by Har Man-kwong
This paper describes the use of narrative practices in working with young people who wish to revise their relationship with substance use. It describes the use of the metaphor of the migration of identity and externalising conversations, and explores issues related to Hong Kong culture. This paper was first published in The International Journal of Narrative Therapy and Community Work, 2004, No. 1.
Keywords: Substance use, narrative therapy, Hong Kong
I work with young people here in Hong Kong who wish to talk about their use of various drugs and substances. Party drugs, such as ecstacy, speed and ketamine, are very popular here. Other substances range from cough mixture to heroin. I have conversations to assist people to break their habits with these substances and I use narrative practices to do so.
Preparing for the journey – and its pitfalls
Before I begin to work with someone on these issues, I use the migration of identity metaphor (White 2000) to prepare the person for three key traps that seem very common on this journey.
The first forecast we make is that if they take drugs again in the future, if they experience a lapse back into drug use, then they may experience this as equivalent to total failure. This experience may overwhelm them and evoke all their previous unsuccessful attempts to kick drug use out of their lives. All their successful experiences in relation to personal agency may become hidden to them. We forecast that a lapse, or even a series of lapses, will not represent an end to the process. Instead we emphasise that what matters is the effort to continue the journey.
The second forecast that we make is that if they do experience a lapse in the future, a return to substance use, then they may feel nervous or apprehensive about telling me about this lapse. They might feel ashamed to tell me that they are using again. This is a common trap and we talk about this at the outset of therapy. This is a hard-won learning and it has a lot to do with shame. In the drug realm, in any society, people often feel considerable shame because certain forms of drug use are not socially sanctioned. Working in a Chinese culture means we need to have an increased cultural sensitivity to this experience of shame. I am sure shame exists in many cultures but it takes a particular form here.
It is vital that I ensure that the therapy experience leaves no room for experiences of shame. If I do not take this care then the person consulting me, if they begin to use drugs again, may not tell me about this and may instead say that everything is going well. Alternatively, they may simply ‘save face’ by disappearing. If I do not take care to forecast possible future disappointments, they may not return to counseling. This has happened to me in the past. The people concerned have not said goodbye, they have just disappeared. Acknowledging the possibility of a lapse back to drug use, or a number of lapses (if only for short times), is quite likely is vital. We must try to find ways in which failure and shame is not part of the therapy experience.
There is a third, related trap that we also try to forecast. When someone has managed to stop their habit for a few months then they often think that they have succeeded, that they have completed the journey and as a consequence they stop taking as much care. At the outset of therapy, I share with the person concerned that even though they may feel so much better after one or two months of being drug-free, that they will not have completed the journey. We discuss how so many people, after they have detoxified for half a year or longer, begin to test themselves to see if they resist the temptation of drugs and how this often places them at the risk of craving again.
These are some of the conversations we share at the outset. We discuss what the journey to break free of substance use often looks like, how it is not a linear path. It has curves and twists. It has ups and downs. And we try to forecast some of the key pitfalls so that if they do occur they are not experienced with shame.
Having set the scene, I then find externalising conversations about drug use to be very helpful. What we most commonly externalize is the ‘craving’ that a person experiences when they are trying to stop using. This craving pushes them to take drugs. I ask questions about how this craving has come into the person’s life, we seek the history of this craving, its aims on their life, its strategies and its tactics. In my experience, while this can sometimes be complex, it is very helpful.
Many of my clients believe that craving is their own problem, that it represents something that is wrong about them. This is understandable because craving often operates in tandem with a range of ‘undesirable thoughts’. Because of these undesirable thoughts, it becomes difficult for a person to distinguish what is their own thinking and what is the thinking of craving. These undesirable thoughts routinely try to take over a person’s thoughts, their aims, and even take over their life. They can be an oppressive presence.
When I tentatively introduce the metaphors of ‘craving’ and ‘undesirable thoughts’ this often resonates for people who are under the thrall of addictive substances. Before I came to understand the operations of ‘craving’ and ‘undesirable thoughts’ I had some difficulty in engaging with narrative therapy practices with those with whom I work. These twin metaphors however have opened space for a constructive engagement on these issues. I think this is because they are not too abstract and can fit smoothly into conversations.
I begin the process by asking the person about their most recent experience of taking drugs. We try to reveal this situation in detail – What did you take? Where? Was it alone or with friends? We then try to externalize the craving itself by asking, ‘One or two minutes before you take drugs, what is it that you feel? Do you feel some power, some force trying to persuade you to take the drugs? What is this?’
Generally, it is not difficult for people to describe this feeling that they experience and how it operates. For instance, they may describe the thoughts that they have, such as: ‘I want to take it. I can’t control myself. I just want to take it.’ Having heard this, I try to externalize it, to emphasise these thoughts as the property of an external voice. So I say something like, ‘Can you tell me more about these thoughts that came to you? What else did they say?’ And they might reply, ‘Just take it one or two times and it will be no problem. I can manage’.
I then ask a series of questions to gain more information about the voice of these thoughts:
- When do these thoughts come to you most – in what situation? or
- Can you tell me more about how these thoughts sound when they come to you? Do they sound like they are conveyed by a male or female voice? or
- Does the voice of these thoughts always sound the same? If so, how would you describe it?
Some people find these questions easy to answer, but others do not. Nonetheless I continue to ask questions because it is vital that we find a way to externalize and personify the voice of craving. Once we have found a resonant way of externalizing the problem, a way that fits with the person, then many options are opened to us. This is the crucial first step.
After they have talked a bit more about their experience of the voice and thoughts that contribute to drug using, we try to come up with an experience-near definition of the problem. We seek a name for the craving that fits for the particular person. Sometimes people refer to the craving as ‘the devil’ or a ‘bad spirit’. In Chinese, there are specific words for spirits that are malevolent and these are sometimes the words that people use to name the craving.
Once the craving is named we can then explore in detail the influence of the problem, how it is interfering with their life. We talk about all the different effects that the problem is having to their health, their friendships, their hopes and dreams. We also talk about the cravings strategies and tactics. Some of these can be very tricky. By exploring these in detail it becomes easier for the person concerned to become more alert and sensitive of the devices, the technologies of the craving. People have told me that this is very helpful.
Having discussed the tactics and effects of the craving, the person is then asked to evaluates these effects. Invariably they declare that the effects are very negative and then I ask them to justify this evaluation. In response they commonly say that they ‘want to have a life free of drugs’ or ‘to get back their confidence’ or ‘to get their relationships with their family back how they were before the drug use.’
It is then time to explore the ways in which the person is influencing the problem. And to do so we are on the look out for key exceptions, unique outcomes to the problem. Most of my clients find it hard to locate these exceptions and persistence is very crucial in this aspect of the work. Some of the people who consult me have had substantial habits for more than ten years. Over this time they have commonly formed identity conclusions of ‘drug user’ or even ‘loser’. They may have a pervasive negative sense of themselves. If this is the case, it can be difficult to create a context for them to speak about an alternative experience of themselves. But with some effort this is always possible.
Many of those who consult me cannot initially identify a successful unique outcome so I ask them a range of questions. These questions focus on exploring any experiences they may have in which they have been able to avoid or resist the craving.
I invite them to describe in detail any situation in which they have been able to avoid or postpone or resist the craving – when was this? where were you? were you alone or with friends? Gradually they paint a picture of the situation and I ask further questions:
- What did you do at this time?
- What were you saying to yourself at the time?
- What were you saying to the craving?
In response they might say, ‘I try to watch television’ or ‘I called my sister and had a long conversation and this helped me to forget or ignore the craving’. I try to get them to describe whatever it was that they did in very minute detail. We try to generate a thick description of the skills and knowledges that they were engaging at the time. As we talk about these unique outcomes the person’s voice and their face tell me that they are happy.
Once we have generated a rich description of one particular time in which they have resisted the craving, I then ask if they have had any similar experiences. We try to recall just one other example. I have found that if you can generate a rich description of a person’s skills and knowledges in one instance, then it becomes more likely that they can think of another time when they have utilised similar strategies. The process becomes easier and builds in momentum.
For example, the same person who said that they avoided a craving once by calling his sister on the telephone may indicate that there have also been times when he has directly refused the opportunity for drug-taking. This is different than avoiding or diverting a craving. Perhaps his friends offered him some drugs and he have turned down this invitation. In hearing this, I then ask many questions to try to generate a rich description of the event. Again I wish to hear exactly how he took these steps, what he was thinking, and why he were taking these steps.
I then ask what these stories of successful events tell him about himself as a person. In asking this sort of question I am seeking a name for an alternative plot, an alternative story-line about his life and identity. Perhaps the young man might say, ‘Well, I am thinking that maybe I am not as hopeless as I first thought. Maybe I do not give in all the time, maybe I am quite determined…I am not sure about this…I have not thought about it in this way before this conversation…but yes, maybe I am kind of determined’. The person concerned often expresses surprise at this point. They are used to understanding themselves only in negative terms, but by slowly and carefully eliciting particular skills and knowledges that the person has used to resist the craving, different identity conclusions become possible.
In order to further develop it, I invite the young person to give a name to this alternative story-line, the story-line that describes their agency, even if limited at the moment, in the face of the problem. Perhaps this story-line is named a ‘story of determination’. Once we have a name, I might then ask, ‘how is it that these acts of determination have been possible? Do you have any past experiences that may have cultivated this determination?’ We seek out some historical evidence to support the new story and this part of the process is not so difficult. By this part of the conversation the young person has generally become more energetic and joyful.
As the preferred story develops I might also ask, ‘how will this trait, or this ability in resisting the problem, help you in the future?’ We try to imagine how they can use the skills and qualities that we are describing to resist their current difficulties. In my experience some people can quickly make these links, but in other circumstances it does not work so well. When it doesn’t work, we go back to naming the problem and its tactics. We seek more detail about the situations when the craving is most powerful…and whether the craving has developed any more recent strategies. This is often the case. Cravings are tricky things! Very often they develop new ways of resisting the gains that the person has been making. In these circumstances we often need to keep checking in about any new strategies of the problem so that there are opportunities for the person concerned to develop new counter-strategies!
Thickening the alternative story
In later sessions, we seek to thicken the descriptions of the alternative story and this often involves the use of therapeutic letters which I regularly send to those who consult me. These can be read many times, especially when the young person feels under pressure or overwhelmed by the problem. Sometimes we also create documents together. I have included here examples of two letters that I wrote to a young man called Ken.
We have met for four times and within that period, I have been surprised to find that you have experienced plenty of changes and new ways to handle the problems confronting you. I sincerely believe that it may be very helpful to now note down all the changes that are occurring and the skills that you engaging with.
When we first met, you were struggling between ‘going on taking drugs’ and ‘abstinence’. You thought it would be okay if you could maintain a low consumption of substances like Ketamine, Ecstasy and Marijuana, especially if you were only taking them occasionally to assist you in social situations. You told me that you thought that your drug-taking habit was under your control. However, you changed your mind and determined to weed out the drug-taking habit after due consideration of the following factors:
- Drugs (Ketamine, Ecstasy and Marijuana) had caused your stomach bleeding and you were dreading having to undergo another gastroscopy.
- You were scared that you may be incarcerated due to the possession of illegal drugs.
After you had expressed a clear determination to stop all drug use, we then tried to explore in detail how substance abuse affected you. You named a particular force ‘the Craving’ that was influencing your substance use and we then figured out its history and features.
1. The purposes, aims and dreams of the ‘Craving’:
- It tempted you and others to take drugs because this recruited more customers in order to make more money.
- It wanted your use of substances to return to the level it had once been where you used a tablet of Ecstasy and two packages of Ketamine every night.
2. The partners of the ‘Craving’:
- Included one or two groups of your friends who offered you free drugs in order to make you fall addicted to drugs. Once this took place they squeezed money out of you.
- The ‘Craving’ unceasingly lured your friends to take drugs (offering them free of charge at the beginning) in order to embed you all into a sticky environment in which you would be circumscribed by substance use.
3. The methods adopted by ‘Craving’:
- The ‘Craving’ always hid himself in discos, camps and karaokes where you had many friends.
- The ‘Craving’ tried to get you to go to the discos, camps and karaokes by means of the birthday parties of your friends.
- The ‘Craving’ harnessed the exciting atmosphere of ‘everybody takes drugs’ in discos to induce you and your friends to purchase drugs.
- The ‘Craving’ encouraged you to use further substances by offering you more economical prices and by telling you:
- ‘Just take a little bit to get a special sensation!’
- ‘It doesn’t matter if you only take a little bit!’
- ‘It is nonsense that you can come to the disco without either drinking or taking drugs!’
4. The influences of the ‘Craving’ on you:
- It spoiled your goal of achieving a drug-free life
- It was harmful to your health.
Based on your understanding of the ‘Craving’ as mentioned above, we started to explore the ways in which you could resist the ‘Craving’ and you mentioned three conditions in which you found this easier to do.
- When there was poor quality music in the disco
- When you were ‘on duty’ the day after you went to disco you would frustrate the person who tried to sell you drugs with repeated ‘No’s’.
- When you wanted to save your money you just frankly told the trafficker: ‘I have no money!’
You told me that you thought that this third condition was the most significant. You told me that you thought yourself to be a ‘frank person’ and we explored what this meant to you. We discussed the various situations in which you handle matters in a frank manner. For example, when you were being manipulated by your boss or ridiculed by your colleagues, you frankly expressed your discontent in order to stop their further bullying. If you had not been able to do this, you think that the bullying would probably have continued. These skills of being able to be a ‘frank person’ have a history and I look forward to hearing more about this.
You told me that you thought that this quality could help you in coping with the temptation from the ‘Craving’ and that if you were able to frankly express your discontent that it would eventually get the message of your insistent rejection.
As a first step you decided upon a good method: ‘just reject the people who try to sell me drugs’. While this would require a lot of ‘frankness’, you expected that this would be a very powerful thing to do in the disco, karaoke and camp.
Ken, throughout this entire process of self-exploration you told me that you could sense the degree of your determination to quit using drugs was increasing. In fact you said that if you were to rate it, your determination would have jumped from a four out of ten to a nine out of ten.
You mentioned something else that had assisted in this. After you had stopped using drugs for a time you put on some weight and you believe this has made your appearance and body shape look better. In fact you said that it now perfectly matches with your dream.
Letter # 2
While you strove to fight against the ‘Craving’, you gradually felt unsatisfied with the rest of your life. During the period of unemployment, you found your everyday life which was consumed with playing electronic games which were highly monotonous and what you felt most unacceptable was that your life lacked ‘personal growth’. You aspired to:
- Enhance your general knowledge
- Get more friends
- Acquire more living skills.
We then discussed your past experiences and you discovered that you possessed a high adaptability which was cultivated from your past working experiences.
Your story started in a fast-food restaurant where you were employed in the past. There were only two staff in the restaurant. You were delegated to the duties of both a cook and a waiter. At the initial phase, you found yourself overloaded; however, you later developed by yourself an effective management style which you named ‘Ken’s Kitchen Theory’:
- Easy tasks should be given the highest priority to be finished while lower priority given to the difficult ones. For example, customers will be first catered for drinks and breads, followed by hot dishes which will take more time to prepare.
- Important tasks should be first completed. For example, if there were a great demand of chicken meats, you would prepare them in a great amount.
- Tasks should be completed promptly. For example, there were many people who ordered coffee and tea, therefore, you would pour milk into cups in advance to speed the brewing process.
- Making preparation beforehand. For example, if you were making fried rice, you would prepare spoons and rice in advance.
After articulating ‘Ken’s Kitchen Theory’ to me, you felt very excited and determined to apply this theory into the process of hunting for a job.
A month later, you told me that you had got a job! And you conveyed to me the changes that had taken place in your life:
1. You have become more energetic because you are involved in more activities.
2. You have become happier. You described how ‘more smiles now hang in my mouth’ because of the greater interactions with others.
3. You have become more confident because:
- You get more exercise
- You have more learning opportunities
- You receive significant encouragement from your supervisors.
4. You have fostered a normal and regular living style which involves you going to bed at 9 pm everyday.
You told me you were fond of this ‘normal life’ because:
You are no longer available to go to discos and this prevents you from:
- Being implicated in gangs’ fighting
- Being falsely accused of possessing drugs by police
- Relapsing into using drugs.
You are also no longer available for night activities and this prevents you from:
- Wasting money
- Fighting with others after you have got drunk.
You are able now to consider designing a saving plan.
Instead of desiring drugs and being disturbed by cravings, you are now concerned about your future.
You are very happy now since you have the opportunity to learn how to actually make Chinese snacks rather than just preparing the materials which is all you have been able to do in the past.
You now hoped to seek other jobs with better rewards and higher responsibilities.
You then reflected on the changes that you have experienced in the past four months:
- You have become happier, more spirited and know more how to smile
- You are now more courageous in expressing yourself
- You have quit taking drugs for several months
- Your memorizing capacity has been restored to a great extent
- You have got an insight into what it means to pursue a drug-free life (I am very interested to knowing more about this in our future conversations).
You contributed your big changes to the following factors:
- You got a job.
- You could manage to have regular meetings with a social worker.
- You could stand on your own feet.
- You had your own volition.
- You could think clearly before taking any action: for example, you thought thoroughly about the effects of substance abuse when you were confronted by the craving.
You have told me that you deeply cherish all of these changes and that you wish to further develop them. Specifically, you mentioned how to you have planned to take some special measures to resist the possible temptation of substance abuse in Christmas and New Year. We decided that you and I will cooperate on developing these special measures in the coming sessions.
Responding to any return to drug use
With assistance, many persons can resist the craving for a long time, for many months, but then may succumb and return to drug use for a further period of time. When this occurs it can be very frustrating and disillusioning. As I mentioned earlier, it’s important to forecast that this is often part of the migration process away from the influence of substance use. This makes it much more likely that a person will be able to tell me if they have begun using again.
At these times, I do everything I can not to construct this return to drug use as failure. I seek out elements from the story of their recent lives to construct a story other than a totalized story of failure. For instance, before they came to see me they may have taken drugs every day, but now they have stopped their habit for a very long time and have only taken drugs again once or twice. I ask them questions to elicit the differences between the time when they first came to see me and what is happening at present.
Some of the things they might say in response include:
- ‘Before I came to therapy I just took the drugs without any struggle. I didn’t even try to fight the craving.’
- ‘I didn’t feel the intensity of sadness, of loss that I do know after I use.’
- ‘I now take drugs much less often than I used to.’
- ‘ I was using for three years before I sought assistance. Now as soon as I start using again I come and talk with you.’
We take time to identify many distinctions between their current experience and what was once the case. In doing this, they come to the conclusion that this is not a ‘full-blown relapse’. They have not gone back to where they were. Instead, this is a part of the journey of migration that they are on.
These distinctions are very important. If we do not make these clarifications it will be possible that they lose hope. If they believe they are back where they started then it is likely that the power of the cravings will be greatly increased and they might rapidly lose ground.
I ask questions to enable the person to describe in detail what has changed between now and when we first talked. I ask what they have learned, what different strategies and ideas they have now. I have found this to be vital at these times when they have again begun using. These sorts of questions can re-energise people. It can put them in touch again with a different territory of their identity. It can enable them to reclaim an understanding of their competence.
We then also investigate carefully the particular strategies that the craving used to influence them this time around. It is important to do this in some detail. To describe this I will share a story.
Last week one of the young women consulting me, Amy, told me that she had broken her habit and resisted the craving for four months until her relationship with her boyfriend broke down and her friends criticized her body-shape. Many times when people stop using certain drugs they put on weight. This can have effects on a person’s sense of identity and make them more vulnerable to the voice of craving. In this situation it was the dominant ideas of the broader culture, about a woman needing to be in a relationship with a man, and needing to be a certain body shape, that made Amy more vulnerable to the voice of craving.
In response, Amy and I had some conversations about the effects of these societal discourses to ensure that she was not locating the problem within herself. When we came back to the precise moment when she experienced the rejection from her boyfriend, we discovered that it was at this moment that the craving returned and Amy lost the ability to control it. Together we examined this in detail to work out what could be learned from it.
In this way, Amy’s return to using drugs was understood as due to the effects of specific circumstances that the craving took advantage of. By learning about this, Amy gained new knowledges and skills to protect her in the future. While Amy was deeply regretful about starting to use again, she began to see this in the broader context of a longer-term migration away from substance use.
Drug use in the broader context of someone’s life
In the so-called drug field in Hong Kong there are a number of prevailing dominant discourses which pathologise and totalise ‘drug users’. Often the pathology is also located in the person’s family. A secondary dominant view in the field is that if drug use is an issue, then it must be seen as the dominant issue and addressed as a priority above all other concerns. This is not the approach that I take. When a young people who uses drugs comes to talk with me I do not want to only explore the issue of substance use. Their lives consist of much more than substance or drug use. When someone comes to talk to me I understand that they are here to talk to me about the things that are important to them in their life at that time – whatever these may be.
Recently, Susan, a young woman of 18 years old, was referred to speak with me. In fact, she was forced to see me by probation order about her drug problem. Working with any involuntary client can be complex. It is especially complicated, however, where drug problems are concerned because any honest conversation can have legal implications. In the first session she attended, Susan was very angry and silent. She didn’t say much and I said a lot!
Susan was angry because she didn’t want to see me, so I tried to engage her in talking about something interesting. I think she was also trying to find out if I was going to be as strict as her probation officer! I tried to convey a kindness that perhaps she was not used to and this seemed to make her more comfortable. I did not impose any ideas about what we were supposed to talk about. I didn’t assume that we would be considering the problems about which the probation officer had referred her. Instead, I asked her what she might be interested in discussing and Susan told me that what most concerned her was her temper.
I was delighted that Susan thought there was something we could usefully talk about! Susan told me that she often loses her temper and tries to attack her boyfriend. A number of relationships had broken down on account of these temper attacks.
So we started talking about the problem of temper and used the statement of position map in the process. I asked her when the ‘quick temper’ (this was her naming of the problem) came to her, when was it most commonly around. Interestingly, Susan said that the ‘quick temper’ often came to her when she was sleeping. It would come to her and talk to her in her dreams. In fact, sometimes the quick temper took such control of her that she attacked her boyfriend in her sleep.
Before we managed to externalize the quick temper, Susan was always late or she missed her appointments. But once the ‘quick temper’ was externalised she came energetically to therapy. She would even call me on the phone to check up when her next appointment was.
Over time, because it is a part of my job responsibility, I asked Susan whether she thought the ‘quick temper’ was relevant to her drug-taking behaviour. And she said yes. Susan estimated that 40% of the times in which she took drugs were to calm herself down when the tempers came to her.
Our conversations then continued to address the ‘quick temper’ and as Susan got more of a handle on this, not surprisingly her drug-taking decreased.
Links to culture and history
Not only is it relevant to talk with people about issues broader than just drug use, I also believe it is relevant for us as therapists to address issues of history and culture in our work.
In Hong Kong, we have internalized many Chinese traditional values and we have also been influenced by British and western values. As therapists, I believe that we need to continually question which values are shaping our work and to take care with this. We need to be asking ourselves how our cultural beliefs are shaping our assumptions about what sort of lives people ought to be living. I do not want to impose my values upon those who consult me.
At the same time, my local cultural context influences my work with people in positive ways. Earlier in this piece I mentioned the importance of ensuring that experiences of shame do not occur in the therapy room. ‘Face-saving’ is an important value in Chinese culture. This is an element of Chinese culture that I value and that deliberately shapes my therapy practice.
There are also some practices of professional culture that I engage with but wish to question. For instance, sometimes, rather than having the patience to ask questions, I may fall into directly suggesting to a person what they ought to do, what actions they should take. This of course, represents an imposition on my part and this is something that I am trying to resist.
In this paper I have tried to convey some of the ways in which I work with young people here in Hong Kong to assist them to overcome the craving associated with drug use and to break their habits. I have described some of the narrative practices that assist in this process, particularly the use of the migration of identity metaphor and externalizing conversations.
I would very much appreciate feedback and welcome conversations with others around these issues.
1. Har Man-kwong is a social worker in Hong Kong who has a great interest in postmodern ideas, especially the realm of micro-politics in therapeutic contexts. He has worked in the area of substance use for seven years and finds narrative practices are very helpful in this work. Har Man-kwong can be contacted via email: email@example.com