the therapist and the individual, to encourage the client, to externalize the problem, to show the effect of the problem on the life of the client and to show the parts in which the client succeeds in relation with the problem (Carr 1998).

The third technique of narrative therapy is externalization which is both the concept and the technique. In the essence of narrative therapy, there is the idea that the individual is not pathological, and the real problem is not the individual but problem itself (Wallis et al. 2011). In the process of externalization, the language used by the therapist should support this statement. For instance, the statements related to a situation involving depression that will be used by the therapist should be "the depression has invaded your life" instead of "you are depressed" or "the stress is affecting your life" instead of "you are stressed" (Payne 2006). In the first sentence, it is implied that the depression is an external problem while in the second sentence it means that the depression is a situation existing inside the individual. Similarly, it is emphasized that stress has entered the life of the individual later. Also, the language used by the therapist should not be hurtful.

While the problem is externalized, the therapists request that the client give a name to the existing problem and while mentioning the problem, they should use this name (Corey 2009). Giving a name to the problem creates the opinion that the problem is an outside object that comes into the individual's life, and it can leave the individual in a similar way. Also, the problem can become more sympathetic that it actually is by giving it a name, and the client become less afraid of the problem. The significant point here is that the main source of fear for the client is uncertainty, and the uncertainty is removed by giving the problem a name.

Another technique which is unique/novel results includes helping the client reveal the skills that they use in order to overcome the problem in the past where they have not experienced or have experienced the problem rarely. Novel results are significant in helping with finding dominant and problematic stories process which is one of the aims of narrative therapy where the clients deny and oppose (Payne 2006). The therapist learns when the dominant stories emerged in the life of the individual, and the client is encouraged with purposeful questions in order to determine the moment where the problem does not exist or the problem is handled effectively (Işık-Terzi and Ergüner-Tekinalp 2013). As an example, such questions as "Was there a moment when you resisted your anger instead of yielding it? How was that moment for you?" are asked. Talking about these novel results in individual's life is also beneficial in the therapy, and it allow the individual to develop new stories in his/her future life. For instance, while talking about the existing energy of a child who has Attention-Deficiency Hyperactivity Disorder (ADHD), understanding that the child can focus his/her attention better when he/she sits close to the teacher or when the sound of television is lover affects the therapy process, and provides material for the therapist to develop new strategies (Metcalf 2011). Epston states that creating awareness in clients about the times when the problem does not exist in their lives or how they cope with the problem when the effects of the problem starts to appear in their life is very significant. For instance, for clients who get worried when they leave home, the therapist can ask questions such as "Today, you mentioned that you managed to take your son to the school. How was this experience for you? Have you ever done something similar?" (Çelik 2017).

In story deconstruction technique, first, the existing structure must be deconstructed in order to re-structure life stories. The concept of deconstruction of the structure was presented in the opinions of philosophers such as Foucault and Derrida (Foucault 2011). While Derrida argues "there cannot exist a thing without its opposite, and it derives its meaning from the opposite pole", Foucault says "do not ask who I am, and do not expect me to stay the same" (Gutting 2010). In the light of these statements, White (2011) defines the deconstruction of the structure as deconstructing "cultural discourse that continues pressure and creates dysfunctional identities" and "situations in which what we do does not match with our preferences. In brief, deconstruction of the structure is the process of breaking a thing into the basic parts in its opposite pole by destroying the existing meaning of it (Işık-Terzi and Ergüner-Tekinalp 2013). With the deconstruction of the structure, the therapist listens to the story of the individual from a different point of view since there is a correlation between dominant stories, and finds the gaps or contrasts in the story; thus, tries to understand the correlation between the dominant story of the individual and other stories. In this way, the therapist creates awareness in the client (Neukrug 2012).

According to rewriting-alternative stories technique, if the individual wants to construct new stories, the structure of the previous stories must be deconstructed. This means making a fresh start. The narrative therapists encourage their clients to write alternative stories thanks to "unique outcomes (the unique acquisitions of the individual)". Therefore, question that will provide the client with the integration with the new meaning in life are asked at the beginning, and these questions are based on rewriting their relationships or lives (Metcalf 2011). The therapist asks questions such as "Have you ever had a moment when you overcame the effect of this problem?". That way, the secret events in the story are discovered (Corey 2009). In the next step, the therapist starts asking questions such as "What is the possible next step as a result of what you have learnt about your own self after this therapy?", "What are the behaviors that can encourage you more or make you behave this way if you try to act with the identity you prefer?" in order to understand what the client wants and what the client's next purposes are.

Therapeutic document/documentation practices include the written documents of the individual. Documentation involves producing other expressions that can be used by the client in order to write letters, form certificates or determine the ways of coping with the problem (Patrick 2011). David Epston supports letter-writing, and states that this is very natural and even it is an expanded version of a conversation (Monk et.al. 1997). He adds one copy of the letters used in the therapy into this file and posts another copy to the client. He states that the individuals feel surprised after they get the letter and they want the letters to be reads in the next session; therefore, where to start the next session is determined (Andrews and Clark 1996).

According to Nylund and Thomas (1994), there must be a formed theoretical frame while writing letters, and the letters should not be written randomly. Thus, a letter must have an introduction paragraph, and this paragraph must relate the client with the previous session. Second, the statements must emphasize the current and previous state of the effect of the problem on the client. Third, some questions that have occurred to the therapist during the therapy can be asked to the client; however, these questions must be linked to the new story being developed the individual. Finally, the letter must emphasize the "unique outcomes" that will be revealed during the session or exceptional situations that are in the story of the client.

Finding outsider witnesses can be carried out with letters or written documents as well as direct witnessing of individuals. In this process, an outsider witness is invited to the therapy. At this point, the actual aim is to fulfill the desire of the individual related to approval of others. This person can be a member of individual's family or friends. In the process, the client tells his/her story, and the witness listens to the client carefully. In an appropriate point of the storytelling, the therapist asks the witness to tell what the problem of the individual is (Leahy et al. 2012). After the narration of the witness, the individual is asked if there is a detail which attract their attention.

Stages of therapy process

Narrative therapy has nine stages. The first stage is solidarist approach of the advisor which constitutes the first step of the therapy process. This stage is the adoption of a cooperative approach which is based on mutual respect between the therapist and the client (White 2009b). In order to create the cooperation between the therapist and the client, curiosity, openness, effective listening and empathy which are based on compassion, interest and respect are needed. The therapist encourages the client who is becoming full of the problem to tell the dominant story with this approach and applies radical listening in order to understand the story that is told by the client (Carr 1998).

Externalization of the problem which is the second stage is accepted as both technical and basic concept. As noted earlier, it is emphasized in externalization of the problem that the problem does not belong to the individual, rather, it is a situation that is affecting the individual (Payne, 2006). The role of the therapist, at this point, is to help the individual to obtain the idea that the problem that the individual experiences is not a part of the self of the individual. In brief, the aim here is to understand that the problem itself is the problem. Both parties who are in cooperation give a name to the problem that can be accepted by both, and during the therapy, the problem is referred using the given name (Carr 1998). Therefore, it is emphasized that the problem is set aside the individual.

In exploration of alternative/novel results which is the third stage, the therapist gravitates towards the exceptional situations in the past by determining the moments when the client does not experience the problem or when the client can cope with the problem effectively (Corey 2009). With an expression such as "Can you tell me about a day or a moment when you did not experience this problem or when you experience the effects of it less?", useful solutions from the past are scrutinized (Işık-Terzi and Ergüner-Tekinalp 2013). The aim here is to find evidences from the past in order to help the individual recover from the pressure of the problem, overcome the problem or handle the problem (Corey 2009).

Focusing on new story which is the fourth stage includes questions related to the event, what the results are, when it has happened, the place and the topic after unique results are revealed. The therapist asks question to let the client notice and evaluate the moments when the problem was not experienced or when it can be coped with and helps the client to focus on the alternative story (Carr 1998).

In integrating the past with the future, which is the fifth stage, the client is asked to shape the new story by getting strength from the exceptional situations in order to strengthen himself/herself after obtaining sufficient evidence in the previous stage. The client, who realizes that he/she is stronger than the problem, is expected to form novel narratives by connecting the past with the present (Karaırmak and Bugay 2010).

In the sixth stage which is inviting a witness, the people who are important to the client are invited to the sessions in order to witness the novel stories recently formed by the client. That the individual uses a new story for himself/herself is not enough since there is the possibility that this can merely stay in the therapy environment and this may not be applied in the real life. Therefore, the people who are invited to the sessions are actually witnesses of the new life of the individual (Payne 2006).

The seventh stage is re-involving stage. At this stage, with the new story that is formed, the client makes sense of the relationship with the family or people from the social environment who gain an important place in his/her life (Carr 1998).

In Use of the written material which the eighth stage, as a technique which is rather different from other therapies, a document is written through the end of the therapy. At this stage, the therapist uses documents, certificates and awards, personal documents and letters of recommendation which support the new novel narrative/story of the client (Karaırmak and Bugay 2010).

In the ninth and the last stage, which is examining applications for individuals in the future, the clients are asked to write about their experiences for the individuals with similar problems in order to show the clients that they succeeded in the therapy. In some cases, the therapist can ask the client benefit from the views and experiences of another individual, who has overcome his/her problem by inviting him/her to the therapy (Lenz et al, 2012).

Expressive art practices

Many therapy types which are accepted as main therapies (Corey 2009) focuses on speech in the recovery period (Degges-White 2011). Although there is not a standard definition for these therapies, there are many different types, and each type has its own definition. In the most general sense, art therapy can be defined as the use of art and different art related materials in the process of psychological consulting process with such aims as solving conflicts, decreasing mental problems and coping with stress (Malchiodi 2003). Expressive art practices have various types such as visual art therapy, music therapy, drama therapy, dance/movement therapy, effective writing therapy and integrative therapies (Corey, 2009; Malchiodi 2003).

Expressive art practices are psychotherapeutic interventions which use art with enunciative and communicational channels (Shostak 1985). These practices have three stages which are introduction, exploration and taking action. In the introduction, the focus is on the aims of the clients and what the clients want to change in their lives; in exploration, the focus is on the problems and their effects on the lives of the clients; and lastly in taking action, the focus is on the practices related to solve the problems of the clients (Kahn 1999).

Expressive art practices enable therapists to form a strong communication with the client. It is recommended especially for the clients who have difficulty in expressing their feelings and thoughts verbally. According to Selekman (1997), it has an easing effect on the expression of feelings in children and adolescents. Since it provides clients, particularly adults, with a new language recently, feelings, thoughts and beliefs can easily be expressed (Gladding 2005). It has acquisitions such as reduction of stress, obtaining conflict and problem-solving skills and strengthening well-being (Malchiodi 2003).

As art therapy can be used as a method all by itself, it can also be used with different theoretical approaches (Corey 2009). There are integrative therapy types which combine techniques borrowed and customized such as Adlerian therapy, solution-oriented therapy, cognitive behavioral therapy, choice therapy, existential therapy, feminist therapy, gestalt therapy, person-centered therapy, narrative therapy and different theoretical tendencies. According to Malchiodi (2003), although almost all possible theoretical models have been applied in art therapy, all the approaches in the literature of contemporary art therapy have not been reflected enough or expressed completely. Some of them are briefly referred while the others were recommended or defined by one practitioner; however, they haven't been used widely. At this point, the reason for integrating and frequent use of narrative therapy and art practices is the similarity of these two approaches (Carlson 1997). When these similarities are scrutinized, restructuring the existent dominant stories which is in the essence of narrative therapy coincides with the idea of expressing the self which exists in the art therapy. The main reason of that is that the art allows the individuals to reveal he hidden sides of them (Mills 1985). The belief in revealing the hidden sides of the self is similar to the belief that the alternative stories are hidden because of the effect of dominant stories on the individual in narrative therapy. Also, both art therapy and narrative therapy have their roots in social structuring. In both approaches, the therapist leaves the role of observer and becomes an active part of the process (Mills 1985). As a result, in the current study, the integration of narrative therapy and art therapy, which can be integrated in the art frequently, is examined.

Expressive art practices and narrative therapy

The integration of narrative therapy and expressive art practices aims to help people create a meaning for the events that they experience (Carlson 1997). Since narrative therapy and art therapy complete another, narrative art therapy is applied especially to children as well as adolescents, adults and families (Malchiodi 2003). Especially in the clients for whom verbal expressions constitute limitations, narrative art therapy provides with the opportunity to externalize the dominant problem, rewrite the story and witness it by removing the limitations (Hoshino and Cameron 2011). Thus, it tries to use channels such as visual arts, music, drama, dance, movement or narration in the clients (Allen and Kreb 2007, Patrick 2011).

While the acceptance of the problems by the individuals are the point in question in traditional therapies, narrative therapy is based on the idea that the problem is beyond the control (Metcalf 2011). Hence, one of the aims of narrative therapy is to help the individuals see that the stories that they form under the effect of dominant culture are not their lifestyles and to change them by externalizing the existing problem. According to Malchiodi (2003), narrative therapy makes use of therapeutic documents to externalize the problem. At this point, including art therapy practices in narrative therapy creates a different way of externalization. Picturing the problem as an art practice or creating collages out of pictures makes the problem apparent for the individual through art. The concretion process also enables the clients to separate themselves from the problem. Especially when working with clients who have difficulty in expressing themselves verbally, it is beneficial to use expressive art practices. Creative art expressions make a behavior or lifestyle in which the problem is hard to externalize with words easy for the clients. Making use of art practices supports the clients in writing an alternative story and in creating new meanings in this story at the same time (Fish 2006).

According to White (2011), since the stories of the dominant culture are very powerful, the individual internalizes these stories after a while. At this point, dominant discourses serve the ones who have interests in this culture, and these are not appropriate for the autonomy of the individual's life. Thus, another aim of the narrative therapy is to get rid of the pressure caused by external problems or dominant cultures by using re-narrating (Corey 2009). In brief, the aim is to enable the individuals to separate themselves from the problems of the dominant culture. At this point, Malchiodi (2003) gives a short case example related to how the client separate himself/herself from the problem by using the art practices of the narrative therapist. The topic of this case example is the fight of a female client with the expectations of her family. The client is the first woman in her family to graduate from a university and to move into her own house before getting married. The mother of the client is unduly attached to the traditions of her culture. According to her culture, women are less valuable than men. At the same time, she expects from her daughter to behave according to the expectations from women of the culture which the mother embraces. The therapist asks the female client to express the positive and negative expectations of the culture by creating a collage with pictures, photographs or even maybe with newspapers in order to externalize the effects of the culture and to separate from the self Later, the therapist asks the client to remove the images in the collage that the female client wants to remove from her story and to keep the ones that she wants to have in her collage. In this case, the client shows herself that she has an alternative choice which separates the problem from herself visually by preparing a collage which symbolizes her individuality without breaking her connection with the family and the culture.

Freeman et al. (1997) emphasizes that art practices are very coherent with narrative therapy especially when working with families and children. One of the main reasons for this coherence is that use of art practices in children makes the process easier just like the use of play in order to provide with an externalizing language (Malchiodi 2003). Another reason is the effect of integrating narrative therapy with art practices like play on the development of self-esteem and coping skills of children (Wood and Frey 2003). Also integrating narrative therapy and art practices is effective in the active participation of the client and the family in consultation sessions (Malchiodi 2003). Lastly, Riley (1997) argues that that many people cannot have the same idea about the perception and solution of the problem even though it is thought that the family members will perceive the problem and cope with this problem in a similar manner in many families. The use of art practices in narrative therapy enables families to discover the different way of perceptions of the same problem and different points of views on how to solve it (Malchiodi 2003).

An activity example which is similar with the aforementioned statements of Riley (1997) is presented by Cook and Sangganjanavanich (Patrick 2011). This activity can be used while working with a group. In the activity "Stories Created Together", the aim is to make the clients see the events differently experienced by them who focuses on the events solely supporting dominant stories and to enable them to form alternative stories. In order to serve this aim, writing which is one of the art practices is used as tool. When the activity instructions are examined, each group member is asked to define the dominant problem that they recently have and then, they are asked to write a story that defines the problem and reflects their reacting against the problem. The story does not need to be absolutely completed. After a six-minute process, each member is asked to hand their stories to the person sitting next to them. The group members read the stories they have received from the beginning and continues them with their point of view. This process continues until the members get their own stories. When the stories get to their owners, the members are given time to complete the stories that they started. The completed stories are shared within the group, and different points of view are discussed. In the discussion, the focus is on how different individuals evaluate the problem with different views, and on the formation of alternative stories with the development of an alternative point of view to the problem.

Therapeutic techniques

the first technique is to ask therapeutic questions. The aim in asking questions in narrative therapy is to give the client the opportunity to re-organize their dominant stories and to externalize the existing problem (Payne 2006). Whatever the aim is, the question that are used are in circular structure, are about relationships and help the clients find new ways (Corey 2009). The questions are separate from the problem, they have a power over the problem, and they have different meanings from what they are perceived as. As a result, they prepare the individual to an empowered end (Carson et al. 2005).

According to Malchiodi (2003), the following questions can be used in the version of narrative therapy integrated with art.

* How long has the problem (attitude, behavior, emotional difficulty, habit, illness) pushed you? What does it make you do which you don't want to? Can you draw a picture of it while pushing you to do the things that you do not want to?

* Are there any times when you do not let the problem affect your life? Can you draw the picture a time when the problem existed recently, but you did not let it affect you?

* Are there any moments when you can cope with the problem? Can you show me how you manage to cope with the problem?

The second technique is therapeutic document and performance. Narrative therapy includes letters that individuals or family members write to each other, autobiographic notebooks, inner dialogues such as stories and various writings which increase the skill of reflecting process (Dallos and Draper 2012). In narrative therapy, letters are used in order to support the newly created stories and the performances of clients in accordance with the situation of clients. Letters are the evidences of the individuals' effort made in order to cope with the problem, and they reveal the differences between the story which is covered with the problem and the story which the individual wants to create. Furthermore, the individual can integrate what is learnt during the therapy into the daily life through letters (Nylund and Thomas 1994). In some occasions, letters can be shared with other people in the community individuals live in order to show how much effort he/she makes and how strong he/she is (Corey 2009). In narrative therapy, letters as well as many other documents (certificates, autobiographic notebooks etc.) can be shared in order to display the success and to support. Sharing these formed documents can create an interested community which consists of the individuals with similar problems with the client and supporters of the person who managed to cope with the problem. This interested community can also metaphorically be created by the client. The aim is to form a community from which the client can received support for his/her alternative story. The use of documentation in order to create interest communities reflects the emphasis of expressive art on the forming a community (Allen and Kreb 2007, Patrick 2011).

The "A Multilev elTimeline" activity formed by Sheri Pickover in which the documentation practices in narrative therapy are integrated into art therapy practices can be presented as an example (Patrick 2011). The aim of this activity is to allow the individual to re-tell his/ her story on the timeline by utilizing art practices. This activity can easily be used both in individual and group works. In the process of activity, the client is asked to divide a large-sized paper into two (by folding it or drawing a line); in the bottom part, the client is expected to chronologically document the important moments of his/her story of life through pictures or words. When the timeline is completed, there are a few different choices to fill in the upper side of the page. The first one is to draw a picture of expression of emotions for each event in the bottom that the individual expressed in the timeline. The other one is to enable the client to find unique results which is one of the aims of narrative therapy, to draw attention to the life events in which the client can cope with the problem and to re-express the feelings about all the life events. The last one is to make the client form a new timeline in the back of the page about the dreams and hopes related to the next five years after the paper is filled and re-draw the feelings about this new timeline.

In life journey technique, various art practices are used; therefore, the client can define where he/she come from and where he/she goes forward. Although this technique can be used in one session, it can also be planned in order to use in all sessions. When it is used in one session, the journey of the entire life of the individual is examined. On the other hand, in use in all-sessions technique, a support group is formed for the people who wants to discover their life journey. The aim of the group is to discover and develop the stories of the clients and experience their alternative stories. First, a group of six is formed and the process is planned as ten-session. In the first five sessions, the childhood of the client and in the last five sessions the adulthood of the client are examined. In the first session, the introduction of the group, what art therapy is and is not and the feelings of the clients are focused. The group members are asked to draw a lifeline in which there are approximately five or six life events. In the third session, the clients are asked to draw a picture of their favorite places in the widest sense during their early childhood period. In the fourth session, the clients are asked to look back to their lives and draw a picture of an event or situation which has a great and permanent impact on their current life. In the fifth session, the clients are asked to draw a picture of a moment or time when they take a right and successful step in terms of their independence as an individual. After the first half of the sessions is completed, the second half continues as follows: in the sixth session, the clients are asked to draw a picture of the time when they first feel that they are grown. In the seventh session, the milestones of the clients are in focus. The clients are asked to draw a picture of a decision or choice which makes a different in their lives. In the eighth session, the focus is on the future and the alternative story that will be supported. The clients are expected to dream about where they want to be in five years, and they express their dreams starting from the first step that they will take for this dream. In the ninth session, all the pictures drawn in the process of sessions are reviewed. The distinct themes which are expressed or not expressed in the pictures by the clients are reviewed, and the clients gain awareness for the change. The last session consists of the completion of the group and saying goodbye to each other. The therapist draws a basket/box for each of the group members as a parting gift and then adds the present which he/she draws. The sessions end with the process assessments made by the group members (Malchiodi 2003).

The tree of life technique is accepted as an art therapy approach developed in narrative therapy (Hughes 2013). Tree of life was first developed with the children who lost their families because of HIV virus in Africa, and it has become a frequently used practice in groups with trauma. This practice aims to make the individuals share their difficult lives without traumatizing them further by correlating their lives with the metaphor of tree, to fix their negatively affected self-concept and to empower their alternative stories. Thanks to the use of this metaphor, individuals will externalize their difficult lives with a metaphor and discover the positive sides of the self which is overshadowed by the negativities formed in their self-concept because of the trauma.

Yiǧit (2019) defines tree of life practice in general as follows: the roots of a tree symbolize people, family members, places (e.g. birth place), friends, religious belief, objects or words that are effective in making the individual the person he/she is. In this phase, questions such as which family member the individuals like spending time with, which family members supports the individual, or which place the individual prefers when he/she wants to relax are asked. The individual shows these people, objects and places writing or drawing on the roots of the tree. On the other hand, the soil represents the things that the individual does, the daily life of the individual, his/her hobbies while the student represents his/her school life. This phase similarly includes the display of what is expressed by the individual on the tree. The tree trunk represents the values of the individual which make him/her strong, what he/ she give importance in life, what encourages the individual in difficult times and the skills of the individual; on the other hand, the client can be asked if the roots and soil have effects on the formation of the tree trunk. For example, the client can be asked the question "who did you learn this skill from?". The branches are the dreams and the hopes of the individual. At this phase, another important point is to examine the effect of the roots, soil and trunk on the dreams and hopes. For example, where do these dreams come from? or who are effective in the formation of these dreams? The leaves symbolize important people in the life of the individual; on the other hand, the fruits symbolize the contributions of the people that are attached to the leaves.

Clinical use of narrative art therapy

When the studies integrating narrative therapy and art therapy are considered, encopresis studies stand out. Some of the early studies explaining these approaches includes the used of externalization technique while discussing encopresis (White 1984). In these studies, White expresses encopresis (bowel problem) in children as an extrinsic figure, names it as "Sneaky Poo" ad supports families and children to determine ways to cope with the problem. He evaluates this as a fight and focuses on the winning the fight. The aim here is to make the child accept that the problem stems from "sneaky poo" instead to feeling guilty. In the process, the "sneaky poo" turns into "poo". In the coming years, it is seen in a study with 108 children that the children, including children with encopresis, with whom the technique of problem externalization is used are more successful in coping with the problem (Silver et al. 1998).

Anger issues are one of the problems in which the integration of narrative therapy and art is used. This method which is used in adolescents with anger towards life enables children to control of their lives, determine of the effect of it on their lives and provide alternative solutions to the problem by externalizing the anger. With this method used by Carlson (1997), the individual was able to make a healthier communication with the family. In the studies where art and narrative therapy were integrated, the focus was on issues such as eating disorders (Frisch Franko and Herzog 2006), trauma (Rankin et al. 2003, van der Velden and Koops 2005) and conflicts in relationships (Hoshino and Cameron 2011).

Advantages and limitations of narrative therapy

There are various advantages of the integration of narrative therapy and art therapy. The greatest contribution to the mental health field is that individuals create new stories using art, and this contributes to the formation of communal stories (Patrick 2011). Moreover, narrative art therapy removes the limitations of the individuals with difficulties in expressing themselves verbally; it provides with the opportunity to rewrite their stories by externalizing their problems and to witness new stories (Hoshino and Cameron 2011). Also, the integration of art and narrative therapies helps to transfer the verbal stories more deeply by giving individuals a visual expression tool in telling their stories (Ehresman 2013). According to Riley and Malchiodi (2003), art therapy can arouse a feeling of how individuals feel about their problems, and it provides the opportunity to form a meaning in new stories and re-process the images. The language barrier is cleared through art that is paralleled with the statement "The barrier to success is language" of Riley and Malchiodi (2003). Interactive storytelling and art-making process also supports the development and sustainment of neural net integration; therefore, it helps individuals to integrate their emotions and behaviors (Cozolino 2010). Lastly, it is stated that narrative art therapy is relevant for the clients from different cultures; that the success rate of the studies on Latin culture is rather high (Bermudez and Bermudez 2002) and that it can be adapted into different cultures (Keeling and Bermudez 2006).

When the limitations of narrative art therapy are considered, it is seen that the studies conducted with the integration of narrative therapy and art therapy are very limited in number (Brimhall et al. 2003, Damianakis 2007). Although there are studies with children, adolescents and elderly people, no study results can be found in terms of showing for which group it is more effective or with which problems it should be used. Besides, there are limitations related to the methods and techniques that can be used in the studies where art and narrative therapies are integrated. Finally, no meta-analysis examining the effectiveness of this method can be found.

A case study in which narrative therapy practices are integrated with art practices

Carlson (1997) presented a case study which shows how art therapy can be integrated into narrative therapy. In this case study, the aim of the therapist is to help the family fight against the problem, instead of fighting against a family member. In the case, the client was a 14-year-old child who lived in a residential area where there were problematic young people; the therapy was conducted with the client and the family. The family complaint that their children had anger management issues. The unmanageable anger of the client harmed different fields/people in his life, and since it posed a threat, urgent intervention was necessary. Individual consultations were held once a week with the client, and family therapy was held with the family members. This case study consists of four phases: revealing dominant stories, externalization of the problem, unique results and performance in front of an audience.

In revealing dominant stories, "self-portrait drawing" practice suggested by Wadison with the aim of allowing clients to express themselves in a different way (1973) was used in order to provide the client with different experiences. Carlson (1997) examined the dynamics among the family members in the first family session and pointed out that the father had accusive and offensive behaviors towards the client. According to the rules of the residential areas, the clients were given a list of problems at certain intervals. The therapist suggested a different idea to the client in the individual consultation and asked him to draw a person who had the problem in this list of problems. The first reaction of the client when the portrait was from was "but this cannot be me". The face drawn in the picture was divided into two. One side of the face was happy; on the other hand, the other side of the face was furious and angry. When the therapist asked what this face expressed, the client explained "I am trying to be happy, but sometimes the anger takes the possession of my body, and I cannot control it". Drawing a self-portrait practice made the story of the clients more understandable for the therapist. In the next family therapy, the client showed his selfportrait to the family and explained his struggle with anger. Art therapy practices, at this point, became a common ground for individual and family therapies. In the family therapy, the other family members were also asked to draw their self-portraits. This practice was used for the other family members to express their fight with their anger issues. The self-portraits drawn by each family member played a key role in fighting against anger, not against each other.

In externalization, the clients can see the problem as the problem, redefine it by externalizing and write their alternative stories through art (Hoshino and Cameron 2011). In the first phase, drawing a self-portrait displayed how the client was mingled with the problem. The conversations on this portrait started and improved the externalization process. In the family therapy held in that week, the externalizing language which was used in the individual therapy was used. The family altered their focus from the client to the anger (Carlson 1997).

In the third phase which is alternative stories and unique results, the therapist asked the client to draw another self-portrait after he realized that the relationship between the client and the problem had started to change. This time, the clients made a big part of his face as happy and diminished the areas where anger affected. In consultation, the client told about the moments where he could control his anger and how he coped with it when the anger tried to take over. In the next family session, the portrait that the client made in the individual session was shared, and the family members mentioned about the moments when they could manage their anger. In this phase, art played an intermediary role in writing alternative stories. The family, at this point, started to see the problem as the problem and gave up blaming the client. In the next individual session, the client made a new selfportrait. In this portrait, he pictured himself standing tall over the anger which was located right under his feet. The therapist examined the previous self-portraits with the client and focused on the progress that the client made. In order to support this progress, reviewing the portraits serves the same purpose as the letters used in narrative therapy. the client started to separate himself from the problem henceforth.

The fourth phase is performance in from of an audience. Narrative therapists think that although individuals form new stories, the stories will not become concrete or settled if therapists do not find witnesses that can support the clients. At this point, a group that will support the individual and his change are sought on purpose (Andrews and Clark 1996). Art practices integrated with narrative therapy, in the final step, includes the "performance" of what is created such as sharing of pictures, performing the dance or telling the written story (Patrcik 2001).

When the therapist and the client decided that it was time to share the progress with the family, the client told his family about the anger which dominated his life, his fight against it and how he started to control his anger by showing them the drawings up to that time in the next family session. By sharing these drawings in front of his family, the client realized the performance phase which is the ultimate aim of the therapy. The client both told his alternative story and showed a concrete picture. The family was the first witness of the alternative story rewritten by the client. When the family externalized the problem and created a new story for themselves, the relationships between the members of the family started to change positively.

Conclusion

Every individual has his/her own story of life. The life story of nobody can be assessed as right or wrong. However, are these stories appropriate for individual's life? Does individual really want to be the protagonist in these stories? Or do these stories enter the picture with the effect of others? Narrative therapy is a type of therapy which helps individuals create different meanings for the stories that are not appropriate for them; in other words, it helps the stories end in different ends.

Narrative therapy which is based on social structuring includes restructuring the lives of individuals by externalizing the problems which brings them to therapy sessions (Carson et al. 2005). In this therapy, life story of an individuals is focused on, and the relationship of individual and life story and the meaning attributed to life story are examined in the cultural, social or political context in which individuals live. Therefore, narrative therapy has a culture-sensitive quality.

Therapist abstains from diagnosing individuals in therapy since therapist does not think that clients are unhealthy. There is an extrinsic problem and this problem enters the life of individual and causes other problems. Thus, individual starts the externalization process by seeing this problem as apart from his/her life. According to Malchiodi (2003), including art practices in externalization process helps the client separate the problem and the self by objectifying it. Art practices makes the client tell his/her story easier in situations where clients have difficulty in expressing the story verbally. With the effect of narrative therapy, the clients add new meanings to their stories or increase their motivation to improve a life event in scale that they wish in the future. At this point, use of art practices means giving the client an opportunity for writing an alternative story and for the new meaning that can be created in this story.

In brief, narrative therapy which helps reinterpreting the stories of individuals by individuals and structuring more appropriate stories in the future embodies an epic reality and emphasizes that there are forces which can restructure individuals' lives and develop new and desired stories. Integration of expressive art practices with narrative therapy constitutes an enabling factor for clients in the re-writing process and objectifies the stories of clients.

Sidebar

и Şule Baştemur, Ordu University Faculty of Education, Department of Educational Sciences, Guidance and Psychological Counseling, Ordu, Turkey

[e-mail] | 0000-0003-3940-0565

Received: 18.07.2020 | Accepted: 01.10.2020 | Published online: 25.12.2020

Authors Contributions: The authors attest that she has made an important scientific contribution to the study and has assisted with the drafting or revising of the manuscript.

Peer-review: Externally peer-reviewed.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study has received no financial support.

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