Abstract
Psychotherapy integration is an approach to treatment that goes
beyond any single theory or set of techniques. The history of
the psychotherapy integration movement is described, along with
several approaches that have been developed to integration.
We then describe our assimilative approach, based on a psychodynamic
model but incorporating techniques from various active approaches
to treatment. A case history is provided illustrating the model
that we described.
Key words: Psychotherapy integration; Assimilative integration
Electronic reprint permission:
Oxford University Press
Psychotherapy Integration: An Assimilative, Psychodynamic Approach
Psychotherapists always have been interested in, and have attempted
to use, new developments in the natural and social sciences, philosophy,
theology, the arts, and literature. However, for the most part,
we have refused to learn psychotherapy from each other if our
ideologies and allegiances are different. This isolationism has
been contradicted by a small, but growing, group of scholars and
clinicians who have been able to cross sectarian lines. These
integrationists have aimed at establishing a useful dialogue among
members of the various sectarian schools of psychotherapy. Their
goal has been the development of the most effective forms of psychotherapy
possible. The integration of therapies involves the synthesis
of the "best and brightest" concepts and methods into
new theories and practical systems of treatment. Given the rise
of publications, journals, and professional societies concerned
with psychotherapy integration, it seems that, as Arkowitz (1991)
has announced, psychotherapy integration has come of age.
The first approach to psychotherapy integration involved the
translation of concepts and methods from one psychotherapeutic
system into the language and procedures of another. A brief historical
overview1 of this movement might begin with an attempt to convert
Freudian psychoanalytic concepts into the terms of learning theories.
As noted by Arkowitz (1984), whose fine history of psychotherapy
integration has influenced extensively this more concise attempt,
perhaps the first article of this type was written by Ischlondy
(1930), and his work was expanded upon by French (1933) and by
Kubie (1934). French was concerned with the correspondences between
the Pavlovian constructs of inhibition, differentiation, and conditioning
and the analytic concepts of repression, object choice, and insight.
Kubie's expansion of these ideas moved him to consider the possibility
of such phenomena as conditioning and disinhibition playing an
important role in the relationship between the analyst and the
analysand.
These early pioneers in integration were following a trend introduced
into psychoanalysis by Freud (1909/1955). He had noted the importance
of compelling the phobic patient to face the phobic object actively--a
preview of in vivo desensitization--and also experimented with
setting time limits on the treatment in order to promote conflict
and to gain access to deeper unconscious material.
As learning theorists began to include operant conditioning
principles and organismic and complex psychological variables
in their systems, such ideas were applied to the dominant psychotherapeutic
approaches of the era. Sears (1944), Shoben (1949), and Dollard
and Miller (1950) recast psychodynamic and client-centered therapies
in the language and concepts of reinforcement and the internally
mediated learning that had been studied by neobehaviorists such
as Hull (1952). These studies emphasized the reinforcement value
of the therapist and, particularly in the case of Dollard and
Miller (1950), preceded modifications in psychoanalytic technique
that emphasized activity and instruction on the part of the therapist.
Procedures that are commonplace today in cognitive-behavioral
therapy and in many forms of integrative therapy were introduced
by Dollard and Miller, and included the use of homework, role
playing, and modeling, as well as active and graded confrontation
of fearful situations and internal states. Wachtel (1977) and
Arkowitz (1984) have noted that the work of Dollard and Miller
was much more influential in general psychology and in learning
theory than in psychotherapy studies, and that their direct impact
on psychotherapy integration was not felt until much later. Alexander
(1963; Alexander & French, 1946) modified his psychoanalytically
oriented approach to therapy by experimenting with active approaches
to the induction of change that were informed by the then contemporary
learning theories. A point crucial to later developments in psychotherapy
integration was his introduction of the idea that insight into
unconscious processes often followed behavioral change, rather
than exclusively being the antecedent to change. This move away
from a unidirectional view of change was highly influential in
the thinking of many later students of integration.
A very important trend that was occurring throughout this same
time period was the search for generic change factors that were
common to all psychotherapies. Although not aimed at integration
or theoretical translation in themselves, these studies were crucial
in breaking down barriers between adherents of specific theories
and methods. Fiedler (1950) demonstrated that observers were unable
to differentiate between psychoanalytic, Adlerian, and client-centered
therapies, or to identify the therapeutic ideology of different
practitioners. Such research, as well as the investigations of
Frank (1961) and of London (1964), pointed to the commonalties
among the variety of contemporary therapies, and collectively
became a voice arguing for a nonsectarian and generalist approach
to psychotherapy. These arguments proved to be extremely generative
of the more specifically integrative work that followed.
As behavior therapy became more sophisticated and more oriented
toward complex clinical problems, some of its theorists and practitioners
came to look to psychoanalysis, humanistic therapies, and systems
approaches for guidance, ideas, and methods. Some pertinent examples
of these truly integrative studies include the works of Beier
(1966), Marks and Gelder (1966), Weitzman (1967), Sloane (1969),
Marmor (1971), and Birk and Brinkley-Birk (1974) among many others.
These students shared a concern for searching out the underlying
theoretical links and similarities among behavioral, humanistic,
and dynamic methods. Brady (1968), Birk (1970), and Feather and
Rhoades (1972) experimented with the technical integration of
psychodynamic, systems, and behavioral methods within single cases.
Goldfried and Davison (1976) acknowledged the utility of, and
the need for, concepts and methods drawn from other systems of
therapy.
If the history of psychotherapy integration had a single watershed
moment, it was the publication of Wachtel's (1977) Psychoanalysis
and Behavior Therapy. This volume remains the most frequently
cited work in psychotherapy integration, and has served as a model
of integration at both a theoretical and a technical level. Wachtel
offered a theory of personality and psychopathology that fully
integrated critical aspects of psychodynamic and behavioral theory
into a unique and synergistic model. Just as important, this new
and integrative theory also allowed interventions from a broad
range of positions to be used clinically in a way that was predictable
and comprehensible.
Norcross and Newman (1992) identified eight interacting variables
that have encouraged the growth of psychotherapy integration.
These include: 1. the enormous expansion in the number of separate
psychotherapies; 2. the failure of any single therapy or group
of therapies to demonstrate remarkably superior efficacy; 3. the
correlated lack of success of any theory adequately to explain
and to predict pathology, personality, or behavioral change; 4.
the growth in number and importance of shorter term, focused psychotherapies;
5. greater communication between clinicians and scholars that
has resulted in increased willingness and opportunity for therapeutic
experimentation; 6. the intrusion into the consulting room of
the realities of limited socioeconomic support by third parties
for traditional, long term psychotherapies, accompanied by an
increased demand for accountability and documentation of the effectiveness
of all medical and psychological therapies; 7. the identification
of common factors in all psychotherapies that are related to successful
outcome; and 8. the development of professional organizations2,
networks, conferences, and journals that are dedicated to the
discussion and study of psychotherapy integration.
Recently, there has been an explosion of integrative works,
and of impassioned debate about the possibility and advisability
of integrative efforts. Of particular note during this period
was a collection of dialogues between supporters and opponents
of psychotherapy integration (Arkowitz & Messer, 1984). A
final sign of the evolving maturity of psychotherapy integration
was the almost simultaneous publication of two recent handbooks
that collected the work of the major contributors in single volume
sources (Norcross & Goldfried, 1992; Stricker & Gold,
1993).
The Modes of Psychotherapy Integration
There are three generally accepted ways in which the methods
and concepts of two or more schools of psychotherapy may be combined
or synthesized. These modes differ from each other with regard
to the hypothesized point at which the component therapies meet
and meld with each other. They also differ in terms of the respective
emphasis placed at each level on technique, change factors, or
broader theory (Norcross & Newman, 1992).
The three most commonly discussed forms of integration are technical
eclecticism, the common factors approach, and theoretical integration.
Technical eclecticism is the most clinical and technically oriented
form of psychotherapy integration. Techniques and interventions
drawn from two or more psychotherapeutic systems are applied systematically
and sequentially. The series of linked interventions usually follows
a comprehensive assessment of the patient. This assessment allows
target problems to be identified and then clarifies the relationships
among different problems, strengths, and the cognitive, affective,
and interpersonal characteristics of the patient. Techniques are
chosen on the basis of the best clinical match to the needs of
the patient, as guided by clinical knowledge and by research findings.
Technical eclecticism need not be guided by an original or integrative
theory of personality or of psychopathology. Instead, it usually
is based on existing theories and goes beyond this conceptual
foundation on a case by case, clinical basis, by adding new techniques
and clinical strategies as they are needed. When theory is not
involved, this style of psychotherapy integration converges with
an eclectic approach.
The common factors approach to integration stems from the assumption
that all effective methods of psychotherapy share to some degree
certain critical, curative factors. Common factors approaches
start from the attempt to identify the specific effective ingredients
of any group of therapies. This effort is followed by exploration
of the ways that particular interventions and psychotherapeutic
interactions promote and contain those ingredients. The integrative
therapies that result from this process are structured around
the goal of maximizing the patient's exposure to the unique combination
of therapeutic factors that best will ameliorate his or her problems.
The search for common curative factors in cross-sectional studies
of psychotherapy has a long and distinguished history. The research
and scholarship of such leaders in psychotherapy as Jerome Frank,
Carl Rogers, and Hans Strupp were central to the establishment
of the common factors approach as viable and important. Rogers
(1961) attempted clinically and empirically to identify the necessary
and sufficient factors that led to therapeutic growth. According
to Rogers, personality change for the patient followed from a
relationship in which the therapist reacted to the patient with
accurate empathy, unconditional positive regard, and self-congruence.
Frank's (1961) work contained a cross- cultural perspective on
healers and psychotherapists and led to the conclusion that the
remoralization of a defeated patient and the provision of hope
were central to all psychological and moral helping relationships.
Strupp and his colleagues (e.g., Strupp, Wallach, & Wogan,
1962) pioneered the empirical study of psychodynamic psychotherapy.
They (Strupp, Hadley & Gomes-Schwartz, 1977) came to very
similar conclusions with regard to the effective ingredients of
analytic therapies.
Contemporary common factors investigators have built on these
earlier efforts and have been able to demonstrate that most therapies
do share a pool of curative ingredients. These common factors
are relational and supportive, in that they stem from the therapeutic
relationship. They also are technical, deriving from the provision
of new learning experiences and the opportunities to test new
skills in action (Lambert, 1992; Lambert & Bergin, 1994).
Each school of psychotherapy capitalizes on certain common effective
factors, and neglects or excludes others (Weinberger, 1995). The
advantage of this common factors integration, then, is to increase
the number of these curative factors, common and unique, to which
the patient systematically may be exposed.
The last type of psychotherapy integration to be considered
here is theoretical integration. This form of integration has
been described as the most sophisticated and important by some
writers, but has been criticized as overly ambitious and essentially
impossible by others (Franks, 1984; Lazarus, 1992; Messer, 1992)
because of the scientific incompatibilities and philosophical
differences among the various schools of psychotherapy. Those
who argue in favor of this form of integration do so because of
the new perspectives it offers at the levels of theory and of
practice. Theoretical integration involves the synthesis of novel
models of personality functioning, psychopathology, and psychological
change out of the concepts of two or more traditional systems.
Integrative theories of this kind generally attempt to explain
psychological phenomena in interactional terms, by looking for
the ways in which environmental, motivational, cognitive, and
affective factors influence and are influenced by each other.
Causation usually is assumed to be multidirectional and to include
conscious and covert factors, and most theoretical integrations
include a focus on the ways that individual's recreate past patterns
and experiences in the present.
The systems of psychotherapy that follow from such theoretical
integration use interventions from each of the component theories,
as well as leading to original techniques that may "seamlessly
blend" two or more therapeutic schools (Wachtel, 1991). At
times, the clinical efforts suggested within a theoretically integrated
system substantially may resemble the choice of techniques of
a technically eclectic model. The essential differences may lie
in the belief systems and conceptual explanations that precede
the clinical strategies selected by the respective therapists.
Theoretical integration goes beyond technical eclecticism in clinical
practice by expanding the range of covert and overt factors that
can be addressed therapeutically. Subtle interactions between
interactional experiences and internal states and processes can
be assessed and targeted for intervention from a number of complementary
perspectives. Expected effects of any form of intervention in
one or more problem areas can be predicted, tested, and refined
as necessary. This conceptual expansion offers a framework in
which problems at one level or in one sphere of psychological
life can be addressed in formerly incompatible ways (Gold, 1990).
The Assimilative, Psychodynamic Model of Psychotherapy Integration.
Our model of psychotherapy integration is one of theoretical
integration. It relies heavily on contemporary psychodynamic theories
of personality structure, psychopathology, and psychological change,
while freely using methods and interventions from other therapeutic
systems. This approach to theoretical integration is described
best as assimilative (Messer, 1992) because a single theoretical
structure is maintained, but techniques from several other approaches
are incorporated within that structure. As new techniques are
employed within a conceptual foundation, the meaning, impact,
and utility of those techniques are changed in powerful ways.
In his discussion of assimilative integration of psychotherapies,
Messer (1992) points out that all actions are defined and contained
by the interpersonal, historical, and physical context in which
those acts occur. Therapeutic interventions are complex interpersonal
actions, so that interventions are defined by the larger context
of the therapy. A behavioral method such as systematic desensitization
will mean something entirely different to a patient whose ongoing
therapeutic experience has been defined largely by psychodynamically
oriented exploration than it will to a patient in traditional
behavior therapy. The process of accommodation is an inevitable
partner of assimilation. Psychodynamically oriented ideas, styles,
and methods are recast and experienced differently in an integrative
system as compared to traditional dynamic therapies. When we choose
to intervene actively in a patient's cognitive activities, behavior,
affect, and interpersonal engagements, we change the meaning and
felt impact of our exploratory work and of our emphasis on insight
as well.
These assimilative and accommodative changes have been detailed
extensively in the recent psychotherapy integration literature.
In earlier writings we have presented a "three tier"
model of personality structure and change (Gold & Stricker,
1993; Stricker & Gold, 1988). These tiers refer respectively
to overt behavior (Tier 1), conscious cognition, affect, perception,
and sensation (Tier 2), and unconscious mental processes, motives,
conflicts, images, and representations of significant others (Tier
3). We emphasize theoretically and clinically the exploration
of this last sphere of experience, but recognize and use therapeutically
the complex and multidetermined interconnections between different
levels of experience. Unlike traditional psychoanalysis, which
treats behavior and conscious experience as epiphenomenal and
as important only in symbolizing underlying issues, we embrace
the realms of behavior and consciousness as areas of important
work in themselves.
Our evolving psychodynamic theoretical base inherits the contributions
of such psychoanalytic innovators as Ferenczi (1930) and Alexander
and French (1946), and interpersonalists such as Sullivan (1953)
and Fromm (1955). These authors all challenged the hegemony of
insight and interpretation within psychoanalytic therapy, instead
arguing that new experience and the corrective interaction between
patient and therapist were as important, if not more important,
than insight in bringing about change. Our thinking closely resembles,
and has been influenced deeply by, innovative psychodynamic theories
such as Wachtel's (1977, Gold & Wachtel, 1993) Cyclical Psychodynamics,
Ryle's (1990) Cognitive-Analytic Therapy, and Andrews' (1993)
Active Self model. These theorists observe that insight and new
patterns of relating to the self and to others are linked in circular,
varied and shifting ways, with insight following new emotional,
interpersonal, and representational processes as often as it causes
those shifts in function and style. Insistence on a unidirectional
model of change (Gold, 1991) suggests, erroneously, that psychological
life and psychotherapeutic effect are straightforward and simple.
One also must rethink a psychodynamic model of the mind when
assimilative integration is employed (Stricker, 1994). In particular,
the unidimensional theory of change that is emblematic of classical
psychoanalysis must be jettisoned in favor of a multidirectional,
circular model (Gold & Wachtel, 1993; Stricker & Gold,
1988). We understand change to occur and to begin at any of the
three tiers of psychological life, rather than always being caused
by changes in unconscious conflict, structure, and motive. We
also argue that insight can be the cause of change, the result
of new experiences and ways of adaptation, or a moderator variable
that intervenes in the effects of other change processes. Often,
it is difficult, if not impossible, to identify the places of
insight and active interventions in the causal chain of events
that preceded a patient's gains.
In attempting to achieve assimilative integration, the selection
among alternative interventions is among the most difficult decisions
that face the therapist. Most frequently, these decisions are
made on the basis of clinical factors, such as theoretical orientation
or prior experience. This leads to highly individualistic decisions
that rarely are reliable, but often appear to be effective. Nonetheless,
the lack of reliability warns us that validity may be suspect,
no matter how much faith each individual clinician has in his
or her own decision. An alternative approach has been suggested
by Beutler (e.g., Beutler & Hodgson, 1993), who is attempting
to develop a research-driven basis for matching interventions
with therapeutic issues. Clearly this is a superior basis for
action, but the literature currently does not allow a broad enough
foundation for action and therefore many clinical situations are
returned to the clinician for decision on the theoretical and
experiential grounds that always have marked clinical intervention.
The assimilative use of active interventions is based primarily
on the therapist's ongoing assessment of the patient's psychodynamic
status. This evaluation includes an emphasis on the tone of the
therapeutic relationship and alliance, as well as consideration
of the most pressing conflicts, defenses, self and object representations,
and emotional states with which the patient is struggling. Active
methods are chosen and are suggested with two or more simultaneous
and compatible objectives in mind: (1) to promote changes in the
person's current functioning that (2) will impact on central intrapsychic
and characterological processes as well.
When indicated, either on the basis of clinical experience or
research evidence, cognitive, behavioral, systemic, or experiential
techniques may be introduced to intervene in any or all of these
psychodynamic issues. For example, we sometimes will use an exposure
based method such as systematic desensitization or assertiveness
training to assist a patient in the task of reducing social anxieties.
Although the change in overt behavior is highly desirable in itself,
it also represents a way to work with resistances and defenses
that may not yield to interpretation. When the patient is engaged
more completely in previously feared relationships, the underlying
intrapsychic contributions to those fears will be accessible to
dynamic exploration in an immediate, emotionally vital manner.
Similarly, an impasse in the therapeutic relationship that might
be brought about by a patient's unconscious, paranoid representation
of the therapist's intentions may be resolved only partially by
interpretation of the immediate and historical roots of those
perceptions. Active testing of the accuracy of the patient's ideas,
as practiced in traditional cognitive therapy, often can be highly
effective in such a situation. As a final example, interpretive
work with a tightly controlled, overly intellectualized person
may be helped immensely by introducing affectively oriented, experiential
methods from gestalt therapy, such as the two chair technique.
The goal here is to combine expanded intellectual awareness of
the emotions that were repressed with immediate and powerful experiences
of those emotions. This active expansion of the patient's affective
life often synergizes with psychodynamic exploration by creating
a blend of insight and experience that is less likely to be worked
into the patient's intellectualizing defensive structure in a
redundant, isolated manner.
The therapist takes an expanded perspective on the variety of
events and process that may affect intrapsychic life. Interpretation
and insight still are accorded a central place, but interpersonal,
cognitive, and emotional variables are seen as maintaining or
provoking wishes, representations of self and others, and complex
states of internal conflict (Ryle, 1990; Stricker & Gold,
1993; Wachtel, 1977). As Wachtel (1977; Gold & Wachtel, 1993)
has pointed out, disowned intrapsychic states sometimes may reflect
the patient's unconscious perceptions of real events and relationships
in the here and now, rather than being remnants of early experiences.
Whether their derivation is past or present, dynamic issues are
shaped, reinforced, and sometimes are modified by the participation
of the significant people in the patient's life. This applies
to all patients, but especially is germane to therapeutic work
with patients whose pathology results from deviations in development.
These "character disordered" individuals lack the internal
structure necessary for such adaptive tasks as affect tolerance,
regulation of self esteem, or self generated initiative (Stricker
& Gold, 1988). These gaps in development manifest themselves
in severe impairment in behavior, cognition, affect, and interpersonal
relationships (Tiers 1 & 2).
Work on these issues must address pathology at all three tiers.
To work only at the psychodynamic level would ask the patient
to go too far beyond his or her pre-existing adaptive capacities.
However, if one ignores the intrapsychic, the therapy may remain
superficial and overly simplified. When Tier 3 issues cannot be
addressed advantageously through interpretation, this expanded
framework allows the therapist to work indirectly on those issues
by using them as a "map" for change in the other tiers.
Work on overt behavior and conscious ideation and emotion can
proceed from any of the three tiers, but will be most effective
when the meaning of the behavior or thought is understood completely
and the selected interventions are presented and used in ways
that are experienced as benign and acceptable to the patient.
Additionally, ideas, affects, behaviors, defenses, and symptoms
do not exist in isolated ways or meaningless states. These Tier
1 and 2 phenomena frequently are invested with much symbolism
and meaning that is unknown to the patient and to the therapist.
For example, a particular cognitive structure, belief, or way
of processing emotion can unconsciously be perceived as a crucial
part of one's identity, or as a way of identifying with a parent.
Thus, active interventions may be experienced as forced wedges
that are aimed at prying loose a cherished self representation
or object relationship. A complete psychodynamically oriented
exploration of these phenomena is necessary to appreciate fully
the patient's needs in these matters, and then to introduce active
methods in ways that will seem most benign and helpful to the
patient (Gold & Stricker, 1993).
This conceptualization of the mutual influence and interpenetration
of the intrapsychic, interpersonal, experiential, and behavioral
spheres of life brings our psychodynamic theory closer to recent
developments in psychotherapy and clinical and developmental psychology
than its traditional psychoanalytic predecessors (see, for example,
Greenberg, Rice, & Elliot, 1993; Guidano, 1987; Safran &
Segal, 1990; or Stern, 1985).
A Case of Assimilative Integrative Psychotherapy
In the case presentation that follows we attempt to illustrate
the use of active techniques. Three of the several assimilated
techniques that marked this essentially psychodynamic psychotherapy
are mentioned. This therapy lasted for about 32 months with the
frequency of sessions moving from once weekly to twice weekly
after about one year. The final six months of the therapy also
was conducted on a once weekly basis.
Mr. S. was a 37 year old single man who came to therapy complaining
of severe anxiety symptoms that had begun at about the time the
small company at which he worked had merged with a larger and
more impersonal firm. Mr. S. was an accountant who increasingly
felt isolated at work, especially after his supervisor retired.
He had formed an attachment to this older person that he described
as parental, and felt that he had been protected and supported
in this relationship. He was preoccupied with the prospect of
being fired by his new supervisor, although his evaluations had
been more than satisfactory. As a result of this concern, he had
been working longer and harder, had ignored any of his few social
connections and sources of recreation, and had fallen into a reactive
state of irritation and pessimism that bordered on depression.
Mr. S's father, with whom he had had a distant and mutually unhappy
relationship, had died suddenly about eight months prior. The
patient reported this in the first session in a seemingly disinterested
way, stating that he had felt little about the loss. However,
his associations, the few dreams he remembered having near the
time he sought therapy, and his description of his relationships
with his supervisor all pointed to repressed grief reactions that
were complicated by pre-existing unconscious issues of loss, rage,
and unrequited love.
The first phase of the therapy involved a broad inquiry into
all relevant experiences necessary to complete an assessment at
Tiers 1, 2, and 3. Tier 1 (overt behavior) was marked by repetitive
patterns of compulsive involvement with work, impulsive and hasty
actions and choices, and avoidant patterns of interaction wherein
Mr. S. took care to limit contact with people to an excessive
degree. Tier 2 (conscious cognition and affect) contained rigid
and moralistic demands for intellectual control over himself and
other people, affective constriction, and a long list of "shoulds"
and "musts." His compulsive preoccupation with work
yielded a conscious sense of perfectionism, pride and ideas about
being better than other people, but he also suffered worries about
his self worth and a dimly perceived but ever present sense of
shame that he could not explain. Tier 3 (intrapsychic representations)
had been shaped by Mr. S.'s relationships with an obsessive and
distant father, and a depressed and passive mother. His father
had focused exclusively on his highly successful and lucrative
career, rarely displaying any interest in his wife or children,
whereas his mother cared for the patient in a dispirited and dutiful
manner. Mr. S.'s inner world was composed of fragmentary andconflicting
identifications with these parents. He unconsciously was caught
between a sense of isolated grandiosity and a portrayal of himself
as vulnerable, without energy, and unworthy of a father's attentions.
The assessment also revealed the multidirectional relationships
among issues at the three tiers. Mr. S.'s psychodynamic issues
were symbolized and expressed in his behavior and thoughts, but
the way he acted and understood his experiences also confirmed
and reinforced his self and object relationships. For example,
each time someone made an attempt to befriend him, he felt caught
between his shameful sense of unworthiness and his identification
with his father's scorn of intimate connections. These conflicts
and the defensive need to avoid were then reinforced by the other
person's discomfort with Mr. S's ambivalent reactions. When his
compulsive behavior and perfectionistic ideas were unrewarded
at work, his rage and his sense of failing to achieve the love
and approval of a father figure also were reinforced.
As the therapy proceeded, Mr. S. became subtly but increasingly
combative, bringing his affectless, perfectionistic, and avoidant
style into the therapy. He could not use interpretations effectively
and, instead, challenged the scientific validity of the therapist's
formulations, general approach, and in particular the therapist's
ideas about the connections between the loss of his supervisor,
his relationships with his father, his reactions to his father's
death, and his current symptoms. These resistive interactions
severely threatened an already shaky therapeutic relationship,
as an increasingly unworkable hostile atmosphere developed. The
therapist became aware that, in his attempts to reach Mr. S.,
he had become an accomplice to Mr. S: the patient needed to keep
the therapist at bay in order to ward off the very psychodynamic
issues that the therapist was concerned with. An assimilative
shift was proposed. The two chair technique from gestalt therapy
was suggested in order to help Mr. S. test his ideas about the
lack of validity of the therapist's formulations. If, as Mr. S.
argued, he had no other feelings about his father, his death,
and the loss of his supervisor, then these techniques probably
would be ineffective as well, demonstrating the therapist's uselessness
to him. On the other hand, if some change did occur, perhaps Mr.
S. would consider some change in his outlook on his psychological
situation and on therapy.
Thus followed an extended period of gestalt work in which Mr.
S. uneasily involved himself in the enactment of dialogues with
his former supervisor, with his father, and, eventually, with
himself as a child and with his mother. Gradually, his affective
constriction was loosened, and he became aware of tremendous anger,
coupled with a deep longing for contact and a pervasive sense
of shame, anxiety, and unworthiness of the love of his parents.
The success of the experiential exercises had tremendous impact
beyond the expansion of Mr. S's emotional range. As hoped, he
began to review his ideas and feelings about the therapist, psychotherapy,
and his relationships in a new and more positive light, with a
strengthened bond with the therapist being one result. The hostile
transference that had developed diminished significantly, and
became the source of fruitful psychodynamic investigation and
insight that now could be integrated. As Mr. S. now had experienced
success in psychotherapy, and perceived directly that the therapist
was effective and on his side, other implications of the transference
(such as aspects of mother's helplessness) became apparent. Mr.
S. felt himself to have been worthy of help, and in this experience
found a basis for making conscious, and for actively testing cognitively
and interpersonally, his fears that others would reject him as
did his father.
A second example of assimilative integration in Mr. S's therapy
occurred when he suffered a severe panic attack when notified
of an unexpected internal audit of some of his work. Dynamic inquiry
and interpretation were impossible given the paralysis that Mr.
S. displayed in the next session. As a result, a move was made
toward active instruction in relaxation techniques, cognitive
measures for self-soothing, and calming imagery. These techniques
were very helpful. As Mr. S. became less anxious, he realized
that he was both exhilarated and saddened by these events: the
therapist had demonstrated an immediate concern for Mr. S. and
an ability to help him that evoked deeply painful memories and
images of father and mother. At times when the patient had been
distressed in the past, his father's disinterest, and his mother's
passive ineffectuality, had convinced Mr. S. of the hopelessness
of nurturance and help from others, and had imprinted a vision
of himself as isolated and reactively self-contained. As these
issues were explored, he became able to acknowledge and to integrate
a full range of affects that he had long avoided. At the same
time that he began to cast off these self and object images, he
used this helpful interaction with the therapist as the source
of new intrapsychic representations and structures.
A final example of our approach to the integration of active
methods is drawn from a situation in which the patient asked for
help in designing exercises to be used to overcome his interpersonal
distancing behaviors. A series of sessions were devoted to behavioral
rehearsal, anxiety management, and to the construction of an in
vivo hierarchy of social situations. These procedures had three
goals: first and most obvious, the reduction of his social anxiety
and improvement in social skills; second, to gain greater access
to the psychodynamic issues that were warded off through his avoidance
of intimacy with others; and lastly, support for, and reinforcement
of, his newly emerging sense of being able to ask for help, and
to be deserving of it. Correspondingly, such a request signalled
the presence of a benign image of the therapist that required
whatever confirmation was possible. The results of this behavioral
sequence were analyzed and led to an ongoing expansion of the
psychodynamic part of the therapy.
In these and all of the other instances when active techniques
were introduced to Mr. S., they were mentioned tentatively and
always with concern for his intrapsychic construal of their meanings.
The effects of these suggestions on his perceptions of the therapist,
their relationship, the therapist's understanding of Mr. S's needs,
and Mr. S's reactions all were explored repeatedly before, during,
and after the interventions were attempted. These discussions
often stood as among the more enriching part of the therapy, as
they highlighted all three tiers of psychological life in an immediate
and vital way. Empirical Considerations
If our assimilative model of integrative psychotherapy is to
be influential and long lasting, it must pass the tests of scientific
validation and reliability by which we evaluate all therapies.
We hope that our case study is clearly illustrative of our thinking
and methods. However, it does not itself demonstrate anything
about the model's efficacy, generalizability, or potential for
replication by other therapists.
At this point in our work we have been concerned exclusively
with clinical and theoretical issues, and have not been able to
subject this model to the empirical tests that it requires. Nonetheless,
it behooves us to raise the critical questions that only can be
answered by research, and also to consider extant research findings
that may speak indirectly to the status of our work.
First, and probably foremost, are the questions concerning treatment
effectiveness and specificity. Is this therapy as or more effective
than its component therapies (psychodynamic, cognitive-behavioral,
or experiential) or any other systems of treatment? Linked to
this question are the issues of prescription and patient matching:
are there particular persons, problems, diagnoses, or psychological
characteristics for whom or which this therapy can be empirically
demonstrated to be most effective? Inquiry also eventually must
be directed at such theoretical issues as our hypothesized revisions
of psychodynamic theory and the assumed circular relationships
between psychodynamics, behavior, cognition, and affective experience.
In particular, this model must be studied in terms of the incremental
validity of our expansion of the psychodynamic perspective when
compared to its traditional conceptualization. Finally, issues
of generalizability must be raised and tested. Will this therapy
work, or even exist, when conducted by therapists other than the
authors of this report? Can the model be taught? Can we formalize
and offer data driven guidelines for when and how to move from
one intervention to the next, or must clinical intuition dictate
exclusively?
Although we do not yet possess direct and data derived answers
to these questions, the research literature does offer some suggestions
and reasons for cautious optimism. For example, research on prescriptive
psychotherapies (Beutler & Hodgson, 1993) and on the stages
of change in psychotherapy (Prochaska & DiClemente, 1992)
have demonstrated the maximized effectiveness of psychotherapies
that include interventions that are drawn from several different
dimensions of psychological life, as does our model. These groups
of studies impressively support the idea that technique serves
the patient best when interventions are matched to the patient's
immediate clinical need and psychological state. This view is
central to our model. Clinical trials of integrative psychotherapies
that resemble ours in their fusion of psychodynamic formulations
and exploration with active interventions have yielded preliminary
but positive results. For instance, the integrative, interpersonal
psychotherapy for depression developed by Klerman, Weissman, Rounsaville,
and Chevron (1984) has outperformed medication and other psychological
interventions in a number of studies. Ryle (1990) reports that
both short term and long term versions of Cognitive Analytic Therapy
(CAT) have been found emphatically to be more effective than purely
interpretive or behaviorally oriented approaches. Omer (1992)
offers empirical support for integrative interventions that heighten
the patient's awareness of his or her participation in psychotherapy,
thus improving the impact of the basic exploratory stance of the
psychotherapist. Glass, Victor, and Arnkoff (1993) point out that
several systems of integrative psychotherapy have been demonstrated,
albeit in limited numbers of studies, to outperform either strictly
psychodynamic or cognitive- behavioral interventions.
Perhaps the most impressive and important collection of studies
of integrative psychotherapy have been carried out by Shapiro
and his colleagues at the Sheffield Psychotherapy Project (e.g.,
Shapiro & Firth, 1987; Shapiro & Firth-Cozens, 1990).
These workers studied the impact of two sequences of combined
psychodynamic and cognitive-behavioral therapy: dynamic work followed
by active intervention or vice versa. They found that the greatest
gains were made, and the smoothest experience of treatment were
reported, by those in the dynamic-behavioral sequence. Patients
in the behavioral- dynamic sequence more frequently deteriorated
in the second part of the therapy, and did not maintain their
gains over time as often as did patients in the other group. These
findings seem to echo and confirm the guidelines of our model,
in which psychodynamic work usually precedes and prescribes more
active interventions.
Other research can be found that points to the possibility of
empirically validating expansions of psychodynamic theory, and
of the construct validity and reliability of clinically generated
integrative psychodynamic formulations. One central source of
these findings is the work of Andrews (1993) on the Active Self
model of personality and psychotherapy. This system, like ours,
posits feedback and feedforward relationships between events in
various psychological domains, with behavior, affect, cognition,
and interpersonal relatedness all serving to express and to reinforce
pre-existing representations of self and of others. Content analysis
of therapy transcripts has yielded much support for this theory,
and for its utility in guiding the selection of interventions
in an integrated psychotherapy.
Kiesler (1992) points out that work in personality theory that
is derived from the variety of interpersonal circles inventories
is supportive of many of the personality theories that drive integrative
models of psychotherapy. He notes that much data exist to confirm
hypotheses about the back and forth nature of the relationship
between intrapsychic and interpersonal variables, and also to
support the central focus of many integrative therapies upon interrupting
the processes that confirm and maintain pathological representations
of self and of others.
Empirical verification for psychodynamic formulations may now
be found in a variety of well designed and extensive research
projects. Methods such as the Core Conflictual Relationship Theme
(CCRT) developed in the Penn Psychotherapy Project (Luborsky &
Crits-Cristoph, 1990) can yield valid and reliable assessment
of central dynamic themes. The Mt. Zion psychotherapy project
(Weiss & Sampson, 1986) has generated the Plan Formulation
Method that yields an assessment of conscious and unconscious
goals, pathogenic beliefs and conflictual emotions, plans for
testing those beliefs, and necessary insights. These formulations
have been employed in a number of studies that impressively have
validated therapist and judges predictions about process changes
in psychodynamics over the course of psychotherapy (Weiss, 1994).
Strupp and his colleagues at the Vanderbilt Psychotherapy Project
(Strupp, 1993; Strupp & Binder, 1984) also have demonstrated
the capacity to develop valid and replicable psychodynamically
informed formulations of a patient's psychological functioning
that drive and guide the therapist's interventive strategies.
These formulations are organized around a concept called the Cyclical
Maladaptive Pattern (CMP), a concept that expands the view of
psychodynamic processes in ways that are identical to ours: internal
variables are assumed both to influence and to be influenced by
interpersonal, cognitive, and emotional states through feed back
and feed forward processes.
The findings of these last few research projects also address
the questions of generalizability and teachability that we noted
above. The Penn Psychotherapy Project, the Mt. Zion group, and
the Vanderbilt Psychotherapy Project all have resulted in the
production of psychotherapy manuals (see Gold, 1995, for a more
extensive review of this work). These manuals offer any psychotherapist
explicit and data driven guidelines for formulation of the patient's
problems and current functioning. Studies indicate (Weiss &
Sampson, 1986; Luborsky & Crit-Cristoph, 1990; Strupp, 1993)
that compliance to the manual can be demonstrated and that the
level of compliance is linked positively to process variables
and to outcome. There is virtually no direct empirical evidence
concerning the model we propose, but there are many encouraging
developments to suggest that this and other models may become
of demonstrable validity, generalizability, and teachability.
Conclusion
An assimilative approach to psychotherapy integration combines
the organizing principle of a theoretical system of understanding
with the range of technical interventions available to the gamut
of schools of treatment. It has the advantages of access to an
expanded set of techniques and of the understanding that comes
from a coherent set of propositions to justify those interventions.
It also stretches the theoretical system in order to understand
better the impact of interventions that ordinarily would not be
available within that system.
Our approach begins with a psychodynamic system of understanding,
but incorporates behavioral and affect arousing procedures that
ordinarily do not follow from such an approach. The success of
these techniques lead us to favor an interpersonal rather than
a solely intrapsychic psychodynamic formulation, as these techniques
are more consistent with such a theory. However, colleagues can
begin with any other theory and also will find it helpful to incorporate
an expanded range of interventions. This leads us back to our
three tier approach. Behavior, the first tier, is the province
of the behavioral approaches. The second tier, conscious cognition
and affect, often draws the cognitive- behavioral and the experiential
theorists. The third tier, dynamics, is the concern of the psychodynamic
therapists. However, patients function and malfunction at all
three tiers, and it behooves a responsive therapist to draw interventions
from all three. We have illustrated one among many possible approaches
to assimilative integration, and would recommend that other therapists
experiment with alternative combinations of theory and technique,
and then test these experiments empirically so that the science
and the practice of clinical psychology and psychotherapy can
be advanced.
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FOOTNOTES
1 - Readers who desire a more extensive discussion of the history
of psychotherapy integration are referred to the excellent works
by Arkowitz (1984) and Goldfried and Newman (1992).
2 - Anyone interested in information about the Society for the
Exploration of Psychotherapy Integration (SEPI) may obtain it
by writing to George Stricker, The Derner Institute, Adelphi University,
Garden City, NY 11530.
Author notes
Correspondence concerning this article should be addressed to
George Stricker, The Derner Institute, Adelphi University, Garden
City, New York 11530. Electronic mail may be sent via Internet
to geostricker@comcast.net
