A Constructionist Clinical Psychology for Cognitive Behaviour Therapy

Kieron P. O'Connor

• Publisher: Routledge
• Year: 2015
• Print ISBN: 9780415855419
• eBook ISBN: 9781317576617
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Most clinical psychologists and cognitive behaviour therapists adopt a perspective which assumes that a client's distress arises from inaccurate perceptions of the external world and that these perceptions are due to the problematic filtering of information about the external world through internal perceptual biases and schemas. A Constructionist Clinical Psychology for Cognitive Behavioural Therapy provides a timely and innovative critique of the dominant trends in CBT theory and practice. It applies a constructionist framework to treatment and offers a constructionist philosophy and methodology to complement existing clinical approaches in cognitive behaviour therapy.

Kieron O'Connor presents a much needed alternative constructionist framework (addressing both individual and social constructionist ideas) which is laid out in a clear fashion for the clinician. He shows how the framework can be integrated into practice and offers an alternative to viewing psychopathology as an isolated problem which focuses on pathology as a response to internal or external events. He reveals how the new constructionist framework can encourage clinicians to look at the client centred context which creates psychopathology and explore areas and experiences not easily accessible to traditional cognitive behaviour approaches, but which are rendered understandable through a constructionist approach to experience.

Using extensive case studies, A Constructionist Clinical Psychology for Cognitive Behavioural Therapy provides a constructionist framework approach which complements existing CBT approaches and shines new light on questions as to why some techniques work and others do not. With new tools for case formulation and evaluation, and trainee exercises for beginners, the book will appeal to clinical psychologists, clinical researchers, psychotherapists and other health and mental health professionals.

1

WHY PHENOMENOLOGY?

Phenomenology (literally, the study of phenomena, or what appears before us) was developed at the turn of the twentieth century by Edmund Husserl, a mathematician, who sought to apply transcendental philosophy to the study of human experience. The word ‘transcendental’ had no mystical implication but referred to the importance of transcending prior assumptions and models, which might prejudice the descriptive rigour of enquiry. A short historical synopsis of the development of phenomenological thinking and its application in psychology is given here, but more exhaustive academic accounts of the philosophy are cited in the references.

Phenomenology has inspired applications in anthropology, sociology, social psychology, linguistics, education, conversation and discourse analysis. However, attempts to apply the phenomenological method to clinical psychological practice – in particular, cognitive behavioural therapy (CBT) – have mostly hit an ontological impasse: namely, how to render a system of knowledge and practices in a way both authentic and accessible for a clinical audience likely to resist its underlying radical and critical epistemology – an epistemology which seems, on the face of it, opposed to current taken-for-granted practice. Any such resistance, however, is more likely to be out of habit than on principle since clinical psychology is a set of practices and an applied philosophy which are quite compatible with phenomenology and constructionism. A phenomenological approach forms the initial basis for a constructionist clinical psychology since it fully describes experience in a person-created context.

Descriptive phenomenology and transcendental phenomenology

Transcendental phenomenology (TP) can be distinguished from descriptive phenomenology (DP). In the DP version, first explicitly advocated by Karl Jaspers in his 1912 general psychopathology, phenomenological understanding is reduced to faithfully reporting or observing clients’ words or experiences and uncritically considering their subjective expressions, interpretations and opinions as the unit of study. As such, DP has formed an important and productive counterweight to more rigid nosological attempts at clarifying clinical experience, which disregard subjectivity. One creative attempt to integrate DP with cognitive psychology is Jonathan Smith’s interpretative phenomenological analysis (IPA) (Yardley, 1997; Smith et al., 2009; Rhodes and Smith, 2014). Smith et al. (1999), for example, discuss IPA’s application to the psychology of health and illness, including the convergence of constructs between qualitative and quantitative studies when exploring the idea of loss of control in chronic illness such as dialysis. A social-cognitive model of stress and control can then be strengthened by looking at the meaning individuals attach to control, uncertainty and safe decisions.

The question TP addresses, on the other hand, is how to contextualize a personal experience without moving beyond the experience itself. The answer is that experience is more than the subjective reports of what a person is seeing and saying; it is the ground for such reports. An experiential context is an inclusive context that embraces a life world of which the immediate and apparent objects of speech and sight, though a key starting point and which reveal the ground, are still only a small part.

Phenomenology deals with the question of how to contextualize the client’s experience without stepping outside of the certainty of what appears before us, and the client’s experience. A way of contextualizing what is there and what is not there is by respecting and exploring variations in phenomenal appearance. In a sense this method of contextualizing experience creates a measure of the person and centres experiences on the person’s complete experiential space. What for this person appears on different occasions under the same reported phenomenon? When a person refers to their panic in a shopping mall is it the same panic that sets in whilst calculating tax returns? What aspects of the phenomenon vary within occasions? Does the fear of authority have the same intensity throughout exposure to all authority, whether the boss or the traffic police? Idiosyncrasy in appearance is sought after, and such contextualizing of the variations of experience has a spatial and a temporal dimension, and also a vertical and horizontal dimension. We can explore the meaning of a particular phenomenon through vertically tracing its essential features and/or we can look horizontally at the surrounding context of other phenomena against which it appears. Behaviour is always directed and this direction is encapsulated in some goal-directed intentional project. All behaviour occurs in an act context where the person is actively pursuing a goal. The term ‘act’ captures the notion of a person actively positioning themselves prior to and with respect to their experience, however involuntarily it appears. It is a unique personal unit and this uniqueness enables comparisons with other act contexts. An act can theoretically be any length that has meaning for the person. It is defined as all meaningful activity constituting a behaviour and can be contextualized within a family of acts which form a metric of the person’s repertoire. Feeling and cognition fall within the act; the dramaturgical allusions implied by an act metaphor are also helpful since the term ‘act’ conveys the sense that all behaviour has a constructed skill level in its self-presentation. The term ‘act’ also captures the more idiosyncratic human and ecological sense of a behaviour that encompasses the whole body and being in a close relation to the world.

Transcendental phenomenology as a descriptive science

When Edmund Husserl developed his phenomenological method he did not see it exclusively as a psychological method. He thought he was developing a general science of consciousness that would lay the philosophical foundations for all types of systematic investigations. According to Husserl (1913/1982), consciousness is what gives the world to us as we find it, ready-made, always ‘there’, imbued with meaning, coherent and thematic and seemingly corresponding very well with our intentions and projects towards it, even whilst sometimes disallowing them. Hence anyone who wished to study any part of the world would, reasoned Husserl, need to study first of all the structure of her/his consciousness in order to know how what was there arrived ‘out there’ in front of the person as something that could be consciously studied in the first place. This concern of phenomenology to study in the first instance not knowledge but what makes knowledge possible sets it apart from the cognitive enterprise to derive meaning from a world which is taken for granted as unproblematically already there.

Husserl himself was not a psychologist; he began his professional life as a mathematician and logician, and it was whilst investigating the logic of mathematical forms in the late 1890s that he realized the limits on such logical relations were not to be found in the intrinsic qualities of shapes or objects but rather in the limits of consciousness itself. Logic features prominently in the phenomenological method and it is by reflecting on our use of logic – in particular, the logic we apply in categorizing the world – that we gain access to the logic of our consciousness. Husserl (1900/1913, 1929/1969), the logician and mathematician, frequently cites examples from mathematics to illustrate his axioms and methods (e.g. the famous triangle example in his demonstration of eidetic reduction; see later).

Husserl took as his starting point the work of Franz Brentano, a lapsed cleric and philosopher who taught in Vienna in the 1870s and who had published his major work, Psychology from an Empirical Standpoint, in 1874, the same year that Wundt had published his seminal and experimentally influential work Physiological Psychology.

Brentano was writing at a time when two schools of psychology were vying for ascendancy: namely, introspectionism and positivism. Introspectionism was still predominant and rested on the premise that since the individual was largely responsible for what s/he felt and experienced s/he was the obvious person to report and judge this experience. Wilhelm Wundt was himself at this time largely following the introspective method in his own fashion, which consisted of participants monitoring the effects on themselves of various manipulations carried out by the experimenters. In an interesting reversal of current North American practice, the participants were usually the professors (e.g. Wilhelm Wundt), whilst the students were the experimenters. Needless to say, it was the participants not the experimenters who were the authors of the ensuing publications! It was only much later with the advent of experimentalists such as Bruno Munsterberg that Wundt’s laboratory became more positivist and brass instrument in orientation.

Positivism as a philosophy and method had recently (in 1834) been espoused by Auguste Comte, who had suggested that reality was beyond the individual’s mind and could only be grasped objectively through collecting facts, which, when tied together, could lead to laws predicting cause and effect. This paradigm was seemingly more in tune with the pragmatic entrepreneurial spirit of the age and led to the idea that social or psychological facts could exist in the same way as physical facts, and that psychological and social laws could be deduced from them. Nineteenth-century social thinkers such as Emile Durkheim and Karl Marx took this positivist spirit to heart and began talking of social facts and laws that derived from a science of society. Indeed, towards the end of the nineteenth century, several such ‘human laws’, such as the Weber–Fechner Law, were emerging in psychophysics and psychophysiology, attesting to an apparent fait accompli by the experimental positivist method.

Brentano was happy neither with introspectionism nor with positivism since he felt that the act of knowing the world and what was known through that act (or, as he termed it, the ‘act of presentation’ and the ‘presentation’) were too closely related to be hived off as separate phenomena. He felt that introspection dealt only with the act of knowing and positivism only with the knowledge, whereas in fact every ‘internal’ subjective act of consciousness (paying attention, memorizing, dreaming), although seeming to originate inside the person, is always directed towards an object ‘outside’ the person. Put succinctly, Brentano claimed that all consciousness is consciousness of something or other. There can be no pure consciousness that just floats aimlessly about unfocused and not conscious of anything in particular. Consciousness always has a content to give it purpose and direction and Brentano termed this properly ‘intentionality’.

Brentano felt himself unfit to say which should be the primary subject matter of psychology: the objects that directed consciousness and provided it with its contents or the consciousness directed towards the objects. He suggested we talk instead about ‘acts of consciousness’, which include both the act of knowing and what is known, and that we seek to classify mental states on the basis of their intentionality. A wilful state is different from a passive state, or a passionate state different from a dreamy state, because the states are necessarily directed towards different objects and hence in each case the act of knowing the object is different.

Brentano also distinguished between description as a primary goal for empirical psychology and what he termed ‘genetic psychology’. Genetic psychology is concerned with drawing causal inferences from what is observed, and Brentano felt that this should come only when a proper descriptive taxonomy of intentional states had been drawn up. Even in 1874 Brentano realized the danger of letting interpretation overtake description, particularly when we are trying to be empirical and are describing what appears before us. The phenomenological idea of describing what is before me has been refined, notably by Amadeo Giorgi (1985), who operationalized phenomenological description, as in Table 1.1.

Husserl elaborated on Brentano’s work and suggested that the best way to ground empirical psychology in the description of what is there is to limit this description initially only to that of which we can be certain. Logically, it makes sense to know what we are certain of before deciding what we can’t be certain of and before launching into an exploration of the unknown. Husserl concluded that all we can ever be absolutely certain of is our own conscious experience at this moment in time. We may know about other people, events and objects existing at other times and places, but we cannot be certain they exist. For example, I may have a fairly good idea that there is an office next to mine with a desk, drawers, windows and a door, even though I have no conscious experience of these items at the moment. On the basis of my past experience I can be pretty sure they exist. But I cannot know for certain, and perhaps someone has removed the desk and demolished the office quietly without my knowledge. This idea of basing behavioural analysis on certain process ascertained descriptively rather than, say, the effects of an uncertain hypothetical process, is explored further in Chapter 2.

Husserl was agnostic regarding the aetiology of consciousness. Following Brentano, Husserl was careful to emphasize that he did not consider consciousness to be located inside the person (for that would be applying a model); rather, conscious experience is what presents the world to us regardless of whether our consciousness is internal, external or somewhere in the middle. His fundamental proposition was that I can be absolutely certain only of what presents itself to my consciousness at this moment. The proposition does not imply that my conscious impressions are necessarily correct since, to quote Husserl’s (1913/1982, 1929/1969) own illustration, although my impression of a scented flower may mislead me to incorrectly infer the presence of a flower, I can never be in error about my initial impression of a flower since what appears to me appears to me as such and nothing else. Husserl is not painting a solipsistic or idealistic picture of the world (that the world is simply an extension of my mind) since what appears to me can be in error of what is there. But he does suggest that empirical enquiry into the world must start with the way the world appears to me. He termed these appearances ‘phenomena’ to distinguish them from external objects or internal ideas of objects, and he suggested that it is only through the study of these phenomena (phenomenology) that I can discover the workings of my own consciousness. At first glance this seems a bit circular. On the one hand, Husserl is saying we must study consciousness to know how we structure the world; on the other, he is saying we can only study consciousness by looking closely at how the world appears to us. Surely, we should isolate and study our consciousness independently of the world before we study it in the world. Unfortunately, according to Husserl, we cannot corner a pure consciousness abstracted from the world and put it under a microscope, since consciousness only shows itself in the context of our everyday concerns. Since I am in consciousness I cannot see its workings. If I could I would not be in my own consciousness but in another consciousness outside of my own, rather as, for example, I would need to be outside of the room in which I am sitting in order to see it in its entirety.

TABLE 1.1 Descriptive seeing

Edmund Husserl, the founder of phenomenology, suggested that a science of description should aim to ‘bracket out’ our natural tendency to impose a priori assumptions on observed phenomena.

Describing exactly what appears before us is a form of awareness training (Husserl termed it ‘descriptive seeing’) and we can become more aware of how premature interpretations infiltrate our observations even if we cannot eliminate them.

Amedeo Giorgi suggests as strategies for eliciting descriptive narratives from clients empathic emergence in the person’s work of description, slowing the person down to dwell on the details of description and magnifying the mundaneness of the client’s situation.

Some pitfalls to avoid in clinical description: 1. Selective, summary or vague description that omits detail. 2. Inferring the presence or relevance of events and associations not actually present. 3. Attributing causal or motivational or hierarchical associations within phenomena that appear simultaneously. 4. Viewing events prematurely as repetitions or examples of other events.

Pure undirected consciousness does not exist (a point expanded in Chapter 4’s discussion of self-experience and introspection) and I cannot detach myself from my own consciousness in order to examine it. As Brentano (1874/1973) noted, consciousness is always intentional and directed to an object, which is to say I can only ever know the patterns of consciousness through the phenomena consciousness presents to me. Husserl’s famous rallying cry was ‘zu den sachen selbst’ or ‘back to things themselves’, by which he meant that a careful, descriptive non-judgemental account of the things that appear in our consciousness is our route to discovering how consciousness operates. What he did not mean was that we should become positivists and start isolating phenomena as facts and things and treat them as if they existed independently outside in the world. Like Brentano, Husserl (1939/1973) was keen to distinguish between description and explanation, or, as he termed it, ‘experience’ and ‘judgement’. He held that anything over and above description of conscious experi...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• List of figures
• List of tables
• Acknowledgements
• Introduction
• 1 Why phenomenology?
• 2 Constructionist evaluation: part 1
• 3 Lived-in imaginations
• 4 Dissociative states
• 5 Narrative construction
• 6 Deconstructing anxiety/distress
• 7 The body as construct
• 8 Constructionist approach to clinical psychology research
• 9 Teaching clinical constructionism/phenomenology
• Epilogue
• Appendices
• References
• Index