Narrative therapy in substance use counseling

Narrative therapy starts from the idea that people make sense of life through stories, and that a problem can come to dominate the story a person tells about themselves. In substance use counseling, it is used to loosen the sense that the problem is who a person is and to make room for other parts of a person's life. The approach is thoughtful and widely discussed. Controlled research on it for substance use, though, is very limited, and this page says so up front.

What narrative therapy is

The APA Dictionary of Psychology defines narrative therapy as treatment for individuals, couples or families that helps them reinterpret and rewrite life events into true but more life-enhancing stories. It holds that people are meaning-making beings and the "linguistic authors" of their lives, who can reauthor their stories by taking them apart, seeing patterns in how they interpret events, and viewing problems in a more helpful light.

The APA's wording stresses that the new stories stay true. The aim is an accurate account that is not defined by the problem.

How it works in outline

Two ideas are central, as set out in a 2022 systematic synthesis of narrative therapy techniques in the Journal of Eating Disorders (a different condition, but one that describes the techniques in detail):

• Externalizing the problem. The problem is positioned outside the person, so that it can be examined and a stance taken toward it. Language is used that separates the person from the problem, sometimes by giving it a name or describing it with a metaphor.
• Re-authoring. The therapist works with the person to find identity stories that the dominant problem has hidden. Techniques named in that review include relative influence questions (about how the problem affects the person and how the person affects the problem), "double listening," and "re-authoring conversations" that produce stories fitting more fully with the person's life.

In substance use, externalizing might mean talking about "the drinking" or "the habit" as something acting on a person's life instead of being what the person is. Another approach built around the person's own account is motivational interviewing.

What sessions can look like

Sessions are largely conversation. The therapist asks questions and listens for parts of the person's identity that the dominant problem has hidden. Together they build a different account of who the person is and who they hope to be. Some programs run narrative work in a group; in one Iranian trial of 26 people with amphetamine use disorder, a group course of 10 sessions asked participants to externalize an issue and rewrite their life story. A clinician can explain the format on offer.

What the research says

Few formal studies exist on narrative therapy for substance use, and the sources opened for this page did not include a systematic review or meta-analysis on the topic. That is itself a finding: the evidence base is thin.

The one controlled study we opened is a 2020 randomized trial in the Iranian Journal of Medical Sciences. In this study of 26 people with amphetamine use disorder, those given group narrative therapy showed significant falls in depression and anxiety scores, while the control group did not change significantly, but quality of life did not change. The authors list limits: a small sample, differences in participants' personality, physical, psychological and social backgrounds, and findings that cannot be generalized. The trial's outcomes were depression, anxiety and quality of life, so it does not show that narrative therapy changes substance use itself.

A 2024 conceptual review in Frontiers in Psychology looked at narrative identity, meaning how people with addictive disorders tell their own stories. It found that their accounts tend to be less coherent and to carry more passivity and negative emotion. This supports the idea that story matters, but it is research about stories, not a test of the therapy. The review notes that most of the studies it examined used unvalidated interviews, lacked control groups and had small samples.

The eating disorders synthesis points the same way in a neighboring field. It reports that many narrative therapy papers were small case studies, often written by the narrative therapists delivering the treatment, which raises a risk of bias, and that some safety considerations were left undiscussed.

Limits and who it may not suit

• Because controlled research on substance use is so limited, narrative therapy is hard to compare with approaches that have more trials, such as cognitive behavioral therapy.
• It does not provide medication or withdrawal care; see medications used in treatment and withdrawal and detox in outline for those parts of treatment.
• The sources opened here do not address how narrative work suits people with trauma histories; see trauma-informed care for that wider topic.
• For another conversation-based approach, see solution-focused therapy. A qualified clinician decides what fits a particular person.

Questions to ask a clinician

• What training do you have in narrative therapy, and how do you use it for substance use?
• What does the research show for this approach, and what is still unknown?
• Will narrative work sit alongside other treatment, such as medication or relapse prevention?
• How will we decide whether this is helping me?
• What support is there if recounting my story brings up distress?