Integrative Therapy

A Practitioner′s Guide

Gaie Houston, Maja O′Brien

• Publisher: SAGE Publications Ltd
• Year: 2007
• Print ISBN: 9781412912112, 9781412912105
• eBook ISBN: 9781446230206
• Edition: 2
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

`The book is comprehensive, and extensively researched and referenced. ….[The] last chapter contains some excellent training resources for trainers of counsellors/psychotherapists. I would therefore endorse it as a useful textbook, especially as there is an excellent in-depth example of an assessment form, and guidance on how this can be used for trainees. These were useful revision points to me as an experienced counsellor? - The Independent Practitioner

`The book would be useful to practitioners who want to start thinking ?outside the box? of a particular orientation. It is also aimed at students and trainers - the last 40 pages in particular are full of practical training exercises. Overall, I would recommend it as a well-reasoned argument for therapy to be rooted in an integrative base? - Therapy Today

`Throughout the book it is assumed that we can learn from each other and that we need to, whatever orientation we were trained in, in the service of the client. I find this pragmatic approach open and refreshing in a period when some of us have polarised around the ?what works best? debate. Both authors are experienced practitioners and trainers and their commitment to integrative counselling and psychotherapy shines through? - AUCC Journal

Integration rather than a single theory has become accepted and widely recommended as a way forward in psychotherapy and counselling. Integrative Therapy, Second Edition, a timely and innovative guide for practitioners, is based on the view that training and practice methods should be evaluated for their usefulness to the client instead of their adherence to a particular model.

Drawing from research on therapy process and outcome, and on human development respectively, the authors highlight striking similarities between the change processes involved in these two areas of study. The findings provide a basis for an adaptable framework for integrative practice.

The authors pinpoint what is common as well as what is different in various approaches, using case illustrations to make comparisons throughout between the three major models: psychodynamic, humanistic-existential and cognitive-behavioural. What emerges is the central importance of the therapeutic relationship in the process of change - ?how to be with clients? as opposed to ?what to do?.

Fully revised and updated, this Second Edition includes new material on neuroscience and practitioner-oriented research methodology showing how the processes of doing research and doing therapy have many things in common.

The book aims to cultivate a spirit of willingness amongst therapists trained in one model to learn from colleagues trained in others. It also features exercises to support its use on courses and will thus be invaluable to trainees of counselling, psychotherapy and counselling psychology.

Maja O?Brien is a chartered counselling psychologist and psychotherapist, supervisor and trainer based in Oxford and a Principal Lecturer on the Doctorate in Psychotherapy by Professional Studies run jointly by the Metanoia Institute and Middlesex University. Gaie Houston is a writer, UKCP-registered psychotherapist and senior lecturer at The Gestalt Centre, London.

1	Introduction

The principal aim of this book is to provide an overview of the areas of study and skill needed by an integrative therapist, and to offer a framework for assessing therapeutic effectiveness in the training in any school or combination of schools. What we hope to convey in this book is not holy writ for an integrative model, but a framework for thinking about therapy that can include theories and ways of working from several different schools.

The words Integrative Therapy have in recent years taken on some respectability. Many therapists light up at their mention, but are not always clear about just what is meant by them. The hope of the authors is to engage the reader in discovering what integration means to them. We maintain that what research shows to be effective practice, and useful theory from many sources, needs to be available for students and practitioners to integrate into their own work.

We offer a guide which we hope will be of value to practitioners trained in a single model who wish to widen their horizons, as well as to trainees embarking on an integrative therapy path. Very similar work gets done under different labels (Chamberlain, 1998). We believe that this book may be of interest to practitioners who call themselves psychotherapists, counsellors, clinical or counselling psychologists, as well as those in allied professions, such as nurses, doctors, psychiatrists and social workers whose work brings them into daily contact with human distress.

We put great faith in what we believe to be at the core of good practice, namely the relating skills of the practitioner. These skills need to be underpinned with the best grasp that can be achieved of the likely meanings and implications of what the client presents in terms of symptoms, feelings, cognitions, attitudes, values and life-story. The therapist* also needs to reflect upon and evaluate likely outcomes of this or that behaviour on her part. In reflecting on her practice she will be aided by some understanding of research, a topic expanded upon in this edition.

Much of what we have tried to discover in writing this book is about what it is that therapists do in common, and what it is that differentiates between different schools. In doing so we have looked at what research has to tell us, as well as at the theory and practice as described by practitioners of different therapy schools. Throughout the book we compare and contrast the three major therapeutic schools: psychodynamic, humanistic-existential and cognitive-behavioural. Above all we have been influenced in our writing by our experience as practitioners over the last 30 years.

One of the authors graduated in psychology and later obtained a Ph.D. in this discipline which saw itself as a branch of science. This made her aware of both the scope and the limitations of scientific inquiry. She entered the career path in clinical psychology which in her early days was primarily influenced by behaviourism. Its narrow focus led her to explore other approaches and, following a period of work in a therapeutic community largely based on psychodynamic principles, she qualified as a psychoanalytic psychotherapist. More recently and still in search of alternatives she qualified as a cognitive-analytic therapist. It was her experience as a lecturer in a psychology department which pioneered courses in psychological counselling within higher education that gave her an opportunity and a stimulus to explore and try to bridge, for the benefit of the students, the many splits in the field, including the one between academic psychology and therapeutic practice. Her commitment to the integration of theory, research, and practice led her to be involved on various committees in the new profession of counselling psychology, and to participate in the development of one of the first practitioner doctorates in psychotherapy in the UK.

The second author read English at Oxford and became a playwright before working for three years at the then St Bernard’s Mental Hospital, Southall, and training with National Training Laboratory (NTL) in the USA. She has remained a writer, and occasional actor and director, and also practised, supervised, and taught Gestalt therapy and group behaviour since 1974, and with the Gestalt Centre London since 1982. In that year she wrote in the Introduction to another book: ‘such dissimilar therapies lead to an identical satori, or, transformation, that I suspect that the ritual that leads to the experience is far less important than the advocates of the different rituals maintain’ (Houston, 1995: 8). This seems evidence of how long she has preferred effectiveness in therapy, rather than orthodoxy. And it is evidence of a humanistic focus on what Maslow (1968) called self-actualisation, rather than an assumption of pathology in the client.

In collaboration here, and in earlier years, we have learned eagerly from each other, and made use of the great overlap in our attitudes to and perceptions about therapy and training. And we work differently too. Some of what each of us has written in this book has sat uneasily for the other. As one, perhaps unsurprising, example M.O’B. has a rather more cautious attitude towards self-disclosure by the therapist of her countertransferential feelings, than does G.H.

As is evident, we have pursued different career paths and our respective training is based on different theoretical premises. Yet neither of us feels that to be described as a psychodynamic therapist, Gestalt, or humanistic therapist, or indeed as a psychologist, does full justice to what we actually do in practice. Both of us have been well disposed over a number of years towards the ideal of widening the perspectives of our work as therapists and trainers, which is in our view the essential precondition of becoming an integrative therapist. It requires also a certain trust in one’s own gut reactions and evaluation, while working with clients, students or supervisees, about what feels right or wrong in given circumstances, regardless of what our teachers or books have told us.

What we need to make clear at the outset is that, in the minds of the authors, integration must never be hijacked into becoming just one more brand of therapy. There is no place for hard and fast rules about precisely what to integrate and just how to behave.

We have used a number of therapies familiar to us to show a possible route to an integrative practice. We hope that readers will turn to existing literature for more detailed study of each theory and method we talk of and will add or substitute many others. A great deal has been written within each of the models we describe and there are many handbooks which include contributions from therapists of different orientations (Clarkson and Pokorny, 1994; Dryden, 1990a; Feltham, 1997b; Palmer et al., 1996; Woolfe et al., 2003). Jacobs and Walker (1995, 1996) offer interesting comparisons between approaches in the series In Search of a Therapist, in which practitioners of different theoretical persuasions comment on the same client. The interest in integration is much in evidence as publications on this subject continue to appear (Dryden, 1992; Hollanders, 2003; Lapworth et al., 2001, Norcross and Goldfried, 1992; Palmer and Woolfe, 1999; Scott, 2004; Stricker and Gold, 1993, 2003).

Most of the writing in this book derives however from our practice as therapists and trainers. We have deviated from this when deciding to include the cognitive-behavioural therapy model of which neither of us has extensive practical experience. Consequently CBT practitioners may feel less well represented than the psychodynamic and the humanistic-existential therapists. It was important to us to give practitioners from the other schools some understanding of CBT, with its current wide application in clinical practice. At the same time we hope that the CBT practitioners will be interested in the other two models, particularly their emphasis on working with the therapeutic relationship.

The authors’ practice is in groups and family therapy, as well as the individual work we describe here. The issues we debate, and the framework offered, may easily be applied also to these other formats.

In this chapter we introduce some of the debates and controversies about therapy integration and begin to outline our own position on these.

The field of therapy

We see integration as a corrective tendency in an over-fragmented field. There is a loss to practitioners, and therefore to the people they serve, in over-compartmentalised and exclusive patches of learning. This is tacitly revealed in the often unacknowledged poaching of the methods of one school into those of another. As an example, Jacob Moreno has been a major inspiration in participative and active skills in this field, yet many who use his methods have never heard his name. Similarly, there are now hardly any books on counselling and psychotherapy which do not include the concepts of transference and countertransference – yet Freud’s name is often not mentioned as their originator. Carl Rogers’ name never appears in psychoanalytic literature, in spite of a great overlap in ideas between the psychoanalytic and humanistic-existential schools.

Jerome Frank posited that

all psychotherapeutic methods are elaborations and variations of age-old procedures of psychological healing. The features that distinguish psychotherapies from each other, however, receive special emphasis in our pluralistic and competitive society. Since the prestige and financial security of clinicians hinge on their particular approach being more successful than that of their rivals, little attention has traditionally been accorded to the identification of shared components. (cited in Norcross and Arkowitz, 1992: 12)

It is fascinating that Frank wrote this in 1961, when there were far fewer psychologies and theories crowding the bookshelves and the pages of journals than is the case today. Twenty years ago, according to Karasu (1986), the number of distinct models of counselling and psychotherapy was over 400.

Why are we behaving like this?

Better work can arguably be done with a developmental difficulty if attention is paid to its aetiology. The paragraph above suggests part of the aetiology of the present often rivalrous and mutually excluding state of the profession. Counselling and psychotherapy are not always respected and welcomed by nearby professions, with whom friendship might be of enormous benefit to learning, and hence to the work with clients.

This book is of itself evidence that there is, alongside the existing fragmentation, already a strong push towards integration. For example a section of the United Kingdom Council for Psychotherapy (UKCP) is named ‘Humanistic and Integrative’. But before putting forward more of the ideas we have of how integration can be furthered in the most practical way it might be as well to speculate on some of what has led to the present divisions.

Norcross and Thomas (1988) conducted a survey of 58 members of the Society for Exploration of Psychotherapy Integration (SEPI) to find their ratings of 12 potential obstacles to integration. The top five, rated in terms of severity were:

1. Intrinsic investment of individuals in their private perceptions and theories;
2. Inadequate commitment to training in more than one psychotherapy system;
3. Approaches have divergent assumptions about psychopathology and health;
4. Inadequate empirical research on the integration of psychotherapies;
5. Absence of common language for psychotherapists.

Obstacles to integration

Investment in one theory

How does the first of these, often in the form of the espousal of one pure theory, come about? Theory itself can be an excellent tool; it can also become an encumbrance or a weapon. Perhaps this is what happens. There is often a useful tendency in the human mind to generalise. We make some kind of model out of experience or hearsay, and try it for size in other scenes. Extremely young babies quickly learn patterns of interaction from their first carers, which they try out on others, and may even stick with for life. The pattern may be mutually rewarding or somewhat the reverse. But the baby has learnt that this is what you do, so he does it. Being without a model of this kind, in other words being without a theory, would be very cumbersome and time-consuming. And most of us who are walking around have put together a good enough theory of human interaction to cope with life, and quite often even enjoy ourselves and each other. One of the repeated findings in the therapy room is that clients are at times even more wedded to their idiosyncratically developed theories of human behaviour than they believe they are. So it is not a great surprise that practitioners too form more attachment to their working theories than is strictly rational.

Another way to behave is to do with belonging. We are social animals, and we seem to have to deal with the idea of the group, of where we belong or refuse to belong. A school of counselling or psychotherapy, or a psychology speciality such as clinical or counselling psychology, is such a group. It can indeed easily become almost a church in the sense of rightness and truth and companionship and accepted ethics that it can give. And we all know that some of the bloodiest wars have been the religious ones. Rothstein (1985) describes some of the differences between schools of analytic theory:

Theories provide models, or puzzle solutions, all of which, if properly employed enhance an analyst’s self-esteem. In addition, theories are associated with traditions and institutions which further enhance the analyst’s self-esteem as he works within them and provide both illusions of security and tangible benefits such as referrals.

The second part of the quotation, like that from Frank earlier, acknowledges another perspective of rivalry, the economic. It may be difficult for a therapist in private practice and with a family to feed to admit that someone who arrives to see them for the first time might do just as well, or a good deal better, with a helper from a different school.

Group psychology shows us that a dependable way to elicit hostility is to have groups of people doing roughly the same tasks, just out of communication, but not out of awareness of each other (Blake, 1964). That is a description of the conditions under which therapy is often practised. Even different training institutes of the same persuasion are often at loggerheads. Eisold (1994) gives an interesting analysis of the intolerance of diversity and of the schisms within the psychoanalytic schools.

So the relations between discernibly different schools are sometimes characterised by fear and ignorance in roughly equal measure. In political terms it is not unlike a feudal system, with rival barons and their liegemen intent on enlarging their territory and maybe making it to be king.

One of the proven ways to break down such hostility is to have tiny mixed subgroupings from the stranger groups get together to find out how each other functions. This book is part of the movement towards such activity. The authors are both therapists trained in different therapeutic traditions. We are perhaps evidence of an emerging movement to explore other thoughts, hopes and ways of working, so we can learn to be more effective. Our collaboration on this book was not only an integrative experience for us both, but proof that such integration is possible.

Ignorance

The second obstacle perceived by Norcross and Thomas (1988) is about inadequate training in more than one system. Feltham (1997a) questions strongly the whole notion of a core theoretical model for counsellors and psychotherapists, though this is still generally seen as a sine qua non of training. On many sides there is disquie...

Table of contents

• Cover Page
• Title
• Copyright
• Contents
• Preface to Second Edition
• Acknowledgements
• 1 INTRODUCTION
• 2 DOES THERAPY WORK AND HOW?
• 3 HUMAN DEVELOPMENT
• 4 A FRAMEWORK FOR INTEGRATIVE THERAPY PRACTICE
• 5 WHY ARE WE HERE AND WHAT DO WE HOPE TO ACHIEVE?
• 6 QUESTIONS OF TIME AND SPACE: WHEN AND WHERE
• 7 TOOLS OF THE TRADE
• 8 THERAPEUTIC RELATIONSHIP
• 9 THERAPIST TRAINING
• APPENDICES
• References
• Author Index
• Subject Index