Using strength based therapies in a medical

model world. Therapeutic intervention in two worlds

Tom Hofmann, PhD, LCSW, LMFT, CEAP, CPPCaroline Hofmann, MS, CAP

Theoretical BackgroundMedical Model:Positivism: Everything will be measurableEssentialism: DSM Criteria

Strength Based:Constructivism Positive Psychology: Taxonomy of Virtues

(Seligman & Peterson, 2003).

Constructivism

Medical Model and Strength Based:“At Odds”

Narrative Therapy: “A deconstructionist position entails empowering clients to subvert taken-for-granted mental-health definitions and practices” (Carr, 1998, 487).

Hypnotherapy Ripple Effect: “symptom formation is viewed as the blowing of a fuse in an overloaded electrical circuit; removal of a symptom (according to this analogy) is like removing an essential fuse and thereby precipitating a more serious conflagration elsewhere” (Spiegel & Linn, 1969, p. 91).

Solution Focused Brief Therapy: “SFBT is a paradigm shift from traditional psychotherapy focus on problem formation and problem resolution that underlies almost all psychotherapy approaches since Freud” (De Shazer et al., 2007, p. 14).

Brief Strategic Therapy: “Typical of the brief/strategic therapist is the avoidance of an elaborate theory of personality or of dysfunction” (Cade & O’Hanlon, 1993, p. 5).

Insurance Company: If the patient is so strength based why should we pay for treatment?

Can we use both approaches—Without irrevocably compromising SB tenets?Theoretically positivism------constructivism and a

taxonomy of virtues------taxonomy of diagnoses are opposite ends of their respective continua.

However

Integrated approach. Moderate constructivism (Wong, 2006)

On the continuum, some things are more agreed upon by all observers, some are from a more flexible reality.

There is an app for that!

Problem oriented Solution focused Medical model Strength based language language

Use constructivist frame. Or……

Work with the client using a strength based approach and language.

Work internally with diagnostic criteria and deep techniques such as CBT core beliefs, and systemic triangulation. These guideposts light the way for direction to take with the client.

Approach 1: Framing the “pathological”

Diagnoses can be seen as “coping behaviors” with a positive intention.

Positive intention underlies much dysfunctional behavior.

Can we frame a positive intention and the virtues being used in a particular instance, even if it is now used to a dysfunctional end?

Ego Defenses

Dissociation-Leave an untenable situation when you have no power to do so.

Introjection-Agree with someone more powerful in order to survive.

Projection-It feels much better to put a disturbing insight onto another person.

Denial- Keeps disturbing content from haunting us.

DiagnosesA negative core belief that fuels the

“coping technique” was probably helpful at one point.

Generalized Anxiety-Staying alert to the constant threat.

Depression-It is a survival mechanism to stop trying or have hope.

Substance Abuse- Temporary gain of soothing.

They are on the same continuum!A virtue can be at either extreme in the

helpfulness of the outcome. So can the behaviors of a diagnosis.

Example: “Co-dependency” can be thought of as combining virtues of persistence, love and hope.

A matter of degree, not a label. How can you do this less, or more?

Inductive Approach 2: De Shazer’s Constructivist

Assumptions

“Assumption one: Complaints involve behavior brought about by the client's world view” (De Shazer, 1985, p.23).

Constructivist Assumption #2

“Assumption Two: Complaints are maintained by the client's

idea that what they decided to do about the original difficulty was the only right and logical thing to do. Therefore, clients behave as if (italics mine) trapped into doing more

of the same (Watzlawick et al., 1974) because of the rejected and forbidden half of the either/or premise” (De Shazer, 1986, p. 25).

Constructivist Assumption #3

“Assumption three: Minimal changes are needed to initiate solving complaints and, once the change is initiated (the therapist’s task), further changes will be generated by the client (the ‘ripple effect’) (Spiegel and Linn, 1969)’ ” (De Shazer, 1986, p.33).

Constructivist Assumption #4

“Assumption four: Ideas about what to change are based on ideas about what the client’s view of reality might be like without the particular complaint” (De Shazer, 1986, p.38).

Constructivist Assumption #5

“Assumption five: A new frame or new frames need only be suggested, and new behavior based on any new frame can promote clients’ resolution of the problem.” (De Shazer, 1986, p. 39).

Constructivist assumption #6“Assumption six: Brief therapists tend to

give primary importance to the concept of wholism: A change in one element of a system or in one of the relationships between elements will affect the other elements and relationships which together comprise the system” (De Shazer, 1986, p.43).

Strength Based Theory and Practice

Solution Focused Therapy - Solution talk

Motivational Interviewing – Evoke From Honest Struggle

Narrative Therapy - Sparkling Narrative

Possible drawbacksHow to get assessment data?

How to get a diagnosis?

How to discuss problems?

What happens to the assessment/assessment summary/diagnosis/goals continuum?

Key Assessment Methods for less “digging” Seligman and Peterson Virtues: Encourage spontaneous

sharing.

Prochaska and DiClemente Stages of Change (Velicer, Prochaska, et al., 1998).

This helps us to hone in on the client's motivation, and enhance sharing.

Self-efficacy = Can I do it? X Do I want to?

This helps us formulate a clients motivation for a certain change.

Key Assessment MethodAvoid righting reflex! Neutral stance. Encourage

ambivalence. Looking for? : Inconsistencies in reports Lack of consistent objective evidence Objective parties with a concern Legal Evidence Use in hazardous situations: Pregnancy, physical health Problematic use following a treatment SASSI, Audit, Audit-C, DAST-Ten, CAGE- AID (Pichot & Smock, 2009)

Key Assessment DataMiracle Question, Scaling, And Circular Questioning

Indirectly reveal assessment data (Pichot & Smock, 2009)

The Spirit of Motivational Interviewing

Partnership with the clientAcceptance of the clientCompassionEvocation (clients have solutions in them,

we just call them forth) (Miller and Rollnick, 2013, p.14-24).

Tenets of Solution Focused Therapy

“If it isn’t broken don’t fix it.”“If it works, do more of it.”“If it’s not working, do something different.”“Small steps can lead to big changes.”“The solution is not necessarily directly related to

the problem.”“The language for solution development is

different from that needed to describe a problem.”“No problems happen all the time; there are always

exceptions that can be utilized.”“The future is both created and negotiable.” (De Shazer et al., 2007, p. 1-3)

Therapeutic Principles and Techniques of SFT

“A positive, collegial, solution focused stance” (De Shazer et al., 2007, p. 4).

“Looking for previous solutions” (De Shazer et al., 2007, p. 4). (Including before session)

“Looking for exceptions” (De Shazer et al., 2007, p. 4).

“Questions versus directives or interpretations” (De Shazer et al., 2007, p. 5).

“Present and future-focused questions versus past-oriented focus” (De Shazer et al., 2007, p. 5).

“Compliments” (De Shazer et al., 2007, p. 5).

“Gentle nudging to do more of what is working” (De Shazer et al., 2007, p. 5).

Narrative Reframing-ExternalizingProblem becomes objectified and specific

questions can be asked.Problem is less fixed and more open to change.Problem is not the person.

1. Ask client to give the problem a name.

2. Identify ways the problem has affected the client.

3. Ask for times when the problem was not active or was overcome.

4. Develop plans to further minimize the problem, using client and allies.

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integration of present and future awareness. Psychotherapy: Research, Practice, Training, 43 (10. 1-12. De Shazer, S. (1986). Keys to solution in brief therapy. New York: WW Norton and co. De Shazer, S., Dolan, Y., Korman, H., Trepper, T., McCollum, E. & Insoo Berg, K. (2007) More than

miracles: The state of the art of solution focused (brief) therapy. New York: Routledge. Miller, W.R. & Rollnick, S. (2013). Motivational interviewing: Helping people change. New York, NY:

Guilford Press Pichot, T, & Smock, S. (2009) Solution-focused substance abuse treatment. Routlege: New York, NY. Seligman, M.P., & Peterson, C. (2003). Positive clinical psychology. In L. G. Aspinwall & U. M. Staudinger

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Spiegel, H. & Linn, L. (1969). The "Ripple Effect" following adjunct hypnosis in analytic psychotherapy. American Journal of Psychiatry, 126 ,(53-58).

Velicer, W. F, Prochaska, J. O., Fava, J. L.,Norman, G. J., & Redding, C. A. (1998) Smoking cessation and stress management:Applications of the Transtheoretical Model of behavior change. Homeostasis, 38, 216-233.

Watzlawick, P., Weakland, J., & Fisch, R. (1974). Change: Principles of problem formation and resolution. New York: WW Norton and co.

Wong, Y. J. (2006). Strength-centered therapy: A social constructionist, virtues-based psychotherapy. Psychotherapy, 43, 133-146.

Handouts

Seligman and Peterson’s 22 virtuesProchaska and DiClemente Stages of Change