Constructing therapy and its outcomes.

Constructing Therapy and its Outcomes Gale Miller Department of Social and Cultural Sciences Marquette University Gale.Miller@Marquette.edu Tom Strong Division of Applied Psychology Faculty of Education University of Calgary strongt@ucalgary.ca In J. Gubrium & J. Holstein (Eds.) (2007) Handbook of Constructionist Research (pp. 609-625). New York: Guilford Press. This chapter examines the promise of social constructionist perspectives and research methods for analyzing therapy and counseling practices. We treat therapy and counseling as interchangeable terms. In most cases, we use the term therapy to refer to both. Our decision reflects typical usage in society and the widespread sharing of assumptions, practices and concerns among professionals who call themselves therapists and counselors. The term clients is used to refer to the persons served by therapists, although some therapists prefer other terms, such as patients. We define therapy as the activities that therapists do. Therapists consult with clients about problems in clients’ lives and how they might be managed. Therapists may also consult with representatives of nontherapy institutions, mediate conflicts, administer and evaluate the results of psychological tests, and serve as gatekeepers, such as when court-ordered therapy is a condition for parents regaining custody of their children. They also sometimes act as imputational specialists, that is, as experts at discovering and classifying deviance (Pfohl 1978). The chapter is not a comprehensive review of constructionist research on therapy. Rather, we draw from aspects of this literature in discussing empirical and analytic strategies for furthering social constructionists’ interest in studying reality construction, maintenance and change in therapy sites. Our approach represents a social constructionism of therapy. We treat therapy philosophies, practices and relationships as objects for study and analysis. While not inherently opposed to one another, our orientation to therapy and social constructionism differs from that of therapists and social scientists that use social constructionist perspectives to advance particular therapy approaches and philosophies (Franklin and Nurius 1998, Hall 1997; McNamee and Gergen 1992; Parton and O’Byrne 2000). The latter use of social constructionist perspectives might be called social constructionism in therapy (Franklin 1995, Franklin and Jordon 1996). We emphasize the close relationship between the qualitative research methods typically employed by social constructionist researchers and the perspectives that they use in analyzing data. These methods and perspectives form a basis for analyzing diverse therapies as institutional discourses (Miller 1994, Miller and Fox 2004). This perspective calls attention to how therapy realities are shaped by persons’ talk in social interaction, the local contexts within which the interactions occur, and by broad-based historical formations within which diverse therapies have evolved. The perspective takes account of how socially constructed therapy realities are shaped by the contingencies of concrete therapy interactions and by wider socio-historical factors. The latter factors have implications for how the purposes and goals of therapy interactions are defined. On the other hand, it is within concrete therapy interactions that these purposes and goals are given practical form and are applied to the practical circumstances at hand. The methods and perspectives emphasized by the institutional discourse perspective contribute to a social constructionism of therapy that recognizes the relativity of social realities while also being empirically and analytically rigorous. We discuss these methods and perspectives in later sections, but first we consider how therapy is nested within an institutional environment that both supports and constrains the actions of therapists and clients. THERAPY ENVIRONMENT Therapy occupies a distinctive niche within human service institutions. Therapists are trained in several different academic disciplines, notably in medicine, education, psychology, social work, psychiatric nursing, and the ministry. They work in a variety of institutional settings (including clinics, hospitals, schools, the military, residential treatment centers, correctional facilities, and the mass media), deal with many different kinds of problems (such as chronic health issues, interpersonal and intergroup conflicts, crime and delinquency, chemical addictions, depression, academic and career problems, and grief) and serve diverse clients (including individuals, families and other small groups, and communities). Many therapists are also accountable to organizations that refer clients to therapy, pay therapists, establish and enforce standards of professional conduct, and assess the effectiveness of therapists’ interventions. The rise of managed care programs over the last 30 years is particularly significant (Hoyt 2000). The programs are regulatory arrangements within which third parties (insurers and reviewers) influence the nature and length of therapy (Hoyt 1995) These aspects of the therapy environment point to how diverse therapies emphasize different social concerns, interests, and formulations of social reality. The differences have implications for therapists’ orientations to their clients’ problems, to how change is most effectively achieved through therapy, what indicators should be used in evaluating therapy interventions, and what constitutes appropriate therapist-client relationships. Consider, for example, the differing social realities associated with therapies based on the medical model and those influenced by social constructionist perspectives. Medically-oriented therapists treat clients’ problems as disease-like and caused by underlying biomedical and psychic conditions that are often undetectable to the untrained observer (Herson & Turner 1994, Perry, Frances & Clarkin 1990, Polatin 1966). Medically-oriented therapists address these conditions by diagnosing their clients’ problems and prescribing treatments (often including, but not limited to, medications) that are designed to ameliorate, if not cure, the problems (Foreman, Jones, & Frances 1995, Oakley & Potter 1997, Reid 1989). Many of the categories used by medically-oriented therapists and clients are codified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IVTR 2000), which also describes the typical or expected course of development for each disease category if it is left untreated (American Psychiatric Association 2004). Constructionist-oriented therapists, on the other hand, stress how their clients’ problems are socially constructed realities and that solving the problems involves developing alternative orientations to clients’ lives (Dean 1993, Efran, Lukens & Lukens 1988, Laird 1993). While not denying the reality of the pain felt by clients, constructionist-oriented therapists emphasize how clients’ senses of their lives as troubled are sustained in their use of language (Anderson 1997, de Shazer 1994, White & Epston 1990). They do not diagnose or look for the underlying causes of clients’ problems, although these therapists sometimes ask clients to consider how their problems might be related to inequalities in society. Constructionist-oriented therapists emphasize how change in therapy involves helping clients to use available resources to assert greater control over their lives. The differences between medically- and constructionist-oriented therapies suggest the range of philosophical and practical orientations practiced by therapists. The differing social concerns and interests that shape medically-oriented, constructionist-oriented and other therapies are conditions of possibility that influence the range and types of social realities constructed in concrete therapy relationships and settings. The conditions include the ideological emphases (such as the medical and constructionist orientations) in different therapies, typical patterns of interaction associated with them and the institutional contexts in which the therapies are practiced. Next, we consider the research methods and analytic perspectives that constructionist researchers use in studying how social realities are constructed in differing institutional discourses. OBSERVING THERAPY REALITIES The qualitative research methods used by constructionist researchers are standpoints for observing therapy. They also shape researchers’ relationships with participants in therapy settings. The relationships range from face-to-face encounters (including various degrees of participation by researchers in therapy settings) to more distanced relationships, such as the analysis of video recordings of therapy sessions and of texts written by and about therapy. Thus, the methods used by constructionist researchers are more than simple or neutral means of collecting data about therapy settings, they are empirical and interpretive frameworks for knowing therapy. We discuss three such frameworks in this section. Micro-Interactional Approaches The first framework consists of micro-interactional research methods and perspectives focused on the intricacies of talk and social interaction (Arminen 1998, Bavelas, McGee, Phillips & Routledge 2000, Czyewski 1995, Edwards 1995, Gale 1991). This research focus casts therapy as interactional encounters that researchers often audio- and video-record. Analysts subscribing to different theoretical orientations attend to different aspects and implications of the interactions that they observe. For example, Alfred E. Scheflin (1973) concentrates on the social organization and meaning of bodily movements (gestures, posture, bodily shifts, etc.) in analyzing therapy interactions. William Labov & David Fansel (1977), on the other hand, stress spoken language in their study, which focuses on the social frames or definitions of the situation within which therapy interactions occur. Labov & Fansel (1977, p. 27) explain that the significance of interactional details “can be defined only when the situation in which they are used is well known.” Irit Kuperfberg & David Green’s (2005) study of metaphorical negotiation in therapy interactions occurring in the mass media and cyberspace represents yet another empirical and theoretical orientation to therapy talk and interaction. An especially promising micro-interactional approach is conversation analysis (Atkinson & Heritage 1984, Boden & Zimmerman 1991, Sacks, Schegloff, & Jefferson 1974). Conversation analysts examine how social interaction is organized as turns at talk, that is, how speakers make and take speaking turns in pursuing their social purposes in interaction. As with its methodological cousin, ethnomethodology (Garfinkel 1967), conversation analysis focuses on the mundane and taken-for-granted aspects of social interaction. Conversation analysts observe how therapists, clients and others show how they make sense of each others’ actions through their words and actions. No attempt is made to get “inside of” people’s heads; instead the focus is on what interactants observably do with their own and others’ talk. Conversation analysts ask, for example, how does a short pause of only three-tenths of second matter to talk between speakers? How might a momentarily averted gaze be related to a speaker’s decision to change what she is saying in the middle of a speaking turn? These questions point to how therapy interactions are reflexively dialogic. A therapist’s raised eyebrow or noted disinterest, as a client says something important, can cue the client to modify what is said which, in turn, would elicit new responses from the therapist. In this way, micro-interactional developments become consequential for how interactants make sense of and respond to each other. We see these aspects of conversation analysis in Anssi Peräkylä’s (1995) and David Silverman’s (1997) studies of systemic AIDS counseling, which defines clients’ problems as recurring patterns of action within social relationships. Systemic therapists treat the problematic patterns as products of clients’ social relationships and as sources for sustaining the relationships. A major purpose of systemic therapy is to “interrupt” the problematic patterns in order to change clients’ social relationships. Peräkylä’s and Silverman’s studies explore how systemic therapists and their clients interactionally construct problems, social systems and interventions designed to change clients’ social systems. They also analyze how therapy participants use their interactional turns to show concern for others’ emotions. Ethnographic Approaches The second methodological standpoint for knowing therapy consists of ethnographic studies. These studies involve observing therapy settings and interviewing the participants. Ethnographic researchers differ from conversation analysts, however, in their greater interest in how therapy interactions are influenced by the institutional contexts within which they take place (Bosk 1992, Miller 1986, 1987, Vandewater 1983). For example, Kathleen S. Lowney (1999) analyzes how therapy becomes entertainment when it is incorporated into the moral dramas of television talk shows. She discusses how therapists appearing on the shows advance the individualistic discourse of the Recovery Movement, which is perhaps most clearly represented by Alcoholics Anonymous. Within this movement, personal and interpersonal problems are defined as addictions stemming from persons’ dysfunctional relationships. As with micro-interactional researchers, ethnographers vary in their theoretical orientations. For example, Cheryl Mattingly (1998) uses a phenomenological perspective to analyze how participants in the occupational therapy settings construct new life stories for clients. The narratives address the biomedical goals of occupational therapy, but they also speak to clients’ changed social and emotional circumstances. Ethnomethodological ethnography focuses on the interpretive methods that people use in making sense of their experiences (Garfinkel 1967, Pollner 1987). Ethnomethodologists treat the social construction of reality as practical activity, that is, as reality work. These ethnographers describe the reality work done by therapy participants and highlight its social implications. For example, Stephen J. Pfohl (1978) and James A. Holstein (1993) analyze the reality work done by therapists in assessing the levels of dangerousness posed by patients in a maximum-security prison and by persons recommended for involuntary hospitalization. The question of how therapy realities are constructed to fit with their institutional contexts is central to several recent comparative studies of therapy. For example, Gale Miller & David Silverman (1995) comparatively analyze how the discourse of enablement is implemented in an HIV counseling center in England and a family therapy agency in the United States. They define the discourse of enablement as “a professional strategy for inciting preferred forms of troubles talk and encouraging preferred forms of change in clients’ lives” (Miller & Silverman 1995, p. 732). Other comparative ethnographies focus on the social construction of family, emotion, intrapsychic forces and moral community. For example, Jaber F. Gubrium (1992) analyzes how orientations to the social reality of family order and disorder are embedded in the assumptions, interests and practices of two therapy settings. Also, Darin W. Weinberg (2005) examines the practical conditions shaping therapy realities constructed in two treatment centers serving persons diagnosed as addicted and mentally ill. Philosophical-Historical Approaches The third framework for knowing therapy is philosophical and historical research (Edelman 1977, Foucault 1977, Sass 1992). These constructionist researchers use methods and perspectives associated with the humanities in analyzing texts of various sorts. The researchers use the word text to refer to both the objects of their analysis (e.g., books, pictures and social interactions) and to their “attitudes” toward the objects. They assume that texts’ significance are not predetermined but emerge as “readers” interpret them. For example, Sander L. Gilman (1988) analyzes images of madness, the asylum and the appropriate therapist in the writings and art of Charles Dickens, Vincent van Gogh and Sigmund Freud. Gilman (1988, p. 2) explains that his study shows how therapy realities are “constructed on the basis of specific ideological needs and structured along the categories of representation accepted within that ideology.” Gilman’s study highlights the critical constructionist impulse in many philosophical and historical studies of therapy. Critical constructionists draw upon several theoretical perspectives in critiquing the assumptions and implications of diverse therapies. For example, Louis A. Sass (1994) uses aspects of Foucaultian, Wittgensteinian and phenomenological theory to critique 20th century therapists’ formulation of schizophrenic delusion as the absence of human reason. He also uses autobiographical texts to reframe schizophrenia as an alternative—solipsistic—reality that emerges from within human reason. Philip Cushman (1995) applies a hermeneutic perspective in discussing how ideologies of self and of therapy are intertwined in history and culture. He examines how therapy ideologies are embedded in the cultural practices and understandings of particular eras. Trends in therapy (e.g., 1950s lab coat behaviorism and the tie-dyed human potential movement of the 70s) illustrate this point. He also emphasizes how psychological theories shape their historical eras, such as how Post-WWII therapy theories construct an “empty self” that needs to be filled through consumerism. The critical impulse of philosophical and historical studies is perhaps most sharply developed in critical discourse studies. These studies analyze how the use of language comes freighted with the values, understandings and rhetorical practices associated with particular cultural formations (Foucault 1972, Volosinov 2006, Fairclough 1992). When clients and therapists talk, their dialogue refracts the discourses from which each draws specific languages, interpretations and actions. To illustrate, a client may present concerns in a relational discourse (heartbreak, bereavement, interpersonal conflict) while a therapist might hear these concerns in the discourse of a diagnostic system. Each language maps problems and solutions differently. For a critical discourse analyst, any choice of discourse means other discourses go unused. No discourse can totally represent the experiences or values of speakers, because language is always partial and allied to particular to values. A major aim of critical discourse analysts is to make evident how dominant therapy discourses exclude alternative possibilities for thought and action (Wainwright & Calnon 2002). We have treated micro-interactional, ethnographic and philosophical-historical approaches as distinct in this section. This treatment reflects how each approach brings distinctive concerns and strengths to the study of therapy. But they also overlap and complement each other. The areas of complementarity are central to the institutional discourse perspective and related approaches to constructionist research, such as discursive constructionism (Buttny 2004) and discursive psychology (Edwards & Potter 1992). We develop this emphasis in the institutional discourse perspective in the next section by discussing how it might stimulate a constructionist imagination about therapy. Researchers express a constructionist imagination in considering how therapy realities are interactional, contextual and historical-cultural constructions. TOWARD A CONSTRUCTIONIST IMAGINATION It is important to begin by pointing out that the institutional discourse perspective is itself an empirical and interactional framework for knowing therapy. Like the other frameworks discussed here, it allows researchers to readily see and understand therapy in particular ways, while offering limited opportunities for other “seeings” and understandings. This point is important because the institutional discourse perspective might appear to be a triangulating strategy that offers researchers comprehensive, objective or privileged access to empirical reality (Denzin 1978). This is not the case. For us, the value of the perspective rests on its usefulness to constructionist researchers of therapy in pursing their research goals and interests. One such interest involves developing a constructionist imagination about the interconnections among therapy philosophies, practices, relationships and contexts. We see a constructionist imagination in Michael Billig’s (1999) critical constructionist critique of Sigmund Freud’s concept of repression (Brill 1938). For Freud, repression is an internal—biological—process through which individuals monitor and control their thoughts and desires. It occurs within the unconscious and operates to keep troublesome impulses secret from both other people and from ourselves. This approach to repression also justifies a depth psychology designed to get beyond appearances and to the underlying reality of repression. Billig accepts the existence of repression as a form of avoidance, but he disagrees with Freud’s claim that it is a hidden or biological process. Repression, for Billig, is an observable aspect of social interaction and occurs when people in interaction close off or avoid potential topics of discussion. Indeed, there is a commonplace word for such practices. It is politeness, an activity that may involve self censorship or conversational collaboration with others. Billig (1999, p. 52) highlights how “we are able to change the subject, pushing conversations away from embarrassing or troubling topics.” He further notes that the topics (particularly sexual issues) repressed in Freud’s conversations with his patients were also topics to be avoided in public conversations in Freud’s Vienna. They were historically and culturally grounded taboos. Within Billig’s constructionist imagination, then, repression is a socially organized activity. He also notes that repression may become institutionalized as unnoticed habits within the conventions of polite conversation in social groups. Billig’s reformulation of repression suggests how conversation analytic, ethnomethodological and historical perspectives and useful in examining therapy realities. His analysis is further developed by considering conversation analysts’ studies of affiliation in social interaction (Heritage 1984). These studies detail the noticed and unnoticed “habits” used by interactants in managing conversational topics and relationships. They also show that polite avoidance is only one way of dealing with potentially troublesome issues. We have already noted, for example Peräkylä’s (1995) and Silverman’s (1997) analyses of how HIV therapists delicately encourage clients to talk about delicate topics. Ethnographic studies therapy realities extend Billig’s analysis by analyzing conversational repression across therapy settings. While these studies might consider how clients avoid troublesome topics, a potentially more promising research focus is studying how therapists avoid and divert undesired topics raised by clients and other therapy participants. For example, Gubrium’s (1992) comparative ethnography points to how therapists’ theories about family systems and troubles are related to how they attend and disattend to aspects of clients’ talk Comparative ethnographies extend ethnographic research on the discourse of enablement (Miller & Silverman 1995) by exploring the ways that therapists signal their disinterest in particular conversational topics. Constructionist researchers also examine how clients acquiesce or resist such therapist moves and the consequences of clients’ responses for therapy. The studies would link ethnographers and micro-interactional analysts to critical constructionists’ interest in attending to what is excluded from therapy. The studies would show how repression in therapy is not predetermined, but is an accomplishment of participants in therapy settings. CONSTRUCTING INNER REALITIES Few ideas are more associated with therapy than the assumption that human behavior is driven by inner forces that are—to varying degrees—beyond the control of the individual. This idea is central to Freud’s the highly influential ideas but it is not limited to him or even to the world of therapy. It is a broad-based cultural theme that may be observed in the everyday conversations of nontherapists, in art and literature, and in popular culture. Social critics emphasize two implications of this cultural practice. First, it individualizes human behavior by removing it from its social contexts. In this way, attention is directed toward individual characteristics (including inner mental and emotional states) as most salient in making sense of people’s behavior. The second implication is that it positions some people as authorities on what should count as normal and abnormal behavior. Nikolas Rose (1990, 1997) uses the term psy complex in analyzing how psychologists are often defined as experts on normal or appropriate personhood, development, and interpersonal conduct and, by implication, what is not normal or appropriate. Rose adds that psychology’s discursive mapping of “individualization” constructs a base of normative understandings and techniques, as well as justifications, for “disciplining difference” (See also Burman, 1994; Hoshamand 2001, Parker & Shotter, 1990; Parker, 1999; Shweder, 1991). When linked to governmental policies, these psychological understandings and techniques can be used to homogenize educational curricula, mental health treatment, or correctional services. Human differences become the focus of therapies designed to “help” people become “normal” by accepting and complying with dominant cultural realities. Accordingly, the justness of cultural practices is treated as given and bypasses critical scrutiny. The critical constructionist methods and perspectives discussed above are beginning points for addressing these issues as research topics. For example, Cushman’s (1995) analysis of the relationship between cultural orientations to self and the knowledges and practices of therapy points to the historical relativity of the psy complex. His study challenges claims to value-free and universally applicable scientific knowledge by therapists. It is also a standpoint for questioning therapists’ qualifications for defining what should count as acceptable and unacceptable behavior. Jeff Coulter’s (1979), George Herbert Mead’s (1934) and L. S. Vygotsky’s (1978) approaches to mind and discursive psychologists’ analyses of psychological constructs as interactional phenomena are also useful starting points (Edwards 1997). Another important research strategy is offered in Dorothy E. Smith’s (1978) analysis of a text describing an interview about a respondent’s belief that a friend (“K”) is mentally ill. Smith stresses how the respondent’s attribution of mental illness to K turns on the use of contrast structures. The structures include one part that might be heard as an instruction for interpreting the situation at hand and the second part reports on the friend’s behavior within the situation. Mental illness may be seen in the contrast between the instruction (which defines appropriate or normal behavior) and the person’s reported behavior. Consider, for example, the following excerpt from the text. Please notice how this statement points to a troubled inner reality that is made observable in K’s “inappropriate” behavior. K is so intense about everything at times, she tries too hard. Her sense of proportion is out of kilter. When asked casually to help in a friend’s garden, she went at it for hours, never stopping, barely looking up. (Smith 1978, p. 29) Kathryn J. Fox’s (1999a, 1999b, 2001) ethnography of a cognitive self change program in several correctional faculties further illustrates how a constructionist imagination is useful in addressing aspects of the psy complex. This therapy approach treats criminal behavior as rooted in the cognitive distortions of the criminal personality. Much of the treatment program involves instructing inmates on how to interpret and describe their feelings and behavior as expressions of their criminal personalities. Fox details the rhetorical and interpretive methods used by the staff to correct the inmates’ distorted cognitions and instruct them on how to properly think, feel and talk about their past, present and future lives. The instructions also justify staff members’ claims to privileged knowledge about inmates’ inner mental states and about what is appropriate behavior. Smith’s and Fox’s studies call attention to the ongoing reality work that organizes and sustains the psy complex. People do reality work by assigning meanings to events and behavior, thus, transforming them into instances of culturally shared realities. In this way, culturally honored orientations to mind and difference are affirmed, and interpreters’ preferred definitions of appropriate and inappropriate behavior are justified. Weinberg’s comparative ethnography of two treatment programs extends this approach to the psy complex by showing how it is shaped by practical organizational contingencies. This study reminds us to notice how therapy settings are organized to produce different kinds of troubled minds and troubled behaviors. These studies also speak to issues raised by Ian Hacking (1986) in analyzing how people are constructed as instances of troubled-person categories in institutional interactions (See also Hall, Juhila, Parton and Pösö 2003). The studies reveal the interpretive practices used by reality constructors to define troubled minds, which are then assumed to be the essential core of troubled persons’ selves. Micro-interactional studies are useful in showing how therapists elicit client accounts of experience that they later reformulate as proof of psychopathology, such as delusions (Georgaca 2004), disability (Antaki 2001), or addictions (Halonen 2006). Conversely, therapists can be shown inviting clients to contest and negotiate pathologizing cultural and professional discourses (e.g., Avdi 2005), or trying on more preferred discourses to construct clients’ predicaments and aspirations (Strong, Zeman & Foskett 2006). Steven M. Kogan (1998) sees such “politics” as an inescapable aspect of constructing therapy realities. SOCIAL CONSTRUCTION OF EVIDENCE The evidence-based movement in medicine took off in the 1990’s and not long thereafter in therapy. The purpose of the movement is to standardize the knowledge and practices of therapy into a common diagnostic language (that of the DSM-IVTR) and to emphasize therapy interventions shown to be empirically supported by research. For example, the clinical division of the American Psychological Association formed a task force to examine empirically validated treatments. Many therapists welcome this development as do many persons who administer therapy programs (including managed care programs), enforce ethical rules and standards, and who train graduate students in therapy. The movement promises to bring together the disparate approaches and interests of the therapy world through the adoption of a common vocabulary and scientifically tested practices. But critics of the movement see it as an attempt to legislate therapy practice to conform to a flawed scientific perspective and to serve the interests of some therapy communities over others, especially the interests of the psy complex. Critics also stress how the evidence-based movement privileges medically-oriented therapies by treating therapy interventions as similar to doses of medication (Stiles & Shapiro 1989). For example, a cognitive therapy intervention (such as stopping criminal thinking) is “administered” to clients. Psychological tests are then used in ways that are analogous to blood samples to measure outcomes purportedly resulting from the therapy intervention. Critics of such studies note that several assumptions are at work in such studies, including the assumptions that psychological tests are a good measure of outcome and that it is the intervention (not other factors in the therapy setting and in clients’ lives) that “causes” change. It is not surprising that one group of critics of evidence-based practice consists of advocates for interactional, constructionist and humanist therapies. [Bohart 2005, Larner 1999, Strong, Busch & Couture in press, White and Stancombe 2003) These critics point out that many of the problems reported by therapy clients are unrelated to the dysfunctions stressed by medically-oriented researchers (e.g., Dumont & Fitzpatrick 2005, Wampold, Ahn & Coleman 2001) They also stress that the emotions, memories, thoughts and attitudes expressed by clients are interactional creations. Therapists’ actions are implicated in clients’ expressed mental and emotional states, since the expressions are responsive to what others are saying and doing. Viewed this way, therapy is not about using interventions designed to treat clients’ diagnosed disorders. It is, instead, an interactional process of “working up” definitions of social reality that make sense to clients and therapists, and that point to practical actions clients might take in changing their lives. The assumptions and claims of these critics clearly resonate with important themes in constructionist research. Thus, it would be reasonable for constructionist researchers to want to enter into this debate to support the interests of interactional, constructionist, and humanist therapists. For example, critical constructionists might examine how the evidence-based movement has emerged to advance some ideological, economic and political interests within therapy and its environment. The researchers might also analyze how scientific evidence is a socially constructed reality (Knorr-Cetina & Mulkay 1983). Such studies are useful in relativizing claims that scientific research reveals universally applicable practices for addressing client problems fitting into particular diagnostic categories. A related line of critical constructionist inquiry is found in the ethnographic literature on rate-producing behavior (Bogdan & Ksander 1980). This literature challenges the evidence-based research assumption that quantitative measures are objective, value neutral depictions of social reality by analyzing how categorization and counting are reality work. Another promising use of the constructionist imagination involves expanding discussions about evidence among therapists. Such constructionist studies might begin with Donald A. Schön’s (1983) research on professional practice as reflection-in-action. Schön examines the ordinary, unacknowledged and artful ways that psychotherapists (but also architects, scientists and city planners) reflexively participate in problem-solving situations. Reflection-in-action is an ongoing process of making sense of problematic situations as practitioners seek to change them. Meaning and action are linked in this process with each working together as foreground and background in socially constructing evidence for understanding and solving practical problems. Mattingly (1998) further develops this perspective in her phenomenological analysis of reality construction in occupational therapy. Susan White and John Stancombe (2003) go further in discussing how social constructionist methods and perspectives are useful in identifying and analyzing tacit aspects of clinical judgment and practices that usually go unnoticed by therapists and evaluation researchers. They explain that constructionist studies of clinical practices do not strive so much for scientific objectivity as for ethnomethodological indifference (Garfinkel and Sacks 1970), that is, “suspending any presuppositions on what constitutes ‘good’ and ‘bad’ clinical judgment” and focusing on what participants in therapy settings actually do in addressing clients’ problems (White and Stancombe 2003, p. 145). Constructionist researchers are positioned to develop this focus through micro-analytic, ethnographic and critical discourse studies of therapy settings, practices and interactions. Each of these research strategies expands the evidence base that therapists, administrators and teachers use in assessing effective therapy practices, seeking not to eliminate existing evidence-based research but to expand its scope and make it more realistic. APPLYING CONSTRUCTIONIST RESEARCH Any discussion of applying social constructionist research must address questions about the epistemological status of constructionists’ knowledge. For example, should we regard constructionists’ research findings as facts, as impressions or as something else? Treated as facts, constructionists’ findings represent objectively real structures and processes that therapy participants cannot wish away. Such “facts” might be used to legislate therapist practices, much as evidence-based research is used. Defined as impressions, constructionists’ findings are expressions of researchers’ perceptions, biases and opinions. While therapy participants might find these findings to be interesting, they face no practical imperative in trying to apply the findings. Given the assumptions of social constructionist perspectives, it is difficult to argue for the “constructionist findings as facts” position, although this does not mean that social constructionist research is devoid of facts or concern for objective realities (Edwards, Ashmore and Potter 1995, Weinberg 2005). But constructionist research findings are also more than impressions; they speak to practical and moral issues associated with observable patterns of activity and relationship in therapy settings. Several of the studies discussed above suggest other ways of using constructionist research in therapy settings. For example, Janet Beavin Bavelas et al (2000) use micro-interactional methods to examine how therapists guide and shape therapy interviews by using particular words, paraphrasing clients’ answers and asking questions. These therapist actions create conditions of possibility for the co-construction (by clients and therapists) of therapy realities. Such studies illustrate how micro-interactional research is a valuable resource for sensitizing therapists to how their talk influences what is likely to be said in therapy (Gale, Dotson, Lindsey & Negireddy 2003). Schön’s (1983), Mattingly’s (1998) and White and Stancombe’s (2003) analyses of therapists’ tacit knowledge illustrate how constructionist research calls attention to otherwise unnoticed aspects of therapy settings. Such research is not designed to produce facts that others must accept and live with, but as sources for discussions among therapy participants and researchers. This use of the sociological imagination treats constructionist research as part of ongoing processes of social construction. For example, Cheryl Mattingly and Maureen Hayes Fleming (1994) discuss how constructionist research can give language to practice. New languages emerge collaboratively as researchers suggest new framings of therapy and therapy participants develop new vocabularies for describing and explaining what they do. Researchers and therapy participants also build distinctive—local—contexts for engaging questions about the evidence base of therapy by continuously exploring and describing what goes on in particular therapy settings. This orientation treats constructionist research as a resource for therapy participants. Particularly noteworthy are its potential uses in constructionist-oriented therapies. These uses involve the overlapping assumptions and concerns of constructionist researchers and constructionist-oriented therapists. Arguably, therapeutic practice that is informed by constructionist understanding involves different kinds of expertise about how therapists orient to and contextually use language in therapy (Strong, 2002). For example, once one acknowledges the constructive or strategic potentials in articulating and answering questions (Tomm, 1988) research and therapy become more than benign exercises in gathering information. This is where the line between therapy and research can blur. Curiosity and collaboration have become central features of the constructionist therapies (e.g., Anderson & Goolishian, 1992). Unlike therapists who answer clients’ questions with clinical wisdom, constructionist-oriented practitioners treat them as invitations to shared inquiry (Heron, 1996). This practice parallels the recent hybridization of constructionist research methods (Denzin & Lincoln, 2006; McLeod, 2001). Much constructionist research focuses on contesting dominant understandings of therapy, identifying generative discursive practices, and contributing to participant-preferred outcomes (Guilfoyle 2003, House 2003, Wade 1997). Sometimes these aims meet in studies which engage participants in deconstructing taken for granted understandings while inviting the construction of more useful understandings (e.g., Avdi, 2005; Morgan & O’Neill, 2001). An interesting spin-off of constructionist research involves therapists’ adoption of qualitative research methods – as therapeutic methods. Critical discourse analysis has furnished questions for narrative therapists, action research (a community empowerment tool) and heuristic inquiry (a powerful means by which resources and preferred experiences can be built upon). Recent efforts to co-construct locally developed therapeutic methods for personal and community transformation are also consistent with the hybridization of methods (e.g., Heron, 1996; Newman & Holzman, 1997). Other therapists see the therapeutic interview as an opportunity to elicit, then innovatively join, clients’ constructions of what change should entail (Duncan, Miller & Sparks, 2000). Micro- and macro-interactional research on how forms of knowledge, actions and relationships are constructed or sustained has promoted a “discursive wisdom” (Paré, 2002) to be added to Schön’s (1983) notion of reflective practice. New ethical domains of practice open up when therapists recognize their rhetorical capacity to supplant, hijack or thwart clients’ and others’ efforts to articulate experience in constructs and idioms different from their own (Strong, 2004). Some use this knowledge to assist in clients’ emancipatory efforts (e.g., Waldegrave, Tamasese, Tuhaka & Campbell, 2003) while others turn to the imaginative and motivating potentials of questions and action-engendering answers they can promote (Cooperrider, Whitney & Stavros, 2003). Recognizing that ones’ questions and responses can “help” others sustain particular constructions and discourses while other responses and questions can disrupt them carries a kind of discursive burden usually unconsidered by non-constructionist therapists. STUDYING CONSTRUCTIONIST-ORIENTED THERAPIES The constructionist research agenda constructed in this chapter focuses on the interactional processes within which therapy realities are constructed, the various contextual factors that influence therapy practices and relationships, and the cultural assumptions and commitments embedded in therapy approaches. These aspects of our constructionist research agenda have equal relevance for studies of constructionist-oriented therapies and realist-oriented therapies. Carolyn E. Taylor and Susan White (2000) state that constructionist studies are sources for developing reflexive consciousness and practices that help therapists to critically examine their routine reality-creating practices. Constructionist-oriented therapists are no less susceptible to unreflexive routinizing influences in therapy settings than are realist-oriented therapists. Nor are they immune from the human tendency to construct realities that express and serve their self interests. We have noted, for example, how the concept of collaboration has emerged as a central defining aspect of many constructionist-oriented therapies (Duncan and Miller 2000, Madsen 1999, Paré 2003). Constructionist-oriented therapists define collaboration as a distinctive therapist-client relationship in which the expertise and desires of clients and therapists are treated as equal. They also contrast this approach to therapy relationships with the “noncollaborative” approach of other (especially medically-oriented) therapies. Constructionist studies of therapy offer a reflexive standpoint for empirically examining these claims. Micro-interactional studies of therapy interactions focus on the details of therapist-client interactions that therapists call equal and collaborative. The studies would not treat collaboration as an inherent feature of some therapy approaches (and not others) but as a practical accomplishment in therapy interactions. Constructionist researchers, “How is a sense of equality constructed in social interactions that are often organized as a division of interactional labor (e.g., clients have problems in need of remedy, therapists do not; therapists ask questions, clients answer them; and therapists give advice, clients receive it.)?” A critical perspective is introduced by also asking, “What is repressed in the collaborative interactions of constructionist-oriented therapy?” And, finally, ethnographic research is useful in considering how the practical meaning of collaboration and equality in therapy is influenced by contextual and ideological factors. Weinberg’s research suggests that the practical meaning of collaboration differs in therapy settings situated in different institutional environments, even if the therapists in the settings subscribe to the same therapy approaches. It is also clear from the literature on contemporary constructionist-oriented therapies that proponents of these therapies differ in how they define collaboration and equality. Constructionist studies of the concept of collaboration in constructionist-oriented therapies call attention to how these approaches to therapy are also social theories. For example, solution-focused brief therapists borrow from Wittgensteinian philosophy in describing problems and solutions as different language games (Miller 1997). They further develop this theory of language, problems, solutions and therapeutic change by explaining how particular solution-focused brief therapy practices form a solutions language game. Constructionist researchers might also examine how narrative therapy is a social theory of language, problems, solutions and therapeutic change. These therapist-theorists apply Foucaultian philosophy in arguing that clients’ problems are often related to clients’ internalization of dominant cultural narratives (Freedman and Combs 1996). Thus, an important emphasis in narrative therapy involves exposing and externalizing problem narratives in order to create new ones. Thus, another way in which the constructionist imagination might be used by researchers is by studying the relationship between constructionist-oriented therapists’ social theories and their practices. These studies might look at the interactional and interpretive methods that organize reality work in these therapies. They might also explore how constructionist-oriented therapies operate to elicit some, and discourage other, forms of talk. A critical view is introduced by considering if and how constructionist-oriented therapies are organized to construct power relations (Foucault 1978). Micro-interactional and ethnographic methods might also be used to examine the concrete ways in which therapists and clients construct relations of power in their talk and interactions. Critical constructionist perspectives might e used to analyze the assumptions and interests at stake in constructionist-oriented therapists’ social theories, including how they might draw upon and affirm aspects of dominant cultural discourses and narratives. Finally, it is important to remember that constructionist-oriented therapists often practice in environments that orient to realist assumptions and concerns. We have pointed out how these concerns are associated with institutional pressures to diagnose clients’ problems, follow evidence-based practices and differentiate between appropriate and inappropriate behavior. We should also mention clients’ realist assumptions and concerns about addressing their “real” problems. Thus, constructionist researchers might also study the ways in which constructionist-oriented therapists interpret and respond to these environmental pressures, including how they acquiesce to and resist them. We conclude by suggesting some ways that constructionist studies might be further developed. CONCLUSION We have discussed how therapy is a site for micro-interactional, ethnographic and critical constructionist research in this chapter. Therapy is a rich and diverse context for observing how social realities are proposed, assessed, negotiated, chosen and acted on by therapy participants. Constructionist studies of therapy might be developed to address issues in a variety of substantive specialties in the social and behavior sciences. These include studies of interpersonal relations, human development, the life course, mind, emotions, health and illness. Constructionists specializing in the study of social institutions (such as family, law, religion, education and medicine) might also find therapy as a promising research site. The chapter also points to some of the ways that therapy might be of interest to applied social and behavioral scientists. Each of these research strategies involves treating therapy as the object of constructionist researchers’ observations and analysis. There is, however, another way in which constructionist researchers might orient to therapy. This approach treats therapy as a site for reflecting on constructionist researchers’ assumptions and practices, and as a source for ideas about how constructionist research might be done differently. The researchers might ask, for example, how are their observations and analyses influenced by the institutional environments (particularly academic environments) of their research? Constructionist researchers might also consider the language games that organize constructionist research and, more generally, how their research methods and analytic perspectives are reality-creating resources. Applied constructionist researchers might critically examine how their suggestions are adapted to fit with the social contexts and interests of therapy. Alternatively, constructionist researchers might examine therapy sites for ideas about how they might better achieve their research goals. Our emphasis on therapy as a discourse of enablement (Miller and Silverman 1995) points to how both realist- and constructionist-oriented therapists are experts at asking questions designed to invite conversations about preferred topics. Constructionist researchers might borrow from and adapt therapy strategies and techniques in their research. Therapy interviews are especially promising sites of learning for active interviewers (Holstein and Gubrium 1995) who ask questions intended to reveal the diverse interpretive methods used by respondents in socially constructing realities. REFERENCES iller/Strong - 31