New Approaches to Integration in Psychotherapy

Eleanor O'Leary, Mike Murphy, Eleanor O'Leary, Mike Murphy

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781136797620
• Edition: 1
• Topic: Psicología
• Subtopic: Asesoramiento psicoterapéutico

Psychotherapy is an area that has seen huge growth in prominence and practice. The range of theoretical schools that have emerged means that practitioners are striving to amalgamate and synthesise new approaches and theories.

New Approaches to Integration in Psychotherapy provides a snapshot of the latest theoretical and clinical developments in the field of integration. Eleanor O'Leary and Mike Murphy bring together contributors from a range of theoretical backgrounds who present new frameworks, theoretical integrations, clinical developments and related research. They critique existing research and provide a thorough overview of the historical development of the movement towards integration in psychotherapy. The book is divided into three sections, covering the following subjects in depth:

• Frameworks and Theoretical Integrations

• 
  
  

• Professional and Clinical Integrations and Special Populations

• 
  
  

• Issues for Professional Consideration

• 
  
  

This book will be welcomed by anyone interested in investigating integrative approaches to psychotherapy. In particular, it will have direct relevance to academics involved in training and research on psychotherapy, psychotherapists, counsellors and clinical psychologists.

Part I

Frameworks and theoretical integrations

Chapter 1

The need for integration

Eleanor O’Leary

The necessity for a movement towards integration within psychotherapy is apparent when we consider that there are purportedly 400 different approaches (Arkowitz, 1995; Feltham, 1999; Feltham & Horton, 2000; Karasu, 1986); that research studies show that the majority of the main therapeutic approaches are equally effective (Glass et al., 1993; Lambert, 1992; Mahoney et al., 1989; Norcross & Newman, 1992; Smith et al., 1980) and that between one-third and a half of practitioners in the US label their approaches “integrative” or “eclectic” (Norcross & Goldfried, 1992).

The history of the origin of the movement has been outlined by Beitman et al. (1989), Goldfried and Newman (1992), Castonguay and Goldfried (1994), Arkowitz (1995), Gold (1996), and Hawkins and Nestoros (1997). Some of the earliest integrative initiatives are ascribed to French (1933), Kubie (1934) and Sears (1944), who discussed parallels between psychoanalysis and conditioning. Originally, psychotherapy integration consisted, for the most part, of attempts to combine these two approaches, with authors such as Dollard and Miller (1950) and Alexander (1963) endeavouring to translate the language of psychoanalysis into learning theory. Gold (1996) pointed out that Alexander’s observation that insight into unconscious processes often followed behavioural change rather than the reverse moved psychotherapy away from a unidirectional view of change. According to Arkowitz (1992: 267-8), Wachtel’s (1977) work was “the most comprehensive and successful attempt to integrate behavioral and psychodynamic approaches” and “one of the most influential books in the entire field of psychotherapy integration”; Gold (1996: 7) referred to it “as a model of integration at both a theoretical and a technical level”. Wachtel’s endeavour developed into what is called the integrative psychodynamic approach (Wachtel & Wachtel, 1986; Wachtel & McKinney, 1992), Central to the theory is the cyclical nature of causal processes whereby experiences from the past linger and lead to present difficulties.

In 1973, the controversy within psychology and psychiatry over new methods led Thoresen to develop an approach that integrated the behavioural approaches with those that were more experiential and humanistic in orientation. He called this synthesis “behavioural humanism” and demonstrated how behavioural interventions could be instrumental in realising humanistic goals and objectives.

It was not until the 1980s that integration in psychotherapy came into its own and became clearly delineated as an area of interest (Gold, 1996; Goldfried & Newman, 1992). Arkowitz (1995) has maintained that the term “psychotherapy integration” was not even used until then. However, by 1994 integration had become a developing movement (Castonguay & Goldfried, 1994). Authors such as Norcross and Newman (1992: 7) and Hawkins and Nestoros (1997: 35) identified the following factors as leading to this development: the inadequacy of single theories; the equality of outcomes among therapies; the commonalities among therapies; the proliferation of psychotherapies; and socio-economic contingencies. In addition, Norcross and Goldfried spoke of opportunities for observation and experimentation with various different treatments, the identification of the significance of therapeutic commonalities to outcome variance, the growth of a professional network for integration and of short-term problem-focused psychotherapy, while Hawkins and Nestoros stressed personal characteristics, the therapeutic encounter, the complementary nature of different orientations and convergence (i.e. that as psychotherapeutic approaches develop, they take on characteristics of other schools and become more similar).

Three approaches to integration within psychotherapy have become generally recognized, namely technical eclecticism, theoretical integration, and common factors. Before these are examined in detail, a brief note on eclecticism and integration is timely. Norcross & Grencavage (1989: 233) viewed eclecticism as technical, divergent, selective, collective, atheoretical, empirical, and realistic. In addition, they held that eclecticism selects from among many and applies what is, the parts and the sum of the parts. Integration, on the other hand, is theoretical, convergent, idealistic, and unifying, and, according to these authors, constructs something new, blends the parts, and is greater than their sum.

The term “technical eclecticism” was devised by Lazarus (1967) and refers to the fact that psychotherapists can use techniques and interventions from different approaches without necessarily agreeing with their theoretical underpinnings (Lazarus, 1992). Arkowitz (1995) claimed that there was little focus on the field in the published literature, although psychotherapists were using it in practice. However, Lazarus was already writing on the subject of multimodal therapy (cf. Chapter 8) as early as 1973, with technical eclecticism as its guiding orientation. Technical eclecticism concerns itself primarily with seeking the best treatment for an individual with a problem. Its proponents seek to integrate two or more interventions or techniques, which they apply methodically and in sequence.

Once the sequence has been determined, the precise method is viewed as being pertinent to other individuals with similar problems and characteristics. Psychotherapists who use this approach believe that a variety of interacting factors are effective in psychotherapy, and do not concern themselves greatly with either the theoretical or research underpinnings of the methodology. Lazarus (1995: 38) held that the questions in technical eclecticism are “What treatment, by whom, is most effective for this individual, with those specific problems, and under which set of circumstances?”

Theoretical integration is a synthesis of two or more theories of psychotherapy, which includes the best elements of these theories. In comparing it with an eclectic approach, McLeod (1993) commented on its goal of bringing together elements from different theories and models into a new gestalt; Gold (1996: 12) stated that while some writers have pointed to its complexity and significance, others have criticized it as “overly ambitious and essentially impossible … because of the scientific incompatibilities and philosophical differences among the various schools of psychotherapy”. London (1988) went so far as to call theoretical integration “theory mushing”. Some examples of theoretical integrations that seek to avoid this criticism are given in the present book. For example, by combining two approaches based on humanistic perspectives, person-centred gestalt therapy (Chapter 3) avoids the incompatibility of philosophical underpinnings referred to by Gold.

The quest for common factors began early in the history of integration. In 1936, Rosenzweig held that the success of the different psychotherapeutic approaches had more to do with their common elements than with their theoretical foundations. Differing views as to the nature of these common factors have been proposed. Rosenzweig stressed the therapist’s personality, interpretations, and the complementary effects of varying psychotherapeutic approaches; Garfield (1957) listed empathic therapists, emotional release, and self-understanding. Gold (1996) held that common factors are of two kinds – supportive and technical. Supportive factors arise from the relationship, while technical factors provide new learning experiences including the opportunity to test new skills in action.

Writings (e.g. Clarkson, 1997) and research (e.g. Hynan, 1981) have focused on the relationship as the common factor in many psychotherapies. Lazarus (1992) considered this to be the soil in which techniques were planted while Goldfried (1980) viewed it as the foundation of all psychotherapies. When success is considered from the perspective of clients, the relationship has been found to be the most effective factor (Luborsky et al., 1983; O’Malley et al., 1983). In a study of 123 second-level students who had sought counselling for various issues (O’Leary, 1982), an increase in client-perceived empathy was associated with an increase in self-acceptance in 67 participants. Forty one of those 67 also reported an increase in the acceptance of others. Thus, positive change occurred irrespective of participants’ problems. Strupp (1979) and Lipsey and Wilson (1993) concluded that, in general, positive changes were due to the relationship between therapist and client.

Most approaches pay some attention to the role of the relationship in therapy. In discussing this issue, Corey (1996: 456) observed that “The existential, person centered and gestalt views are based on the personal relationship as the crucial determinant of treatment outcomes. It is clear that some other approaches – such as rational emotive therapy, cognitive behavior therapy and behavior therapy – do not ignore the relationship factor, even though they do not give it a place of central importance.” Reality therapy, psychoanalysis and psychodynamic therapy could accurately be added to the latter list.

Apart from the three aforementioned approaches to integration, Schwartz (1991) distinguished between fixed or relatively stable systems and open systems. The latter allow for ongoing evaluation and appraisal and are characterized by adaptable boundaries that facilitate the inclusion of new research findings from meta-analytic studies in the model. The resulting new integration can then be evaluated. Open systems were also advocated by Horton (2000) and O’Brien and Houston (2000). The latter authors speak of the interdependence and possible mutual enrichment of numerous psychological therapies. Previous publications in this area include works by O’Leary (1993, 1997a, 1997b). O’Brien and Houston provide a guide to integrative therapy that combines an emphasis on the therapeutic relationship with a framework for the process of integrative psychotherapy and the assessment of its therapeutic effectiveness. The framework outlined in Chapter 2 is a further example of an open system. Although such systems will of their very nature be general, it is important that the underlying assumptions are clear and capable of being subjected to research.

The research of Lambert (1992) and Duncan and Moynihan (1992) indicated that the approach to integration in psychotherapy should not be an either/or decision with respect to the three main orientations but rather a combination. Approaches identified as possessing common factors can be combined with theoretical integration approaches, with a probable increased prediction of outcome.

Nevertheless, obstacles exist to the movement towards integration in psychotherapy. Hawkins and Nestoros (1997: 53–57) named seven: (1) partisan zealotry and territorial interests of different psychotherapies and their adherents; (2) divergent visions of life, health, psychopathology and change; (3) inadequate empirical and clinical research on psychotherapeutic change and insufficient evaluation of psychotherapy (including integrative) outcomes; (4) lack of a common language for psychotherapies; (5) insufficient training in eclectic and integrative psychotherapy; (6) differences in the effectiveness of psychotherapies and (7) the proliferation of different schools of eclectic and integrative psychotherapies.

The definitions of approaches to integration in psychotherapy provided thus far are useful in that they reflect various strands within the movement. However, it is important that all these endeavours be subjected to research initiatives ...