Friday, September 26, 2014

The Social Construction Therapy Framework


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Copyright Brian Milliken, LMFT 2014. All rights reserved.

The Social Construction Therapy Framework

Psychopathology can be viewed as stories gone mad, and psychotherapy as exercises in story repair. - George Howard (1991)


In the late 1800's, the field of psychology was developed which was the study "ology" of the mind "psyche" and started an individual approach to resolving human problems.  A classification system was adopted in 1918 to meet the need of the Federal Bureau of the Census for Uniform Statistics from psychiatric hospitals which in the 1950's had developed into the Diagnostic and Statistic Manual for Mental Disorders.  Many therapists use this manual in order to treat disorders of behavior and mood.  

In the 1950's a paradigm shift took place which opened up a new field called Systemic Family Therapy.  This "systems" perspective took human disorders of behavior and mood from an individual psyche perspective to a family systems perspective, which saw the symptoms as tied to family dynamics.  A systems approach to resolving human problems focused on the family stress, rather than viewing the symptom bearer as having an individual disorder.   Family therapy would be used to adjust the family system so the symptom bearer would be relieved of their symptoms.

In the 1980's another paradigm shift took place which is now approaching human problems with a social construction approach.  No longer is an individual psyche or the family system seen as developing disorders that need to be resolved.  This approach views that, when our social constructions no longer work for us, we need to develop new solutions, alternative stories, or find new possibilities of existing with each other.  No longer does the therapist utilize interventions which are "about" the individual or family.  Instead, the therapist collaborates "with" the individual and/or family to co-construct new ways of being.

A Closer Look:  The Three Paradigms of Psychotherapy

Individual psychology looks at how the individual is coping with life. The therapist attempts to change the individual’s cognitions, emotions, and behaviors. Some examples of these models are Gestalt Therapy, Rational Emotive Behavioral Therapy, Person Centered Therapy and Cognitive Behavioral Therapy.

Gestalt Therapy looks at the individual’s emotional unfinished business and barriers to those emotions. If a client has emotions of anger, the therapist would separate those emotions of anger to an empty chair. The client would then start dealing with those emotions of anger. A Gestalt therapy goal, in the individual therapy paradigm, is for the client to break through their negative emotional barriers of unfinished business to process the emotion. The client would be freed up from the negative emotions and start living life more fully again.

In Rational Emotive Behavioral Therapy REBT, the goal is for the client to change their irrational thoughts to more rational ones. lt follows an A-B-C-D format. The client has an activating event (A) and then a belief system (B) of that activating event. If the belief system is irrational, a consequence (C) to that belief system will happen. The goal of the therapist is to dispute (D) the belief system so it changes the consequence. REBT is an individualistic model to therapy, designed to correct irrational thoughts and patterns believed to reside within the individual.

Cognitive Behavior Therapy (CBT) is also in the paradigm of individual psychology. CBT is the integration of behavioral therapy, cognitive therapy, and rational emotive behavioral therapy. Cognitive behavioral therapy and individual psychology theories focus on changing the individual’s thoughts, emotions, and behaviors. For example, behaviorally, the therapist attempts to intervene when it comes to undesirable individual behaviors by classical conditioning, rewards (to reinforce), or punishments, in order to help shape individual behaviors so that they become normal.  

Systemic family therapy, the first paradigm shift, created a variety of models under the same paradigm. These models include Strategic, Structural, Communication, Experiential, and Bowenian etc…

The Systemic Family Therapy perspective is a process that observes a family system and figures out how to intervene within the system of the family. The Systemic family therapy paradigm focuses on interactions between people and the context in which behaviors exist. Systemic family therapy believes, “All behavior makes sense given its context.”  Systemic family therapy utilizes interventions which focus on changing the family system instead of any one individual.  In this viewpoint, client behaviors make sense given the interactions of other people and in other contexts.  Family interactions are viewed as having a certain homeostatic balance. When the homeostasis breaks down and is not working, it means the stress is getting the best of the family system.

Murray Bowen, founder of Bowenian Therapy, believed that when the homeostasis of the family system breaks down, the system is anchored by the identified patient who bears symptoms that recalibrate the system in a dysfunctional way. The identified patient was usually the oldest child in the family who took on the family stress. Bowen viewed the identified patient as being the strongest member of the dysfunctional family system, as they act out so the focus of the stress can be diverted toward a balanced state. .This is how dysfunctional families and functional families came to be identified.  There is a certain norm that the family needs to attain in order to be considered a healthy family system.

Social Construction Therapy is the second paradigm shift, which is essentially an integration of postmodern  models.    The prominent models are Solution-Focused Brief Therapy, Solution-Oriented (Possibility) Therapy, Narrative Therapy, and Collaborative (Language Systems) Therapy.

Social Construction Therapy maintains a systemic view but does not operate within a theory.  Social Construction Therapy is an epistemology which is different than the theory.  An epistemology is a branch of philosophy that investigates the origin, nature, methods, and limits of human knowledge.

Social Construction Therapy assists clients and therapists in exploring different concepts, institutions, and conventions in order to open up awareness to solutions, possibilities and alternative stories. Therapist and client embark on co-constructing a reality to better exist in the world, and there is no picture of what that would be.  The therapy process is active and live, as the conversation unfolds. The therapeutic resolution happens within the process. The process of co-constructing preferred realities starts dissolving problems, building solutions, enhancing possibilities and developing alternative stories.

Theory of Normality

Social Construction Therapy does not have a theory of what the resolutions for the client need to look like. The therapist may be shocked about the change the clients have made by end of the therapy. This is because the therapy process is an active construction and actively happening in the eternal present moment.

Instead of looking at the problem as to who is right or wrong in session, or trying to fit the clients  into a certain theory of being, the process is about what is working and what is not working.  Are the stories working for the clients? Are the solutions working for the clients? Some may be working while some may not.  How can the client and therapist make adjustments for the stories and solutions that are not working?  The therapist may have ideas, but the therapist does not have the answers. The co-construction happens with the therapist and client co-creating the preferred ways together, rather than the therapist maintaining an expert position and dominant theory. The therapist’s process may sound something like, “How are we going to make adjustments to what is happening? Here are some ideas, what are your ideas? How can we shape these things together and then come up with something useful?  As the conversation unfolds, the therapist’s internal and/or external dialogue may sound like, “Wow. Well that was interesting.  I never knew it would go in that direction.  I never knew that would be useful or helpful.” The resolutions are going to be unique each time for each individual, couple, and family.

The Social Construction Therapist will not know which direction the therapy conversation is going to flow when entering into a therapy session. The content will unfold during the active “live” conversation.  The therapist expertise is developing the process with the client towards building a strong connection. How the connection happens with clients depends on the process with the therapist.  The process, if formulaic, can be directive. Insoo Kim Berg stated, “I like to lead from behind.” Listening to the clients and discovering what is useful with them is integral to this approach.

Brief Therapy

Social Construction Therapy tends to be a brief therapy because of how the therapist works with clients. Working from a theory slows down the therapy process, requiring more sessions than if the therapist was working from a place of plausible epistemology.

A traditional therapist is trying to assess the client as it relates to their theory. The therapist has an assessment process of asking pointed questions and using the clients answers to discover problems.  It is a process of problem discovery where the therapist tries to change the discovered problem.  Then, the therapist has to get the client to fit into a certain set of normative criteria.  When some clients don’t fit, there is an encounter of resistance from the client. Breaking through the resistance can take many sessions as the therapist will be in search of compliance. Therapists often blame the longevity of the therapy on the client by saying that the client has a “lack of insight.” Therapists might say, “This client has lack of insight because they are not seeing how their actions, behaviors, and feelings are affecting their life circumstances.” The therapist tries to bring the client along to see how they should be relating to the world. The client may respond with, “What are you talking about?” The therapist is seeing a problem that doesn’t exist or that may be irrelevant as to why the client has entered therapy. Hence, the client leaves the session with more problems as a result of seeing the therapist.  It is the dictatorship of the theory of normality that sometimes will get in the way of change and develop client resistance. Steve de Shazer wrote an article called, “The Death of Resistance.”  He said that resistance is dead because there’s nothing to resist coming from the therapist. There is only a co-construction process with the therapist. The therapist moves with the client in participatory conversation.

It is not the Social Construction Therapist’s expertise to analyze problems through a theory and change the clients in order to fit their theory of normality.  The therapist’s goal is developing a process with the client that fits with how the client wants to work with the therapist.  Different clients with the same issue can come into session with completely different desires for the therapy process.  The client and the therapist may want to discover more solutions together, develop alternative stories, have a collaborative conversation, or discover what’s working and building on those things. The process is very live during each session as the therapist and client are co-constructing together what is needed for the therapy to be successful.

In Social Construction Therapy, it is the client who decides when therapy is completed.  Case closure is the clients decision (client-directed) and not informed by any kind of theory.  The therapist would never say, “Okay you are healthy now and you have my blessing to go.”  Instead the therapist would be more likely to say, “It appears you are doing well.  Do you want to stop the counseling process or make longer intervals between sessions?”  There is no such thing as dropping out of therapy in Social Construction Therapy.  If the client stops coming, they are done.

By comparison, in Structural family therapy, the therapy is viewed as a failure if the structure hasn’t changed and the family does not return to counseling.  The therapy is seen as a failure because the family dropped out before they were able to fit into the structural theory of how the family should be structured.

This kind of failure doesn’t exist in Social Construction Therapy, because both the client and therapist are co-constructing preferred ways of being. The client brings the content as the therapist produces the process to help the client shape whatever co-constructed reality is useful to the client. The process of therapy helps the client figure out what changes or adjustments are going to be made. The client may just feel relief from the therapy process. The therapist’s job is to connect with the client wherever they are at with whatever process the clients prefer.

Language Games

Ludwig Wittgenstein constructed the term “language game” to describe the meanings of words as they are being used. By using the term “game” he emphasizes the fact that language is like a game in which rules are involved and there are often multiple players. A language game is how words are defined by how two or more people, in a particular context, use them. Language is an activity within certain contexts, and is not something that is captured by dictionaries. For example, if we are talking about the word “mouse” we would need to know the context in which the word is being used. The meaning of the word “mouse” as used in computers is entirely different from what a mouse means when it is the rodent the runs around. Different rules of language games are played out as well, depending on the context which exists.  For example, there are certain language game rules which play out in a courtroom setting which would be entirely different in a backyard barbeque; and being a audience member in a lecture has different language game rules than engaging in a two-way dialogue with a friend.

Examples of language games in the mental health field include diagnosing, mental health screening, prescribing an intervention, giving homework assignments, and engaging in a therapeutic conversation. When a therapist diagnoses, the DSM-V is used, in which the therapist locates the appropriate disorder that fits the emotional/behavioral symptoms that matches the client story of the problem. This language game is meant to identify the disorder. Mental health screening is used to validate any diagnosis that the therapist assigns. This language game is meant to legitimize the mental illness story. When the therapist and client converse in session, they undertake a language game in which the client has a possibility of working through the concern that brought them to treatment. A therapist may prescribe an intervention or assign a homework assignment that is related to the language game that occurred during the session.

The difference between a theory approach and a language game approach can be demonstrated with the following driving metaphor: A therapist and a client are in a car (representing the client’s life) where they are discussing difficulties with driving (representing the client living life). In a theory approach, the therapist would take the drivers seat and the client would be in the back seat of the car.  A CBT therapist, for example, would show the client how to drive by where to hold the steering wheel, how to shift, how to steer appropriately, and all the driving techniques that will take the client to the “Land of Rational Thinking.”  In a language game approach, the therapist would be in the back seat while the client would take the drivers seat.  A SFBT therapist, for example, would ask curious questions with compliments, “How are you able to shift so smoothly? I would like you to take us to the ‘Land of Miracles’ so we can see what it is like.  How many miles have we gone and how many more miles is there left to go?” A language game approach does not have any correct answers for the client, but is actively present and co-constructing. Making a switch from a theory approach to a language game approach can be hard for the therapist who is used to operating from an expert theory of resolving problems.

Differences between a theory and a language game:

THEORY                                                                      LANGUAGE GAMES
An idea or set of ideas                                                  No explanations
that is intended to                       
explain facts or events.

An idea that is presented                                              No concern with Truth
as possibly true but that
is not proven to be true.

A language game is a so-of-itself
process of co-construction…

Language Game Rules

There are eight main language game rules that are the foundation of Social Construction Therapy and develop a connection with clients. They are 1) Non-pathology; 2) Respecting Differences; 3) Non-judging; 4) Collaboration; 5) Appreciating clients reality; 6) Being transparent about ideas; 7) Strength-based; 8) Open about preferences.

Using the diagnostic statistical manual of mental disorders involves pathologizing a specific criterion of behaviors.  These problematic behaviors are to be eliminated in the client, in order for him or her to fit within a certain western cultural norm.  The “mental disorder” story involves a western cultural view of all behaviors evolving from a person’s cognitive mental process located somewhere in the individual brain.  These ideas are what psychiatrist R.D. Laing called the “medical model” in his book The Politics of the Family and Other Essays (1971). The aim of treatment in an appropriate “evidenced based” therapy, within the medical model perspective, would be to either have the individual mental disorder be resolved in its entirety or adequately coped with.  The goal is for the individual to rejoin the cultural norms that are more acceptable under a western ideology.  The aim of the medical model is to introduce techniques, interventions and medications to treat the diagnostic pathology ( ie.depression, anxiety, ADHD etc…).

The notion of viewing a client with a disorder, such as Borderline Personality Disorder, and treating that pathology, gets in the therapist’s way of seeing alternative aspects of the clients behavior.  This is because therapists of a medical model orientation are focusing on the disorder and treating it, instead of truly connecting with the client.  The process of treating pathology often gets in the way of actually listening to the client and the concerns that brought them into therapy.  The medical model approach sees clients as having to be treated for a disorder instead of co-creating preferred ways of being with them.

Most cases of voluntary therapy involves a person or persons deciding that they are stuck and unable to free themselves from a concern that has been bothering them.  Treating client  pathology tends to interfere with the creative process of freeing the clients from their concerns.  Jay Haley describes this as crystalizing the concerns that brought them to treatment, making change a much harder and longer process. This process of crystalizing concerns into pathology leads to the therapist disconnecting with the client.  Attention is instead paid to a diagnosis that comes from a certain set of criteria.  The clinician becomes the expert at picking out the appropriate diagnosis for the client which may overshadow many possibilities for change.  This can also interfere with listening to the client’s unique solutions or stories to their situation.

Carl Rogers, as a therapist,  viewed the client differently than from a medical-model position. His approach, known as Person-Centered Therapy, is not a Social Construction Therapy, however some of his ideas are consistent with the main language game rules discussed in this chapter. Person-Centered Therapy is deeply rooted in the idea of Unconditional Positive Regard which is the basic support of a person no matter what he says or does. Rogers believed in creating a condition in which the person can experience personal growth as it exists naturally within the person’s internal resources. Alan Watts book Psychotherapy East and West (1961) discusses Carl Rogers approach as different from a medical model:

He (Carl Rogers) thrusts in the wisdom of the “positive growth potential” of every human being to work out the solution of the problem if only it can be clearly and consistently stated. The therapist himself is “stupid” and “passive” like a Taoist in that he has no theory of what is wrong with his client and what he ought to become in order to be cured. If the client feels that he has a problem, then he has a problem. If he feels that he has no problem, he stops coming for therapy. And the therapist is content in the faith that if the problem is really unresolved, the client will eventually return.   

This approach excels in developing client connectedness with the therapist, but the approach does not take the aspects of social institutions and conventions into account in situations.  Nevertheless, this approach is how a Social Construction Therapist can interact with clients in a non-pathological way when they come in for therapy.

Respecting Differences
When pathologizing processes, it is difficult to respect the uniqueness/differences that each client brings to each session. These differences may appear as sexual, religious, philosophical etc...  Instead of labeling clients, a Social Construction Therapist will flow with the client in conversational language games that produce unique spins on the clients concerns.  The therapist may not have any idea of what solution, alternative story, or possibility may arise given each connective conversation they have in a therapy session.  The therapist realizes each client is unique and is open to any possibilities that may be therapeutic for the client.  Each session opens the opportunity to connect in a way that can alter each participant, including the therapists, ideas, life direction or path.

Social Construction Therapy takes a non-judging attitude with the clients.  The therapist does not have the responsibility of judging whether the client has a disorder or what kind of disorder is to be treated.  Instead, the therapist comes into each conversation with an open mind of what will transcend during the conversational space that is co-created by both therapist and client.  If an idea or certain language game is rejected by the client, the therapist does not force judgment onto the client, or decide that the client is resistant to therapy or being gamey. The therapist respects the client and accepts the rejection, believing that the client knows what they need for a useful conversation. The therapist views the rejection as a misstep within the direction of the language game process.  The therapist then realigns the language game in order to better connect within the clients conversational desires. The therapist approaches each session with compassion and is able to listen effectively to the client in order to build a solid connection.

Collaboration is a way of talking with the client in a non-expert posture.  The therapist is talking with, and being with, instead of talking “at” and “doing to.” Harlene Anderson’s collaborative therapy model focuses on being conversational partners with clients.  The model pays more attention to the process of the conversation and utilizes the content to develop more process.  Harlene calls this, “talking to listen instead of listening to talk”. Harlene wrote:

In my experience, listening is always being in a process of trying to understand what the other person is saying. We try to understand by participating in and responding to what we think the other has said. Participating and responding involve being genuinely curious, asking questions to learn more about what is said (not what you think you should have been said) and checking-out to learn if what you think you heard is what the other person hoped you heard. I make a distinction between responses such as questions to participate in the storytelling that in turn help, for instance, to clarify, expand and understand and responses-such as questions-that seek details and facts to determine things such as diagnoses and interventions or seek to guide the conversation in a particular direction. (Listening, Hearing, Speaking.)

A “talking to listen, rather than listening to talk” approach gives the therapist the opportunity to connect with the client in order to promote therapeutic change.

Appreciating Client’s Reality
A Social Construction Therapist feels passionately about appreciating every client’s reality.  It is through this appreciation that the therapist learns about the ways of connecting with the client.  The therapist is very inquisitive about how the client’s behavior may make sense given their context.  The client’s story and viewpoints are not compared to a norm, or subjected to scrutiny about if they are functional or rational viewpoints.  During conversation, the therapist is interested in co-constructing preferable possibilities, solutions, and stories with the client.  The appreciation of the client’s story and viewpoints help to open up a good listening connection.

Being Transparent about Ideas
Being transparent is essential when building the connection with clients. During sessions, the therapist presents ideas to the client as thoughts that may or may not work.  For example, the therapist may introduce an idea of anxiety being a wave, which has a beginning and an end.  A tidal wave of anxiety would be a panic attack.  The therapist can suggest that the client flow with the anxiety wave to decrease the anxiety.  The client may like this metaphor or not. The therapist might get more information through the conversation that will change the direction of the ideas.  The therapist might even express, “I do not think I agree with what I said before.”  Then the therapist and client can continue to move in another direction.  For instance, if the therapist finds out later that the client is in a hostile work environment, the anxiety would make sense given the context.  The client may not want to go with the wave of anxiety in such a setting and instead want to change the context.

Social Construction Therapy views clients as strong, resilient, and resourceful.  Being strength-based helps increase the client’s personal agency. Personal agency means the client has confidence in their ability to make their own decisions and recognizing their strengths/potentials toward achieving better life paths.  The therapist's attitude is that of an outside-witness asking curious questions and entertaining ideas about the client's abilities and potentials.  When inquiring about these things, the therapist is in a position to learn valuable life lessons out of what they both co-create.  This increases their connection, since the client is valued, rather than seen as someone incapable of handling their challenges without the help of an outsider. The client may establish a new sense of hope and faith in themselves as a result of the connection with the therapist.

Open about Preferences
Being open about preferences is another way of keeping the connection open with clients.  When a client states that they want a particular approach to counseling that the therapist is uncomfortable with, the therapist can be open about their counseling preferences.  The client can then make an informed decision about their own therapy.  Cognitive Behavioral Therapy is very popular throughout the United States.  It is important for the Social Construction Therapist to be open about having certain disagreements about approaches like Cognitive Behavioral Therapy.  A Social Construction Therapist can inform clients that Social Construction Therapy will address their cognition, and it can assist in changing their behavior.  However, the therapy views problems as socially constructed rather than psychologically created and maintained.  It does not view clients as having irrational beliefs as it believes in a strength-based (the solution lies with the client) view of clients.    If the therapist views the client as irrational, as in CBT, and also believes the solution lies with the client, the therapist would be engaging in double-bind communication that would subsequently make the clients situation worse.

Language Game Maneuverability

A good therapy session with clients depends on entering the right kind of language game with them.  If the clients motivation or desire is to get straight to the solutions, then a Solution-Focused language game may be the best way to proceed.  If the client’s issue is more politically problem focused, Narrative Therapy may be the best language game choice. A language game may change during a session, depending on the flow of the conversation.  Many times the therapist may start with being collaborative then to switch to solution-focused which may lead to a more narrative conversation.  For example, the therapist can start the conversation with the question, “Is there anything you would like to talk about today?  If not, I could lead the conversation by asking you a few questions.”  If the client states that they have something that they would like to talk about, then the therapist may enter into a collaborative dialogue around what they want to discuss.  If they want the therapist to lead the conversation, the conversation would be more scripted and begin with leading questions.  With the latter, the therapist may begin with leading a solution-focused language game by asking about any pre-treatment change or successes followed with the miracle question, exception questions, etc… Sometimes the solution-focused language game lasts for about 30 minutes out of a 50 minute session.  Then, the client may become more relaxed and want to engage in another language game. Part of the client’s desires for therapy may involve getting coping skills from the therapist.  “Getting the coping skills” would be an indication for the therapist to enter into a solution-oriented language game that would entertain different ideas about how the situation or pattern can be approached differently.  The client may be given homework to experiment with.  If the client discusses having a certain mental disorder that needs to be treated, then the therapist may switch to a narrative therapy language game that would include externalizing the mental disorder concept. At the end of each session, the therapist can either give them a session rating scale or simply ask if it was a useful conversation in order to gauge the compatibility of the language game process for future sessions.

We can view the utilization of any of the social construction models, their lines of questions, and what we pay attention to, as all part of conversationally connecting with the client.  Whether we decide to externalize the problem or develop a miracle with them, it is always most powerful when we do not force our language game upon the client.  It is essential that we listen to which language game our client is open to, and do our best to engage in that language game process with them during the conversation.

We have to stay empirically sound while we flow in and out of different language games. The flow would be inconsistent for the therapist to be building solutions with a client while asking questions that indicate the client has an irrational belief system from a cognitive behavioral perspective.  A solution-focused position that views the client as resourceful, strong and capable is completely incompatible with a position that views the client as irrational and needing to be straightened out by a more rational human being.  This would be breaking the Social Construction Therapy language game rules of being strength-based.  Again, our role as Social Construction Therapists is to increase the client’s personal agency through the therapist’s connection and process with the client.  However, solution-focused can be combined with a narrative position because both are consistent in believing the client is resourceful and capable.

A therapist will still run into clients that are difficult.  Some clients may be difficult when they feel that they have failed to resolving problems on their own.  This may come out in sarcasm, defensiveness to alternative ideas, trying hard not to be in agreement etc… The therapist will have to try to maintain maneuverability.  A good position for a therapist to take, in this circumstance, is the one-down position.  This means that the therapist should not try to argue their position with the client.  This can be done by simply saying, “Every client is different and what works for one client may not work for another.  So if you have any reservations about the direction this conversation is going we can always change it.”  Usually the clients will appreciate this statement and will start to understand the Social Construction Therapist is not there to judge them.

To quote Bruce Lee:  “Be like water making its way through cracks. Do not be assertive, but adjust to the object, and you shall find a way around or through it. If nothing within you stays rigid, outward things will disclose themselves. Empty your mind, be formless. Shapeless, like water. If you put water into a cup, it becomes the cup. You put water into a bottle and it becomes the bottle. You put it in a teapot, it becomes the teapot. Now, water can flow or it can crash. Be water, my friend.

Connection with clients by therapeutic maneuverability is a very important component in therapy.  It is important to remember that a therapist can integrate different models to connect with the client’s language game as long as they are models that are consistent with each other in sharing certain language game rules.  The therapist must stay consistent so as to not confuse the client with mixed messages. There may be some difficult clients to connect with.  Embracing a non-expert social construction stance with them may increase the probability of connection, by not forcing, but yielding and staying present, like water, my friend.