Systems of Psychotherapy: A Transtheoretical Analysis

1. Systems of Psychotherapy:A Transtheoretical Analysis Chapter 15. Constructivist Therapies

2. A Sketch of Constructivist Therapies • Constructivism: one cannot attain knowledge of reality that is objective or independent of knower • Constructivism ≠ nihilism; real things exist, but we cannot access reality outside of language • Constructivism vs. empiricism • Clients cannot be reduced to universal principles to explain personality or pathology • Part of postmodern movement

3. Precursors to Constructivist Therapies • Found in many theoretical orientations, including psychoanalytic and behavioral • George Kelly’s personal construct therapy: seeing humans as curious, amateur scientists who actively construct their worlds • Roy Schafer’s new conceptualization and language for psychoanalysis: a constructivist position that emphasized narrative tradition

4. Two Influential Constructivist Therapies • Solution-focused therapy (SFT) (Insoo Kim Berg) • Narrative therapy (Michael White)

5. Solution-Focused Therapy: Personality & Psychopathology • Assumption: people are healthy & competent • Focus on solutions rather than problems • Real causes of psychopathology can never be known • Knowing the cause of a problem does not mean you have the cure • Solution-focused, not problem-oriented

6. Guidelines for Constructing Goals • Positive (what behavior will replace the old behavior, positive alternatives) • Process(focus on how change will occur) • Change what happens in the present • Must be practical and attainable • Are specific • Must be client controlled • Set in the client’s language

7. Therapeutic Processes • Consciousness raising: more conscious of problem exceptions; solution talk (not problem talk); miracle question identifies exceptions • Choosing • If it works, don’t fix it. Choose to do more of it • If it works a little, choose to build on it • If nothing seems to be working, choose to experiment

8. Pathways for Constructing Solutions • Small changes lead to larger changes • Each solution is unique • Solutions evolve out of conversations • Language is our reality Same pathways build solutions with mandated or involuntary clients

9. Methods with Involuntary Clients • Discover what client wants • Define what will satisfy the referring person • Talk in terms of solutions, not problems • Find past and recent successes • Determine what will repeat exceptions • Ask about the next steps in achieving goal • Ascertain how others will scale progress • Assist client in establishing sufficient treatment

10. Therapeutic Relationship • Shift focus from problems to solutions • Ignites client initiative, improve use of their response-ability • Clients are experts on goals to construct • Clinicians are experts on the process & structure of therapy • Relationship is a multidisciplinary collaboration toward a shared solution

11. Practicalities of SFT • Time-effective tx usually lasts 3 to 5 sessions • Focus on solutions is tightly maintained • Designed to start, not finish, the solution process • Client continues solutions after therapy ends • Applied to virtually all disorders & all tx formats • Frequently employed in coaching, education, & substance abuse • Training is widely available

12. Narrative Therapy • Clients construct their past by stories they tell in the present • Past can be changed by constructing new narratives or stories • “Reality” is our stories • Narrative therapists are antirealists: There is no objective reality behind our stories

13. Personality & Psychopathology • Empirical theories of personality can be oppressive & even destructive • Empiricism tells clients who they are • Narrative therapist asks clients who they are and who they want to be • Narrative therapists reject theories of personality and psychopathology • Construct new stories & thus new meanings

14. Therapeutic Processes • Change emerges from de-constructing old stories & constructing new, liberating ones • Consciousness raising: become aware how stories were constructed by others (dominant discourse) • Choosing: plot alternative story to overcome the dominant discourse; use post-session letters • Counterconditioning: externalize old problem; use new, fuller words; become authors of own stories

15. Therapeutic Relationship • Each relationship is unique, not predetermined by theories or principles • Nothing can be generalized from one client to another • Therapist gently guides clients into constructing new, more liberating stories • Therapists contribute to the “reality” of a story by narrative empathy

16. Practicalities of Narrative Therapy • Initially introduced in family therapy • Used for children, adults, couples, families, & communities • Length typically varies • 50-minute sessions • No rigid boundaries

17. Effectiveness of Constructivist • Meta-analyses of SFT, but most studies neither controlled nor randomized • SFT conclusions: superior to no treatment, frequently briefer and less costly than alternatives, small to medium effect sizes • Few RCTs on effectiveness of narrative therapy; under-researched • Narrative exposure therapy consistently demonstrates cost-effective, medium effects on reducing trauma

18. Criticisms of Constructivist • From a Cognitive-Behavioral Perspective (lack of controlled research, small effect sizes in existing research) • From a Psychoanalytic Perspective (a central theory is necessary, reality is ignored) • From a Humanistic Perspective (can be ironically dehumanizing) • From an Integrative Perspective (no need to choose between constructivism and empiricism)

19. Future Directions • Retained popularity in academia and with students • Enlightened response to evidence-based practice • Extensive criticism and deconstruction of traditional DSM/ICD diagnosing • Short-term constructivist should prosper in era of shrinking healthcare resources • Will need to produce empirical evidence on its cost-effectiveness

20. Key Terms anti-realism constructivism constructivist therapies counterconditioning deconstructing dominant discourses empiricism evidence-based practices exception-finding questions exceptions externalization of problem goal focus miracle question narrative empathy narrative exposure therapy (NET) narrative therapy narratives personal constructs postmodern privileged position problem talk reminiscence therapy scaling question social constructivism solution focus solution-focused therapy solution talk

21. Recommended Websites • European Constructivist Therapy Network: www.pcp-net.org/ectn/ • Dulwich Centre (Narrative Therapy): www.dulwichcentre.com.au/ • Personal Construct Psychology: www.personal-construct.net/ • Solution-Focused Brief Therapy Association: www.sfbta.org/