constructivism

Report
Therapeutic intervention in two worlds
Tom Hofmann, PhD, LCSW, LMFT, CEAP, CPP
Caroline Hofmann, MS, CAP
Theoretical Background
 Medical Model:
 Positivism: Everything will be measurable
 Essentialism: DSM Criteria
 Strength Based:
 Constructivism
 Positive Psychology: Taxonomy of Virtues (Seligman &
Peterson, 2003).
Constructivism
Medical Model and Strength Based:
“At Odds”
 Narrative Therapy: “A deconstructionist position entails empowering clients to subvert
taken-for-granted mental-health definitions and practices” (Carr, 1998, 487).
 Hypnotherapy Ripple Effect: “symptom formation is viewed as the blowing of a fuse in
an overloaded electrical circuit; removal of a symptom (according to this analogy) is like
removing an essential fuse and thereby precipitating a more serious conflagration
elsewhere” (Spiegel & Linn, 1969, p. 91).
 Solution Focused Brief Therapy: “SFBT is a paradigm shift from traditional
psychotherapy focus on problem formation and problem resolution that underlies almost
all psychotherapy approaches since Freud” (De Shazer et al., 2007, p. 14).
 Brief Strategic Therapy: “Typical of the brief/strategic therapist is the avoidance of an
elaborate theory of personality or of dysfunction” (Cade & O’Hanlon, 1993, p. 5).
 Insurance Company: If the patient is so strength based why should we
pay for treatment?
Can we use both approaches—Without
irrevocably compromising SB tenets?
 Theoretically positivism------constructivism and a
taxonomy of virtues------taxonomy of diagnoses
are opposite ends of their respective continua.
However
 Integrated approach. Moderate constructivism
(Wong, 2006)
 On the continuum, some things are more agreed upon
by all observers, some are from a more flexible reality.
There is an app for that!
Problem oriented
Medical model
language
Solution focused
Strength based
language
Use constructivist frame. Or……
 Work with the client using a strength based approach
and language.
 Work internally with diagnostic criteria and deep
techniques such as CBT core beliefs, and systemic
triangulation. These guideposts light the way for
direction to take with the client.
Approach 1: Framing the
“pathological”
 Diagnoses can be seen as “coping behaviors” with a
positive intention.
 Positive intention underlies much dysfunctional
behavior.
 Can we frame a positive intention and the virtues
being used in a particular instance, even if it is now
used to a dysfunctional end?
Ego Defenses
 Dissociation-Leave an untenable situation when you have
no power to do so.
 Introjection-Agree with someone more powerful in order
to survive.
 Projection-It feels much better to put a disturbing insight
onto another person.
 Denial- Keeps disturbing content from haunting us.
Diagnoses
A negative core belief that fuels the “coping
technique” was probably helpful at one point.
 Generalized Anxiety-Staying alert to the constant
threat.
 Depression-It is a survival mechanism to stop trying
or have hope.
 Substance Abuse- Temporary gain of soothing.
They are on the same continuum!
 A virtue can be at either extreme in the helpfulness of
the outcome. So can the behaviors of a diagnosis.
 Example: “Co-dependency” can be thought of as
combining virtues of persistence, love and hope.
 A matter of degree, not a label. How can you do this
less, or more?
Inductive Approach 2: De Shazer’s
Constructivist Assumptions
 “Assumption one: Complaints involve behavior
brought about by the client's world view” (De Shazer, 1985,
p.23).
Constructivist Assumption #2
“Assumption Two:
 Complaints are maintained by the client's idea that
what they decided to do about the original difficulty
was the only right and logical thing to do. Therefore,
clients behave as if (italics mine) trapped into doing
more of the same (Watzlawick et al., 1974) because of the
rejected and forbidden half of the either/or premise”
(De Shazer, 1986, p. 25).
Constructivist Assumption #3
 “Assumption three: Minimal changes are needed
to initiate solving complaints and, once the change
is initiated (the therapist’s task), further changes will
be generated by the client (the ‘ripple effect’) (Spiegel
and Linn, 1969)’ ” (De Shazer, 1986, p.33).
Constructivist Assumption #4
 “Assumption four: Ideas about what to change
are based on ideas about what the client’s view of
reality might be like without the particular
complaint” (De Shazer, 1986, p.38).
Constructivist Assumption #5
 “Assumption five: A new frame or new frames
need only be suggested, and new behavior based on
any new frame can promote clients’ resolution of
the problem.” (De Shazer, 1986, p. 39).
Constructivist assumption #6
 “Assumption six: Brief therapists tend to give
primary importance to the concept of wholism: A
change in one element of a system or in one of the
relationships between elements will affect the other
elements and relationships which together
comprise the system” (De Shazer, 1986, p.43).
Strength Based Theory and
Practice
 Solution Focused Therapy - Solution talk
 Motivational Interviewing – Evoke From Honest
Struggle
 Narrative Therapy - Sparkling Narrative
Possible drawbacks
 How to get assessment data?
 How to get a diagnosis?
 How to discuss problems?
 What happens to the assessment/assessment
summary/diagnosis/goals continuum?
Key Assessment Methods for less
“digging”
 Seligman and Peterson Virtues: Encourage spontaneous sharing.
 Prochaska and DiClemente Stages of Change (Velicer, Prochaska,
et al., 1998).
 This helps us to hone in on the client's motivation, and enhance
sharing.
 Self-efficacy = Can I do it? X Do I want to?
 This helps us formulate a clients motivation for a certain change.
Key Assessment Method
 Avoid righting reflex! Neutral stance. Encourage
ambivalence.
Looking for? :
Inconsistencies in reports
Lack of consistent objective evidence
Objective parties with a concern
Legal Evidence
Use in hazardous situations: Pregnancy,
physical health
Problematic use following a treatment
SASSI, Audit, Audit-C, DAST-Ten, CAGEAID (Pichot & Smock, 2009)
Key Assessment Data
 Miracle Question,
 Scaling,
 And Circular Questioning
 Indirectly reveal assessment data (Pichot &
Smock, 2009)
The Spirit of Motivational
Interviewing
 Partnership with the client
 Acceptance of the client
 Compassion
 Evocation (clients have solutions in them, we just
call them forth)
(Miller and Rollnick, 2013, p.14-24).
Tenets of Solution Focused
Therapy
 “If it isn’t broken don’t fix it.”
 “If it works, do more of it.”
 “If it’s not working, do something different.”
 “Small steps can lead to big changes.”
 “The solution is not necessarily directly related to the
problem.”
 “The language for solution development is different from that
needed to describe a problem.”
 “No problems happen all the time; there are always exceptions
that can be utilized.”
 “The future is both created and negotiable.”
(De Shazer et al., 2007, p. 1-3)
Therapeutic Principles and
Techniques of SFT
 “A positive, collegial, solution focused stance” (De Shazer
et al., 2007, p. 4).
 “Looking for previous solutions” (De Shazer et al., 2007, p. 4).
(Including before session)
 “Looking for exceptions” (De Shazer et al., 2007, p. 4).
 “Questions versus directives or interpretations” (De
Shazer et al., 2007, p. 5).
 “Present and future-focused questions versus past-
oriented focus” (De Shazer et al., 2007, p. 5).
 “Compliments” (De Shazer et al., 2007, p. 5).
 “Gentle nudging to do more of what is working” (De
Shazer et al., 2007, p. 5).
Narrative Reframing-Externalizing
 Problem becomes objectified and specific questions
can be asked.
 Problem is less fixed and more open to change.
 Problem is not the person.
1.
Ask client to give the problem a name.
2.
Identify ways the problem has affected the client.
3.
Ask for times when the problem was not active or was overcome.
4.
Develop plans to further minimize the problem, using client and
allies.
Bibliography
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Cade, B. & O’Hanlon, W.H. (1993). A brief guide to brief therapy. New york, NY: W.W. Norton and co.
Carr, A. (December,1998). Micheal White’s narrative therapy. Contemporary Family Therapy, 20 (4) 485-503.
Cepeda, L.M. & Davenport, D.S. (2006). Person-centered therapy and solution-focused brief therapy: An integration of
present and future awareness. Psychotherapy: Research, Practice, Training, 43 (10. 1-12.
De Shazer, S. (1986). Keys to solution in brief therapy. New York: WW Norton and co.
De Shazer, S., Dolan, Y., Korman, H., Trepper, T., McCollum, E. & Insoo Berg, K. (2007) More than miracles: The state
of the art of solution focused (brief) therapy. New York: Routledge.
Miller, W.R. & Rollnick, S. (2013). Motivational interviewing: Helping people change. New York, NY: Guilford Press
Pichot, T, & Smock, S. (2009) Solution-focused substance abuse treatment. Routlege: New York, NY.
Seligman, M.P., & Peterson, C. (2003). Positive clinical psychology. In L. G. Aspinwall & U. M. Staudinger (Eds.), A
psychology of human strengths (pp. 305–318). Washington, DC: American Psychological Association.
Spiegel, H. & Linn, L. (1969). The "Ripple Effect" following adjunct hypnosis in analytic psychotherapy. American
Journal of Psychiatry, 126 ,(53-58).
Velicer, W. F, Prochaska, J. O., Fava, J. L.,Norman, G. J., & Redding, C. A. (1998) Smoking cessation and stress
management:
Applications of the Transtheoretical Model of behavior change. Homeostasis, 38, 216-233.
Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles of problem formation and resolution. New York:
WW Norton and co.
Wong, Y. J. (2006). Strength-centered therapy: A social constructionist, virtues-based psychotherapy. Psychotherapy,
43, 133-146.
Handouts
 Seligman and Peterson’s 22 virtues
 Prochaska and DiClemente Stages of Change

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