Narrative Based Approach: Exploring Substance Use

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A Narrative-Based Assessment Tool for Exploring Substance Use

There tends to be some black and white thinking that exists around substances in our society. Use seems to be either overly normalized and accepted for some, while others experience intense shame or stigmatization around their use. What if you could explore and reflect on your relationship to substances in a way where the primary focus is to foster further understanding around the role substances have played in your life? Therapy can be the place to do that! 

With a clinical tool rooted in a harm reductionist, narrative based approach, and a strong therapeutic alliance, this kind of exploration of one’s substance use can change the story one carries around their use. In this blog post, I’m just going to share a “SparkNote version” so to speak of what the approach entails. I will be hosting a training later this year where I go more into depth about the approach and how to apply it in the therapy room - so stay tuned if you’re interested! 

Overview: 

This comprehensive tool explores client’s environmental contexts, history of use, and facilitates clients’ insight into patterns that impact them. It is critical to start at the very beginning of one’s relationship to substances and work in chronological order to best be able to support the growth of client insight around patterns that exist around their relationship to substances. As an MFT, I really value the relational nature of this assessment - the emphasis on viewing substances as an entity that one has a relationship with allows for a different approach to reflection. 

Length of Assessment: 

The approach itself usually takes at least four sessions to work through, sometimes more, depending on the length of use and variety of substances that have played a role in one’s life. 

Clinical Tips Around Assessment: 

Empathy and compassion are essential components of a therapeutic relationship! When exploring one’s experiences around substances, it may be that this is the first time one has reflected on their relationship to substances in this way, let alone at all. Remain mindful of this throughout the assessment. It is a very vulnerable experience and it is essential that your client trusts you and feels comfortable in the therapeutic space in order to take this step towards further exploration. 

This being said, it is important to follow the structure of the assessment and focus on guiding the client through the process in the most clinically effective way. A large part of the intervention is rooted in slowing a client down. There is a strong benefit in bringing them back to walking through the history around some of their experiences to aid in fostering meaning making around experiences and recognizing patterns around their use.

Breakdown of Assessment: 

1) Set The Stage:

Provide the client with a general outline around the goals and structure of the assessment. 

2) Conduct Narrative Portion:

Start with the client’s very first use of a substance. I like to think of the narrative portion as constructing chapters of one’s story with a client. Move through each period of substance use in a way that focuses on the contextual factors and provides a comprehensive picture of what was going on in a client’s life. 

Essentially explore the who, what, when, where, why’s around the chapter of use. Some example questions around alcohol exploration include: 

• “What did your drinking look like?"

• "How often did you drink?"

• "When you drank, who were you with?"

• "What positive experiences did drinking bring you?"

• "Were there any consequences or outcomes of drinking that you felt impacted you negatively?” 

Prompt further reflection around impacts of use - whether positive impacts or negative consequences. Only move onto the next chapter when a change in use occurs. Exploration and further reflection on changes in patterns is the most essential component of this assessment. 

3) Explore Problematic Episodes:

Further reflection around problematic episodes can be implemented throughout the narrative portion, but can also be revisited once the entire narrative is constructed. Be direct in going back to explore events that the client identified and recognized may have stood out in a certain chapter of use. Discuss contexts, quantities, and consequences from these experiences. Are there patterns around these events? 

4) Assess Current Use:

Once you move through all the past chapters of a client’s substance use, it is crucial to shift the focus to current use. Now that all the context has been provided around the client's past experiences in a more structured format, prompting the client to talk about current use aids clients in meaning making around experiences and recognizing patterns around use. 

5) Assess Family History:

This may pop up in the narrative portion, but there are also times when family experiences around substances don’t come up naturally in the narrative portion. It is a very impactful part of the assessment and critical to ask directly about drug and alcohol use in the family. This includes directly prompting the client to reflect on family culture that exists around substances, typical patterns around use for family members, and both implicit and explicit messages around substances. 

6) Set Goals:

Only once all of the information gathering and context around all areas of client’s use has been collected, is it time to discuss goals around what client wants their use to look like. The goal is to set extremely specific goals that are informed by the

assessment. Discussing quantity, frequency, context, and pace are all important aspects in the goal setting phase. 

7) Assess Motivation & Constraints:

Reflect on how the client feels about the goals that they have set for themselves. Utilize scaling questions to assess how the client feels around both motivation and confidence around each of their goals. Assess and discuss potential constraints that may impact the client in reaching their goals. 

8) Make Clinical Recommendations:

Alongside actively aiding the client in setting goals, it is our role as mental health providers to recognize and provide clients with the appropriate level of care. Making clinical recommendations and providing referral resources if a client potentially needs a higher level of care is an important element of the assessment. 

In my clinical experience, I have seen this approach alter the relationship clients have to substances and the role that substances play in their lives. If you are a therapist or a potential client interested in this approach in any way, please reach out with any and all questions! There are a lot of aspects to this assessment and it is an extremely vulnerable assessment process to fully step into. I hope reading this prompts reflection on how to view substances through a relational lens, and provides a potential new road map to help clients (or yourself) explore relationships to substances. Stay tuned for a more comprehensive training later this year.

References: 

Goldsmith, J. (2023, March 9). Introduction to Substance Use Assessment [PowerPoint slides].