Constructivism in Psychotherapy: Part I,II

Robert A. Neimeyer , Ph.D., é Professor e Director of Psychotherapy Research no Departamento de Psicologia da Universidade de Memphis, onde mantém também prática clínica. Esta entrevista teve lugar a 18 de Outubro de 2010 em Lisboa, com contributos de M. Gonçalves. Está segmentada em 6 blocos temáticos - que perfazem cerca de 50 minutos-, e um sétimo segmento final de abertura aos participantes. São abordados os seguintes temas:
Part I - Constructivist Psychotherapies distinctive features and evolution;
Part II -  the empirically supported treatments and manuals;
Part III-  psychotherapy schools and approaches;
Part IV -  the Integrationist movement and Psychotherapy evolution;
Part V - the Constructivist Grief Therapy approach;
Part VI - the training in psychotherapy
As questões dos participantes,  Part VII - Elaboration o loss, Buddhism, being a psychotherapist, compassion, everyday losses.

Transcrição de A. Ganho e T. Alfama. Tradução de A. Santos. Produção e Edição Video e Audio de Vasco Henriques.

Part I - Constructivist Psychotherapies distinctive features and evolution;

A.H.: Robert, thank you so much for willing to have this conversation. You say about post-modern constructivist therapies – and I’m quoting you – that in general they tend to be more collaborative than authoritarian, more developmental than symptom oriented, more process oriented than content focused and more reflective than psychoeducational. You have just published recently a book on the distinctive theoretical and practical features of constructivist therapies … so, could you tell us shortly about some of these distinctive features, if you want to pick some among others…
 
R.N.: Well, the book that you mention Aníbal is in a series that concerns different Cognitive and Cognitive-Behavioural approaches to therapy. And so, I was especially asked to distinguish Constructivism from these other approaches - approaches like Beck’s or Linehan’s or the Rational-Emotive Behaviour therapy, the work of Meichenbaum and others. And fortunately this was easy to do because at levels that ranges from the epistemological premises of Constructivism on through its specific strategies of engagement with a client and even particular techniques that are preferentially used by constructivists its pretty comprehensibly different. And so at virtually any level at which you would like to hold the lens of inspection over the contrasts between constructivist work and cognitive-behavioural work you would see differences that are substantial. At an epistemological level of course, various constructivist approaches are joined by the assumption that we do not have a kind of access to reality, to the furniture of the universe in a simple sense.
 
A.H: Do you believe in furniture?
 
R.N.: The furniture of the universe, including the literal furniture. It supports us and we have a relationship to it. But that relationship is very much mediated by our structure, by our functioning - the way in which we construct ways of relating to one another, for example on the way we configure these chairs to support us, to support a certain kind o conversation. The way we construct other technologies in order to meet our purposes. So our interaction with the world is deeply humanized, it is deeply integrated into our structure as individuals and particularly as social systems, as intersubjective pairings as in our conversation here today. So, in all of these ways when constructivists think about intervention we think about intervening in meaning and not merely in intervening in the objective circumstances of people’s lives, although therapy of course that may also embrace change at very practical levels and actual oriented levels in addition to the level of our deepest meanings, feelings, reflections on self and others and so on.
 
A.H.: Ok, so do you think contemporary psychotherapy somehow has been or is being influenced by constructivist theories, metatheories and practices and if yes to what extend is this recognized nowadays? 
 
R.N.: I think that the impact of constructivism is more subtle. It occurs at nearly a cultural level that I believe that in post-modernity we have largely relinquished the assumption that we have easy access to the truth of human beings. And in this stance then which certainly extends far beyond constructivist therapy - into expressions in the domain of art and even science – we have assumptions that really provide a premise or foundation for all of our cultural life that are deeply constructivised. Constructivist psychotherapy participates in those movements and gives them specific expression in the context of the helping relationship and also more generally in terms of the pursuit of research programs that tend to be more reflective, more “qualitative”, that treat the so called subject as a data contributor. And so, in psychological science - and most particularly in psychological practice - constructivist theory does shape the way in which we engage the work of psychology.
 
A.H.: Ok. So, we know for sure that there is a constructivist paradigm but is there or was there any time a constructivist movement among clinical practitioners and researchers? And if yes how well is it breathing today?
 
R.N.: Yes, in fact there’s a very important contribution being made at an organizational and institutional level by a friend of mine who lives in Lisboa (laughs)…
 
A.H.: Oh yes? (laughs)…
 
R.N.: I think you should interview him some day because I think he has a lot to say about this question these questions! And in this respect you would be one of several people who anchor developments in their respective regions and countries – one can find them for example with people like Les Greenberg in Canada, Robert Elliott now in Scotland,  Guillem Feixas, Luís Botella, and others, Guerreiro, Manuel Villegas in Barcelona, numerous constructivists in Italy, in Chile, in Argentina, in Mexico. So in one region after another one would find vital centres of constructivist thought and training. But I think it is fair to say that in few of these places has constructivism competed successfully with dominant cognitive-behavioural approaches for a place in the academy – that is in the University structure. There, the pride of place, the priority, the hegemony is usually claimed by cognitive-behavioural approaches.
 
A.H.: And for empirically supported treatment. So you think that this movement did it reached its strongest moment and influencing in the nineties or is now less strong?
 
R.N.: Oh, I think its still building. No doubt the next decade will be better than the one before. I say that with some humour but also with the sense that in some ways the shift toward a constructivist ethic – if you will – in psychotherapy has changed its focus somewhat. 

Whereas during the decades of the nineties and much of the current decade there have been a series of conferences organized around constructivism. Many books, some journals devoted to constructivist thought - such as the journal of constructivist psychology. What we have now is something that is a broader kind of diffusion of constructivist themes into many approaches, into many models. So if you look at the work of people like ....  and Young within the cognitive paradigm, you have people who are moving closer and closer to a constructivist view with respect to attention to deep meaning, schemas, tacit knowing. When you look at the field of family therapy, in particular brief therapy you see many people such as my late colleague and friend Michael White, David Epston - still living and contributing – and others, helping shape the narrative therapy movement. When you look at brief therapy approaches you see people like Michael Hoyt who are clearly constructivist in their orientation and explicitly so. And of course, Bruce Ecker who you, not long ago also, invited here and I suppose also interviewed.  So I think that what we have is not so much an organization of constructivists that are requiring people to sign their identity cards and salute the same flag but more a kind of giving a way of constructivist themes. A subtle influencing of many perspectives – humanistic, psychodynamic, systemic and more – which I think is ultimately the healthier contribution to make to culture.
 

Part II - the empirically supported treatments and manuals;

A.H.: You mentioned the mainstream, the cognitive-behavioural therapy. I will change the topic now to the empirically supported treatments. What’s your position about the empirically supportted treatments movement? How should the constructivist movement position itself regarding this trend? Shall it play the game of the EST or shall reject it? And either way what is the possible impact of empirically supported treatment in the constructivist paradigm? 
 
R.N.: I’d say the answer to your question is largely YES. That is we should do all of the above! That we should position ourselves as the loyal opposition to approaches that seek a kind of hegemonic control over therapy, that seek to have just a certain list of approved methods or ways of working and others are disallowed. Because we know from the work of Wampold and many others that the evidence based strongly supports psychotherapy, probably more efficacious for psychological and psychiatric conditions than psychotropic medication for example. And yet there are very few distinctions that can be drawn empirically and defended among different approaches to psychotherapy, even for quite specific problems. And when differences are observed they’re typically trivially small and they vanish completely when you take into account investigator allegiance. That is when you look at the researchers commitment to proving their theory right and constructing some kind of a non-credible alternative with which to compare in order to demonstrate their superiority. When one takes into account statistically these allegiance effects, these biases then any differences among the therapies are mitigated to the point of vanishing completely. So I do think there it is the healthy thing for us to ask - in what way are our therapies helpful? But I don’t think that it is a constructive thing - to play the game of my therapy is better than your therapy. And so I think as constructivists we will do well to demonstrate that our work works. That it can not simply be justified on the basis of theory alone. But by the same token we should be ware the smug assumption that we now are superior to other approaches as we construct treatments that do demonstrate efficacy. And in this way I would much prefer that we position ourselves in humility and curiosity, right? Rather than in a stance of superiority or knowingness. Harlene Anderson and Harold Goolishian years ago spoke about the importance of adopting a stance in therapy of not knowing and I would argue the same stance as a healthy one to adopt with respect to psychotherapy research. To adopt a humble stance of saying we’re no sure of all of the factors that are involved in this mystery that is human being and is human change. And we want to participate in that and facilitate it with the greatest degree of compassion and understanding we can but we should never reach a place of assuming that we have all the relevant answers.
 
A.H.: We have seen and we continue seeing a lot of efforts to create manualized treatments, above all empirically supported. Did manuals change or should change in some way?
 
R.N.: Well I think manuals have moved in clinical contexts toward greater ambiguity that is toward a greater allowing of the clinician to modify the circumstances under which the manual manualized interventions are applied. So, more room is typically being made in contemporary manuals for therapy for the clinicians own wisdom and judgment. However I think it is possible to manualized some aspects of therapy but ultimately I am not an enthusiast for that. I believe that we’re far better served by cultivating our responsiveness to this unique moment of possibility with this client or clients who sit here with us now and who always in every conversational turn - both in verbal, non verbal and co-verbal ways co-verbal being the way the manner of speaking, the rhythm of speech or the emphasis or de-emphasis that a person uses) - people will always tell us exactly what they need in this moment if we only have antennas that are long enough to pick up the signals. And I think that by focusing on manualized interventions we minimize the presence of the therapist. The therapist can barely see the client through the pages of the manual and I think the client also tends to disappear beneath the label of the diagnosis. So I largely would support - as we speak latter of psychotherapy training – the importance on functioning in a much more intersubjectively responsive way with the client, really helping therapists become comfortable with themselves and their language as instruments of change with specific techniques being secondary in their importance.