Integration in Counselling & Psychotherapy

Developing a Personal Approach

Phil Lapworth, Charlotte Sills

• Publisher: SAGE Publications Ltd
• Year: 2009
• ISBN:
  9781446243169
• Edition: 2
• Topic: Psychologie
• Subtopic: Psychotherapeutische Beratung

Now in its second edition, this book is established reading for any practitioner or trainee wishing to develop their own personal style of working. As well as examining contemporary integrative approaches, the authors show how to develop an individual approach to integrating theories and methods from a range of psychotherapies.

Offering clear strategies for integration rather than a new therapeutic model, this practical new edition:

- puts added emphasis on the integrative framework, and procedural strategies, extending discussion of the individual practitioner as integrator

- is accessible for the new trainee, whilst posing questions for discussion and reflection for the more experienced practitioner

- integrates recent thinking and research in psychotherapy, human development and neuroscience

- discusses how developments in relational approaches impact on integration in practice

- addresses integration within humanistic, psychodynamic, cognitive-behavioural and existential approaches.

This book should be on the desk of every trainee studying integrative counselling and psychotherapy, as well as on the shelves of practitioners wanting to develop their own personal frameworks for therapy.

PART I

INTEGRATION: CONTEXT AND CONCEPTS

1

A BRIEF HISTORY OF INTEGRATION AND SOME RECENT DEVELOPMENTS

If we were writing a complete history of integration, we would need to devote not just one chapter but several volumes to the subject, for the history of integration is the history of psychotherapy itself. We might well begin with Freud, who within his own developing psychoanalytic frame attempted to integrate influences from his medical and psychiatric studies, from academic psychology, and from his collaborative work with Joseph Breuer, as well as from his neuropathological lectureship under Professor Charcot whose work using hypnosis suggested the power of the unconscious, the phenomena of attachment between patient and doctor and a link between sexuality and neurosis. We would then go on to describe the works of the next generation who broke away, diverged, incorporated, yet always in some ways integrated concepts from and into the structure of psychoanalysis. Even as early as 1932, Thomas Morton French, addressing the American Psychiatric Association, suggested similarities between the psychoanalytic concept of repression and the behavioural concept of extinction (French, 1933) and Rosenzweig (1936) was exploring common factors across various approaches.

By about volume 10, we would still not have done justice to the many and various alternatives that have developed from those early beginnings, converging, competing or reforming neo-Freudian and non-Freudian strands and developments as they proliferated into the hundreds of approaches that now exist. Needless to say, therefore, this developmental integration over the century will only be covered generally here, our purpose being to show that integration is not a new phenomenon and to explore, in its historical context, the more recent thrust of integration which seems to be of a different order to that of the past.

Within the general development of psychology, psychotherapy and counselling, there have been, and still are, distinct and separate models of counselling and psychotherapy. These models are based on different theoretical and philosophical foundations which are supported and furthered by the respective training organizations and professional associations to which they belong. The different models are normally divided into three distinct, though often overlapping, schools or traditions of theoretical approach which have informed the practice of counselling and psychotherapy. The first, already referred to, is the psychodynamic (or psychoanalytic) school with its roots in the theory and methodology of Freud, characterized by the unconscious conflict brought about by instinctual drives and repression. The second is the behavioural tradition with its roots in the experiments of Pavlov and Skinner and characterized by conditioned learning. The third is the humanistic/existential tradition with its roots in the works of such pioneers as Moreno, Maslow, Rogers, Perls, Berne, May, Boss and Binswanger and characterized by a belief in self-actualization and choice. Recently, some therapists have begun to identify a ‘fourth force’ of thought and practice, which has grown in strength perhaps as a response to the ills of the twentieth century and is characterized by a transpersonal element and a focus on the spiritual path of human beings. Its forebears are such theorists as Assagioli, Brazier and Wilbur.

These schools, though claiming a distinction from each other, have spawned a proliferation of approaches to counselling and psychotherapy not only within their own school of thought but also across the four schools. These various approaches, though seemingly unique, can often be traced back to early beginnings in one or more of the schools. For example, Perls, in his Gestalt therapy, developed across schools by integrating Gestalt psychology, Freudian psychoanalytic theory, the theories of the ‘interpersonal psychoanalysts’ such as Fromm, Adler and Rank and ‘radical analysts’ such as Reich, as well as existential philosophy, Zen Buddhism, phenomenology, field theory and psychodramatic techniques as developed earlier by Moreno (see Sills et al., 1995). Transactional analysis, although basically an object relations theory that integrates elements of cognitive behaviour theory and social psychology, is considered humanistic because of its philosophy and value system (see Lapworth et al., 1993). Self-psychology (Kohut, 1971) originally integrated elements of drive theory and object relations while centralizing the importance of empathic understanding (traditionally associated with person-centred practice) in the healing of a damaged self. Intersubjectivity theory (Atwood and Stolorow, 1984) has developed from a psychoanalytic root, especially the empathic immersion of self psychology, yet centralizes the co-creativity of experience more usually associated with Gestalt, person-centred or constructivist approaches. Relational psychotherapy integrates exploration of unconscious, intrapsychic dynamics whilst prioritizing the co-created, authentic relationship as the central vehicle for change.

From psychoanalysis there have been many offshoots. Some examples of these are analytical psychology, ego psychology, object relations theory, self-psychology and, most recently, intersubjective and relational psychoanalysis. The behavioural school has led to cognitive behaviour therapy, constructivist theories, assertion trainings, neuro linguistic programming (NLP), solution focused therapy and dialectic behavioural therapy. Within the humanistic school, the offshoots have been so plentiful that it is sometimes difficult to keep track even of the names, let alone their theoretical slant. Among the more established humanistic or existential approaches such as psychodrama, person-centred counselling, existential psychotherapy, Gestalt and transactional analysis, there have been developments presented under names such as focusing, reclaiming your inner child, rebirthing, primal integration, and many others.

Many psychotherapy and counselling books specialize in some specific approach and many of the general counselling and therapy textbooks have sections or chapters devoted to individual theoreticians and approaches. Readers of these books, therefore, may come to the decision that all counsellors and psychotherapists are to be classified as purists. However, research indicates that many counsellors and psychotherapists will use and will also have studied a variety of approaches besides their ‘basic’ training and would not define themselves as purists at all. Increasing numbers are identifying themselves as integrative. For example, in 1996, out of 2,334 practitioners listed in the British Association for Counselling’s (BAC) Counselling and Psychotherapy Resources Directory, 499 (21 per cent) identified their theoretical orientation as integrative. By 2008, a search of the BACP’s website directory in randomly chosen regions across the UK showed a range from 30 per cent to 50 per cent of therapists describing their theoretical approach as integrative. These figures challenge the current (2009) moves by the government to categorize therapies according to specific and discrete skills and competencies – a task that is obviously unsuited to the flexibility of an integrative approach.

In light of the natural evolutionary development of ideas and approaches within the world of counselling and psychotherapy from its very beginnings a century ago, the question arises as to what is the difference between this integration and the movement towards integration that has been happening over the last thirty years. We suggest that the difference is in the intention of the integration. Whereas it was often the intention of past developments to invent something new, an innovative package that could be used as a complete model of counselling and psychotherapy, this is not necessarily the case with modern integrative developments. Rather, the integrative challenge of today is to discover overarching frameworks within which compatible or complementary, tried and tested aspects of various theories and approaches can be integrated. This involves embracing a meta-perspective of the field of therapy and taking stock of commonalities within theories and approaches (and the concomitant differences), as well as utilizing practical techniques from the wealth of such operations offered by the many and different approaches. It is more of a bridge-building exercise between and within the three schools than the construction of a new orthodoxy. Integrative counselling and psychotherapy seek, therefore, to build philosophical, theoretical and technical networks between compatible, workable and useful aspects of the various schools.

By and large, up until the l960s, counselling and psychotherapy were restricted to the wealthy or the insane – often both. In the social and cultural revolution of the 1960s in the West, therapy and counselling not only matched the zeal and innovation of that time but were an essential part of it. However, though more accepted as legitimate means of personal growth, and in that sense normalized, counselling and psychotherapy were still considered unusual by the wider population. The enormous expansion in the technology of international and interpersonal communication in the 1980s has meant an egalitarianism of information, understanding and knowledge such that counselling and psychotherapy can be offered to and participated in by a much wider and diverse clientele. During this time, the term ‘counselling’ reached a wide audience in the UK and elsewhere through ‘phone-in’ counselling shows on television and national and local radio, as well as via programmes presenting counselling and psychotherapy with celebrities or exploring various approaches. Indeed, radio and TV soaps were often to include the need for therapy for many of their life-battered characters. Comedy sitcoms have also been attempted which revolve around therapy and therapy practitioners. The result is that the public has not only been informed of the existence of counselling and psychotherapy, but also educated in its terminology, methodology and variety of approaches.

Increasing numbers of people are turning to therapy, therapeutic workshops or groups to address the stress they experience in their modern-day lives. Many companies and organizations now incorporate counselling services in their employee care packages. The therapeutic population is slowly becoming more representative of the general population found in our richly diverse and multicultural societies. Theories and approaches based upon white, middle-class, often male, Western ideologies and values no longer suffice to answer the needs of this population with its diversity of internal and external values, social complexity, differing family patterns and spiritual and cultural beliefs, as well as limitations of time or finance. To answer this need, models with a broader scope are required. Developing an integrative or integrating attitude within counselling and psychotherapy may be part of the answer.

This development towards integration is not confined to the world of counselling and psychotherapy but is also evident in educational approaches, political and social reorganization, economic theory and practice, industrial theory, anthropology, psychiatry and medicine. It is evident that while such a trend for integration exists within these individual areas, there is also room for integration across them. For example, psychotherapy and counselling may need to take note of and make room for aspects of social and political change and incorporate new knowledge and discoveries in the world of anthropology and medical science. In other words, integration is essential to an holistic view of human existence.

SOME DISAGREEMENTS

However, as is often the case where boundaries are being changed, there are some who do not agree with the developments that have taken place within counselling and psychotherapy and would argue strongly against any further developments of an integrative nature. Three major debates have emerged. First, some purist practitioners argue against eclectic or integrative psychotherapy or counselling approaches. Second, a debate continues between eclectic and integrative counsellors and psychotherapists. The third debate arises between the proponents of different versions of integrative approaches. Some practitioners identifying themselves with a specific or purist approach consider that any attempt to combine different approaches will result in confusion and an inauthenticity of some kind or another because each specific training is based on different underlying philosophical assumptions. They hold that, even if there is an overlap of a few of these assumptions, to lift a part of any whole would result in a distortion of not only that part but also of any other whole into which it is intruded/included. Further, they would argue that integration leads to an undisciplined spirit of translation which loses the subtleties and nuances of the individual approach.

Among the more purist writers who led the early argument against eclecticism and integrative approaches was Eysenck (1970) who argues that the only scientific and sufficiently consistent approach is behaviour therapy and that any integrative or eclectic therapy is a confusion of models. He criticizes eclectics for their lack of an acceptable rationale and a shortage of empirical evidence for their approach. Without mincing his words, he describes eclecticism as ‘a mishmash of theories, a hugger-mugger of procedures, a gallimaufry of therapies and a charivaria of activities having no proper rationale, and incapable of being tested or evaluated’ (1970: 140–6). From another perspective, the radical critic of psychoanalysis, Szasz protests against integration by saying that combinations of theories and practices result in inauthenticity:

The psychotherapist, who claims to practice in a flexible manner, tailoring his therapy to the needs of his patients, does so by assuming a variety of roles. With one patient he is a magician who hypnotises; with another, a sympathetic friend who reassures; with a third, a physician who dispenses tranquillisers; with a fourth, a classical analyst who interprets; and so on. The eclectic psychotherapist is, more often than not, a role player; he wears a variety of psychotherapeutic mantles, but owns none and is usually truly comfortable in none. Instead of being skilled in a multiplicity of therapeutic techniques, he suffers from what we may consider, after Erikson, ‘a diffusion of professional identity’. In sum, the therapist who tries to be all things to all people may be nothing to himself; he is not ‘at one’ with any particular method of psychotherapy. If he engages in intensive psychotherapy his patient is likely to discover this. (Szasz, 1974: 41)

Against this purist attitude, integrationists and eclectics suggest that the similarities between approaches are so fundamental that the using of ideas from different approaches will enrich an approach rather than confuse it. Though a confirmed eclectic rather than an integrationist, Lazarus (in Norcross, 1986) in writing of his multimodal therapy presents an argument which is in direct opposition to Szasz’s by stating that there is no one way to approach people’s problems and that individuality and flexibility are the key to good practice. He says:‘If a number of clinicians, unfamiliar with me or my therapeutic orientation, were to observe me with different clients, their views and conclusions about my methods and school identification would differ considerably.’ He goes on to suggest that one observer might see a Gestalt therapist, another a behaviourist, another a Rogerian, yet another a psychoanalytic therapist, and so on. He maintains that technical eclecticism (see the procedural integration strategy in Chapter 3 and Lazarus’s multimodal therapy in Chapter 8) ‘draws on all and any effective technique without necessarily subscribing to the theories or systems that gave rise to them’ (1974: 82). His emphasis rests on a flexibility of style and specificity of intervention designed to fit each client’s individual and idiosyncratic needs and expectancies, rather than attempting to fit the client into one particular approach or methodology. Wachtel certainly supports this view when he writes:

… there is no single way to conduct psychotherapy. When I think of the many different ways in which I have engaged with my patients over the years, I am struck by the incredible variety of things that I have done or said in the name of psychotherapy and by the ways that different patients have seemed to need or to be helped by different ways of being with them or interacting with them. Whatever “rules” may guide our work, perhaps the most important rule is not to take those rules too seriously (cf. Hoffman, 1998). By this I do not mean take them lightly. The responsibility we assume as psychotherapists is a weighty one. But every patient teaches us something new about what people need. The day we think we know all we need to know in order to help people is probably the day we cease to be able to help at all. (Wachtel, 2008: 303)

The second debate between those using eclectic methods and those using an integrating framework involves, among other things, the belief that integrative approaches require a greater academic and theoretical discipline than that required by any form of eclecticism. In the 1960s the term ‘eclectic’ was more popular than it is today. An eclectic approach to therapy is perceived as one that involves a practitioner assessing the needs of his client and choosing from a range of approaches the intervention which seems to best suit the situa...