Narrative-based psychotherapies for mood disorders- A scoping review of the literature

(1)

SSM - Mental Health 3 (2023) 100224

Available online 27 May 2023

Review

Narrative-based psychotherapies for mood disorders: A scoping review of the literature

Lisa D. Hawke

^a^,^b^,^*

, Anh T.P. Nguyen

^a

, Terri Rodak

^c

, Philip T. Yanos

^d

, David J. Castle

^e

aCentre for Addiction and Mental Health, Centre for Complex Interventions, 60 White Squirrel Way, Toronto, ON, M6J 1H4, Canada

bUniversity of Toronto, Department of Psychiatry, 250 College St, 8th Floor, Toronto, ON, M5T 1R8, Canada

cCentre for Addiction and Mental Health, CAMH Library, Department of Education, 1025 Queen St W, Toronto, ON, M6J 1H1, Canada

dJohn Jay College of Criminal Justice, 524 W 59th St, New York, NY, 10019, United States

eUniversity of Tasmania, Churchill Ave, Hobart, TAS, 7005, Australia

A R T I C L E I N F O Handling Editor: Prof B Kohrt Keywords:

Narrative therapy Mood disorders Depression Bipolar disorder

A B S T R A C T

Background: Narrative-based psychotherapies are strengths-based psychotherapeutic approaches that could be beneficial for people with mood disorders. This scoping review synthesizes the research on the outcomes of various modalities of narrative-based psychotherapies for adults with mood disorders.

Methods: Scoping review methodology was followed. Relevant studies were identified via systematic database searches. Articles were eligible if they reported on the outcomes of narrative therapy, narrative therapy integrated with other treatment modalities, and other narrative-based psychotherapies delivered to adults with mood disorders, and were published in English or French. Eighteen reports were included in the review.

Results: A small body of research has applied the original narrative therapy model, integrated narrative therapies, and other narrative-based psychotherapies to depressive disorders and, to a lesser extent, to bipolar disorder.

Across studies and methodologies, these approaches are associated with improvements in mood symptoms and other metrics. Comparative research tentatively suggests that outcomes of narrative approaches may be similar to those of other psychotherapeutic approaches, across a range of populations.

Conclusions: Narrative approaches to psychotherapy may constitute promising psychotherapeutic modalities for adults with mood disorders. However, these approaches are under-researched to date; ongoing research is justified to establish a more robust evidence base on the efficacy and effectiveness of narrative-based psychotherapies for mood disorders.

1. Introduction

Epidemiological data from the United States estimates the lifetime prevalence of mood disorders at about 21.4% of the adult population (Kessler et al., 2012). Major depressive disorder affects approximately 18.3% of the population in their lifetime; bipolar disorder (BD) has a lifetime prevalence of about 1.1% for type I BD (i.e., cycles of depression and mania) and 1.4% for type II BD (i.e., cycles of depression and hy- pomania) (Kessler et al., 2012), in addition to those experiencing sub- threshold bipolar spectrum disorders. Mood disorders typically first emerge in early adulthood (Kessler and Bromet, 2013; Rowland and Marwaha, 2018). Mood disorders show consistent negative impacts on occupational and social functioning, role performance, financial status,

morbidity, and mortality (Kessler and Bromet, 2013). They are associated with widespread personal, family, and economic burden due to lost productivity, psychiatric care, extensive physical and psychiatric co- morbidity (Bessonova et al., 2020; Kessler and Bromet, 2013). Risk factors are multi-facetted, including genetic heritability together with environmental factors such as loss, psychosocial adversity, medical adversity, and trauma (K¨ohler et al., 2018; Potter, 2013).

Treatment guidelines for depression include a variety of options for psychological and pharmacological interventions (National Institute for Health and Care Excellence (NICE), 2022); treatments are to be chosen based on the individual’s presentation and needs, accompanied with active exploration of the patient’s preferences. BD treatment guidelines recommend pharmacotherapy as the first line of treatment, with

* Corresponding author. Centre for Addiction and Mental Health, 60 White Squirrel Way, 316, Toronto, Ontario, M6J 1H4, Canada.

E-mail addresses: [email protected] (L.D. Hawke), [email protected] (A.T.P. Nguyen), [email protected] (T. Rodak), [email protected] (P.T. Yanos), [email protected] (D.J. Castle).

Contents lists available at ScienceDirect

SSM - Mental Health

journal homepage: www.journals.elsevier.com/ssm-mental-health

https://doi.org/10.1016/j.ssmmh.2023.100224

Received 3 April 2023; Received in revised form 13 May 2023; Accepted 14 May 2023

(2)

adjunctive psychosocial treatments (Murray, 2018). Even when medication is adhered to, psychosocial interventions can provide benefits in helping ameliorate residual symptoms and impairment (Huxley and Baldessarini, 2007). Leading models of psychosocial treatments include cognitive-behavioral therapy, psychoeducation, and interpersonal therapies (Murray, 2018; National Institute for Health and Care Excel- lence (NICE), 2022), while a variety of other interventions have shown benefits.

A number of psychotherapies focus on the development of a self- narrative. The original narrative therapy model initially emerged from a tradition of ‘post-positivism’, i.e., a stance that critiques the traditional scientific position regarding the existence of an objective reality and the role of science in unveiling that reality (Fox, 2008). It was historically built out of emerging social movements such as feminism and fights against racism, classism, and other structural inequalities (Madigan, 2019; White and Epston, 1990). The narrative therapy approach views people as experts in their own lives, acknowledging that there are multiple stories that people can use to describe themselves. Rather than focusing on problems and deficits, narrative therapy focuses on strengths, abilities, successes, and exceptions to the problem, encour- aging patients to ‘re-author’ the stories of their lives in ways that enable them to derive meaning from strengths (Madigan, 2019). It is a flexible psychotherapeutic approach that lends itself to a wide range of populations and cultures by focusing on individual experience and strengths, firmly rooted in cultural context, personal meaning, and social justice (Combs and Freedman, 2012; Madigan, 2019). Narrative therapy aims to deconstruct dominant cultural and institutional dis- courses that lead to problem-based understandings of self, instead helping individuals find unique outcomes and personal meaning (Combs and Freedman, 2012). Given its historical roots, there has not been an emphasis on quantifying the outcomes of narrative therapy, which has limited the research conducted on its efficacy (Madigan, 2019).

While the original narrative therapy model has been examined to some extent in its original stand-alone format, other narrative-based approaches have also been examined, including approaches that integrate narrative therapy with other psychotherapeutic approaches and analogous psychotherapeutic approaches that use self-narrative development principles. Examples include narrative cognitive therapy and narrative exposure therapy, in individual and group formats (Gonçalves and Machado, 1999; Lely et al., 2019; Menard et al., 2018).

Narrative-based psychotherapies are not incompatible with the aims of cognitive-behavioral therapy, which, although taking more of an inter- nalized approach, might see personal stories as illustrative of mal- adaptive beliefs or schemata. Studies have also examined narrative approaches as applied to certain vulnerable populations, notably survivors of trauma, adversity, and end-of-life care; for example, the literature demonstrates benefits among patient groups such as victims of war, torture, or intimate partner violence, as well as refugees (Gwozd- ziewycz and Mehl-Madrona, 2013; Hensel-Dittmann et al., 2011; Mor- eira et al., 2022; Park et al., 2020; Tribe et al., 2019). A meta-analysis found positive impacts of narrative exposure therapy among trauma- tized refugees (Gwozdziewycz and Mehl-Madrona, 2013). Biographical interventions that resemble narrative-based approaches in their focus on the development of a life story narrative, such as life review or remi- niscence therapy, are well established among older adults (Rubin et al., 2019). Numerous reviews and meta-analyses demonstrate that these interventions have positive impacts on depressive symptomatology, improve cognitive and social functioning, and enhance quality of life among older adults (Al-Ghafri et al., 2021; Menn et al., 2020; Westerhof and Slatman, 2019; Yen and Lin, 2018). These approaches have some similarities in their approach to developing a life narrative with growth-oriented themes, but also notable differences from the formal narrative therapy model (White and Epston, 1990).

Narrative-based approaches to psychotherapy might be comple- mentary treatment options for individuals with mood disorders when a narrative exploration aligns with patient preferences. Early trauma

histories are common among individuals with depression or bipolar disorder, interacting with neurobiological mechanisms, increasing sui- cidality, and impairing inter-episode functioning (Aas et al., 2016; Etain et al., 2008; Marshall et al., 2018; Xie et al., 2018). Negative biases have been identified in memory recall of individuals with depression for both recent memories and holistic life stories (Habermas et al., 2008; Urban et al., 2018). Identity disturbance are also observed (Farmer et al., 2012;

Inder et al., 2008). Since narrative-based approaches to psychotherapy focus on building positive meaning in the context of adversity, empha- sizing strengths, enhancing meaning, and constructing positive self-narratives, these approaches may provide particular benefits for individuals with mood disorders who have experienced early adversities.

While some research has emerged testing narrative therapy, its integrated adaptations, and other narrative-based approaches to psychotherapy for adults with mood disorders, this literature has yet to be rigorously synthesized. This scoping review synthesizes the research to date on the outcomes of this range of narrative-based psychotherapies for adults with mood disorders.

2. Methods

PRISMA Extension for Scoping Reviews (PRISMA-ScR) guidelines were followed in the conduct of this review (Tricco et al., 2018). The scoping review methodology was chosen based on the research question, which required a broad investigation of the diverse research on the topic (Munn et al., 2018). The scoping review process incorporated the following major steps: 1) defining the research question, 2) identifying relevant studies, 3) screening and selecting studies, 4) extracting the data, and 5) summarizing the data and reporting.

2.1. Defining the research question

The scoping review aimed to understand the published academic literature reporting research on the outcomes of narrative therapy as per the original model (White and Epston, 1990), therapies that integrate the original narrative therapy model with other psychotherapeutic approaches, and other narrative-based approaches to psychotherapy, delivered to adults with mood disorders. Based on the PICO (population, intervention, comparison and outcomes) framework (Huang et al., 2006), this review focuses on adults with mood disorders (population), receiving a narrative approach to psychotherapy (intervention). It includes studies with or without comparison groups and reports on outcomes related to intervention efficacy, effectiveness, or acceptability in relation to mood symptoms and other mental health symptomatology, as well as other outcomes highlighted in the selected literature.

2.2. Identifying relevant studies

A comprehensive search strategy was developed with a health sciences librarian (TR), who conducted the searches on September 27, 2022. Considering the subject areas of the research question, the search was developed, tested, and finalized in APA PsycInfo (Ovid), then translated and run in the following bibliographic databases: APA Psy- cInfo, Medline, Embase, Cumulative Index to Nursing & Allied Health Literature (CINAHL), Web of Science, Applied Social Sciences Index and Abstracts (ASSIA), and Cochrane Central Register of Controlled Trials (CENTRAL). The search strategies used database-specific subject head- ings and keywords in natural language, as well as advanced search operators such as truncation and adjacency operators, to capture two main concepts. The mood disorder concept included variations of search terms such as “affective disorders," “mood disorders," “bipolar disorders," and “mania.” The narrative concept included variations of search terms such as “narrative psychotherapy,” “narrative approach,” and “life review,” as well as related terms such as “biography or autobiography or storytelling” linked with “therapy or psychotherapy” using an adjacency

(3)

operator. No limits were applied on publication year, language, or study type. See supplemental materials for the core search strategy developed for APA PsycInfo. To supplement the database searches, a hand search of reference lists and Google Scholar searches were conducted. Given the nature of the research question, the gray literature search was limited to dissertations in APA PsycInfo, registered clinical trials in the CENTRAL search, and non-traditional publications indexed in the CINAHL database.

2.3. Study screening and selection

To be included, articles had to present the results of research on narrative therapy or a psychotherapeutic approach incorporating either the original narrative therapy model or another narrative approach to psychotherapy, for adults with mood disorders. Articles could report on any study design and any sample size. Patients had to be adults aged 18+ and not samples of older adults (age 65+) or end-of-life populations.

Articles had to be published in English or French. Excluded were any studies not reporting on the results of narrative approaches to psychotherapy delivered to adults with mood disorders, research conducted on children or older adults, research focusing on end-of-life care or pallia- tive care, research focusing on mood symptoms in the absence of a mood disorder, research on approaches not connected with narrative development, and discussion papers that did not present research results.

Table 1 presents inclusion and exclusion criteria, which were developed to optimize the ability to address the research question.

The database search generated 3097 unique items (see PRISMA diagram, Fig. 1). One additional record was identified by hand search.

Records were uploaded into Covidence software (Veritas Health Inno- vation, 2022) and 1611 duplicates were removed using the Covidence duplicate detection system and manual identification. The remaining 1487 titles and abstracts were screened by two independent reviewers based on the inclusion and exclusion criteria (authors LDH, ATPN); any conflicts were discussed and resolved by consensus. A total of 1419 records were excluded at the title and abstract screening level. The remaining 68 articles were reviewed at the full-text level by the same two independent reviewers following the same procedure, and 50 were excluded. A total of 18 documents were selected for inclusion in the review, including 17 journal articles and one doctoral dissertation.

2.4. Data extraction

From the final 18 selected articles, data were extracted (ATPN) and verified (LDH) using a spreadsheet. The data extraction form included study identification information (e.g., reference, location, funder/

sponsor, data collection year(s), objectives/hypotheses), intervention description (e.g., name, treatment model, structure, delivery, frequency, duration, therapist, setting, control arm), sample description (e.g., age, gender, ethnicity, diagnostic information, inclusion and exclusion criteria), study methods (e.g., design, sampling method, sample size,

assessment timing), and outcomes regarding symptomatic or functional improvement and other highlighted outcomes (e.g., measures, qualitative themes, quantitative outcomes).

2.5. Data summarization and reporting

The data extracted from the articles are summarized narratively and in table format. To aid the interpretation of the findings, results are summarized separately for studies examining narrative therapy according to its original model (White and Epston, 1990), those examining integrated narrative therapy interventions, and other narrative-based approaches. Quality assessment was not conducted, as this is not a pri- ority in scoping reviews in which a wide range of diverse research is mapped.

3. Results

A brief overview of the selected studies is provided in Table 2;

Table 3 presents a detailed description of the studies and their findings.

3.1. Narrative therapy

A small body of research has applied the original narrative therapy model (White and Epston, 1990) to individuals with mood disorders.

Seven reports, describing three studies, examined individual narrative therapy for adults with mood disorders. The studies were conducted in Portugal (Lopes, 2014; Lopes et al., 2015; Lopes et al., 2014; Lopes et al., 2014; Lopes et al., 2015), Australia (Vromans and Schweitzer, 2011), and the United States (Ngazimbi et al., 2008). They focused on populations with major depressive disorder, a major depressive episode, and bipolar disorder respectively; many participants had comorbid anxiety disorders or other comorbid mental health disorders.

The most substantial body of research is derived from a doctoral dissertation (Lopes, 2014), which led to four peer-reviewed journal articles (Lopes et al., 2015; Lopes et al., 2014; Lopes et al., 2014; Lopes et al., 2015), comparing narrative therapy to cognitive-behavioral therapy (CBT) conducted with individuals experiencing a major depressive disorder and tested using a randomized-controlled trial (RCT) design. Findings generally showed that participants receiving narrative therapy achieved improvements in depressive symptoms and general psychosocial symptoms and problems, including interpersonal relations. In most analyses, there were no statistically significant differences between CBT and narrative therapy in terms of effects on depression, general psychosocial symptoms and problems, interpersonal relations, dropout, time to improvement, or maintenance/continued improvement at follow-up. However, CBT out-performed narrative therapy at pre-post analyses in terms of depressive symptom improvement when dropouts were included in the analyses.

Complementing this work is a single-arm trial of narrative therapy for individuals with a major depressive episode (Vromans and Schweitzer, 2011). The trial demonstrated statistically significant improvements in depressive symptoms after treatment, with a large effect size and maintenance of effects at follow-up. Significant improvements were also observed for interpersonal relations, with a medium effect size and some maintenance at follow-up. Furthermore, a benchmarking ex- ercise suggested that the outcomes of narrative therapy were comparable to those multiple other treatment modalities, including CBT.

Lastly, one case illustration described the application of narrative therapy to an individual living with a diagnosis of bipolar disorder (Ngazimbi et al., 2008); the participant reported subjective improvements in wellbeing. The client also reported medication adherence, greater acceptance of the diagnosis, and goal attainment in terms of employment and housing.

Table 1

Inclusion and exclusion criteria.

Inclusion criteria Exclusion criteria

Presents original research outcomes of narrative therapy, integrated narrative therapy, or another narrative-based psychotherapy

Psychotherapeutic approach is not either narrative therapy, an integration of narrative therapy, or another narrative- based psychotherapeutic approach.

Treated participants with mood

disorders. Intervention includes only self-directed activities, without psychotherapist- delivered psychotherapy.

Reports on an adult sample. Sample does not have a mood disorder.

Report is in English or French. Sample is a child or older adult population.

Does not present original research findings or outcomes.

Report is not in English or French.

(4)

3.2. Integrated narrative therapy

Two studies have examined interventions that integrated the original narrative therapy model with other psychotherapeutic modalities.

Burgess et al. (2022) integrated narrative therapy with Southern African Indigenous principles to create a program focused on developing collective responses to economic and social hardship among women living with depression and adversity. This was a modular group intervention, and a single-arm trial was conducted. The intervention was associated with significant decreases in depression across the range of depression scores at post-treatment.

Seo et al. (2015) integrated narrative therapy with emotion-focused therapy for adults experiencing depression in South Korea. Using an RCT design, the investigators compared a waitlist control group to the integrated approach. The study found that, in pre-post analyses, the integrated narrative therapy arm outperformed the wait-list controls on hope, positive and negative affect, and depression; improvements in self-awareness were noted at the non-significant trend level.

3.3. Other narrative-based psychotherapies

An additional body of research has applied interventions including narrative principles and techniques to mood disorders, almost exclu- sively with individuals experiencing depressive disorders. While some of these models refer to the original narrative therapy model in their conceptualization, they are not explicitly built based on that original model, yet focus on self-narrative development in other manners. Four studies, encompassing 9 articles, were conducted across three conti- nents, in various settings and socioeconomic conditions. These included narrative cognitive therapy (Beutler et al., 2003; Ibrahim and Allen, 2018; Molina et al., 2017; Mondin et al., 2014, 2015; Moreira et al., 2015; Silva et al., 2017) and narrative exposure therapy (Mauritz et al.,

2020, 2022).

These studies examined diverse populations: young adults with major depressive disorders in Brazil (Molina et al., 2017; Mondin et al., 2014, 2015; Moreira et al., 2015; Silva et al., 2017), adults meeting diagnostic criteria for depression comorbid with stimulant dependency in the United States (Beutler et al., 2003), adults with severe mental illness (82.6% with mood disorders) and comorbid post-traumatic stress disorder in the Netherlands (Mauritz et al., 2020, 2022), and adults with bipolar disorder in the United Kingdom (Ibrahim and Allen, 2018). The interventions were provided in individual and group format. Study designs included two RCTs and two single arm trials, which were qualitative and mixed-methods designs.

As a whole, these narrative-based psychotherapies were associated with reductions in depressive symptomatology or remission of depression (Beutler et al., 2003; Mauritz et al., 2020, 2022; Mondin et al., 2014). Studies also revealed positive impacts on associated symptoms of anxiety and PTSD, functioning, and biological rhythm disruption.

Feasibility indicators showed strong retention (Beutler et al., 2003), acceptability, and tolerability of the interventions (Ibrahim and Allen, 2018; Mauritz et al., 2022). Subjective improvement and acceptance of this therapeutic approach were also reported among participants with bipolar disorder or severe mental illness through qualitative data (Ibrahim and Allen, 2018; Mauritz et al., 2022).

Two RCTs were conducted. One RCT, conducted in the United States, found improvements in depressive symptoms and substance use associated with narrative cognitive therapy, cognitive therapy, and prescriptive therapy, with no outcome differences between treatment modalities; dropout was lowest in the narrative cognitive therapy arm (Beutler et al., 2003). The trial further found that the fit between the therapy modality and the patient was a key factor in achieving optimal outcomes.

A second RCT, conducted in Brazil, achieved positive impacts with Fig. 1. PRISMA diagram.

(5)

Table 2

Summary of the selected studies.

Authors,

Year Country Funder/Sponsor Sample

description Intervention

name Intervention description Delivery

mode Sessions (n x duration)

Treatment duration

Narrative therapy

Lopes (2014) Portugal The Portuguese Foundation for Science and Technology (FCT)

Adults with MDD Narrative

therapy Narrative therapy treatment manual based on the work of White and Epston (1990), using talk therapy to re-author life narratives

Individual 20 ×1 h 24 weeks Lopes et al.

(2014) Lopes et al.

(2015) Lopes et al.

(2015) Ngazimbi et al.

(2008)

United

States Not reported Adult with BD Narrative

therapy Narrative therapy described as

per White and Epston (1990) Individual Not

reported 11 months Vromans and

Schweitzer (2011)

Australia Not reported Adults with a

current MDE Narrative

therapy Manualized narrative therapy intervention informed by White and Epston (1990)

Individual 8 ×50

min 8–16 weeks

Integrated narrative therapies Burgess et al.

(2022) South Africa The Naughton/Clift

Matthew Fund Women with

depression and adversity

COURRAGE-

Plus Narrative therapy following White (2003) integrated with a program developing collective responses to economic and social hardship, using Southern African Indigenous principles

Group 13 x 3–4 h 13 weeks

Seo et al.

(2015) South Korea Not reported Adults diagnosed

with depression Narrative therapy with an emotional approach (NTEA)

Integration of narrative therapy as described by White and Epston (1990) with emotion-focused therapy ( Johnson, 2004); externalize problems, identify unique outcomes, construct alternative narratives, using emotion-focused techniques to help with self-expression.

Group 8 ×90

min 4 weeks

Other narrative-based psychotherapies Beutler et al.

(2003) United

States National Institute on

Drug Abuse (NIDA) Adults with comorbid depression and substance dependence

Narrative cognitive therapy

Facilitated discussions of drug use and depression following the work of Gonˆccalves (1994)

Individual 20

sessions Patient selected

Silva et al.

(2017) Brazil Foundation for Research Support of the State of Rio Grande do Sul - FAPERGS and Coordination for the Improvement of Higher Education Personnel - CAPES

Young adults (age 18–29) with MDD

Narrative cognitive therapy

Integration of narrative components with cognitive therapy support clients in rewriting life stories that have become incoherent and integrating new interpretations. Follows manual for NCT (Gonçalves, 1998).

Individual 7 ×1 h 7 weeks Molina et al.

(2017) Mondin et al.

(2014) Mondin et al.

(2015) Moreira et al.

(2015) Ibrahim and

Allen (2018)

United

Kingdom Not reported Adults with BD CBT with

narrative therapy

Integration of CBT with narrative therapy principles with the tree of life, including psychoeducation, coping strategies, and development of meanings and identity, values, and purpose, following Rhodes and Jakes (2009)

Group 8 ×1.5 h 8 weeks

Mauritz et al.

(2020) Netherlands GGNet Mental Health

Center Adults with

severe mental illness (65.2%

MDD, 17.4% BD) and comorbid PTSD

Narrative Exposure Therapy

Integration of narrative components into prolonged exposure in the life story with attention to positive life events, using Dutch NET manual ( Jongedijk and Mauritz, 2016).

Not reported 5–16 ×

90 min 10–43 weeks Mauritz et al.

(2022)

BD =Bipolar Disorder; CBT =Cognitive Behavioral Therapy; MDD =Major Depressive Disorder; MDE =Major Depressive Episode; NCT =Narrative Cognitive Therapy; NET =Narrative exposure therapy; NTEA =Narrative therapy with an emotional approach; PTSD =Post-traumatic stress disorder.

(6)

both narrative cognitive therapy and CBT on depressive and anxiety symptoms, quality of life, and the regulation of biological rhythms (Mondin et al., 2014; Silva et al., 2017). Some variation in outcomes was seen at discrete assessment time points favoring CBT, for example with a non-significant trend toward CBT superiority at 12 months (Mondin

et al., 2015). However, significance and non-significance were observed at various time points, providing a mixed picture of the comparative results. The study also found a non-significant trend toward CBT superiority on depressive symptoms among young men, but this was not observed among young women (Molina et al., 2017). CBT was favored Table 3

Detailed description and findings of the selected studies.

Authors Research

design Sample

size Timing of

assessment Primary and secondary outcomes Findings Narrative therapy

Lopes (2014) RCT NT: n =34 Pre, post- treatment, 21 & 31 month follow up

Depression, general psychosocial symptoms and problems (including interpersonal relations)

NT =CBT on depressive symptoms in completer analyses

Lopes et al.

(2014) CBT: n =

Lopes et al. 29

(2014) CBT >NT on depressive symptoms when including

dropouts (intent-to-treat analyses) Lopes et al.

(2015) Lopes et al.

(2015) NT =CBT on general psychosocial symptoms and

problems, interpersonal relations, dropout rates, time to improvement, maintenance/continued gain at follow- Ngazimbi et al. up

(2008) Case

illustration n =1 n/a Client-defined goals: live life to the fullest despite BD; (b) regain driver’s license; (c) find employment (d) find own apartment

Gained employment, moved into own apartment, accepted BD diagnosis, medication compliant, subjectively ‘doing well’

Vromans and Schweitzer (2011)

Single arm trial n =47 Pre, post- treatment, 3 month follow up

Depression, interpersonal relations Improvement in depression (large effect); maintenance at followup

Improvement in interpersonal relations (medium effect); some maintenance at followup

Depression outcomes broadly comparable to CBT and other modality outcomes in benchmark research Integrated narrative therapies

Burgess et al.

(2022) Single-arm trial n =47 Pre, intra- treatment (9 weeks), post treatment

Depression Statistically significant decrease in depression scores for all baseline severity levels

Seo et al. (2015) RCT NT: n =24 Pre, 1 week post

treatment Self-awareness, hope, positive and

negative affect, depression NTEA >waitlist on positive affect, negative affect, hope, depression

Waitlist: n

=26 NTEA =waitlist on self-awareness (non-significant

trend) Other narrative-based psychotherapies

Beutler et al.

(2003) RCT NCT: n =

12 Pre, post-

treatment, 6 month follow up

Depression, substance use NCT =CT =PT for depressive symptoms, substance use

CT: n =15 Lower dropout in NCT

PT: n =13 Fit between therapy and patient +therapeutic alliance

predicted outcomes Silva et al.

(2017) RCT NCT: n =

51 Pre, post-

treatment, 6 & 12- month follow-up

Depression, quality of life, biological rhythms (sleep, social activities, eating), anxiety, proinflammatory cytokines

CBT >NCT for depression at post-treatment; NCT =CBT for depression at 6 months, maintenance at follow-up Molina et al.

(2017) CBT: n =

46 NCT =CBT for anxiety, maintenance at follow up

Mondin et al.

(2014) NCT =CBT for regulation of biological rhythms,

maintenance at follow up Mondin et al.

(2015) Trend toward CBT >NCT for young men, no difference

for women at post-treatment Moreira et al.

(2015) CBT =NCT for QoL in intent-to-treat analyses. CBT >

NCT for completers on some QoL subscales at 12 months CBT >NCT for decrease in proinflammatory cytokines at post-treatment

Ibrahim and

Allen (2018) Single-arm,

qualitative n =6 Post-treatment Perspectives on the group Participants received social support by connecting with others and gained a sense of hope. They found the Tree of Life activity important for reframing their life stories.

They learned about others’ BD experiences and coping strategies. They found group processes largely positive.

Mauritz et al.

(2020) Single-arm trial, mixed methods

n =23 Pre, 1 month post- treatment, 7 month follow up

PTSD and dissociative symptoms, QoL,

SMI symptoms, functioning Reduced PTSD symptoms, PTSD severity, dissociative symptom severity, SMI symptoms, increased functioning; maintenance or improvement at follow-up Mauritz et al.

(2022) No change in QoL

Qualitative: Perceived post-treatment improvement for many participants in PTSD, dissociative, and SMI symptoms and QoL. Care provided during and after treatment reported as sufficient by many participants.

CBT =Cognitive behavioral therapy; CT =Cognitive therapy; NCT =Narrative cognitive therapy; NT =Narrative therapy; NTEA =Narrative therapy with an emotional approach; PT =Prescriptive therapy; PTSD =Post-traumatic stress disorder; QoL =Quality of life; RCT =Randomized-controlled trial; SMI =Severe mental illness.

(7)

for the decrease in proinflammatory cytokines considered to be associated with depression (Moreira et al., 2015).

A single-arm mixed-methods trial found that narrative exposure therapy was associated with reductions in PTSD symptoms, dissociative symptoms, and severe mental illness (SMI) symptoms (Mauritz et al., 2020, 2022). Increased functioning was also found, but there was no change in quality of life.

4. Discussion

This scoping review of the literature synthesized the research examining the outcomes of narrative-based psychotherapies for adults with mood disorders, inclusive of narrative therapy, narrative therapy integrated with other psychotherapeutic approaches, and other narrative-based psychotherapies. The outcomes of narrative-based psychotherapies as a treatment for depressive disorders have been examined by a small body of international research, while inquiries into its application with bipolar disorder remain scarce. As a whole, results suggest that psychotherapies using a narrative approach have positive impacts on depression and other mental health symptomatology and are well accepted by patients with varying characteristics. The positive impacts appear to be generally in line with those of various other models of psychotherapy, although it is possible that CBT outperforms narrative cognitive therapy in some aspects. However, since the evidence base remains limited, definitive conclusions about comparative efficacy cannot be drawn.

The research reviewed here suggests that narrative-based psychotherapies can have positive impacts on depressive disorders in various populations, including special populations with comorbidities. Previous research has suggested positive impacts of narrative-based psychotherapeutic approaches on depressive symptoms among individuals with other primary mental and physical health concerns, such as PTSD, alcohol dependence, autism, and cancer (Bonilla-Escobar et al., 2018;

Cashin et al., 2013; Cloitre et al., 2017; Moreira et al., 2022; Park et al., 2020; Park and Kim, 2021; Sajadian, 2018). A meta-analysis demonstrated that narrative exposure therapy is effective for PTSD, while reducing depressive symptomatology secondary to PTSD (Raghuraman et al., 2021). Given the negative biases that have been identified in the memory recall associated with depression (Habermas et al., 2008; Urban et al., 2018), the development of more coherent, more positive life stories in this population through narrative means has the potential to alleviate the symptoms of mood disorders and comorbidities, notably with regard to trauma and adversity. Indeed, the coherence of life narratives has been associated with wellbeing (Waters and Fivush, 2015).

Depression is associated with high levels of past trauma (Marshall et al., 2018; Xie et al., 2018), and narrative exposure therapy has been applied to post-traumatic conditions, with some positive results, although further evidence is needed (Raghuraman et al., 2021; Tribe et al., 2019).

Nevertheless, this context highlights the potential for narrative principles and techniques in treating adults living with depressive disorders.

Additional rigorous research is thus required to identify for whom narrative-based approaches work, and when; for example, these approaches might be studied as an alternate psychotherapy for those among whom a gold standard treatment like CBT does not produce the desired outcomes, or among those who prefer a narrative approach.

There is very limited research available testing narrative-based psychotherapies for individuals with bipolar disorder. However, background literature does suggest its relevance to this condition. Potter (2013) described that interruptions to the self-narrative in bipolar disorder prevent individuals from consolidating a self-identity that includes bipolar disorder, but expands beyond it. Self-identity disruptions emerge as a key factor in bipolar disorder (Inder et al., 2008), and there are examples of using narrative to build identity and self-understanding (Mannon, 2019; Rauch, 2007). According to recovery-oriented practice, personal recovery in bipolar disorder includes not only symptomatic stabilization, but also the development of social interaction, positive

roles, coping strategies, and goal attainment (Mezes et al., 2021; Tse et al., 2014), which could be supported through narrative means. Re- covery in bipolar disorder may further include the consolidation of identity and self-acceptance (Inder et al., 2011). This intersects with high levels of self-stigma in bipolar disorder (Hawke et al., 2013), which is a major barrier to recovery (Yanos et al., 2010) and might be addressed through narrative means (Hansson et al., 2017; Roe et al., 2014). The preliminary findings reviewed here suggest feasibility and applicability of narrative-based psychotherapies for people with bipolar disorder; more research is needed to determine whether narrative-based psychotherapies hold potential as recovery-oriented interventions for this population.

Narrative therapies are flexible approaches that appear to be adaptable and feasible to various cultures and patient groups. Given narrative therapy’s strong roots in cultural context and personal meaning (Combs and Freedman, 2012; Madigan, 2019), it is adaptable to different contexts. Previous literature includes examples of narrative-based approaches for a diverse range of populations, including intercultural couples (Kim et al., 2012), Indigenous populations (Nga- zimbi, 2016; Smeja, 2019), immigrants (Farrell and Gibbons, 2019), and sexual and gender minority populations (Nylund and Temple, 2017).

The integration of narrative-based approaches with other treatment modalities such as cognitive therapy, emotion-focused therapy, and exposure therapy further demonstrates the flexibility and adaptability of self-narrative development as part of psychotherapy. The literature reviewed in the current review emerged from various countries and cultural contexts, presenting multiple narrative-based approaches to psychotherapy, which confirms interest in and applicability to diverse communities. Narrative-based psychotherapies might, then, be relevant approaches to offer to individuals with non-minority cultural backgrounds who might have a preference for culturally-sensitive interventions. Their adaptability might also make these approaches of interest to therapists with backgrounds in a variety of psychotherapeutic modalities.

Given narrative therapy’s initial roots as a post-positivist approach, some have argued that it does not lend itself to gold standard efficacy trials such as RCTs (McKenzie-Smith, 2020). A recent literature sythensis highlighted the methdological idiosyncracities of the narrative therapy literature, which departs from standard efficacy evaluative approaches (Conti et al., 2022); this is consisent with the arguments that narrative therapy is not strongly aligned with modern quantitative research methodologies and is therefore under researched (Etchison and Kleist, 2000). Indeed, the quantity of research identified in the current review was low, showing that narrative therapies are less researched than other psychotherapies like CBT. Calls have been made for more empirical research and a variety of evaluative approaches to understand the impacts of narrative therapies in various vulnerable populations (Jordan, 2020; McKenzie-Smith, 2020; McLeod, 2014).

From a complex intervention evaluation standpoint (Skivington et al., 2021a), a broad range of research approaches is needed to understand the impacts of complex interventions. While RCTs are considered the gold standard for intervention testing, they are not always the most relevant way to understand the impacts of complex interventions embedded in complex systems (Hawe et al., 2004; Skivington et al., 2021b). Approaches conducive to the evaluation of the family of narrative-based psychotherapies include qualitative research, case study designs, conversational analysis, and process research (McLeod, 2014).

For example, qualitative and case study research can add to the evidence base on narrative-based psychotherapies beyond standard efficacy research in manners more consistent with narrative therapy’s post-structural theoretical and values-based underpinnings (Combs and Freedman, 2012; McLeod, 2014). Process research, a methodology not reviewed in the current literature synthesis, departs from evaluations of whether an intervention works (efficacy) and instead examines how it works with individuals; further process research can add to the evidence base.

(8)

McLeod (2014) called for patients to be involved in interpreting narrative therapy outcomes. Patient-engaged research approaches respect the values that individuals with lived experience can bring to research endeavors (Forsythe et al., 2019). The evaluation of complex interventions requires a pragmatic stance to capture the impacts of interventions in innovative ways, leveraging research creativity alongside the expertise of people with lived experience of the health issues at hand (Craig et al., 2008; Skivington et al., 2021b). Hence, future research should include collaborative engagement with people with lived experience, as their insight can be an asset to understanding the impacts of narrative therapy and its adaptation on patient recovery.

Several limitations should be kept in mind when interpreting the findings. The search was conducted in September 2022 and any documents published after this date would not have been retrieved. Only articles published in English or French were obtained, potentially limiting the scope of the findings. It should be noted that a number of reports emerged from the same studies; more research, by different research teams, is required. The interventions reviewed were heterog- enous in nature; different treatment modalities using narrative-based frameworks may be associated with differential treatment outcomes.

Only research reporting on outcomes in standardized quantitative or qualitative manners was included. A review of process literature examining the way narrative-based psychotherapies work, outside of the framework of traditional outcome research, would add depth to the understanding of therapeutic processes, but was not within the scope of this article.

Narrative-based psychotherapies seem to consitute promising psychotherapeutic modalities for individuals experiencing depressive disorders or bipolar disorders. Symptomatic reduction appears to be observed after participation in various forms of narrative-based psychotherapies, among a range of different populations and in various contexts. However, narrative-based approaches to psychotherapy are under-researched to date. Ongoing work is justified to establish a more robust evidence base on the efficacy and effectivenes of narrative-based psychotherapies for individuals living with depressive disorders or bipolar disorders. Given the complex nature of this family of interventions, the use of a wide range of research methodologies is recommended in future work to better understand the utility of narrative-based psychotherapies for individuals with mood disorders.

Funding

This review was financially supported by the Centre for Complex Interventions at the Centre for Addiction and Mental Health.

CRediT authorship contribution statement

Lisa D. Hawke: Conceptualization, Methodology, Formal analysis, Investigation, Writing – original draft. Anh T.P. Nguyen: Formal analysis, Investigation, Writing – original draft. Terri Rodak: Method- ology, Investigation, Writing – review & editing. Philip T. Yanos:

Methodology, Writing – review & editing. David J. Castle: Methodol- ogy, Writing – review & editing.

Declaration of competing interest

The authors declare the following financial interests/personal re- lationships which may be considered as potential competing interests:

Lisa D. Hawke holds grant monies for research from the Canadian In- stitutes of Health Research and from the Department of Psychiatry, University of Toronto. Anh T.P. Nguyen and Terri Rodak have no conflicts of interest to declare. Philip Yanos holds grant support from the US National Institutes of Health and the US Department of Health and Human Services. David Castle has received grant monies for research from NHMRC (Australia), Barbara Dicker Research Fund, Milken Insti- tute, Canadian Institutes of Health Research and Psyche Foundation;

consulting fees from Seqirus; honoraria for talks from Seqirus, Servier, and Mindcafe Forum; honoraria as advisory board member from Seqirus and Lundbeck; he is a founder of the Optimal Health Program (OHP), and holds 50% of the IP for OHP; is part owner and board member of Clarity Healthcare; is unpaid board chair of the Psyche Institute; he does not knowingly have stocks or shares in any pharmaceutical company.

Appendix A. Supplementary data

Supplementary data to this article can be found online at https://doi.

org/10.1016/j.ssmmh.2023.100224.

References

Aas, M., Henry, C., Andreassen, O.A., Bellivier, F., Melle, I., Etain, B., 2016. The role of childhood trauma in bipolar disorders, 2016/01/13 Int. J. Bipolar Disord 4 (1), 2.

https://doi.org/10.1186/s40345-015-0042-0.

Al-Ghafri, B.R., Al-Mahrezi, A., Chan, M.F., 2021. Effectiveness of life review on depression among elderly: a systematic review and meta-analysis, 2021-11-18 Pan.

Afr. Med. J. 40. https://doi.org/10.11604/pamj.2021.40.168.30040.

Bessonova, L., Ogden, K., Doane, M.J., O’Sullivan, A.K., Tohen, M., 2020. The economic burden of bipolar disorder in the United States: a systematic literature review.

Clinicoecon. Outcomes. Res. 12, 481–497. https://doi.org/10.2147/ceor.S259338.

Beutler, L.E., Moleiro, C., Malik, M., Harwood, M.T., Romanelli, R., Gallagher- Thompson, D., Thompson, L., 2003. A comparison of the Dodo, EST, and ATI factors among comorbid stimulant-dependent, depressed patients. Clin. Psychol.

Psychother. 10 (2), 69–85. https://doi.org/10.1002/cpp.354.

Bonilla-Escobar, F.J., Fandiño-Losada, A., Martínez-Buitrago, D.M., Santaella-Tenorio, J., Tobón-García, D., Muñoz-Morales, E.J., Escobar-Roldán, I.D., Babcock, L., Duarte- Davidson, E., Bass, J.K., Murray, L.K., Dorsey, S., Gutierrez-Martinez, M.I., Bolton, P., 2018. A randomized controlled trial of a transdiagnostic cognitive- behavioral intervention for Afro-descendants’ survivors of systemic violence in Colombia. PLoS One 13 (12), e0208483. https://doi.org/10.1371/journal.

pone.0208483.

Burgess, R.A., Jeske, N., Rasool, S., Ahmad, A., Kydd, A., Ncube Mlilo, N., 2022.

Exploring the impact of a complex intervention for women with depression in contexts of adversity: ailot feasibility study of COURRAGE-plus in South Africa. Int.

J. Soc. Psychiatr. 68 (4), 873–880. https://doi.org/10.1177/00207640211010203.

Cashin, A., Browne, G., Bradbury, J., Mulder, A., 2013. The effectiveness of narrative therapy with young people with autism, 2013/02/01 J. Child Adolesc. Psychiatr.

Nurs. 26 (1), 32–41. https://doi.org/10.1111/jcap.12020.

Cloitre, M., Garvert, D.W., Weiss, B.J., 2017. Depression as a moderator of STAIR narrative therapy for women with post-traumatic stress disorder related to childhood abuse, 2017/01/01 Eur. J. Psychotraumatol. 8 (1), 1377028. https://doi.org/

10.1080/20008198.2017.1377028.

Combs, G., Freedman, J., 2012. Narrative, poststructuralism, and social Justice: current practices in narrative therapy, 2012/10/01 Counsel. Psychol. 40 (7), 1033–1060.

https://doi.org/10.1177/0011000012460662.

Conti, J., Heywood, L., Hay, P., Shrestha, R.M., Perich, T., 2022. Paper 2: a systematic review of narrative therapy treatment outcomes for eating disorders—bridging the divide between practice-based evidence and evidence-based practice, 2022/09/12 J. Eat. Disord. 10 (1), 138. https://doi.org/10.1186/s40337-022-00636-4.

Craig, P., Dieppe, P., Macintyre, S., Michie, S., Nazareth, I., Petticrew, M., 2008.

Developing and evaluating complex interventions: the new Medical Research Council guidance. BMJ 337, a1655. https://doi.org/10.1136/bmj.a1655.

Etain, B., Henry, C., Bellivier, F., Mathieu, F., Leboyer, M., 2008. Beyond genetics:

childhood affective trauma in bipolar disorder, 2008/12/01 Bipolar Disord. 10 (8), 867–876. https://doi.org/10.1111/j.1399-5618.2008.00635.x.

Etchison, M., Kleist, D.M., 2000. Review of narrative therapy: research and utility. Fam.

J. Alex. Va. 8 (1), 61–66.

Farmer, C., Farrand, P., O’Mahen, H., 2012. ‘I am not a depressed person’: how identity conflict affects help-seeking rates for major depressive disorder, 2012/10/02 BMC Psychiatr. 12 (1), 164. https://doi.org/10.1186/1471-244X-12-164.

Farrell, I.C., Gibbons, M.M., 2019. Using narrative therapy to assist college-age Latino immigrants, 2019/04/01 J. Coll. Counsel. 22 (1), 83–96. https://doi.org/10.1002/

jocc.12116.

Forsythe, L.P., Carman, K.L., Szydlowski, V., Fayish, L., Davidson, L., Hickam, D.H., Hall, C., Bhat, G., Neu, D., Stewart, L., Jalowsky, M., Aronson, N., Anyanwu, C.U., 2019. Patient engagement in research: early findings from the patient-centered outcomes research Institute. Health Aff. 38 (3), 359–367. https://doi.org/10.1377/

hlthaff.2018.05067.

Fox, N.J., 2008. Post-positivism. In The SAGE encyclopedia of qualitative research methods 2, 659–664 (Sage).

Gonçalves, O.F., 1998. Psicoterapia cognitiva narrativa: manual de terapia breve [Cognitive psychotherapy narrative: brief therapy manual]. Editorial Psy.

Gonçalves, O.F., Machado, P.P.P., 1999. Cognitive narrative psychotherapy: research ´ foundations. J. Clin. Psychol. 55 (10), 1179–1191. https://doi.org/10.1002/(SICI) 1097-4679(199910)55:10<1179::AID-JCLP2>3.0.CO;2-L.

Gonˆccalves, O.F., 1994. Cognitive narrative psychotherapy: the hermeneutic construction of alternative meanings. J. Cognit. Psychother. 8, 105–125.