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Where's the gimmick? Future prospects for constructivist psychotherapy.

There is a scene in Gypsy--the Styne-Sondheim-Laurents musical about stripper Gypsy Rose Lee--in which three jaded burlesque queens give the young Louise advice about how to succeed in show business. It's not really about talent, they explain, it's about finding the right gimmick: "You can bump in a dump till you're dead," but "you gotta get a gimmick if you wanna get ahead." Anyone paying careful attention to the shifting trends in the field of psychotherapy might come to a similar conclusion. Over the years, clinicians have been attracted to a long succession of enticing methods, including Rogers' (1951) nondirective reflection, Wolpe's (1958) systematic desensitization, Frankl's (1963) paradoxical intention, Stampfl's (1970) implosive therapy, Janov's (1970) primal scream, Peris' (1973) empty chair technique, Selvini Palazzoli's (1986) invariant prescription, de Shazer's (1988) miracle question, Shapiro's (1995) eye-movement desensitization (EMDR), and--our l atest obsessions--anything with attachment (e.g., Johnson & Whiffen, 2003) or mindfulness (e.g., Germer, Siegel, & Fulton, 2005) in the title.

Historically, practitioners have been more attracted to the techniques themselves than the theories on which they are based. For example, many clinicians using Perls' empty chair exercise know nothing about his writings on Gestalt theory. Similarly, of the dozens of therapists who have adopted Steven Hayes' Chinese finger trap demonstration, only a handful have read the relational frame theory that justifies it (Hayes, Strosahl, & Wilson, 2012). Given such facts, it seems clear that the popularity of many schools of therapy is more attributable to the novelty of their methods than the elegance of their theories or the superiority of their results. In fact, once investigator allegiances are taken into account, differences in therapy outcomes are hard to come by (Wampold, 2001)--the equivalence of treatments turns out to be one of the most robust findings in the entire psychological literature (Hubble, Duncan, & Miller, 2009).

We mention all this as a prelude to addressing the editors' two main questions: First, why hasn't personal construct therapy (or its derivatives) become more popular and, second, are there aspects of these approaches that still deserve our time and attention?

PERSISTENT MISINTERPRETATIONS

To begin at the beginning, we should note that shortly after his mammoth two volumes on personal construct theory (PCT) appeared in print, Kelly (1955) began grumbling that his ideas were falling on deaf ears, being misinterpreted, or both. Of course, this was to have been expected--given that, at the time, academic psychology was in the midst of a love affair with learning theory, and psychoanalysis ruled the roost in mental health. Kelly's theory was out of step with both of those traditions. It was also at odds with the only other model gaining momentum at the time--the "third force" humanism of Rogers, Maslow, and Perls.

Further, Kelly upset some readers by throwing the notion of learning overboard altogether and dispensing with most other familiar concepts, such as ego, emotion, motivation, reinforcement, drive, and the unconscious. This set the stage for some highly original psychological theorizing but made his views harder to digest. To make matters worse, he declined to bolster his arguments with empirical evidence or provide detailed references.

His reluctance to situate his ideas in a larger theoretical context bothered the two psychologists who first penned reviews of Kelly's volumes--Carl Rogers (1956) and Jerome Bruner (1956). While expressing admiration for his originality, they both struggled over how to locate his ideas in existing psychological space. Bruner, for example, wrote that "one misses reference to such works as Piaget's The Child's Construction of Reality, the early work of Werner, and the writings of Harry Stack Sullivan, Lewin, and Allport" (p. 357). He wondered why Kelly would not have availed himself of these potentially "good allies." Rogers, too, commended Kelly's willingness to "launch out on his own" (p. 358) but criticized his dogged reliance on his own experience.

These first two reviews also contained harbingers of the misinterpretations that have plagued PCT ever since. Rogers, for example, critiqued Kelly's therapy as being overly intellectual, lacking in depth, and leaving little room for developing "an emotional relationship with a client" (1956, p. 358). Ironically, he also faulted Kelly (the inventor of personal constructs) for not having greater faith in his clients' personal constructions.

Bruner, too, found Kelly's approach ultra-cognitive, accusing him of "failing to [deal] convincingly with the human passions" (p. 357). He wrote that "If Freud's clinical world [was] a grotesque of fin de sicle Vienna, Kelly's [was] a gloss on the post-adolescent peer group of Columbus, Ohio." Because so many considered Kelly's approach too cerebral, he once quipped that he was going to have to write a second book to clarify that he "wanted no part of cognitive theory" (1969, p. 216). He was also forced to battle those who insisted on labeling him an existentialist, a dialectical materialist, a psychoanalyst, a Zen Buddhist, and--much to his amusement--a learning theorist. Even authors of personality texts who wanted to include a chapter on PCT were often puzzled about which section to put it in.

A MORE POSITIVE RECEPTION

Kelly took comfort in the fact that his writings received a better reception overseas than in America. European psychologists--less caught up in the logical positivism that was sweeping the States--seemed receptive to his "softer," more philosophical approach. To this day, PCT has had more impact in Europe and Australia than in the States.

Perhaps it was this compatibility between Continental psychology and Kelly's thinking that prompted him to spend his 1960 sabbatical year meeting with groups of psychologists in 37 countries, including England, Denmark, Germany, Russia, Finland, Iceland, and Sweden. (2) When he returned, he complained that Ohio State doctoral students were far too parochial. Therefore, he initiated a project to send all Ohio State clinical students abroad for a second internship year. First, they would do a regular internship stateside, absorbing a full "dose" of this country's mental health practices. Then, they would spend an additional year in Europe, immersed in the psychology of another culture. Although the project never got off the ground, it illustrates the value Kelly placed on having individuals--even lowly psychology trainees--expand their construct systems.

An exception to the generally cool American response occurred during a successful visit to Harvard. When he returned to Ohio State, a beaming Kelly made sure to tease his advisees for being "slow" to grasp the full implications of his approach. Cambridge types, he boasted, were far quicker on the uptake!

TOO MANY DETAILS

In addition to those who considered Kelly's approach overly intellective, some complained about what might be called an embarrassment of riches. They were put off by the prospect of studying Kelly's "ten types of weeping," "nine techniques for reducing anxiety," "twelve techniques" for prompting movement, and "fifteen criteria" for establishing client readiness (Rogers, 1956, p. 358). By the same token, they had difficulty figuring out how to integrate his eclectic list of techniques. At a minimum, these included assigning behavioral activities, offering interpretations, exploiting the transference, reflecting feelings, analyzing dreams, playing back session tapes, and helping clients tighten and loosen their constructs. Whereas Rogers' one-size-fits-all approach seemed excessively narrow, Kelly's catalog of possibilities was utterly overwhelming.

For comparison, consider the relatively succinct narrative approach of White and Epston (1990). They devised two "signature" procedures, each with several secondary elaborations. First, they suggested externalizing the client's problems, sometimes using cute personifications. For instance, they labeled a child's enuretic struggles "sneaky wee" (p. 194). Second, they recommended writing formal letters to clients, summarizing what had happened in the previous session and proposing a plan for going forward. Both of these methods were easy to grasp, novel, intuitively appealing, and widely applicable. Without such "gimmicks" it is unlikely that the White and Epston brand would have gained as much traction.

Similarly, Albert Ellis' (1993) bombastic style and arsenal of catch phrases (e.g., "must-urbation" and "awfulizing") helped catapult rational-emotive behavioral therapy (REBT) to the top of the therapy hit parade (Simon, 2007). Although many thoughtful clinicians dismissed his approach as too dogmatic and rationalistic, it attracted many novices because they could pick up the basics at an evening seminar or a weekend workshop. Unfortunately, PCT has no such crowd-pleasing "hooks." Therefore, it tends to be ignored.

THE FIXED-ROLE GIMMICK

Despite their misgivings about other aspects of Kellyian therapy, both Rogers and Bruner applauded the fixed-role procedure as a genuinely creative therapeutic departure. It is as close as PCT comes to having a bona fide gimmick. (3) Briefly, fixed-role therapy invites clients to participate in a time-limited experiment in which they role play somebody else. Although clients continue answering to their real name (to avoid confusing family and friends), they act and react as if they are this other person. The role they play is designed by a team of psychologists with extensive knowledge of the case. It usually includes subtle reframings of the client's self perceptions. For instance, clients who considered themselves "shy" might be asked to play someone who is "thoughtful." Thus, they might still be reserved, but their low participation level is now construed in terms of speaking when you have something to contribute, rather than remaining quiet because you fear rejection.

While immersed in the fixed-role experience, clients meet regularly with their therapist to work out any ambiguities in the role description. At the end of the agreed-upon time--usually about a month--the individual "returns from vacation" and has a chance to reflect on how life appeared when seen through this alternative set of lenses. Kelly was emphatic that the purpose of the fixed-role exercise was not to replace a defective personality with a healthier persona, but to help individuals experience new aspects of themselves and the world.

Unfortunately, the fixed role method is not suitable for routine use. First, doing it "by the book" requires a committee of professionals who can craft adroit role descriptions. Second, the client has to be willing and able to attempt this rather odd and demanding experiment. Therefore, at least in terms of gimmicks, PCT and its derivatives remain at a competitive disadvantage.

SEEKING PRACTICAL GUIDELINES

Many of us had high hopes that Michael J. Mahoney's (2003) book, Constructive Psychotherapy: A Practical Guide would rectify the situation. The title promised the kind of "how-to" guide for which many of us had been waiting. Unfortunately, the book was a dud. If anything, it reinforced the view that constructivist therapy is an amorphous conglomerate of ill-defined procedures. He advised, for instance, that constructive practitioners "draw on the full spectrum of therapeutic and teaching techniques," adding that this "creativity and spirit cannot be formalized in a particular procedure" (p. 58). In other words, no gimmicks!

Mahoney does describe lots of interventions, from stream of consciousness techniques to having clients study their mirror images. However, these seem to be an eclectic hodgepodge of procedures rather than a disciplined methodology. For instance, in one bizarre incident, he reports instructing a distraught workshop volunteer to place his finger on his own forehead, then on his abdomen, and then back on his forehead. After Mahoney and the volunteer repeat these gestures three times, slowly and in synchrony, Mahoney says "I don't know if this will be helpful or not, but I would encourage you to practice [this] whenever you begin to feel distressed" (2003, p. 186). That evening, the chairperson of the conference asked Mahoney how he knew to do this and where workshop attendees might read more about the technique. Mahoney replied that he had never done anything like it before, adding: "I don't know why I did it, or what it means." Such spur of the moment impulses, devoid of either empirical support or theoretical justification, are bound to leave potential converts adrift in a sea of ambiguity.

Even some of us who studied directly with George Kelly felt the need for a set of simple, concrete guidelines. Thus, before embracing PCT, the first author experimented with using Wolpe's (1958) systematic desensitization (SD). It was a brand-new methodology that was getting a lot of attention. However, a research project in which the author was involved demonstrated that SD's underlying theory was flawed. The same outcomes could be achieved just as easily using a pseudo-conditioning procedure that had been designed to purposely violate the laws of learning on which SD was presumably based (Marcia, Rubin, & Efran, 1969; Woy & Efran, 1972). Thus, the successes of SD seemed mainly due to the fact that clients had an opportunity to reevaluate their beliefs. This idea--that therapy is a place for clients to test their perceptions accords with Kelly's notion, unique at the time, that therapy is basically a "protected laboratory where hypotheses [can] be formulated, test-tube sized experiments [can] be performed, field trials [can be] planned, and outcomes [can be] evaluated" (1969, p. 229). In this case, clients were given a chance to learn more about the snakes and spiders they had previously avoided.

At the time, however, defining therapists as "research consultants" wasn't very popular. It clashed with the field's strong commitment to the medical model and the disease-entity approach. Mental health workers classified psychotherapy as a "treatment," thereby committing what philosopher Gilbert Ryle (1949) called a "category mistake" (p. 16)--that is, placing something in the wrong conceptual envelope. Category mistakes vastly complicate our attempts to understand what we do because they invoke a set of concepts ill-suited to the task at hand. Although it is true that the term "psycho-therapy" literally means "mind treatment," Thomas Szasz (1988) reminded us long ago that therapy is basically rhetoric--not medicine. Therapists do not apply ointments, prescribe medications, or perform surgery. They do not cure any diseases, even if these have been relabeled "disorders" to make the venture seem more plausible.

Therapists listen to and tell stories, pose questions, propose options, and encourage inquiry. Furthermore, because therapy is dialogue, improvisational elements must always be a part of the process. Unlike pharmaceuticals, therapeutic discourse cannot be dispensed in tidy, standardized doses. Each client-therapist interaction is a unique collaboration with partially unpredictable results. Ironically, although research studies keep reaffirming that therapeutic outcomes are largely attributable to client and therapist characteristics and the alliance they establish, the medical model compels us to keep writing cookbook-like manuals and devising new and glitzier gimmicks (Hubble et al., 2009).

THERAPY AS RESEARCH

Although the idea of the therapist as a research consultant never caught on, we consider it an aspect of constructivist therapy that is well worth preserving and perhaps promoting more loudly. Kelly's model of small-scale, client-centered investigation incorporates the virtues of the scientific method without lapsing into a rigid and inappropriate scientism. In addition, this therapy-as-research model has a surprisingly contemporary flavor, fitting nicely with today's renewed interest in idiographic studies and single case designs (e.g., Barlow & Nock, 2009; Barlow, Nock, & Hersen, 2009).

Lately, even CBT practitioners have tried to lay claim to the research mantle, arguing that the homework they assign provides clients with opportunities to test their beliefs. However, because it is grounded in metaphysical realism, CBT assignments are mainly designed to show clients that their thinking is irrational. Thus, the outcomes are more or less preordained. By contrast, Kelly eschewed such fake investigations--he wanted clients to know that he was a "fellow experimenter, not an unctuous priest" (1969, p. 53). He favored genuine research, knowing full well that it involved the risk of blind alleys and unpredictable outcomes. Furthermore, because Kelly understood that many alternative life pathways are legitimate, he refrained from prejudging his client's thoughts or thought processes.

Like any good investigator, Kelly knew that good research requires a good research question. Trivial, academic, or poorly framed questions can stymie the process. He also understood that clients do not necessarily need better answers to their announced questions. Often, they simply need better questions. In our own work, we test that proposition by asking clients what they would tell a friend who had a similar problem. We find that in response to that task, most clients voice the kinds of advice that some therapists would have otherwise wasted time dispensing. For example, clients who ask about how to lose weight, stop smoking, or avoid procrastinating frequently know more than the therapist about the latest diets, nicotine patches, and study strategies. Similarly, couples who begin by saying that they need to learn to "communicate" soon prove that they are experts at predicting each other's responses. Thus, their problem cannot be communication, per se. They know exactly what their partner is thinking--they just don't like it. So, before going down these investigatory paths, it is important to check whether the question at hand is a substantive issue.

We submit that Kelly's notion of therapy as research, skillfully done, is a workable framework for the constructivist therapy of the future. It is the first of our suggestions for modernizing practice. The second concerns the need to strengthen the focus on social context.

BRINGING BACK CONTEXT

Both the medical model and the pharmaceutical juggernaut have perpetuated a decontextualized view of individuals. There was a brief period when many clinicians were persuaded that mental health problems had systemic roots and that family and communal influences needed to be taken into account (e.g., Bowen, 1978; Minuchin & Fishman, 2004; Nichols & Schwartz, 1995). However, now that the heyday of family and systems therapy is over--the Family Therapy Net-worker had to be renamed The Psychotherapy Networker--we have reverted to a near-exclusive emphasis on the individual (Efran, Lukens, & Greene, 2007). This has been a persistent weakness of PCT. Kelly's supporters correctly note that he never entirely ignored the social milieu. On the other hand, perhaps because he wrote during the era of individual treatment models, he never fully transcended the "personal" aspect of personal constructs.

Overlooking context is a major detriment. Over a century ago, philosopher Wilhelm Dilthey (cited in Prus, 2000) recognized that meaningful human behavior is contingent on communal interaction and cannot be understood as a series of individual, decontextualized elements. Yet, that is exactly what many therapists are still trying to do. For example, CBT therapists treat "maladaptive thoughts" as if they were freestanding entities that could just be plucked out of the person's psyche and replaced, one-by-one, with healthier cognitions. This overlooks the all-important communal narrative from which such thoughts emanate (Burns, 2012).

Interpersonal conflicts largely arise because people are members of overlapping "clubs," each with its own membership requirements. As essayist Mignon McLaughlin (1960) explains, "It's impossible to be loyal to your family, your friends, your country, and your principles, all at the same time" (p. 58). Although the conversations that define our lives seem to take place in our heads, they actually constitute a kind of social dance that takes place in communal space (Efran & Fauber, 1995). Thoughts and images are not just private possessions--they are the tools of social negotiation. When the choreography is going well, it is a smooth waltz and we are barely aware of the linguistic machinations we use to sustain our relationships with others. However, if things go awry, we become self conscious, lose the beat, and begin stepping on toes. If things get really awkward, people seek therapy! This is why Szasz described symptoms as "declarations of [social] independence and dependence" (1973, p. 88-89) made by individuals experiencing the strain of conflicting group loyalties.

As we have implied, earlier forms of PCT short-changed these contextual issues. By contrast, we explicitly define therapy as a place to investigate contradictory role demands and determine which club affiliations clients might want to preserve and which they should modify or abandon. To do this research, it helps if clients understand that all of their beliefs are man-made--not decrees from on high or direct reflections of reality. Constructivist therapists are ideally positioned to communicate that message. They recognize that anything said by a human being is said from a tradition (Varela, 1979) and that all such assertions reflect the "real or imagined demands of [constituencies] that exist in the person's experience" (Efran & Fauber, 1995, p. 283). In helping clients make this shift from realism to constructivism, we often quote Kelly's dictum that "whatever exists can be reconstrued" (1969, p. 227). Like the Zen notion of "detachment," Kelly's mantra helps clients recognize that their "certainties" are just strongly held beliefs.

Because we are dealing with club affiliations, a factor that affects the success of the therapeutic collaboration is the degree of similarity between the backgrounds of client and therapist. In this connection, we like Szasz's (1973) depiction of the psychotherapist as a kind of court jester. Jesters had to be familiar enough with the mores of the court to be able to understand the king's plight but cosmopolitan enough to envision fresh solutions. If the jester was too mired in the court culture, he would not have the perspective he needed to do his job. Also, by playing the fool, the jester could be granted enough leeway from court etiquette to challenge the king's most cherished beliefs (without losing his head). Therapists, too, need sufficient detachment to broach touchy subjects without permanently damaging the therapeutic alliance.

After all, effective therapy research requires that everything be open to question. There can be no sacred cows. Clients have to be able to freely voice thoughts that might constitute heresy elsewhere. Too much club overlap can inhibit that process. Thus, we have to be wary whenever client and therapist are of the same gender, religion, ethnic group, social class, profession, sexual orientation, political persuasion, and so on. From our perspective, pastoral counseling is not always the best option for a religious individual and feminist therapy can inadvertently constrain a female client. By the same token, we reject the conventional wisdom that addicts should always be seen by recovering addicts and gay clients must be seen by gay therapists. Again, the ideal arrangement is for the therapist to comprehend the club traditions but not be wedded to them.

At a conference years ago, we were amused to hear a gay client report that he had consulted three different therapists--one gay, one straight, and one bisexual. Each urged him to be what they were--gay, straight, or bi. Presumably, the field has progressed since those days, but we still need to be on the alert to the danger of overlapping backgrounds hindering exploration.

Because individualism is such a strong bias in our culture, contextual factors are easily overlooked. Consider, for a moment, the successes of CBT. These are typically attributed to cognitive and behavioral retraining. Yet, they are probably due to contextual factors--particularly unnoticed shifts in communal rhetoric. Psychotherapy critic Robert Fancher (1995) points out that CBT inducts clients into a particular subculture that peddles a series of healing fictions as scientific truths. "By becoming a member of this [therapeutic] culture, one gets to believe an overly simple, inaccurate, optimistic notion of how minds work and what simple methods of empirical logic can accomplish" (p. 214). However, the CBT message--as American as apple pie--is enormously appealing to clients. Therefore, even though the method rests on scientific hokum, it often succeeds in boosting client morale and encouraging proactive behavior.

Kelly, too, realized that "preposterous interpretations" (1969, p. 54) are sometimes effective. To work, they must "account for the crucial facts as the client [sees] them" and "[carry] implications for approaching the future in a different way." Note that these are the very same ingredients that make White and Epston's (1990) letters to clients effective. It makes one wonder if all therapies succeed because they create a novel "club" in which the participants agree on an explanation for the client's plight and a plan for moving forward (Frank, 1973).

To reiterate, our proposed revision of constructivist therapy uses Kelly's therapy-as-research model as the framework and focuses on the exigencies of social context as the content. We next propose borrowing several concepts from Maturana's theory of structure determinism (Maturana & Varela, 1987) to modernize our understanding of therapeutic change.

RATIONAL SUPREMACY AND THEORIES OF CHANGE

Humberto Maturana is a renowned biologist and cyberneticist whose ideas are fully compatible with the constructivist stance. His concepts of orthogonal and instructive interaction are useful additions to our traditional views, streamlining our understanding of therapeutic change.

Most people--including many therapists--subscribe to what constructivist Mahoney (1991) called the "doctrine of rational supremacy" (p. 446). This is the belief that "reason and rationality can and should control everything 'below' them in the human organism." Fancher (1995) considers this "one of the grand myths of western culture" (p. 244). Of course, if it was really true, dieting would be a snap, Alcoholics Anonymous could close up shop, and the $11 billion self-help market would dry up overnight. Counseling would be a breeze. Therapists would merely review the facts with their clients, and they would then venture forth and live happily ever after. Obviously, it doesn't work that way. Smart people do incredibly stupid things, and even those who pride themselves on their "willpower" stumble badly on the road to self improvement. It is not that such folks have secret motives for staying ill or derive some perverse pleasure from thwarting helpers. Few of them wake up each morning thinking up new ways to mess up their lives. Contrary to public opinion, all of us come by our problems honestly and do our best to solve them (Gregson & Efran, 2002).

The problem is that the doctrine of rational supremacy seduces us into accepting a flawed theory of change. As Maturana (1988) explains, change is not about having a superior intellect or great self discipline. It is about orthogonal interaction. In a nutshell, it occurs when a system component bumps into a non-system component and is modified by that interaction. Consider an auto mechanic who adjusts the gap of a spark plug. When the adjusted plug is reinserted in the engine, the car runs more smoothly. In this example, the spark plug is a component of the engine and the mechanic is the non-system component with which it temporarily interacts. Their exchange is orthogonal--literally, at right angles--to what normally happens to spark plugs when they are seated in the engine (Efran, Lukens, & Lukens, 1990).

A fictional example may help clarify the issue. In A Christmas Carol (Dickens, 1843/1991), Ebenezer Scrooge is visited by the spirits of Christmas past, present, and future. These three spirits engage him in interaction that is thoroughly orthogonal to his everyday experiences. Therefore, when dawn arrives, he emerges as a transformed individual who then automatically interacts differently with everyone he meets. Because most individuals have no access to Dickensian apparitions, they have to make do with a therapist. Nevertheless, orthogonal interaction is the principle at work in both settings.

Years ago, the first author treated a young man who was trying to come to grips with his homosexuality. During one of their sessions, the author suggested that he go to see Harvey Fierstein's Torch Song Trilogy (which was playing on Broadway at the time). As the reader may know, Fierstein's trilogy depicts various aspects of the gay lifestyle in touching, humorous, and insightful ways. The client agreed that seeing the show might be a good idea, but he complained that he could neither afford the price of the ticket nor the train fare to New York. The author replied, "That's why I intend to pay for both!" Although a bit flabbergasted at first, the client accepted the offer. The trip turned out to be a turning point in both his therapy and his life. He had grown up in a small town and had a very limited and very negative perception of what it meant to be gay. The show was an eye-opening experience. However, it was the audience's enthusiastic response that made the biggest impression on him. He had not imagined that theatregoers of different sexual orientations would respond so positively to gay themes.

This vignette illustrates orthogonality at many levels. The therapist's monetary offer illustrated that rules are meant to be broken and that life does not always need to follow the same predictable pattern. It also demonstrated that even mental health professionals can be flexible, inventive, and determined to achieve their goals. In case the reader is wondering, paying for this client's trip ultimately proved cost effective because of the large number of referrals this client provided.

Of course, Kelly didn't use the concept of "orthogonal interaction," but he certainly argued that clinicians were too rule-bound, especially given how little we know about which interventions might work. Why do sessions have to be scheduled at weekly intervals? Why do they have to last 45 or 50 minutes, even if the client and therapist have little to talk about? Neither surgeons nor shoe salesmen would agree to such ridiculous constraints. In our own work, the pace of the project determines when we schedule meetings--not the clock or the calendar. Thus, we have had sessions as short as fifteen minutes and as long as four hours. We have seen clients as often as two days in a row and as infrequently as once every several months.

Again, orthogonal interaction takes many forms, both in and out of the consulting room. As Kelly surmised, living in a foreign culture can be a life-altering experience for many. We recall an individual whose life plan changed dramatically following a near-fatal rowboat accident. Another person left his wife of twenty years after a chance encounter with his former high-school sweetheart. These sorts of orthogonality generate change, but the myth of instructive interaction virtually guarantees that the change produced will not turn out exactly as planned (Efran & Lukens, 1985). In fact, predicting the exact effect of any particular orthogonal event is next to impossible. The problem is that the nervous system operates only on internal correlations. Therefore, although it can be "triggered" by an environmental event, it cannot be "instructed" by external forces. In other words, you can turn out the bedroom light but cannot force yourself to fall asleep. Parents can punish their children for leaving toys around, but this will not necessarily instill a passion for neatness.

Cyberneticist Gregory Bateson used to challenge his learning-theory colleagues with a tale about a mother who rewarded her daughter with ice cream whenever she ate her spinach. He then asked these psychologists what they needed to know to be able to predict whether the daughter would grow up (a) loving spinach, (b) hating ice cream, or (c) hating her mother. Of course, it would only be possible to make an accurate prediction if instructive interaction really existed.

If it did, teachers would not need to bother with classroom tests. They could simply provide students with the relevant information and be confident that everyone "got it." As Maturana points out, the only place where true instructive interaction exists is in the fable of King Midas. Because he did a favor for the god Dionysus, King Midas was granted his wish that whatever he touched would turn to gold. He soon discovered that this wasn't such a great idea. For instance, anything he wanted to eat turned to gold before he could ingest it. One day he made the mistake of touching his daughter, and she turned to gold. Maturana comments wryly that the tragedy of King Midas is that he could never become an analytic chemist! Chemistry, of course, depends on substances reacting in their own characteristic ways to the chemist's probe. If they all reacted similarly, the science of chemistry would grind to a halt. Although electricity "triggers" both toasters and coffeemakers, their responses to that trigger are different--toasters toast and coffeemakers brew (Efran & Lukens, 1985).

Because instructive interaction is mythical, the best any therapist can do is make educated guesses about the kinds of orthogonal interventions that might generate a desired effect. Such guesses are often correct because they are based on our past experience with ourselves and other people (including clients). However, nothing is surefire. Even experienced therapists have their surprises, which is what makes being a therapist continually challenging and infinitely interesting.

A client the first author saw early in his career returned years later to thank him for what they had accomplished. This individual said that during one of their sessions, the author had said something truly inspirational. He wrote it down on a piece of paper and has carried it with him ever since. Hearing about this, the author was breathless with anticipation to see what this "gem" of therapeutic legerdemain might be. Perhaps it could work similar miracles with other clients. At this point, the ex-client proudly took a tattered slip of paper out of his wallet, carefully unfolded it, and showed it to the author. It said, "Every cloud has a silver lining." Huh? That was the earth shattering nugget of therapeutic wisdom the client had been carrying around all these years? What about the hard-won therapeutic insights discovered during our sessions? To tell the truth, the author was chagrined to think that he had ever uttered such a lame cliche, and still more dumbfounded to learn that this was the moment the client remembered. Yet, we could multiply such surprising incidents ten-fold.

For instance, a socially anxious elementary school student, being treated as part of a Temple University research project, was asked which aspects of her therapy had been the most important. She immediately cited the time her therapist tripped over a wastebasket that had been left in the hallway. Why was this so important? She noticed that when the therapist stumbled, several people came to her assistance and none of them laughed or made fun of her for being clumsy. That incident--more than any of the manualized exercises they did together--convinced the girl that people are allowed to make mistakes!

What works magically with one client may have no effect on the next, and--as we have said--there is no guaranteed way of knowing in advance which bit of orthogonality might do the trick. Thus, Adlerian Harold Mosak tells his trainees that "if one tactic, response, or interpretation does not work," move right on to the next (Mosak & Maniacci, 1998, p. 3). He also teaches that even though a trainee may not always know what to do, he or she can be sure that there is always something that can be done. Orthogonality is always a possibility.

On the other hand, because change requires novelty, merely listening empathically to the client's story, week after week, is not apt to produce dramatic results. In fact, research shows that short-term or time-limited approaches are more effective than long term therapy, and initial sessions are more impactful than later meetings (e.g., Sharma, 1986). We propose that this is because as clients and therapists accommodate to each other, it becomes more difficult to generate orthogonal input. Woody Allen, who has been in analysis for over thirty years, was fond of saying that he could not imagine being out of treatment. Of course, he added quickly, he could not imagine changing either!

Because therapists tend to lose leverage over time, we begin intervening right away, postponing any detailed history-taking for later. We start by inquiring about the client's "upset"--the event that prompted him or her to pick up the phone and make an appointment. There may be other background problems, but therapies that do not deal effectively with the initial upset are not likely to be successful. Like Szasz' court jester, our goal is to demonstrate that we grasp the problem and have some idea about how to go about "fixing" it. Similar to the content of the White and Epston letters, we make an educated guess about the current circumstances and offer a tentative investigative plan. If we are successful, the client should leave that first session (a) feeling understood, (b) experiencing some symptom relief, (c) agreeing to an initial therapeutic contract, and (d) eagerly anticipating what comes next.

We have described how Maturana's concepts can help constructivists understand the dynamics of change. To have an impact, client therapist collaborations must generate orthogonal interaction. One of the simplest ways to do this is through the creative use of language.

WORD PLAY

Aldous Huxley (1940/1962) wrote that "words have the power to mold men's thinking, to canalize their feeling, [and] to direct their willing and acting" (p. 2). Fresh metaphors and novel distinctions galvanize attention and invigorate conversation. For instance, in first sessions with couples, we frequently accuse them of engaging in a "conversation of recrimination, accusation, and characterization" (Efran, Lukens, & Lukens, 1990, p. 185). Never having heard that expression before, they are all ears. This gives us an opportunity to emphasize the differences between the blame game and a problem-solving dialogue. We explain that these are two separate conversational domains with entirely different purposes. They cannot take place simultaneously. The couple soon becomes proficient at hearing when they shift from one domain to the other, and they begin to self monitor their nonproductive discourse. Of course, we could have just said, "The two of you are arguing again," but that phrasing would not have had the same punch.

A youngster once told well known child therapist Haim Ginott that he did not want to go to school. Ginott replied, "Is that your considered opinion?" The boy was thrilled to discover that he not only had an opinion, but that it was a considered opinion! By the time they got back to talking about his school fears, they were no longer positioned as adversaries. Ginott's phrasing was orthogonal to what the boy was expecting to hear from an adult, and that made all the difference.

In our clinical work, we have gotten great mileage out of distinguishing between the "mind" and the "self." Because we have described this linguistic maneuver elsewhere (Efran & Soler-Baillo, 2008), we will only touch upon it lightly here. Following Smothermon (1979), we define "mind" as the totality of the person's survival mechanisms and defensive postures. By definition, it is fear-driven and risk-averse. When people operate from mind, they are focused on winning, dominating, and being right. The self, on the other hand, represents our connection to others and to the larger community. A person operating from self is more interested in contributing than dominating; more interested in living than surviving.

Everyone has both a mind and a self. The trick is to keep them in balance. The mind is always worried about what it perceives as dire consequences. Therefore, whenever it grabs the microphone, it overreacts and drowns out the voice of the self. Metaphorically, we can say that successful therapy consists of lowering the mind's volume control. When we discuss the mind and the self with clients, we also invoke a series of subsidiary distinctions that empower them to untangle their relationship quandaries. For instance, we discuss the differences between mastery and avoidance, and we distinguish between living "at cause" (as the responsible party) and living "at effect" (as the victim). Again, it helps that many of these phrasings are a bit offbeat.

Constructivists should be receptive to this emphasis on linguistic subtlety, recognizing that it is in language that problems are created and resolved. Note that even seemingly unbearable circumstances do not become "problems" until someone--using words and symbols--says so and someone else agrees. In other words, to have a problem, you have to make something of something! Similarly, it is the client who says when a problem ceases to exist--when his or her questions have been answered.

CONCLUSION

The prospects of constructivist therapy are, of course, tied to the overall state of the therapy market. And, given the current economic downturn and the increased influence of the pharmaceutical industry, the news is not good. Recently, a piece in the New York Times (Gottlieb, 2012) suggested that the only therapists prospering are those who have carved out trendy specialties for themselves. The article suggests that therapists hire branding consultants. Who knew there were such things?

If constructivists had such a consultant, he or she would probably suggest immediately ditching the constructivist moniker as a label that has lost its cachet. These days, few are startled to learn that reality is as much invented as discovered (Watzlawick, 1984). Furthermore, the distinctiveness of the constructivist brand has been eroded by its shameless appropriation by therapists of other persuasions. Consider the following quote from cognitivist Donald Meichenbaum (1993): "It is not as if there is one reality and clients distort that reality ... rather, there are multiple realities, and the task for the therapist is to help clients become aware of how they create these realities and of the consequences of such constructions" (p. 203). Even Ellis (1993), toward the end of his career, discreetly climbed aboard the constructivist bandwagon.

An attendee at last year's Psychotherapy Networker Symposium summed it up nicely. He noted that soon none of our therapy school affiliations will matter because CBT will have gobbled up all of the competition, having "oozed" over the mental health landscape like a giant amoeba. Indeed, we already have a Mindfulness-based CBT and an Emotion focused CBT (Suveg, Kendall, Comer, & Robin, 2006). Despite the incompatibility in world views, this leaves little doubt that there will soon be an "official" Constructivist CBT.

In fact, very few therapy brands retain their identities, their purity, or their popularity. Consider Eric Berne's (1972) transactional analysis (TA). It was once a hot topic on the talk-show circuit, and the TA organization had established an international network of training centers. Now, it is practiced in its original form only by a shrinking band of devoted followers. Similarly, we rarely hear much about William Glasser's (1965) reality therapy or Yalom's (1980) existential approach. The integrationist movement (Strieker & Gold, 1993), introduced in the '70s, continues to limp along, neither capturing market share nor being completely overlooked. Even psychoanalysis, once the King of the Hill, has been reduced to a mere shadow of its former self, remaining viable mainly in large metropolitan areas. Against this backdrop, the current status of constructivist approaches hardly seems surprising.

As we have argued, PCT has always been a tough sell. With the possible exception of the fixed-role procedure and Kelly's grid technology, it lacks the pat formulas and nifty gimmicks that have boosted the popularity of other modalities. Kelly's thousand pages may contain clinical jewels, but mining these is not a task for the faint at heart. Then, too, PCT came along at a time when behavior therapy, psychoanalysis, and the humanistic approaches were battling it out for the upper hand--and PCT got lost in the shuffle. Before it could get a secure foothold, it was dismissed as a limited, cognitive approach that failed to adequately address clients' emotional lives.

Kelly himself predicted that even if PCT was wildly successful, it would--like any good theory--sow the seeds of its own destruction. He felt that it would be quite an achievement if it lasted one or two decades before being replaced by something more elegant. He modestly talked about it as a "theoretical vessel" (1969, p. 95), designed to launch a voyage of discovery. He was clear from the outset that those aboard were free to turn back at any time or to search for something more seaworthy. Personally, we are not yet ready to jump ship. Instead, in this chapter, we have recommended several updates to the ship's aging navigational equipment.

In brief, our four recommendations are (a) to highlight the notion of therapy as a research enterprise, (b) to focus squarely on issues of interpersonal context, (c) to adopt Maturana's theory of change, and (d) to use novel linguistic distinctions to generate orthogonality. These proposals are probably not catchy enough to qualify as therapy gimmicks, and it is doubtful that any such suggestions will propel constructivism into the mainstream of contemporary practice. However, these revisions are necessary correctives that will improve how constructivist therapy is practiced and enable it to keep up with changing times.

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(1) The authors thank Elsa R. Efran for her editorial assistance.

(2) The reader might want to consult the intriguing account of this sojourn that he presented at the 1962 Nebraska Symposium on Motivation (Kelly, 1962).

(3) PCT does contain a gimmick that we have not yet discussed--the Role Construct Repertory Test. This has been a boon to researchers and, like fixed-role therapy, is an element of the theory that has enjoyed independent, sustained success. In the clinic, it has proven valuable for a multitude of diagnostic and assessment tasks and has become even more useful now that computer programs have simplified the analysis of grid data. However, because this chapter focuses on therapy rather than assessment or research, we will not say more about this measurement technology, except to note that, once again, it shows how a concrete tool can enhance the popularity of a theory.
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Title Annotation:PART III: CONSTRUCTIVIST PSYCHOTHERAPY
Author:Efran, Jay S.; Cohen, Jonah N.
Publication:Studies in Meaning
Date:Jan 1, 2015
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