By Kiersten Anderson, MSW, LICSW, OSW-C 

Cancer threatens not only one’s health and life, but also one’s sense of self. As Cohler (1982) aptly described, “a traumatic illness such as cancer threatens a person’s cohesive sense of past, present, and future – otherwise known as the personal narrative.” Cancer and its treatment effects can interrupt life plans, alter social roles and functioning, and create acute uncertainty, often leading to hopelessness and cancer-related distress (Bhattacharjee, 2013; Curbow et al., 1990). These disruptions can erode one’s sense of self, overshadowing the “preferred stories” of identity and life (White, 2001). Narrative therapy, a form of psychotherapy centered on life stories, offers cancer patients and survivors opportunities to reclaim and reauthor their personal narratives, helping them reconnect with a broader, richer sense of self beyond the “problem story.” 

Externalizing Cancer and Cancer-Related Effects 

A core principle of narrative therapy is externalizing conversations. Patients often arrive to therapy engaged with a “single story” — a narrow, rigid narrative in which they are defined by their illness. As White (2007) noted, “people come to believe that their problems are internal to their self,” accepting them as “truths” about their nature and character. In oncology, we hear this often: “I’m just a statistic now,” “I am a burden to others,” “People will only see me as a cancer patient.” These problem-saturated stories can eclipse pre-existing identities, trapping patients into a cancer-defined self. 

Externalizing conversations offer an antidote by separating the problem from the person: “the problem becomes the problem, not the person” (White, 2007). For example, Susan*, a patient struggling with Fatigue, experienced significant self-judgment and loss of purpose. Once a self-described “go-getter,” she now spent much of her day on the couch, grieving the perceived loss of her identity and feeling powerless. Without intervention, this belief system reinforced itself and fostered feelings of hopelessness (which we later externalized as “the Doom and Gloom”). 

To facilitate externalizing, oncology social workers can guide patients through structured questions via Michael White’s (2007) statement of position map: 

1. Name and describe the problem: Begin to separate the problem from the person; make it an external presence (e.g., “What is it like when Fatigue shows up? How do you know it’s there? When does it usually show up?” “What does Doom and Gloom sound like?”) 
2. Explore the effects: Map how the externalized problem affects different parts of life (e.g., “How does Fatigue affect your energy, relationships, and sense of self? How does it affect what you want to do or how you see yourself?” “What does Doom and Gloom try to convince you about yourself or the future?”) 
3. Evaluate the effects: Invite the patient to take a position on whether they like or don’t like the problem’s activities (e.g., “Is Fatigue pulling you toward or away from the life you want? How do you feel about its impact?” “When Doom and Gloom stops you from reaching out or doing what matters to you, how do you feel about that?) 
4. Justify the evaluation: Uncover the values, hopes, or dreams behind why they evaluate the problem the way they do (e.g., “What does your frustration with Fatigue reveal about what matters to you; about the kind of person you are?” “What does it suggest about what’s important to you that you don’t like sitting on the couch all day?” “What does your anger toward the Doom and Gloom say about who you want to be?”)

As patients separate from the problem-saturated story, they regain a sense of personal agency and a renewed capacity to shape their lives. In Susan’s case, these questions helped distinguish her identity from Fatigue and uncovered her deeper values, setting the stage for re-authoring conversations. 

Listening for the Sparkling Stories 

Re-authoring conversations are grounded in the idea that we are all “multi-storied” — no single story can fully define a person (Carey & Russell, 2003). A key technique is double listening, in which the clinician looks for moments, actions, or thoughts that contradict the problem story. These are known as subordinate storylines, “unique outcomes,” or “sparkling stories” (White, 2007). By highlighting these moments, we begin to explore preferred identity stories and co-create narratives that better reflect patients’ values and reconnect with their sense of self.  

To help initiate re-authoring conversations, oncology social workers can use questions that draw out these unique outcomes and develop new stories:  

1. Locate unique outcomes: Find moments when the problem did not dominate. (e.g., “Can you tell me about a moment this week when you felt most like yourself?” “When did you do something despite the Fatigue?” “How have you stopped Doom and Gloom from getting worse?”) 
2. Explore the meaning of unique outcomes: Connect unique outcomes to personal values, hopes, or commitments. (e.g., “What do you still work hard for?” “What does making dinner, despite Fatigue, say about you?” “What qualities in you made this possible?”) 
3. Trace the history of the preferred story: Find past examples that show this identity and/or qualities are deeply rooted. (e.g., “Has working hard always been important to you?” “Were you raised in an environment where perseverance was valued?” “When have you been proud of your ability to persevere?) 
4. Reimagining a future linked to the preferred story: Help the patient envision future actions, possibilities, or next steps that support their preferred story. (e.g., “What would it look like to continue working hard while caring for your health?” “How might you measure success now by your commitment rather than the outcome?”)

Re-authoring conversations create space for patients to reconnect with values, strengths, and parts of their identity that may have been overshadowed by illness. In Susan’s case, she began to recognize the small ways she had resisted Fatigue, even when it was difficult. This opened up the possibility that she still had agency — not only in her actions, but in shaping her preferred story. Through re-authoring, Susan reclaimed the ability to define her narrative, rather than allowing cancer to do so. 

Narrative therapy is an important intervention in the field of oncology social work, as it aims to honor patients’ full identities, not just their diagnoses. Research has shown that narrative therapy can even be offered as a brief intervention, with rich and meaningful stories often emerging within a single session (Young, 2006). While a cancer diagnosis can threaten a patient’s sense of self, narrative therapy helps protect personal narratives and empowers patients to continue shaping their stories, even in the face of illness. 

If you’re interested in talking about narrative therapy and using this approach in your practice, please email me at kanderson37@mgb.org.  

References 

Bhattacharjee, A. (2013). Self-concept of cancer patients: A comparative study. Voice of Research, 1(4), pp 40-43. https://www.voiceofresearch.org/doc/Mar-2013/Mar-2013_8.pdf.  

Carey, M. & Russell, S. (2003). Re-authoring: Some answers to commonly asked questions. International Journal of Narrative Therapy and Community Work, (3), pp 19-43. Re-authoring: Some answers to commonly asked questions.  

Cohler, B. J. (1982). Personal narrative and the life course. In P. Bates & O. Brim (Eds.), Life span development and behavior (Vol. 4, pp 205-241). New York: Academic Press.  

Curbow, B., Somerfield, M., Legro, M., & Sonnega, J. (1990). Self-concept and cancer in adults: Theoretical and methodological issues. Social Science & Medicine, 31(2), pp. 115-128. https://doi.org/10.1016/0277-9536(90)90053-U.  

White, M. (2001). The narrative metaphor in family therapy: An interview with Denborough, D. In D. Denborough (Ed.), Family therapy: Exploring the field’s past, present & possible futures. Dulwich Centre Publications. 

White, M. (2007). Maps of Narrative Practice. New York: W.W. Norton & Company.  

Young, K. (2006). When all the time you have is now: Narrative practice at a walk-in therapy clinic. When All the Time You Have is NOW: Narrative Practice at a Walk-In-Therapy Clinic – Narrative Approaches.